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LELAND STANFORD JUNIOR UNIVERSITY 
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The Hygiene of the School Child 
By Lewis M. Terman 
Deals with the broader relations of educational hygiene; the 
physical basis of education; the laws of growth; physiological 
characteristics of children; disorders of growth; malnutrition of 
school children; tuberculosis and the school; children’s teeth; 
hygiene of the nose, throat, eye and ear; children’s headaches and 
sleep; speech defects; preventive mental hygiene; and evil effects 
of school life. 417 pages, illustrated. Price $2.25 
Health Work in the Schools 
By Ernest Bryant Hoag and Lewis M. Terman 
Deals with the social responsibility for the health of school children; 
health supervision; plans for organization of, and its administration; 
the school nurse, health grading of school children; observation of 
defects; the school medical clinic; school dentistry; transmissible 
diseases; open-air schools, school housekeeping; the teaching of 
hygiene, by grades; the teacher’s health; what the world is doing 
for the health of school children; and school health organization in 
American cities. 321 pages, illustrated. Price $2.25 THE PRE-SCHOOL CHILD 
FROM THE STANDPOINT OF 
PUBLIC HYGIENE AND EDUCATION 
BY 
ARNOLD GESELL, Ph.D., M.D. 
i •) 
Director of Yale Psycho-Clinic and Professor of Child Hygiene 
Yale University 
HOUGHTON MIFFLIN COMPANY 
BOSTON NEW YORK CHICAGO SAN FRANCISCO 
QHje Mfoewfoe JJrcss (Carn bridge COPYRIGHT, 1923 
o* 
BY ARNOLD GESELL 
ALL RIGHTS RESERVED 
tJtfje »ibersfte $re«g 
CAMBRIDGE . MASSACHUSETTS 
PRINTED IN THE U.S.A. EDITOR’S INTRODUCTION 
The World War served to give an entirely new empha- 
sis to child-welfare and child-hygiene work. While 
causing untold suffering to millions of children, it 
served to give new rights to millions of others. These 
rights childhood might have waited a decade or more 
to obtain had not the frightful destruction of human 
life served to focus attention on the care of the next 
generation. In England in particular, but in France, 
Belgium, and other countries as well, an entirely new 
attention to child welfare and child hygiene has been 
given by direction of the State. The effect of this new 
work abroad, and of the attention to child life which 
the War brought to all lands, has been felt in our 
American cities and States, and in consequence we 
seem to-day to be on the eve of a new and a very 
important extension of educational activity and ad- 
vantages in a new and until recently an unexpected 
direction. 
As soon as the problem is taken up and studied a 
little, it is seen, as it has been seen wherever studied 
but nowhere more clearly than in England, that any 
adequate attention to child health and child welfare 
must go back into the pre-school age to begin, and 
that the work must really commence with mothers 
and babies and lead up to a close connection with the 
kindergarten and the primary school. The creation of vi 
EDITOR’S INTRODUCTION 
The Children’s Bureau, at Washington, for the study 
of pre-school-child and maternity problems; the enact- 
ment of the Sheppard-Towner maternity bill by Con- 
gress, giving aid to the States for maternity and infant- 
hygiene work; the formulation of minimum standards 
for child-welfare work by a national committee; the 
creation of divisions of Child Hygiene by twenty- 
three additional States between 1918 and 1920, mak- 
ing thirty-two in all, with every prospect that all the 
States will soon create such divisions; the establish- 
ment of a rapidly increasing number of city and county 
health centers for pre-school-child service; and the 
enactment of much recent legislation making better 
provision for school health service are among the more 
important recent evidences that a national awakening 
is already under way with us as to the importance of 
the care of children during the pre-school years, if we 
are to eliminate many disease defects with which 
school children suffer and to produce stronger and 
more capable children for the years with which the 
school has to deal. 
The problems of child care, feeding, health, nutri- 
tion, diseases, abnormalities, preventive hygiene, and 
mental hygiene, and the dissemination among parents 
of proper ideas as to the care, nurture, training, and 
instruction of their children are of such tremendous 
importance to a nation that the work which this 
volume of this series describes should prove of large 
significance to all persons charged with the organiza- 
tion and administration of public education. To be- EDITOR’S INTRODUCTION 
vii 
come familiar with the main outlines and purposes of 
a movement that is already beginning with us is an 
important thing for a schoolman to do. It is not only 
an educational problem, but also a public-welfare 
problem of utmost importance to the statesman as well 
as the educator. 
The writer of this volume has given a simple and an 
interesting description of what is already under way, 
has pointed out the relations of the new child-welfare 
movement to the school, and in particular has shown 
the possibilities of a redirected and expanded kinder- 
garten in the work of parental guidance and infant 
hygiene that will soon be turning to some organized 
agency of society for its administration. This volume 
should be of special interest to school administrators 
and students of child hygiene, while for those inter- 
ested in the work of health centers and infant-welfare 
movements the volume will be almost indispensable. 
Ellwood P. Cubberley PREFACE 
The 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 in- 
vestigation. 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 educa- 
tional 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 move- 
ment. 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 pre- 
vented 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 men- 
tal hygiene, the significance of pre-school childhood is 
likewise receiving a new emphasis. Dynamic psychol- 
ogy, 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 substan- 
tial items as weight, diet, teeth, rickets, adenoids, and 
diphtheria. 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 be- 
come a good 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 pro- 
foundly 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 fundamen- 
tally 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 com- 
prehensive 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 uncoordinated, 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 accomplish- 
ment. 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, educa- 
tional, 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. Supple- 
mentary 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 con- 
sidered 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 educa- 
tion 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 cen- 
ter,” or any convenient equivalent. 
The kindergarten, however, has a place in our edu- 
cational traditions and history; why should it not 
have a future in our policies? 
Much of the material in the chapter on “Handi- 
capped 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-paren- 
tal 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 sub- 
ject for speculation, and also for study and experimen- 
tal demonstration. That in a future day the principle 
of compulsory education (and health) may be legally 
extended to include the kindergarten and pre-kinder- 
garten 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 pediat- 
ric 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 meas- 
urement 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 pro- 
fessional, 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, Connecticut CONTENTS 
I. The Significance of the Pre-School Period 1 
II. The Growth of Infant Welfare and Child 
Hygiene 13 
III. Nurseries and Nursery Schools 38 
IV. The Kindergarten 57 
V. School Entrance 68 
VI. Handicapped School Children 85 
VII. Pre-School Provision for Handicapped Chil- 
dren 104 
VHL Pre-School Children deprived of Parental 
Care 130 
IX. The Pre-School Child and the Home 151 
X. Pre-Parental Education 165 
XI. The Social Control of Pre-School Hygiene 178 
XII. The Organization of Pre-School 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 THE PRE-SCHOOL CHILD 
CHAPTER I - 
THE SIGNIFICANCE OF THE PRE-SCHOOL 
PERIOD 
The sixth-year molar may be regarded as a con- 
venient 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 2 
THE PRE-SCHOOL CHILD 
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. Biological 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 re- 
lation 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 impor- 
tant 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 in- 
fluences all subsequent development. These years SIGNIFICANCE OF PRE-SCHOOL PERIOD 
3 
determine character, much as the foundation and 
frame determine a structure. 
The very laws of growth make these the most form- 
ative of all years. The younger the creature the 
more rapid its growth. When measured by percent- 
age 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 4 
THE PRE-SCHOOL CHILD 
completely human depends on the realization of the 
growth possibilities of the first sexennium. 
2. Medical significance 
Excessive mortality in pre-school period. The medi- 
cal 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 in- 
telligence 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 in- 
fantile deaths occur within the first month, and one SIGNIFICANCE OF PRE-SCHOOL PERIOD 
5 
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 or- 
ganization against infection. To be sure, in the first 6 
THE PRE-SCHOOL CHILD 
months of life his blood may still carry protective sub- 
stances 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 con- 
quer disease can be safeguarded. 
Successful reaction of his organism against infection 
depends primarily upon the nutrition of his proto- 
plasm. Body maintenance, body growth, and im- 
munization 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 r61e 
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 SIGNIFICANCE OF PRE-SCHOOL PERIOD 
7 
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 educa- 
tional in character. Unfortunately, they do not solve 
themselves; but fortunately, inf ant-welfare work is 
coming more and more to include the personal hygiene 
of the pre-school child. 
3. Psychological significance 
Rapidity of mental growth. From the psychological 
and educational standpoint the conditions of the pre- 
school period are interesting and challenging. Le- 
gally, 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 ad- 
vance from the stage of protoplasmic vegetation at 
birth to the mastery of physical and personal relations 
— language, art, and science — which he has at- 
tained when he first slings his school bag over his 
shoulder. This remarkable velocity of mental devel- 
opment parallels the equal velocity of physical growth 
during these early years. 8 
THE PRE-SCHOOL CHILD 
The character of this mental development is by no 
means purely or preeminently 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 coordina- 
tions; 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 person- 
ality, but which psychologically are at the core of 
personality. On every level of behavior, the physio- 
logical, 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 or- 
ganization of the nervous system, and there they 
continue to dispose and to predispose the latter-day 
individual. SIGNIFICANCE OF PRE-SCHOOL PERIOD 
9 
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 neurologic ally 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 remark- 
able tendency to persist, particularly those which are 
highly colored emotionally and closely knit to instinc- 
tive 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. Dur- 
ing the last century a great body of legislation and 
administrative procedure have been built up to pro- 
tect and fulfill the rights of children, but the safe- 
guards 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 oppor- 
tunity 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 eight- 
een. 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, 10 
THE PRE-SCHOOL CHILD 
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 oi 
legitimate children before those of children born out 
of wedlock. We need here simply to recall that SIGNIFICANCE OF PRE-SCHOOL PERIOD 
11 
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 funda- 
mental, 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 judg- 
ment, however, favor another solution — one which 
will strengthen the home and raise its efficiency. 
New tendencies in legislation. It is very significant 12 
THE PRE-SCHOOL CHILD 
that compulsory continuation education beyond the 
age of fourteen is laying increasing stress on civic in- 
struction, and training for home and family life. If 
we consistently develop in our pre-marital youth, 
both boys and girls, a concrete education and a 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 promis- 
ing 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 educa- 
tional 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 coordination 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 at- 
titude toward infancy and childhood; (2) by the in- 
crease and diffusion of knowledge concerning the 
health and development of children; (3) by vital statis- 
tics 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 back- 
ground for the subsequent chapters of this volume. 
i. 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 His- 
tory 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 14 
THE PRE-SCHOOL CHILD 
factors which have had and always will have a deter- 
mining infhience 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; some- 
times the weaker twin alone is killed; sometimes the 
pair; sometimes both mother and twins. Cannibalism 
may or may not be associated with infanticide. Eco- 
nomic 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, there- 
fore, cannot be allowed to select their children. Birth 
carries an inalienable right to existence. INFANT WELFARE AND CHILD HYGIENE 
15 
The doctrine of infant depravity. The Christian 
Fathers insisted that babies had souls, and, according 
to Payne, this idea more than any other reduced the 
practice of infanticide. But by the tragic ironies of 
theology these same Fathers, and the Lutherans, the 
Council of the Reformation, the Calvinists, and the 
Puritans, enunciated the doctrine of child depravity. 
The babies had souls, but “ by their carnal conception 
and nativity ” these souls “came into the world steeped 
in sin and guilt.” From St. Augustine to Jonathan 
Edwards this gloomy doctrine was proclaimed and 
applied. Remnants of it were combated by the val- 
iant pen of Charles Dickens. 
It is not our purpose here to attempt an evalua- 
tion of these various attitudes and misconcep- 
tions. It would be very misleading, however, not 
to mitigate the story with facts of different hue. Take, 
for example, the infanticide of the Chinese. China is 
also notable for very fine and attractive expressions of 
family life. Infanticide in China has been compara- 
tively rare in recent years. Dr. Bolt says, that in the 
face of starvation, it is reported to be increasing among 
40,000,000 northern Chinese; but he also states that 
during six years of residence in the country he did not 
see a single typical case of rickets in China. “The 
absence of rickets and scurvy in China has been ex- 
plained in various ways. Some of the factors to be 
considered are the universal prevalence and long- 
continued breast feeding; the comparatively open-air 
life of the Chinese children: the early introduction of 16 
THE PRE-SCHOOL CHILD 
vegetable and fruit juices into the child’s dietary; the 
freedom from native patent foods and the absence of 
the nursing bottles.” Incidentally it should be men- 
tioned that rickets is one of the most common disorders 
of pre-school childhood, in America as well as in Euro- 
pean countries. 
Christianity has contributed much besides the 
doctrine of innate depravity to our conceptions of 
children. The total influence of the New Testament 
has been to ennoble these conceptions, and through 
many forms of art and tradition the Church has lifted 
the race to loftier interpretations of childhood. The 
wealth of associations that have gathered about the 
Child in the manger have softened somewhat the 
hardness of man. In the music and sentiment of some 
of the old Christmas carols we have evidence of what 
the folk soul was able to achieve, even centuries ago, 
by way of homage to infancy. In these and many 
other ways, social inheritance has nurtured parental 
tenderness, and made possible the wider humanitari- 
anism which underlies the child-welfare movements of 
to-day. 
2. The increase of knowledge concerning children. 
Many of the past sins against “the historical child” 
have had the competent if not always justifiable excuse 
of ignorance. Harmful superstitions and traditions 
have had the same excuse. This ignorance has been 
due to a failure on the part of man to utilize the gifts 
of common sense, and his inability to maintain a scien- 
tific attitude toward the problems of life. Where the INFANT WELFARE AND CHILD HYGIENE 
17 
truth has been attained by leaders of the race, there 
has often been a failure to diffuse it through popular 
education and methods of propaganda. Dr. Foote 
cites the reluctance of the English people, up to the 
seventeenth century, to use cow’s milk in infant feed- 
ing as an illustration of this point. Progress in child 
care is still dependent upon the diffusion of whole- 
some information in simple matters, and in the delib- 
erate extension and application of scientific knowledge 
of life. 
In a very basic manner, then, the birth, health, 
disease, and death of children have been influenced by 
the growth of the fundamental biological and medical 
sciences. The major figures in the historical devel- 
opment of these sciences — Harvey in physiology, 
Vesalius in anatomy, Pasteur in bacteriology, Mendel 
in genetics, Darwin in biology, Liebig in chemistry, 
Jenner in medicine — have left an impress upon the 
fortunes of the children of to-day and to-morrow. 
These men, being geniuses of the first order, have 
guided and energized the activity of countless other 
men of science who, building on the accomplishments 
of their past, contribute to that cumulative mass of 
knowledge upon which civilization is reared, and on 
which infants and children are dependent. We are, 
perhaps, accustomed to give too much credit to the 
purely humanitarian leaders of history. It is the men 
of science, the engineers, the inventors, who bring 
about those fundamental changes in subsistence, 
shelter, clothing, intercommunication, sanitation, and THE PRE-SCHOOL CHILD 
18 
vitality which multiply and improve human relations. 
Assuming a working capital of humanitarianism, the 
progress of child welfare will depend upon the ac- 
quisition, application, and diffusion of ascertained 
truth. 
The most obvious illustrations of this fact are in the 
field of preventive medicine. Smallpox in the eight- 
eenth century was one of the scourges which helped to 
cheapen the value of an infant. One out of every five 
children born died of smallpox before the tenth year; 
one third of all the deaths of children were due to this 
cause (Holt). Vaccination, one of the most remark- 
able discoveries in the history of science, conquered 
this scourge. 
Diphtheria offers a contemporary illustration. The 
calculated yearly mortality from this disease in the 
United States is from 20,000 to 22,000; and the mor- 
bidity from 150,000 to 200,000. With the introduc- 
tion of anti-toxin the mortality has been reduced from 
70 or 75 per cent to 10 per cent. Every case could 
be cured if the anti-toxin could be applied early 
enough; every case could be ultimately prevented if 
we could universally produce active immunization 
through the administration of toxin-anti-toxin to those 
children who by the Shick test show susceptibility to 
the disease. The most favorable age for this pro- 
phylactic procedure is from six months to two years. 
The further control of this dread disease is a problem 
of pre-school hygiene. Scientific knowledge awaits 
its judicious application. INFANT WELFARE AND CHILD HYGIENE 
19 
As with infectious disease, so with rickets, nutrition, 
orthopoedic abnormalities, nervous disorders, and 
mental defects, scientific research alone will point the 
true way to prevention, cure, and management. 
Science does not, however, automatically remedy 
the ills of childhood. The facts must be assimilated 
and applied, often in very personal situations. A 
vitamine may be discovered; it may be located in the 
juice of the tomato; but the juice must go into the 
baby’s mouth (and further) to accomplish its pro- 
phylactic purpose. In other words, we must also 
reckon with personal relations. We deal not only with 
the substantive facts of biochemistry and immunol- 
ogy; but with the behavior of human beings — babies 
and parents. Here is a vast field for analytic and ap- 
plied science. Psychology is the science of behavior. 
The future growth of pre-school hygiene, both physical 
and mental, will see a more deliberate use of this great 
science to solve the behavior problems of child develop- 
ment and of child care. Through applied psychology, 
society can not only increase its knowledge of social 
problems, but its control over them. 
3. Vital statistics and child hygiene. If we had a 
complete set of vital statistics dating from primitive 
times, we could trace the growth of infant welfare and 
child hygiene with great accuracy. Needless to say 
no such data are available. Even in our own en- 
lightened country we are to-day without an adequate 
system for the registration of human births. We do 
not appreciate how vital, for child welfare, vital statis- 
tics are. 20 
THE PRE-SCHOOL CHILD 
“Vital Statistics” has been called the Cinderella of 
modern public hygiene. “She sits in the chimney 
corner and sifts the ashes of dusty figures, while her 
proud sisters, Bacteriology and Preventive Medicine, 
go to the ball and talk about the wonderful things they 
have done.” Dr. Newsholme, however, has gone so 
far as to say that in England public-health progress 
has been largely actuated by records of mortality, 
and he quotes with approval Dr. Fulton’s statement 
that “every wheel that turns in the service of public 
health must be belted to the shaft of vital statistics.” 
It is now recognized that the vital statistics of a 
country, county, or city constitute a sensitive index of 
the social status of the inhabitants. This is particu- 
larly true of the figures which relate to the birth and 
death of infants. The infant mortality rate is the 
number of infants dying under one year of age per 
thousand infants born; while the birth-rate represents 
the number of infants born per thousand of the whole 
population. In nearly all modern nations there has 
been, during the last two generations at least, a decline 
in these two rates. The figures for England and Wales 
for the period from 1890 to 1919 are shown below: 
Year 
Infant Mortality 
Rate 
. „ Birth-Rate 
1891-1895 
151 
30.5 
1896-1900 
156 
29.3 
1901-1905 
138 
28.2 
1906-1910 
117 
26.3 
1913 
107 
28.0 
1916 
91 
21.6 
1917 
97 
17.8 
1918 
97 
17.7 INFANT WELFARE AND CHILD HYGIENE 
21 
Statesmen who are interested in soldiers and in- 
dustrial laborers, and public-health leaders interested 
in national vitality, sense the import of these vital 
statistics. Newsholme believes that “among the 
outstanding events in the medico-sociological history 
of the last fifty years a foremost position must be given 
to the steady decline of the birth-rate which has oc- 
curred in most civilized countries, and to the increased 
attention devoted to the welfare of infants and their 
mothers.” The various factors in this new situation 
have reacted on each other. The lower birth-rate has 
given the fewer babies bom a better competitive 
chance in the struggle for survival, the declining 
birth-rate has stimulated governmental grants-in-aid 
for maternity and child hygiene; this hygiene has 
been further reenforced by higher wages and better 
standards of living. More money is being invested in 
babies; babies are worth more. 
Lowering the death-rate. Turning to the past we 
find that excessively large families and an excessive 
death-rate operated to depreciate the value placed on 
infant life. Although the beginning of vital statistics 
may be dated back to 1538, when Henry VIII ordered 
parishes to register all christenings, weddings, and 
funerals, complete records were not kept until a much 
later time. From the tombstones of eighteenth-cen- 
tury graveyards, and from the leaves of diaries and 
biographies, some glimpses can be caught of “the 
profuse waste or imperfect workmanship of Nature.” 
Holt, in an interesting historical sketch of this subject 22 
THE PRE-SCHOOL CHILD 
says, “At this time, the latter half of the eighteenth 
century, we are warranted in stating that the infant 
mortality generally was over one fourth of the total 
mortality, and the mortality under five years over half 
the total mortality.” The emphasis on pre-school 
hygiene might well have begun in that age, but Black, 
writing in 1782, states that in Great Britain during the 
latter half of the seventeenth century there were only 
three men who gave any special attention to the 
diseases incident to young infants. “Up to this 
century the management of these tender creatures in 
sickness was left to ignorant old nurses and rude 
quackery. Even at present the bills of mortality, in 
cities especially, are a melancholy proof that the car- 
nage made among the young part of the human species 
has not yet attracted the attention of medical writers.” 
(Quoted by Holt.) 
Differences between cities and nations. A century 
and a half has elapsed since the above was written, 
and the new “bills of mortality” show that real prog- 
ress has been achieved. London and New York City, 
two of the largest cities in the world, in 1920 had an 
infant mortality rate of 76 and 84 respectively. In the 
same year the rate for 51 cities in the United States 
birth-registration area, all having a population of 
over 100,000, was 90. In 1916, the rate was 101. In 
the year 1921, the rate has fallen to the remarkably 
low figure of 74, according to a preliminary statement 
of the Bureau of the Census. The lowest rate reported 
for the registration-area cities were Seattle, Portland, INFANT WELFARE AND CHILD HYGIENE 
23 
Oregon, St. Paul, 47; San Francisco, 48; New Haven, 
59; Yonkers, 61; and Bridgeport, 64. If the prelimi- 
nary rate of 74 holds good for the whole United States, 
it means, according to Dr. Van Ingen’s calculation, 
that nearly 40,000 babies were saved in the year 
of 1921. We are beginning to realize the slogan of 
Children’s Year. 
America has not, however, attained a world record. 
According to figures issued by the Registrar General 
of England and Wales (for the third quarter of 1921), 
Christiania, with an infant mortality rate of only 33, 
has the lowest rate of any city in the world. Amster- 
dam comes second with a rate of 42, Stockholm and 
Copenhagen follow with 47 and 48. Bombay trails 
near the end with 630. New Zealand has for years 
maintained a favorable rate. Six foreign countries 
have a lower infant mortality rate than the United 
States; but in the matter of maternal mortality our 
position is still less enviable, for our rank is 16 in a 
group of 17 countries. We have a higher maternal 
death-rate than any other of the principal countries 
except Spain or Switzerland. In the United States, in 
1920, one mother died for every 135 babies born. 
Whereas in other countries there has been a decrease 
in the death-rate from child-birth, the rate in the 
United States has perceptibly risen in the period from 
1915 to 1920. 
Death-rate correlations. Not only do vital statistics 
reveal differences between cities, states, and nations, 
but they bring into focus correlations that would other- 24 
THE PRE-SCHOOL CHILD 
wise escape our attention and perhaps our solicitude. 
For example, in Pittsburgh as a whole there was, in 
1920, a loss during infancy of one life out of every 9; 
but the rates varied enormously for different parts of 
the city. In the most favorable ward it was 64 deaths 
(per 1000 births); in the less favorable it was 157. The 
relations of infant mortality to income and, in a meas- 
ure, perhaps to intelligence, were shown in compara- 
tive studies made by the Children’s Bureau. In 
Waterbury, Connecticut, “the mortality rate for 
children born in rear houses or houses on alleys was 
172, while the rate for children born in houses located 
on the street was 120.6. The study in Manchester, 
New Hampshire, showed the infant mortality rate to 
be 123.3 where the persons in a room averaged less 
than one, and 261.7 where they averaged two, but less 
than three.” When low income drives mothers out- 
side the home for employment, the mortality rate for 
babies apparently more than doubles. 
Vital statistics, like any other statistics, need care- 
ful interpretation; but they are indispensable for the 
appraisal as well as guidance of public-health work. 
The last decade, in particular, has shown that the 
infant mortality rate was not fixed by God, but will 
yield to the pressure of child-welfare and child-hygiene 
enterprise. Not only is public health purchasable, but 
with proper bookkeeping the transaction is written 
on the public ledger of vital statistics. 
4. State protection of children. The modern im- 
provement in the status of children finds its official INFANT WELFARE AND CHILD HYGIENE 
25 
and in many ways its most significant expression in 
public laws and tax-supported provisions. Indeed, 
before the last century the child scarcely had a legal 
status. Sophonisba Breckinridge notes that even 
“under the common law the child was peculiarly 
devoid of rights.” “ The recognition of the child as the 
subject of rights toward whom legal as well as natural 
and moral obligations could be formulated and en- 
forced rather than the object of practically unlimited 
and unrestrained parental and especially paternal 
rights, underlies much of the most modern legislation 
and most important organization.” 
An impressive series of child-protective laws and 
judicial decisions has accumulated during the nine- 
teenth century, and is continuing with momentum 
into the twentieth. In 1811, the Decree of Napoleon 
declared that the unprotected infant was a charge on 
the State. The Factory Acts of 1815 in England gave 
a measure of protection to the children in the mills, 
and established the principle of State responsibility for 
child welfare. In 1837, a compulsory birth-registra- 
tion law, followed, in 1907 and 1915, by the notifica- 
tion-of-births acts, were of great importance from the 
viewpoint of the child-hygiene movement. Massachu- 
setts, in 1842, passed the first American child-labor 
law, and in 1852 the first compulsory-education law. 
In 1872, England passed the Life Protection Act pro- 
viding for the registration, licensing, and supervision 
of infant-caring institutions. This has been called the 
first legal effort to diminish infant mortality. America* 26 
THE PRE-SCHOOL CHILD 
in 1912, created by law a broad governmental agency 
in the interest of children of all ages — The Federal 
Children’s Bureau. The Maternity and Child-Wel- 
fare Act of 1918 (England), the Fisher Education Act 
of the same year, and the Federal (United States) 
Maternity and Infancy Law of 1921, are notable acts 
of legislation which clearly indicate the changing 
status of the pre-school child. For still other acts 
and measures of social control, the reader is referred 
to the chronology given in Appendix A. 
Early institutional work. In the matter of creat- 
ing actual provisions for needy children we find that 
private initiative and philanthropic and religious or- 
ganizations are in advance of official State action. 
Thus Saint Vincent de Paul founded the first per- 
manent asylum for children as early as 1648. At 
about the date of our Declaration of Independence, 
Oberlin in France and Pestalozzi in Switzerland began 
their educational work with young children. In the 
second decade of the nineteenth century, Robert Owen 
originated his infant schools in England, and Froebel 
the kindergartens in Germany. Both institutions 
spread to America. In 1844, France established a day 
nursery in Paris. In the sixties, the pioneer agencies 
for maternal nursing and home visitation were organ- 
ized in France and England. In 1889, the first milk 
dispensary was opened in New York City. 
In many respects, however, the most notable event 
of all was the establishment, by Dr. Budin, in 1892, of 
the first Inf ant-Welfare Center (Consultation de Nour- INFANT WELFARE AND CHILD HYGIENE 
27 
rissons). It was a simple but practical conception — 
a consultation center for the examination of babies and 
the instruction of mothers in child care. This idea 
has spread the world over, and infant-welfare centers 
can now be found in Alaska, Australia, China, Mexico. 
They have multiplied at an almost phenomenal rate 
during the last few years in England and America, and 
still have unlimited possibilities of growth and elabora- 
tion. Ambassador Jusserand, speaking at the first an- 
nual meeting of the American Association for the 
Study and Prevention of Infant Mortality, in 1910, 
said: “When its far-reaching results shall have been 
gauged, France will be as proud of Dr. Budin, for his 
good work, as she is even of the discovery of the most 
startling inventions made by any of her sons in the 
realm of science or industry.” The Ambassador 
spoke even better than he knew; for the victories of 
France at war were in some measure dependent on the 
conservation of infant soldiers. 
Influence of the World War. Happily, the World 
War has had a stimulating rather than depressing 
effect upon child-welfare activity, particularly that 
basic activity which is concerned with the physical 
well-being of the child. Even in the most war-ridden 
districts, partly as a reflex of their very misfortunes, 
the germs of permanent infant-welfare and child- 
hygiene work have been planted. For example, in 
1921, the chairman of the American Red Cross in 
Europe reported the appropriation of $5,000,000 for 
the establishment of child-welfare units; and that 28 
THE PRE-SCHOOL CHILD 
twenty units were speedily put into operation, three 
in Montenegro and most of the others in Poland, with 
a minimum of a hundred units in view. These are not 
primarily relief units, but a device for initiating and 
spreading permanent child-welfare work, with medical, 
nursing, and social features. 
Since 1914, England has been making grants, out of 
Government funds, of fifty per cent of approved ex- 
penditures for infant-welfare work by voluntary, city, 
and county agencies. These grants-in-aid have 
totaled into the millions, and cover every form of child 
and maternity welfare. France subsidizes similar 
work to the extent of twenty per cent, and, in 1918, 
appropriated 650,000 francs for infant welfare, and 
3,000,000 francs for nursing premiums and maternity 
benefits. In Austria and Germany there have been 
marked new developments and extensions of child- 
welfare work. In 1919, the Belgian Chamber passed 
a bill creating a national children’s bureau, and pro- 
viding a fifty per cent subsidy for the continuance of 
the infant-welfare and maternity work brought into 
being by the stress of war. Thus the War has had in 
Europe a paradoxical result on child life. It has 
caused untold suffering and irreparable hardship on 
millions of children; it has given new rights and gifts 
to millions more. 
Recent developments in the United States 
We pass now to a brief review of the pre-war status 
and the recent developments of pre-school hygiene in 
the United States. INFANT WELFARE AND CHILD HYGIENE 
29 
i. The pre-war status of infant welfare and child 
hygiene. The pre-war status of infant-welfare work by 
public and private agencies in the United States was 
summarized in a tabular statement issued by the 
Children’s Bureau, in 1916. Even then the chief of 
the Bureau noted that the extent of the movement 
to protect infant life was nation-wide, and that a 
revolution was taking place in the attitude of physi- 
cians and social students. 
As shown in the statement of forty-eight State 
Boards of Health, all except four reported that definite 
attention was given to infant-welfare work. Only 
four States, however, had at that time organized dis- 
tinct departments of child hygiene. Work for the 
improvement of the registration of births and deaths 
was reported by thirty-six States. The New York 
State Department of Health sent out a traveling 
exhibit to stimulate communities to organize infant- 
welfare stations in city and rural districts. The 
exhibit was viewed by 1,300,000 people. The ex- 
tension divisions of thirty-one State Colleges and 
universities reported similar educational activity 
through lectures, motion pictures, exhibits, demon- 
strations, courses, bulletins, etc. 
Of 555 city health departments in cities with a 
population of 10,000 and over, 134 reported no infant- 
welfare work, and 255 nothing except milk inspection. 
Twenty cities reported distinct divisions or bureaus 
of child hygiene, as branches of municipal departments 
of health; twelve of these were in cities with a popula- 
tion between 100,000 and 500,000. 30 
THE PRE-SCHOOL CHILD 
Infant-welfare work by both municipal and private 
agencies was reported under six headings. The facts 
are easily summarized, and give a convenient picture 
of the situation. 
Infant-welfare stations. These are of four kinds: 
(a) Stations which do not dispense milk, but to which 
mothers may bring their babies for examination by 
doctors or nurses, and which send nurses into homes 
to instruct mothers in the care of the baby, home 
modification of milk, etc. (6) Milk stations where a 
good quality of milk is dispensed, either free or at the 
prevailing price, for the use of mothers who are unable 
to nurse their babies, (c) Feeding clinics, established 
by certain hospitals, (d) Health centers, which carry 
on educational work in a prescribed neighborhood, 
and which deal with health and other problems affect- 
ing not only the baby but the entire family. 
Infant-welfare nursing. Inquiries were sent to these 
organizations which were understood to specialize in 
this work. The total number of cities reported as 
carrying on infant-welfare work, by municipal or 
private agency, either through stations or through 
nurses not connected with stations who visit mothers 
in their homes, was 28 per cent. There were 926 
infant-welfare nurses not connected with stations who 
were employed in summer, and 613 in winter. Nurses 
are playing an important part in the prevention of 
infant blindness; 251 agencies in 181 cities report such 
work on the part of nurses. 
Pre-natal work. This work was interpreted to in- INFANT WELFARE AND CHILD HYGIENE 
31 
elude “the care and instruction of prospective moth- 
ers in the hygiene of pregnancy, by doctors and 
nurses attached to infant-welfare stations and obstet- 
rical clinics, and by nurses not attached to stations 
who visit mothers in their homes.” No attempt was 
made to address all hospitals and clinics. The num- 
ber of cities reporting pre-natal work as carried on by 
departments of health or by private agencies was 186; 
the total number of agencies reported was 286, repre- 
senting all sections of the country. The number of 
nurses reported as giving their entire time to pre-natal 
work was 45; the number giving part time was 893. 
This number is small enough considering the needs of 
a whole nation, but it is also large enough to indicate 
the growing recognition of the importance of maternal 
hygiene in relation to infant-welfare work. 
Classes for instructing young girls in inf ant hygiene. 
Under this heading were included classes in infant 
hygiene for girls of school age, either as a feature of the 
school curriculum or as an activity carried on outside 
of school hours by the health authorities or by private 
agencies. There were forty-four cities of 10,000 
population and over which conducted such classes as 
a municipal activity. The number of girls annually 
instructed was over 48,000. In addition, there were 
some seventy-five private agencies who conducted 
similar work through lectures, demonstration, etc. 
Milk inspection. Of 599 cities addressed by the 
Children’s Bureau, 410 replied that milk inspection 
was carried on. Of 298 cities which furnished specific 32 
THE PRE-SCHOOL CHILD 
information, 240 reported country milk inspection; 
228 use score cards to score dairies; 98 score also stores 
selling milk, the card used by the Department of 
Agriculture or a modification of that card being the 
form most frequently used; a bacteriological standard 
is enforced in 176 cities; a pasteurization ordinance 
is reported by only 43 cities. 
Baby-week campaigns. We may include in this re- 
sume a summary account of the nation-wide Baby- 
Week campaign of 1916, held under the joint auspices 
of the Children’s Bureau and the General Federation 
of Women’s Clubs. Historically this interesting 
movement goes back to a Baby-Week inaugurated in 
Chicago, in 1914, and to similar events which were 
celebrated in New York City, Pittsburgh, Indianapolis, 
Topeka, and Grand Rapids. In the fall of 1915, the plan 
for a similar campaign, national in scope, was an- 
nounced. March 4 to 11, 1916, was the appointed 
week. This developed into a typical American event, 
and foreshadowed in its way the more solemn drives 
and campaigns which were to be so frequent during 
the World War. 
This nation-wide baby-welfare campaign had the 
public endorsement of President Wilson, the Secretary 
of Labor, and many governors and mayors, to say 
nothing of the very valuable aid of newspapers, jour- 
nals, and cartoonists. The United States Reclamation 
Service, the Commissioner of Indian Affairs, the Public 
Health Service, the Office of Home Economics of the 
Department of Agriculture, the National Congress of INFANT WELFARE AND CHILD HYGIENE 
33 
Mothers and Parent-Teacher Associations, univer- 
sities, colleges, churches, and numerous civic and child- 
welfare organizations cooperated in a manner to make 
the effects of the celebration far-reaching. 
The number of local communities which held cam- 
paigns, which were afterward reported to the Children’s 
Bureau, was 2100; but this number is far below the 
total actually held. Of fifty cities having a population 
of over 100,000, only three failed to report celebrations; 
seven hundred were reported from small villages or 
rural districts. This is a remarkably good showing, 
considering that the total number of incorporated 
cities, towns, and villages in the United States is 
reckoned at 14,186. 
The Baby-Week programs varied with different 
communities. The features ranged from the scientific 
to the picturesque and dramatic; they included baby 
Sunday, fathers’ day, birth-registration day, baby 
parades, demonstrations, exhibits on baby care, baby- 
health conferences, baby competitions, posters, plays, 
pageants, slogans, leaflets, cards, tags, a special Baby- 
Week literature, baby-improvement contests, motion 
pictures, and follow-up work. 
2. The war and after. The remarkable popularity 
of the National Baby-Week was an encouraging augury 
for those who were interested in improving and or- 
ganizing the hygiene of infants and young children. 
Progressive legislation and the successful reduction of 
infant mortality in many communities, both at home 
and abroad, had added promise to the outlook. Then 34 
THE PRE-SCHOOL CHILD 
came our entrance into the War, and a vague fear that 
much would be undone and much would be delayed in 
all the fields of child welfare. 
The Children’s Bureau early concluded that “it 
could offer no more valuable contribution to the coun- 
try during the War than to assist in stimulating and 
coordinating public and volunteer effort for child 
welfare, and to put its experience at the service of the 
Council of National Defense and other agencies under- 
taking work in behalf of children.” 
The Children’s Year campaign. In this spirit a 
Children’s Year campaign was formally inaugurated, 
on April 6, 1918, the beginning of the second year of 
this country’s participation in the War. The program 
included the protection of children of all ages, but its 
results were particularly important with reference to 
the hygiene of pre-school children and their mothers. 
The Children’s Bureau and the Child Conservation 
Section of the Council of National Defense issued a 
public appeal. The response of the country was 
genuine and almost unanimous. At the close of the 
Children’s Year in 1919, all but two States were partici- 
pating in the program. It is estimated that at least 
17,000 committees were organized, with a total mem- 
bership of 11,000,000 women. Cities, hamlets, and 
remote country districts everywhere were soon display- 
ing placards announcing the Weighing and Measuring 
Test for children of pre-school age. The height and 
weight were duly recorded on score cards, which were 
sent to the office of the Children’s Bureau, a duplicate INFANT WELFARE AND CHILD HYGIENE 
35 
record with height and weight standards being retained 
by the parent or agency. In all, 7,606,303 such cards 
were distributed! Not all of these were used, but the 
number of pre-school children measured and weighed 
was at least impressive enough to suggest the examina- 
tion of the recruits for the army, and the possibility of 
preventing many of the physical defects of adult years. 
In many cases a complete physical examination was 
added to the measuring and weighing. In one State, 
California, 40,000 such examinations of pre-school 
children were made, and the tabulations showed 47 
per cent correctible physical defects. 
Results of the war work. As a result of the find- 
ings, seventeen permanent county health centers were 
established in California, in ten counties health nurses 
were employed, and a division of child hygiene under 
the State Board of Health was also established by law. 
A similar impetus from the Children’s Year seems 
to have been felt in many parts of the country. Before 
the announcement of the Children’s Year campaign, 
only nine States had child-hygiene divisions; in 1918, 
four more were added, and in 1919, nineteen more were 
added; so that in May, 1920, the total was thirty-two 
States. The directors of these State Bureaus of Child 
Hygiene have formed a national organization to coor- 
dinate their efforts. New public health nurses and 
children’s health centers have been reported from 
twenty-four States. Twenty-nine new health centers 
were started in one year in the city of New Orleans. 
A statistical summary of present infant-welfare 36 
THE PRE-SCHOOL CHILD 
activities, similar to that given for the pre-war year of 
1915, would show significant gains. The pre-school 
child in particular has gained a large measure of bene- 
fit from the War. We are becoming more systemati- 
cally concerned about his health and development 
than ever before. 
When President Wilson wrote his public approval 
of the Children’s Year campaign, he said, in a letter to 
the Secretary of Labor: 
I trust that the year will not only see the goal reached of 
saving 100,000 lives of infants and young children, but that 
the work may so successfully develop as to set up certain 
irreducible minimum standards for the health, education, 
and work of the American child. 
Formulation of minimum standards. To what ex- 
tent the slogan, “Save 100,000 Babies," has been 
realized, it is difficult to estimate, but the formulation 
of minimum standards for child welfare has been 
achieved. In May, 1919, a notable conference of ex- 
perts both from abroad and from this country was held 
under the auspices of the Children’s Bureau. As a 
result of this conference, and of eight regional confer- 
ences held in New York, Cleveland, Boston, Chicago, 
Denver, Minneapolis, San Francisco, and Seattle, a 
brief but important statement of child-welfare stand- 
ards was drawn up. This statement, as published by 
the Children’s Bureau (see Appendix B), is the cul- 
minating contribution of Children’s Year. 
