The pre-school child from the standpoint of public hygiene and education 1923

Front matter

RIVERSIDE TEXTBOOKS IN EDUCATION

EDITED BY ELLWOOD P. CUBBERLEY.

PROFESSOR OF EDUCATION LELAND STANFORD JUNIOR UNIVERSITY ©

Preface

Tux pre-school period of childhood was, a very few years ago, called the “No Man’s Land” in the field of social endeavor. Recent literature contains frequent reference to “the neglected pre-school years,” and “the gap” between the infant welfare and the school age. Child-welfare provisions, public-health activities, and social legislation have hitherto shown a tendency to slight the pre-school years, or to entrust them to the home — and to Providence. Scientific investigation has reflected a similar tendency, and we know less about the capacities, developmental needs, and norms of children of pre-school age than of any other period of growth. It has proved more convenient to study children of school age. The toddler and runabout, in comparison, have been much less accessible for investigation. It is remarkable how little we really know about them.

Our whole outlook upon the pre-school period is undergoing rapid and significant changes. The famous Fisher Education Act of 1918, passed by a Parliament not given to fads, confers upon local educational authorities power to establish nursery schools for children over two and under five years of age. The stamina of England as a nation and the health of her children are the goal of the new nursery-school movement. It has even been suggested that the nursery x PREFACE school must become the foundation of the English system of education and health administration. Sir Arthur Newsholme, late principal medical officer in England, observes that the chief value of medical inspection of school children has been to demonstrate the extent to which children of school age are suffering from defects and disease which might have been prevented or minimized by attention to the pre-school period. From the standpoint of public health, the pre-school child is coming into a new and revealing perspective.

From the broad standpoint of education, or of mental hygiene, the significance of pre-school childhood is likewise receiving a new emphasis. Dynamic psychology, the behaviorist approach to the study of human conduct, and the genetic interpretations of recent psychiatry, all serve to accentuate the basic importance of the pre-school years of mental development. Social workers and visiting nurses in the active field of child and family welfare are coming to a new realization of the educational aspects of sanitation and of physical hygiene.

Although the first requisite still is to be “a good animal,” it is almost impossible to confine a discussion of the welfare of the pre-school child to such substantial items as weight, diet, teeth, rickets, adenoids, and diphtherm. They are of prime importance, and our first solicitude should be, as it has proved to be, the physique of the child; but the child cannot even become a goed animal unless he is wholesomely trained

PREFACE | xi and organized through mental and motor habits. He must be properly domesticated! Herein he lies at the mercy of his parents, for his more intimate personal hygiene must be attained through his parents. This whole problem of adequate domestic training profoundly involves educational issues touching both parents and child alike. It is not surprising, therefore, that there are many signs on the social horizon which show a steady drift toward bringing the pre-school period more completely under educational control.

Partly as a reflex of the World War, but fundamentally as a result of the peculiar social status of the pre-school child, this field of social endeavor is now in an extraordinary state of ferment and formativeness. Because of the diversity of the agencies concerned, and because of the many-sided interests and tendencies displayed, it seemed profitable to undertake a comprehensive survey of the problems of the pre-school child from the standpoint of public hygiene and of education. ‘This brief volume attempts an inventory and interpretation of the situation, with the hope that the reader will be guided in making his own estimates. Since the achievements in the field of socialized pre-school hygiene, when judged by the future, are as yet relatively small and uncoérdinated, the author has used such auxiliaries as “‘will,’’ “should,” and “may” perhaps more freely than would otherwise be tolerable. He may also have fallen into occasional prophecies and hortatives, but trusts that he has not underestimated either accomplishments or. obstacles to accomplishment.

xii PREFACE

The scope of the present volume is indicated by the sub-title and the table of contents. The significance of the pre-school period is discussed in Chapter I, with reference to its general biological, medical, educational, and administrative aspects.

