AN EXPLORATORY INVESTIGATION OF CASES
RBOPENED AT THE FLINT CHILD
GUIDANCE CLINIC III 1952
by

‘Ward wayne Weed

November, 1956

 

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m mmmmay mmsrmmmw oz? CASES RECPEEJED
AT T2122: FLINT CHILD (mm-zen emu-c m 1952
by

Ward wayne Wood

A PROJECT REPORT

Submitted to the School of Social ficrk,flichigan
State University in partial fulfillment of hue
Requiremeuts for the Degree of

MASTER OF SOCIAL ECRK

November 1956

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# Chairman, Réfieufcn Committee

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ACKNOWLEDGEMENTS

The author wishes to extend his sincerest apprecia-
tion to Kiss Margery Ross for her patience and able assist-
ance in the writing of this project. I should also like to
express my personal appreciation to Dr. Gordon Aldridge and
Ir. lanfred Lilliei’ore for their assistance and valuable
suggestions.

I an especially grateful to the more or the Flint
Child Guidance Clinic staff for their observations and sug-
gestions as to the formulation of this study.

Finally I would like to acknowledge the assistance
the typist, Mrs. Ann Brown,gave in establishing a degree or
order to a paper that formerly had none.

11

TABLE OF CONTENTS
Page

Acknowledgments. . . . . . . . . . . . . . ii

Inst of Tables . . . . . . . . . . . . o . iv
CHAPTER

I. INTRODUCTION . . . . e . o . . . . . 1

II. HISTORICAL.BACXQROUND AND CURRENT OPINION . . 9

Related Studies . . . . . . . . . 12

III. METHODOLOGY’AND PROCEDURES . . . . . . . l9

Objectivity and Validity . . . . . . 20

IV. PRESENTATION AND ANALYSIS OF DATA . . o e . 22

‘Testing Only” Cases. . . . . . . 22
Diagnostic and Treatment Cases . . . . 24

V. SUMMARY AND CONCLUSIONS . . . . . . . . 42

SWry o o e o e e e e. o e e e “'2
COIIClUSiOIlS. . e g e o o o Q Q o 46

BIBLIOGRAPHY. .- e e e e e o e e e o e e e 52
APPENDIX 0 e o e o e e e e o e e e e e o 514

ill

TABLE
1.
2.

3.

5.
6.

LIST OF TABLE

”Testing Only“ Cases ReoPened in 1952. . .

Occupations or Income-Earner at Time of
Original.0penin3 and Reopening of
Treatment Cases . . . . . . . . .

Referral Sources at Original Opening and
Reopening of Treatment Cases . . . . .

Referral Reasons of Treatment Cases . . .
Disposition of Treatment Cases . . . . .

Length of Time Between Closing and.noopenins
0f Treatment 03533 e e e e e e e o

iv

PAGE
23

31
3t
36

CHAPTER I

INTRODUCTION

In his second year field placement at the Flint Child
Guidance Clinic the writer became progressively interested
in the characteristics of the intake and consequent service
given to the great number of referrals made to the clinic.
Because the number of referrals exceeded by far the number
which could be adequately processed the starf“nenmers were
exnndning agency procedures to determine whether changes might
be made to enable them.to handle more cases. The writer was
interested in this problem as he had observed some referrants
which seemed to need immediate attention but due to the four
to five week waiting period became discouraged and lost in-
terest in clinical service. Also in a few cases it seemed
that the problems were stated in words that indicated the
parents' need and desire for help in correcting an upsetting
situation. After a four or five week waiting period they
did not respond to the clinic‘s offer or an appointment to
clarify the situation. The reasons for such reactions can
be as varied as the cases involved and are sufficiently cone
prehensive to entail an entire study.

In this regard the staff members of the Flint Child

Guidance Clinic had long been wondering if there were any

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uniform characteristics in reopened cases. If these char~
acteristics were known, they wondered, would the clinic be
able to reduce the need for additional and possibly repetitive
service. In this way the waiting list might be reduced. The
interest in the nature of reapplications was expressed in ques-
tions of the following nature: Eh was the case reopened?
has it for the same reason as the previous opening? Who
requested the reopening of the case-the same person as at
last Opening or some other person? How much time had clasped
since the case was closed? What type of service was given at
the last opening--diagnostic treatment or testing? It was
believed that the answers to these questions might indicate
need for same modification of clinic procedure and perhaps
furnish insight as to where and how the change should be
made. It was hoped that extra time and duplicated effort
could be minimized so that a maximum amount of time could be
directed tosard the processing of new cases.

Three hypotheses were formulated for this project:
(1) Few cases are reopened for treatment. “Psychological
Testing Only" is the primary reason for the reopening of
cases. (2) when initial treatment has not included both the
child and his parents, it is more likely that there will be
need for "reopening“ than when both parents and child have
been included in the treatment services. (3) Cases carried
on.s continued casework treatment basis are less likely to
be reopened than those which have received only intenlittent

services.

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The first hypothesis follows the staff's belief that

”Psychological Testing Only" is in a decided majority cine.
it in standard procedure to retest infants and young cnild-

It is not considered possible to ascertain their cap...

ren.
The

acities reliably with Just one occasion of testing.

second ypothesis is predicated on the ass'mption tnat i

both parent and child are involved in the treatment process
the treatment will be more effective and there will be less

need to return to the clinic. The third hypothesis contains

much the sme principle of effectiveness but length of time

is advanced as one of the necessary factors.

Dennis B--o:~:n, a staff member of the Flint Child Guid-
ice Clinic carried out a similar project as partial fulfill-

ment of the requirements for the degree of Easter of Social

Work at the University of Michigan. He described the charac-

teristics of cases reopened at the Flint Child Guidance

Clinic during 1954. In the present report the your 1952 has

been selected in order to determine whether there is a clear

trend or pattern in reopened cases during the two years ,

1952 and 1954.
The setting for this study is the Flint Child Guidanc

Clinic, which has been operated since 1946. A clinic had

existed before 1946 for short periods of time but shortage

of operatir‘ig funds and/or lack of available trained personnel

during World ‘e‘ar II forced it to discontinue operations. Hord-

ever, in 1946 a group of Flint civic leaders were instrumental

in. arai‘ging meaty-.33 with officials of the State Department

14
or Hental Health to have one or the Joint state and community
supported child guidance clinics established at Flint; The
Flint clinic was established to serve, within the lhnitetions
or personnel, time, and distance, Genesce, Lapoer and Shiawas-
sec counties. The services and functions have been described
in the Flint Child Guidance c inic By-Laws as follows:
(a) The diagnosis and treatment or children tron
birth to the age of sixteen, or until they have
finished high school, who present emotional,
personality, or behavior problems to themselves,
their parents or the community.
(b) To counsel and aid parents.

(c) To work for the prevention of maladjustments of
Children through community education.

(d) To help children and parents by cooperating with
social agencies and other community organizations
interested in the welfare of children.

(e) To cocperate with the Depar'mmnt of Mental Health
in the overall State Plan for the prevention of
mental illness.

Direct diagnostic and treatment services are offered
to patients and consultation given to various community
agencies in regard to the behavior problems of children who
are of interest to those agencies and whom the agencies are
attempting to assist.

Diagnostic cases are those in which the child and his

parent(s) have been seen by the clinic to determine the nature

 

1 tate of’fiichigan De? tment of‘fiental Heal h,
"Progrun.and Policy Statement‘afnetroit, Michigan: 1952),
PP. 2-4-(Mimeographed).

5
of the child's difficulty, but subsequent tothe evaluation

of the situation are not seen for treatment by the clinic.
However, he clinic may make recommendations for the care
of the child. Cases handled in this manner are for the most
part accepted for "psychological testing only.“ In this sit-
uation a child is administered a psychological test to dotor~
lino his intellectual Operating level and potential capacity,
and treatment is not considered. A recommendation is sent
to appropriate agencies and interpretations of fins child's
functioning level are always given to the parents along with
suggestions as to his handling.

A trlatnant case is one in which subsoquont appoint-
Isnts are made for the child or parent(c) for the purpose of
influencing a chango in tho child’s reactions to his situso
tion or through the parents effect a change in tho situation.
Often the parent or parents are soon tozlaintoin an involve~
Innt in the child‘s problem.but they are not interviOwed for
tho purpose of providing personal insight. satin” only
the parent or parents cons regularly to tho clinic since tho
child scene to bo reacting quit. naturally to a disturbing homo
situation. It is consider-0d lost effective however, in tom
of a satisfactory readjustment of the relationship between the
child and parent, to have the parents and child concurrently
"coin clinic services. One staff mentor my be involved in
thorspy with the child while another staff“nunbor usually has

contact with the parent or parents.