The standards cover, among other things, the funda- 
mental needs of maternity and infant care and the hy- INFANT WELFARE AND CHILD HYGIENE 
37 
giene of the pre-school child. Some of these standards 
are now being written into Federal law. Of special sig- 
nificance is the Sheppard-Towner Maternity Bill, 
passed by Congress in 1921. The minimum standards 
relating to the pre-school child, and also a summary 
analysis of the provisions of the Sheppard-Towner Law, 
are to be found in the Appendix of this volume. The 
chronology in Appendix A gives a suggestive review of 
significant events in the field of pre-school hygiene, 
since the close of the eighteenth century. 
Incomplete as the above survey is, it carries con- 
vincing evidence that the social concern for the pre- 
school child has grown into a veritable movement. 
We have every reason to believe that a coordinated 
series of safeguards and opportunities is being devel- 
oped which will give the pre-school child a new place 
in our educational system and a new importance in 
community hygiene and national welfare. CHAPTER III 
NURSERIES AND NURSERY SCHOOLS 
The term “nursery” carries with it many meanings. 
It variously suggests the children’s room at home, a 
residential institution for children without a home, a 
day home for babies with one or both parents working, 
and more recently the appellation, “nursery school,” 
has come to suggest a place where mothers with and 
mothers without limousines may leave a child of 
pre-school age. Nurseries vary so widely in their 
merits and their organization that it is difficult to 
develop any generalizations in regard to them, but the 
nursery as a social institution bears such important 
relations to the welfare of young children that we 
should attempt to estimate its true place in a program 
of hygiene for the pre-school child. 
1. The functions of day nurseries 
Relation of the nursery to the pre-school period. 
The Washington Conference of the Children’s Welfare 
Standards, held in 1919, under the auspices of the 
Children’s Bureau, included a discussion of the nursery 
in relation to the care of the pre-school child. This 
discussion was so authoritative and pointed in char- 
acter that it reveals in a true light the difficulties and 
implications of the nursery problem. It will serve our 
purpose to quote pertinent passages from the report NURSERIES AND NURSERY SCHOOLS 
39 
of the discussion, which is printed in full in Bureau 
Publications No. 60. 
Dr. S. Josephine Baker, Director, Division of Child 
Hygiene, Department of Health, New York City, said: 
It cannot be claimed that the day nursery as at present 
constituted is a predominant factor in the care of the pre- 
school age child; but its possibilities are almost unlimited. . . . 
In the United States there are no universal standards at the 
present time. . . . Day nurseries should be maintained under 
proper and competent supervision, which can best be carried 
out by governmental authorities. . . . Standards for day 
nurseries must take cognizance of the construction and 
equipment of the building in which the day nursery is to be 
located; the provision of the necessary rooms and their proper 
furnishings; general hygiene and maintenance of nursery 
routine; medical supervision of the children for the purpose 
of controlling epidemic diseases, as well as the prevention of 
disease in general and the correction of existing physical 
defects; and general physical care, including rest, exercise, 
and proper diet. In addition, the day nursery must offer to 
children of the two to six age group some mental and social 
training. 
The development of properly supervised day nurseries or 
nursery schools for children under six years of age may well 
be considered as an important contribution to the solution 
of our present problem as to how to care for the child of pre- 
school age. 
Miss Myra Brockett, of the Mary Crane Nursery, 
Chicago, said: 
The object of day-nursery effort is fundamentally to raise 
the standard of home and family life, and follow-up visits to 
the home will readily reveal whether or not the nursery 
service is helping to accomplish this result. . .. Dr. Baker’s 
recommendation of home visiting is a recognition of the fact 
that effective service to the child must be based upon a 
knowledge of his home environment, and that the family 
rather than the individual child must be made the unit of effort. 40 
THE PRE-SCHOOL CHILD 
Mrs. Eleanor Barton, of the Women’s Cooperative 
Guild, of England, said: 
I am going to take an entirely opposite point of view from 
that which has been given you this evening. I am absolutely 
opposed to day nurseries. I think that day nurseries are part 
of the great industrial problem. 
.. . Why not spend your money on the mother? Why not 
give it to the mother, and let her stay in her own home? We 
in England at the present time are discussing some of these 
problems. We are discussing family endowment, which, it 
seems to me, will solve the problem of these children. 
I am against day nurseries, because I do not think we 
should send our women out of their homes to go into industry. 
I am not against day nurseries when they are necessary. 
Dr. Clothilde Mulon, of the French War Depart- 
ment, said: 
... I perfectly agree with Mrs. Barton that mother and 
child must not be parted. And it is for that reason that we 
have nursing rooms. But if the mother is obliged to work, 
what can we do? 
We have nursing rooms, not only for factory workers, 
but for shop-girls. We have a charming nursing room now 
in one of our biggest shops, on the roof, and the babies there 
are beautiful. Before it was established, those girls were 
obliged to send away their babies, and the babies died. 
Dr. Jessica B. Peixotto, of the University of Cali- 
fornia, at Berkeley, said: 
I venture to speak because I come from the State of Cali- 
fornia, which is, I think, one of the few States that license day 
nurseries.... I take emphatically the position of Mrs. 
Barton, and when I went on the State Board of Charities 
I resolved to see that something was done so that day nurs- 
eries should not grow in our State. . . . 
As an entering wedge between the practice of kindly, 
friendly, cordial care of other people’s children, which is the 
Ideal of the day nursery, and the idea which I share with Mrs. NURSERIES AND NURSERY SCHOOLS 
41 
Barton of abolishing the day nursery as fast as possible, it 
seems to me that it would be of great benefit to require every 
case in a day nursery to be treated, exactly as a case in any 
other type of relief. That is, a definite inquiry into home 
family conditions so that an adequate living wage is received. 
Mrs. Julia C. Corcoran, of the Factory Inspection 
Department, of the State of Connecticut, said: 
... I am very much opposed to the industrial nursery, al- 
though I am afraid it has come to stay, unless you work to 
secure mothers’ pensions or State aid for widows, and even 
then there may be day nurseries, because there may be 
women who will not accept the pension, but will go out to 
work. 
Miss Lydia Burcklin, of the Friendship House, 
Washington, D.C., said: 
I think the fact that we have had practically no standards 
for our day-nursery work in this country is giving some worth- 
while work a bad name. I have been connected with a day 
nursery for ten years. We have never taken a child from 
its home when there was any other possible plan.... I am 
sorry to say that day nurseries are a necessary evil in our 
present state of social development. 
Nursery undeveloped in America. There is as yet 
in America no solid body of opinion regarding the 
functions and the future of the day nursery. Social 
workers, parents, educators, and physicians have 
numerous and divergent views on the subject; stand- 
ards are very uneven in different communities and 
often in the same community, and too often standards 
do not appear to exist at all. The nursery never 
comes under educational supervision, and only some- 
times under compulsory medical supervision. Only 
in a few States are nurseries controlled through li- 42 
THE PRE-SCHOOL CHILD 
censes and inspection. In short, the day nursery is 
far from being a commonly accepted official agency 
of child hygiene in this country. 
2. Nurseries and nursery schools in England 
Nursery control in England. In England the situa- 
tion is somewhat different. There both day nurseries 
and nursery schools are eligible for Government grants- 
in-aid; and come definitely within the scope of govern- 
mental control. Significantly enough, this control is 
both medical and educational. The day nurseries (or 
creches) come under the supervision of the Ministry of 
Health, and the nursery schools fall under the Board 
of Education, in accordance with the Education Act 
of 1918. Both of these governmental bodies have is- 
sued rather detailed regulations setting forth the pur- 
poses, standards, and arrangements of nurseries and 
nursery schools, in accordance with which grants of 
State aid are made. 
A few excerpts from the memoranda of regulations 
will indicate the official status of both nursery and 
nursery school. 
(a) Ministry of Health memorandum in regard to day 
nurseries (1919): 
Day nurseries are intended primarily to provide for the 
care of healthy infants and young children whose mothers 
are obliged to engage in daily work which takes them away 
from their own homes or who are temporarily in distress; it is 
not intended to encourage the establishment or maintenance 
of day nurseries for children who do not come within any of 
the above categories. 
Day nurseries are most suitable for children under three NURSERIES AND NURSERY SCHOOLS 
43 
years of age who mainly require special physical care and 
attention. Infants under nine months should not as a rule 
be admitted. Children over three years of age should attend 
a nursery school instead of the day nursery whenever this is 
possible. If it is essential for them to remain at the day 
nursery, every endeavor should be made to provide for 
training in good habits and personal hygiene, and to ac- 
custom the children to help themselves and one another as 
much as practicable. When there are fifteen or more children 
over three in regular attendance at a day nursery, a teacher 
having kindergarten or nursery-school experience should be 
engaged. 
Day nurseries ought not to provide for children whose 
mothers might reasonably be expected themselves to bestow 
on them the necessary care and attention. 
In some districts, homes have been established for children 
under five whose parents are temporarily unable to keep 
them properly in their own homes, and such institutions may 
be found more suitable than a day nursery for the retention 
of (such resident) children. Neither a home for children nor 
a resident day nursery should be regarded as affording a 
satisfactory permanent home for children under five, who 
should be brought up in circumstances approximating as 
closely as possible to home and family life. 
(6) Board of Education regulations for nursery 
schools; prefatory memorandum (1919): 
A nursery school or class is an institution providing for the 
care and training of young children aged from two to five 
years, whose attendance at such a day school is necessary or 
desirable for their healthy physical and mental development. 
It has therefore a twofold function: first, the close personal 
care and medical supervision of the individual child, in- 
volving provision for its comfort, rest, and suitable nourish- 
ment; and, secondly, definite training, bodily, mental, and 
social, involving the cultivation of good habits in the widest 
sense, under the guidance and oversight of a skilled and in- 
telligent leader, and the orderly association of children of 
various ages in common games and occupations. 
It is much more than a place for “minding” children. THE PRE-SCHOOL CHILD 
44 
The need of nursery schools is greatest in the more congested 
areas of the large towns. The influences which an adequate 
supply of efficiently managed nursery schools could exercise 
upon both children and parents in such areas can hardly be 
overestimated. 
The English nursery-school law. These memo- 
randa indicate that governmental policy with respect 
to the nursery problem is more clearly formulated in 
England than in America. They make a significant 
distinction between the creche type of day nursery and 
the nursery school; and definitely recognize the educa- 
tional function of the latter. Indeed the leaders of the 
movement see in the new nursery-school law a prac- 
tical venture on a national scale; and a decision to 
make the nursery school the very foundation of Eng- 
land’s system of education. The basic legislation is 
contained in section 19 of the justly celebrated Fisher 
Education Act of 1918, and reads in parts as follows: 
The powers of Local Education Authorities ... shall include 
power to make arrangements for supplying or aiding the sup- 
ply of nursery schools (which expression shall include nursery 
classes) for children over two and under five years of age, or 
such later age as may be approved by the Board of Edu- 
cation, whose attendance at such a school is necessary or 
desirable for their healthy physical and mental develop- 
ment. ... 
Although this provision is not compulsory, it never- 
theless opens far-reaching possibilities, and is of unique 
historical importance. Fundamentally it is a product 
of the health movement which grew out of the World 
War, and represents a determination to reduce an 
alarming amount of physical defect through preven- NURSERIES AND NURSERY SCHOOLS 
45 
tive pre-school measures. The law may also be re- 
garded as an offset to the formalizing and unhygienic 
tendencies of the present infant schools, and a recogni- 
tion of the value of the progressive type of work of 
such pioneer nursery schools as that of the Macmillan 
sisters. Dr. Grace Owen points out that the nursery 
school was definitely foreshadowed ten years before 
the Fisher Education Act, in the recommendations of 
the Consultative Committee of the Board of Educa- 
tion, published in 1908. The following passage from 
the Committee’s Report bears out her statement: 
The evidence brought before the Committee showed 
clearly enough: (1) That the infant schools of the time were 
unsuitable for very young children, both as regards hygienic 
conditions and mental occupation. (2) That, nevertheless, 
large numbers of children would be left all day uncared for 
or unsuitably “minded”; if they were not allowed to come to 
school before the age of five. 
3. The historical origin of the nursery school 
History of the nursery school. The beginnings of 
the movement can be easily sketched in outline. We 
do not trace it back to Pestalozzi, because, although 
his methods of instruction were to have a marked in- 
fluence on nursery education, he himself was most 
intent upon keeping the training of young children in 
the home, under the responsibility of the mother. 
Jean Frederic Oberlin, pastor, philanthropist, and 
educator, established the first Infant School, in 1774, 
as part of an effort to offset the ravaging effects of war 
upon the fortunes and morale of his people in the 46 
THE PRE-SCHOOL CHILD 
village of Walbach, France. These schools assembled 
infants and young children and attempted to teach 
them the three R’s, but the program also included 
manual activities, outdoor walks, plays, and games. 
These schools led to the establishment of the first 
French creche, in 1801, which in turn led ultimately to 
the establishment of numerous infant schools all over 
France. These soon received State recognition and 
inspection; and, in 1848, became establishments of 
public instruction under the name ecole maternelle. 
Every commune of over two thousand inhabitants 
must have such a school, which may be attended by 
children from two to six years old. The ecole mater- 
nelle, like the infant school in England, has shown 
a tendency to over-emphasize formal instruction and 
to neglect hygienic nurture. 
The English infant school. This goes back to the very 
beginning of the nineteenth century. Robert Owen, in 
1800, opened at Lanark, Scotland, a “New Institu- 
tion,” to which toddlers and runabouts were admitted, 
“to form their dispositions to mutual kindness” and 
to teach them “whatever might be supposed useful 
that they could understand.” Although it was Owen’s 
expressed intention that “the children were not to be 
annoyed with books,” the infant schools soon began to 
copy the ways of schools for older children and to 
stress formal instruction and discipline. This tendency 
was not altogether overcome by the introduction of 
Froebelian ideas in later years. 
When the infant-school idea was transplanted to NURSERIES AND NURSERY SCHOOLS 
47 
America, in 1816, it represented a formalized method of 
teaching the three R’s. The first school was estab- 
lished in Boston, and the first Infant School Society 
was organized in New York, in 1827. This was also 
the date of the first Infant Sunday School (Episcopal), 
to be founded in this country. The movement spread 
generally throughout the Eastern cities, and in time 
led to the organization of public provisions for primary 
education. It had little permanent influence on the 
education of the pre-school child in America, though 
this country was later on to become the foster home of 
the Froebelian kindergarten. 
The kindergarten. This was first introduced into 
the United States in 1855, and has had a notable 
development with us. It bears such important re- 
lations to the present problem of nursery education 
that it will be reserved for special treatment in the 
following chapter. Founded through the labor and 
vision of Friedrich Froebel, in the second and third 
decades of the nineteenth century, it has followed 
a rather independent course of growth, but has pro- 
foundly influenced other educational agencies and our 
relations to young children. Historically the kinder- 
garten has accomplished much; it may have an equally 
important role in the future in solving the complicated 
problems of pre-school education and hygiene. 
Dr. Maria Montessori’s work. The much-heralded 
“Houses of Childhood” were a venture into the field 
of nursery education. They originated as nursery 
schools, established as part of a model tenement enter- 48 
THE PRE-SCHOOL CHILD 
prise in Rome, in 1907. “Let us,” said the founder, 
“place the school in the home; not only that, let us 
place it there as a collective property, and let us place 
under the eyes of the parents the entire life of the 
teacher, in the accomplishment of her high mission.” 
The Casa dei Bambini was an experiment in the “ social- 
ization of the maternal function.” It kept its children 
eight hours or more each day under the socialized 
maternal control of professional trained directresses, 
with physician and caretakers assisting. The daily 
program included so-called exercises of practical life, 
such as washing, dressing, dusting, sweeping; gym- 
nastic exercises, singing, dancing, rhythm work, speech 
training, luncheon, serving luncheon, playing in the 
garden, and sleeping. With the aid of some 1100 
pieces of auto-sensorial didactic apparatus, children 
from four to five years old learned to write and read 
and cipher with the facility of children of the second 
and third grades.1 
This graded sensory and didactic material captured 
the attention of the public, and was adopted in differ- 
ent countries the world over. In many minds it 
became synonymous with “the Montessori Method,” 
although actually the Montessori idea was a socialized 
type of pedagogical nursery, which could be adopted 
only by making fundamental social and architectural 
adjustments such as characterized the original Casa 
dei Bambini. The didactic apparatus was sold in 
large quantities, both in this country and England, and 
1 See Gesell: The Normal Child and Primary Education, p. 323. NURSERIES AND NURSERY SCHOOLS 
49 
was introduced into existing kindergartens and infant 
schools; but without fundamentally altering either 
their organization or policy. Many of the so-called 
Montessori schools which opened in the United States 
were merely more or less progressive kindergartens, 
with the additional paraphernalia of Montessori ap- 
paratus, and with a partial application of her pedagogy; 
only rarely were they true nursery schools. 
What the nursery school may be. The present 
wave of renewed interest in nursery schools in America 
has had its origin in recent developments in England, 
which have already been referred to. Miss Grace 
Owen, in her book on Nursery School Education, 
and Miss Margaret McMillan in a book on The Nurs- 
ery School, have described some of the accomplish- 
ments and still more the hopes of the new English 
movement. Miss McMillan calls the nursery school 
a new departure “which is distinct in aim and 
method from all that went before.” Miss Owen, 
however, seems to regard it as part of the post-war 
health movement, and as a means of transforming the 
prevailing infant schools and extending their influence. 
Both writers are determined to make it clear that the 
nursery school is in no sense a substitute for the home. 
The nursery school “ should be included in every hous- 
ing scheme, and meanwhile lead the way, by securing 
for groups of children the healthy conditions of life 
which are the right in every home.” (Grace Owen, 
p. 14.) The nursery school “is the private nursery 
enlarged, and adapted to the average family’s needs; 50 
THE PRE-SCHOOL CHILD 
and there is no reason at all why it should not rival 
any private nursery in its home likeness and efficiency, 
or why, for that matter, it should not one day be pre- 
sided over by the mothers themselves.” (Margaret 
McMillan, p. 23.) 
For details regarding the actual conduct of the 
English nursery schools the reader is referred to the 
books above mentioned. There is nothing novel or 
startling in the methods themselves. The project rep- 
resents an effort to blend what is best in day-nursery 
and kindergarten practice, and to develop an institu- 
tion which shall function in close physical and personal 
connection with the home, and preserve the best 
values of the home. 
4- Nursery schools of America 
It remains to mention one or two of the recent en- 
terprises in the field of nursery education in America. 
A nursery school experiment in New York City. 
In an attractively equipped building, in the lower part 
of Manhattan Island, New York City, the Bureau of 
Educational Experiments established a nursery school 
which is now completing its third year. “The City 
and Country School” receives children at three years 
of age, with separate teachers and rooms for the three- 
year, four-year, five-year, and six-year-old groups. 
Its buildings adjoin the Bureau of Educational Ex- 
periments, and children are transferred to it as they 
reach the upper age limit of the nursery school. The 
physical equipment of the nursery school includes NURSERIES AND NURSERY SCHOOLS 
51 
generous indoor and outdoor play space, a playground 
on the roof, sleeping-quarters isolated from the sound 
of voices and divided so that the sleepers will not 
disturb each other, an isolation room, a good-sized 
kitchen, and a dressing-room with toilet. 
Miss Harriet M. Johnson, Director of the nursery 
school experiment, has kindly furnished a statement 
in advance of her printed report, from which I briefly 
quote: 
After the first year we decided to limit the age range to 
from about eighteen months to three years. We are more 
and more convinced that the homogeneous group is desirable. 
Advocates of a mixed group always refer back to the family 
unit as a model. We believe that the extension of the fam- 
ily grouping into the school is unwise. The older chil- 
dren either have to submit to continual interference by the 
younger ones or they adopt the role of mother or nurse, 
in which case the younger tend to become passive and lose 
their impulse to independence and initiative. The con- 
structive and purposeful functioning which we expect from 
the older group is turned into artificial channels. 
The set-up for a group of children under three years of age 
ideally should be that of a home in its intimate unity and in 
its equipment for physical care, but it must be planned in its 
space and furnishings with children not adults in mind. It 
thus differs from the home on the one hand, but also es- 
sentially from the institution, school, or day nursery on the 
other. The fact that our problem was one of research intro- 
duced another factor, limiting the scope of our work in point 
of view of numbers and making a larger staff necessary than 
is called for by the usual day-nursery situation. Stating the 
requirements in terms of our aims we might say that we 
desired, first, to give children as efficient physical care as that 
of a well-ordered home; second, to provide them with an 
environment which should be favorable for their fullest de- 
velopment; and, third, to work out through our records a 
method of checking up our educational procedure and of 
gathering data which could be used for research purposes. 52 
THE PRE-SCHOOL CHILD 
We believe that there is no process in the care of a child 
that is not educational to him and illuminating to the adults 
who are trying to learn from him. Therefore, we as teachers 
assume the entire care of the children. We include no maids 
on our staff except one for the cleaning and laundry work. 
We planned originally for ten children, but as our first 
year progressed we found that two teachers with an assistant 
in the kitchen were necessary for the care of eight children. 
Again this year we have attempted a registry of ten, adding 
the new children late in the year when the group was well 
established and when we were assured of an additional assist- 
ant. Again we are convinced that eight is a more satis- 
factory number. A social group of two-year-olds is quite 
different from one of “fours.” It is a group of individuals 
playing individually. Too close contact results in inter- 
ference and in a disturbance of the serenity which is essential 
for success. 
We are, moreover, concerned with the research aspects of 
the experiment, and together with the physician and psy- 
chologist are trying to develop a technique of observing and 
recording children’s responses. We have as yet done little 
more than state the problem tentatively... . We do not 
consider ourselves ready to make a statement of results. 
Our experiment is still too young and our findings are too 
tentative. We are following our children into the City and 
Country School with interest, to see how they adapt them- 
selves to the program there in contrast to those who have not 
had nursery experience. 
From the above account it will be seen that, in the 
New York Nursery School, the emphasis is on the ex- 
perimental or investigative side. This is less true of 
the Ruggles Street Nursery School and Training Cen- 
ter of Boston, where the objectives are more immedi- 
ately practical. 
Work in Boston. In 1920, the Woman’s Education 
Association of Boston (for fifty years this organiza- 
tion has been instrumental in starting and furthering NURSERIES AND NURSERY SCHOOLS 
53 
new lines of work in matters of educational importance) 
decided to start a nursery school along the lines of the 
English nursery schools. Because no one could be 
found ready to take charge of such an experiment, the 
Association sent Miss Abigail A. Eliot, the present 
Director of the Ruggles Street Nursery School, to 
England for six months to study the nursery schools 
there. The Ruggles Street Nursery School actually 
came into being on her return, January 1, 1922. It is 
under the auspices of the Woman’s Education Associa- 
tion of Boston, and the committee in charge of its 
affairs is a committee of this Association. 
There are now twenty-three children enrolled in the 
school, which admits any children of two and three 
years of age whose parents wish to send them. The 
children may be at the school from half-past eight to 
four o’clock, five days a week. The morning is spent 
in educational play and occupations, with milk to 
drink at ten o’clock. Dinner is served at twelve, and 
the children sleep from one to three. When weather 
permits, the school is held out of doors most of the day, 
including the nap time. The parents pay fifteen cents 
a day for the dinner. 
The school has two chief objectives. The first is to creat® 
the right environment for children of this age and to dis- 
cover what are the educational needs of the pre-kindergarten 
child. The work is almost wholly individual. The second 
objective is to demonstrate to the parents the value of right 
physical, mental, and moral care for their children. 
The Detroit Foundation. In 1918, in Detroit, there 
was admitted to probate a will which contained the 
following interesting provision: THE PRE-SCHOOL CHILD 
54 
I hold profoundly the conviction that the welfare of any 
community is divinely, and hence inseparably, dependent 
upon the quality of its motherhood, and the spirit and char- 
acter of its homes, and moved by this conviction, I hereby 
give, devise, and bequeath all the rest, residue, and remainder 
of my estate, of whatsoever kind and character, and where- 
soever situated, for the founding, endowment, and main- 
tenance, in the City of Detroit, or in the Township of 
Greenfield, County of Wayne, State of Michigan, of a school 
to be known as the Merrill Palmer Motherhood and Home 
Training School, at which, upon such plan and system, and 
under such rules and regulations, as shall, in the judgment and 
wisdom of those upon whom the administration shall de- 
volve, be adopted, girls and young women of the age of 
ten years or more shall be educated, trained, developed, 
and disciplined with special reference to fitting them men- 
tally, morally, physically, and religiously for the discharge 
of the functions and service of wifehood and motherhood, and 
the management, supervision, direction, and inspiration of 
homes. 
Under the terms of this will, the “Merrill-Palmer 
School of Homemaking of Detroit ” was organized, in 
1920, with Edna M. White as Director. The school 
has undertaken three lines of activity: (1) One of 
general education and advisory work in the fundamen- 
tals of nutrition; (2) unit extension courses in home- 
making, dealing with (a) clothing, (6) food, (c) home 
and the family, (d) health; (3) a nursery school. 
The Merrill-Palmer Nursery School was established 
in 1921, Miss White spending the summer of that year 
in making a first-hand study of the English schools. 
The official report of the school describes its objectives 
as follows: 
In order to insure that sufficient emphasis should be 
placed upon the mental development of the children, a NURSERIES AND NURSERY SCHOOLS 
55 
psychologist, Mrs. Helen Thompson Woolley, was secured to 
organize and develop the Nursery School, and instruct the 
resident college students in child psychology and child man- 
agement. The engagement of Miss Henton, of the Gypsy 
Hill Training College, to take immediate charge of the work 
with the children assured us of the advantages of the best 
experience of England. We feel, therefore, that the plan 
offers not merely a real opportunity to young children for 
physical, mental, and social development, but also an op- 
portunity to a group of young women for a vital type of 
laboratory work in child psychology, child health, and nutri- 
tion. Training in the sociological problems immediately 
related to the family, and in field work connected with social 
agencies devoted to children’s problems, is also part of the 
plan. 
If education of the nursery-school type is ever to be made 
available for the community at large, it must, of course, be 
through the agency of the public and private schools. Ac- 
cordingly, we have from the start worked in as cloce coopera- 
tion with public and private schools of the city as possible, 
in order that we might have the constant advice and interest 
of those responsible for public education. 
The future of nursery establishments. Reviewing, 
then, the origins and present status of the nursery, 
it is clear that we are still far from a satisfactory solu- 
tion of the problems involved. The day nursery as an 
economic necessity is still on the defensive and should 
be kept there. It cannot be fully justified on purely 
economic grounds, if there is any possible social device 
which will enable the mother to preserve her natural 
relations to her young children. Wherever day nurs- 
eries are maintained, the rights of the family should 
be safeguarded by insisting on rigorous investigation 
of each case before admission. Is it possible so to con- 
duct nurseries that they will not be merely receiving 56 
THE PRE-SCHOOL CHILD 
and relief stations; but will actually have a strength- 
ening effect on the home? May they be used as cen- 
ters of education for mothers and fathers; and thus 
become supplementary instruments for improving the 
physical and mental welfare of pre-school children? 
It may be part of the mission of the nursery school 
to point a way for the safe and logical development of 
the day nursery. It may also be part of the mission 
of the nursery-school movement to indicate new lines 
of development to the present-day kindergarten. Or 
is the nursery school destined to displace the kinder- 
garten? 
As a sociological venture and educational experi- 
ment the nursery school will be watched with interest 
and critical expectation. It cannot be a panacea for 
the pre-school child; it may even have a hidden dan- 
ger or two. As an effort to supply parental guidance 
and training for parenthood, its contributions will be 
welcomed. We hope that it will at least demonstrate 
the latent power of the American kindergarten, and stir 
it to larger life. CHAPTER IV 
THE KINDERGARTEN 
1. The strategic position of the kindergarten 
Importance of the kindergarten in America. There is 
no agency concerned with the welfare of early child- 
hood which, in America, holds more power for effective 
service than does the kindergarten. The kindergarten 
is strategically situated in our educational scheme. 
It is the very vestibule of our vast public school sys- 
tem. Its outer door opens into the homes of the people, 
and its inner door into the elementary school, into 
which each year some 3,000,000 children are recruited. 
Ever since its introduction into this country, the 
kindergarten has maintained itself as a kind of inter- 
mediate station between the home and the primary 
school. It has not surrendered its prerogatives to 
either institution, and has won for itself at least the 
presumptive right to existence. How independent 
this existence should be is an important question; but 
we no longer ask, “Will the kindergarten be abolished 
or absorbed?” Most of us have come to the con- 
clusion that there is something about it which is in- 
destructible. The question is, rather, How completely 
will the kindergarten respond to the demands that are 
to be made upon it in the interests of the pre-school 
child? 
In spite of economic and administrative pressure, 58 
THE PRE-SCHOOL CHILD 
the kindergarten happily has resisted benevolent as- 
similation. It remains to this day a silent, visible 
protest against the mechanistic tendencies and in- 
stitutionalization of primary education. In spite of 
its own very serious errors, those of sectarianism and 
pedagogical mysticism and symbolism, it still is in a 
peculiarly favorable position to make a new contribu- 
tion to public education and to child hygiene. It is not 
subject to curriculum domination; it is not embarrassed 
by prescriptions of academic requirements; it is archi- 
tecturally freer, being unbound by the stationary 
rigidity of conventional school furniture; and its best 
traditions place a premium upon that liberty and 
happiness which the Greeks at least knew were in- 
separable from health. 
Possible readjustment of the kindergarten. The 
kindergarten may again become the rallying-ground 
for a forward movement in child hygiene, if it will 
assert in unmistakable terms, and by modern works 
and deeds, the sacred right of young children to 
physical and mental health. To do this the antique 
doctrines about finger plays and gifts, the Hegelian 
dialectics, and the Gliedganzes must be safely stored in 
their old bottles. There must be a radical, courageous 
reconstruction which will align the kindergarten with 
all the vital work which is now being done in the field 
of baby welfare and make it an integral and culminat- 
ing part of a system of pre-school hygiene. In this 
country, we do not so much need a new nursery-school 
movement patterned on what England is doing, nor do THE KINDERGARTEN 
59 
we need a revival of Montessorianism. Instead, we 
need a fearless, fundamental readjustment and ex- 
tension of the present American kindergarten to meet 
the elementary necessities of a program of continuous 
health supervision and developmental hygiene for the 
much-neglected pre-school child. 
Such a readjustment would do least violence to our 
existing system of public education. It would revi- 
talize the kindergarten itself — no small benefit; it 
would preserve the responsibilities of the home; and 
it would aid in the solution of perplexing problems 
relating to the administration of pre-school hygiene, 
school entrance, and health supervision. 
A consecutive child hygiene program. There is 
need of more experimental work in kindergarten or- 
ganization and administration. School superintend- 
ents and boards of education in general have neg- 
lected this field. A multitude of problems concern- 
ing children of school age have been considered more 
pressing, and the kindergarten has been regarded as a 
somewhat exceptional, supplementary feature of the 
public school plant, not to be unduly molested. The 
fact that the kindergarten deals with children who have 
not reached compulsory school age has also affected the 
situation. When the kindergarten has been made a 
subject of conscious administrative attention, the ques- 
tion has usually centered about the methods of read- 
justment between the kindergarten and the first grade. 
Although this question is not without importance, it 
represents only a very partial aspect of the large prob- 60 
THE PRE-SCHOOL CHILD 
lem of the reconstruction of the kindergarten. The 
big administration problem concerns the ways and 
means of identifying the kindergarten with a consecu- 
tive program of developmental hygiene for pre-school 
children, and of making that program, through the 
kindergarten, continuous with a more flexible and 
hygienic type of primary school. 
The kindergarten is to-day distinguished by a kind 
of isolation which is becoming more and more unjusti- 
fiable. A gap separates it from the public school; a 
chasm separates it from the infant-welfare and public- 
health organization of the community. If it is to 
realize its destiny, it should become an organic part of 
a unified system of public health and education. Its 
strategic, intermediate position in the social scheme 
presses upon it the duty to assist in bringing about 
such a unification. 
2. Present status of the kindergarten 
The modem kindergarten greatly modified. What 
has the kindergarten done to meet the situation? It 
has prepared itself in part. The progressive kin- 
dergarten has abandoned a blind devotion to the 
ten formal gifts, the traditional occupations, and the 
mother plays and finger songs. It has given up the old 
insistence on formal sequence, symbolism, and pre- 
scribed program. It has recognized the necessity of at 
least supplementing Froebel’s philosophy with a scien- 
tific type of genetic psychology; has introduced a 
freer life, with constructive activities which are defi- THE KINDERGARTEN 
61 
nitely intended to promote the mental vigor of its 
children. The liberal wing of kindergartners have 
caught some concept of the possibility of actually 
applying the principles of mental hygiene in early 
childhood, through a thoroughly modernized kinder- 
garten; and this goal has been so well striven for that 
we must perhaps say that the nearest approach to ideal 
educational procedure in our public schools has been 
attained in just such kindergartens. These positive 
achievements justify a great faith in the power of the 
kindergarten to meet at least the educational demands 
which the future will make and which the present is 
forming. 
What the kindergarten still needs. But when we 
consider that the basis of all true nurture is physical, 
and when we survey the kindergarten situation from 
this viewpoint, the outlook is not so clear, and not 
equally encouraging. There has been a deplorable 
tendency to ignore the physical aspects of develop- 
ment, to disregard the symptoms of physical defect and 
disease, and in actual practice to neglect even such fun- 
damentals as sunshine, milk, free outdoor play, and 
sleep. We do not, of course, believe that there has 
been a conspiracy against the physical welfare of the 
kindergarten child; but we ask, Has there been a con- 
spiracy to promote this physical welfare? Where do 
we find an individualized medical inspection and a 
health supervision ? Where do we find this supervision 
begun in babyhood and continued into the nursery 
and kindergarten years, and deliberately related to 62 
THE PRE-SCHOOL CHILD 
school entrance and school program? Do we have any 
evidence that the kindergarten generally considers 
itself part of a social effort to reduce childhood mor- 
tality and morbidity, and to raise the natural stand- 
ards of physique and vitality? The day nursery, it is 
freely granted, should safeguard the physical welfare 
of the child, but the kindergarten is often supposed to 
have a higher concern. 
G. Stanley Hall, who would gladly have himself 
called a true disciple of Froebel, said several years ago: 
“If my interpretation of him be correct, he would be 
appalled and horrified at much that he would find in 
the average American kindergarten and would vastly 
prefer a good day nursery.” 
Conditions have improved in the decade since this 
statement was published (1911); but more than mere 
improvement is necessary if the situation is to be 
remedied. It will not suffice simply to introduce 
ordinary medical school inspection, to teach a few 
health habits, and to open the windows. There must 
be a fundamental reconstruction of outlook and pro- 
cedure. It need not be sudden, but it must be sin- 
cere, and much of it will be administrative in char- 
acter. 
Professional kindergarten training. In principle 
the distinctions between nursery, nursery school, and 
kindergarten ought to disappear. The kindergarten 
must assimilate all that is best in nursery and nursery 
school, and possibly even some of the actual func- 
tions of these two institutions. The day nursery has THE KINDERGARTEN 
63 
shown a disposition to annex kindergarten features. 
It is even more important that the kindergarten 
should adopt the highest standards and methods of 
the nursery; but there should be no false distinctions 
between bodily care and spiritual training. The pre- 
school child is a unit, and there is really but one hy- 
giene for him, and that is a developmental hygiene. 
An appreciation of this type of hygiene demands 
more than the prevailing courses in kindergarten 
methods and child psychology. It demands some of 
the professional training of the nurse, and an elemen- 
tary knowledge of certain fundamental chapters in 
pediatrics. Indeed, it may be questioned whether the 
ordinary primary-kindergarten normal school course 
will be adequate for the future. The training of both 
medical and public-health nurses and of social workers 
and visiting teachers is undergoing significant advances 
which offer many suggestions toward the development 
of a new type of professional training for kindergart- 
ners. If the kindergarten is to become articulated with 
the gathering public-health movement, a revision of 
professional training and outlook is necessary. 
Relations of the kindergarten to infant welfare. 
The starting-point in safeguarding the developmental 
rights of the child is the infant welfare conference in 
which figure the mother, physician, nurse, — and the 
child who in a few short years will be a candidate for 
the kindergarten circle. Is it possible that these baby 
welfare conferences have no interest, no significance 
for the kindergarten, and that there are no vital threads 64 
THE PRE-SCHOOL CHILD 
of contact which it can carry to the new infant, so 
that he may be brought more securely along the paths 
which lead from the home through the kindergarten 
into the public school? The kindergartners should be 
the first and not the last to see the pregnant implica- 
tions of all this infant-welfare work which is spreading 
the country over, but which is growing in its own 
field, often unnoticed, by the very agencies it most 
concerns. 
For some reason infant-welfare work has become 
associated in the minds of people with pasteurization 
and with milk modification. As a matter of fact the 
infant-welfare conference is an educational institution 
with endless possibilities of elaboration, development, 
and upward extension. It is groping now to establish 
contacts with the nursery and public school. The 
term “ milk station ” is falling into disuse, and broader 
terms, such as “conference,” and “children’s health 
center,” are taking its place. The magnitude of this 
new social device can be inferred from the following 
minimum standard proposed for the public protection 
of the health of infants and pre-school children, as 
published by the Children’s Bureau: 
Sufficient number of children health centers to give health 
instruction, under medical supervision, for all infants and 
children not under care of private physician, and to give in- 
struction in care and feeding of children to mothers, at least 
once a month throughout the first year, and at regular in- 
tervals throughout the pre-school age. This center to in- 
clude a nutrition clinic. 
Children’s health center to provide or to cooperate with 
sufficient number of public-health nurses to make home visits THE KINDERGARTEN 
65 
to all infants and children of pre-school age needing care— 
one public nurse for average population of 2000. 
If this minimum standard is even approached, we 
shall soon have in this country a most potent and ex- 
tensive institution, with which the kindergarten will 
be compelled to reckon in some form or other. It is 
essential that this institution be incorporated into a 
unified system of child hygiene which will be continu- 
ous with the organization of the public school, and 
include educational as well as medical activities from 
the earliest stage upward. The kindergarten, by 
coming into closer working relations with nurseries 
and with public-health administration and visiting 
nurse activities, can render much service in bringing 
about a unification of a child-health program. 
3. Lines of future development 
Possible immediate connections. There are several 
lines of readjustment which the kindergarten could 
venture upon in the interests of such a program. 
Kindergartners in service, and cadets as well, could 
assist in infant-welfare and home-visitation work. 
An effort could be made to conduct certain children’s 
health centers in kindergartens or near kindergartens. 
Kindergartens could cooperate in developing methods 
for more parent-teaching in connection with the con- 
ferences. They could take over a certain amount of 
this parental work themselves. The kindergarten 
might also become interested in developing an obser- 
vation and information record of prospective kinder- 66 
THE PRE-SCHOOL CHILD 
garten children while they are still in the infant-wel- 
fare period of development. The kindergarten is in- 
dispensable for the proper conduct of pre-school nutri- 
tion clinics and classes. 
Kindergartens should judiciously take on the best 
features suggested by nurseries and nursery schools — 
emphasis on physical care and cleanliness, provisions 
for lunches, ample outdoor life, frequent outdoor ex- 
cursions, liberally increased opportunity for free play, 
and finally for rest, perhaps even for sleep. The kin- 
dergarten of the future will probably reflect more the 
atmosphere and technique of a health-promoting 
agency and less that of a sub-primary schoolroom. In 
this setting the bodies of children will thrive better, 
and there will be ample opportunity for mental and 
spiritual nurture as well. 
Necessary changes in organization and work. A 
flexible type of kindergarten could readily assume 
certain nursery functions, and could even take over, 
for short periods, the care of children three years of 
age and younger. Such a kindergarten would be 
equipped and staffed to permit of multiple uses. It 
should be as adaptive and responsive to the childhood 
needs of the neighborhood as, in their field, are a hospi- 
tal and dispensary. It should become a center for 
home instruction, for parental training, and a clinic 
for the education of adolescent boys and girls and 
working youths who, in a few years, will be fathers and 
mothers. 