Chapter II is a summary statement of current agencies and tendencies in the administration of pre-school hygiene. The pre-war status of infant welfare and child hygiene, and their development during and immediately after the War, are considered. Supplementary to this chapter, Appendix D gives a compact description of typical agencies and activities in the field of pre-school hygiene in this country: and in Canada. The list of agencies given in Appendix E will give the student a concrete impression of what is being done for the pre-school child through private and public effort, and will assist him to make some survey of the agencies and activities in his own community. Curiously enough, kindergarten and _ elementary-school teachers are not accustomed to receive, as part of their professional training, any introduction to the non-academic problems of child welfare which are so vitally related to the task and outlook of the teacher. The concrete material here presented may furnish a glimpse in the right direction.

Because of their importance and interest, a special chapter has been devoted to nurseries and nursery schools. The present status of the kindergarten is discussed in Chapter IV. The kindergarten is considered not only as a sub-primary educational institu-

PREFACE xiii tion, but as a health-promoting and social-welfare agency as well. Its relations to problems of school entrance, handicapped children, and parental education are developed in succeeding chapters. It will be evident that the author has put great faith in the future of the kindergarten. If that faith has been misplaced, the reader may freely substitute for the term “kindergarten”’ such expressions as “educational nursery,” “induction school,” “developmental center,” or any convenient equivalent.

The kindergarten, however, has a place in our educational traditions and history; why should it not have a future in our policies?

Much of the material in the chapter on “ Handieapped School Children” first appeared in the author’s contribution to the child-welfare number of the Annals of the American Academy of Political and Social Science (November, 1921). A special chapter deals with children deprived of parental care; because of the numerical, hygienic, and educational importance of the problem. There is a chapter on the relations of the home, and of parental responsibility to the hygiene of the pre-school child. The concluding chapters deal in a broad but concrete manner with the large problems of the social control and administrative organization of pre-school hygiene. The significance of pre-parental education in terms of social policy is stressed. It is one of the purposes of the book to indicate the vital interdependence between pre-school hygiene and pre-parental education.

xiv PREFACE

The future development of public hygiene and education in the pre-school field offers an inviting subject for speculation, and also for study and experimental demonstration. That in a future day the principle of compulsory education (and health) may be legally extended to include the kindergarten and pre-kindergarten child is, at least, an interesting possibility. It is apparent even now that socialized if not compulsory ways should be found to improve the educational lot of certain types of handicapped children of pre-school age. A developmental supervision of wider scope may be extended to pre-school children in general, whether handicapped or not. We must develop methods of approach whereby the psychological and educational aspects of hygiene may become associated with pediatric and public-health activities in the pre-school field. This does not require that we congregate all babies, toddlers, and runabouts in institutions; it is possible to graft a mental-hygiene and an educational service upon existing arrangements.

The realization of these possibilities is to a great degree dependent upon more definite and more usable information concerning the development of children of — pre-school age. Much progress has been made in the definition of standards of physical growth; less with respect to mental growth. Even child psychology has favored children over six years old, because of their accessibility and convenient grouping in schools. But the present movement aiming at the scientific measurement and interpretation of individual differences

PREFACE XV cannot and should not be confined to the period of school age.

Such considerations have led the Yale Psycho- Clinic to undertake a program of research into the norms of mental or behavior development for the pre-school years. A large number of unselected pre-school children are being studied at the ascending-age levels, including the four-months, the six-months, nine-months, twelve-months, eighteen-months, and the yearly levels up to age six. Photographic and other data are being collected, with the hope that when formulated and published they will contribute toward defining methods of social as well as clinical procedure in this field. Norms or standards of development are essential not only to the diagnostician; but in some form they may also guide others, amateur and professional, who are called upon to notice the maturity and normality of growing children.

The bibliography appended to this volume is of necessity a selected one. It lists the references in the text, and includes further titles which will lead the reader either to more detailed discussions or to fuller bibliographies. The literature in this field is bound to increase, and it will be interesting to note what the next ten years bring forth.

ARNOLD GESELL New Haven, CoNNECTICU?