6

when consultation service is given to another social
agency the child and family are no usually interviewed by
the clinic staff, but rather the Consultation is offered on
the basis of the infumation submitted by the agency concor.ed.
Frequently the clinic and another social agency will nor}
cooperatively. That is, the clinic will provide direct ser-
vice for the child while the community agency'maintains con~
tact with the parent(s).

The clinic is primarily interested in prevention of
behavior disorders, emotional disturbances, and mental illness.
Prevention, more than any other function, is its reason for
boing. The founders of the child guidance program and the
staff’mcmbers of the clinic realise that this aim is not
realized by the communities they serve. The clinic is trying
through whatever media are available to educate people to use
lore effectively the service offered by the clinic. This
process is an essential Job; a prerequisite to effective
social work practice and.more markedly important in the area
of prevention. Prevention involves an awareness of “warning
signals." The parents, the teachers, and the comnmnity need
to know what is a deviant behavior problem, what is abnonmal
behavior and not a ”phase” in the child‘s development. The
clinic tries to provide this knowledge by meeting with
Parents and Teachers‘ Organizations, Child Study Clubs and many
other groups, which might affect the mental hygiene care of

hildren. The Flint Child Guidance Clinic has had to acknowl-

edge that the pressure of current demants for treatment and

7

iagnosis of the more severely disturbed children has pushed
prevention into the backgro 1d. They have learned that educa-
ion is a slow process which.may at times show no progress
but nevertheless ie an extremely'important function.2

In 1952 the F int Child Guidance Clinic had a staff
of one full time psychiatrist who was the clinic director,
three psychiatric social workers, two clinical psychologists,
and a mental health nurse. The three psychiatric social
:orkers provided casework treatment to parents and children
and in addition one functioned as casework supervisor. The
clinical psychologists provided clinical treatment and psycho-
metric services. The mental health nurse served primarily as
liaison person between the clinic and the Public Health De-
partments of the three counties served, as well as being a
teacher and consultant to the hospitals, eciools, various
associations for the retarded, blind, and other groups con-
cerned with physical and mental health. The nurse was instru-
mental in crganizing,many of these groups. She also did
incidental counseling to clinic patients and their parents.

In-service training was offered at the clinic for stu-
dents of psycniatry, psychology, and social work with stipends
financed by both the local community and the State Mental
Hygiene D=partment.

The Flint Clinic serves three counties, Genesee,
Lapcer, and Shiauassee in which there is a population of

-

2Interview with Chief Social Worker, 4-1-55.

8
approximately 350,000. his area is highly industrialized
with two automobile factories, Chevrolet and Buick located

in Flint, enesee County. Fanning is more prevalent in Lapeer

and Shiawaseee Counties than in Oenesee County, althoujh the
the farming is usually supplementary to the main Jobs at the
factories in Flint. This means two Jobs, extra long hours
and a fairly high standard of living so that one light find
homes bereft of mutual activities but rich in household rur-
nishings and clothes. There will be no attempt to prove or
disprove this conjecture but it is believed that the factor
of the father and sometimes the mother being absent because
or employment may be significant in the development or prob-
lenm broght to the clinic.

Thus this study of the cases reopened at the Flint
Child Guidance Clinic in 1952 will focus on the characteris-
tics of the cases to deterudne whether or not there are
trends or patterns present in 1952 and 195h.

CHAPTER II
HISNRICAL BACKGROUND AND CURRENT OPINION

Although there is considerable literature about the
child guidance movement and about therapy with children, the
writer was unable to find any studies dealing specifically
with the reopening of cases in child guidance clinics}

The rise of the child guidance movement, which was
largely a product of interest in preventive psychiatry, is
usually dated from about 1921, when the National Co-nittee
for lental Hygiene, backed by the Comonwealth Fund, entered
upon a program for the prevention of delinquency.

'l'he forerunners of this movement-«411 Chicago, Phil-
edelphis‘, Baltimore and elsewhere-«are well known, and some
of the most distinguished pioneers both here and abroad made
their contributions during the 1920's. A study identified
eleven psychiatric clinics for children in 1919 and found
776 in the United States in 1939- These clinics for children
were of my types, lost of the: closely following hospital
Iodels, others an educational pattern, and still further the
"denonstration" type of clinic, described by Stevenson,

A“ A_. _“_____

1major sources of possible information considered were
Social Casework Journal of Orthops chiat gental gygiene,
ournaI‘of“iszchiatrig_socia1 nor .

 

9

lO
Witmer and others.2 The first demonstration clinics were set
up in 1922 in St. Louis and Rorfolk with the purpose of

showing the Juvenile courts and child caring agencies
what psychiatry, psychology, and social work have to
offer in connection with the treatment of the problem
child, and by properly directed and effective methods
of treatment not only to help the individual delinquent
to a.more promising,care§r but. . . todecrease the
amount of delinquencies.

Stevenson and Smith record in detail the development

of child guidance theory and practice during the demonstra-

a

tion period and later. Out of their experience certain

conclusions emerged which form.the basis for much of the
present child guidance work. One of the earliest policies
was that which is nos a basic principle: that child guidance
services should not be limited to any one diagnostic group,
such as delinquents or ”pre-psychotics” and that services are
most effective with children of adequate intelligence whose
difficulties have not been of too long duration.

The theory that clinics should find s.nesns of
distinguishing and then treating all maladjusted
children was put to test in connection with a health
survey'in.flonmouth County, New Jersey. There it was
found by investigators that thirty-nine per cent of
the children in the public schools needed further
psychiatric study and treatment. A demonstration
clinic unit, consisting of psychiatrist, psychologist
and psychiatric social worker, worked in the county
for about a year and showed conclusively that need for
psychiatric help is not the only factor determining

A % w A

2Gordon Handlton, Ps chothera in Child Quidance
(New Yerk: Columbia.univers¥ty Press, 9477) P. 6.

3Lauson G. Lowrey, ”The Child Guidance Clinic,”
Childhood Education, Vol. 1 (1924). p. 100.

“Stevenson and Smith, op. cit.

ll

amenahility to treatment. The full hmplications of

the failure were perhaps not seen at the time. Em-

phasis was put upon the magnitude or the problem.and

the lack of community facilities to carry out the

treatment program, and the individual families' atti-

tudes toward the treatment of the children were largely

attributed to rural outlook rather than to variation

in the desire for psychiatric help.5

Through the demonstration clinic experience clinic

structure and policies were established which have been fol-
lowed by most urban child guidance clinics since that period.
Typically a child guidance clinic staff consists of psychiat-
rists, psychologists and psychiatric social workers in the
ration of l: 1: 2 or 3, and sometimes includes a pediatrician
as well.

The objective of such a clinic is held to be bettering
the adjustment of children to their immediate environ-
ment, with special reference to their emotional and
social relationships, to the end that they may be free
to develop to the limit of heir individual capacities
for sell balanced.maturity.-

Child guidance clinic staffs no longer think.primarily in
teams of prevention but are interested in helping children
with their present problems for the sake of present satisfac-
tions. To this end the clinic offers its social, psychiatric,
and psychological services to children and their parents and,
in addition, usually carried on a program of education design-
ed spread a knowledge of‘mental hygiene throughout the cam-

nunity.

‘4...“ i A , _ A

w fi— Wt

5}{EIOH Wimr,
reek: The Commonweelt

 

6
Laid. . pp. 513-55.

ll

amenability to treatment. The full implications of

the failure were perhaps not seen at the time. Em-

phasis was put upon the magnitude of the problem and

the lack of community facilities to carry out the

treatment program, and the individual families' atti-

tudes toward the treatment of the children were largely

attributed to rural outlook rather than to variation

in the desire for psychiatric help.5

Through the demonstration clinic experience clinic

structure and policies were established which have been fol-
lowed by most urban child guidance clinics since that period.
Typically a child guidance clinic staff consists of psychiat-
rists, psychologists and psychiatric social workers in the
ration of l: l: 2 or 3, and sometimes includes a pediatrician
as well.