The principle of multiple use could be put into THE KINDERGARTEN 
67 
practice, also, by shortening and multiplying sessions, 
and by having certain age-groups or developmental- 
groups report on alternating days. It is not advan- 
tageous for the kindergarten to operate on a schedule 
or basis which, after all, is historically an imitation of 
or a concession to traditional public school practice. 
We are, of course, assuming here a reconstructed kin- 
dergarten, and not the circumscribed, conventional 
organization under which it functions to-day. The 
kindergarten must burst these patterns if it is to fully 
serve the pre-school child of the future. CHAPTER V 
SCHOOL ENTRANCE 
The kindergarten and school entrance. The whole 
problem of the function of the kindergarten comes to 
a crux when we inquire, What should be the relation 
of the kindergarten to school entrance? If the kinder- 
garten has no vital business in this field, it may be 
questioned whether it should be part of our public 
school system at all. 
No feature of public school administration is ap- 
parently under less control than that of school en- 
trance. There are laws which state the age when 
compulsory education shall begin, permissive laws 
which state the age when children may be admitted, 
and often a statute which requires vaccination, but 
beyond these there are few regulations except as to 
attendance and promotion. The excessive repetition 
in Grade 1 (about one out of four first-graders fail of 
promotion) is itself a sad commentary. We virtually 
place a premium upon failure by insisting so speedily 
on academic standards of promotion. As for medical 
inspection, ordinarily no preference is given to primary 
grades; often they are even slighted, and it is a very 
exceptional school which insists on a thoroughgoing 
physical examination of the school beginner. In 
other words, we annually recruit three millions of SCHOOL ENTRANCE 
school children into our great educational camp with- 
out meeting the hygienic responsibilities and opportu- 
nities involved. 
And what is the relation of the kindergarten to this 
great responsibility, and still greater opportunity? 
Possible kindergarten control of school entrance. 
In weighing this question let us visualize the kinder- 
garten as an intermediate station, or a corridor which 
lies between the first two epochs of childhood — the 
pre-school period and the school period. The kinder- 
garten derives much of its power, indeed, from the 
fact that it lies within the borders of the pre-school 
epoch, which, all things considered, is the most im- 
portant period in the whole span of development. 
The problems of pre-school hygiene and of school 
entrance are inseparable, and both are in turn in- 
separable from the kindergarten. The whole matter 
of school entrance is in last analysis one of hygiene. 
Matriculation into school life should be conditioned 
primarily by standards of health and development; 
and should be regulated by a policy of medical over- 
sight and educational observation. Instead of uncere- 
moniously and haphazardly admitting three millions 
of children and failing one fourth of our first-graders 
at the end of the first year, we should gradually reor- 
ganize the kindergarten and the primary school in 
such a way that the school beginner will be under 
systematic, purposeful observation. This means a 
gradual relaxation of our present zeal to “teach” 
him, and the substitution of a much more whole- 
69 70 
THE PRE-SCHOOL CHILD 
some solicitude, namely, one to saleguard his health 
and to understand his psychology. 
Administrative readjustments. The kindergarten 
is admirably fitted for the development of a policy of 
observation of school beginners leading to a hygienic 
control of school entrance. The kindergarten and first 
grade could be gradually reorganized in a manner to 
bring at least the first half of school life under sys- 
tematic, purposeful scrutiny. Teachers, program, 
schedule, equipment, and medical inspection could be 
adapted to this end. There should be an induction 
period, with a system of record-keeping, and classifica- 
tion of pupils to determine their immediate educa- 
tional treatment and their subsequent treatment in 
the grades. 
Fully aware of the practical difficulties involved, let 
us sketch some of the features of an ideal induction 
plan. Let us assume a kindergarten organized with a 
flexibility which will bring it into actual contact with 
the pre-kindergarten period of the child, and which will 
also give it some freedom of operation in the period, 
ordinarily preempted by the first grade. Let us as- 
sume the complement of this — that the organization 
of the primary department will be elastic enough to 
permit full emphasis on the basic developmental needs 
of the child, rather than on reading, spelling, and arith- 
metic. These are generous assumptions; but we are 
counting upon a generous reader and a real disap- 
proval of the present haphazard and unhygienic 
conditions which surround school entrance. SCHOOL ENTRANCE 
71 
The solution of the problem of school entrance can 
be discussed under the three following heads: 
1. Health examination and health supervision. 
2. Psychological observation. , 
3. Educational adjustment. 
A school entrance examination. Surely there should 
be, at a minimum, a thorough and comprehensive 
physical examination of the school beginner. The 
desirability of this is obvious to common sense, but 
strangely enough only here and there has the idea been 
put into practice. Candidates for army life, for in- 
dustry, and for insurance are subjected to a careful 
medical investigation. Why not the candidate for 
school life, which is by no means without its hazards 
and burdens? A physical examination for every 
school beginner is so important that, if necessary, the 
summer vacations should be used for the purpose, and 
such examinations, whenever possible, should be made 
in the presence of, and with the cooperation of, the 
parents. 
But what is a school beginner? Is he the six-year- 
old boy who, for chronological reasons, then comes 
under the law of compulsory education? Naturally 
and ordinarily this is what the true term means. But 
from the standpoint of systematic hygiene it becomes 
necessary to ask whether this examination at school 
entrance ought not to be anticipated by periodic 
examinations throughout the whole pre-school period, 
1. Health examination and health supervision 72 
THE PRE-SCHOOL CHILD 
and by a policy of health supervision which will con- 
secutively follow the child through this period, and 
perhaps become intensified during the kindergarten 
age. This is the goal toward which health work is 
rapidly moving, and as it is reached, a specialized 
school entrance overhauling becomes of less impor- 
tance. 
The objective in public health work. One of the 
great objectives of public health work is the preven- 
tion of disease and the reduction of defects. From the 
standpoint of preventive medicine, it is more impor- 
tant that the child should receive careful health exam- 
ination and oversight when he is four years old than 
when he is six years old, and every argument which we 
make for a physical examination at school entrance 
becomes stronger as we recede to the period of in- 
fancy. 
The conclusion which follows from this simple logic 
is that there should be an unbroken system of health 
supervision which will perhaps have its places and 
times of emphasis, but which will never be relaxed. 
Indeed, the school beginner should have behind him 
a record of consecutive periodic examinations, and a 
series of special health adjustments made in his behalf, 
both at home and in kindergarten. The ignorance 
which we now maintain regarding his health and de- 
velopmental history cannot persist indefinitely. 
The kindergarten as a recruiting station. It is in the 
administration of this health supervision and of health 
adjustments that the kindergarten will find a new SCHOOL ENTRANCE 
73 
field for usefulness. The medical profession can fur- 
ther the development of young children in two ways: 
(a) by directly or indirectly advising parents as to 
treatment, and (6) by utilizing agencies and institu- 
tions, such as nurses, social workers, nurseries, kinder- 
gartens, playgrounds, etc., to bring about actual 
health-promoting changes. Frequently these “health- 
promoting changes ” are bound up with habits, with 
conduct, with morale, and with regime; they are always 
likely to have some educational aspect. Health is not 
a commodity which can be dispensed by any single 
agency. It is something so personal that the funda- 
mental responsibility for it must always rest with the 
home and the individual, but the deficiencies or limi- 
tations of home and individual must frequently be 
corrected and compensated through social devices. 
In health instruction, in nutritional work, in con- 
structive measures, both group and individual, for 
physically handicapped children, the kindergarten 
might become an indispensable instrument, particu- 
larly for the age period from three to six. 
If “ school entrance ” is in any way to be regulated in 
terms of physical fitness, the kindergarten may become 
not only a recruiting station, but even a development 
battalion for our vast public school army. Equip and 
staff the kindergarten so that it will function as a 
combined health and educational agency, and it will, in 
a new setting, and with more plastic material, accom- 
plish works of human salvage surpassing those done 
under the stress of vzar.' THE PRE-SCHOOL CHILD 
74 
2. Psychological observation 
Importance of an intelligence rating. All that has 
been said in regard to examination and supervision of 
physical development applies with equal force to 
mental development. It is important to discover 
the individual differences and the psychological excel- 
lencies and weaknesses of the school entrant. This 
can be done if the problem is definitely made part of 
the policy of the kindergarten. Under present con- 
ditions the kindergarten makes little effort to take 
account of the diverse capacities of its charges. Ter- 
man reports that “ When asked to estimate the intelli- 
gence of each child on the usual scale of five; very 
superior, superior, average, inferior, and very inferior, 
the teachers protested that there was almost nothing 
in kindergarten work on which they could base a 
judgment.” 
This statement emphasizes the necessity of intro- 
ducing some form of applied psychology into the kin- 
dergarten. In some cities an effort has been made to 
test school beginners with the Binet measuring scale 
of intelligence, which furnishes ratings in terms of 
mental age. Myers has offered a pantomime group 
intelligence test, given without language and designed 
for kindergarten to Grade Six in districts where there 
are many foreign-born children. The Detroit public 
schools are meeting the situation with individual tests 
devised for kindergarten children, and with a group 
test for the first-graders; the purpose of which tests is SCHOOL ENTRANCE 
75 
to differentiate the children into (a) slow, (6) normal, 
and (c) fast-moving groups. “This gives all children 
the satisfaction and encouragement which comes from 
real accomplishment; it saves time for the bright pupils 
who may often be promoted after a half year, thus 
reducing the cost of instruction; and it prevents dull 
pupils from becoming contented with poor work.” 
The revised version of the Detroit Kindergarten 
Test consists of thirty pictures which the pupils sim- 
ply mark with a pencil, in response to commissions 
like the following: Test 1: “Show me the thing that is 
up in the sky.” “ Show me the thing that gives light.” 
Test 8: “See these pictures.” “Point to two things 
which show that it is summer.” The testing takes 
from seven to twelve minutes, and the score is used 
to classify the pupil into one of the above-mentioned 
groups. 
The Detroit First-Grade Intelligence Test is really 
an adaptation of the army mental test to meet the 
mental level of the six-year-old child. The children 
in small groups hold their pencils up, as did the army 
recruits, and bring them down, on the appropriate 
command, to solve by some mark or line a pictorial 
problem printed on the test sheets before them. The 
score is a numerical index, which is translated into a 
lettered rating corresponding to the intelligence group- 
ings used by the army: A, B, C+, C, C—, D, E. 
Limitations of psycho-metric classifications. The use 
of intelligence tests with school beginners represents 
a constructive effort to improve the prevailing hap- 76 
THE PRE-SCHOOL CHILD 
hazard conditions of school entrance. Their purpose 
is to prevent or reduce the excessive number of failures 
which occur in the first grade. It is important, never- 
theless, to call attention to the limitations and dangers 
of purely psycho-metric tests. Our numerical ratings, 
however accurate they may seem because of their 
statistical formulation, need to be supplemented by 
data which cannot be secured by ordinary psycho- 
metric methods. These ratings do not supply an in- 
fallible index of a child’s capacity, though they may 
be very valuable aid in developing a true estimate of 
his mental status. A true estimate depends upon an 
evaluation of those moral, social, and emotional traits 
which constitute the most consequential factors of his 
personality make-up. 
There is a real danger that the convenience and ap- 
parent precision of psycho-metric tests will lead to a 
somewhat mechanical classification of pupils; and it is 
already evident that these tests will tend to be used 
to determine academic capacity and school promotion. 
The tyranny of the three R’s has asserted itself even 
in kindergarten tests. We hope that mental classifica- 
tion in the kindergarten will not yield too exclusively 
to this influence. 
From the broad yet concrete standpoint of mental 
hygiene, the determination of academic capacity at 
the time of school entrance should be a secondary con- 
sideration. However important educational measure- 
ments and numerical ratings may be in the adminis- 
tration of the elementary grades, the function of a SCHOOL ENTRANCE 
77 
psychological service in the kindergarten should be 
nothing less than an attempt to estimate and interpret 
differences in personalities and character formation. 
Methods of observation. Such a service, when fully 
developed, implies competent psychiatrists and psy- 
chologists attached to the school organization; but 
the burden of this work could be carried by the kin- 
dergartners themselves, under direction. What we 
need is more deliberate and patient psychological 
observation, of a non-technical type — the kind of 
observation which tests sometimes actually inhibit. 
Psychological observation, as we use the term here, is 
daily, hourly observation of the child engaged in the 
activities of school life. 
His behavior at plays, games, hand-work, dancing, 
in conversations, and in his constructive enterprises 
becomes of real significance when made an object of 
purposive observation. When duly recorded and in- 
terpreted, this will prove to be psychological observa- 
tion of the highest value which may be made to throw 
important light upon the moral and emotional equip- 
ment of the school beginner. Certainly such observa- 
vation is necessary to supplement the raw rating of an 
intelligence index. 
The social and constructive activities of the kinder- 
garten give fine scope for this very observation which is 
needed if we are to regulate school entrance. Through 
them we can discover the superior, the balanced, the 
inadequate, the unstable, the infantile, the speech 
defective, and all the exceptional children who need a 78 
THE PRE-SCHOOL CHILD 
specialized educational hygiene and a readjustment of 
procedure as to school entrance. 
Such a policy of intelligent observation of the chil- 
dren is not incompatible with the program of the pro- 
gressive kindergarten of to-day. It simply gives to 
these programs a double trend, one which is educative 
and another which is interpretative. 
Observational value of the project. One of the 
best examples of this double aspect is represented by 
the so-called “project method” which has been so 
fruitfully developed by the kindergarten. A project 
is an enterprise of some complexity which requires 
purposive thinking to bring it to a conclusion. It is 
not something which is done from mere habit or 
prescription. A typical schoolroom project implies a 
motive on the part of the child, a desire to do some- 
thing for himself or for the group; a consecutive, con- 
structive thought process; and a result which gives 
sincere satisfaction to himself and possibly to the 
group in which he is working. Whether it is the con- 
struction of an aeroplane, of a grocery store, or of a 
bean bag (and a kindergarten child will attack any one 
of these problems), it is not only an avenue for self- 
expression, but it is virtually an objective, psychologi- 
cal, behavior test through which he reveals himself 
to the observer. And it is a particularly valuable 
psychological “test,” because it brings into play so 
many personality traits, moral and social. 
In a recent study made in a Meriden kindergarten, 
in which we were interested, the teachers found that SCHOOL ENTRANCE 
79 
the deliberate observation of the project work of the 
children gave objective evidence for estimating the 
degree of such qualities as initiative, originality, so- 
ciability, self-assertion, alertness, span of attention, 
imitation, and leadership. Twice a week there was a 
period or session given over to free activity, in which 
the children had free choice of kindergarten materials. 
This free period was justified alone because of the in- 
formation which it gave to the teachers. At the end 
of the year they had an intelligent judgment as to 
which children should be promoted, and which de- 
tained for further development work in the kinder- 
garten. 
Indeed, it would be possible to classify children 
on their ability to achieve certain types of project 
work; and it would be possible to grade them serially 
as Project A, Project B, and Project C, etc., pupils. 
It would also be possible to graph for each child a 
project profile, indicating his development in certain 
emotional and attitudinal respects. But here, again, 
lurk the dangers of psycho-metric methods. What we 
should strive for, in addition to index and graph, is a 
succinct descriptive paragraph which will summarize 
the important traits and outlook of each child. It will 
require a very practical kind of psychological observa- 
tion to attain to such a paragraph! 
Good psychological observation requires an educa- 
tional setting. Those who have a certain sentimental 
attachment to the kindergarten may fear any features 
which might destroy the idealizing, optimistic spirit of 80 
THE PRE-SCHOOL CHILD 
its work, but this fear is unfounded. In the first place, 
we cannot observe children at their best unless they 
are in an educational environment and an atmosphere 
which puts them at their best. The modern kinder- 
garten is potentially an effective observation station, 
because its best educational work is informed with a 
fine, free spirit. We cannot set into operation an in- 
terpretative individual psychology without the aid of 
a favorable educational setting. Such a setting is in- 
dispensable for the timely detection of cases of psycho- 
pathic personality, and nervous and border-line con- 
ditions for which preventive work is most hopeful. It 
is well to remember that our best justification for 
applied psychology is, after all, one of prophylaxis or 
prevention — and prevention must start early. Why 
not in the kindergarten? 
But the principle of prevention always leads us 
backward in time and space. We arrive at the same 
viewpoint in regard to the child’s “mind” that we 
reached with regard to his physique. There should 
be periodic physical examinations and a consecutive 
health supervision throughout the whole pre-school 
period, beginning with the nursling; and practically, 
as well as theoretically, there is every reason why this 
oversight should be made to include developmental 
observation and educational guidance. Indeed, if 
mental hygiene in this field is to be anything more than 
a vague abstraction, we must devise some way by 
which important errors and defects of mentality or of 
character development can be detected and perhaps SCHOOL ENTRANCE 
81 
mitigated. The conferences at health centers, and the 
periodic health examinations, may be widened in their 
scope, so that standards of healthy mental as well as 
physical development will come more fully into effect. 
Developmental history a desirable aid. From the 
standpoint of school entrance, it is both desirable and 
practical that we should have in our possession a brief, 
cumulative biographic record, which will summarize 
the child’s previous development. A physician would 
not undertake a difficult diagnosis without an anam- 
nesis of the case. Hygiene and education cannot 
do their best for the child unless his developmental 
history is known. The very adaptation of the pro- 
gram of the kindergarten to the needs of individual 
children requires an appreciation and often a careful 
interpretation of what has happened to those children 
during their pre-kindergarten careers. 
The kindergarten may aid the elementary school by 
furthering a hygienic rationalization of school entrance; 
but the kindergarten itself has its own matriculation 
problems, which must be solved in the same manner by 
taking systematic account of the previous career of 
the candidate. Mechanical classification by psycho- 
metric methods will never solve these problems. We 
shall always need a biographic, quasi-clinical type of 
observation all along the line. The farther back we 
push this observation, and the more closely we knit it 
to our public health technique, the more likely we are 
sometime to accomplish preventive and reconstructive 
results in the field of mental hygiene. 82 
THE PRE-SCHOOL CHILD 
3. Educational adjustment 
Kindergarten and first grade. The kindergarten is 
not only an instrument for determining the develop- 
mental differences and needs of school beginners and 
fledglings. It is an educational institution which must 
perform its proper and essential part in the actual work 
of education. Indeed, the two functions are inter- 
dependent; each reenforces the other. One reason 
why the skeptics hold the work of the kindergarten 
in low esteem is because they see in it an idealistic edu- 
cational enterprise which is made fatuous because it 
is not discriminatingly adapted to the varying needs 
of individual children. 
The educational value of the kindergarten will be 
heightened if its methods become psychologically more 
scientific, and if its motive becomes sincerely that of 
hygiene. To make possible the operation of such 
methods and motive, the primary school must modify 
its objectives. Surely the first grade, at least, must 
relax its excessive emphasis on the so-called “funda- 
mentals,” and shift it to true fundamentals. A 
modernized first grade will bear a striking family 
resemblance to a modernized kindergarten. We may 
even dispense with the teaching of reading, although 
this is not necessary. With a community of spirit 
between the first grade and the kindergarten, and an 
interlocking flexibility of procedure, much can be 
hoped for the improvement of school entrance through 
educational adjustment work. SCHOOL ENTRANCE 
83 
Mental, social, and moral maturity. These adjust- 
ments must take into account the developmental 
maturity of the children, a factor which is at present so 
much ignored that approximately one pupil out of 
every four fails of promotion at the end of the first 
year. Miss Cuneo made a mental test of 112 children 
attending California kindergartens. All but 19 of 
these pupils were from 4 to 6 years of age. The men- 
tal ages ranged from 3 years and 4 months, to 7 years 
and 7 months. Comparison of the mental ages of 
these 112 children with the mental ages of 150 un- 
selected first-grade children tested by Dickson showed 
that nearly a fourth of the kindergarten children 
equaled or exceeded the median mental age of those in 
the first grade, and more than half equaled or exceeded 
the lowest fourth of first-grade children. Educational 
classification cannot be safely determined by mental 
age alone, but the overlapping revealed by these 
figures points to the necessity of fundamental read- 
justments between the kindergarten and first grade, 
and of differential provisions for relatively superior 
and relatively inferior groups. 
If we had numerical devices for portraying differ- 
ences in social and moral maturity, we should un- 
doubtedly find the same degree of overlapping and 
many amazing disparities and incongruities which are 
now lost sight of. These individual differences in 
emotional and volitional traits are of more importance 
than those which are purely intellectual. A program 
giving a large place to individual and social project 84 
THE PRE-SCHOOL CHILD 
work, and to plays and games, will reveal those chil- 
dren who are most in need of corrective educational 
work in this field. It is important that infantile, dif- 
fident, and seclusive children should not be too hastily 
“promoted.” It is desirable that children with traits 
of courage and leadership, and with gifts of artistic 
imagination, should have opportunities for their ex- 
pression. 
The kindergarten and a hygienic control of school 
entrance. If the kindergarten and first grade con- 
jointly develop into a kind of vestibule or induction 
school, the present gap between them will be bridged, 
and the lamentable rigidity of the present regulation 
of school entrance will break down. Ideally such an 
induction school should detain some children a very 
long time, and others it should speed on; some children 
might attend it for specific purposes only a portion of 
a day, or a few days in the week; other children, even 
after promotion, might be returned to it for short 
periods; and it may be that for still other children 
who are seriously handicapped very special provisions 
should be made for ages as low as two and as high as 
eight. The function of the kindergarten in this field 
will be indicated in a later chapter. 
Unless we choose to limit the kindergarten to a very 
narrow, independent sphere of work, it seems that it is 
destined to play an important role in a much-needed 
hygienic rationalization of school entrance. CHAPTER VI 
HANDICAPPED SCHOOL CHILDREN 
The school as a child-welfare agency. When the 
term “handicapped children” is used, we usually 
think of school children. We associate the term with 
those children who, by reason of physical or mental 
defect, are unable to profit from ordinary instruction 
and therefore need special educational or hygienic 
adjustments in their behalf. The problem of handi- 
capped school children is indeed a large one, and the 
responsibility of the elementary-school system in re- 
lation to the problem rests upon broad legal and social 
sanctions. 
In a later chapter it will be our purpose to consider 
the importance of the pre-school period in the causa- 
tion and control of handicaps; but a proper perception 
of these pre-school aspects depends upon an apprecia- 
tion of the functions of the public school in the care 
and treatment of its exceptional children. 
In the consideration of certain problems of child 
welfare, we are apt to forget or to undervalue the im- 
portance of our public school system. Our vast ag- 
gregation of elementary schools ought, however, to be 
regarded as our largest and, in a sense, most legitimate 
official child-welfare agency. Certainly the historic 
sanction and strategic position of the public school 
system in the American commonwealth make it the 86 
THE PRE-SCHOOL CHILD 
most promising instrument for the further develop- 
ment of public policies in behalf of a very large pro- 
portion of those exceptional children who, because 
of handicap or other circumstances, need a special 
measure of extra parental care during the years of their 
education. 
A few statistics will convey the broad outlines of the 
national situation. The figures are rounded, but 
sufficiently accurate for the purpose in hand. There 
are twenty millions of children enrolled in the elemen- 
tary public schools of the country. These children are 
provided for in over a quarter of a million of buildings, 
with a valuation of two billions of dollars. The per- 
sonnel of this vast plant consists of over a half-million 
teachers, supervisors, and superintendents; and, in 
city districts, of about three thousand physicians and 
school nurses and sixteen hundred truant officers. The 
welfare of no less than three quarters of a million of 
physically and mentally handicapped children is af- 
fected by the policies of this huge institution. 
Types of educational handicap. A complete classi- 
fication of handicapped children would include all those 
children who, by virtue of exceptional circumstances or 
of inherent or acquired constitution, deviate so much 
from the normal as to cause a special status to arise 
with reference to their educational and social treat- 
ment. Sometimes the courts determine when the 
special status exists; sometimes it is a matter of com- 
mon knowledge; sometimes it is only recognized by 
experts; but, in one way or another, the handicapped HANDICAPPED SCHOOL CHILDREN 
87 
child generally comes within the purview of the public 
school system and educational law. 
A comprehensive list of the consequential forms of 
handicap would include those of environmental char- 
acter, abnormal home, and economic conditions, such 
as illegitimate parentage, dependency, neglect, and 
injudicious employment; and a large group of con- 
stitutional and acquired handicaps affecting physique, 
sensation, motor capacity, social conduct, and men- 
tality. We shall consider mainly the children with 
constitutional and acquired handicaps. 
It is, of course, impossible to set precise limits to 
such a term as “handicap.” The scope of our dis- 
cussion, however, is indicated by the following quota- 
tion from a recent Connecticut statute: 
The term educationally exceptional children shall include 
all children over four and under sixteen years of age who, 
because of mental or physical handicap, are incapable of re- 
ceiving proper benefit from ordinary instruction and who 
for their own and the social welfare need special educational 
provisions. 
It will be noted that this statutory definition partly 
recognizes the pre-school as well as the school aspect 
of the problem, by including children of ages as low as 
four and five. 
Distribution of handicaps. On the basis of this 
definition I would estimate that about one public 
school pupil out of twenty-five may be regarded as 
exceptional. From the standpoint of child welfare 
and school administration, the distribution of such ex- 88 
THE PRE-SCHOOL CHILD 
ceptional children per 1000 of all children of compul- 
sory school age would be approximately as follows: 
Blind and partially sighted 3 
Deaf and semi-deaf 2 
Crippled 2 
Physically defective 12 
Psychopathic 2 
Delinquent 4 
Speech defective 3 
Mentally deficient 12 
Total number per 1000 40 
If we give the term “exceptional” a still wider con- 
notation, we would include in the above list two further 
groups of children: (a) those who are not classified as 
feeble-minded, but who are extremely dull or non- 
academic; and (6) those who are unusually gifted or 
endowed with superior intelligence. These two groups 
combined would bring the total up to 50 per 1000. 
They are by no means unimportant from the stand- 
point of social and educational policy. 
No one of the above groups can be limited with 
absolute precision. A speech defect, for example, may 
be so mild as to be negligible or so severe as to consti- 
tute a real handicap. The figures we have given are 
intended to include school children whose defect or 
deviation is so serious as to call for special considera- 
tion, even in a non-Utopian state. 
New conceptions of educational obligation. A gen- 
eration ago the exceptional child was not conceived 
as being a legitimate public school problem. It was 
assumed, it is even now sometimes argued, that the HANDICAPPED SCHOOL CHILDREN 
89 
business of the schools is to teach the statutory sub- 
jects — reading, writing, and arithmetic; but the 
principle of compulsory education in a democratic 
country has carried with it implications which have 
brought about an altogether different point of view. 
A policy of exclusion would have led to only confusion 
and injustice. The public school in progressive com- 
munities is steadily shouldering the whole problem of 
defective and handicapped pupils, and one can find 
examples of special tax-supported provisions for every 
type of exceptional school child. 
The present status and possibilities of these provi- 
sions can be briefly indicated for each of the eight classes 
of children referred to in the preceding classification. 
i. Blind and partially sighted. The number of 
pupils in schools and classes for the blind in 1918 was 
5386. About nine per cent of these were receiving 
their education in ten cities where classes for the blind 
are part of the public school system. The first city 
school classes for the blind were inaugurated by New 
York City and Cleveland in the year 1909. One or 
more classes were maintained in 1921, by Chicago, 
Detroit, Jersey City, Newark, Cincinnati, Mansfield, 
Toledo, and Milwaukee. It is very significant that in 
a short period of twelve years such a large proportion 
of blind children should have been reached by the 
public schools; and that such states as Pennsylvania, 
Ohio, Minnesota, and New Jersey should have passed 
laws providing liberal State aid for the education of 
blind children in public school classes. 90 
THE PRE-SCHOOL CHILD 
Cleveland has been a pioneer in having the blind 
taught in classes with seeing children. The special 
teachers for the blind children are tutors for the group, 
and segregation is reduced as much as possible. Since 
the blind must find a place in life beside the seeing, this 
Cleveland plan has much to commend it. This same 
consideration is a reason for further fostering public 
school provisions. It is not impossible that State de- 
partments of education and commissions for the blind 
will gradually develop an administrative technique, 
through supervising experts, visiting instructors, and 
training centers, whereby an increasing number of 
blind children from small communities can be educated 
under public school auspices. The fact that the per 
pupil cost of education in a public school class for the 
blind is less than half of the per pupil cost in a public 
institution will fortunately not act as a deterrent. 
The education of the near blind or partially sighted 
is a problem which falls peculiarly within the scope of 
the public school. Surely it is not a problem to be 
solved by erecting State institutions, or by excluding 
the child from school attendance. The task is not a 
small one. The Massachusetts Commission for the 
Blind found that four per cent of all school children 
tested had less than one half normal vision, and that 
0.4 per cent (one in ten of this group) were so seriously 
handicapped as to require special educational pro- 
cedure. Special sight-conservation classes for par- 
tially sighted children are being established in several 
of the larger cities of the country, and with very bene- HANDICAPPED SCHOOL CHILDREN 
91 
ficial results. These classes should be fostered, but 
here again the special class has its limitations. More 
flexible provisions, more abundant materials, including 
large-type texts, can be created to reach the individ- 
ual child who, in spite of his visual handicap, must 
be maintained in a regular school. 
2. Deaf and semi-deaf. The drift toward public 
school care has, in the case of deaf children, been even 
more marked than in the case of the blind. This is all 
the more remarkable when it is recalled that the educa- 
tion of the deaf is one of the most difficult of pedagogi- 
cal tasks. Government statistics show that the number 
of State and private schools for the deaf since 1900 
has remained practically the same throughout the 
United States. The number of public day-school 
classes has increased from 41 in that year to 69 in 1918. 
The enrollment in these classes has mounted from 749 
in 1900 to 2482 in 1918, an increase of 231 per cent; 
while the relative enrollment in State institutions has 
decreased in the same period from 89 to 78 per cent. 
This is a wholesome tendency. The care of the 
deaf, like that of the blind, should so far as possible be 
de-institutionalized. The deaf child should, when 
practical, grow up in contact with the hearing child. 
Such contact can be supplied in the public school. 
Moreover, public school provisions for the deaf en- 
courage the beginning of the oral method at the tender 
but favorable age of three or four, when families are 
naturally reluctant to commit to a distant institution. 
Several States now foster the extension of public school 92 
THE PRE-SCHOOL CHILD 
classes by special grants of State aid. This fortu- 
nately is an administratively economical as well as a 
humane policy. The average annual cost per deaf 
pupil enrolled in public schools was (in 1918) $195. 
The corresponding average per capita expenditure in 
State institutions was $399; a difference of $200 per 
pupil in favor of those communities where deaf chil- 
dren were trained to speak and to read the lips, without 
being separated from their homes and from the com- 
panionship of more fortunate schoolmates. 
3. Crippled children. Chicago, in 1899, established 
the first public school for crippled children in the 
United States. It now maintains under the Board 
of Education a permanent school building for the 
exclusive use of crippled children. The New York 
classes, inaugurated in 1906, now register over a thou- 
sand pupils. As many as eleven special classes for 
crippled children are maintained in one building. 
The provisions for crippled school children now to be 
found in the larger cities often include school lunches 
and transportation. Sometimes the transportation is 
to regular classes. The per capita cost is not pro- 
hibitive, being less than that for the education of the 
blind and deaf. In Chicago, in 1916, it was $51 for 
teachers’ salaries, $8 for lunches, only 16 cents for sup- 
plies, and $86 for transportation, a total of $145. 
The complete and careful survey made in Cleveland, 
in 1916, showed that there were six cripples for each 
1000 inhabitants; 22 per cent of all cases were under 
15 years of age; nine per cent were from 15 to 19 years HANDICAPPED SCHOOL CHILDREN 
93 
of age. The age distribution of the blind shows that 
only 7 per cent are under 15 years of age. Further- 
more, in only 26 per cent of the blind does the disability 
occur before the age of 15; while in the case of the 
crippled the proportion is 49 per cent. These figures 
emphasize the public school importance of the crippled 
child. The solution of the problem, however, involves 
much more than the creation of special classes and pro- 
visions of transportation. Many crippled children 
need medical care over long periods of time. This care 
can be rendered best by a hospital type of school, which 
should, however, maintain close relations with the 
public system of education. Here again it is desirable 
to avoid, so far as possible, unnecessary segregation or 
any tendency that would make the cripple self-con- 
scious and dependent. The purely educational and 
vocational part of the task is one which the public 
school could undertake, even in sparsely settled com- 
munities. 
4. Physically defective. This group is a difficult 
one to define. We include in it all children who are so 
seriously handicapped by malnutrition, cardiac defect, 
or chronic disease as to be urgently in need of special 
hygienic arrangements in school. To place the num- 
ber of such children at over one per cent is conserva- 
tive. The number of under-nourished children in an 
ordinary school population has been placed as high as 
from fifteen to twenty per cent; and as many (to a 
large extent the same children) are considered to 
be predisposed to tuberculosis. Medical inspection, 94 
THE PRE-SCHOOL CHILD 
health instruction, physical education, nutrition classes, 
school lunches, home visitation, etc., must be counted 
upon to reach this large group of inferior children. 
Open-air rooms and hospital schools are, however, 
necessary for the adequate treatment of many children. 
The first open-air schoolroom in the United States was 
established in Providence, in 1908. Since then such 
rooms and open-window classes have spread with 
great rapidity over the country, and can now be num- 
bered by the score. New York alone has in the neigh- 
borhood of one hundred open-air classes. Vacation 
camps and summer outdoor schools for physically 
defective children will undoubtedly be further devel- 
oped as a legitimate part of public school work. The 
welfare of the physically defective child in smaller 
communities depends upon a close coordination of 
public health, medical, and educational control. Much 
can still be done for him by special adaptations and 
supervision within the regular school. 
5. Psychopathic. Although mental or nervous dis- 
ability constitutes one of the heaviest burdens of 
society, almost nothing has been done by the public 
schools in the way of preventive mental hygiene. In 
1920 there were 232,680 patients with mental disease, 
14,937 epileptics, and 1971 alcoholic and drug addicts 
actually in institutions in the United States. A con- 
siderable proportion of all cases of mental and nervous 
disease are conditioned, if not caused, by factors which 
operate in childhood and youth. There are no con- 
venient or accurate methods of diagnosis which will HANDICAPPED SCHOOL CHILDREN 
95 
reveal those children who are harboring a latent 
insanity or developing the basis for an insanity. Or- 
dinary special-class methods will have decided limita- 
tions in this field, but careful observation and guidance 
of pupils with psychopathic tendencies has, on a small 
scale, been successfully inaugurated in the New York 
public schools. The first step in the development of 
constructive school measures lies in recognizing pupils 
who show serious defects in personality make-up, 
symptoms of emotional instability, emotional shallow- 
ness, perversions, irritability, morbid fears, psychas- 
thenia, social maladjustments, infantile dependency, 
etc. The psychopathic child is father to the psycho- 
pathic man. Once the significance of this type of 
child is grasped, ways and means for ameliorating his 
condition and forestalling its latter-day consequences 
can be found. 
We need, perhaps, to develop a new type of school 
nurse, who, by supervision, corrective teaching, and 
home visitation, will undertake the concrete tasks of 
mental hygiene. This psychiatric school nurse would 
be a counterpart of the medical school nurse and work 
in close contact with her, but she would revolve in a 
different circle of problems. Instead of pupils with 
discharging ears and deteriorating molars, her clients 
would be the child with night terrors, the nail-biter, 
the over-tearful child, the over-silent child, the pervert, 
the infantile child, the unstable choreic. There should 
in time be schools, classes, and camps in close relation 
to city and State school systems where children of this 96 
THE PRE-SCHOOL CHILD 
type may go, 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. From a financial 
viewpoint these suggestions seem extravagant; but 
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 sanitation administered through the public 
schools may, after all, prove to be a form of socialized 
thrift. 
6. Delinquent. What has just been said about 
psychopathic children applies in great measure to the 
delinquent group. Both groups comprise disorders of 
conduct, faulty social adjustment, abnormal behavior, 
and instability. The psychological and psychiatric 
approach emphasizes the close relation and sometimes 
the identity of the problems involved in both fields. 
Our increasingly scientific attitude toward crime is 
bound to reflect itself in public school procedure. 
Cleveland, in 1876, was the first city in the country 
to organize a school for incorrigible boys. A promi- 
nent motive was that of segregation and discipline. 
Similar “disciplinary classes,” refractory classes, and 
day schools for truants have sprung up in our larger 
cities. Reformatories for boys and girls have usually 
been organized as State institutions and largely in- HANDICAPPED SCHOOL CHILDREN 
97 
dependent of the State educational system. It is de- 
sirable in many ways that public school provisions 
for the delinquent be further developed, so that the 
number of commitments to reformatories may be re- 
duced and more timely preventive work may be done. 
A very considerable proportion of all careers of juvenile 
delinquency first manifest themselves in truancy, and 
a thoroughgoing interest in and study of all types of 
misfits and exceptional school children would ulti- 
mately lead to the reduction of crime. About one fifth 
of the population of reformatories is ordinarily defec- 
tive in mentality. Industrial training and supervised 
vocational provisions, in close relation to local school 
systems, would make it unnecessary to commit many 
of this class of delinquents to State institutions. 
The public schools ought to function in closer coop- 
erative relations with juvenile courts, probation serv- 
ice, and industrial schools. The establishment of 
a “Twenty-Four Hour School,” conducted by the 
Whittier (California) State School (for delinquent 
boys), is a promising experiment; it may be an object 
lesson of what public schools, by modified methods, 
might accomplish for the delinquent, without sending 
him out of the community for reform. 
7. Speech defective. Stuttering children are sadly 
in need of attention, for as a rule they are neglected by 
both parents and physicians. Only those familiar 
with the subject can appreciate how serious this handi- 
cap is, what suffering it causes, and what effects it 
produces on the more sensitive child. Stuttering is a 98 
THE PRE-SCHOOL CHILD 
disease, often associated with serious mental and 
nervous complications, but it is definitely curable, and 
responds to corrective training. For many years 
European public schools have provided this speech- 
corrective work. To-day it is coming to be considered 
a natural function of the schools in this country, as 
shown by recent subsidy legislation in Ohio, Minne- 
sota, Wisconsin, and elsewhere. New York started a 
class in 1909, and has demonstrated the possibility of 
reaching a relatively large number of speech-defective 
pupils by assigning them, for portions of a day and term, 
to a speech-improvement class and permitting them 
to remain in their regular room the rest of the time. 
8. Mentally deficient. Inborn and acquired de- 
ficiency of intelligence handicaps at least one child out 
of a hundred. In some respects this handicap is more 
serious than other forms already discussed; but in 
other respects it may actually be less serious for the 
individual and less burdensome to the State because it 
yields to social control. 
In 1919-20 the National Committee for Mental 
Hygiene made a survey of provisions for mentally 
defective children. Thirty State and seventeen pri- 
vate institutions reported 26,774 children; 108 cities 
in the United States reported 1177 special classes pro- 
viding for 21,251 defective pupils We know that the 
number of cities reporting is incomplete. It is safe to 
say that the public schools of the country are provid- 
ing special provisions for as many mentally defective 
children as are now cared for by institutions Feeble- HANDICAPPED SCHOOL CHILDREN 
99 
mindedness is more and more coming to be regarded as 
a public school problem. Newark, Rochester, Boston, 
New Haven, and other cities have demonstrated that 
it is possible to create, within the public school system, 
day schools for defectives which embody the best fea- 
tures of State institutions, and which offer significant 
evidence of the adaptability of our public school sys- 
tem. These special schools, and special classes as well, 
often provide for children whose mentality is no higher 
than that of the institutional imbecile. Their chief 
function, however, is the timely training of the moron 
along lines which will make him more secure, useful, 
and happy in his community. 
Feeble-mindedness is, of course, incurable, and even 
the graduate of a special class may need to be sent to an 
institution; but public school training, supplemented 
by a system of community after care, will not only 
reduce enormously the necessity of institutional com- 
mitment, but also many of the classic consequences of 
feeble-mindedness — vagrancy, prostitution, depend- 
ency, crime — and more feeble-mindedness. 
