coveries and eventually decreasing the incidence of insanity and psychoneuroses.

II. NEED OF A NEWER METHOD OF APPROACH TO PROBLEM

While it is true that social service, as at present organized, functions most satisfactorily with cases of manic depressive insanity, it must be recognized that psychiatric social work has been largely limited to treating and caring for acute, chronic and occasionally borderline cases, and that the much broader field of prevention has in the main been neglected. Why this should be so is quite understandable. The attention of the public, of the legislatures, and of physicians has been absorbed in providing suitable places of confinement for those who have already shown symptoms of mental disease; and, as has been repeatedly pointed out, even this phase of the problem is still far from being adequately met.

During the past few years, particularly since the development of the mental hygiene movement, it has become more and more apparent that one of the chief reasons for the low percentage of recovery and improvement has been the circumstance that those ailing mentally are not reached soon enough either by mental hygiene clinics or by the state hospitals. Only in cases of acute attacks are the patients given early care and treatment; where the onset of the disease is gradual and spread over weeks or months, the patient too often comes to the attention of the specialist in mental diseases when nothing but state hospital care can be recommended.

The implications of these facts are obvious, and if we are to achieve greater success in helping those who are headed towards the state hospital for the insane, we must begin to attack the problem in a different way. Maintaining clinics for the mentally sick, psychiatric social work, state hospitals for the insane, psychopathic hospitals, and

other agencies that are called upon to help meet the problems that arise, are one and all essential in a program aiming to conserve the mental health of a community. But the goal to be sought by all who are interested in the problem of insanity should be a gradual decrease in the number of persons whom it is found necessary to commit to state hospitals and similar institutions. Instead of striving to obtain larger and still larger appropriations for additional state hospital accommodations, as is unfortunately being done at the present time, ordinary prudence would indicate that some other or additional action was necessary to limit the ever increasing need to maintain in comparative indolence thousands of persons who have or will become mentally ill.

III. MENTAL HYGIENE AND CHILDHOOD

From the point of view of mental hygiene, individuals may be said to fall into one of the following groups: (a) those now sane, and who will remain sane except through the working of some exogenous factor; (b) those now sane, but who will become insane under certain conditions; (c) those now insane; (d) those who have been insane but who are now recovered and have returned to the community. To this might be added a fifth group those yet unborn.1 From this it is seen that those who belong to the first two groups, whether children or adults, may, under certain unfavorable conditions, come in time to be a part of groups (c) and (d). Our chief problem is how to prevent this from coming about, particularly insofar as the children are concerned.

1

Students of psychiatry have come to realize more and more that the patients whom they have observed in hos

1 Williams, Frankwood E., " Psychopathic Hospitals and Prophylaxis," Boston Med, and Surg. Jaur., June 24, 1915, p. 933.

pitals for the insane and elsewhere were in need of special study and care as children, and that it was the duty of society to have discovered their special needs and to have given them the attention which their future welfare demanded.1 Viewing the matter from the basis of our present knowledge, we may be inclined to forgive the failings of a generation ago, though an enlightened public opinion is to-day demanding that preventive measures be taken early enough in the lives of children to discover and when possible to correct, faulty habits of mind and action which in later life may result in the development of some neurosis or psychosis. A program which would show definite results would of necessity have to concern itself with children of a very early age. A plan prepared by Prof. Arnold Gesell of Yale University for the complete examination of children includes the following measures, which would be particularly applicable to a large city, though likewise adjustable to rural and village conditions: "

(a) A hygienic supervision of the pre-school period. This to result in a cumulative biographic record of every child from birth registration to school entrance.

(b) A psycho-physical entrance examination of every school beginner. This examination should be comprehensive, thoroughgoing and in close cooperation with parent or guardian; it should also summarize the main conclusions from the pre-school career of the child and disclose those children either superior or atypical who most urgently need a specialized school career.

(c) A reorganization of the kindergarten and first year, which will place the first half year of school life under systematic, purposeful observation.

1 Yerkes, Robert M., "How We May Discover Children Who Need Special Care," Mental Hygiene, April, 1917, p. 252.

• Gesell, Arnold, "Mental Hygiene and the Public School," Mental Hygiene, Jan., 1919, pp. 4-10.

(d) The development of a new type of school nurse, who by supervision, corrective teaching, and home visiting, will further the concrete everyday tasks of mental hygiene. Her problems would be children with night terrors, the nail biter, the over tearful child, the over silent child, the stammering child, the extremely indifferent child, the pervert, the infantile child, the unstable choreic, and a whole host of suffering, frustrated and unhealthily constituted growing minds, that we are barely aware of in a quantitative sense, because we do not have the agencies to bring them to our attention as problems of public hygiene and prophylaxis.

of

(e) The development of reconstruction schools, special classes and vacation camps for certain groups of children who need specialized treatment, such as the speech defective, psychopathic and nervous groups. To such schools, classes and camps, children could be assigned for long or short periods, and secure a combination of medical and educational treatment which alone is adequate to reconstruct them mentally. These provisions imply neurological and psychiatric specialists, educational psychologists and teacher-nurses, cooperating as public health experts in a work of mental salvage and prophylaxis.

Only by such radical and sincere methods can we ever hope to reduce the massive burden of adult insanity. Expensive in the beginning, a preventive juvenile system of mental sanitation may after all prove to be a form of socialized thrift.

IV. MENTAL HYGIENE AND ADOLESCENCE

Adolescence is generally recognized as a critical period in the mental life of the individual. Not only is it a period during which disorders are very apt to develop, but it is also a time when the mental balance of probably every boy and

girl is disturbed to a greater or lesser degree. In fact, many of the breaks, perhaps most of them, occur in the adolescent period or the period of early adulthood.' The disturbance is shown in a variety of ways, as for example, by a tendency to become irritable and discontented or to indulge in daydreams and romantic fancies. The changes in behavior and disposition which young people display at that time frequently make them difficult to deal with and cause a great deal of trouble and worry to those who are responsible for their care and upbringing.

Emphasis has already been placed upon the need for the early recognition of latent or active mental disorders; and upon the fact that approximately sixty per cent of the patients in the state hospitals in New York State have been diagnosed as cases of dementia praecox, with a history, following the age of puberty, of inability for healthy mental adjustment. In these patients, the inability to adjust themselves resulted in unwholesome habits of thought and conduct, in bad sexual practices or antisocial acts, and in certain types of mental reactions usually regarded as manifestations of mental disease.

In preventing the development of these unhealthy types of mental adjustment during the adolescent period, there is a very important field of work and one in which very little has as yet been done. There are few boys or girls who would not be the better for some assistance and guidance during the adolescent period. There are many with whom it would make all the difference between becoming useful members of society and permanent inmates of institutions. The time to deal with these disorders and difficulties of adjustment is just as soon as they appear, though the pre

1 White, William A., "Childhood: the Golden Period for Mental Hygiene," Mental Hygiene, Apr., 1920, p. 266.