The objective of such a clinic is held to be bettering
the adjustment of children to their immediate environ-
ment, with special reference to their emotional and
social relationships, to the end that they may be free
to develOp to the innit of gheir individual capacities
for well balanced maturity.

Child guidance clinic staffs no longer think primarily in
terms of prevention but are interested in helping children
with their present problems for the sake of present satisfac-
tions. To this end the clinic offers its social, psychiatric,
and psychological services to children and their parents and,
in addition, usually carried on a program.of education design-
ed spread a knowledge of’mental hygiene throughout the com-

munity.

L— “ __-

5Helen Witmer, Psychiatric Clinics for Children (New
York: The Commonwealth Fund, 1940), pp. 52-35.

6
Ihidop pp. 514-550

12

For the most part such clinics receive patients
through the medium of social agencies (including courts and
schools) although referrals from.parents are beginning to
outweight social agency referrals in some clinics. The
clinics tend to exclude from.service or to give only limited
service to children suffering from.extremc mental defects or
neurological handicaps and refer such situations to the cam-
lnnity resources which are established for the case of such
conditions. The methods of psychiatric and casework treat-
ment used in the clinics vary considerably but few, if any,

clinics confine their work chiefly to diagnosis.
Related Studies

In Brown's study seventy-four cases were reopened.7
Twenty—eight were reopened for "testing only" and forty~six
were reopened for regular diagnosis and treatment. There win
a ratio of thirty-three boys to thirteen girls in the diagnosis
and treatment category. Also within this category there was
only one negro child. While the negro population is not pro-

portionally represented in the reopened cases of 1954 in the

Flint Child Guidance Clinic it was found in a research report8

7George Dennis Brown, "The Nature and Description of
iases Reopened in the Flint Child Guidance Clinic in 1954”
unpublished.naster‘s thesis, university of Michigan, 1954).

8“Differential Utilization of the Facilities of a
Iichigan Child Guidance Clinic,“ Research Report Ho. 1?,
march, 1955, Michigan Department of Mental Health.

13

made for the Michigan Department of H,elth of the Lansing
Child Guidance Clinic that " if the total area is considered
the proportion of non-white clients does not differ signifi-
cantly from the proportion of non-wh.tes in the general pepula—
tion tn the one-to-nineteen age group. That is, non—whites
are neither over nor under represented in the clinic group.'9
It was found, however, that two of the six counties in the
clinic area account for all the non-white clients. Thus, it
should be said that even though non-white clients were not
represented in preportion to the population in each of the six
counties they were represented in proportion to the population
when the entire six county area is used as the basis for anal-
ysis. The noteworthy fact that Inghem County, in which

county the clinic is located, accounts for eighty-seven per
cent cf the clinic's non-white population raises the question
as to whether or not accessibility through proximity is the
cause for this representation. However, the issue remains that
for the total area the non-whites were proportionally repre-
sented whereas in he two studies of reopened cases in the
Flint clinic there cannot prOportionate representation.

At the reopeninge during 1954 the cases were serviced
in the following manner: twenty-one were achdduled for
treatment; eight were referred to other community agencies;
seven cases were scheduled for child treatment only if the

parents followed through on he clinic‘s recommendations for

 

91bid.

is
than to request assistance at other agencies for their parti-
cular difficulties; placement was recomended in four cases;
in five instances the family failed to complete the diagnostic
process; and one case was given consultation only.

Brown stated in his conclusions “that the greater num»
ber of the study children were either eldest or youngest in
the sibling order" and that I'the age range of the children
placed them.primarily in the latency to adolescent psycholo-
gical growth periods.’ He felt that problems at these stages
could be indicative not only of the youngstcr's confusions as
they loved from one stage to another. but also to the parents
feelings or their inabilitice to understand and assist the
youngsters as tuey begin. to move from being quite childlike
to a greater exploration or the desire for independence.

It was also noted by Brown that the maJority or rererw
rals came from sources other than the parents which gave some
indication of the way in which the clinic is meeting the needs
of the community as referrals usually reflect community knowl-
edge of the clinic's availability and functions. He also con-
sidered that the fact that parent31nade as many referrals as
they did.delwnstrated the satisfactions gained by the parents
during the original contact and that if the parents had
grasped tee purpose or the clinic on the previous contact
they would, theoretically, recognize earlier the re—emergence
of a problem.and nasten to use the available facilities to
combat tnat problem. He also indicated tnat previous contact

with tne clinic might have had quite the opposite effect

15
upon the parents in that their increased awareness of their
involvement in the problem could build a stronger resistance
to returning to the clinic especially if their guilt feelings
regarding the problem have not been resolved.
The theo:y c1 be lief that cases whicn had been involvedi

in the trcauLclt process are less likely to be reopened was

1
()

t substantiated or refuted by'Mr. Brown's study. The

A.

r alts were 1 co elusive. This pattern was not startling

(D
C)

because such typtt.esis assumes tco many conditions to be
considered in a study wb lien is only concerned witn it as a
single asgect of a larger problem. that kind of "treatment"
is presupposed is one question that might be asked. Psycho-
therapy, case work, relationship tnerapyysupportive tiflera by
are " rea Mnext' processes whicn seem.to have different mean-
ings to different peerle. An aazuer to the question of ”what
ind of treatment" is that the suggested processes are dif-
ferent depths of tnerapy adapted to personality 'nd reality
factors but with tne same long range goal of a more satisfactory
adjustment for tne individual.
Diagnosis, as defined by Florence Hollis, is
the attempt of the worker to understand the nature
of the clierts difficulty in order to offer rim tne
kind of assistance most lilcely to er .able him to im-
pr ve nis social functioning. One of the first
broad questions to be answered when we begin working
vzith a client is: Does this person's tro able arise
mainly from inner or outer pressures: Is it due

nrimarily to tbs situation in wbicn he finds himself
or principally to elements within his own personality

1.6

which We in dealir2g with tr e normal vicissitudes
of lifeil

If the social situation is the primary cause of the trouble
then the casework treatment deals with modifying or helping
the client to modify the external situation so far as this is
possible. However, if the trouble is primarily due to an
inability to deal adequately with their social relationships
because of an emotional disturbance ti re is a different
focal point for treatment. ‘Modificaticn of the individual's
feelings toward his social situation is he goal to be reached
in this instance. Naturally neither internal or external
sources of problems are mutually exclusive. Because of the
importance of diagnosis to treatment any supposition as to
the effectiveness or ineffectiveness of treatment sho did also
consider he accuracy and completeness of the diagnosis.
Treatment is definitely strengthened or weakened by the accur~
acy of the diagnosis. (Miss) Hollis felt that

it is tie difference between starting to build an

unknown picture from a pile of Jigsaa puzzle pieces

and undertaking tlat same Job with the coeledge

tiat the puzzle is 0T? of a lialf do fin with which

one is already thoroubhly familiar.

There is another question regarding reopened cases and

the treatment process in general which 3 ould be considered
and that is hos was termination of treatment a footed. Did

-

the as ncy plaJ' an active role in this process?

An

loFlorence Hollis, "The Relationship Between Psycho-
social Diagnosis and Treatment,“ Social casesorn February,
1951. pp. 55-56.

llIbid.

17

Termination is a part of the total treatment pro-
cess and with relationsiiip as the medium of treatment,
it fol.lows that in a child so laxcc clELic, parent
and child will inevitably move tosard a neg beginning

1-,)

apart from clinic support and degeudenoy.ee
The ending should be part of the beginning. The inclusion of
tne parents not only at the beginning of treatment t

b
ending in terms of the support they give their children has an

.7

easing effect on the oniidreg.

In cases where pa1e e11ta l c311w1ation is enli3tod
from the first, every step fo rt e child from begin-
n;inc to end seems easi er. . . . ”here a c‘ ild feels
a parente' suoport in ente ring the treatngnt situa-
tion and has been givei a pas tire and 1 nine reason
far coming, his begiqning may be matiy tim.e more mean-
ingful and he 5313ms to preseit tie inner problems in
relations ip more quickly and with a milder a21d more
coz1structive the of anxiety. When a child is read y
to ead his therapeutic experience, the availability of
par13ntal support in reality makes the transition less
painful and less time con2311173111113;.‘L

Very little has been said about termination in cases
which are not responsive to treatment. This is an important
area in efficient use of clinic time, recognition of limits,
development of skills diagnostically ax1d treatment-nib e, appro-
priate and timely referral, protection to client and community.
P anned termination which includes the parents' and the child'd
thinking about what it will mean to them is essential because
trey need the opportunity to 13ork tl1rough some of the conflict-

ing feelings aroused by the planned separation from the clinic.