New Jersey, Massachusetts, New York, Wisconsin, 
Pennsylvania, Missouri, and Minnesota all had laws, 
by 1921, making the establishment of special classes 
for mentally subnormal children obligatory. In all 
of these States there is supervision by the State De- 
partment of Education, and in most of them some 
financial aid is granted by the State. Wisconsin bears 
one third of the expenses for such classes; Pennsylvania 
one half; Minnesota pays annually the liberal sum of 100 
THE PRE-SCHOOL CHILD 
$100 for each child receiving special class instruction. 
Prompt State-wide enforcement of these compulsory 
laws is inexpedient, but the general policy behind such 
laws is correct. Feeble-mindedness is both a State 
and a local problem, and to a remarkable extent it is 
a public school problem. A consistent development 
during the next generation of the policy of public 
school training and community supervision of these 
handicapped children will prove that the problem of 
mental deficiency is not overwhelming, but, on the 
contrary, is manageable. 
Handicapped children and State policy. The above 
review of the different types of exceptional children is 
necessarily sketchy and imperfect. It reveals, how- 
ever, a group of closely related problems of great sig- 
nificance from the standpoint of child-welfare adminis- 
tration. It appears that the public school is a funda- 
mental child-welfare agency with vast powers as yet 
only partly realized. Sanctioned by far-reaching law 
and by tradition, and founded on the broad demo- 
cratic principle of compulsory education, which carries 
it into the remotest rural corners, this great agency of 
the State must in large measure determine the future 
welfare of handicapped children. 
There are several factors and considerations which 
favor the extension rather than the restriction of public 
school provisions for handicapped children: These are: 
(а) The principle of compulsory education. 
(б) The wide distribution of public school facilities. 
(c) The growth of medical inspection of schools and of 
clinical child psychology. HANDICAPPED SCHOOL CHILDREN 
101 
(d) The joint relations of State and local authority in 
school administration 
(e) The relative economy of public school provisions. 
(/) The disadvantages of institutional segregation. 
(jf) The desirability of maintaining the responsibility of 
the home. 
(A) The importance of fostering local responsibility and 
community control of social problems. 
The social significance of the principle of compul- 
sory education has been well stated by Cubberley: 
Neither does the State establish schools because by State 
cooperative effort they can be established and conducted 
more economically than by private agencies, but rather that 
by so doing it may exercise the State’s inherent right to 
enforce a type of education looking specifically to the preser- 
vation and improvement of the State. 
The extension of compulsory education. The 
creation of public school provisions for handicapped 
children represents a reasonable, constructive, self- 
protective extension of the principle of compulsory 
education. This principle has justified, in spite of 
initial opposition, the development of medical inspec- 
tion, the establishment of school nurses and clinics, 
and the certification of juvenile employees. 
Public school provisions for exceptional children 
began through local initiative, but the States of the 
Union are now framing legislation and organizing sub- 
divisions within their State Departments of Educa- 
tion, through which they will exercise their funda- 
mental jurisdiction. Connecticut, in 1915, appointed 
a school psychologist under the State Department of 
Education, and, in 1920, passed a law creating a direc- 
tor of special classes. Wisconsin, Pennsylvania, New 102 
THE PRE-SCHOOL CHILD 
York, Massachusetts, and Wyoming are among the 
States that have a special organization for supervis- 
ing and directing the education of handicapped chil- 
dren. 
The functions which naturally fall to the State in 
the public school care of handicapped children may 
be briefly summarized as follows: 
1. To issue and enforce regulations regarding school enu- 
meration and school registers, which will result in the 
reporting of all children of school age who, because of 
serious handicap or exceptional physical and mental 
condition, cannot be properly educated or trained under 
ordinary conditions. This would result in a simple 
form of registration very important for child welfare 
and social welfare. 
2. To issue regulations and printed forms, and to render 
expert advice and assistance in the educational meas- 
urement and mental examination of handicapped or 
exceptional school children, including children passing 
through the children’s court. 
3. To furnish similar direction and assistance in the or- 
ganization of special classes. 
4. To initiate and direct special educational measures in 
behalf of exceptional pupils who cannot be assigned to 
special classes, schools, or institutions. 
This particular function, though of extreme impor- 
tance, is one which remains almost completely unde- 
veloped. Measures must and can be found which 
will reach the handicapped child in rural and village 
communities. Through special courses in normal 
schools, special visiting supervisors, special training 
centers, school nurses, and circulating auxiliary teach- 
ers, a technique can be worked out which will remove 
the present neglect of the handicapped child in the HANDICAPPED SCHOOL CHILDREN 
smaller community. When a special class cannot be 
provided, a special program for the individual handi- 
capped child must be created. 
5. To administer the distribution of State aid for special 
classes and auxiliary education. 
6. To maintain general relations with all schools conducted 
in connection with special State or county institutions 
for dependent, neglected, defective, and delinquent 
children. 
7. To foster and direct, as far as expedient, measures of 
vocational guidance and supervision for the benefit of 
educationally exceptional or handicapped youth up to 
the age of eighteen or twenty. 
These powers are a natural expression of the relation 
of the State to children and to education. It should 
also be recognized that they imply a responsibility to 
handicapped children of compulsory school age who 
may be attending private and non-public schools or 
who may not be attending school at all. This re- 
sponsibility must be carefully exercised, but it cannot 
be evaded. As in child hygiene the most primary 
necessity is a registration of birth, so in the case of ex- 
ceptional school children the most elementary obliga- 
tion of the State is the enumeration and registration of 
all seriously handicapped school children. Through 
the school census and school register, over which the 
State has fundamental control, let us find out how 
many school children are thus handicapped, where 
they are, and how badly they need our help. 
The importance of gradually extending this solici- 
tude into the pre-school age will be considered in the 
following chapter. 
103 CHAPTER VII 
PRE-SCHOOL PROVISION FOR HANDICAPPED 
CHILDREN 
Medical and educational significance of pre-school 
years. A considerable proportion of the handicaps of 
school children are inherited, and a very large fraction 
of those not inherited are acquired in infancy. This 
means that the hygiene of handicapped children must 
have due regard for the pre-school years. The impor- 
tance of these years has not received full recognition. 
Here, as elsewhere, the pre-school period is relatively 
neglected, often by parents, more often by the State; 
and provisions for handicapped children of pre-school 
age have only, to a most limited extent, become part 
of public policy. 
The significance of the pre-school years will be 
briefly indicated for each of the eight major classes of 
handicap found among school children. No attempt 
will be made to cover the medical technicalities of 
this broad subject, but some suggestions of a practical 
nature will be ventured. Although funds and the ad- 
ministrative equipment are as yet lacking with which 
to do full justice to the handicapped child of pre-school 
age, much can be done even with present facilities to 
improve his status and his outlook. It is important 
that baby-welfare agencies, public-health nurses, and 
social workers should do more to direct parents in the PRE-SCHOOL HANDICAPPED 
105 
proper care and training of handicapped infants. It 
is also important that public school provisions should 
gradually penetrate downward into the nursery period 
of the children who are peculiarly in need of special 
educational treatment. 
We shall now consider each of the eight forms of 
handicap listed in the preceding chapter, and indicate 
the kind of provision that should be made for their 
pre-school care and education. 
Distribution and cause. From a statistical point of 
view the problem of blindness in the pre-school period 
is not so great as it is in later years. Indeed, blindness 
is peculiarly incident to adult and old age. Only one 
per cent of all the present blind are under five years of 
age; but from the standpoint of educational hygiene, 
which must always regard the individual rather than 
the mass, this small group of blind young children is 
extremely important. Moreover, from the standpoint 
of causation, the pre-school period is very significant. 
One third of all cases of blindness occur before the age 
of twenty-one, over one half of the cases occurring 
before that age come before the fifth year, and over one 
third before the first year of life. 
In about four fifths of the cases of blindness, it is as- 
cribable to disease, and in about one tenth of all the 
cases there is an hereditary factor at the basis of the 
disease or the blindness. Best has studied the distri- 
bution of the blind by the most important causes, ac- 
1. Blindness 106 
THE PRE-SCHOOL CHILD 
cording to the age of the loss of sight, and found in 
substance the following results: In congenital blindness 
the leading causes are malformations, ophthalmia 
neonatorum, atrophy of optic nerve, and hydrophthal- 
mus. During the first year of life by far the most impor- 
tant cause is ophthalmia neonatorum. Other causes re- 
ported are sore eyes, hydrocephalus and brain fever, 
cataract and corneal ulcer. From the first to the 
fourth year external injuries are in the lead, with 
meningitis, measles, scarlet fever, “sore eyes,” small- 
pox, cataract, and atrophy of the optic nerve as minor 
causes. External injuries include accidents, and other 
injuries from burns, firearms, sharp instruments — 
such as scissors and knives — explosives, flying ob- 
jects, and falls. About twenty per cent of the cases of 
blindness occurring in the pre-school years from one to 
six are apparently due to such injuries. A greater 
amount of prudence on the part of parents would un- 
doubtedly reduce the amount of blindness from this 
source. The safety first campaign has further con- 
quests to make in this field. 
State laws on blindness. Ophthalmia neonatorum, 
an inflammatory disease caused by the gonococcus 
germ, is yielding somewhat to preventive endeavor. 
Forty States now have laws making it obligatory to 
report inflammation of the eyes in the newborn. 
Many States supply a prophylactic solution free by 
statute or by health regulation. In some States there 
are special protective measures relating to the practice 
of midwives. With proper enforcement these laws PRE-SCHOOL HANDICAPPED 
107 
unquestionably bring results. The disease has shown 
some decline, but by no means enough to justify any 
relaxation of effort on the part of health officers, 
nurses, and physicians. 
In addition to the general compulsory education 
laws, there are special applications of the laws to the 
blind in over one half of the States of the Union. These 
laws, however, do not give recognition to the very 
great importance of the pre-school period; indeed, in 
many cases they specify the educational period to be so 
many years after the age of seven or eight, etc. Never- 
theless, the pre-school years are in many respects the 
most important in the education of the blind child. 
It is so easy to make the child in this period the victim 
of unintelligent compassion or of positive neglect, and 
to plant into his growing character traits which it will 
be difficult for later reeducation to eradicate. Much 
of the unnecessary dependency of the blind, many of 
their psychological peculiarities, and their mannerisms 
(the so-called “blindisms”) are the outgrowth of 
faulty training in the pre-school years. 
The care of blind babies. Dr. Saemisch has there- 
fore made the following general rule for parents in 
the management of their blind babies: “Treat the 
blind child exactly as if it were a seeing child.” This 
is a safe rule, with a few reservations which common 
sense will supply. The important thing in the rearing 
of a blind child is the protection of his personality. 
This must be made strong, self-reliant, and happy. 
He should therefore learn to walk at a normal age, 108 
THE PRE-SCHOOL CHILD 
even though he gets bumps; he should romp, and ex- 
plore, and play with toys; he should be as active in 
body and as investigative in mind as a seeing child. 
He should learn to dress and undress, comb his hair, 
take care of his person and possessions, keep himself 
clean, and acquire agreeable habits of deportment. 
He should not be made conscious of his handicap, but 
rather of his obligation to take a normal place, with 
normal responsibilities, in the family life. These are 
the primary lessons in the formation of his character, 
and they can be learned in a good home. 
If the home is such that these lessons cannot be 
learned, the child should be boarded out in a competent 
home, or attend some nursery or kindergarten; or he 
should be placed in the nursery department of some 
institution for the blind. A considerate, responsible, 
domestic home, however, is, for educational reasons, 
to be preferred to a merely custodial asylum. 
The needs of the pre-school blind child are so vital 
that there is room here for the development of a new 
kind of home-teaching service. This service as now 
conducted by State and private agencies is mainly 
confined to those of adult life; but it should be directed 
also to the parents of the blind babies and to the in- 
fants themselves. Lacking such service, it is incum- 
bent on nurses, social workers, and visiting teachers 
to impart and to apply these important elementary 
principles in the mental hygiene of the visually handi- 
capped. PRE-SCHOOL HANDICAPPED 
109 
2. Deafness 
Distribution and cause. Deafness is in a double 
sense a problem of the pre-school period. Unlike 
blindness, the vast majority of the deaf acquire their 
handicap at birth or during infancy. Figures pre- 
sented by Best give the following percentages for the 
different ages: at birth, 35.5 per cent; from birth to 
two years, 16.9 per cent; from two to four years, 17.1 
per cent; from four to six years, 7.3 per cent; making 
a total of 76.7 per cent for the pre-school period; and 
only 23.3 per cent for the whole span of school and 
adult life. In other words, three out of every four of 
all deaf individuals are so handicapped before their 
sixth birthday. 
Of the 35.5 per cent of cases which occur at birth, a 
large proportion are strictly hereditary, and probably 
in the majority of these instances some parental or 
ancestral deafness will be found. The reduction of 
these hereditary cases will depend upon the gradual 
adoption of eugenic safeguards. 
Nearly all the remaining cases arise in infancy or 
early childhood, and are due to infections of the middle 
ear or of the internal ear. The chief causal diseases are 
scarlet fever and meningitis. Other diseases which to- 
gether swell the total are brain fever, typhoid, measles, 
catarrh, diphtheria, whooping cough, and influenza. 
The reduction of this group of cases is plainly depend- 
ent upon the growth of medical prophylaxis, and the 
control of complications in these diseases where pre- 110 
THE PRE-SCHOOL CHILD 
vention fails. The major enemies that close the Ear 
Gate of the City of Man Soul are bacilli. 
Important consequences from the defect. As in 
almost all physical handicaps the most important 
consequences are of a psychological character, and 
have to do with the mental welfare of a personality. 
The most serious of all these consequences are those 
which concern the production and interpretation of 
speech, and these are important because they have 
such a direct influence upon the social life of the deaf. 
It follows, then, that with the deaf, as with the blind, 
we should so far as possible treat the child as though 
he were normal, make him active in mind and body, 
and give him full opportunities for companionship and 
responsibilities. 
The importance of preserving the health of person- 
ality is the strongest argument in favor of the use of the 
oral method (as opposed to the manual sign method) in 
the training of deaf children. By means of this method 
even the congenitally deaf child can acquire some de- 
gree of speech; and the semi-mute child who has ac- 
quired his deafness after he learned to talk is enabled to 
retain and to perfect his speech. The same method 
assists both the deaf mute and the semi-mute to read 
through sight the speech of others. The psychological 
importance of developing these speech abilities along 
natural lines need not be argued. 
The oral method of instruction. The most favor- 
able time for giving instruction by the oral method is 
in infancy and early childhood — before the custom- PRE-SCHOOL HANDICAPPED 
111 
ary age when deaf children are sent to institutions. 
The ideal arrangement for such instruction would be in 
kindergarten or nursery establishments, and our day 
classes for the deaf, which are increasing rapidly in 
our public schools, should make every effort to secure 
their pupils before the legal compulsory school age. 
The public schools are apparently in a better position 
to reach down into the homes and into the infancy 
period than are State institutions; so the former as well 
as the latter may develop a type of home teaching 
which will be of incalculable service to parents and 
children. Even illiterate parents have sometimes used 
the oral method with success, and it has been said that 
the most skillful lip readers have been recruited from 
those homes where mothers have persistently and con- 
sistently used this method from the time the baby 
suckled in their arms. 
The pre-school period is preeminently the period of 
language development for normal children, and for 
this very reason it must also be the most promising 
period for the oral education of the deaf. Teachers, 
social workers, and nurses may guide parents better 
to utilize these precious years in behalf of the deaf and 
semi-deaf. They are also sometimes needed to reveal 
the presence of deafness where it is not suspected. As 
Cornell says, “No one has ever recorded that a small 
child of his own initiative complained of inability to 
hear.” 112 
THE PRE-SCHOOL CHILD 
3. Crippled children 
Distribution and cause. We consider a child crip- 
pled when he is handicapped because he lacks the 
normal use of skeleton or skeletal muscles. This 
handicap, like deafness, occurs more frequently among 
children than adults. One fourth of the whole crippled 
population, as shown by the Cleveland Survey, are 
under fifteen years of age, and in over one third of all 
the cases the disability originated before the age of 
five years. About one half of the disabilities due to 
defect of foot or leg occur before the age of six. It is 
evident that the problems of prevention and treatment 
involve to a considerable degree the pre-school period. 
A careful analysis of the statistics of causes among 
the children of Cleveland shows that infantile paraly- 
sis is by far the most important factor, accounting for 
41 per cent of all the cases. Tuberculosis of bones and 
joints comes second, accounting for 15 per cent. These 
two diseases are, therefore, responsible for well over 
one half of all cases among children. Fortunately, 
both diseases yield in some measure to preventive 
control, and skillful medical and surgical care can 
ameliorate their consequences. 
Desirable and possible training. The primary im- 
portance of timely medical attention must always be 
emphasized. Parents and social workers, however, 
often make the serious error of placing exclusive stress 
on the medical and surgical aspects. The error is 
serious, because it means the neglect of mental and PRE-SCHOOL HANDICAPPED 
113 
educational hygiene. Although everything should be 
done to reduce or remove the handicap in a physical 
sense, our ultimate objective ought to be the training 
of the child so that he will be a healthy individual in 
the psychological sense. If his personality is not dis- 
torted or crippled, he may still be a useful and happy 
member of society. The elementary lessons in char- 
acter formation begin in the nursery period. It is easy 
to spoil a child in this period; and if he needs, as so 
often is the case, a somewhat prolonged treatment in 
an institution, it becomes doubly important that he 
should not be spoiled, but should acquire habits of 
self-help, attitudes of self-reliance, and a spirit of con- 
quest toward his physical defect. Fortunately, at 
least three out of four of all crippled persons over 
fifteen years of age are probably capable of profitable 
employment alongside normal persons. 
The war has made it clearer than it has been before 
that the final handicapping effect of disability depends 
often upon the morale of the individual. Indeed, 
physical failure, if not too extreme, may actually be 
the stimulus to a development of intellectual and spir- 
itual power. Adler states this theory of mental com- 
pensation, through the intervention of the nervous 
system, in these general terms: “The realization of 
somatic inferiority by the individual becomes for him 
a permanent impelling force for the development of 
his psyche.” If reeducation can build up the morale 
of a soldier so that he can successfully or even trium- 
phantly carry his disability, it follows that judicious 114 
THE PRE-SCHOOL CHILD 
education in the morale of physically defective chil- 
dren will have a preventive, hygienic value. Morale 
has been described as a kind of mental preparedness. 
This policy of preparedness should include the pre- 
school years, which are often of critical importance. 
Jf. Physically defective children 
Great importance of the pre-school period. The 
term “physically defective” has been used for con- 
venience, in the previous chapter, to include all chil- 
dren so seriously handicapped by malnutrition, cardiac 
defect, or chronic disease as to be urgently in need of 
special hygienic or educational arrangements in school. 
The term loses even this precision when applied to 
children of pre-school age. It is, however, profitable 
to ask to what extent is the physical defectiveness of 
school children traceable to the pre-school period? 
This simple question has not been adequately reckoned 
with. Indeed, the future developments in the fields of 
medical inspection of school hygiene and of social 
pediatrics cannot be intelligently directed without a 
frank acknowledgment of the fact that a large pro- 
portion of the physical defectiveness of children 
originates in the pre-school stage of childhood. 
The preeminent importance of the pre-school period 
is concretely shown in the following table which com- 
pares in parallel columns the frequency of physical 
defects in children of pre-school age and of school age. 
The findings are reported by Dr. Jacob Sobel, of the 
New York City Bureau of Child Hygiene, and are PRE-SCHOOL HANDICAPPED 
115 
based on (1) a study of 1061 children (ages 4 to 6) and 
(2) 243,416 examinations of school children. 
Physical Defects 
(1) Pre-School 
Age 
(2) School 
Children 
Hypertrophied Tonsils 
.... 26.3 % 
15.3 % 
Defective Masai Breathing. . 
.... 23.1 % 
11-6 % 
Malnutrition (3 and 4) 
.... 19.2 % 
17.5 % 
Defective Teeth 
.... 72.6 % 
61.8 % 
Pulmonary Disease 
.... 1.12% 
0.19% 
Organic Cardiac Defect 
.... 0.94% 
1.3 % 
Nervous Disease 
.... 0.66% 
0.5 % 
Orthopedic Defects 
.... 1.12% 
0.9 % 
Malnutrition. This has recently come to the fore- 
ground as a handicap of basic importance, and at 
present it is being attacked through nutrition classes 
and educational measures. This is a splendid work, 
and yet the fact remains that a very large percentage 
of these numerous under-nourished pupils were under- 
nourished before they entered school. Furthermore, 
an equally large number of candidates for the nutri- 
tion classes, three or four years hence, are under- 
nourished toddlers now. The logic of the situation 
needs very little elaboration. The most important 
field for the extension of nutrition hygiene is “the gap” 
between the milk-station period and the first grade. 
The following statement was applied to Scotland, but 
it is still true enough of other countries to merit quo- 
tation here: “The baby, if he lives, receives a certain 
amount of daily care in feeding, washing, and clothing, 
and the school children are made ready for school; but 
the toddlers from two to five are nobody’s care.” 
Dr. W. R. P. Emerson has listed the following 116 
THE PRE-SCHOOL CHILD 
factors as jointly responsible for the clinical picture of 
malnutrition as found among school children: (1) diet; 
(2) health habits; (3) rest and fatigue; (4) home con- 
trol; (5) special physical defects. It is clear that none 
of these factors is peculiar to the school period. There 
are, of course, certain cases which are caused or ex- 
acerbated by vicious school conditions, but these are 
probably more than offset by cases in children of pre- 
school age which have not enjoyed the normalizing 
influence of school life. We should, therefore, be at- 
tacking the problem of malnutrition more nearly at its 
source by reaching the children in their pre-school 
years. It would not require very revolutionary changes 
in the present technique of infant-welfare and public 
school work to accomplish the results. Pre-school 
clinics and children’s health centers are pointing the 
way. 
Rickets. Another phase of the great problem of 
malnutrition is rickets. This common disorder con- 
cerns the pre-school period peculiarly. It may not 
date back to the foetal stage of development, but it 
is very characteristic of the ages from six to eighteen 
months. Although there is still some obscurity re- 
garding its true origin, recent studies have shown that 
it is clearly a disturbance of nutrition, and one which 
will yield to control on a large scale through system- 
atic measures, including codliver oil and heliotherapy. 
Such preventive control will not only reduce the handi- 
cap of rickets, but the rachitic complications which 
increase mortality and later morbidity. PRE-SCHOOL HANDICAPPED 
117 
The teeth. Still another aspect of the same great 
problem of nutrition is represented in dental caries, by 
far the most common defect in American children. 
One of our best authorities who has worked on a large 
scale with school children, and who in the beginning 
placed great stress upon the importance of cleanliness 
of the teeth, has come to the significant conclusion that 
the most important factor in the causation of caries is 
dietary, and that “correct feeding of a child from birth 
to twelve years of age would in itself partially, if not 
wholly, eliminate dental decay.” 
The development of the teeth, indeed, presents a 
pretty example of the importance of the pre-school pe- 
riod, and of the temptation to ignore that importance. 
The cusp or biting surface of the sixth-year molars are 
formed before the child is even born, and the enamel 
organ for the wisdom teeth is formed as early as the 
third year of life. It is quite in harmony, therefore, 
with the facts of embryology to suppose that the nu- 
trition of mother, infant, and child is a decisive factor 
in determining the vitality of the teeth. Probably 
the most foresighted and the most thrifty method of 
dental hygiene is the improvement of the nutrition of 
children with milk teeth. 
A manual in pediatrics would be required to review 
all of the chronic and acute diseases which handi- 
cap early childhood. Statistical tables analyzing the 
causes of mortality, and less complete statistical data 
showing the age incidence and frequency of diseases, 
reveal with quantitative emphasis the significance of 118 
THE PRE-SCHOOL CHILD 
the pre-school years for bodily health. Medical in- 
spection and health supervision of school children are 
completely justified only when based upon an adequate 
preventive program of health supervision of the pre- 
school period. 
5. Mental abnormality 
In its broadest sense the term “psychopathic” in- 
cludes all forms of mental abnormality, not only the 
definite mental diseases (the psychoses) which come to 
the attention of the court and the physician, but the 
less pronounced disturbances which express themselves 
in various forms of “nervous” invalidism and mental 
inefficiency. 
On first impression no problem would seem to be 
more remote from the scope of pre-school hygiene than 
that of “insanity.” Senile dementia seldom occurs 
before the age of sixty; involution melancholia, seldom 
before forty; over half of the cases of general paralysis 
are seen between the ages of thirty-five and fifty; of all 
the cases of dementia praecox and manic-depressive 
psychosis, more than half develop before the age of 
thirty (Rosanoff). From statistics it appears (in New 
York) that only one psychotic child under fifteen is 
admitted for hospital treatment per 200,000 of popula- 
tion. Furthermore, a considerable proportion of the 
various insanities are caused by such factors as heredi- 
tary predisposition or transmission, alcoholism, syph- 
ilis, drug addiction, and head injuries. 
Environmental influences of early childhood. A PRE-SCHOOL HANDICAPPED 
119 
closer analysis of the situation will, however, reveal 
that there is an important group of mental disorders, 
the psycho-neuroses (the hysterias, neurasthenia, 
psychasthenia) and certain forms of dementia praecox 
in which environmental and educational factors play 
an important role. In many of these instances the 
origin of the conditions may be chiefly psychogenetic, 
and the date of genesis may go back to very early 
childhood. This must also be true of innumerable 
border-line conditions, in which the individual does 
not manifest a frank psychosis, but is maladjusted, 
and inadequate in his social behavior. It is disorders 
and deviations of this character which are most sub- 
ject to control, and will respond to preventive and 
ameliorative treatment. It is in this domain of men- 
tal hygiene that the pre-school period again asserts its 
fundamental importance. 
It is unnecessary to accept uncritically the doctrines 
and interpretations of psychoanalysis, but we are 
compelled to recognize the justice of an emphasis upon 
infancy in any dynamic or behavioristic type of psy- 
chology. We must at least subscribe to such a conserv- 
ative statement as the following one from the well- 
known British psychiatrist, Dr. Richard Rows. The 
statement occurs in an address on “The Biological 
Significance of Mental Illness,” made at the recent 
celebration of the one hundredth anniversary of the es- 
tablishment of the Bloomingdale (New York) hospital: 
Of special importance also are the experiences of childhood. 
An unhappy home or unjust treatment as a child may warp 120 
THE PRE-SCHOOL CHILD 
the development of the personality, lead to a lack of self- 
confidence, to the predominance of one emotional tendency, 
and so prevent that balanced equilibrium which will allow 
a rapid and suitable emotional reaction such as we may con- 
sider normal. This may lead to a failure of development or a 
loss of the sense of value, because the existence of one domi- 
nating emotional tendency so often produces a prejudiced 
view which may render a just appreciation of our general 
experience almost impossible and may serie usly disturb our 
mental activity. 
Rows himself illustrates the truth of this by describ- 
ing the case of a mentally ill woman in whom “the 
germ of her serious breakdown thirty years later was 
laid in her fifth and sixth years.” 
In somewhat the same strain Freud has said: “The 
little human being is frequently a finished product in 
his fourth or fifth year and only reveals gradually in 
later years what has long been ready within him.” 
Important responsibility of the home. To give the 
broad psychological principles above suggested im- 
mediate practical application would be a prodigious 
task, because it would involve the reeducation of 
countless parents who are unconsciously moulding the 
character of their children in the pre-school years. 
But if the principles are true they must at least guide 
us. They will serve to place in a new light the respon- 
sibility and power of the home, the great value of all 
social work which improves family welfare, and the 
importance of recognizing psychoneurotic symptoms 
in their earliest stage. Such symptoms are often 
overlooked and “dismissed as signs of badness or 
naughtiness.” Whether the symptoms come to clear PRE-SCHOOL HANDICAPPED 
121 
clinical expression or not, there is only one safe rule. 
We must have due respect for both chronic and epi- 
sodic abnormalities of conduct even in young children, 
and should shape our nurseries and kindergartens so 
that they may serve a more premeditated function in 
the field of mental hygiene. 
6. Delinquency 
Age and causation factors. The general observa- 
tions made with reference to psychopathic conditions 
apply to the problem of delinquency. The whole 
subject is so complicated that very few generalizations 
may be ventured. Frequently crime has an entirely 
adult setting and background; but it is coming to be 
recognized that many adult delinquents were juvenile 
delinquents, and that the most promising field of pre- 
vention is that of juvenile delinquency. Here again 
the causation factors often appear to be peculiar to 
adolescence. Frequently, also, the genesis of the 
delinquent career can be readily traced to the period 
of childhood, preceding adolescence. The history of 
the case reveals prodromal symptoms at the age of 
eight and nine, and we are justified in saying that the 
potential delinquent boy of that age is a particularly 
promising subject for reform or guidance. 
The home and delinquency. Now, whether the 
delinquent traits in many of these cases could be 
traced still farther back to the pre-school period is a 
fair problem for consideration. The concept of de- 
linquency when applied to very young children may 122 
THE PRE-SCHOOL CHILD 
only confuse us and obscure the true facts, but the 
concept of character formation is one which cannot be 
pushed too far back. Character in the psychological 
sense, and even in the ethical sense, has roots which 
go down to the cradle. The elementary lessons of 
obedience, inhibition, poise, self-control are normally 
learned in the nursery period, just as elementary speech 
is then acquired. The child does not learn all he is ever 
going to say in that period, but the instrumentality 
and to no small extent the very manner of his subse- 
quent speech are then established. So in the field of 
conduct. Social attitudes, personal prejudices and 
predilections, and the balancing of emotional tenden- 
cies are in broad outline determined before school 
entrance. Later delinquencies may be but symptoms 
of irritabilities and inharmonies which date back to an 
abnormal home life. 
This is all vague enough, and common sense must 
save us from errors of emphasis; but kindergartner, 
nursery matron, and parent cannot safely ignore per- 
sistent behavior anomalies and conduct disorders in 
the pre-school child. Such symptoms may have a 
prognostic import. 
7. Speech defects 
Distribution and cause. Speech defect is unques- 
tionably a problem which concerns the hygiene of the 
pre-school period. This period is preeminently one for 
the acquisition of oral speech, the most distinctive and 
in many ways the most complex of human accomplish- PRE-SCHOOL HANDICAPPED 
123 
ments. From the first birth-cry to the busy question- 
ing and sound plays of his kindergarten years, the 
normal child is steadily engaged in the task of acquir- 
ing the elementary technique of speech and of lan- 
guage. Instinct aids him, evolution has imparted to 
his nervous system both the propensity and the ca- 
pacity to talk, but to no small extent speech is an art 
which has to be learned anew by each individual. It 
is not purely automatic, and full perfection comes to 
but few. 
Mild imperfections of speech and deficient voice 
control are extremely common, and over two per cent 
of all school children are reported as being speech 
defective. Sometimes these defects have been attri- 
buted to faulty school hygiene and to unwise methods 
of teaching spelling and reading. There is no doubt 
that our public schools have very much neglected 
standards of oral expression, but there is good evidence 
that the overwhelming proportion of speech defects 
originate in the pre-school period. Wallin, who made 
an extensive census of speech defects in St. Louis 
school children, found that 81.4 per cent of all the 
cases of stuttering began before the age of six; only 15 
per cent between the ages of six and ten; and 3.4 per 
cent after ten. The figures for lisping emphasized 
even more strongly the significance of the pre-school 
period. The term “lisping” was used in its technical 
sense to include all forms of faulty articulation, in- 
abilities and difficulties of pronunciation, slurring and 
sound substitution. It was found that 96 per cent of 124 
THE PRE-SCHOOL CHILD 
the “lispers” began to lisp before the age of six; 3.2 
per cent between the ages of six and ten; and .8 per 
cent after the age of ten. 
Combining these figures we are compelled to recog- 
nize that at least fifteen out of every twenty cases 
of speech defect originate in the pre-school period. 
These defects are not, of course, equally important. 
Stuttering is usually much more serious than lisping. 
By stuttering is meant an uncontrolled or spasmodic 
repetition of sounds, syllables, or words. About five 
children out of one thousand are affected with mild 
stuttering, and two out of one thousand with stutter- 
ing of a severe character. About fifteen more children 
are affected with various forms and degrees of lisping. 
It is difficult to analyze briefly the different causes 
for these speech defects. In stuttering the follow- 
ing factors may operate singly or in combination: 
nervous shock, intense fear, anxiety neurosis, exhaus- 
tion diseases, neuropathic disposition, and imitation. 
Mental factors are very important, and one authority 
has gone so far as to describe stuttering as “a diseased 
state of mind which arises from excessive timidity.” 
Another writer refers it rather vaguely to an abnor- 
mality in the “region of personality.” 
A problem of reeducation. Only a very small pro- 
portion of all speech defects can be ascribed to mal- 
formations of the speech organs, to specific paralyses, 
or to tied tongue. Practically all cases of lisping are 
functional in character, due to subenergetic phonation, 
absence or faultiness of imitative standards, lack of PRE-SCHOOL HANDICAPPED 
125 
ear conscience, persistence of baby talk, lack of physi- 
cal tone and lack of emotional tone, defective breath 
control, etc. 
It is difficult to generalize in this field; each case, 
whether of stuttering or lisping, is individual. It may 
have a medical aspect, but usually the problem is one 
of education or reeducation, and often the approach is 
indirect. Fortunately, most speech defects are defi- 
nitely curable, and many are as definitely preventible. 
It ought to become part of our general Americanization 
program as well as general health program to insist on 
better opportunities for conversational English in the 
early years of childhood. Surely the primary teacher 
ought not to attempt to teach the pupils to read and 
write before they have really learned to talk, and 
kindergartners should make oral expression one of the 
chief objectives of their educational program. If 
nurseries and kindergartens meet the responsibility 
which is before them in this important field, they will 
not only improve the speech of all of their immediate 
charges, but may aid in the development of corrective 
measures which will reach the speech defective while 
still of pre-school age. Timely recognition and timely 
treatment here as elsewhere make for larger results at 
a smaller outlay. 
8. Mental deficiency 
Causes and treatment. Nearly all cases of mental 
deficiency are recognizable and become established 
before the age of six. In about three cases out of four 126 
THE PRE-SCHOOL CHILD 
the causal factors are hereditary; in one case out of 
four we have to reckon with some inflammatory or 
toxic disease, or some traumatic damage which usually 
occured at birth or early childhood and brought about 
an actual destruction of brain tissue or an arrest of its 
development. Feeble-mindedness is always associated 
in some way with an incomplete development of the 
cerebral cortex. 
The control and treatment of feeble-mindedness, 
therefore, must take due account of the pre-school 
period. The wisdom of ample public school provisions 
for mentally deficient pupils is becoming gradually 
more evident. It serves no purpose to emphasize the 
fact that feeble-mindedness is incurable. It is more 
important to recognize that most feeble-minded chil- 
dren respond to the right kind of training, and that, with 
certain readjustments and safeguards, they may main- 
tain a place for themselves in community life. It is 
one of the functions of the public school system, both 
through State and local agencies, to provide special 
occupational training and perhaps even to assist in the 
vocational guidance and supervision of pupils who 
have had this training. 
Pre-school treatment and training. Inasmuch as 
proper training has unquestionably demonstrated its 
efficacy in the case of the mentally deficient children, 
it is natural to ask whether we can afford to neglect as 
completely as we do the pre-school development of 
these children. The present tendency is to delay their 
school entrance. They are usually slow to hold up PRE-SCHOOL HANDICAPPED 
127 
their heads when babies, slow to sit up, slow to walk 
and to talk, and likewise slow to go to school. If a 
zealous parent enters a defective child in kindergarten 
at the legal age, the child is frequently sent home to 
wait another year, and even the special classes may ex- 
clude such a child on the plea that he is too young and 
that he will be more ready in a year or two. 
It may be questioned whether this policy is alto- 
gether justified, at least from the viewpoint of the 
educational psychology of the feeble-minded. Would 
it not be educationally advantageous to furnish a sub- 
kindergarten type of training for the mentally sub- 
normal in their nursery years? These are the years 
when they are most likely to be neglected or misunder- 
stood. The defective child from three to six years of 
age frequently gets severe corporal punishment be- 
cause he is not understood by his own father and 
mother, and it is during these years that he may be 
peculiarly troublesome at home. Sometimes the sit- 
uation drifts into one of unconscious cruelty to the 
child and extreme vexation for the parent. 
Parental guidance. Many a mother who will not, 
and probably should not, send her defective child to an 
institution is entitled to some form of community as- 
sistance. More should be done to provide nursery 
facilities for subnormal children, and by concrete 
guidance to aid the mothers in the task of caring for 
such children at home. Too frequently diagnosis and 
advice are not forthcoming until the child has become 
of school age. This fact, which I have often observed 128 
THE PRE-SCHOOL CHILD 
in my own experience, betrays a serious defect in 
our present administration of child hygiene. Feeble- 
mindedness is a developmental defect which, no less 
than rickets, should have the benefit of early diagnosis. 
To be sure, we cannot cure feeble-mindedness, but by 
timely diagnosis we can bring it under better control 
and may render a service to parent and child alike. 
And how much we could do in an educational way by 
giving more systematic attention to the pre-school 
years of the defective child, no one knows. 
General conclusions. The net result of this survey 
of the status of the handicapped child of pre-school 
age leads to a few general conclusions and suggestions. 
It appears that he is in a somewhat precarious position, 
and that he may become a victim of hardship and 
sometimes of actual injustice. He has no school status, 
and in a legalistic sense he has no educational rights, 
even though he may be peculiarly entitled to them. 
Whether he will receive medical attention will depend 
upon the quality and severity of his handicap and the 
perception of the physician. The psychological and 
educational aspects of his condition are in danger of 
being ignored, even when his physical welfare is not 
neglected. A careless faith is placed in the vague 
formula that he will outgrow his difficulties as he gets 
older. 
Imperfect as our knowledge is concerning the de- 
velopment of young children, it is in advance of our 
provisions for their welfare, and this knowledge PRE-SCHOOL HANDICAPPED 
129 
should be more deliberately applied as part of our so- 
cial policies. In the effort at application we shall come 
nearer to a solution of the problems involved. We 
should develop a specialized type of nursery and kin- 
dergarten service, which will be neither purely cus- 
todial nor conventional, but which will aim by educa- 
tional procedures to reduce developmental handicaps 
and demonstrate how similar measures can be intro- 
duced into the home. Even one specially trained 
expert kindergartner in a large city could render in- 
calculable benefit to mothers of defective children, 
through methods of conference and demonstration. 
The solution of the problem, after all, does not 
involve a staggering institutional program, but is 
rather one of engineering, and requires a special adap- 
tation of the same technique which is being so suc- 
cessfully worked out in the field of the visiting nurse 
and the visiting teacher. Public-health nurses should 
in general be better trained to perceive developmental 
defects in young children, and should play a more ac- 
tive part in this new kind of family-welfare work. 
A consecutive health and development supervision 
of pre-school children, the hygienic regulation of 
school entrance, a special adaptation of nursery and 
kindergarten methods in behalf of exceptional children, 
educational social workers in the field of infant wel- 
fare, and special mobile teachers for home visitation 
and home training — these are some of the possibili- 
ties which a public mental hygiene of the future may 
have in store. CHAPTER VIII 
PRE-SCHOOL CHILDREN DEPRIVED OF 
PARENTAL CARE 
Social significance of this problem. There is one type 
of handicap which has not been touched upon in the 
previous chapters, but which is so frequent and socially 
so important that it deserves separate consideration. 
We refer to the great numbers of children in town and 
country who, on account of adversity or bereavement, 
are deprived of the fundamental safeguard of parental 
care. It is difficult to give adequate statistics on this 
point for the whole nation, but the relative size of the 
problem is indicated by the following round figures 
which apply to the State of Connecticut. One child 
in every thousand is receiving institutional care; the 
total number of children in State institutions is five 
thousand. Three fifths, or three thousand in all, are 
in institutions because of dependency or neglect. These 
figures take no account of a large but indeterminate 
number of similar children who are not receiving offi- 
cial State care and supervision. 