Contents

I. Tue SIGNIFICANCE OF THE PRE-ScHOOL PERIOD 1 II. Taz Growts or Inrant WELFARE AND CHILD HyGirnge 13 III. Nurseries anp Nursery ScHoors 38 IV. Tue KinpercartEn 57 V. Scuoont ENTRANCE 68 VI. Hanpicappep ScHoot CHILDREN 85 VII. Pre-Scuoot Provision ror HanpicapPpED CHIL- DREN 104 VIII. Pre-Scnoot CHILDREN DEPRIVED OF PARENTAL CARE 130 IX. Tue Pre-Scuoout Curitp anp THE Home 151 X. Pre-Parentat Epucation 165 ’ XI. Tue Socran Controu or Pre-ScHoot Hyerens 178 XII. Tue ORGANIZATION or Pre-Scuoot HyGienE 197 APPENDICES: A. Chronology of Pre-School Hygiene 215 B. Minimum Standards for Child Welfare 218 C. Workings of the New Maternity and Infancy Law 221 D. List of Representative Child-Welfare Agencies 224 E. Organization and Activities of Pre-School Agencies 226 F, The Examination of School Beginners 250 G. A Mental Hygiene Service for Pre-School Children 252 H. Bibliography 258

INDEX 261

Chapter I The Significance Of The Pre-school Period

THE sixth-year molar may be regarded as a convenient punctuation point in the development of a human being. The eruption of this first permanent molar marks the termination of the early fundamental years of human existence. These are the pre-school years. The next six years bring the child to the teens (and to his second molars), and if he passes through his elementary education at an average rate he is then ready for a junior high school, which it will take him another six years to complete. At the age of eighteen he may be ready for college and professional training. His wisdom tooth will not have erupted ordinarily until the close of the twenty-fourth year. We have here four periods, each about six years in length.

In a broad biological sense these four sexennia constitute the total span of infancy — of physical and mental maturation. The first sexennium is the pre-school period; the second is the school period; the third is the period of early adolescence; the fourth of later adolescence.

The long period of plasticity. These four chapters span the gap between birth and maturity, and together they confer upon man a longer period of plasticity than is enjoyed by any other creature. This prolongation of plasticity is not a privation, but the very condition of growth. It embodies man’s unique “ability to develop.” A highly trained surgeon is not ready, nowadays, to begin an independent professional career until after thirty years; while a newly hatched chick can almost shift for itself after as many hours.

The significance of the pre-school period may be interpreted from four points of view, the biological, the medical, the psychological, and the administrative.

1. Brological significance

Relation of pre-school period to later development. The biological significance of the pre-school period can only be appreciated when the period is viewed in relation to the whole span of immaturity. Let us regard the surgeon as an exception, and consider this span as made up of four stages of six years each. No stage is of course sharply marked off from the other; each stage blends into another and colors it; no stage is altogether independent. But there is one stage which has an autocratic position in the series, and therefore dominates all the rest — the autocracy of priority. The pre-school period is biologically the most important period in the development of an individual for the simple but sufficient reason that it comes first. Coming first in a dynamic sequence, it inevitably influences all subsequent development. These years determine character, much as the foundation and frame determine a structure.

The very laws of growth make these the most formative of all years. The younger the creature the more rapid its growth. When measured by percentage of increment in weight and height, the growth activity of the first six years is incomparably greater than that for any subsequent period of six years. The individual begins as a fertilized ovum weighing about half of a milligram. By the time of birth the growth has been reckoned by Minot as 5,000,000 per cent. Between the ages of three and four months alone the foetus increases fivefold. During the first five months of life the baby doubles its weight. During the first year there is a total gain of 200 per cent. During the next year the gain is about 30 per cent. This rate steadily declines until at the age of six the annual increment is only 10 per cent. After six the curve of growth remains almost on a level until puberty, when there is a slight return to the earlier growth intensity.

Adolescence. This has been called a second birth. There is a partial resurgence of the wave of growth at that time, as though nature meant the individual to enjoy, on a higher plane, the same remarkable potency which characterized his infancy. Man would surely become superman if such a supplementary period brought with it a range and degree of achievement comparable to that of the first heyday of growth in the pre-school age. Meanwhile his ability to become completely human depends on the realization of the growth possibilities of the first sexennium.