—— f M— .r V?

12:Clarice Flatt, "Termination Planning in a Child Guid-
once Clinic,“ Jouw al of F: 50113 trio Social dork, Vol. XXI,
March 1953, p. iii.

 

13Jonn A. Rose, M.D., “Relation of Therapy to Reality
of Parental Connection with Children,“ Journal of Orthopsy-
££é£££19 April 19491 pp. 351-357.

18
“Movement in the termination phase of treatment is character-
ized by the ambivalence common to all steps from.beginning

through ending.hm

Also within the termination planning per-
iod because of the tendency to compare past and present think-
ing there is much of a productive nature about the last few
interviews. It is as if the parent or child is hurriedly
taking inventory of his feelings before coming and while
coming to the clinic as compared to his present feelings.
There may be some fear that the present cdmfort can not and
will not exist without the support of the worker he or she
has been seeing. It is, therefore, well to know that future
contact can be made at any time.

The foregoing discussion has attempted to delineate
possible areas needing concentration in clinics and social
work agencies in general. This has been done within the con-
text of this study because it is felt that reopened cases are
an indication of a need that was unmet during the original

contact for various reasons.

1“:b g.

CHAPTER III
METHODOLOGY AND PROCEDURES

The problem.and the reasons for its selection have
been presented in the introductory chapter. In order to have
a sample which the writer could analyse within a feasible
time during his second year in the School of Social work a
time factor of one year was selected. Since a comparison
between this study and.Brosn's study of 195h was to be made,
the year 1952 was chosen to elhninate the factor of a dif-
ferent admdnistration and changing policies.

In planning a procedure or’method to test the hypoth-
eses it was decided to use a schedule1 simdlar to the one
used by Brown to detenmine the predominant characteristics
of the cases reopened in 1952.

The data were obtained fronrthe clinic reports for
1952 and from.the records of the reopened cases. The clinic
reports provided the writer with the case numbers of all cases
reopened in 1952 which permitted an investigation of all such
cases when pulled from the files.

The writer's tabulation was done by the hand sorting
{method and the analysis was concerned with that which predomr

inated or was most prevalent. There were no classifications

i.—

1See Appendix.
19

20
of the writer's making, rather it was felt that a descriptive
account of the data would be more helpful. In this respect
too the analysis consisted of determining the prevailing pic-
tures or trends if any were present.
Both before and during the organization and writing of
this paper a search for related literature was made to document

statements made in the study.
Objectivity and Validity

The writer has some reservations as to the degree of
success he had in meeting the criteria of "adequacy, validity
and representativeness,“‘2 The criterion of adequacy of docu-
ments for scientific investigation refers to the regularity
with which they supply certain kinds of data, that of validity,
to the correspondence to reality of the information that they
contain, and that of representativeness, to their being chosen
in such a way as to permit inferences to a larger universe.
The rather arbitrary use of terms in situations which were not
class fied or categorized tended at times to make the collec-

ion of a certain type of information difficult and sometimes
impossible without some personal Judgment. For instance there
was no consistent method of recording the reasons for closing
a case and sometimes one reason sounded the same as another

that was found to be entirely different. More extensive

 

2Hilde Landenberger Hochwald, "The Use of Case Records
in stearch," gpcial Casework, (No. XXIII, February 1952). PP.
71"? o

21
research was necessary to clarify this point. The facts then
were not adequate.

The size or the sample is a.limiting factor as to its
representativeness. The inferences made fron.tho information
in this study are not substantiated in sufficient strength to
allow application to a.more general universe. The problem.is
too specific in time and ares-nne year and only roopened
cases as opposed to reopened cases in relationship to the

total number of opened cases within the same time limit.

CHAPTER IV
PRESENTATION AND ANALYSIS CF DATA

"Testing Only“ Cases

In i952 there were sixty-nine reopened cases, thirty-
one of which were reOpened only for testing purposes. Since
the reasons for having the tests administered are not particu-
larly relevant to the questions and assumptions of this study
little consideration will be given to those cases. It was
assumed that there would be a large proportion of “testing
only cases" and this was verified to the extent that almost
half the total population fell into that category. However,
since interpretation of the test results is often a function
of the social worker and therefore represents an expenditure
of clinical time some aspects of these cases will be discussed.
It may be noted that in 1952 there were sixty-nine reapened
cases while in 195% there were seventy-four reopened cases.
Approximately two-fifths of the reopened cases in each of
these years were "Testing Only“ cases.

Most of the thirty-one youngsters were being tested
because they were being considered for adoption either immedi-
ately or in the near future. Several were born out of wedlock,
deserted, or placed for adoption by one or both parents who,

for many and individualized reasons, felt unable to care for

22

23
thong For some of the children there was a question of organic
brain damage and concomitant low mental capacity so that in—
tonation was needed to aid in long range planning for then.
ibis question was often raised by child placing agencies in
which the workers and foster parents had only limdted soCial
histories and observation of the child‘s behavior.

For eight of the thirty-one children the boarding or
adoptive parents were seen immediately after the testing to
interpret the children‘s feelings and limitations and tosug-
goat ways or meeting with the youngsters for*mutual satisfac-
tions.

In the testing only group there were seventeen males
and fourteen females which is a rather even distribution. For
the first time tested their ages ranged from three months to
nine years and the average age was four years three months.
For the last time tested their ages ranged from.thirteen
months to fourteen years with an average age of five years
eight months. Therefore there was an average length of time
between the first and last testing of one year five months.

Every child was seen more than once as Table I indicates.

TABLE I
"TESTING ONLY“ cases REOPENED IN 1952

 

 

Times Tested Number of Children
Total 31‘ '
2 l7
3 13
4 l

 

24
The average number of times a youngster was tested amounted
to a fraction less than 2.50. This means that in the seven-
teen months average time between the first and last testing
each child was tested on the average two and one-half times
or once in a six and two-thirds month period.

A contributing factor to the number of times these
children were seen was the fact that the clinic, in 1952,
worked very closely with the Genesee County Association of
Parents and Friends or’Retarded Children. Hany'children were
retested for the purpose or providing material for clinic
discussions within this group.2

Diagnostic and Treatment Cases

In 1952 thirty-eight cases were reopened for diagnos-
tic evaluation and treatment of which twenty~rour were male
and fourteen were female. The preponderance of boys over
girls being seen at clinics has been noted and substantiated
in other studies concerned with clinic intake. George Steven—
son and Geddes Smith noted that “the clinic tends to see many
more boys than girls"3 and.Hary Ellen Lippink noted too that
"out of the thirty-eight children in the study, thirty-three

were boys and five were girls.“4 This proportion is similar

2Interview with Dennis Brown, April 5, 1955.

3George S. Stevenson, I.D., and Geddes Smith, Child
guidance Clinics (New Yerk: The Commonwealth Fund, 1933),p.56.

“flary'Ellen Lippink, "Reopened Bases in a Child Guid-
ance Clinic For a SixLMcnth Period“ (unpublished.naster's
thesis for the degree of’MSW, University'of'Michigan, 1951).

C} i“
h

to that found in Brown‘s study where he had thirty-three
males and thirteen females.

11;may be noted that among these thirty-eight cases
there was none of the Jewish faith. This may be explained by
the small sample that is under study here but it might be
significant when compared to the average number of Jewish
peeple seen yearly. It would be interesting to know hos the
so-called minority groups are represented in the total clini-
cal population. In eleven instances no religious affiliation
was declared while seventeen were of the Protestant faith,
denomination unspecified, and eleven were of the Catholic
faith.

In Brown's study he found only one Catholic, none of
the Jewish faith, and one who did not specify religion. It
would appear that the reasons for the relatively low number
of Catholic and Jewish parents and children might be explored
to determine slother hey had other resources or whether the
clinic facilities did not meet their needs.

There were no Negro children among the thirty-eight
children in our study group and thissgain directs the focus
upon the question as to the clinical representation of the
minority groups relative to their population ratio. This
study indicates for the year 1952 in the Flint Child Guidance
Clinic that Negroes did not reapply or were not referred for
the second time to the clinic.