From the very nature of this handicap there is no 
field of child welfare in which the State through its laws 
and agencies must more completely function in loco 
parentis. There is also no field in which social reme- 
dies and relief measures can less afford to ignore the CHILDREN DEPRIVED OF CARE 
131 
importance of the developmental hygiene of the pre- 
school period. 
Scope of the problem. The scope of the problem 
is indicated, in a concrete manner, by the following 
definitions recommended by a report of the Connecti- 
cut Commission on Child Welfare. These definitions 
include all children who have lost or are in danger 
of losing the normal developmental safeguards of pa- 
rental care. 
1. Dependent child. A dependent child is a child whose 
home is a suitable place for such child save for conditions 
arising from the poverty of its parents, parent, or guardian, 
but who, solely because of the poverty of its parents, parent, 
or guardian, is in need of care. 
2. Uncared-for child. An uncared-for child is a child: 
(a) who is homeless, or whose home is unsuitable, due to 
death of parents, parent, or guardian; or 
(b) who is homeless because of the fact that the persons 
liable for his support are inmates of charitable, humane, 
remedial, or penal institutions; or 
(c) who cannot be cared for in his own home, due to the 
unsuitability of such home because of the mental or 
physical infirmity of parents, parent, or guardian; 
and who may not lawfully support himself without 
becoming chargeable with neglect as defined in section 
5, paragraph (i) of this Act. Provided, that this defini- 
tion shall not be construed to include a child who must 
be removed from his home for purely temporary causes. 
3. Neglected Child. A neglected child is a child: 
(a) who is abandoned and who may not support himself 
lawfully without becoming chargeable with neglect as 
defined in paragraph (i) of this section; or 
(b) who is living in a house of ill-fame, or with vicious, 
disreputable, immoral, or criminal persons; or 
(c) whose home, by reason of the improvidence, depravity, 
neglect, or cruelty of parents or legal custodians, is 
unfit; or 132 
THE PRE-SCHOOL CHILD 
(d) who is permitted by parents or legal custodians to 
grow up in idleness, vice, or crime, or under conditions 
exposing him to idleness, vice, or crime; or 
(e) who begs or receives alms; or 
(f) whose parents when able to do so refuse to provide 
surgical, medical, or other remedial care of which the 
child is in need; or 
(g) who is in need of special training because of mental 
defectiveness, and whose parents refuse to provide 
such training or to make application for the admis- 
sion of such child to the State school; or 
(h) whose home environment, social environment, or both 
is such as to warrant the State in assuming guardian- 
ship; or 
(i) who engages in any occupation illegally, or legally 
i under conditions prejudicial to his normal develop- 
ment, physically, socially, mentally, and morally; or 
(j) who is born out of wedlock and may not support him- 
self without becoming chargeable with neglect as de- 
fined in paragraph (i) of this section. 
Though framed in unemotional, legal phraseology, 
the above definitions clearly reflect the seriousness 
and complexity of the task of securing adequate pro- 
tection to children who have been deprived of normal 
parental care. This deprivation bears with dispro- 
portionate weight upon children of pre-school age. 
Home care and mothers’ aid. During the past 
century there has been, on the one hand, a steady de- 
velopment of laws and machinery to enforce parental 
obligations, and, on the other hand, a tendency to 
provide congregate institutions for the care of children 
deprived of their natural homes. It was the ominous 
growth of the latter tendency toward institutionaliza- 
tion which led to the White House Conference of 1909, 
called by President Roosevelt. This conference pro- CHILDREN DEPRIVED OF CARE 
133 
posed that children should not be deprived of natural 
parental care except for inescapable reasons; that 
(through private funds) mothers should be aided to 
maintain their homes; and that orphaned and other- 
wise dependent children should so far as possible be 
placed in suitably supervised homes rather than in- 
stitutions. Miss E. O. Lundberg notes that there was 
strong sentiment against mothers’ aid through public 
funds at the time of the conference; but since then 
forty States and Alaska and Hawaii have embodied 
the idea of State mothers’ aid in their legislation. The 
Children’s Bureau Conference, in 1919, reaffirmed 
most of the conclusions of the White House Confer- 
ence of 1909; but went definitely on record in favor of 
mothers’ pensions in this statement: 
Home life which is, in the words of the conclusions of the 
White House Conference, “ the highest and finest product 
of civilization,” cannot be provided except upon the basis of 
adequate income for each family. 
The policy of assistance to mothers who are competent to 
care for their own children is now well established. It is 
generally recognized that the amount provided should be 
sufficient to enable the mother to maintain her children 
suitably in her own home, without resorting to such outside 
employment as will necessitate leaving her children without 
proper care and oversight; but in many States the allowances 
are still entirely inadequate to secure this result under pres- 
ent living costs. The amount required can be determined 
only by careful and competent case study, which must be 
renewed from time to time to meet changing conditions. 
Unless unusual conditions exist, the child’s welfare is best 
promoted by keeping him in his own home. No child should 
be permanently removed from his home unless it is impossible 
so to reconstruct family conditions or build and supplement 
family resources as to make the home safe for the child, or so 134 
THE PRE-SCHOOL CHILD 
to supervise the child as to make his continuance in the 
home safe for the community. In case of removal, separa- 
tion should not continue beyond the period of reconstruction. 
The aim of all provision for children who must be removed 
from their own homes should be to secure for each child 
home life as nearly normal as possible, to safeguard his health, 
and to insure for him the fundamental rights of childhood. 
To a much larger degree than at present family homes may 
be used to advantage in the care of such children. The stay 
of children in institutions for dependents should be as brief 
as possible. 
Causes for institutional commitment. What are 
the causes which thrust the children into these insti- 
tutions? 
A study of 157 unselected cases committed to 
county homes for dependent children in Connecticut 
showed that the immediate reasons for commitment 
were distributed as follows: 
1. Death of father 12 
of mother 26 
' of both 1 
21.8% 
2. Desertion of father 9 
of mother 10 
of both 1 
12.7% 
3. Separation, 5 or 3.2% 
4. Illness of father 2 t 
of mother 7 
of both 0 
5-7% 
5. Insanity or feeble-mindedness 
of father 1 
of mother 11 
of both 0 
7.7% 
6. Drunkenness 
of father 8 
of mother 6 
of both 2 
10.2% 
7. Character defects 
of father 4 
of mother 17 
of both 14 
22.3% 
8. Incorrigibility of 
child, 3, or 1-9% 
9. Not classified 18, or 11.5% 
Total 100% CHILDREN DEPRIVED OF CARE 
135 
Mental status of dependent children. The proverb 
says misfortunes never come singly, and the same 
might be said of the handicaps of childhood. This is 
particularly true of “dependency,” which is very fre- 
quently found to be associated with physical and men- 
tal defect. Syphilis, tuberculosis, and serious mal- 
nutrition are more common than among unselected 
children, and likewise mental dullness and deficiency. 
The Yale Psycho-Clinic recently made a study of the 
mentality of 198 dependent children who had been 
committed to an orphan asylum and two county 
homes. It was a representative group of dependent 
children, recruited from both industrial and urban 
communities. Although they were all above pre- 
school age, the results of the study give an approxi- 
mate picture of the individual differences in mental 
status to be expected in any large group of “depend- 
ent” children of any age whatsoever. 
The estimate of mentality was based upon the 
Stanford Revision of the Binet Measuring Scale of 
Intelligence. A slightly abbreviated version of this 
scale was employed and the mental age of each child 
was determined. The intelligence quotient (I.Q.) 
was then computed. This is a convenient index of the 
intelligence of any given case. It represents a ratio 
between mental age and chronological age. If the 
numerator and denominator in this ratio are equal 
we get unity, or 100 per cent, or an I.Q. of 100. If the 
numerator (that is, the mental age) is 2 and the de- 
nominator (that is, the chronological age) is 3, we get 136 
THE PRE-SCHOOL CHILD 
a value below 100, an I.Q. of 67. If the conditions 
are reversed, and the numerator is 3 and the denomi- 
nator 2, we get an I.Q. of 150, which indicates a very 
superior intelligence. An I.Q. of 67 or less, however, 
most frequently means feeble-mindedness. 
I.Q. distribution curve. A plotting in one curve of 
the I.Q. of all 198 cases of dependent children above 
mentioned gives a normal surface of frequency, with 
a range from 37 to 122, median at 81, and mode in the 
76-85 group. [For graph and details, see report by 
Margaret Cobb, 1922.] This is a curve very similar to 
that obtained by Terman from 905 unselected school 
children, except that it is shifted a considerable dis- 
tance down the scale. With Terman’s cases the range 
covers nine groupings of 10 points each, as it does with 
ours. But his range is from 56 to 145, while ours is 
from 36 to 125. Terman’s mode is the 96-105 group; 
ours the 76-85 group. For this group of 198 chil- 
dren, then, the normal is 20 points below the normal 
for unselected children, with a corresponding distri- 
bution about this mode. 
These figures are in complete accordance with the 
author’s findings in a similar survey of the mental 
status of 100 New Haven County Home children. 
This study led to the general conclusion that average 
mentality among county home dependents is about 
as rare as brightness among ordinary children, while 
dullness and near-deficiency are as frequent as the 
normal average. Likewise, definite mental deficiency 
appears to be as frequent as dullness ordinarily is. In- CHILDREN DEPRIVED OF CARE 
137 
asmuch as all cases of mental deficiency are either 
hereditary, or date from infancy and early childhood, 
the statistics just cited give a fair picture of the pre- 
school as well as the school period. 
The character development, the educational ca- 
pacity, and the placement outlook of dependent chil- 
dren show differences no less significant than those 
which have been given for “ intelligence.” For exam- 
ple, on the basis of the examination of the 198 cases 
above mentioned, Miss Cobb concluded that 18 per 
cent of the children would derive greater benefit from 
special class training than from ordinary school in- 
struction; that 21 per cent could probably finish fifth 
or sixth grade and profit by practical continuation 
instruction; that 35 per cent gave promise of complet- 
ing the grammar grades, supplemented with voca- 
tional and trade instruction; that 7 per cent would be 
competent to finish a high-school course, and 17 per 
cent more part of a high-school course; and 2 per 
cent apparently had mentality that would qualify 
them for college training. 
Importance of proper home placement. Although 
it is most undesirable to make rigid classifications, 
and unnecessary to attempt precise predictions, our 
policies with respect to dependent children should take 
due account of all differences of this character. The 
principle of placement in supervised family homes 
should be applied to the utmost practical limit, but 
also with due regard to the physical and mental status 
of the children. In cases of doubt, home placement 138 
THE PRE-SCHOOL CHILD 
should always be given a trial. More frequently than 
we may realize, the symptoms of mental dullness and 
inertness of dependent children rest on habits of in- 
hibition and inferiority which will respond to reeduca- 
tion in a favorable foster home. 
The more superior a child is, the more urgently does 
he demand placement in a home with optimum op- 
portunity. The more defective a child is, the less he 
is harmed by institutional care. Indeed, he may be 
very much benefited by institutional training. We 
should not, however, go on the theory that all men- 
tally deficient and border-line children are non-place- 
able. As a matter of fact, we should develop a dif- 
ferential type of placement, with quasi-probationary 
safeguards, for large numbers of children who are 
neither candidates for institutions nor for ordinary 
foster homes. While children are still of pre-school 
age, however, we need to make only a comparatively 
few exceptions to the rule of family home placement. 
Social neglect of pre-school dependents. The 
infant deprived of ordinary parental care presents a 
pathetic picture of human helplessness, and yet it 
is these very infants who, as a group, often receive 
the least effective protection from the State. There 
is scarcely a State in the Union where it would not be 
possible to find instances of appalling abuse and neg- 
ligence surrounding the care of babies and children 
under four years of age. In many States the number 
of such instances would be found to be incredibly 
large. In a few States laws of license and supervision, CHILDREN DEPRIVED OF CARE 
139 
firmly enforced, are reducing the abuses to a civilized 
minimum. Neglect and abuse of children of pre-school 
age come to their most disgraceful, even if somewhat 
picturesque, expression in the old-fashioned baby 
farm which is far from extinct. The following is from 
a very recent report of a child-welfare commission. 
Information as to the extent of baby farming and the loca- 
tion of these homes was obtained from the various private 
agencies and the visiting nurses association of . . . and . . . 
Fifteen homes were visited, and the number of children 
cared for varied from two to twelve. There were thirty- 
nine children in all; most of them under two years of age. 
Most of the homes were located in . . . and . . . The latter 
place is apparently a paradise for women wishing to board 
babies without interference from authority. 
There is some attempt in . .. and ... to keep in touch 
with the women who make a business of boarding children, 
through the city department of charities, but the importance 
of strict supervision of these homes is overlooked. In . . . 
these homes are allowed to flourish without restraint unless 
an active complaint is brought up, when the matter is re- 
ferred to the Humane Society and to the State Board of 
Charities. 
The agent secured the following information by repre- 
senting herself to be a young woman looking for a home for 
the infant daughter of a friend. No State visitor, as such, 
would have been able to get by the front door. 
Mrs. B.’s baby farm. In her travel the agent finds 
the Home of Mrs. B., who for many years has run a 
baby farm, and at the date of this recital was “taking 
care” of thirteen children under seven years of age, 
most of them infants. Of this home she says: 
In a recent visit to this home the visitor found that the 
history of Mrs. B. was much like the history of other women 
who are engaged in the baby-farm business. She is a large 140 
THE PRE-SCHOOL CHILD 
Irish woman, ignorant, but confident that she knows more 
than any one else about the care of babies — remarked that 
she never had to have a doctor for the children as she knew 
more about their feedin’ than any doctor did. She was 
quite willing to take a baby only a few days old; in fact, 
preferred them as young as possible. “ It is all nonsense, this 
doctor’s advice to mothers to nurse her baby for two weeks 
if she has to board it out — makes it hard for us women to 
break ’em into the bottle then.” 
While Mrs. B. was enlightening the visitor on how to feed 
children, three babies of about fifteen months were crawling 
on the floor near the visitor’s chair. All looked pale and mal- 
nourished. Their arms and legs were soft and flabby. All 
of them were drenching wet and dirty. One of them had 
several boils on his body and a rash on his hands and wrists. 
It was evident, from the appearance of these babies and 
from the fact that Mrs. B. had no one to help her, that they 
had scant attention. 
The B. house was small, and from where the visitor sat 
most of the kitchen was in view. Three little children — all 
about two years of age — were running and playing with 
each other there. At one side was a large coal stove covered 
with kettles of steaming food and water. Had one of the 
children, in a moment of play or curiosity, reached up for a 
handle which extended beyond the stove, no one could have 
been swift enough to save the child from scalding. Under 
the sink in the kitchen was a large pile of soiled diapers. On 
the drain board were two rows of nursing bottles and nipples 
not yet washed. 
There is one small attic-like room upstairs, and here all the 
little beds have been arranged. The beds are crowded 
together, and indications are that Mrs. B. knows nothing of 
the air space needed by each child. In summer, when the 
very warm weather comes, there is nothing to protect this 
room from becoming insufferably hot. Neighbors testified 
to the fact that small babies cried and fretted through the 
long hot nights with nothing done to relieve their discomfort. 
Many of Mrs. B.’s children are deserted by their parents 
after a year or so, and Mrs. B. has undertaken to place these 
children in homes for adoption. She never hesitates to take 
a baby under any conditions, because she can always find — CHILDREN DEPRIVED OF CARE 
141 
perhaps with profit — a home if the child is abandoned. 
Mrs. B. makes it easy for a woman to relieve herself of the 
responsibility of providing for her own child by offering to 
clothe it and assuring the mother that she can find good 
homes if she cannot support the baby. 
“ Good-bye, Mrs. B.” “Good-bye, be sure to let me know 
if your friend ain’t goin’ to bring her baby to me so’s I won’t 
miss takin’ the other two babies, but I’d rather have your 
friend’s baby because it is so young and would be easier to 
break into my ways.” The visitor departs wondering how 
much longer the State will continue to let Mrs. B. “ break 
babies into her ways”! 
We should not be inclined to quote the above 
“story ” if it had come from one of Dickens’s novels, or 
even if it disclosed extremely exceptional conditions. 
It is, however, sufficiently typical to strengthen the 
argument for a policy of vigorous supervision over 
the welfare of dependents of pre-school age. 
Licensing of baby homes. It is possible to license 
boarding-homes for babies. It is also possible to in- 
spect them, and to enforce minimum standards as to 
sanitation, medical and nursing attendance, and equip- 
ment. Such measures make for decency and actually 
reduce infant mortality; but it has been found that 
even in highly improved institutions, unless the ratio 
of babies to attendants is extremely low (about 1 to 4), 
it is impossible to keep the mortality rate from rising 
above the average level. It seems that babies are not 
vegetables, after all, and that even their physical wel- 
fare demands an environment which is equivalent to a 
home and a mother. 
Mental hygiene in relation to family life. Even as- 
suming that the physical conditions of institutional 142 
THE PRE-SCHOOL CHILD 
care could be made so aseptic that the children would 
physically survive, we should still have to reckon with 
the welfare of their mental life. This phase of the 
subject is always in danger of being neglected, and, 
though it is important for children of any age, it is of 
profound significance for children of pre-school age. 
The body thrives on milk, but the mind on personal 
relations. The dependence of a baby on a personal 
environment is almost as close and direct as was the 
placenta of the baby to its host. The affection, the 
handling, the ministrations, the language of parental 
care together constitute the very matrix for the early 
growth of mind and character. The docility of the 
child and the solicitude of the mother establish an in- 
terdependence ordained by instinct and perfected by 
tradition. Brothers, sisters, the father, toys, house, 
garden, street, all become interwoven into this relation, 
and contribute to the kernel of the growing personal- 
ity. Through these influences the child becomes 
anchored to his home and acquires a fundamental 
trust in life. In many subtle ways he also acquires 
permanent predispositions. Take all these influences 
away or distort them, and the result is a starved or 
distorted personality. Better fortune in later years 
may compensate, but it can never replace the value of 
normal domestic experience in the pre-school stage of 
life. 
These are by no means sentimental considerations. 
They are psychological facts from which there is no 
escape if we are to regard the mental hygiene of the CHILDREN DEPRIVED OF CARE 
143 
child. If we have to neglect dependent children, let 
us neglect those of maturer years; the pre-school period 
is developmentally of such basic importance that it 
deserves our primary concern. Miss Jessie Taft, who 
speaks from a wide and first-hand experience, sums 
up much in the following paragraph. 
The case worker with dependent children faces a pecu- 
liarly difficult situation in that the dependent child, by virtue 
of his very dependency, is always potentially a behavior 
problem. The family background, on which the mental 
health of every child must largely depend, is in his case in- 
evitably distorted. Thus at the very root of dependency is 
the soil of potential maladjustment. The normal child 
develops in strength and confidence on the basis of the se- 
curity and assurance that the mother and father supply. He 
has the possibility of achieving a wholesome and necessary 
sense of power because he has this stable foundation on 
which to fall when his sense of safety is threatened. He can 
be sure of his home. It will not vanish overnight. Father 
and mother are all-powerful and can save from every ill. 
The family may oversupply the love and backing which the 
child demands and make a weakling of him, but, on the 
other hand, the absence of such an assurance of safety is 
equally fatal to the growth of a normal and free, outgoing 
energy. The child who lacks this fundamental protection 
becomes at once a prey to fear, uncertainty, and inferi- 
ority. 
Children born out of wedlock. It remains to dis- 
cuss the welfare of one group of neglected children who 
come into the world unwelcomed, undesired, and at 
present under such hazards that only seven out of 
every ten survive the first year of life. We refer to 
children born out of wedlock whose fate hangs so 
largely upon the hygiene of their early years — and 
early months. 144 
THE PRE-SCHOOL CHILD 
Within recent times “illegitimacy” has come to be 
recognized as a definite, though most baffling social 
problem. There are, in the United States, about 
9,000,000 single, widowed, and divorced white women 
of child-bearing age. In the sixteen States for which 
figures of illegitimate births were obtained, the rate 
per thousand of these women was estimated at 3.7 per 
cent. The annual estimated number of white illegiti- 
mate births in the United States may be estimated at 
32,400. The estimate is conservative, because of in- 
complete and erroneous birth registration. 
Factors in this problem. The control of this prob- 
lem involves many factors. In an investigation made 
in Boston, it was found that one fifth of the mothers 
of infants born out of wedlock were below normal 
mentality, and that 8.8 per cent were diagnosed as 
feeble-minded. In a study of 2178 children born out 
of wedlock and under the care of Boston social agen- 
cies, it was found that the mothers, fathers, or mater- 
nal grandparents of 62 per cent were alcoholic, im- 
moral, or otherwise delinquent, or of poor character. 
The community supervision or segregation of feeble- 
minded girls, and ample public provision and regula- 
tion of recreation, will reduce immediately and per- 
ceptibly the amount of illegitimacy. Another line of 
preventive work would be a more nearly universal 
education of all high-school and continuation school 
youths, both boys and girls, in “the opportunities 
and privileges of a deliberate and responsible parent- 
hood.” CHILDREN DEPRIVED OF CARE 
145 
But we are, in this chapter, more interested in the 
problem of illegitimacy as it affects the child. As Dr. 
W. Leslie Mackenzie said in his report on conditions 
in Scotland, it is in many respects less difficult to make 
provision for the mothers, in spite of all the difficulties 
that assail them, than for the annual crop of babies. 
The mothers, however they are provided for, can at least 
fight for their lives and often attain to a passable living. The 
new-born infant can do nothing for himself. He hangs on 
the service of others. Within hours of his birth he may be 
taken from his mother’s breast and put among those whose 
skill is often no substitute even for an unskilled mother’s 
care. He may pass from hand to hand and from place to 
place. Besides the risks he has encountered in coming to 
birth, he encounters a thousand others that fall only to the 
children of the unmarried. If, starting from the same line, 
he loses in the race with his legitimate fellows, it is from no 
fault of his own. He has not sinned, but he comes short of 
the glory. That is the tragedy of the unmarried mother’s 
child. 
Infant mortality and legislative protection. The 
handicap of birth out of wedlock promptly writes its 
effects into the infant mortality statistics. In Eng- 
land and Wales the annual average number of deaths 
under one year per 1000 live births is for the legitimate 
group about 100, and for the illegitimate, over 200. 
Corresponding figures for Boston (1914) were 95 and 
281; for Baltimore (white, 1915), they were 95.9 and 
315.5. The child born in wedlock, therefore, commonly 
has from two to three times better chance to survive 
the first critical year of life. The better chance is his 
chiefly because he is not deprived of natural parental 
care. To protect the rights of the child born out of 146 
THE PRE-SCHOOL CHILD 
wedlock, we must in some way soften the stigma 
which attaches to him and often prevents the mother 
from caring for her child with “ decent dignity.” This 
must be done for the sake of the child, if for no other 
reason, and without compromising on the standard of 
monogamy. 
Perplexing and grave as the whole problem is, there 
appears to be no controversion of a statement of Mr. 
Ethelbert Stewart: “There may be illegitimate par- 
ents — there can be no illegitimate child.” This 
statement is quoted by Miss Julia Lathrop, former 
chief of the Children’s Bureau, who through her 
bureau has been commendably active in improving 
the status of children born out of wedlock. As early 
as 1918 she issued a translation of the Norwegian laws 
concerning illegitimate children (1915), and referred 
to them as “ the first complete national recognition of 
the inherent right of the child to nurture, protection, 
and education, irrespective of this parentage, and of 
the State’s responsibility for ascertaining parentage 
and for holding both parents equally and continuously 
responsible for the illegitimate child.” 
Care of children bom out of wedlock. During 
the last few years there has been much discussion and 
legislation directed toward adequate protection of 
the illegitimate child, and, however divergent many 
views of the problem still are, there is a consensus of 
approval of the minimum standards for care of chil- 
dren born out of wedlock, as drawn up by the Washing- 
ton and Regional Conferences on Child Welfare held CHILDREN DEPRIVED OF CARE 
147 
under the auspices of the Children’s Bureau, in 
1919: 
The child born out of wedlock constitutes a very serious 
problem, and for this reason special safeguards should be 
provided. 
Save for unusual reasons both parents should be held 
responsible for the child during his minority, and especially 
should the responsibility of the father be emphasized. 
Care of the child by his mother is highly desirable, particu- 
larly during the nursing months. 
No parent of a child born out of wedlock should be per- 
mitted to surrender the child outside his own family, save 
with the consent of a properly designated State department 
or a court of proper jurisdiction. 
Each State should make suitable provision of a humane 
character for establishing paternity and guaranteeing to 
children born out of wedlock the rights naturally belonging 
to children born in wedlock. The fathers of such children 
should be under the same financial responsibilities and the 
same legal liabilities toward their children as other fathers. 
The administration of the courts with reference to such cases 
should be so regulated as not only to protect the legal rights 
of the mother and child, but also to avoid unnecessary 
publicity and humiliation. 
The treatment of the unmarried mother and her child 
should include the best medical supervision, and should be so 
directed as to afford the widest opportunity for wholesome, 
normal life. 
Minnesota, North Dakota, and Maryland have 
taken important legislative steps toward the realiza- 
tion of the above principles. In many States the laws 
and customs for dealing with the problem are still 
archaic. 
Child adoption 
Adoption, in legal phraseology, is defined as the 
act by which relations of paternity and filiation are 148 
THE PRE-SCHOOL CHILD 
recognized as lawfully existing between persons not 
so related by nature. The child, as the probate 
law phrase puts it, becomes, on adoption, “ as though 
born in wedlock.” This legal fiction traces back to 
very primitive times. It was in various forms im- 
portant for the organization of early society. It is 
socially of considerable importance to-day as a means 
of multiplying the stabilizing and cohesive relations of 
the family institution. Marked as the recent move- 
ment toward home placement has been, we have only 
partially realized all the social advantages that would 
go with a wider use of the beneficent institution of 
adoption. 
The benefits of adoption are great, acting mutually 
on parent and child. But the responsibilities are also 
great, and the child must be safeguarded against the 
effects of hasty, ill-advised legal action. Miss Lund- 
berg therefore writes that the most constructive fea- 
ture of adoption laws, which is being gradually placed 
on the statute books, “relates to investigation prior to 
legal adoption, both of the necessity for parental re- 
linquishment and the character of the foster home, 
also a required probationary period before final adop- 
tion can be granted.” The necessity of such safe- 
guards is partly borne out by the interesting historical 
fact that among the Romans, from whom our adop- 
tion laws descended, the motive to the act of adoption 
was not so generally childlessness, or the gratification 
of affection, as the desire to acquire certain civil rights. 
The Minnesota law as to adoption. Adoption is CHILDREN DEPRIVED OF CARE 
149 
now regulated by statutes varying with the different 
States of the Union. State supervision is relied upon 
in the progressive States to secure proper applica- 
tion and enforcement of the laws. A bureau of child 
welfare or corresponding department is the natural 
agency for such supervision. The 1919 law of Minne- 
sota may be cited, in part, to indicate the best type 
of practice. It reads: 
Adoption — Petition and consent. Any resident of the 
State may petition the District Court of the county in which 
he resides for leave to adopt any child not his own. If the 
petitioner be married, the spouse shall join in the petition. 
All petitions for adoption of a child who is a w ard or pupil of 
the State Public School shall be made jointly by the person 
desiring to adopt such child and the superintendent of the 
State Public School. 
Investigation by board of control. Upon the filing of a 
petition for the adoption of a minor child the court shall 
notify the state board of control. It shall then be the duty of 
the board to verify the allegations of the petition; to investi- 
gate the condition and antecedents of the child for the pur- 
pose of ascertaining whether he is a proper subject for adop- 
tion; and to make appropriate inquiry to determine whether 
the proposed foster home is a suitable home for the child.... 
No petition shall be granted until the child shall have lived 
for six months in the proposed home... . 
Consent when necessary. Except as herein provided, no 
adoption of a minor shall be permitted without the consent of 
his parents, but the consent of a parent who has abandoned 
the child, or who cannot be found, or who is insane, or other- 
wise incapacitated from giving such consent, or who has lost 
custody of the child through divorce proceedings or the order 
of a juvenile court, may be dispensed with, and consent may 
be given by the guardian, if there be one, or if there be no 
guardian, by the state board of control. In case of illegiti- 
macy, the consent of the mother alone shall suffice. In all 
cases where the child is over fourteen years old his own con- 
sent must be had also. 150 
THE PRE-SCHOOL CHILD 
Status of adopted child. Upon adoption, such child shall 
become the legal child of the persons adopting him, and they 
shall become his legal parents, with all the rights and duties 
between them of natural parents and legitimate child. . .. 
Annulment. If within five years after his adoption a child 
develops feeble-mindedness, epilepsy, insanity, or venereal 
infection as a result of the conditions existing prior to the 
adoption, and of which the adopting parents had no knowl- 
edge or notice, a petition setting forth such facts shall be 
filed with the court which entered the decree of adoption, and 
if such facts are proved, the court may annul the adoption 
and commit the child to the guardianship of the state board 
of control. In every such proceeding it shall be the duty of the 
county attorney to represent the interests of the child. 
The intent of the provision of annulment is obvious. 
Such a provision ought not, however, to be too freely 
invoked. The necessity of applying it should be 
anticipated by thoroughgoing physical and mental ex- 
aminations of the child prior to adoption. Since the 
pre-school period is a peculiarly important one for the 
exercise of adoption, the value of accurate diagnostic 
estimates of development for this period is clear. 
Annulment, in any event, remains a highly excep- 
tional court procedure. Overwhelming testimony in 
favor of the fine human adventure of adoption can be 
gathered from the highest of all authorities on this 
subject — namely, thousands of adoptive parents. CHAPTER IX 
THE PRE-SCHOOL CHILD AND THE HOME 
Significance of the home in pre-school hygiene. To 
say that the home is the most fundamental institution 
of society is to state a truism which has been so often 
repeated that it has lost all flavor and force; but truisms 
are likely to have a latent vitality. Bernard Shaw 
was, therefore, sure of an audience when he said that 
parents are the worst possible people for children to 
live with. When vague suggestions are made regard- 
ing the socialization of the maternal function, and the 
establishment of classified State nurseries for pre- 
school children, the truth of the truism begins to shed 
its triteness. 
We cannot assess the value of any policy with 
regard to the welfare of the pre-school child until we 
have taken full account of its direct or eventual effect 
upon the home as a social institution. Indeed, we may 
be certain that with the pre-school age, child welfare 
and family welfare are inseparable and mutually inter- 
dependent. Although in exceptional and abnormal 
situations society must intervene and remove a child 
from its “home” to protect the child’s rights, the goal 
of the best social effort is toward rehabilitation of the 
home, and the provision of foster family homes for 
children deprived of parental care. This is the goal be- 152 
THE PRE-SCHOOL CHILD 
cause the welfare of society and the child alike hang 
upon the integrity of the home. 
From the psychological standpoint the significance 
of the home is summarized in the following words of 
G. Stanley Hall: “All human activities, when reduced 
to their ultimate instinctive psychic elements, origi- 
nated in and consist in impulses toward nest-building, 
home-making, or providing better conditions for 
posterity.” Sociologists and historians provide us 
with equally sweeping conclusions regarding the 
fundamental importance of family life. 
In spite of all these considerations, civilized society 
appears to be constantly confronted with unsolved 
problems concerning the place and functions of the 
home, and with enforcing elementary standards of 
monogamy and of parental responsibility. 
Optimists count upon the home to counteract many 
of the evil tendencies of modern times; pessimists 
point out how these tendencies are successfully under- 
mining the home. When practical programs con- 
cerning child hygiene and education are discussed, 
there are likely to be divergent views regarding the 
efficiency and duty of the home. The concentration 
of populations into cities, and the effect of modern 
inventions on hamlet and rural life, have alike in- 
creased the complexity of the problems. 
Pestalozzi and home education. It is, therefore, 
very interesting and instructive to turn back to 
Pestalozzi, who is regarded as a leading educational 
reformer, and who spent most of his life among a HOME AND THE CHILD 
peasant people, in an agricultural age, before the 
industrial revolution had got fairly under way. There 
is some evidence that in his elderly years he was dis- 
quieted by the trend of the times and signs of decay in 
the good old domestic virtues, but his whole career 
was an effort to exalt and to reconstruct the home. 
He believed that social reform and educational reform 
could come through the home alone. 
His very first educational treatise — and he was 
a voluminous writer and pamphleteer — contained 
these two aphorisms: “A man’s domestic relations are 
the first and most important of his nature. . . . The 
home is the true basis of the education of humanity.” 
One of his most important writings was entitled, My 
First Book for the People, Leonard and Gertrude. This 
was a kind of sociological novel in which Pestalozzi 
shrewdly set forth the virtues and methods of the ideal 
mother teacher, “who makes her house a temple of the 
living God, and wins heaven for her husband and her 
children.” Everything which he afterwards wrote 
and did was to fulfill the vision of this book. Note 
some of the titles of his later productions: Christopher 
and Elisa (in which a father and mother discuss chap- 
ters from Leonard and Gertrude}; The Good Jacob, how 
he teaches his Son; How Gertrude teaches her Children 
(an attempt to give mothers a guide so they might 
themselves teach their children); The Natural School- 
master (a practical guide for home instruction for the 
pre-school period); A Book for Mothers (a guide for 
mothers, enabling them to teach their children to 
153 154 
THE PRE-SCHOOL CHILD 
observe and talk); An Address to the British Public 
(soliciting them to aid by subscription Pestalozzi’s 
plan of preparing teachers for the people, that man- 
kind may in time receive the fundamentals of instruc- 
tion from mothers, 1818); The Simplest Methods 
whereby to Educate a Child at Home from the Cradle to 
its Sixth Year (the title of Pestalozzi’s very last speech, 
made when he was over eighty years of age). 
Pestalozzi’s writings are full of exhortations and 
shibboleths like the following: 
Forget, mothers, if it is necessary, all other work, all other 
attachment, in order to penetrate into the purity and sacred- 
ness of your maternal vocation. 
The mother is qualified by the Creator himself to become 
the principal agent in the development of her child. 
Froebel and the nursery school. There are good 
reasons for believing that the kindergarten originated 
with Froebel as a movement for nursery reform. Al- 
though he never adhered as tenaciously as did Pes- 
talozzi to the view that the home was the chief agency 
for early education, there is evidence that he approved 
the idea and wished to make the kindergarten consist- 
ent with it. He had a sort of education of parents in 
mind when he started the kindergarten. “ The destiny 
of nations lies far more in the hands of women — the 
mothers — than in the possessors of power, or of those 
innovators who for the most part do not understand 
themselves. We must cultivate women who are the 
educators of the human race, else the new generation 
cannot accomplish its task.” Baroness von Maren- HOME AND THE CHILD 
155 
holz-Biilow, who became one of his leading exponents, 
claimed that this was almost always the sum of his 
discourse. The following from one of his letters sup- 
ports the view that he wished the kindergarten to be a 
demonstration model for mothers to copy: “There is 
little hope for improvement until mothers will begin to 
educate themselves. Let them attend kindergarten 
and study the system themselves.” 
The following quotation is peculiarly suggestive 
from the standpoint of the recent nursery-school move- 
ment. It is taken from a Prospectus of an Institution 
for the Training of Nurses and Educators of Children. 
The institution intends to render generally accessible an 
education in agreement with the nature of the child and of 
man, and satisfying the demands of the age, and to show how 
such an education can be carried on in the family. This can 
only be done by preparing young ladies for the business of 
nursing, developing, and educating a child from its birth un- 
til it can go to school. The course will also qualify its pupil 
to prepare children for the first grade of the elementary 
course of the public school. 
These “child nurses” and “child guides” were to go 
out as professional women, as Misawa points out, to 
“provide kindergarten training in the family” as 
mothers’ helpers. “But since every family cannot 
afford this individually, it should be carried out as a 
problem of general cooperation, to be solved by and 
for all the people.” 
We have quoted these views of Froebel, not so much 
for their intrinsic worth, but as an answer to those of 
his followers who would confine the organization and 156 
THE PRE-SCHOOL CHILD 
operation of the kindergarten to a narrow circle painted 
on the floor of a schoolroom. The problems of the 
hygiene and education of the pre-school child cannot 
be separated from those of home and parenthood. 
The kindergarten cannot realize its full objectives 
unless some form of parental training and cooperation 
is incorporated into its program. 
Modern agencies for parental training. In this 
chapter we shift the discussion from the child to the 
mother — and the father. In last analysis, many of 
the issues of pre-school hygiene depend upon the good- 
will of parents, both toward their advisers and their 
children. Even administrative problems frequently 
resolve themselves into methods of increasing or util- 
izing that good-will. 
The agencies directly engaged in some form of 
parental training and parental-guidance work are 
numerous. There is much diversity in their activities. 
State, Federal, local, and purely voluntary private 
agencies all contribute a share of educational work for 
parents, but there is nothing resembling a coordinated 
program. Most of the activities are quite independent; 
they are partial, piecemeal, and unrelated. There is 
much overlapping. Chaos would not be a just word 
to describe the work in this field, because most of the 
efforts are constructive in spirit and in accomplish- 
ment. Considerable portions of the field, however, are 
not covered at all. What we have in the present situa- 
tion is an incomplete mosaic without much pattern. 
Nothing like a comprehensive policy of parental educa- HOME AND THE CHILD 
157 
tion and guidance has taken shape, but the necessity 
and the promise of such a policy are gradually becoming 
evident. 
Baby week. The most gigantic intensive campaign 
for parental education that was ever staged was the 
nation-wide baby week, which was promoted by the 
General Federation of Women’s Clubs and the Chil- 
dren’s Bureau, in 1916. This parental propaganda 
reached not only some two million women identified 
with women’s clubs, but mothers and fathers through- 
out the country. Probably over three thousand cele- 
brations took place in urban, village, and rural com- 
munities, and on Indian reservations. It cannot be said 
that this was a spasmodic affair, for it left permanent 
results, and gave a general impetus to baby-welfare 
publicity. Better-baby contests, which have always 
aroused considerable public attention, have been re- 
peated in many places since. 
Child-welfare exhibits. These have become an 
accepted means of popular education. As early as 
1915, the Children’s Bureau issued a bulletin describ- 
ing concretely the organization and uses of such ex- 
hibits. It is significant that these exhibits are not 
always imposed by an external agency, but that the 
initiative often comes from the parents themselves. 
“The demand for an exhibit may arise in a community 
in many ways. A mothers’ club or infant-welfare 
station may desire some new and graphic way of 
teaching mothers the methods of infant care; a settle- 
ment or club may wish to interest parents more vitally 158 
THE PRE-SCHOOL CHILD 
in the development of the growing boy and girl.” 
Traveling child-welfare specials have combined the 
features of both clinic and educational exhibit. 
Literature. The printing press has been a very 
powerful ally of the baby. Tons of literature have 
been distributed through State and Federal bulletins, 
posters, cards; through illustrated articles in news- 
papers and magazines and special child-welfare period- 
icals. One State Department of Health consumed four 
thousand pounds of paper so that it might distribute 
850,000 leaflets, on infant welfare, during a baby-week 
campaign. The moving picture has contributed many 
miles of visual education. 
General publicity has sometimes been criticized 
because of superficiality and emotionality. It con- 
fessedly has its limitations, but it also has all the power 
of beneficent propaganda. It arrests the attention, 
directs the interests, and moulds the prejudice of large 
numbers of people, both parents and future parents. 
Conferences and classes for parents. An important 
form of parental training has developed as a by- 
product of medical infant-welfare activity. This 
welfare work was at first altogether non-educational. 
The allaitement maternel, established in 1876, in Paris, 
was chiefly a canteen for nursing mothers. The early 
milk stations, both here and abroad, were simply dis- 
pensaries for doling out and “humanizing” cow’s milk. 
But the mutualite maternelle, founded in 1892, pro- 
vided for visitation and instruction in the home. The 
Ghent School for Mothers, founded in England, in HOME AND THE CHILD 
159 
1901, conducted not only a milk depot, but provided 
training classes for foster mothers, girls’ classes in child 
culture, and home instruction. The St. Pancras School 
(London, 1907) provides classes for expectant and 
nursing mothers, and a club for older girls; although it 
is called a motherhood school, it has also conducted 
an evening department for fathers and husbands. 