2. Medical significance

Excessive mortality in pre-school period. The medical significance of the pre-school age can scarcely be exaggerated. Certainly exaggeration is not needed. The problems of development and disease peculiar to this period are so numerous that Pediatrics constitutes the broadest and in many respects the most important specialty in medicine.

The curve of human mortality is of decisive import. Of all the deaths of the nation, over one third occur below the age of six. Ten times as many deaths occur in the first half decade of life as in the full decade from five to fifteen years.

That this pre-school mortality is excessive can hardly be denied even by those who call attention to the racial benefit of many infant deaths. Medical science and public hygiene must continue to work on the assumption that it is in general a good thing to save the lives of babies. Consequently the infant mortality rate tends to vary inversely with the intelligence and progressiveness of a community.

Opportunity for life conservation. It is almost a statistical law that the younger the child the greater the opportunity for life conservation. At least one tenth of the total deaths at all ages, according to Newsholme, occur in infancy; one half of these infantile deaths occur within the first month, and one fifth in the first week after live birth. This author adds:

If therefore it were practicable to halve these early or neo-natal deaths, a greater saving of life could be obtained than by having the death rate at any other period of life of equal length. There is ample work for further preventive measures against infant mortality in the last eleven months of the first year; but the most fertile and least tilled soil is that of the neo-natal period.

Nowhere does the great object of medical science, namely, life conservation, come more completely to realization than in the constructive work in behalf of infants and young children. ‘To save a baby means not only a temporary victory over the hosts of death. It may mean the contribution of a complete or nearly complete adult life to the strength of the Nation. The rewards of medical service, whether private, social, or philanthropic, are in this field extremely far-reaching. An adequate program of physical preparedness, whether for war or for peace, must in the nature of things place most stress on the pre-school period. The very quality of the recruits whom we train in school and camp depends first of all upon the attention we have paid to their pre-school years.

The curve of morbidity. This is as eloquent as that of mortality. Infancy is not only a period of physical helplessness, but it is to no small degree a period of biochemical helplessness against disease. The infant does not only have to learn to see, to grasp, to walk; but the very juices of his body have to acquire an organization against infection. To be sure, in the first months of life his blood may still carry protective substances derived from the maternal blood stream that so recently was his very own. Children under six months, for example, rarely get the measles. But when these protective substances have been exhausted, or are not definitely inherited, his body must produce its own defense against bacteria, toxin, and fatigue. This biochemical defense is part of the struggle for existence which begins anew in every newborn infant. It follows, as Holt has said, that “‘the younger the patient the worse the prognosis in all the diseases of childhood.”

Significance of period for preventive medicine. Yet there is no more promising field in medicine, as this same authority has recognized, than the prevention of disease in this very period. First of all, infections can in large measure be forestalled, delayed, or controlled. Secondly, the strength of the child to resist or to conquer disease can be safeguarded.

Successful reaction of his organism against infection depends primarily upon the nutrition of his protoplasm. Body maintenance, body growth, and immunization are all forms of metabolism, which are based on adequate food and proper feeding. Nutrition is the key to prophylaxis and often to cure. The rdéle of nutrition in human welfare is always a great one; but it is of preponderant importance in the pre-school period.

With disease and defect reduced to a minimum, there remains a vast field of hygiene, both physical and mental, which has to do with healthful habits of living on the part of the children themselves, and with wholesome methods of caretaking on the part of their elders. These problems are both medical and educational in character. Unfortunately, they do not solve themselves; but fortunately, infant-welfare work is coming more and more to include the personal hygiene of the pre-school child.