It has been the opinion by the clinic staff, as

well as the staffs of some other agencies, Family
Service in particular, that Negroes have not availed

26

themselves of many of the community services offered

by various agencies, and that too often Negroes cone

to the clinic under pressure from.the court for par~

ticipation in some delinquent type of activity.5
If the clinic staff's opinion is an accurate assessment of the
situation this could partially explain the lack of "recidivism”
for the negrocs in this study group.

In Blown's study the same pattern could be distinguished
as he found only one negro among the reopened cases.

Among the thirty-eight children there were only six
who had no siblings; eight had one sibling, nine had two sibl-
ings, six had three siblings, four had four siblings, four had
five and one had six siblings. Of the thirty-two children who
had siblings thirteen were the I‘oldest" child, ten were the
"second child“ and eight were the "youngest child." Four were
the "third child,“ “three were the fourth," and "two were the
fifth child." Actually there were more "oldest" and "youngest”
children than second, third, or fourth children as some of the
"youngest" children had only one sibling so they were the"sec-
0nd child" which explains the slight numberical advantage in
the “second child" category.

Brown also found that the oldest and youngest children
predominated the reopened cases.

The youngest child at the original Opening was two
years old, the oldest child was eighteen with twenty-four of
the thirty-eight children coming from the age group four
through nine. In the ten through eighteen years of age

SIntorviow with Chief Psychiatric Social Worker.

27
category there were thirteen children. There is a decided
majority of children in this instance, who are entering or are
in the "latency period" which evidently for these children was
_ so “latent." The highest incidence of cases occurred in this
age group as there were six children in this group,

The youngest child at the last opening was four years
old, the oldest child was eighteen with a distribution of
eighteen in the roar through nine age group and twenty in the
ten through eighteen age group. In comparison with the first
opening it appeared that there was a more even distributhmn tn
the last opening of the cases. This difference was to be ex-
pected since the same group is being observed on a longitudinal
basis as is also the fact that the number or children eight
years old had the highest incidence of cases. When the first
and last openings were compared, the higher proportion of
cases occurred in the "latency period," a time span of approxi-
mately five years in which the child is “at rest" after the
' stormy confusing years in which he has supposedly resolved the
problems of socialization and identification in terms of both
ego development and sexual identification. English and Pearson
consider the latency period to exist from age "six to eleven
and adolescence from.eleven on."6 At the last opening a slightly

higher preportion ocurred in the adolescent period which, in

WA A

65. Spurgeon English, H.D. and Gerald H. J. Pearson,
Emotional Problems of Living (New York: s. w. Norton and
Company,;ihc., 1945), pp. 133-270.

28
our culture, is generally accepted as a time of moodiness,
high aspirations, restlessness, and fluctuating degrees of
self confidence.

Children in the latency and adolescent periods were
also in the majority in Brown's study.

Since it is recognized that the stability of the home
has a profound influence on children's sense of well being or
their lack of it some consideration was given to the marital
status or the parents involved in this study. Twenty-one of

he children had parents who were married and living together
and mung this group there were no remarriages. Fifteen child-
ren had divorced parents but in four instances the mother had
remarried. Two children had only one parent because their
fathers had died. These are instances of complete separation
of parents which is only one criterion of the stability of

the home. Such a criterion only indicates those cases where
the marriage partners have felt for their own reasons, that
their*marriage should be ended. It does not indicate in any
way the relationship of those who have not separated. It is
significant to note that with the four instances of remarriage
following a divorce there are twenty—five children who have
two parent figures in their homes. This is approximately a
two to one ratio; (25-13) that is, there are almost twice as
many children who have two parent figures than there are
children who have only one. How this is reflected, if at all,
on the children's problems will be noted later under the dis-

cussion of “referral problems.“ A relatively significant

29

correlation is expected between the happiness of children and
the marital happiness of their parents. Terman suggests that
there are two reasons for such a correlation:

(l) The probability that happy temperaments are in

part a matter of heredity, and (c) the equally strong

probability that long exposure of the child to an

atmosphere Charged with tension and conflict between

parents conditions the immature personality in any?

anion mane any kind of socialadJustment oiillcult.

It would appear that Brush found more family disinte-
gration than could be ascertained in tne case records of the
reopened cases in 1952.

he area which the Flint Child Guidance Clinic serves
is primarily urban and highly industrialised because in Flint,
the hub of this service area, tnere are tao large factories
manufacturing Buick and Chevrolet automobiles. Therefore, in
such a community it is assumed that a major portion of the
working population will be employed by industry and they will
be "factory workers."

In our study group there is a high represnntation of

.8

O
"factory workers, as fifteen of those employed classified

themselves as such. There was no specification of degrees of
"skill“ or titles applied to their Jobs. Fifteen “factory

workers" is a high percentage of our study group as there were
only thirty-four cases in which occupations of parent was cone

sidered since four children were living in a small institution.

7Lewis H. Terman, Paul Buttenwieser, Leond N. Ferguson,
Winifred Bent J hnson, and Donald P. Wilson, Psychological
Agactors in Marital Happiness (New York: McGras:Hill.Book 60.,
1938), g. 32.

Factory worker designates that the parent is a skilled
or semi-skilled worker in an industrial plant.

30
In seven cases it was indicated that both parents were employed;
however, this fact was not specifically covered on the face
sheets or other material which was examindd so the actual nuns
ber of cases in which both parents were employed was not deter-
ldned. In general the occupations of the income earners were
those that would Place them in the middle class income brackets.
The following table shows a slight decrease in white collar Jobs.

TABLE 2

OCCUPATIONS 0P IRCOHEmEARNER AT TIME OP’ORIGINAL
OPENING AND REOPENING 0F TREATMENT CASES

 

 

 

 

=3:==:: i L Y i,
Occupation Original Opening Reopening
Total 33 33
Factory 15 15
"White Collared" Jobs 9 7
Other 9 10
unknown 5 6

In similar’manner the Brown's study demonstrated the
high incidence of referrals of children of factory workers.

The answer to the question of “who sought help for
these children" showed that the peeple who were closest by
association to the child or are engaged in children's work
either advised the parent to refer the children, or referred
directly to the clinic. Mothers had the highest number of

referrals at the original opening in that thare were fourteen.

31
In onlv five cases were the fathers involved and only one re-
quest for service was made by a father without a mother. The
number of parents who applied to the clinic at the last re-
opening of the cases increased from.fcurteen to twenty~slx
cases which means that twelve ”re-referrals“ still came from
outside th home situation. This is shown in the following
table.
TABLE 3

REFERRAL SOURCES AT‘ORIGINAL OPENINGS
AKD REUPENING OF TREATMENT CASES

 

 

 

Source Original Opening Reopening
Total 38 38
Parents 14 26
SCI-300.1. 10 7
Agency 8 3
Lther 6 2

W M

 

Since it is believed that treatment will be more effective if
the persons involved see a need for it this may indicate that
in twelve cases a need was recognised which formerly was un-
recognized or at least they now knew where to take their prob-
lems. The other sources of referral «are social agencies,
schools, and physicians. Teachers were the second highest
source of referrals in both the original and the last opening.
Actually their influence in getting the pareut(s) to make

application doubtlessly makes them a larger source of intake

32

than the numbers indicate in that they really are the initiator
of the request. It is clinic policy to encourage the schools
to suggest that the parents refer themselves to the clinic.
Such a policy'may decrease the number of school referrals.
"School referrals to the Worcester Clinic were said to have
declined because the staff often suggested that teachers re-
quest mothers to make direct referrals.'9

Brown also found that the parents and agencies tended
to be the usual source of referral and that when cases were
reopened it was usually the parents who initiated the contact.

Among the thirty-eight reopened cases there mere three
cases that were referred primarily for “testing only“ because
of suspected retardation and the attendant learning difficul—
ties. They were reclassified as diagnoses and treatment cases
when it appeared that an emotional problem.uas predominant to
the extent that it was impairing he otherwise adequate intel-
lectual capacity. The remaining thirty-five cases were referred
because of behavior problems that indicated, to the referral
source, an unusual degree of emotional stress.

The Flint Clinic uses the State Department of'Mental

Health code of classifying referral problems or reasons.lu

* A .- AH L

9”A Children’s Clinic as a State Heepital Contribution
to the Community,“ Bulletin of the Massachusetts Department of
Mental Diseases, XI, p. 4- , quoted by Helen sitmer in Ps‘chia~
tric Clinics tor Children New York: The Commonwealth Fahd,
1940}. pp. 4544153.