Many local educational authorities in England have, 
out of an educational budget, provided teachers of 
classes conducted under the auspices of the English 
Association of Infant Consultations and Schools for 
Mothers. The grants of the Board of Education for 
England and Wales, in 1916, included $76,000 for day 
nurseries and schools for mothers. In this type of 
parental instruction England has been in advance of 
other countries. 
Parental training has, in America, grown out of the 
highly personal relations of the baby-welfare confer- 
ences. After the baby is weighed, measured, and 
examined, it becomes necessary for physician, nurse, 
and parent to take counsel together. This creates an 
educational situation of a real kind, with no artifi- 
cial pedagogical incentives. The possibilities of this 
situation have been only slightly exploited. The in- 
struction is usually limited to the immediate practical 
problem in hand, and sometimes it is perfunctory in 
character. In addition to this individual instruction, 
infant-welfare stations frequently conduct classes or 
clubs for mothers. Goodwin reported such classes for 
two hundred and fifty stations in 1916. Similar 160 
THE PRE-SCHOOL CHILD 
classes and clubs have been conducted by private and 
quasi-public nurseries and social settlements. The 
Murray Crane Day Nursery, of Chicago, has enlisted 
the participation of its mothers in such a way that the 
nursery has become a demonstration and training 
center in child care. Dealey, in 1917, reported that of 
four hundred social settlements in the U.S., twenty 
per cent had nursery establishments and forty per cent 
kindergartens. Only to a limited extent have these 
been used as means for parental education. Public 
kindergartens have barely recognized that such educa- 
tion is within their province. 
Home visitation. A very vital kind of parental 
teaching is that which is carried out by professional 
home visitation. This visitation is now largely done 
by social workers, school nurses, visiting teachers, and 
district and public-health nurses. In the aggregate 
these home visitors accomplish each year a vast 
amount of educational work, though they do not or- 
dinarily consider themselves as educational agents and 
are not so regarded. Much of their teaching is by 
direct prescription and demonstration. They rely 
chiefly on their personal contact and common sense, 
and have not in a professional way become fully con- 
scious of an educational mission or technique. To a 
very meager extent has home visitation made deliber- 
ate application of the principles of educational psy- 
chology to increase the effectiveness of its results. We 
need a more systematic formulation of certain aspects 
of social work in terms of parental education. HOME AND THE CIHLD 
161 
Three kinds of nurses engage in home visitation. 
These are the public-health nurse, whose particular 
province is the prevention of disease; the district 
nurse, whose field is sickness and emergency care; and 
the school nurse, who is concerned with the treatment 
of disease and defect in the school child. These 
various functions are frequently combined in the 
same individual. There are great differences of 
opinion and practice in regard to the vexed question of 
specialized and combined nursing. In England the 
term “nurse” is being dropped in favor of “health 
visitor,” to emphasize the hygienic and educational 
functions. At bottom these questions are admin- 
istrative and by no means call for a uniform solution, 
but in any event the solution should take full account 
of the purely educational problem of parental training. 
This problem is not a vague abstraction; it can be 
readily analyzed into the formation of concrete habits 
of action and perception. Professor C. E. A. Winslow 
believes that the ideal organization for health nurs- 
ing consists of generalized regional nurses, assisted by 
an advisory and supervisory staff specialized along 
functional lines. One of the functions which calls for 
specialized recognition is the educational one, so that 
more effective work will be done in the important 
sphere of parental training. 
This does not mean that we should segregate the 
task of education from other activities. On the con- 
trary, the favorable opportunity for effective instruc- 
tion is the baby’s bath, or the sick bed, or the emer- 162 
THE PRE-SCHOOL CHILD 
gency as the case may be. This gives the work of 
education its natural, project setting. Much, however, 
remains to be done, through improved nurse training 
and supervision, to bring about the maximum utiliza- 
tion of these teaching moments. 
The relation of the school nurse to the problem of 
parental training is a very interesting one. It is 
recognized that she has a specific group of school 
problems, but she can scarcely confine her interest to 
children of school age. She is bound to come into con- 
tact with the younger brothers and sisters, of pre-school 
age, who are not on her register, but who offer tempt- 
ing opportunities for preventive work. Some cities —- 
notably Pittsburgh — are developing the promising 
practice of drafting their school nurses into infant-wel- 
fare work during the summer period. Such procedure is 
bound to break down some of the artificial distinctions 
which now separate school and pre-school hygiene. 
The visiting teacher. There is another agent who 
promises to do still more toward wearing down these 
distinctions. This is the visiting teacher. The visit- 
ing teacher began as an educational experiment, and 
the initiative came from outside of the school system. 
In 1906-07 three cities, New York, Boston, and Hart- 
ford, began the work which has now been taken up by 
twenty-nine cities in fifteen states, and in all but 
four cities is part of the public school organization. 
In 1919 the National Association of Visiting Teachers 
and Home and School Visitors was organized. 
The visiting teacher has been well described as “the HOME AND THE CHILD 
163 
arm of the school extended into the home to draw the 
school and the home together for the benefit of the 
child. It is her work to visit and establish friendly 
relations with the homes of those children who exhibit 
the first symptoms of falling below the school standard 
in scholarship and conduct.” A report on the visiting 
teacher in the United States, issued in June, 1921, by 
the National Association of Visiting Teachers and 
Home and School Visitors, tabulates the specific 
reasons for referring children to visiting teachers, as 
shown in the accompanying table. It will be noted 
how completely the problems lie within the general 
field of mental hygiene, and how largely they include 
Reasons for Referring Children to Visiting Teachers 
Specific Reasons 
fob 
Referring Children 
Total No. of 
V.T.’S NAMING 
this Reason as 
OCCURRING AMONG 
Theib Cases 
Number of V.T.’s nam- 
ing this Reason as 
occurring First, 
Second, Third, etc. 
in Order of Fre- 
quency among Theib 
Cases 
1st 
2d 
3d 
4th 
5th 
1. Maladjustments in scholarship: 
M Subnormality 
50 
11 
6 
26 
7 
(b) Retardation 
49 
11 
31 
5 
2 
(c) Deficiency in lessons. . .. 
48 
29 
10 
8 
1 
(d) Precocity 
34 
1 
2 
8 
23 
2 Adverse home conditions 
(a) Poverty 
48 
26 
14 
4 
3 
1 
(b) Neglect 
47 
17 
19 
8 
3 
0 
(cl Improper guardianship.. 
39 
7 
8 
16 
5 
3 
(d) Immorality 
32 
0 
5 
8 
6 
13 
(e) Cruelty 
31 
0 
1 
6 
14 
10 
3, Misconduct: 
(a) In school 
45 
33 
4 
8 
- - 
(b) Out of school 
41 
10 
20 
11 
(c) Involving morals 
38 
6 
16 
16 
4. Irregu’ar attendance: 
(a) Suspicious absence 
42 
17 
13 
12 
(b) Due to home conditions. 
38 
20 
15 
3 
(c) Half-days absence 
37 
9 
13 
15 
• • 
Lateness and physical condition were also given among other general rea- 
sons for referring cases. 164 
THE PRE-SCHOOL CHILD 
work with parents through teaching and interpreta- 
tion. It is also clear that it is altogether illogical to 
confine the field of the visiting teacher to children of 
school age. 
Adult education for parents. There has been a most 
significant movement for adult education within the 
past few years. The World War has intensified a 
thirst for knowledge which is innate in grown men and 
women and not peculiar to childhood and youth. 
Adults are plastic, inquisitive, and under favorable 
educational stimulus they are even eager for learning. 
Remarkable stories have recently come from England 
of groups of working-men pursuing studies of univer- 
sity grade in economics and history, without even the 
motive of a certificate or a degree. The ardor with 
which these labor-union groups are seeking truth 
might bewilder many a college youth. 
Although these special study groups undoubtedly 
are composed of picked men, there is ample evidence 
that a corresponding educability is very widely dif- 
fused, and that Aristotle was very nearly right when 
he said, “All men desire knowledge.” 
The whole field of parental education and guidance 
is uniquely fertile for educational exploitation, because 
within all normal parents there are psychic impulsions 
which pertain to home life. These impulsions are so 
basic that they determine an all but universal desire 
for knowledge which bears on the health and develop- 
ment of children. Only a cynic would say that there 
is no such common desire. It is there, and we must 
find our way to it. CHAPTER X 
PRE-PARENTAL EDUCATION 
It was about two generations ago, that Herbert 
Spencer contributed to the Westminster Review a 
notable article entitled “What Knowledge is of 
Most Worth?” It contains the following passage: 
“If by some strange chance not a vestige of us de- 
scended to the remote future save a pile of our school- 
books or some college examination papers, we may 
imagine how puzzled an antiquary of the period would 
be on finding in them no indication that the learners 
were ever likely to be parents.” Lest this suggestion 
convey levity, the young philosopher began the next 
paragraph in a more solemn vein: “ Seriously, is it not an 
astonishing fact that, though in the treatment of off- 
spring depend their lives and deaths, and their moral 
welfare or ruin, yet not one word of instruction on the 
treatment of offspring is ever given to those who will 
hereafter be parents?” 
Only a few years ago, in a large Eastern city, ob- 
jections were raised against introducing a live baby 
into an educational exhibit, to be used to illustrate 
methods of infant-welfare work and baby care. The 
objections carried the day and a doll was used instead. 
Although this was historically a very minor incident, 
it reflected the quasi-squeamish attitude which has 166 
THE PRE-SCHOOL CHILD 
long colored our conservatism in the vital field of 
parental education. 
Present educational provisions. A survey of the 
present-day educational provisions directly designed 
for training in the tasks and responsibilities of parent- 
hood reveals a situation which might be described as 
a desert with many oases. There are several “ mother- 
craft schools.” “Caroline Rest” in New York City 
annually reaches thousands of mothers in their period 
of convalescence and trains them through practical 
demonstration and guidance. This is the largest 
institution of the kind. There are extension and 
Chautauqua courses and even correspondence courses; 
and there are Y.W.C.A. classes, continuation classes, 
and specialized departments in home economics in an 
increasing number of vocational schools. Domestic 
science and so-called household arts have become 
almost a staple item in public instruction, but a frank 
analysis of the content and method of the work shows 
that these courses are pitifully inadequate. Some- 
times they appear to be a means for evading the real 
issues involved. The courses themselves may be 
conducted with efficiency and excellent spirit, but 
without meeting the real requirements of an educa- 
tional preparation for parenthood. 
Colleges and home training. In a delightfully 
ironical article in the January, 1922, number of the 
Journal of the American Association of University Wo- 
men, Mrs. Eva Vom Baur Hansl exposes the paucity 
of college provisions for training for parenthood. She PRE-PARENTAL EDUCATION 
167 
notes that relatively few colleges or universities offer 
even courses in child psychology, and that these 
courses either ignore or slight the pre-school period of 
development, which, from the parental viewpoint, is 
of preponderant importance. Courses in child hygiene 
and home nursing are equally rare. There are scatter- 
ing courses announced in the catalogues, as “markets 
and marketing,” “economics of the family,” “dietet- 
ics,” “child-welfare problems”; but nothing compara- 
ble to a well-rounded “department of the home,” with 
definite courses in child care and family welfare. The 
author refers with approval to the semi-centennial 
address at Vassar College, in which Miss Julia La- 
throp “ expressed the wish that colleges would do their 
share in making for a more intelligent motherhood, 
and even dared to hope that some day they would 
establish graduate departments of research in the 
affairs of the home.” 
Through extension divisions, occasionally through 
correspondence courses, State universities have given 
a certain amount of parental instruction and have 
reached large numbers of patrons. Some vocational 
schools and normal schools have entered the field more 
systematically. It is estimated that the American 
School of Home Economics has reached twenty thou- 
sand persons through correspondence courses. The 
State University of Iowa has founded a Child-Welfare 
Research Station which will undoubtedly exert a 
practical influence in this field of education. Re- 
cently the Michigan Agricultural College has made an 168 
THE PRE-SCHOOL CHILD 
arrangement whereby seniors will have theoretical 
courses in child psychology, child hygiene, nutrition, 
and household management. Laboratory experience 
in some of these courses will be provided through an 
experimental nursery school which has just been es- 
tablished in Detroit, as part of the Merrill Palmer 
Motherhood and Home Training School. 
Progressive libraries sometimes have organized in- 
formation service for parent and household problems. 
The Federation for Child Study has published a 
bibliography of books for parents. A few publishers 
have issued manuals on child nurture and home edu- 
cation. Various organizations have formed study 
and reading circles. The Duluth public schools have 
created a department of home teaching for foreign 
women. It is really part of the Americanization 
work; but the reading material is related to problems 
of housekeeping, child training, and home-making. 
The early lessons, following the principle of suggestion, 
contain such interesting sentences as, “I keep the 
house clean.” “A clean store has no flies and little 
dirt in it.” “Cooked prunes are good for children.” 
The public schools. Passing now to the public 
school system, we find that perhaps the most effective 
educational enterprise in this field is one which origi- 
nated, in 1908, in the Department of Child Hygiene of 
New York as a kind of extra-curriculum activity, and 
has since been imitated by many cities. In 1915 there 
were Little Mothers’ Leagues in forty-four cities, en- 
rolling 48,475 girls, who were instructed by lectures PRE-PARENTAL EDUCATION 
169 
and demonstrations during and after school hours, both 
in vacation and school time. The League reaches 
girls from the fifth to the eighth grades, and includes 
badges, prizes, plays, and pageants in its devices. 
Most important of all is the healthy motivation which 
it builds up through first-hand introduction to the 
actual work of infant care. Similar in conception and 
method is the work in the “Fire Makers” order of the 
Camp Fire Girls. Promotion to this order can be 
gained only by passing certain tests, informational 
and otherwise, relating to infant welfare — a dim re- 
minder of the adolescent initiation rites found among 
primitive peoples. Although the Little Mothers’ 
Leagues and Camp Fire Girls are not officially rec- 
ognized agencies of public education, they have im- 
portant suggestions to offer to these agencies as to 
methods of motivation and appeal. 
Vocational home-making education. The whole 
question of training for parenthood as a task of public 
education is rising into clearer prominence for two 
reasons: (1) The pressing importance of an improved 
control of the hygiene of the pre-school period. (2) 
The passage of the Smith-Hughes Act providing 
grants of Federal aid for vocational training in home 
economics. This act applies to other forms of voca- 
tional education as well; indeed, home economics was 
not included until the eleventh hour. The Federal 
Board for Vocational Education has experienced some 
administrative difficulties in fitting the ordinary 
principles of vocational training to the field of home 170 
THE PRE-SCHOOL CHILD 
economics. The policy of the Board is summed up in 
Bulletins 28 and 37. In the latter bulletin the term 
“home-making” is substituted for the more specific 
term, “home economics.” Home-making is described 
as a composite vocation and as a social and business 
enterprise. As a vocation it is analyzed into the fol- 
lowing distinct lines of activity: 
a. The care and rearing of children. 
b. The care of the house and its equipment. 
c. The selection, preparation, and serving of food. 
d. The selection and care of clothing, and to some extent 
its actual construction. 
e. The care of the health of the family. 
In terms of this analysis, home-making proves to be 
numerically, at least, the most important of all oc- 
cupations, far outnumbering the next most numerous 
occupational group of farming. 
There are easily twenty million homes in the coun- 
try, with an even larger number of house mothers, 
house daughters, and aunts who are potential candi- 
dates for training in home-making. In view of this 
situation, the public schools of the country have, by 
their few, slender courses in home economics, only 
touched the hem of the garment. There are, in round 
numbers, over twelve thousand public high schools in 
the country, with only one fourth offering courses in 
home economics, attended by one out of six of the 
entire enrollment of high-school girls. These courses 
have been conventionally limited to cooking and sew- 
ing. The Children’s Bureau of the United States 
Department of Labor has just prepared, in codpera- PRE-PARENTAL EDUCATION 
171 
tion with the Federal Board for Vocational Education, 
a five-hundred-page guidebook of outlines for study of 
child care and child welfare. This is to be used in the 
training for vocational teachers of home economics, 
and will help to broaden our current “domestic 
science.” 
The work done as yet very meager. Moreover, 
there are vast contingents of prospective home-makers 
who are not reached by the existing courses in home 
economics, and by the relatively meager provisions of 
grammar-grade and night-school instruction. About 
two fifths of all girls, from sixteen to twenty years of 
age, are engaged in gainful occupations; there are also, 
as Bulletin 37 points out, large numbers of girls beyond 
compulsory school age who have dropped out of school 
and are relatively idle or engaged in non-gainful 
(household) occupations. There are also large num- 
bers of girls and women above school age, and there are 
large numbers of girls in rural and sparsely settled 
communities, who have not been reached. The 
Federal Board for Vocational Education suggests that 
the needs of these various groups be met by short unit 
courses, by part-time schools or classes, and by all day 
schools. The Board would also insist that the pre- 
vailing home-economics courses, which are now part of 
general education, be definitely placed on a vocational 
basis. From an administrative point of view they 
must be put on that basis to entitle them to any of the 
$600,000 which will be available for their support, in 
1925, by the Smith-Hughes Act. Incidentally, it may 172 
THE PRE-SCHOOL CHILD 
be noted that this sum is only one tenth of that which 
will be available to States for training in agriculture 
and trades and industry in the same year, under the 
same act. 
In his recent book on Vocational Education Pro- 
fessor Snedden subjects the current situation in home- 
making education to a critical analysis. He almost 
exhausts the letters of the alphabet to list the vari- 
ous types of homes which must be considered; he 
classifies ten different kinds of skills which must be 
evaluated to ascertain what powers and capacities are 
now prevailingly found among home-makers; he in- 
dicates how the objectives of home-making education 
must be classified by case studies of typical situations. 
He believes that from an administrative viewpoint it is 
necessary to distinguish between extension teaching, 
technical instruction, and basic vocational education. 
Finally, he comes to the conclusion that it is very im- 
portant that schools of general education for girls 
from twelve to sixteen years of age “should offer 
courses of household arts, conceived very much as are 
now home gardening, scouting, and the best manual 
training, as a means of genuine liberal education.” 
“The courses should not be obligatory, but elective; 
they should not have the serious singleness of purpose 
of vocational education, but should be diffusive, catho- 
lic, and cultural in spirit.” 
The possibilities of pre-parental education. It is 
evident, from the above survey of current practices 
and tendencies, that the problem of training for parent- PRE-PARENTAL EDUCATION 
173 
hood is far from solved. The immediate administra- 
tive problems are being met, and there will doubtless 
be a rapid increase of educational provisions in home 
economics, but whether we have faced and grappled 
with some of the deeper issues of the question may well 
be doubted. The basic problem of rearing children — 
that is, the vital part of the problem of parenthood— 
still holds a minor place in our discussion and our 
schemes. 
And even when it is theoretically considered, boys 
and fathers have been left almost completely out of the 
reckoning. I do not recall that either the term “boy,” 
“young man,” or “father” is used in the two Federal 
bulletins on home-making, and most educators present 
the subject purely from the feminine angle. What- 
ever justification there may be for this, the situation is 
anomalous. Even after home-making has been ana- 
lyzed into five different activities, and after all of these 
have been generously placed on the house daughters 
and house wives, we are still confronted with the 
biological and sociological axiom that home-making is 
a joint enterprise in which the father must share. In 
our arrangements of education, and in our prospectuses 
concerning these arrangements, we cannot afford to 
imply that the father is the economic bread-winner of 
this social unit, and that he needs no training or sense 
of responsibility in the composite activities of home- 
making. It ought to be one of the major objectives of 
our popular home-making education, here in America, 
to blot out that disastrous implication, and to give 174 
THE PRE-SCHOOL CHILD 
“the head of the household” a little glimpse of his 
domestic future. Indeed, we ought to count home- 
making one of his career motives, and we ought to 
tap it. 
The second fundamental defect in our present 
educational conception of the problem is that home- 
making is being formulated too much in terms of voca- 
tional skills, and too little in terms of motivations and 
ideals. Although little is gained and much is lost by 
making a sharp distinction between vocational and 
liberal or cultural education, it is essential that the 
psychological factors of desire and attitude be made 
of primary importance in our educational procedure. 
If home-making is a vocation, it is unique; and it is 
unique, for it is in a sense universal. Children share 
in it as well as cooks and seamstresses, and so do 
fathers. Technical skill in cooking, sewing, washing, 
teaching are invaluable, but neither educationally nor 
actually does skill count for as much here as it does in 
stenography. Home-making and parenthood are more 
akin to ethics and citizenship than they are to any 
specific vocation. This is not to say that they should 
not be defined into their specific motor activities, when- 
ever these can be determined for purposes of training, 
but these motor habits do not comprise the whole job 
analysis. We must rank first in our inventory the less 
tangible but very real factors which have to do with 
the deepest instinctive attributes of life, and with 
nothing less than a philosophy of life. 
How can we aid the development of such a philoso- PRE-PARENTAL EDUCATION 
175 
phy unless we go beyond the ordinary standards of 
purely vocational pedagogy ? By philosophy of life we 
do not mean some unattainable system of metaphysics, 
but the groups of ideas and attitudes, inarticulate and 
articulate, which concern the home in one way or 
another and condition one’s whole outlook upon the 
world. 
Any one who has seen an average young woman, 
from a simple walk of life, bring her first baby to an 
infant-welfare conference and caught some of the inner 
radiance which she betrays in the experience, knows 
that parental education deals with some of the most 
profound impulses of life. Even before the event of 
actual parenthood, these impulses in a submerged 
form make their presence and their power felt. They 
exist even in rather colorless youths, and they consti- 
tute the most sacred and potent interest with which 
education has to deal, either directly or indirectly. 
The key to the baffling problems of adolescence lies 
in the enlightened capitalization of these instincts and 
complexes which are set toward parenthood. 
It has long been clear that the problem of sex educa- 
tion cannot be solved by any tour de force, and that 
didactic instruction to remove ignorance will in itself 
be of little avail. Nor will prudishness be of much 
avail. The problem is so fundamental that it must be 
solved in other ways. 
We have fallen into a kind of evasion and prudish- 
ness with regard to the problem of training for parent- 
hood. We have not bothered the boys about it at all. 176 
THE PRE-SCHOOL CHILD 
Even with girls we have avoided some of the basic 
realities of embryology, birth, infancy, development, 
and child nurture. Active, frank relations with the 
problems of child care have not marked our efforts. 
We have neglected to build up in our rising youth the 
healthiest and most spiritual of all sex complexes; 
namely, those which are concerned with the rearing 
of children and the significance of family life. Surely 
we can develop a type of home-making education 
which will bring the realities and significance of child- 
hood into the vision of youths who in a few years will 
be fathers and mothers. Unless we really bring such 
a vision, this education is virtually a failure, and if we 
succeed in developing a sincere, sound type of pre- 
parental education, we shall find that by a benevolent 
process of substitution we have also, in large measure, 
solved the so-called problem of sex education. The 
only anchor for a really wayward youth is his own 
home, or a prospective home which he or she will help 
to create. 
Where the kindergarten may serve. In conclusion, 
what do we mean by a sincere type of parental educa- 
tion? We mean one that will actually concern itself 
with actual children; not only by means of “home 
projects” and doll demonstrations, but by active 
participation in the care of children, particularly those 
of younger age. The whole wide-flung pre-school 
period is open for exploitation as a training ground, 
and our adolescent youths can be employed as junior 
assistants in such a manner that their apprenticeship PRE-PARENTAL EDUCATION 
177 
services will be a civic contribution. It would not 
require superhumanly ingenious engineering or man- 
agement to assign these youths, for periods of obser- 
vation and help, to infant-welfare stations, pediatric 
clinics, to rounds with visiting nurses, to settlements, 
nurseries, children’s homes, and kindergartens. 
The monitorial system of education once had great 
vogue. It fell quite properly into disuse because it 
was misused. Nevertheless, there is a kind of natural 
sympathy between youths in their teens and young 
children which could be made to thrive for the bene- 
fit of both ages concerned. The uninhabited model 
apartment, which has been used with some success in 
teaching the household arts, is hopelessly inadequate 
when it comes to teaching child hygiene and strength- 
ening the growing fibers of parenthood. We must 
strike for something broad-gauged and real, and the 
whole span of years and agencies from the milk station 
to the primary grades lie at our disposal. 
Here, as elsewhere, the kindergarten, because of its 
strategic location in the scheme of things, is in a posi- 
tion to make an invaluable contribution toward solving 
the stupendous problem of popular pre-parental educa- 
tion. Incidentally, the welfare of the pre-school child 
of both this and the next generation is partly at stake. CHAPTER XI 
THE SOCIAL CONTROL OF PRE-SCHOOL HYGIENE 
The movement toward systematic social control. It 
is evident from many signs of the times, both here and 
abroad, that the developmental hygiene of the pre- 
school age will gradually be brought under systematic 
social control. It is clearer than it has ever been 
before that the first months and years of infancy can- 
not be entrusted completely to the unaided instincts of 
parental protection. The State must provide general 
laws, specific regulations, and special social devices 
for safeguarding the precarious “rights” of early 
infancy; it has done much to secure similar rights for 
children of school age, and repeated judicial decisions 
have strengthened this protective social control. 
The practical exercise of social control will involve 
certain administrative difficulties arising out of the 
fact that there is no convenient clearing house for 
children of pre-school age comparable to the public 
school. Pre-school children are scattered among nu- 
merous homes, and rarely congregate. The hygiene of 
the pre-school child in rural districts presents pecul- 
iar difficulties. Whether in country or city, there is 
the basic problem of securing adequate home coopera- 
tion. There are also numerous problems of coordina- 
tion between private physician practice and public 
health supervision, and between medical and educa- CONTROL OF PRE-SCHOOL HYGIENE 
179 
tional forms of control. The latter question may be 
discussed first, because of the important and interest- 
ing issues which it involves. . 
Medical and educational control 
The concrete problems of pre-school hygiene may 
be purely medical in character, or educational, or both 
simultaneously. It is this very community of interest 
which may bring about administrative conflict. 
The overlapping interest of both health and educa- 
tional authorities in the pre-school period has come 
into definite expression in England. We have noted 
that nurseries are put under the Ministry of Health 
and nursery schools, under that of Education. In the 
administration of maternal and infant welfare we have 
the following situation described by Brend: 
If the mother wishes for advice or help in the care of her 
baby, she may go to a “school for mothers” which is under 
the Education authorities, or to an “infant-welfarecenter” 
under the control of the local authority and assisted by 
grants from the Local Government Board, and either of these 
institutions may send a health visitor to advise her as soon 
as the infant is born. 
The result is that the Board of Education and the 
Local Government Board are doing essentially the 
same work in the field of infant welfare, as shown by 
the similarity of their annual reports on this subject. 
The chief difference between the two agencies is that 
one is primarily educational and the other provides 
surgical and medical treatment; but, as Mrs. Acland 
has said, “ When Mrs. Smith’s baby begins to put on 180 
THE PRE-SCHOOL CHILD 
weight, who shall say whether we rejoice primarily 
because that means an improvement in Mrs. Smith’s 
education or in baby’s health?” 
The above was written before the passage of the 
recent Ministry of Health Act which relieves the 
Board of Education of responsibility (1) for the 
medical inspection and treatment of school children 
and young persons, and (2) for the care of the health 
of expectant and nursing mothers and of children under 
five. 
Sir Arthur Newsholme, although recognizing the 
excellent medical work accomplished under the di- 
rection of local education authorities, where it was 
first placed, and recognizing that the work in its initial 
stage developed more rapidly because of this connec- 
tion, has the following to say regarding the adminis- 
trative issue: 
The separation of the medical work of educational authori- 
ties from public-health medical work was contrary to the 
first principles of sound administration. 
Whether this observation applies with equal force 
to American conditions is not altogether clear. The 
tremendous development of the public school system 
in America, and a corresponding increase in the pres- 
tige of boards of education, accentuated by a retarda- 
tion in the development of boards of health, has tended 
to diminish the power of the latter in relation to the 
health supervision of school children. For the period 
of infancy, however, where the problems are so deci- 
sively medical and sanitary, boards of health have CONTROL OF PRE-SCHOOL HYGIENE 
181 
maintained their authority. Logically enough, this 
responsibility extends through the whole pre-school 
period, and this health service should be made con- 
tinuous with that of the schools. On this point Dr. 
Josephine Baker writes: 
Health authorities generally view the problem of child 
health as part of any coordinated program for the conserva- 
tion of the health of all persons in the community. ... To 
assume that a health board can care for the health of the 
population under six years of age, and then neglect such 
health measures until the age of fifteen, implies a neglect of 
opportunity which should be condemned. 
Functions of a bureau of child hygiene. Dr. Baker 
was the first director of the first department of child 
hygiene to be established, that of New York City, in 
1908. Similar departments or bureaus have become 
an almost standard feature of both municipal and 
State health organization. Less than a half dozen 
States in the Union are now without such a subdi- 
vision. Dr. Baker defines the functions of a well- 
organized bureau of child hygiene as follows: 
1. Regulation and standardization of obstetrical proce- 
dure by: 
a. Education, licensing and control of midwives. 
b. Supervision of standards of lying-in hospitals. 
c. Provision of maternity nursing. 
2. Prenatal work, including: 
a. Establishment of prenatal or maternity centers. 
b. Supervision and instruction of expectant mothers. 
c. Essential legislation for protection of women of 
child-bearing age or pregnant women in industry. 
3. Reduction of infant mortality by: 
a. Measures outlined under (1) and (2). 182 
THE PRE-SCHOOL CHILD 
b. Instruction of all mothers of children under one 
year of age, with necessary health supervision of 
such infants. 
c. Readjustments of social, economic, and environ- 
mental conditions. 
d. Education of young girls in personal hygiene and 
in the care of infants. 
4. Health supervision of children of pre-school age by: 
a. Maintenance and supervision of day nurseries. 
b. Supervision and control of institutions caring for 
dependent and delinquent children. 
c. Health examinations and follow-up of children of 
pre-school age. 
5. School medical inspection by: 
a. Health supervision of all children of school age. 
b. Establishment and maintenance of standards for 
school hygiene. 
c. Establishment or supervision of adequate facilities 
for the treatment of defects or illnesses of children. 
6. Child Labor. 
a. Establishment of legal standards controlling the 
employment of children. 
b. Supervision of children under 16 years of age en- 
gaged in industry. 
c. Establishment of health standards essential for 
the issuance of employment certificates. 
The above is logically a reasonable outline of the 
proper functions of a bureau of child hygiene, and it 
represents a field of activities which has been success- 
fully administered by the largest bureau of child 
hygiene in America. There has been much local 
difference of policy and procedure in this country with 
regard to the group of functions listed under item 5. 
This diversity in practice has developed in spite of 
the fact that in the United States, out of thirty-four 
States which have laws requiring or permitting the CONTROL OF PRE-SCHOOL HYGIENE 
183 
employment of medical inspectors, twenty-nine have 
put the work under the State Board of Health, and 
four under the State Board of Education. 
Educational versus Medical Control. Cubberley, 
in his volume on Public School Administration says 
(p. 348): 
Medical inspection everywhere began as an extension of the 
work of boards of health, but in something over three 
fourths of the cities of the United States now supporting 
health work in the schools, the service has since been placed 
under the control of the board of education. This must now 
be regarded as its proper place, because the work is essentially 
an educational service. 
On the same question he quotes the following from 
the Portland School Survey Report (p. 349): 
While it is possible for the work to be efficiently carried on 
by a board of health, it is extremely unlikely that it will be. 
The board of health lacks the educational point of view, 
usually makes the work curative rather than preventative, 
neglects the so-called “minor” forms of defectiveness, makes 
the school service a side issue of the public health work, and 
fails to secure the maximum cooperation from teachers and 
parents. 
Terman and Hoag add another reason why the 
health service should not be administered by non- 
educational machinery; namely, that it would result 
in a “bifurcated educational aim, which has wrought 
such havoc in education for hundreds of years, and 
which becomes through this system of divided re- 
sponsibility more strongly intrenched than ever. The 
school looks after the child’s mind, the board of health 
after its body.” 184 
THE PRE-SCHOOL CHILD 
Rapeer, likewise, says: 
Efficiency cannot come through administering any part of 
the school’s work for children by some outside agency. 
W. H. Maxwell, Superintendent of the New York 
City Schools, in 1909 summed up his argument in 
favor of putting the work of school physicians under 
the direction of school authorities as follows: 
In the first place, we should wrong ourselves if we did not 
raise our voices against another city department drawing ju- 
risdiction over work that is purely educational in character. 
In the second place, dual authority and responsibility in a 
school — that of the school authorities and that of the health 
authorities — always have resulted, and always will result, 
in confusion and inefficiency. 
In the third place, the accomplishment of the results 
desired requires experts; and experts in school work are not 
developed by health authorities. 
Some of the above strictures with respect to the 
limitations of medical control are less justified to-day 
than when they were written. Medical literature 
shows an increasing volume of emphasis on the edu- 
cational aspects of health supervision on mental 
hygiene and the psychological factors in medical 
treatment. Moreover, there are innumerable in- 
stances in which educational methods have been de- 
liberately put into practice in dispensary, hospital, 
clinic, health center, medical social work, nursing, etc. 
It can no longer be said that the members of the medi- 
cal profession are dull to the educational implications 
of their work. 
A similar transformation has been manifesting itself 
in the field of public health; this term once suggested CONTROL OF PRE-SCHOOL HYGIENE 
185 
sewers and typhoid, but now its connotation is broad- 
ening with every year. As Newsholme says: 
It embraces physiological as well as pathological life, 
being as much concerned with improving the standard of 
health of each person as with the prevention and cure of 
disease. 
This statement may be found in Newsholme’s volume 
of American Addresses on Public Health and Insurance, 
dedicated “To the Right Honorable John Burns, a 
leader in public health; who in particular made the 
public realize the importance of concentrating on the 
Mother and her Child.” 
The maternity and pre-school phases of health work 
are from the standpoint of preventive medicine assum- 
ing paramount importance, and medical-inspection 
service in schools is dropping to a more secondary 
position. With the development of pre-school hygiene, 
however, the educational and psychological phases of 
this health work with children of pre-school age will 
become increasingly evident. In the future, as in the 
past, conjoint and cooperative methods of attack must 
be evolved by both medical and educational agencies. 
The National Child Health Council, in its recom- 
mendations relating to child health in Erie County, 
New York, proposes this principle as the basis for 
coordination: 
The jurisdiction of neither the school authorities nor of the 
health authorities of the county should be relinquished, but 
both should be administered through one administrative 
head, whether on the pay-roll of the schools or of the nearest 
health administration unit. 186 
THE PRE-SCHOOL CHILD 
The rural pre-sclwol child 
There are two sufficient reasons why the rural pre- 
school child must be included in the public health 
program: 
1. The majority of all children of pre-school age live 
in rural communities. 2. The health of rural children 
is neither “naturally” nor actually superior to that 
of urban children. 
Indeed, the rural mother and child may often, be- 
cause of limitations of environment and outlook, have 
a peculiar claim on socialized health service. One of 
the most inspiring features of the recent public-health 
movement is the organization of such service, through 
statutes and through public and voluntary agencies. 
The country doctor, whose training and traditions 
have emphasized the purely curative side of medicine, 
is beginning to cooperate in a preventive program 
which will in the long run give him a greater oppor- 
tunity for remedial work of a higher order. Local 
communities in increasing numbers are coming to the 
point where they themselves take initiative and re- 
sponsibility in the organization of health service. 
Outside stimulus and guidance are important, but the 
service which is developed out of local interest is 
likely to be the most satisfactory and the most per- 
manent. 
A rural community, by the classification of the 
United States Bureau of the Census, is any place or 
district having a population of less than 2500. Cities CONTROL OF PRE-SCHOOL HYGIENE 
187 
seem to dominate our civilization, but fully sixty per 
cent of the children of the Nation live in rural com- 
munities. The number of rural children of pre-school 
age was, in 1920, about 7,000,000. Interesting meth- 
ods have been used to reach these children. Federal 
and State Governments have motorized medical, 
nursing, and educational service, and demonstrated 
the feasibility of bringing such service to very remote 
districts. The Wisconsin Board of Health, through 
an appropriation of the last legislature, has fitted out 
a “Child Welfare Special,” modeled after the one used 
by the Federal Children’s Bureau — a large motor 
truck equipped as a clinic and in charge of a woman 
physician and a nurse. The policy of the Wisconsin 
Bureau of Child Welfare and Public Health Nursing, 
however, is to encourage the establishment of per- 
manent health centers in village and country districts, 
and to place both initiative and responsibility upon 
the local community. 
Organization of rural health work. The character 
of the organization of rural health work will naturally 
vary with the locality. The Red Cross Country 
Nursing Service, in 1920, demonstrated the possibility 
of conducting clinics in the schoolhouses of a large 
county (Kalamazoo County, Michigan) and of utiliz- 
ing the cooperation of both local physicians and ex- 
perts and specialists from the county seat. School 
was dismissed for the day in the community where the 
clinic was held; the teacher and other volunteers as- 
sisted; clinic day was made a community event and 188 
THE PRE-SCHOOL CHILD 
something of a holiday. In the evening stereopticon 
slides on general health subjects were shown, the 
lantern being connected by extension cords to the 
nurses’ automobile when local electricity was not 
available. “The hopeful beginnings in team thinking 
and community participation in health programs” 
which resulted from the rural clinics point to the 
desirability of permanent service of a similar kind. 
In more sparsely settled communities, it may for 
some time prove impractical to establish clinical serv- 
ice for the diagnosis and treatment of ambulatory 
patients; but in such communities the educational 
type of health station, with nursing service, can be 
developed. Under the auspices of a well-trained pub- 
lic-health nurse, working in cooperation with the local 
teachers and physicians, such a health center may ac- 
complish much in the field of child hygiene. 
Mrs. M. P. Morgan, director of the Bureau of Child 
Welfare and Public Health Nursing in Wisconsin, 
says, “There is no doubt that infant clinics can be con- 
ducted successfully by public-health nurses.” Miss 
LaForge, of the Children’s Bureau, however, is of the 
opinion that “the rural mind more readily compre- 
hends a family health service,” which would also 
include actual bedside nursing and care of the sick. 
There are psychological as well as practical adminis- 
trative reasons why a generalized kind of family wel- 
fare health work is likely to be more successful under 
rural conditions. There is no reason, however, why 
the educational type of work should suffer from such CONTROL OF PRE-SCHOOL HYGIENE 
189 
an arrangement. The personal relations which grow 
out of maternity and bedside care furnish a favorable 
opportunity for effective teaching in disease preven- 
tion, child hygiene, and infant care. 
The administrative problems of rural health service 
are difficult, but not insoluble. Local interest and the 
ingenuity of leaders will find a way. 
The social unit plan of community organization 
The larger administrative problems relating to the 
social control of infant and family welfare do not limit 
themselves to considerations of economy and efficiency, 
but involve fundamental issues of political science 
and perhaps of democracy itself. It is for this reason 
that the unique social unit experiment, conducted in 
Cincinnati for the three years ending July, 1920, is 
peculiarly instructive. The results of the experiment 
have been recently reviewed in a critical manner by 
Courtenay Dinwiddie, and the history and principles 
underlying the project have been set forth by Mr. and 
Mrs. W. C. Phillips, who were the executives of the 
National Social Unit Organization, and closely identi- 
fied with its inception. 
The Cincinnati experiment, in Dinwiddie’s estimate, 
was “founded upon perhaps the most philosophical 
conception of human relations in community service 
that has been offered for thorough test in this country.” 
He believes, also, that, in spite of the setbacks and the 
political attack to which the undertaking was sub- 
jected, the citizens of the district, and those serving 190 
THE PRE-SCHOOL CHILD 
them, made “a real and outstanding contribution to 
human progress.” 
The general merits of the social unit idea have re- 
ceived the endorsement of many prominent persons 
and organizations, including Professor John Dewey, 
Dr. L. Emmet Holt, Mr. J. P. Foey, editor of the Iron 
Molder's Journal, Mrs. J. Borden Harriman, John 
Spargo, Rabbi Simon, the Federation of Churches of 
Cincinnati and Vicinity, and the American Federation 
of Catholic Societies. 