8. Psychological significance

Rapidity of mental growth. From the psychological and educational standpoint the conditions of the pre-school period are interesting and challenging. Legally, the pre-school child has no educational status in this country. Compulsory education does not begin to operate in most States until the age of six. The tacit assumption is that it is not an educational period at all. Psychologically nothing could be more erroneous than such an assumption. In a certain sense the amount of mental growth which takes place in the first sexennium of life far exceeds anything which the child achieves in any subsequent period. Indeed, it may be doubted whether all of his scholastic strides taken together bulk for as much as his brilliant advance from the stage of protoplasmic vegetation at birth to the mastery of physical and personal relations — language, art, and science — which he has attained when he first slings his school bag over his shoulder. This remarkable velocity of mental development parallels the equal velocity of physical growth during these early years.

The character of this mental development is by no means purely or preéminently intellectual. Almost from the beginning it is social, emotional, moral, and denotes the organization of a personality. The infant is not only acquiring perceptions and motor coérdinations; he is acquiring attitudes toward things and persons, prejudices, inclinations, habitual preferences, inhibitions; he is incorporating modes of behavior which do not, of course, constitute a mature personality, but which psychologically are at the core of personality. On every level of behavior, the physiological, the sensory-motor, and the higher psychical, he is acquiring both healthful and unhealthful habits of activity. Though he may not learn to read in the pre-school years, he is mastering the alphabet of life. So potent are these fundamental lessons that this period easily becomes the soil of perversion, inefficiency, and distorted or curtailed development. It is natural that the new genetic psychology places great emphasis upon the influence of infancy over character formation. Psychoanalysis reveals significant instances in which unfortunate experiences in the first years of life were competent to produce developmental disharmonies resulting in abnormal adult behavior.

Importance of this formative period. The years of pre-school childhood are forgotten, but they do not ever completely depart; they are registered in the organization of the nervous system, and there they continue to dispose and to predispose the latter-day individual.

This is somewhat figurative language, but it is true to the modern dynamic concept of the mind which holds that every action is conditioned by previous action. Man is neurologically a bundle of neurone patterns, and psychologically a bundle of habits, complexes, and conditioned reflexes. The patterns and complexes which are first formed have a remarkable tendency to persist, particularly those which are highly colored emotionally and closely knit to instinctive tendencies.

Such considerations, though broad and general, point to the unique educational potency of the pre-school period.

_ 4. Administrative aspects ©

From an administrative viewpoint the pre-school period presents a likewise interesting situation. During the last century a great body of legislation and administrative procedure have been built up to protect and fulfill the rights of children, but the safeguards have benefited chiefly the child of school age. There is a definite movement, both in this country and in England, to extend the rights of educational opportunity and full physical development well through the teens. The Education Act of 1918, in England, and recent laws in the United States, virtually extend the principle of compulsory education to the age of eighteen. Legally and adminstratively the social control of children below the age of six is much less advanced.

Lack of definite State policy. There are, of course, very significant statutes in many States relating to birth registration, neglect, abandonment, employment of expectant mothers, inspection of milk, etc., which not only clearly reflect the growth of State regulation, but also reflect a tendency to transmute the infant from “well-nigh a thing, the object of rights, to a person, the subject of rights.” Taken as a whole, though, the status of child welfare, and of educational agencies for pre-school children, indicates a lack of general State policy and a relative lack of standards and even of guiding principles. Nowhere are our social efforts more unrelated and piecemeal, or more at the mercy of unaided tradition. Nowhere does the curve of child care fall so low as in numerous nurseries, baby farms, and incompetent homes which retain almost complete control over their young charges, and which have not felt the quickening influence of child-labor and school-attendance laws. It is almost as if the super-mother State had said, “These tiny children do not have to work: therefore they may be neglected — at least for the time being!”

Historically there are many factors which explain, if they do not justify, the comparative official neglect of the pre-school period. One of these is the natural conservatism of social legislation. The rights of fathers were formulated before those of mothers, the rights of the rich before those of the poor, the rights of parents before those of offspring, the rights of legitimate children before those of children born out of wedlock. We need here simply to recall that

Robert Owen met bitter and irreconcilable opposition only a hundred years ago when he wished to establish ten as the minimum working age of factory children. No wonder the child of less than six must wait for the benevolence of the law.