10Michigan State Department of Mental Health, Code for

I‘ I“: " ‘ ‘ A - i‘z :2 r 6' '~ ‘ . , x7
lasiif+lnginelerril Freeland.

33

There are four general classifications: Conduct Disorders,
Habit Disorders, Personality Problems, and Learning and Devol-
ogment Problems. The behavior problems of all the children
referred to clinics usually can be most aptly described by
one of the four classifications although the children were
manifesting symptoms which also might be included under other
classifications. Behavior problems are described by the
classification which most characteristically fits them. The
problem behavior covered by those descriptive headings in
listed below.11

Referral Problems

Conduct Disorders
Truancy
Stealing
Defiance
Running; Away
Overly Aggressive
Sex Offenses *
Destructive
Negativism
Lying
Fire Setting
Sibling Rivalry

Habit Disorders
Stuttering
Nail Biting
Scratcning and Flashing of the self
Hyperactivity
Enuresis
Feeding Problems

Personality Problems
Withdrawal
Depression
Anxiety
Inferiority
Suicidal
Fearful

llibid.

34‘s

4 -- «he 'I {W}? n
a. 13 a. in DCVCJJOJm : Again. bLUJ--C:nU

Slowness in academic learning
SHCCifiC SUbJGCt dLGJbilit C5
Mental retardation

Slow development

:J

A ’3

At the end of the diagnostic gerlod the referral
reasons for tnc original opening and last opening were tab-

ulated in the following manner.

 

 

 

TABLE 4
REFERRAL REASONS OF TREA'IWENT CASES
Reason Original Opening Reopening
.Total 38 38
Conduct Disorders 18 21
Personality
Problems 1% 9
Learning and
Development 4 2
Habit Disorders 2

W

A noteworthy fact 13 that in botho Mp dings tb e mmst
frequent referral reason is in the catenory of conduct d13-
ordere, and that the number of such referrals increased
rather than decreased at the last opening. It might be
assumed that such diagnosis would predominate as long as
there were more children in the latency and adolescent etagea

of development. It may also be due to the fact that the prob-

lem is not only the child’s problem but a problem of the

35
people around him. Does the “problem child” conetitute the

largest proportion of referrals to clinics for emotionally
disturbed children? This is only nidly eugguted by the few
cases surveyed in this study since there in no difference in
the amber of referrals for “conduct disorders" compared to
the number for "personality proble‘nc'.‘

In 1951: it was found that conduct disorder: also were
the major cause of both the initial referral and the morn-
ing. however, in 1952 there were far fewer learning problems
than in 19514. '

The stated reason: for originally closing the thirty-
eight cases indicated that five were cloned because of in-
provenent, six were referred to another agency. really Ber-
vice or a Children's Institution, three had required only con-
sultation, seven actually received teetins services only and
did not complete the diagnostic sequence even though it seemed
indicated, one was closed after diagnosis, eight were closed
because of untreatability and eight were closed because of
uncoomrativeneac. Sixteen of the twenty-one treatment cases
were closed because of untreatability and uncooperativeneu
whereas impmvmnt was statedin only five cases. It been
reasonable then to conclude that the prognoeie for the case-
tumed uncooperative and untreatable would be unfavorable 3
that it is probable that the clients may continue to be upset
by the symptom and may therefore reapply to the clinic.
Therefore. lone degree of predictability as to who will re-

apply may be possible.

36

The stated reasons for the last closing of these cases'
indicated that four had improved, eleven were not treatable,
ten were not oooperative,five were referred to another agency,
three received ”consultation" only, one was referred for
"testing only," and four were closed because further clinic
service was not indicated. The latter statements referred to
four cases in which a combination of environmental manipula-
tion and consultation had affected a sufficient change in they
child's life situation to enable hau,to:lake a satisfactory
adjustment. There was some question on the part of the writer
as to why these cases were not termed "improved" but the dif-
ferences were not explained satisfactorily. A pattern is
evident when the original and last closing statements are
compared in that the ”not treatable" and "not cooperative" rea-
sons for closing the cases are in a decided.maJority. A comp

parison of the initial and last closures is shown in Table 5.

TABLE 5
DISPOSITION or mantras cases

 

—T

w —

 

 

Initial Last

Disposition Closure Closure
Total 38 38
Progress 3 a
Consultation Only 4
Lack of Cooperation 23 21
Referred another agency 6 5

Further service not

indicated 0 u

 

37
Twenty-one of twenty—five “treatment cases” were closed for
those reasons leaving only four cases that were closed be~
cause of "improvement." Many of the so called "treatment
cases" were never involved in treatment interviews but are
termed treatment cases because treatment was indicated and
recommended to them" Only seventeen cases were actually in-
volved in weekly interviews.

Because of inconsistent tabulation of the reasons for
closings it was impossible to compare the 1952 and 195h sit~
uations.

The average length of time cases were originally Open
for either treatment or diagnosis was four months with the
longest opening being for twelve months and the shortest one
month. The average length of time of service for the last
opening was approximately six.months with the longest open-
ing being twenty-four months and the shortest two months.
Those cases in which improvement was noted were open for an
average or fourteen.months.

The length of time between the first closing and the
reopening ranged from one month to five years with an average
ofapproximately twenty’months between closing and reopening.
The distribution is scattered as Table 6 shows ..

Brown found the longest time between openings was
eighty-four months with an average of twenty-five and ono~
half months.

In the initial closing there were nine cases referred

to other agencies and three of these were referred to two

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37

reatment cases” were closed for

Twentybone of twenty—five
those reasons leaving only four cases that were closed be~
cause of "improvement." Many of the so called "treatment
cases" were never involved in treatment interviews but are
termed treatment cases because treatment was indicated and
recommended to them, Only seventeen cases were actually in--
volvcd in weekly interviews.

Because of inconsistent tabulation of the reasons for
closings it was impossible to compare the 1952 and 195h sit-
nations.

The average length of time cases were originally open
for either treatment or diagnosis was four months with the
longest opening being for twelve months and the shortest one
month. The average length of time of service for the last
opening was approximately simeonths with the longest Open-
ing being twenty—four months and the shortest two months.
Those cases in which improvement was noted were open for an
average of fourteen.months.

The length of time between the first closing and the
reopening ranged from.one month to five years with an average
ofapproximately twenty’months between closing and reopening.
The distribution is scattered as lgble 6 shows.

Brown found the longest time between openings was
eighty-four months with an average of twenty-five and one-
half months .

In the initial closing there were nine cases referred

to other agencies and three of these were referred to two

38

agencies at separate times. Five of the nine referrals were
made to the F mily Service Agency and one of these resulted
in a subsequent referral to the outpatient clinic at Pontiac.
Other referrals were made to the Neuro~Psychiatric Institute
at Ann Arbor, the Juvenile Court, a children's institution
and the Association of Parents of Mentally Retarded Children.
The two referrals to the children's institution involved
direct placement but the other three were referred to deter-
mine the possibility of placement. Placement, then, was con-
sidered the most beneficial change for five of thirty-eight
children, however, placement might have been considered in
more than those five cases if there were more possibilities
for placement.

TABLE 6

LENGTH OF TIME BETWEEN CLOSING AND REQPENIfiG
OF TREATMENT CASES

Tim number or cases

Total 38

Less than 6 months

6'months less than 12 months
12 months less than 18 months
18 months less hen 2% month:
24 months less than 36 months
6 months less than 48 months
8 or'more

1 not determined

HMk‘OHt‘l

Of the thirty-eight cases, thirty-two were re-opened
once, five were re-opened twice, and one was re-cpened three

times.

39
Twelve children were retarded in school, two were in a

specialized education room and five were not in school at all.
or the last group three were diagnosed as mentally retarded,
one tenninated school when he was sixteen and one had been
expelled for creating a disturbance in school. Thus, there
was a total of nineteen children who were not perfonling sat-
isfactorily in school. Half of the study group were experi~
encing some difficulties in school. Five of these, however,
were intellectually limited and could not be expected to func-
tion in the usual classroom.

As stated before there were only seventeen cases in
which treatment interviews were conducted upon their re-
opening. or these eight were treatment cases involving both
mother and child, as siz.children were treated alone and
three mothers came for treatment without their children. At
the original opening the number of mother and child treatment
cases was the same as at reopening but some children were seen
for treatment at the reapening for whom treatment had not been
previously considered. For eight cases the same persons were
involved in treatment.