The Milwaukee experiment. From the standpoint 
of pre-school hygiene the history of the unit plan is 
particularly significant. The plan was the outgrowth 
of a health center experiment carried on in Milwaukee, 
in 1911-12, under the auspices of a municipal child- 
welfare commission. Here, as later in Cincinnati, 
preventive health work was the point of attack, and a 
sincere effort was made to put the program on a demo- 
cratic, community, self-help basis. The cooperation of 
the parish priest was secured; block workers were ap- 
pointed for each of thirty-three blocks to gather facts, 
to interpret, and to advertise the contemplated infant- 
welfare and health work; citizens’ committees were 
chosen; and a cooperating group of physicians was 
organized to develop a preventive program. The 
Milwaukee enterprise came to an untimely end because 
of a change in city administration, but it furnished a 
practical basis for developing the principles of or- 
ganization and procedure which were put to such no- 
table demonstration in the Mohawk- Brighton District CONTROL OF PRE-SCHOOL HYGIENE 
191 
of Cincinnati. Fundamental among the principles 
“was the democracy of the plan — the idea of working 
from the bottom up as well as from the top down — 
of trying out a new method through which people can 
study their own needs, make their own surveys, call 
in experts of their own choosing, and pass upon plans 
suggested by such experts.” 
The Cincinnati experiment. Cincinnati was chosen 
for the social unit experiment because of its demon- 
stration of interest in the project, and because of other 
civic, geographical, and populational advantages. 
The Mohawk-Brighton District, in that city, compris- 
ing thirty-one blocks with about one hundred families 
to each block, and numbering in all about 19,000people, 
was organized, in the summer of 1917, by a district 
committee of over two hundred residents. The na- 
tional social unit organization raised a sum of $90,000, 
and Cincinnati underwrote an additional sum of 
$45,000, making a total of $135,000 for the three years 
planned. The work of organization involved coopera- 
tion between the city authorities, the district repre- 
sentatives, and the fostering national society. In 
spite of an unfortunate public controversy over the 
social unit, the demonstration was carried through 
a period of three years, yielded constructive results, 
and won the almost unanimous, sympathetic endorse- 
ment of the citizens immediately concerned. 
Organization of the social unit. The administra- 
tive organization which was adopted may be briefly 
sketched as follows (for details, see Dinwiddie’s re- 192 
THE PRE-SCHOOL CHILD * 
port): The residents of each of the thirty-one blocks 
in the district elected a block council of seven members. 
Each council elected a block worker, with executive and 
social worker duties. These block workers together 
formed the citizens' council for the whole district. 
This council had its own executive. Similarly each 
group, having some professional skill or expert service 
to render, organized on a district basis and elected 
an executive representative. These representatives 
together constituted the local occupational council of 
the district, and functioned as the planning body for 
the various specialists comprising the seven occupa- 
tional groups — the physicians, dentists, nurses, social 
workers, clergymen, teachers, and recreation leaders. 
The occupational council and citizens’ council acting 
in combination constituted a general council, which 
elected a general executive for the entire district or- 
ganization, and jointly or concurrently administered 
the affairs of the neighborhood. 
Dinwiddie summarizes the novel features of this 
type of community organization as follows: 
1. The clear-cut and intimate basis upon which small 
population units of the district were represented by the 
elective members of the citizens’ council, known as block 
workers. 
2. The mingling of policy-making and executive functions 
in the membership of the citizens’ council, which was part of 
the theory of the plan of operation. 
3. The plan of occupational representation of the district, 
by groups formed on the basis of service rendered to the 
community. 
4. The definite coordination of the representatives of the 
citizens’ and occupational groups in the general council, the 
policy-making body of the community organization. CONTROL OF PRE-SCHOOL HYGIENE 
193 
It is in respect to the fourth feature just mentioned 
that the social unit made a unique contribution to the 
public-health movement. It has been asserted that 
control of health service by experts leads inevitably 
to paternalistic procedure and an autocratic type 
of government. The Cincinnati unit organization 
demonstrated the possibility of establishing organic 
working relationships between the agents of commu- 
nity service and the recipients of that service. It was, 
of course, to the advantage of the experiment that the 
activities of the unit were confined so largely to the 
relatively non-controversial field of health work; but 
it is encouraging that in this field it achieved real suc- 
cess — a success that was reflected in a marked in- 
crease of both civic and human neighborliness, and in 
a deeper, broader concern for the welfare of the pre- 
school child. 
Achievements in pre-school hygiene. It was no 
small achievement which enabled the chairman of the 
general council to say: 
No community in the United States has done as much for 
the babies, so far as we know, as our Mohawk-Brighton 
Social Unit has. The number of babies under supervision in 
the district have increased twelve hundred per cent, and 
eighty-six per cent of all mothers with children under six 
years of age have brought them to the local health stations 
in charge of the Mohawk-Brighton physicians and had them 
thoroughly examined. 
The following statistics summarize some of the 
significant results which were attained in the pre-school 
service. In December, 1917, only twenty-three in- 194 
THE PRE-SCHOOL CHILD 
fants were recorded in the baby health service. By 
the middle of next year eighty per cent of all babies 
under two years of age were examined medically. 
During the first nine months of 1919, ninety-two per 
cent of the babies born in the district during that period 
received nursing care. The pre-natal service also 
showed a marked increase. By April, 1918, the block 
workers had registered 1173 children under six years 
of age. During the remainder of the year, 1075 of 
these were examined; 640 serious defects were found 
in children between two and six years of age; 446 
children had defects so serious that they were placed 
under the supervision of nurses. These figures are 
undoubtedly fairly representative of the physical 
status of unselected pre-school children, and lead to 
the broad but significant conclusion that a majority 
of such children, the country over, are physically de- 
fective in the sense that they require definite medical 
and nursing supervision. 
Scope of the pre-school hygiene problem. The 
development of parental training, home teaching, and 
pre-parental education is unquestionably part of the 
administrative problem of pre-school hygiene. Did 
the social unit experiment shed any fresh light on the 
solution of this important question? Unfortunately, 
no. The question came up for frank discussion when 
it was proposed to develop an educational extension 
service in home economics.. It was decided not to have 
a home economics teacher as such, but a coordinator 
of all educational work in the home, including that of CONTROL OF PRE-SCHOOL HYGIENE 
195 
the visiting housekeeper, the social workers, and the 
hygiene instruction of the district nurses. The deci- 
sion, however, was never carried out, and no vital con- 
nections were established with the administration of 
the public schools. In his conclusions on Education 
and the Teachers’ Council, Dinwiddie was obliged to 
say: 
The relationship of the educational work of the neighbor- 
hood organization to academic instruction in the public 
schools and the cooperation between the organization and the 
teachers of the schools was almost negligible, due to the gap 
between the immediate fields of operation of the two, and 
the failure of either to make a thoroughgoing effort to bridge 
this gap. 
The significance of the kindergarten in the situation 
was not altogether missed. A report of the nursing 
service, for 1918, of the Mohawk-Brighton Social 
Unit Organization, contains this interesting reference 
to the kindergarten: 
Classes for mothers in child care were organized and held 
in the schools. The kindergarteners assisted by caring for 
the children while the mothers were in class, and helping with 
the social hour which followed. This gave the kindergarten 
teacher an opportunity to become acquainted with her little 
pupils while they were still babies. 
It would be impossible to continue an arrangement of 
this kind very long without making the kindergarten a 
working part of both the maternity and infant-welfare 
work. 
If the social unit plan is put to further test and 
elaboration, we may hope that it will furnish some 
specifications for the construction of a bridge between 196 
THE PRE-SCHOOL CHILD 
the pre-school and the school domain. It is most im- 
portant that organic functional connections should, in 
the future, be laid down, uniting the public school 
system with the field of pre-school hygiene. This 
coordination can be accomplished in many ways. The 
most fundamental, and therefore the most promising 
approach is through the creation of a new, concrete 
type of parental and pre-parental education, which 
will inevitably bring adults, youths, and pre-school 
children into vital contacts. It is for this reason that 
in the development of a new policy in home-making 
education lies the solution of some of the deeper ad- 
ministrative problems in the social control of pre- 
school hygiene. CHAPTER XII 
THE ORGANIZATION OF PRE-SCHOOL HYGIENE 
Many problems underlying the administration and 
organization of pre-school hygiene have been touched 
upon in previous chapters. It is our purpose here to 
bring the situation into summary review, and to sug- 
gest what appear to us to be the more important lines 
for future development. 
The whole field of pre-school hygiene is in such a 
state of formativeness that it would be hazardous to be 
either too dogmatic or prophetic. The discussion will 
consider in order: (1) medical and health service; (2) 
kindergarten and nursery establishments; (3) the 
family. 
1. Medical and health service 
Objectives. The objectives of pre-school hygiene 
are double — the prevention of disease and handicap, 
and the timely treatment of disease and handicap. In 
a commendable zeal to stress the first objective, we 
have sometimes failed to respect its organic relations 
with the second. Health and disease are relative and 
contiguous concepts For this reason the organization 
of all forms of health service should be basically medi- 
cal. It can scarcely be otherwise in the early months 
and years of development. It is equally important at 
later stages whenever promptness and accuracy of 198 
THE PRE-SCHOOL CHILD 
diagnosis are fundamental to our procedure. In many 
critical instances a modern hospital organization and 
equipment are necessary to secure accuracy of diag- 
nosis as well as of treatment. 
Maternity care. Leaving eugenics out of account, 
the policy of prevention in child hygiene begins with 
maternity care. Almost more important than univer- 
sal birth registration would be a timely reporting and 
supervision of all pregnancies. To make up for the 
inadequacy and incompleteness of present conditions, 
the community must frame and enforce protective 
laws for mothers, furnish instruction and material aid, 
control midwife practice, supply expert obstetric serv- 
ice in emergency, and provide neo-natal as well as pre- 
natal service. 
All of this service, in the very nature of things, must 
be under medical auspices. Theoretically such service 
should be available to all mothers and babies. How 
this community diffusion of professional skill and 
oversight will be accomplished is not yet clear. There 
are several possibilities. The alternatives are not 
confined to a choice between the good old family doc- 
tor (the private practitioner) and a contract State 
doctor. The socialization of medicine, judiciously 
interpreted, means simply the development of such 
cooperative techniques and arrangements as will en- 
able the maximum number of men, women, and chil- 
dren to secure the benefits of medical science in the 
maintenance of health. 
The infant-welfare conference. This forms the ORGANIZATION OF PRE-SCHOOL HYGIENE 
199 
next link in the chain of safety. The emphasis in this 
work has been on nutrition. The baby-welfare sta- 
tion, therefore, becomes a place where babies are 
weighed and milk is modified, and the clientele drops 
off sharply at about the age of one. Where the num- 
bers are large and time is short, it is natural that the 
efforts should be thus restricted. Ideally, however, 
infant-welfare work should have the full scope of 
health supervision from the beginning, and should 
be continued as such throughout the pre-school period. 
This means that the feeding work should be supple- 
mented by thoroughgoing examinations to discover 
disease and defect. For this, high medical standards 
of diagnostic procedure, and nothing less, will suffice. 
Although it is at present inconvenient to realize these 
standards, they should be striven for. Otherwise in- 
fant-welfare work, in the medical sense at least, is in 
danger of becoming superficial and ineffective. 
The children’s health center. This is the out- 
growth of the infant-welfare and milk station, and it is 
a recognition of the importance of maintaining health 
supervision beyond the bottle stage. Regulation of 
nutrition is an important feature of this supervision, 
but a complete diagnostic oversight is essential for the 
best results. 
Limitations of finance and personnel make impos- 
sible an ideal program, but the medical resources of 
the community should be organized to permit at least 
a few intensive periodic health examinations during 
the pre-school stage of development. This would be 200 
THE PRE-SCHOOL CHILD 
a very natural application of the life-extension idea, 
which both common and professional sense endorse. 
The Federal Conference on Minimum Standards has 
suggested monthly visits to a children’s health center, 
during the first year, and at regular intervals through- 
out the pre-school age. Dr. Baker, in the report of 
the Cleveland Health Survey, recommends that 
“Each child of pre-school age should receive a physical 
examination at least once every six months, and after 
any acute illness.” 
Specialized health clinics. The tendency of pre- 
school health agencies is to develop specialized clinics, 
like the nutrition, dental, and nose and throat, and 
rickets clinics; these make for efficiency when the work 
is properly coordinated. The best means of insuring 
such coordination is always to make the child and not 
the defect the point of departure and basis of correla- 
tion. The merit of complete periodic examinations is 
that it personalizes the work of health supervision and 
makes it somewhat more sincere. 
These successive, life-extension examinations should 
culminate in a thorough health inventory at the time 
of school entrance, although the necessity of such 
a special examination is greatly reduced if we follow 
the logical policy of continuous pre-school supervision. 
If the administration of public health, through health 
centers, becomes as widely diffused as our present facil- 
ities for public education, then practically all children 
will receive the safeguards of such supervision. 
Mental hygiene service. We are to-day only in an ORGANIZATION OF PRE-SCHOOL HYGIENE 
201 
embryonic stage of development with reference to the 
supervision of the health of young children. Some 
day our present provisions will seem meager, indeed, 
for it will be taken for granted that the whole pre- 
school population should be reached, and that the 
total developmental welfare of the child shall come 
definitely under scrutiny and guidance. Even now 
it is becoming clear that our supervision should have 
more concern for the mental and conduct aspects of 
development, and that it should aim to apply at least 
the elementary principles of mental hygiene. 
The principles of mental hygiene are less nebulous 
and fugitive than is commonly supposed. It is not 
impossible to develop simple procedures in connection 
with health-center consultations, public-health nurs- 
ing, and home visitation which will disclose many 
instances where the mental health is endangered or 
where the course of mental development is sub- 
normal. The periodic health examinations should, in 
time, broaden into developmental examinations. They 
should be made to include a psychological inquiry into 
the health habits, the dispositions, capacities, and 
personality traits of the child, so that errors of devel- 
opment may be detected, and so that the parents 
may, from the beginning, assist the child to achieve 
mental as well as physical health. Many factors at 
the basis of healthy development, such as eating, sleep- 
ing, play, and social reactions, have to do with habit 
and with personality. Even in very young children 
health depends upon personal hygiene, and in the last 202 
THE PRE-SCHOOL CHILD 
analysis pre-school health supervision must reckon 
with those intimate aspects of healthful living which 
will yield only to educational control. 
The most promising method of approach for such 
control is the periodic developmental examination in 
consultation with one or both parents. Systematic 
parental group instruction in the educational psychol- 
ogy of child care and standards of normal personality 
development will also achieve results. This impor- 
tant field of combined medical and educational effort 
must be developed in the future if we are to organize 
a well-rounded, complete health service for the pre- 
school child.' 
2. Kindergarten and nursery establishments 
The kindergarten as a child-welfare agency. We 
have repeatedly emphasized the importance of the 
kindergarten as a social and health-promoting agency. 
It is undesirable to make any sharp discrimination be- 
tween the hygienic and educational functions of the 
kindergarten. In an effort to visualize a well-balanced 
organization of pre-school hygiene, the kindergarten 
presents itself as a flexible agency which might be put 
to varied uses for the whole age period from two to six 
years of age. 
It has been suggested by Professor Snedden, in a 
recent paper in School and Society (March 4, 1922), 
that: “1. For fairly normal children from four to six 
years of age, schools are not greatly needed in the more 
normal, rural, village, and suburban environments. ORGANIZATION OF PRE-SCHOOL HYGIENE 
203 
2. Nor are they needed in the more prosperous urban 
environments where mothers regularly devote their 
available ‘working’ time to the care of their children.” 
This would restrict the field of the kindergarten mainly 
to custodial and auxiliary welfare work for needy or 
abnormally circumstanced children living in thickly 
populated communities. The questions raised by 
these suggestions are far from academic. They con- 
cern the social policy of a very important part of our 
public school system, and the future administrative 
organization of a system of pre-school hygiene. 
The kindergarten is not a universal feature of Amer- 
ican education. In some communities it has by tradi- 
tion become an integral and cherished part of the 
public school system; in other communities it is al- 
together lacking. There are in round figures four 
million American children between the ages of four 
and six. About one in ten of these attend a kinder- 
garten. California, New York, New Jersey, Michigan, 
and Connecticut enroll in their kindergartens a pro- 
portion of from 32 to 25 per cent of the children of 
kindergarten age. Arkansas, Tennessee, West Vir- 
ginia, North Carolina, and North Dakota enroll from 
.19 to .53 per cent. Note the decimal point. 
This diversity is apparently not altogether condi- 
tioned by economic factors. Miss Julia Wade Abbot, 
of the Bureau of Education, cites two cities of the same 
size and wealth, of which one has kindergartens with 
an enrollment of 3693 children, and the other no 
kindergartens. She says: THE PRE-SCHOOL CHILD 
204 
The first city spends $92.16 per child for education, the 
other $37.12. In eight cities with a population between 
100,000 and 200,000, the total wealth of four cities that have 
no kindergarten is larger than the wealth of those that have 
kindergartens. The inclusion of the kindergarten and other 
progressive educational features seems to be more a matter 
of intelligent opinion than a matter of finance.... In the 
past two years, there has been an increase of 37,811 children 
enrolled in kindergartens of varying size, distributed through 
thirty-one States. Thirty-seven per cent of this gain is in 
towns under 10,000. The steady increase in kindergartens 
distributed over thirty-two different States during this 
after-war period, when economy is still a large consideration 
in every school budget, together with the fact that the 
growth of the kindergarten is most marked in small com- 
munities, indicates that the kindergarten is being accepted 
as the right of every child in city and country, instead of 
merely being regarded as a welfare-agency for children living 
under abnormal conditions in large cities. 
The kindergarten subject to pressure from two di- 
rections. This discussion discloses again the unsettled 
status of the kindergarten situation, and the complex- 
ity of the questions which the future must solve. For 
years the kindergarten has been under pressure from 
above to justify its usefulness as an educational 
agency. Much of this pressure has been exerted by 
school teachers and by educators, as well as by tax- 
payers. Now a new pressure is welling up from 
beneath, forcing the kindergarten to justify its useful- 
ness as a health-promoting agency in the field of pre- 
school hygiene. This pressure represents the accumu- 
lating demands of public health, medical, and social 
agencies concerned with the welfare of young children. 
We believe that the kindergarten may survive both ORGANIZATION OF PRE-SCHOOL HYGIENE 
205 
pressures by evolving into an adaptable health and 
educational service institution which will reach both 
handicapped and relatively normal children. This 
adaptability can be achieved only by gradually en- 
larging the current conception that a kindergarten is 
a big room for the training of forty children of four to 
six, from nine till noon, five days in the week, from 
September to June. We imply, by our prevailing 
procedure, that all children equally and alike need the 
same kind of kindergarten, and that the kindergarten 
should be conducted on the same schedule and basis 
as an ordinary schoolroom. 
The problems of pre-school hygiene are so individ- 
ual, and so closely bound up with the home, that the 
kindergarten ought to develop a more versatile and 
distinctive technique. It should wield a freer lance 
and fill more discriminating functions in its field. 
Functions of a reconstructed kindergarten. These 
functions have been described in some detail in pre- 
vious chapters (Chapters IV, V, VII). They may be 
recapitulated here to indicate their many-sided rela- 
tions to a comprehensive organization of pre-school 
hygiene. 
1. The developmental education of “normal” chil- 
dren from three to six years of age. By this is meant a 
type of education which definitely stresses physical 
and mental hygiene, which is concerned with habits of 
healthful activity and wholesome social and motor 
development. The best modern kindergarten doubt- 
less has an educational value even for favorably cir- 206 
THE PRE-SCHOOL CHILD 
cumstanced children. We should not, however, as- 
sume that such education is needed every school day 
in the week throughout the school year for all of these 
age groups. The principle of part-time education and 
multiple use should be put into effect, so that the same 
facilities will reach a proportionately larger clientele. 
Even if certain groups “attended” only once or twice 
a week, the value of truly educational work would 
assert itself. Education being conditioned by growth, 
of course, takes time; but education does not depend 
exclusively on continuous stimulation; sometimes the 
educative process is analogous to that of infection. 
A few exposures may suffice to innoculate. 
It has not yet been demonstrated that it is educa- 
tionally necessary or hygienic to send even first and 
second graders back to school in the afternoon for the 
same sort of experience which they had in the morning. 
Shorter and less frequent periods of institutional educa- 
tion for children of pre-school age may accomplish 
almost as much as longer and more frequent periods. 
Perhaps we should also consider the advisability of 
increasing our available personnel by putting the 
first grade on a half-time, one-session basis. By ad- 
ministering the kindergarten on the multiple and 
differential use plan, we can maintain effective con- 
tacts with a larger group of children and develop some 
of the more specific welfare and hygienic functions 
indicated below. 
2. Parental guidance and training. The kinder- 
garten should be more deliberately utilized as a dem- ORGANIZATION OF PRE-SCHOOL HYGIENE 
207 
onstration and training center for parents. High- 
school and part-time continuation pupils could serve 
courses of apprenticeship and observation, rendering 
valuable assistance in the process. The parents of the 
children themselves ought, periodically, to come to the 
kindergarten for stimulus and concrete instruction in 
child care. Even with full-time sessions the child is 
in his own home for most of each day, and only by 
exploiting methods of parental training and guidance 
can the fundamental home life of the child be reached. 
Altogether apart from the welfare of the parents them- 
selves, this kind of educational service must be rendered 
by the future kindergarten if it is to promote the full 
welfare of the pre-school child. Kindergarten adjuncts 
of nurseries and settlements likewise ought to make 
parental work a major objective. 
3. Educational provision for handicapped pre-school 
children. In some way or other we must ameliorate 
the developmental handicaps of subnormal and ex- 
ceptional children of pre-school age. What social 
institution is in a better position to work out provisions 
and procedure in this complex field than the kinder- 
garten? In cooperation with the State and local 
divisions of special education, on the one hand, and 
with local child hygiene agencies on the other, it can 
grapple with this undertaking. In large communi- 
ties auxiliary nursery kindergartens, comparable to 
special classes and special schools, would offer a partial 
solution. Full or part-time shelters for certain cases 
may ultimately be provided by local communities. 208 
THE PRE-SCHOOL CHILD 
There are children and mothers enough who need 
such substantial help. The most promising line of 
immediate attack is an auxiliary type of kindergartner 
who, as an expert, would initiate and supervise special 
programs and arrangements created for the benefit of 
the handicapped child, both at home and at school. 
Just as departments for the blind are sending special 
teachers as agents into the home to teach the adult and 
aged who have lost their vision, so can the responsible 
authorities of the kindergarten create mobile agents 
who will assist the handicapped pre-school child both 
through the home and school equipment. Remote as 
this kind of educational adjustment work may now 
appear, it will steadily grow more urgent as the present 
embryonic activities of pre-school clinics and consulta- 
tion centers come to their fuller issue. 
4- The hygienic regulation of school entrance. This 
function is closely related to the one just mentioned. 
When the kindergarten becomes informed with the 
spirit and armed with the methods of child hygiene, it 
will take on the aspect of a health station where chil- 
dren will be observed, conditioned, and adjusted in the 
most plastic period of their development. The primer, 
the multiplication table, and age six, may then sink 
into proper perspective, and the kindergarten become 
a living instrument of hygiene which will bind into 
functional union the public school and fundamental 
agencies of infant and family welfare. ORGANIZATION OF PRE-SCHOOL HYGIENE 
209 
3. The family 
Home factors in the organization of pre-school 
hygiene. The social control of pre-school hygiene 
need not result in a decline of power or responsibility 
in the home. On the contrary, it should be the central 
objective of such control to increase and to direct the 
parental care of young children. If we were to follow 
the easiest path of State regulation, we should soon 
be considering some glorified compulsory form of State 
nursery for the rearing of all infants, and a benevolent 
type of State medicine to insure their complete de- 
velopment. The fundamental administrative and 
governmental problem in the organization of pre-school 
hygiene consists, negatively, in avoiding just such 
tendencies, and positively in elevating the standards 
and practice of domestic life. 
It has been outside the scope of this volume to 
consider in any detail the relation of economic factors 
to the efficiency of the home. The number of dollars a 
father earns, the number of hours he and his wife work, 
the number of rooms in the home and the square feet 
of windows, all bear with lawful effect upon the life and 
death of children, particularly young children. The 
correlation of infant mortality and of rickets with liv- 
ing conditions has been given mathematical demon- 
stration. Adequate city planning, housing reform, 
mothers’ pensions, and living wages, therefore, will 
have a decisive determination on the influence of the 
home. Social regulation of the welfare of young 210 
THE PRE-SCHOOL CHILD 
children ought so far as possible to make good defi- 
ciencies in the child environment through rehabilita- 
tion of the home. Much, indeed, that we say about par- 
ental training and responsibility becomes hollow words 
in the presence of poverty. 
Side by side, however, with the economic or material 
factor normally stands the educational or functional 
factor. Even nutrition depends not only on dollars 
and cents, but upon the “functional factor” of intelli- 
gence — intelligence in the selection, preparation, and 
proper eating of food. In the whole field of child 
hygiene we have to reckon with the good judgment, 
the attitude, the prejudices, and the good-will of 
mothers, fathers, and brothers and sisters, because, in 
the last analysis, the hygienic fortunes of the pre-school 
child largely hang upon these intangibles which make 
up the morale and effectiveness of the home. 
The problems of public sanitation include such 
tangibles as plumbing, cubic air space, and bacterial 
content of milk, which are truly fundamental; but in 
addition we have that vast psychological complex of 
problems which must also be reckoned with and at- 
tacked by whatever methods of engineering we can 
devise. No small part of the administrative task of 
organizing pre-school hygiene must resolve itself into 
just such engineering. 
Basic significance of pre-parental education. Hith- 
erto we have depended, for influencing the home, upon 
general publicity, personal persuasion through con- 
ferences and home visitation, and by various forms ORGANIZATION OF PRE-SCHOOL HYGIENE 
211 
of family-welfare approach. Valuable as all these kinds 
of approach are, they are too piecemeal and supple- 
mentary in character to meet the growing needs 
of the future. If higher standards and improved 
methods of child care are so essential to the organiza- 
tion of an adequate program of pre-school hygiene, 
then must systematic parental and pre-parental educa- 
tion be made a major problem in civic administration. 
There will be no simple solution for this problem. 
It will not suffice to give girls ordinary home-making 
courses, which, in spite of their concrete aspect, miss 
countless issues in the field of child care that might 
be educationally anticipated. Pre-parental education 
must be made to include boys as well as girls, and it 
must be less incidental in character. It should be 
based on first-hand acquaintance with at least all the 
public and socialized aspects of child hygiene and child 
welfare. It should be enriched in content and detail. 
It should embrace in a concrete way the mental devel- 
opment and the mental hygiene of infancy. It should 
include a course in the educational as well as the phys- 
ical hygiene of rearing children. It should be so 
sound in content and direct in spirit that pious morali- 
zation about the ideal home will become superfluous. 
If society depends upon education as a form of self- 
conscious evolution, how else can we fill the present 
void in our curriculum, and bring to the home, as a 
social institution, the support which it seems to need? 
This deep-reaching type of pre-parental education 
can be evolved only by close cooperation between 212 
THE PRE-SCHOOL CHILD 
public health, medical, and educational leaders. It 
represents the kind of cooperative enterprise which is 
becoming more and more imperative in many fields of 
social endeavor. Fortunately the basic principle for 
the cooperation is one which in itself should draw 
all minds together — “ Children need wise and good 
parents.” 
This is the principle. And the problem is to in- 
crease that wisdom and goodness by timely education. 
Formulated in these terms the task of the organiza- 
tion of pre-school hygiene falls with no small weight 
upon the leaders of public education — the custodians 
of that vast social agency which enrolls not only 
twenty million pupils, but, by the same token, holds 
the millions who in a few years will be the parents of 
the Nation’s pre-school children., APPENDICES 
A. CHRONOLOGY OF PRE-SCHOOL HYGIENE 
B. MINIMUM STANDARDS FOR CHILD WELFARE 
C. WORKINGS OF THE NEW MATERNITY AND 
INFANCY LAW 
D. LIST OF REPRESENTATIVE CHILD-WELFARE 
AGENCIES 
E. ORGANIZATION AND ACTIVITIES OF PRE-SCHOOL 
AGENCIES 
F. THE EXAMINATION OF SCHOOL BEGINNERS 
G. A MENTAL HYGIENE SERVICE FOR PRE-SCHOOL 
CHILDREN 
H. BIBLIOGRAPHY APPENDIX A 
CHRONOLOGY OF PRE-SCHOOL HYGIENE 
1774. Nursery school opened by Pastor Oberlin, France. 
1780. Prophylactic power of vaccination discovered by 
Jenner. 
1781. Pestalozzi publishes Leonard and Gertrude: My Book 
for the People. 
1799. Infant factory school established by Robert Owen, 
Scotland. 
1811. Decree of Napoleon. Imperial decree declaring 
State obligations to foundlings, abandoned children, 
and poor orphans. 
1826. The Education of Man. Published by Froebel, 
founder of the kindergarten. 
1827. Infant School Society organized in New York. 
1837. Compulsory birth registration enacted in England. 
1844. Day nursery founded in Paris. 
1859. I ublication of Origin of Species, by Charles Darwin. 
1865. Society for the Protection of Infants organized in 
France to instruct mothers in child care and to en- 
courage maternal nursing. 
1865. The Manchester and Salford Ladies’ Health Society. 
The pioneer (English) agency for child-welfare home 
visitation. 
1872. Life Protection Act passed in England, providing for 
the registration, licensing, and supervision of infant- 
caring institutions. (First legal effort to diminish 
infant mortality.) 
1874. Roussel Law for the protection of infants to correct 
the abuses of the practice of wet-nursing in France. 
1876. Allaitement Maternel established as a refuge for 
mothers to encourage them to nurse their children. 
1877. First law forbidding employment of women before 
and after child birth. (Switzerland.) 
1878. First laboratory in experimental psychology, founded 
by Wilhelm Wundt. 216 
APPENDIX A 
1880. The Contents of Children's Minds on Entering School, 
published by Dr. G. Stanley Hall, genetic psychologist 
and father of child-study movement. 
1889. Good Samaritan Dispensary opened in New York 
City. The first American milk station. 
1889. First English milk station for babies opened in 
England, at St. Helen’s. 
1892. First Infant Welfare Consultation Center established 
at the Charite Hospital in Paris, by Dr. Budin. 
1892. Founding of Mutuality Maternelle, a mutual benefit 
society for mothers. 
1896. National Congress for Infancy. (Florence.) 
1896. First “Psychological Clinic,” established in Philadel- 
phia. 
1901. The Ghent School for Mothers. 
1902. League against Infant Mortality. (Paris.) 
1902. The Midwives Act. (England.) 
1905. International Congress of Milk Depots. (Paris.) 
1906. Committee of One Hundred on National Health 
formed. (United States.) 
1906. First infant-welfare consultation center established 
in England. 
1906. National Conference on Infant Mortality. (London.) 
1907. St. Pancras (England) Motherhood School. Caro- 
line Rest (New York) for Mothers. 
1907. Notification of Births Act (England). Makes regis- 
tration of births within thirty-six hours compulsory. 
Amended, 1915. 
1907. International Union for the Protection of Child Life. 
(Brussels.) 
1908. First municipal Department of Child Hygiene, 
established in New York City. 
1909. American Association for the Study and Prevention 
of Infant Mortality, founded in New Haven, Con- 
necticut. 
1912. Federal Children’s Bureau organized “to investigate 
and report upon all matters pertaining to the welfare 
of children and child life among all classes of our 
people.” 
1914. First State Department of Child Hygiene, estab- 
lished in New York. APPENDIX A 
1916. National Baby Week. 
1917. Federal Board for Vocational Education created by 
the Smith-Hughes Law. Provides for vocational 
home-making education. 
1918. The Education Act (England). Provides for grants 
in aid for nursery schools. 
1918. Maternity and Child Welfare Act (England). 
1919. League of Nations Covenant signed at Versailles. 
Article 23 contains clauses providing for international 
cooperation in matters relating to the health and 
welfare of women and children. 
1919. Ministry of Health Act (England). Provides for 
medical inspection and treatment of children of pre- 
school and school age, under the Ministry of Health. 
1919. Children’s Year. Federal Conference on Minimum 
Standards for Child Welfare. 
1920. National Child Health Council formed. (See Ap- 
pendix D.) A similar Central Council of Infant 
and Child Welfare was formed in England. 
1920. Child Welfare Department established by the Cana- 
dian Government. 
1921. Federal Maternity and Infancy Law. (United States. 
Sheppard-Towner Act. See Appendix C.), 
217 APPENDIX B 
MINIMUM STANDARDS FOR CHILD WELFARE 
The Children’s Bureau Conference on Child-Welfare Stand- 
ards was called by the Secretary of Labor at the request of 
the President of the United States. The purpose of the 
undertaking was to formulate and to publish standards for 
the better protection of children. The preliminary confer- 
ence was held at Washington, May 5-8, 1919. 
The Washington Conference was participated in by many 
American authorities. It was advised by representatives of 
Belgium, France, Great Britain, Italy, Japan, and Serbia. 
The foreign delegates reported especially on what their na- 
tions had learned concerning the better protection of chil- 
dren as a result of their war experiences. 
We reproduce herewith the minimum standards proposed 
for the public protection of the health of mothers and of pre- 
school children. (Children’s Bureau Publication No. 62.) 
Maternity 
1. Maternity or pre-natal centers, sufficient to provide for 
all cases not receiving pre-natal supervision from private 
physicians. The work of such a center should include: 
■ a. Complete physical examination by physician as 
early in pregnancy as possible, including pelvic 
measurements, examination of heart, lungs, abdo- 
men, and urine, and the taking of blood pressure; 
internal examination before seventh month in 
primipara; examination of urine every four weeks 
> during early months, at least every two weeks after 
sixth month, and more frequently if indicated; 
Wassermann test whenever possible, especially 
when indicated by symptoms. 
b. Instruction in hygiene of maternity and super- 
vision throughout pregnancy, through at least 
monthly visits to a maternity center until end of 
sixth month, and every two weeks thereafter. APPENDIX B 
Literature to be given mother to acquaint her with 
the principles of infant hygiene. 
c. Employment of sufficient number of public-health 
nurses to do home visiting and to give instruction 
to expectant mothers in hygiene of pregnancy and 
early infancy; to make visits and to care for patient 
in puerperium; and to see that every infant is re- 
ferred to a children’s health center. 
d. Confinement at home by a physician or a properly 
trained and qualified attendant, or in a hospital. 
e. Nursing service at home at the time of confine- 
ment and during the lying-in period, or hospital 
care. 
f. Daily visits for five days, and at least two other 
visits during second week by physician or nurse 
from maternity center. 
g. At least ten days’ rest in bed after a normal de- 
livery, with sufficient household service for four 
to six weeks to allow mother to recuperate. 
h. Examination by physician six weeks after de- 
livery before discharging patient. 
/ Where these centers have not yet been established, 
or where their immediate establishment is impracti- 
cable, as many as possible of the provisions here enu- 
merated should be carried out by the community nurse, 
under the direction of the health officer or local physician. 
2. Clinics, such as dental clinics and venereal clinics, for 
needed treatment during pregnancy. 
3. Maternity hospitals, or maternity wards in general 
hospitals, sufficient to provide care in all complicated 
cases and for all women wishing hospital care; free or 
part-payment obstetrical care to be provided in every 
necessitous case at home or in a hospital. 
4. All midwives to be required by law to show adequate 
training, and to be licensed and supervised. 
5. Adequate income to allow the mother to remain in the 
home through the nursing period. 
6. Education of general public as to problems presented by 
maternal and infant mortality and their solution. 
219 220 
Infant and Pre-School Children 
APPENDIX B 
1. Complete birth registration by adequate legislation re- 
quiring reporting within three days after birth. 
2. Prevention of infantile blindness by making and en- 
forcing adequate laws for treatment of eyes of every 
infant at birth and supervision of all positive cases. 
3. Sufficient number of children’s health centers to give 
health instruction under medical supervision for all 
infants and children not under care of private physician, 
and to give instruction to mothers in breast feeding and 
in care and feeding of children, at least once a month 
throughout first year, and at regular intervals through- 
out pre-school age. This center to include a nutrition 
and dental clinic. 
4. Children’s health center to provide or to cooperate with 
- sufficient number of public-health nurses to make home 
visits to all infants and children of pre-school age need- 
ing care — one public-health nurse for average general 
population of 2000. Visits to the home are for the 
purpose of instructing the mother in — 
a. Value of breast feeding. 
b. Technic of nursing. 
c. Technic of bath, sleep, clothing, ventilation, and 
general care of the baby, with demonstrat’ons. 
d. Preparation and technic of artificial feeding. 
e. Dietary essentials and selection of food for the 
infant and for older children. 
f. Prevention of disease in children. 
5. Dental clinics; eye, ear, nose, and throat clinics; vene- 
real and other clinics for the treatment of defects and 
disease. 
6. Children’s hospitals, or beds in general hospitals, or 
provision for medical and nursing care at home, sufficient 
to care for all sick infants and young children. 
7. State licensing and supervision of all child-caring in- 
stitutions or homes in which infants or young children 
are cared for. 
8 General educational work in prevention of communi- 
cable disease and in hygiene and feeding of infants and 
young children. APPENDIX C 
WORKINGS OF THE NEW MATERNITY AND 
INFANCY LAW 
Facts of interest about the Sheppard-Towner Act, of De- 
cember 23, 1921, for the Promotion of the Welfare and 
Hygiene of Maternity and Infancy, as summarized in 
“Mother and Child,” vol. 3, No. 1. 
How the States may secure the benefits of the Act. 
1. The State Legislature must, or the Governor may, for 
a period limited to six months after the adjournment of 
the first regular session of the passage of the Act — 
a. Accept the provisions of the Act. 
' b. Designate a State agency with which the Chil- 
dren’s Bureau is to cooperate in carrying out the 
purposes of the Act. In any State having a Child 
Welfare or Child Hygiene Division in its Health 
Department or Board, that division must be 
designated. 
2. The Child Hygiene or Child Welfare Division of the 
Department of Health or other designated agency 
must — 
a. Submit detailed plans for carrying out the pro- 
visions of the Act within the State to the Children’s 
Bureau for approval by the Federal Board of 
Maternity and Infant Hygiene. Section 8 of the 
Act provides that if the plans submitted by a 
State are in conformity with the provisions of this 
Act, and reasonably appropriate and adequate to 
its purposes, they shall be approved by the Board. 
b. Make such reports to the Children’s Bureau con- 
cerning its operations and expenditures for the 
purposes of the Act as shall be prescribed or re- 
quested by the Bureau. 222 
APPENDIX C 
What the benefits of the Act are. 
1. Funds available. 
a. For the fiscal year ending June 30,1922 $1,408,000 
To be equally apportioned among the 
States and granted outright to States 
accepting the provisions of the Act. . . 480,000 
To be apportioned to the States if 
matched dollar for dollar by State ap- 
propriations, $5000 to each State 240,000 
To be apportioned to the States if 
matched dollar for dollar by State ap- 
propriations in the proportion which 
their population bears to the total pop- 
ulation of the States of the United 
States 710,000 
For Federal administration, not to ex- 
ceed 50,000 
b. For each of five years after June 30, 
1922 1,240,000 
Of this amount, $240,000 is to be equally appor- 
tioned among the States and granted outright, and 
the remaining items are the same as authorized 
for 1922. 
2. Prohibitions as to use of funds. May not be applied to 
the purchase, erection, preservation, or repair of any 
building or buildings or equipment, nor for the purchase 
or rental of any buildings or lands, nor for the payment 
of any maternity or infancy pension, stipend, or gra- 
tuity. 
Powers and duties of the Children's Bureau under the Act. 
1. To cooperate with the agency designated by the several 
States. 
2. To make such studies, investigations, and reports as will 
promote the efficient administration of the Act. 
3. To certify to the Secretary of the Treasury of the United 
States and to the Treasurers of the States the amount 
which has been apportioned to each State for the fiscal 
year. 
4. To carry on the general administration of the Act. APPENDIX C 
The Federal Board of Maternity and Infant Hygiene. 