Education conceived of as academic instruction. Educational science and philosophy have also shown some retardation in the recognition of infancy. Taken as a whole, the history of education shows a persistent tendency to place a disproportionate emphasis upon didactic instruction and academic accomplishment. The modern biological point of view, which shifts the emphasis to development and health, is after all a recent one which has not even as yet leavened the mass of educators and teachers. The ancient confusion of education with academic instruction will continue for some time to limit the welfare of the pre-school child, both in the home and in the community.

Another consideration, perhaps the most fundamental, which accounts for the present administrative status of pre-school-child welfare is the reluctance of the home to surrender its prerogatives. This is a healthy reluctance. If it did not exist, we should in a few years be developing a great glorified nursery for the pre-school children of the State. It has been seriously suggested that this is the natural goal of child welfare in this field. Instinct and good judgment, however, favor another solution — one which will strengthen the home and raise its efficiency.

_ New tendencies in legislation. It is very significant that compulsory continuation education beyond the age of fourteen is laying increasing stress on civic instruction, and training for home and family life. If we consistently develop in our pre-marital youth, both boysand girls, a concrete education anda practical philosophy with respect to the vital problems of child care, we shall be attacking the administration of child welfare in the pre-school period from the most promising angle. The welfare of the pre-school child begins with his grandmother and with his parents. We need for these parents a new type of education, one which will deal more directly and sincerely with the problem of infancy. ‘The systematic exploitation of the educational possibilities of the continuation-school period from fourteen to eighteen offers the most promising field for the improved control of the neglected pre-school period.

Social control over the pre-school period must be increased, but it need not be autocratically done. New legislation and administrative coérdination of existing agencies, and new methods of regulation and supervision must be evolved, but our main reliance should be placed upon methods which will preserve the integrity and responsibility of the home.

Chapter II The Growth Of Infant Welfare And Child Hygiene

THERE are several ways in which the growth of infant welfare and the public hygiene of the pre-school child may be measured: (1) by the changes in the social attitude toward infancy and childhood; (2) by the in- — crease and diffusion of knowledge concerning the health and development of children; (3) by vital statistics recording the birth and death of children; (4) by the evolution of laws and provisions for the protection of the mother and the child. A full discussion of any one of these items would require a treatise by itself. It may, however, be profitable to attempt a brief survey and a chronology, which will serve as a background for the subsequent chapters of this volume.

1. Old and new attitudes toward childhood. How the attitude of parents and of society toward children, ancient and modern, has modified in breadth, depth, and direction is a theme which it would take a super- Wells to adequately portray. An Outline of the History of the Child in Human Culture would have to go back to primitive days of arboreal and cave life. It would be extremely difficult to reconstruct, with psychological fidelity, the real attitude of our successive forefathers; but even fragments of the truth would be significant, because it is these very psychological factors which have had and always will have a determining influence on the progress of child welfare. Such an outline of history would have chapters on Infanticide, Cannibalism, Child Sacrifice, Child Slavery — primitive-sounding titles, succeeded by more modern captions such as The Christian Doctrine of Child Depravity, Industrialism and Child Labor, Societies for the Prevention of Cruelty to Children, Infant Mortality, The Children’s Famine in the World War, and The Purification of Milk.

Infanticide. This is an amazing practice which is found in almost every age and stage of human culture; among Papuans, Kaffirs, American Indians; Homeric Greeks, ancient Athenians, Romans, Franks; in modern India, and in modern China. In the case of twins the practice shows interesting variations; sometimes the weaker twin alone is killed; sometimes the pair; sometimes both mother and twins. Cannibalism may or may not be associated with infanticide. Economic motives may be at the origin of the practice, but custom, “superstition,” and religious belief come in to fix and shape it. Laws and juries even may regulate it. Cruelty alone does not explain infanticide. It must be remembered that even to-day there are occasional returns, if not reversions, to an advocacy of this historic institution, but if the philosophy of democracy prevails it will never again be adopted. Children cannot select their parents. Parents, therefore, cannot be allowed to select their children. Birth carries an inalienable right to existence.