The treatment goals in those nine cases where only the
mother or only the child was treated are an issue to be ques-
tioned in.terms of Whether or not psychotherapeutic aims are
met. Psychotherapy cannot supply ‘real" parental relation-
ships; it is a special technique applied within the living
experience, but not as a substitute. It arms to strengthen

the person's ability to deal with real life situations,

40
helping him to meet his own basic needs, both economic and
affectional. Psychotherapy is designed to affect the total
functioning of the personality. According to Dr. Nathan
Ackenman it means a person to person relationship, with pro-
gressive exposure and dissolution of the pathological patterns
of defense. It attempts to relieve the handling of resistance
”Chm-118mg e
Concealed fears, hates and blunted pleasures must
be exposed and the true self be given the opportunity
to assert itself. The patient must be sufficiently
freed from fears to participate in satisfying new
experiences. The corollary is that in child guidance
satisfying and constructive opportunities for new
ggperiences in the family and in societg must Be made
available, and the whole process mus therapeu-
tically conditioned.12
It is questionable whether or not the six children seen alone
will have the 'new experiences in the family and in society,“
however, it would be well to know what the problems of the six
children were before concluding they could not derive any
therapeutic benefit from being seen at the clinic. It would
be interesting, therefore, to know what the clinic hoped to
do for these children.
This chapter has shown that there is a trend suggested
by the characteristics of cases reopened in 1952 and 1954.
The similarities are as follows:
In both years “Testing Only“ cases comprised two-
fifths of the reopened cases. Also, there was only a very

limited number of reapplications made by Negroes, Catholics,

and Jewish peOple found in both studies. The youngest or

12Gordon Hamilton, Ps chothera in Child Guidance
(new York: Columbia Univ. Press, 1936;, (CEp. V1.5, pp.123-4.

 

Ml

oldest child in the sibling order was referred more than the
second, third, or fourth child in both studies. The majority
of the children referred were primarily in the latency to
adolescent period. ”Conduct Disorders” as a reason for re-
ferral were in the majority at both the initial opening and
reo;ening. “Factory workers“ predominated as the occupation
of the head of the household in both studies.

There were a few dissimilarities noted; namely'Brown's
study indicated a higher degree of fomilyxflsintegration, and

that learning problems were more prevalent;

CHAPTER V
SUMMARY AND CONCLUSIONS
Summary

This study concerns “An Exploratory Investigation of
Cases Reopened at the Flint Child Guidance Clinic in 1952."
Questions were asked and working hypotheses were formulated
to ascertain what characteristics, if any, were peculiar to
the reopened case. Perhaps if certain features seem to be
characteristic of the reopened case it might then be possible
to predict and prevent some duplication of effort required in
regrocessing a case.

Since the client's degree of motivation for seeking
help is essential in his ability to receive it and utilize it

the question ‘

'who requested the reopening of the case?" was
asked. The answer was interesting, especially when compared
to the source of the original referral of the child to the
clinic. It was found that on the original referral fourteen
mothers had contacted the clinic whereas the second chief
source of referrals was the schools which had made nine.
Physicians, social agencies, and court authorities were the
other sources of referrals. In only five of the fourteen
referrals made by the mothers were the fathers involved, that
is, the men came with their wives and children to the clinic.

’3

p.
f

43
Upon the reopening, the number of referrals made by mothers
increased to twenty-sixe—an increase of twelve. The schools
were still second in number of referrals but because it is
clinic policy to encourage the school authorities to recan-
mend that the parents make their own referrals it was believed
that their influence was greater than might be indicated by
the source of referrals. The number of referrals made by
physicians, social agencies, and the court diminished propor-

H

tionately. In fact these three sources of referrals contri-
buted the increase to the parent referrals as those from.tho
school remained constant. Since it in clinic policy to on-
courage all agencies to recommend that the parents rotor
their child the question of who referred the child become-
less an index of’motivation than one of attaining involvement.
The increase in parent referrals, which almost doubled those‘
at the original Opening, is rather remarkable if it really
indicated an increased feeling of involvement in twelve
parents.

Another aspect of the reopened case that was investi-
gated was the question ”Will the same persons be involved,
mother and child for instance?" In eight cases the same per-
sons were seen for treatment, that is both mother and child.
However, the remaining nine cases seen for treatment at the
reopening did not involve the same persons as the treatment
cases of the original opening. In six instances only the

child was seen while three mothers came alone to the clinic

for treatment.

an

The question of the time which elapsed between closing
and reopening was asked primarily to determine_if the periods
sere short enough to indicate that the case had been closed
without sufficient reason. Of course this factor would only
be significant if the clinic had initiated the closure as too
many var ables would exist if the parents had terminated
their visits and therefore the clinic service. However, in
the latter instance the question of elapse time would still
have some application. Would the parent who in actuality
terminated tne clinic's service by abruptly ceasing to come
return as quickly as the parent who in agreement with the
clinic ceased comdng? The average time between closing and re-
opening nas twenty months with the shortest time being one
m nth and the longest being five years. Ten returned within
less than a year, eleven returned in time ranging from twenty-
five months to sixty months.

t is interesting to note that although an average
span of twenty'months existed between the original opening
and reopening the same problems were predominatly' stated in
both instances. iowever, the factor of time/or the previous
contact with the clinic had somewhat affected the nature of
the problems. Conduct disorders and personality problems
constituted the two main reasons for referrals at both the
original Opening and the reopening but personality problems
as a reason for a referral decreased from a total of fourteen
at the original opening to nine at the reopening. This com-

pared to an increase in “Conduct Disorders“ and "Habit

45

“ as referral reasons at the reopening. "Conduct

Disorders
Disorders" referrals increase from.eighteen to twenty-one
while “Habit Disorders" referrals Jumped from two to six. It
is to be wondered what caused this change in stated reasons
for referrals and was this an indication of rregression“ in
those youngsters who were first termed 'Personality Problems"
and then later termed ”Habit Disorders“?
Deviations in the earliest stage of the selfhood

express themselves as habit disorders. If the baby

does not get adequate mothering he is forced back to

his own body for pleasure and attention and the ordi~

nary thumb-sucking, masturbation, and other body play

may be prolonged or intensified as 'autoerotism'-~

extreme physical indulgence having somewhat shmilar

effects. The child thus forced to love himself pro~

longs his infancy, does not outgrow his infantile

habits, which, if not treated, continue as part of the

permanent personality structure.‘
If the reverse had been true, that is a decrease in the
“Habit Disorders” referrals and a corresponding increase in
”Personality Problems“ referrals at the reopening this would
not have been surprising. This is a question which can only
be speculated upon since insufficient detail as to treatment
and diagnosis was available. Another noteworthy fact is the
predominance of “Conduct Disorder“ referrals and their in~
crease at the reopening of the cases. This trend raises the
question of how much “change“ has occurred within the primary

relationships because this disorder ‘will persist only when

lGordon Hamilton, Pslchotherag1;in Child Guidance
(Ned gork: Colwmbia University Press, i947), (Chapter’II),
Pp. 2 27o

 

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46

there are severe parental frustrations, harshness, or lack of
love for the child."2
The above observation becomes more meaningful when it
is considered that only seventeen cases had been involved in
treatment interviews and at the reopening not even the same
persons were seen as was discussed earlier in this chapter.
The service that was given at both the original opening and
the reopening was primarily diagnostic. In twenty-five in-
stances treatment was recommended but for eight children
treatment never eventuated while nine referrals were termin-
ated after diagnosis because of referrals to other agencies
or "consultation only" was sufficient. Thirty-one of the
sixtybnine cases reopened in 1952 were for "testing only."
So in summation the service that was given to these sixty-
nine cases was: "testing only" for thirty-one cases, diagno-

sis and treatment for seventeen cases, and diagnosis only for

twenty—one cases.
Conclusions

It was hypothesized at the start of this study that
when initial treatment has not included both the child and
his parents, it is more likely that there will be need for
"reopening" than when both parents and child have been in-
cluded in the treatment services. There were only seventeen

treatment cases and of these eight included both child and

_.__ *

2£b1de 3 Do 290

47
parent and nine involved only one of the two persons. If
this could be extended by induction it.might be said that the
results or this study tend to negate the hypothesis but this
is not conclusive evidence owing to the small number of treat-
ment cases. A.much larger number of treatment cases would be
necessary before a valid comparison could be made on which to
base a conclusion having any general application.

The results of this study, inconclusive as they are,
tend tO'make one wonder if the inclusion of both child and
parent in treatment is the crucial issue in reopened cases
because of other characteristics peculiar to then. The length
and regularity of treatment for instance might have s more
direct bearing on the likelihood of a case being reopened.
This was stated as an hypothesis as follows: Cases carried
on a continuous casework treatment basis are less likely to
be reapened that those which have received only intermittent
service. The study tends to substantiate the hypothesis in
that only seventeen original treatment cases were reopened.
However, there are too many questions unanswered, to state
that"continuous casework treatment" will decrease the number
of reapened cases. For instance it is now known that many of
the reapened cases were better served by diagnosis, consulta-
tion or a referral to another social agency and so when this
is considered one wonders if this study only indicates that
fewer oases required treatment as compared to the other services
or the clinic. The hypothesis would be supported more fully

it it could be shown that cases carried on a "continuous

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48

treatment" basis were in a minority when compared to those
cases needing but not receiving treatment for different reasons.
However, this information has not been demonstrated. Another
questionable part of the hypothesis was the arbitrary use of
the term.”continuous“ in that it placed treatment cases in
two categories; those on a “continuous" basis as opposed to
those not on a ”continuous" basis, and no definition of the
distinguishing term was given. Since the hypothesis was form-
ulated to test the belief that fewer treatment cases would be
reopened if the treatment were of sufficient regularity and
length of’time to affect improvement or change it should be
restated to include those qualifications. It would read as
follows: Fewer treatment cases will be reopened if the treat~
ment interviews are of sufficient regularity and duration to
effect improvement or change. This implies that the therapist
and the patient tenminate the treatment process since improve-
ment or change is stated as a condition. The converse situa-
tion, that is, the treatment was terminated by the client
alone,existed in the treatment cases of this study. Several
were closed because of "failure to keep appointments" and un-
treatability" within a four month period. In actuality they
were "treatment cases“ in name only as treatment can not exist
if there is no utilization of it.

The third hypothesis stated that it is believed that
the largest single category of reOpened cases is "Psychological
Testing Only." This was supported by the fact that of the

sixty-nine cases thirtyoone were referred for “testing only“;

49
a figure close to two-fifths of the total number of reopened
cases.

The number of reopened cases in 1952 closely.paralleled
the number of reopened cases in 1954. There were seventy-four
reopened cases that year. five more than in 1952. Also. the
number of “testing only" cases in 1954 coincided with the
number of such cases in 1952--twenty~eight to thirty-one.

This similarity for the two years indicates a pattern of the
probability of cases returned to the clinic. There is no
control over the number of referrals made to the clinic and
generally the referrals are scheduled for a diagnostic evalua-
tion in the orderofthe date the clinic was contacted. So
assuming there is little control over the referrals made to
the clinic and the subsequent reopening of cases there then
must be other selective factors contributing to the shmilarity
in numbers for those two years.

A comparison of the facts found in 1952 and 1954
revealed other shmilarities such as the increase in referrals
from.parents at the reopening. The parent referrals at re-
ppening almost doubled thosecf the original opening in 1954
which is greater increase than occurred in 1952 but still in-
dicating the same trend. Here significant perhaps is the
shmilarity in the predominant complaint at both the original
opening and reopening for both years. “Conduct Disorders"
were the referral problem.in the majority of cases at both
openings in 1952 and 1954. There was also an increase at the

reopening in the number of "Conduct Disorders" referrals for

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50

the two years. So it seemed that during 1952 and 1954 the
majority of the cases were returning with the same problem.
It is to be noted also that there was a similarity in the
relatively low number of cases involved in continuous treat-
ment interviews, which factor in itself tends to point to a
cause for the unresolved problem” Again it might be asked,
"What kind of help did the parents want and how radically dif-
ferent was the help offered?" "Could the parents have been
treated more effectively"? Of course there are many other
factors to be considered. One might speculate on the fact
that aggressive, mean, acting-out children represented the
highest number of referrals in reopened cases for the two
years. It seems significant to note that in the initial
referral, as well as in the reopening, conduct disorders are
in the majority. Why is this so? What are the distinctive
differences in the problem.of adjustment for those children
and their parents that they should ask for help and not get
it or use it? Is it the nature of the problem--the kinds of
parents and children, the skills of the staff, or isit a
combination of all these factors? Further clarification is
needed in this area.

It would be helpful if further study might also be
done in establishing whether the trends which the writer has
observed might be consistent over the past decade. It might
also be helpful if comprehensive research.might be done con-

cerning the diagnostic aspects as well as the treatment

51
provided to determine the differential factors between cases
which return for future service and those which do not re-
apply.

In conclusion, the writer has dcmcnstrated:

1. That about two-fifths of the reopened cases are
for "Testing Only."

2. That there is a consistent picture of more boys
of the latency and adolescent periods referred to the clinic,
and there are few Catholics and Negroes re-referred and that
the oldest and youngest child seem to predominate in re-
referrals.

3. That parents usually make the greatest number of
referrals and that "conduct disorders" were the prhmary
reasons were also substantiated. However, the writer found
that in the Brown study there seemed to be a trend of greater
learning problems than in the reopened cases of 1952.

The writer could not conclusively prove that the
factors of "continuous treatment" status or parent and child
participation in treatment were significant in the reopened

cases of the year 1952 or 1954.

BIBLIOGRAPHY

Books

English, 0. Spurgeon and Pearson, Gerald H. J. Emotional
Problems of Living. New York: w. W. Norton and
Company, Inc., 1945.

Hamilton, Gordon. Psycholotherap in Child Guidance. New
York: Columbia university ress, 1947.

Harms, Ernest. "Organization of a Child Guidance Clinic,"
Handbook of Child Guidance. New YOrk: Child Care
Publications, 19fi7.

Lowrey, Lawson G. "The Child Guidance Clinic," Childhood
Education. Vol. 1 (l92fl) Columbia University Press.

Stevenson, George S. and Smith, Geddes. Child Guidance
Clinics: A Quarter Century of Development, New York:
The Commonwealth.Fund, 1934.

Articles

Hochwald, Hilde Landenberger. "The Use of Case Records in
Reseagch," Social Casework (V01. XXIII February 1952),
PP. 7 0

Hollis, Florence. "The Relationship Between Psychosocial
Diagnosis and Treatment," Social Casework, February
1951: PP. 81-87.

Platt, Clarice. "Termination Planning in a Child Guidance
Clinic,“ Journal of Psychiatric Social Work (Vol. XXI,
March 1952), p._125. fi'fifi

Rose, John A., H.D. "Relation of Therapy to Reality in
Parental Connection with Children," Journal of Ortho«
s chiatr , April 1949, pp. 351-356.

Reports

Michigan Department of’Hental Health. "Differential Utiliza-
tion of the Facilities of afllichigan Child Guidance
Clinic," Research Report No. 17, March, 1955.

52

53

Unpublished Material

Brown, Dennis. “The Nature and Description of Cases Reopened
in the Flint Child Guidance Clinic.“ Unpublished
Master's thesis, University of Michigan School of
Social Work, Univers ty of Michigan, 1955.

I.

II.

AP PEI-{DIX

Schedule

Testing only cases

1.
2.

i:

5.

Case number

Sex

Age when first tested
Age when last tested
Number of times tested

Diagnosis and Treatment Cases

1.
2.

15.
16.

l .
l .
19.

Case number

Sex

Religion

Rate

Number of siblings

Place in sibling order

laximum age at original opening and reOpening
Minimum age at original opening and reOpening
Average age at original opening and reopening
Marital status of parents at original opening and
reopening

Occupation of head of household at time of opening
and reopening

Referral source at thme of opening and reopening
Referrals reasons at Opening and reopening
Referal problemszm opening and reopening
Disposition and reasons for closing at original
opening and reOpening

Length of time open for treatment at original opening
and reopening

Length of time betueen closing and reopening
Reasons forclosing and who initiated same

Number of reopened cases taken on for treatment
a. Parent(3)

b. Child

C. Other

Referrals to other agency

Number of time cases were reopened

Grade at time of first and last referral

 

 

 

 
 
  
    

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