1. Membership — Chief of the Children’s Bureau, Sur- 
geon-General of the United States Public-Health Serv- 
ice, and United States Commissioner of Education. 
2. Chairman — to be elected by the Board. 
3. Powers — 
a. To approve or disapprove plans submitted by the 
States. 
b. To withhold further certification of Federal funds 
to a State if the money is not properly expended. 
A State may appeal from the decision of the Board 
to the President of the United States. 
223 APPENDIX D 
LIST OF REPRESENTATIVE CHILD-WELFARE 
AGENCIES 
National Agencies Working for the Welfare of the 
Child 
A. Federal agencies. 
1. Children’s Bureau, United States Department of 
Labor. 
2. Bureau of Education, United States Department of 
the Interior. 
3. Public Health Service, United States Treasury 
Department. 
4. States Relations Service, United States Department 
of Agriculture. 
5. United States Federal Board for Vocational Educa- 
tion. 
B. Agencies financed by private funds. 
Some representative agencies are as follows: 
*1. American Child Hygiene Association, 532 Seven- 
teenth Street, N.W., Washington, D.C. 
*2. American Red Cross, Washington, D.C. 
3. American Social Hygiene Association, 105 West 
Fortieth Street, New York City. 
*4. Child Health Organization of America, 156 Fifth 
Avenue, New York City. 
5. Child Welfare League of America, 130 East Twenty- 
Second Street, New York City. 
*6. National Child Labor Committee, 105 East Twenty- 
Second Street, New York City. 
7. National Child Welfare Association, 70 Fifth 
Avenue, New York City. 
8. National Committee for Mental Hygiene, 370 
Seventh Avenue, New York City. 
9. National Committee for the Prevention of Blind- 
ness, 130 East Twenty-Second Street, New York 
City. APPENDIX D 
225 
10. National Congress of Mothers and Parent-Teacher 
Association, 1201 Sixteenth Street, N.W., Washing- 
ton, D.C. 
11. National Organization for Public Health Nursing, 
156 Fifth Avenue, New York City. 
12. National Probation Association, 380 Seventh Ave- 
nue, New York City. 
*13. National Tuberculosis Association, 381 Fourth Ave- 
nue, New York City. 
14. Playground and Recreation Association of America, 
1 Madison Avenue, New York City. 
15. Russell Sage Foundation, 130 East Twenty-Second 
Street, New York City. 
16. National Child Health Council, 370 Seventh Ave- 
nue, New York City. This is a coordinating organi- 
zation consisting of representatives from the five 
national agencies indicated above by an asterisk. 
State Agencies Working for the Welfare of the Child 
A. State boards of health and bureaus of child hygiene. 
B. State boards of charities and correction and child-welfare 
divisions. 
C. State departments of education? 
D. State departments of labor. 
E. State institutions for dependent, delinquent, and physi- 
cally or mentally handicapped children. 
F. State child welfare or children’s code commissions, and 
other special boards. 
Local Agencies Working for the Welfare of the Child 
A. City and county: Departments of health, divisions of 
child hygiene, departments of charities, children’s in- 
stitutions, juvenile courts, departments of education, 
recreation, etc. 
B. Private: Child hygiene associations, health centers, visit- 
ing nurse associations, day nurseries, associated charities, 
children’s aid and protective societies, children’s in- 
stitutions, etc. APPENDIX E 
ORGANIZATION AND ACTIVITIES OF PRE-SCHOOL 
AGENCIES ‘ 
What is being done for the pre-school child? A concrete 
answer to this question can be found in part in the official 
reports of various organizations, such as those listed in this 
and in the preceding appendix. Useful printed literature 
may usually be secured by writing a postal card or letter of 
request to the secretary of the agency. 
The subjoined reports are convenient summaries, most of 
which have been made out in accordance with a standard 
form used by the American Child Hygiene Association, for 
reporting in its annual volume of proceedings the activities 
of its affiliated societies. A selection of representative or- 
ganizations has been made from these reports. 
The standard form is also printed below. This will furnish 
a suggestive outline to any student group desiring to make a 
survey of local pre-school hygiene agencies. 
1. Outline for reporting the Organization and 
Activities of a Child Welfare Agency 
Name and address of organization. 
When organized. 
I. A. Federal. State. County. Municipal. 
B. Voluntary. 
II. Scope of work: 
(Describe fully.) 
III. A. Governing Board: 
1. Number of men. 
2. Number of women. 
B. Auxiliary Board: 
IV. Staff: 
A. Nurses: 
1. Number of supervisors. 
(Indicate type of supervision.) 
2. Number of field workers. APPENDIX E 
227 
B. Doctors: 
1. Number on full time. 
2. Number on part time. Number of hours. 
3. Number on free service. Number of hours. 
C. Dentists: 
1. Number on full time. 
2. Number on part time. Number of hours. 
3. Number on free service. Number of hours. 
D. Social Workers: 
1. Trained. 
2. Volunteers. Full time. Part time. 
E. Nutritionists: 
1. Number on full time. 
2. Number on part time. 
F. Clerical assistants: Number and salaries. 
V. Divisions of work: 
If a part of a Health Center indicate by H.C. 
A. Pre-natal: 
1. Number of weekly clinics with obstetricians in charge. 
2. Number of nurses doing 
a. Clinical work. 
b. Field work. 
c. Supervisors. 
d. Number on full time. 
e. Number on part time. 
f. Number of hours on supervisory work. 
B. Obstetrical: 
1. Number of deliveries by obstetricians 
a. In hospital. 
b. In out-patient service. 
c. In patient’s home. 
2. Number of deliveries by midwives. 
3. By whom licensed and supervised. 
C. Infant care (under 1 year): 
1. Number of centers at which clinics or conferences 
are held. 
2. Total number of weekly conferences or clinics. 
a. Preventive consultations. 
b. Clinics for sick babies. 
c. Combination clinics for sick and well infants. 
3. Percentage of breast-fed babies under six months on 
your roll. 
D. Pre-school age (1-6 years): 
1. Total number of weekly clinics or conferences. 
a. Preventive consultations. 228 
APPENDIX E 
b. Clinics for sick children. 
c. Clinics for both sick and well children. 
d. Number of nutritional classes separate from the 
clinics. 
e. Nutritional classes affiliated with infant clinics. 
(1) Same hour. 
(2) Separate time. 
2. Is the mental health of the child given especial con- 
sideration at this age? In what manner? 
3. Dental clinics. 
4. Immunization. 
5. Cardiac clinics. 
E. School age and adolescence: 
1. What is your city or town or county doing in regard 
to medical inspection in your schools? 
a. How many full time medical officers? 
b. How many part time medical officers? / 
c. How many school nurses? 
(1) Average time (weekly) given to school 
inspection. 
(2) Average time (weekly) given to home 
visiting. 
(3) Duties of school nurses during summer 
months. 
2. Have you health development classes? 
a. Under supervision of teachers? 
b. Under supervision of medical officers? 
c. Under supervision of nurses? 
d. Under physical educators? 
3. How are your Medical Inspection, Health Develop- 
ment, and Physical Education Departments co- 
ordinated? 
4. Percentage of defects corrected during the year 
1920. 
5. Please state nature and frequency of mental tests 
made. 
6. Nutritional classes: 
a. Number of weekly classes for school children. 
b. Conducted by whom: 
(1) Physician. 
(2) Nurse. 
r (3) Dietitian. 
c. Method: 
(1) Is class method used? 
(2) Is individual method used? APPENDIX E 
229 
. d. State average weekly number of home visits 
(1) By nurses. 
(2) By dietitians. 
F. Communicable disease control, including tuberculosis 
and venereal diseases: 
1. What is your city or town doing towards the con- 
trol of communicable diseases? 
2. What communicable diseases are 
" a. Reported? 
b. Isolated? 
c. Quarantined? 
d. By whom is quarantine controlled? 
e. By whom is quarantine lifted? 
3. Are quarantined cases cared for by nurses? 
a. By special nurses? 
b. By general group nurses? 
4. Is a Wassermann test given routinely? 
a. At what ages? 
b. Are positive reactions followed by routine 
treatment? 
G. Are your activities limited to your own city or town? 
H. If you direct county or State work in connection with 
the work of your local organization, please describe ex- 
tension work. 
I. Have you a mobile unit in service? (Describe fully.) 
J. Care of dependent children: 
1. Have you a boarding-out system? Age limits. 
a. Number of homes supervised. 
b. Average number of children in each home at 
one time. 
c. Medical and nursing supervision. 
K. Children of unmarried mothers: 
1. Have you made an especial study of the health and 
environment of the children born of unmarried 
parents? 
2. What action has been taken to improve such con- 
ditions? 
VI. Statistical: 
A. Pre-natal care: 
1. Total number of mothers cared for during the year. 
2. Average number of months under care. 
3. Total deaths of mothers — 
a. During pregnancy. 
b. At childbirth. 
c. During the puerperium. 230 
APPENDIX E 
4. Total number of infant deaths — 
a. At birth. 
b. During the first month. 
5. During what month of pregnancy do the women 
come under your care? 
a. Average cases. 
b. Earliest cases. 
B. Post-natal care. Infant care. Pre-school age and 
older children. 
1. Age limit of babies or young children under 
care. 
2. Total number under 1 year cared for. 
3. Total number between 1 and 5 years cared for. 
4. What percentage of babies born in your city or 
town during the current calendar year or during 
your current fiscal year are under the supervision 
of your organization? 
5. What percentage of the babies born within the 
preceding year, in the districts covered by your 
association, have come under the supervision of 
your association? 
6. Total attendance during the year at consultations 
or clinics — 
a. Under 1 year. 
b. From 1 to 5 years. 
C. Is your city zoned into health districts? . 
D. General: 
1. Total population of your city or town. 
2. Total births in your city or town for year ending 
December 31,1920. 
3. Total deaths under 1 year: 
a. In your city or town for year ending Decem- 
ber 31. 
b. Among the infants under your care. 
4. Total deaths among children from 1 to 5 years: 
a. In your city or town for year ending Decem- 
ber 31. 
b. Among the children under your care. 
VII. Record systems: 
A. Have you a continuous record of child, including pre- 
natal care and extending through school age period? 
1. Does your record indicate 
a. Defects remedied? 
b. Character of feeding? 
c. Environmental surroundings controlled? APPENDIX E 
2. Do you use 
a. A national record form? 
b. One of your own? 
VIII. Public-health education: 
Have you a wide-awake public-health education commit- 
tee, which is putting across to the community health facts, 
which will enable all children to secure their right to intel- 
ligent care and healthful surroundings? 
IX. Cooperating agencies: 
A. Does your town, city, or county have a Children’s 
Council? 
B. AV hat is the nature of cooperation between your or- 
ganization and other groups interested in child life? 
1. State— 
a. Department of Health. 
b. University. 
2. City Department of Health. 
3. Hospitals. 
4. Medical schools. 
5. Relief organizations. 
6. Private groups. 
7. Nursing groups — 
a. Undergraduates. 
b. Post-graduates. y 
X. Have you a Division of Child Hygiene in your State? 
XI. Have you a Division of Child Hygiene in your city? 
XII. Improvements observed as a result of activities of previous 
year: 
A. Improved health among children. 
B. Lessening of communicable diseases. 
C. Increased intelligent care on the part of fathers and 
mothers. 
D. Wider community interest in the health of children, as 
manifested by , 
1. Increase in number of clinics or classes. 
2. Increase in medical and nursing care. 
3. Increase in budget for care of children. 
4. Decrease in 
a. Infant mortality rate. 
b. Death rate of children. 
5. Decrease in morbidity rates — 
a. Infant. 
b. Children from 1 to 5. 
XIII. Financial. 
A. Total budget for the current fiscal year. 
231 232 
APPENDIX E 
B. How is your organization supported? 
1. By membership dues. 
2. By appropriation from city or State. 
3. By special contributions. 
4. Through a community chest. 
C. What method or methods have you found most success- 
ful in raising funds? 
D. Is the work that is done by your association given free 
of charge or do you ask a fee? 
1. Amount of fee if one is asked. 
XIV. Supplemental statement. 
2. Visiting Nurse Association 
Santa Barbara, California 
1. Organized 1908. 
2. Scope: Community visiting nursing and public health 
education; infant welfare clinic and follow-up service; dental 
clinic for school children; health supervision of parochial 
schools and orphanage. 
3. Governing board of twelve women. 
4. At present the staff consists of a supervisor and three 
day nurses, with a registrar who takes care of the office, and 
also acts as interpreter of Spanish. A night nurse has re- 
cently been added. The city is divided into three districts, 
each nurse doing all the work in the district assigned to her. 
Three Ford cars are in use, thus the working value of the staff 
is almost doubled, as distances in Santa Barbara are long and 
street car service very poor. 
The districts are small and each one embraces a parochial 
school or other institution such as an orphanage, the super- 
vision of which is included in the nurses’ work. 
6. Statistical. Pre-natal care: Two hundred and nine 
mothers during the year. Post-natal care was given to 381 
children under 1 year, and to 424 between 1 and 5 years. 
Sixty per cent of the babies born in Santa Barbara are under 
the care of the Association. 
Total population of Santa Barbara, 19,500. Total births 
for year ending December 31,1920, 463. Total deaths under 
1 year for same period, 34 stillborn, or within 24 hours; 20 
deaths. 
7. Record forms: The forms prepared by the N.O.P.H.N. APPENDIX E 
are used by the Association. They give a continuous record 
from the pre-natal period through school age. 
14. The Santa Barbara Visiting Nurse Association was 
started in 1908 with about 200 members and such donations 
as could be obtained. Its object is to make visiting nurse 
service available in the community, and further the interests 
of public health in all ways possible. 
It is financed through membership fees and special contri- 
butions. After the first year, two nurses were supported, 
and in 1910 the Association purchased its present office and 
home, where a general dispensary was opened. To this the 
physicians of the city gave generously of their time and sup- 
port, until 1917, when that phase of the work was taken over 
by the Cottage Hospital, in order that this Association might 
devote more of its time to nursing in the homes. 
A third nurse was found to be necessary in 1913, and a year 
later the Association inaugurated school nursing, which has 
since been continued by the Board of Education and in close 
cooperation with our work. 
Because of the number of undernourished children in the 
public schools, who are easy victims of tuberculosis, an Open 
Air School, the first in California, was established in 1915, 
with the proceeds of the Christmas Seal Sale, and in coopera- 
tion with the City Board of Education. The present school 
is in a building which is donated rent free by the Associated 
Charities. It has been remodeled to meet the requirements 
of an open air room, and an attractive dining room and 
kitchen added. It is open to visitors during school hours. 
In 1916 a dental clinic for children was established, and has 
been maintained twice weekly since. It is for children whose 
parents cannot pay for dental service, but all who can do so are 
required to pay for materials used. 
In 1918, as an outcome of the Children’s Year program, an 
infant welfare clinic was established and has been maintained 
weekly since. To this clinic mothers bring their infants for 
weighing and advice as to feeding, etc. 
The clinic rooms have recently been remodeled in order to 
give greater comfort to the waiting mothers and babies. 
Small white enamel tables with tops 2 X 3 J feet having a 
partitioned shelf underneath, have been made. During the 
clinic the tops are covered with washable pads. Chairs are 
233 234 
APPENDIX E 
provided and the mothers are enabled to undress their infants 
on the tables, while the clothing is put on the undershelf. 
Sixteen babies may be undressed at a time and wrapped in 
blankets awaiting inspection by the physician in the con- 
sulting room. Thus the danger of contact of clothing is 
obviated, and the process of dressing is more comfortable for 
both mother and baby. 
The nurse from whose district the baby comes is present 
when the doctor sees the child, thus enabling her to work 
more intelligently with the mother in the home. 
In 1910, 3241 visits were made; in 1920, 9569. 
No special rates are charged for nursing care. All patients 
are expected to pay in accordance with their means. It is one 
of the objects of the Association to make a skilled hourly 
nursing service available to every resident of the city of Santa 
Barbara. 
Helen A. Parks, R.N., Superintendent 
3. Province of Quebec 
Child Welfare Association, Montreal 
1. Organized in 1916. A voluntary organization operat- 
ing throughout the Province. 
2. Scope: Educational propaganda in connection with 
child welfare. 
3. The Association is governed by a board of 11 men and 4 
women. 
4. Staff: One doctor, one trained social worker, two 
clerical assistants. 
6. Total population of Montreal, 900,000. 
10. There is no Division of Child Hygiene in the Province 
of Quebec. 
11. There is no Division of Child Hygiene in connection 
with the Montreal Board of Health. 
13. The Association is supported by membership dues, 
special contributions, and the work is done free of charge. 
The Child Welfare Association conducts each year in the 
city of Montreal a “Child Welfare Week” which deals with 
all phases of child welfare. During the summer the Associa- 
tion made a child health tour of one month’s duration through 
the Province of Quebec. The train was composed of two APPENDIX E 
235 
coaches, one fitted as an exhibit and demonstration car and 
the other as a consultation room and living quarters for the 
staff of eight professional workers: Drs. W. A. L. Styles and 
H. Lapointe; nurses, Miss L. Gauthier, Miss S. Panet- 
Raymond, Miss M. Slattery, and social workers, Miss H. T. 
Lambert, Miss M. E. Whalen and Mr. Fred McCann. 
During the tour the “Child Health Special” visited 37 
communities and covered 1100 miles. The tour was made 
possible through the cooperation of the Canadian Pacific, the 
Grand Trunk, the Central Vermont, and the Quebec Central 
railways. All towns touched by the “Special” were visited 
either by nurse in charge, Miss L. Gauthier, or by Mr. E. C. 
Gannon, who acted as advance agents and explained the aims 
of the tour. 
The expense connected with this health pilgrimage was 
borne by the Child Welfare Association of Montreal, with the 
exception of an additional salary being paid to one French 
physician and to one French nurse by L’Universite de Mont- 
real, and a contribution of $500 from the Provincial Red 
Cross toward the movement. 
The staff made a thorough physical examination of 1014 
children under the age of 14 years and partial examination of 
several hundred others, giving advice to mothers in each 
case. A motion picture apparatus and films were carried on 
the train, and in towns where an assembly hall was available 
the health films were shown and addresses given in the mat- 
ter of public health by Dr. Lapointe, Dr. Styles and Miss T. 
Lambert. Direct contact was established with the children 
at each point by Miss Whalen. Literature and instructions 
were given in the matter of health habits and throughout the 
province hundreds of children are playing the “Health 
Game.” 
The interest elicited by the “Child Health Special” was 
shown by the fact that mothers with their children came from 
distances of ten to twenty miles to consult the doctors regard- 
ing the health of their little ones and to receive supplemen- 
tary advice. One mother came twenty miles with her two 
children. They were healthy but she wanted to find out 
whether or not she was doing what she should for them. 
Mary E. Whalen, Asst. Executive Secretary 236 
APPENDIX E 
4. Health Center 
New Haven, Connecticut 
1. Date of opening: July 12, 1920. 
Auspices: Board of Health, Visiting Nurse Association, 
New Haven County Chapter of the American Red Cross, 
New Haven Medical Association. 
Area served: Wards 10, 11 and 12; 75 city blocks in form 
of triangle, measuring a mile along its base and a mile along 
its perpendicular. Approximately 360 acres. 
4. Staff: 
At headquarters: 1 director, 1 medical director, 1 assistant 
medical examiner (afternoons), 2 part-time physicians (well- 
baby conferences), 1 secretary-stenographer, 1 headquarters 
nurse (V.N.A.). 
Field work (V.N.A.): 1 supervising nurse one third time 
(V.N.A.), 1 assistant supervising nurse, full time (V.N.A.), 
7 public health field nurses (V.N.A.), 1 dietitian, 2 days each 
week (V.N.A.). 
Field work (Department of Health): 2 school nurses (D. of 
H.), 1 sanitary inspector (D. of H.), 1 dental hygienist (D. of 
H.), 1 one half time contagious disease nurse (D. of H.). 
Volunteers (giving from 3 to 10 hours per week): 1 clerical 
and statistical worker, 2 social service follow-up workers, 1 
copier of birth and death certificates. 
5. Activities (educational): Health Center circulars, 7; 
free health literature, on request; window exhibits, about 40; 
newspaper articles, about 80; health clowns, 4 performances; 
lantern slides (in automatic attractoscope), 100 special slides; 
motion pictures (in portable machine), on special occasions; 
posters, a large number; health lectures, on request; health 
information service in daily use. 
Activities (medical): General medical examination and 
consultation service, including pre-natal, held daily; average 
number attending monthly, 350. Four infant welfare con- 
ferences held weekly; average number attending monthly, 
360. Examination of school children for release to school 
(during term) held daily, 8: 30-10; average number attending 
monthly, 166. 
Classes: Two nutritional classes (held in settlement houses) APPENDIX E 
237 
held weekly; average number attending each class each week, 
15. 
Board of Health duties: As Associate Epidemiologist, in 
charge of communicable disease control in district. Per- 
forms the examination of school children for readmittance to 
school. 
6. Population of New Haven 165,000 
Population of District by U.S. Census, January 1, 1920 26,840 
Foreign-born 40% 
Born in Italy 26% 
Born in Ireland 4% 
Born in Poland 3% 
Born in Russia 2% 
Born in other countries 5% 
Native-born of foreign parentage (largely Italian)... 48% 
Native-born of native and mixed parentage 12% 
Dwellings 2,036 
Families 5,150 
Year 
ENDING 
Health services (summarized) June,1921 
School nurses 27,523 
Dental hygienist 1,639 
Sanitary inspector 6,379 
Visiting nurses 22,998 
Dietitian 983 
Baby conference attendance 3,406 
Health Center Headquarters 6,770 
Total health services 69,748 
Nursing districts: The district is divided into seven 
nursing districts, each having one nurse doing generalized 
work. However, the school child population of 5300 is 
under the supervision of the two school nurses, except where 
bedside nursing is required, which is infrequent. 
9. Cooperating agencies. Excellent cooperation exists with 
all health and social welfare agencies of the city. There is a 
local Advisory Council of 30 representative citizens in the 
district, which meets at the call of the Director to discuss 
local problems. APPENDIX E 
238 
14. Sources of support: Department of Health: Gives 
its moral support, details five employees and has contributed 
$11,050 for first year and three-quarters. Visiting Nurse 
Association: Has undertaken demonstration of generalized 
nursing work in district, providing eight nurses, two super- 
visors, and a part-time dietitian. American Red Cross: 
Initiated the idea of the Health Center, made preliminary 
survey, loaned all office furniture and contributed $17,400 
for the first year and three-quarters. New Haven Medical 
Association: Appoints two members to serve on Board of 
Control 
Philip S. Platt, M. A., C. P. H., Director 
5. Child Welfare Research Station, State University 
Iowa City 
1. Organized in 1917. 
2. Scope of work: Investigation of the best scientific 
methods of conserving and developing the normal child, the 
dissemination of information acquired by such investigation 
and the training of students for work in such fields. 
3. Governing board: Director, President of the University, 
and the State Board of Education, with an Advisory Coun- 
cil. 
General purpose: Recognizing the presence in every com- 
munity of increasing numbers of defectives, delinquents, 
degenerates, derelicts, and social misfits, the energies of the 
station are turned to the constructive problem of materially 
reducing this social and economic waste by preventive means. 
The purpose of the station is to develop practical methods 
of child-rearing, modified to suit the varied needs of child 
life, and to give to parenthood dependable counsel to insure 
the continuous improvement of every child to maximum 
ability, consistent with its native endowment and special 
abilities. 
The points of view of the Research Station are those of the 
natural and applied sciences, where a limited number of 
definite basic problems are selected with the conditions 
standardized so that the experiments may be repeated, con- 
trolled and modified. The station performs three closely 
interrelated functions as provided by law: investigation, APPENDIX E 
dissemination of information and training of research stu- 
dents. 
Investigation: As its name implies, the Iowa Child Wel- 
fare Research Station is organized primarily for scientific 
analysis of the factors contributing to child betterment. A 
laboratory group of children of pre-school age has been or- 
ganized to furnish subjects for research in the mental, motor 
and social development of young children. 
Experimental laboratory studies on mental and motor 
development are carried on by the Department of Psychol- 
ogy with special reference to child welfare, with field studies 
for the purpose of assembling data for establishing develop- 
mental norms. 
Anthropometry: The Department of Anthropometry 
conducts experimental and field work to determine how 
children grow. By cooperation with the Federal Children’s 
Bureau, measurements were obtained on 40,000 Iowa boys 
and girls between the ages of birth and six years. A study of 
these records reveals important characteristics of the growth 
of Iowa children who are taller than the average of children 
in the United States as a whole, but also lighter than they 
should be for their height. Another investigation deals with 
the growth of the wrist bones, studied by means of the X-ray 
photograph. Since the size of these bones is a very accurate 
indication of the general physical development of a child, the 
formulation of a scale of anatomical development will prove 
of great value for diagnostic purposes. A study on the bor- 
derline of psychology and anthropometry will work out the 
relation between stages of physical development and mental 
maturation. 
Nutrition: The Department of Nutrition, working in 
cooperation with the College of Medicine, is making contri- 
butions to the theory and technique of stimulating growth 
and preventing malnutrition during the pre-school age. 
Sociology : The Department of Sociology aims to study, by 
the statistical method, through field surveys and research 
among existing statistical records, the social, civic and eco- 
nomic environment of the child, its social development and 
the social factors that condition child welfare. 
Eugenics: The allied field of eugenics includes such prob- 
lems as the effect of general and specific conditions of heredity 
239 240 
APPENDIX E 
and environment on the conservation and betterment of 
normal children, the influence of physical health, superior 
mentality and moral development as affecting selection in 
marriage and the relative distribution in the State of normal 
as compared with inferior children. Work is also going on in 
the field of physiology where a study is being made of the 
circulation and respiration of children as affected by the out- 
put of physical and mental energy. 
Cooperating institutions and agencies: The station has been 
located in Iowa because the people of this State have keenly 
felt its need and the University and the State Legislature have 
been willing to take the initiative in organizing such a re- 
search center, which is contributing basic principles of child 
conservation to the country at large. The National Re- 
search Council is cooperating with the station in connection 
with some research of importance to the children of the 
country. The station is also affiliated with the Smithsonian 
Institution of Washington. The Federal Children’s Bureau 
has cooperated directly with the station in some important 
investigations in the ninety-nine counties of Iowa, and other 
surveys with this bureau and with other associations and 
private foundations are in the process of development. 
Bird T. Baldwin, Ph.D., Director 
6. Baby Hygiene Association 
Boston 
1. Organized 1909. Under voluntary auspices. 
2. Scope of work: Education of mothers in care of their 
infants and children up to school age by means of home visits 
of nurses and conferences with physicians. 
3. Governing board: Eleven men and 10 women with 
auxiliary station committees. 
4. Staff: Nurses, 1 supervisor, 25 field workers. Doc- 
tors, 1 medical director, part time, 28 part-time conference 
physicians; 6 post-graduate students on free service. Nutri- 
tionists, 5 on full time, G on part time. Clerical assistants, 3. 
5. Divisions of work: 
Infant care: Twenty-one centers at which weekly con- 
ferences are held. Seventy-nine per cent of the babies under 
six months on the roll are breast-fed; 21 per cent bottle-fed. APPENDIX E 
Pre-school age: Twelve weekly conferences; 12 nutrition 
classes affiliated with infant clinics. 
[Since this report was written, the association has inaugu- 
rated a Habit Clinic under the direction of Dr. Douglas A. 
Thom. This clinic deals with cases of behavior disorder, 
faulty habit formations, and conduct problems in young 
children.] 
6. Statistical: Age of babies or young children under care, 
school age. Total number under one year cared for, 9296; 
total number between 1 and 5 cared for, 5176. Total at- 
tendance at conferences during the year, 6205. 
Total population of Boston, 750,000. Total births for the 
year ending December 31,1920,19,537. Total deaths among 
infants under care of the Association, 166; among children 
from 1 to 5, 78. 
7. Record forms: We use our own record form which 
gives a summary of pre-natal and obstetrical care and a 
continuous record for the child from infancy through school 
age. 
9. Cooperating agencies: There is good cooperation be- 
tween the Association and other groups in Boston interested 
in child welfare, including the City and State Departments of 
Health, hospitals, medical schools, relief organizations and 
nursing groups. 
13. Financial: Total budget for the last fiscal year, 
$74,920. The Association is supported by membership dues 
and contributions. 
14. In July, 1921, the Dietetic Bureau, which was estab- 
lished in July, 1918, became a department of the Baby 
Hygiene Association. The Bureau was established as a cen- 
tral organization to help the various agencies working in the 
community to solve the food problems in the families with 
which they came in contact. The experience of the Bureau 
demonstrated the fact that nutritional work is a part of health 
work and that the greatest opportunity for constructive work 
is with the little children. As a department of the Baby 
Hygiene Association the Bureau is still ready to serve all 
agencies in helping to solve the food problems of their families 
and the work with the pre-school age children is being de- 
veloped and strengthened. 
Urgent needs: The great need is for the babies and children 
241 242 
APPENDIX E 
who are not yet reached. Over 6000 babies came to us last 
year, but it is safe to say that at least 4000 more might have 
been benefited by supervision. Fourteen hundred babies 
had to be discharged when they were two years old because 
there were not enough workers to continue to care for them. 
Of the approximately 75,000 children between the ages of 
two and five in Boston, only about 2200 were under our care. 
We are barely making a beginning in this field and the need 
is very great judged by the work we have found to do with 
the 2200. 
This work cost $6.71 per baby last year. But in spite of 
the low per capita cost the sum total makes the support of 
such work a serious question for the public to consider. And 
yet can the public afford not to support it? For after all the 
chief business of the “grown-ups” is to safeguard the chil- 
dren. 
The mothers of babies have contributed over $2200 to the 
work by becoming associate members of the organization, 
and they have also assisted in local activities for the support 
of their particular station. 
During the year, station committees for as many stations as 
possible have been formed for the purpose of increasing the 
efficiency and activities of the stations and also for the pur- 
pose of developing local support. The beginning promises 
well for the future, for we must look to community support 
for a community need. 
Winifred Rand, R.N., Director 
7. Child Welfare League of America 
New York City 
1. Organized 1921. , 
The League has no direct contacts with children. It is a 
League of about 75 child welfare agencies scattered through- 
out the United States and Canada. Its work is largely 
educational and for the purpose of standardization. Studies 
are being made of conditions in the field of our agency mem- 
bers; at the same time studies are being made of standards of 
child hygiene, in order that they may be incorporated as far 
as they are applicable in the programs that are recommended 
by the League. APPENDIX E 
243 
The object of the League is to secure the following results: 
1. The better understanding of child welfare problems. 
2. The formulation and improvement of standards and 
methods of the different forms of work with children. 
3. The making available for all of its members the as- 
sured results of successful effort in any part of the field. 
4. The development of inter-society service. 
C. C. Carstens, Secretary 
8. National Federation of Day Nurseries 
New York City 
1. Organized 1898. 
2. Scope: To bring about cooperation between the dif- 
ferent organizations and to raise standards of work. 
3. The Federation is governed by a Board of 12 women. 
14. Supplemental statement: The work of the Federation 
is toward cooperation. There are four centers under it, which 
require that members shall follow the minimum standards 
that have been adopted. In four States, California, New 
York, New Jersey, and Massachusetts — and in three cities, 
Chicago, New York, and Cleveland — the Departments of 
Health have power to issue and withdraw licenses. Each 
nursery in the country is supposed to have a doctor connected 
with it, who examines children before entrance, and in many, 
examines all children who have been admitted, twice a month. 
Many nurseries have a visiting nurse connected with the staff, 
and many have a trained nurse as superintendent. 
Mrs. Arthur M. Dodge, President 
9. Ruggles Street Nursery School and Training 
Center 
Boston 
The daily program of the Ruggles Street Nursery School 
is not rigidly fixed except for the hours set for meals and 
sleep. Lunch comes at ten o’clock and dinner at twelve; the 
children lie down for the nap at one o’clock and wake at three. 
From half-past eight to half-past nine the children are ar- 
riving. A trained nurse examines each as he comes in, to 
prevent infection and to teach the mothers and children 244 
APPENDIX E 
health habits. As soon as the inspection is over, the children 
play about freely with toys until it is time to gargle with salt 
and water just before the nurse leaves at half-past nine. 
Then we form a circle and sing the morning hymn followed 
by rhythmic exercise and simple dramatic singing games. 
After lunch there is approximately three quarters of an hour 
spent in individual occupations at tables. These consist of 
certain pieces of Montessori apparatus (notably the solid 
cylindrical insets, the geometrical insets, the color tablets, 
the blocks graded in sizes, and sometimes the buttoning 
frames), kindergarten blocks, beads and peg boards, draw- 
ing with chalk on the blackboard, plasticine, paper-cutting, 
sand, etc. During the period the children may change their 
occupation. Some will be engaged in three different occupa- 
tions in that time, others in only one. The children’s needs 
vary so that we make no rules in regard to the use of materials 
except that it shall not be destroyed. We mean, however, 
to have them make a real effort to use what is in their hands, 
especially if they have chosen it. Following this period is one 
of physically active free play, and then comes preparation for 
dinner. After the nap there is again time for free play until 
the children are called for. 
The most important thing from the educational point of 
view seems to be the emphasis on the child’s individual 
needs. Our aim is to give them true freedom to develop 
themselves within law. We have few rules and fewer 
prohibitions, but the lesson of self-control is one of the most 
important of the school. The atmosphere is happy and 
joyful, for each child is contentedly occupied with some- 
thing which satisfies him. 
The response of the parents to the opportunities in the 
school has been very gratifying. Two mothers come once a 
week to help us, one bringing her nine-months-old baby with 
her to sleep all day outdoors. Several mothers’ meetings 
have been held; many of the mothers and other relatives have 
visited and the fathers frequently bring or call for the chil- 
dren, evidently in order to have a look at the school. Some 
of the fathers have shown especial interest in the mental 
ability and development of their children. In several strik- 
ing cases the school has clearly been a demonstration to the 
parents in the matters of physical care and discipline. APPENDIX E 
245 
Through success with the children we gain the parents’ con- 
fidence, and when we see the parents’ eyes sparkle with de- 
light in the newly discovered possibilities in their children, we 
know we have not taken the children away from them, but 
given them to them more truly than ever. Of course the 
reaction of all the parents is not equally good. Some of them 
look upon us as a convenience, not an opportunity; but in 
most cases these are parents whose children have been with 
us only a little while. Time for demonstration is needed. 
Abigail Adams Eliot, Director 
10. Henry Street Settlement, Nursing Department 
New York City 
A study of the work of the nursing service as shown by the 
yearly statistics and a comparison of these statistics with 
those of the preceding year (1919) show an appreciable prog- 
ress along all branches of the work. The staff in 1920 aver- 
aged 212 members; in 1919, the average was 165. The in- 
ternal composition of the staff during 1920 differed from the 
staff of 1919 largely because of the student body. In 1920, 
55.2 per cent of the staff were graduate nurses, and 29.7 per 
cent were student nurses. In the previous year 67.9 per cent 
were graduate and only 18.2 per cent were students. This 
large increase means that the educational work of Henry 
Street’s Nursing Service has become a very important factor, 
indeed. The student nurses fall into three groups: 
1. The graduate students who through the affiliation with 
Teachers College obtain a field experience of ten weeks or 
four months before or after the course at the college. 
2. The undergraduate students who are released by their 
school for a period of four months. This course includes 
twenty-eight to thirty-two hours in the field and six points 
at Teachers College. The subjects for which these students 
are entered are, unless previously covered: Nursing, 41; the 
Principles of Public Health Nursing, Social Service, 87; 
Principles of Social Work, and a course in Nutrition. These 
students come to us from the training schools of the Presby- 
terian, the Post-Graduate, St. Vincent’s, Lenox Hill, and 
Bellevue, New York City; the Newton Hospital, Newton 
Lower Falls, Massachusetts; the Samaritan Hospital, Troy; 
and the Army School of Nursing. 246 
APPENDIX E 
3. The undergraduate students in obstetrics, who through 
an affiliation with the Manhattan Maternity Hospital have 
a month in the 79th Street Center where the nursing care 
rendered the maternity case includes pre-natal, attendance 
at birth, and post partum. The students obtaining this ex- 
perience come from some twenty-six schools of nursing. 
In 1920, 316 students completed their course — 189 Gen- 
eral and 127 Manhattan Maternity. 
In 1919,169 students completed their course — 58 General 
and 111 Manhattan Maternity. 
This change in the composition of the staff does not trans- 
late itself into any loss in work accomplished. The student 
body composed slightly more than one-quarter of the staff 
of the 1920, but made one quarter of the total visits made. 
The increase of the staff by forty members allowed the serv- 
ice to be extended to 7469 more patients than was possible 
to take under care in 1919, and it was possible to make 
52,954 more visits than during the previous year. 
Number of patients in 1920 42,902 
Number of visits made in 1920 336,722 
Average number of nurses during 1920 212 
7910 patients under 1 year 274 deaths 
1895 patients under 2 years 121 deaths 
3242 patients 2 to 5 years 90 deaths 
4576 puerperium 6 deaths 
525 pregnancy 0 deaths 
2629 pregnancy and puerperium 2 deaths 
Jessie Rogers, R.N., Assistant Director of Nurses 
11. Maternity Center Association 
New York City 
1. Organized April 1918. Voluntary. 
2. Scope: 
(1) Through maternity centers the Association provides 
medical supervision and nursing care throughout pregnancy 
to every expectant mother who can be reached and who is 
not already receiving medical and nursing care. She is taught 
how to prepare for the new baby. Through the cooperation 
of doctors, hospitals, midwives and existing organizations 
the best possible arrangements are made for the mother’s APPENDIX E 
247 
care at the time of her baby’s birth and during the following 
month. 
(2) The Association maintains a clearing house at its 
headquarters, to which hospitals, individuals, and organiza- 
tions report all maternity patients in order to prevent dupli- 
cation in maternity work. 
(3) It acts as an educational agency for the entire coun- 
try in popularizing the need for pre-natal care and in demon- 
strating the possibilities of life-saving through intensive pre- 
natal work. 
3. The Association is governed by a board of 4 men and 38 
women. 
4. Staff: Nurses: 1 director, 2 supervisors, 22 field work- 
ers. Doctors: 2 on full time, one on free service. Clinic As- 
sistant: 1 lay woman. Clerical Assistants: 8. 
5. Divisions of work: Pre-natal: 20 weekly clinics. 
6. During 1920 the Maternity Center Association cared 
for over 11,000 mothers and their babies through its 25 ma- 
ternity centers and its staff of doctors and nurses. Patients 
made 25,102 visits to the clinics, and 63,488 visits were made 
to the homes by the nurses. 
13. Financial: Estimated budget, $104,000. 
14. Supplemental statement: In 1920 in Manhattan 1 
mother died for every 205 babies born; 1 out of every 26 
babies died under one month of age; 1 out of every 21 babies 
was born dead. When pre-natal care was given the mother 
under the supervision of the Maternity Center Association 
only 1 mother died for every 500 babies born; 1 out of every 
51 babies born died under one month of age; 1 out of every 
42 babies was born dead. 
Anne A. Stevens, R.N., General Director 
12. Public Health Federation Division of Council of 
Social Agencies 
Cincinnati 
1. Organized 1918. 
Until the formation of the Public Health Federation there 
was no organization for coordinating the work of the many 
agencies dealing with the different phases of the health 
problem. The specific purpose of the Federation is to co- 248 
APPENDIX E 
ordinate the work of all of these groups, formulating com- 
prehensive programs for meeting the important problems in 
the health field and keeping each agency informed of the 
work being done in other fields. 
Cincinnati was the first city in the country to federate its 
health activities in this way and is still the only city which 
has been able to bring about effective cooperation of all its 
agencies. The Federation is the health branch of the Coun- 
cil of Social Agencies and is financed by the Community 
Chest. 
The Federation is made up of representatives of all or- 
ganizations in Cincinnati doing any phase of health work. 
Each organization is entitled to two representatives. 
The Federation operates through Divisional Councils on 
the important phases of health. The Federation has the fol- 
lowing Divisional Councils: Cancer Control; Child Hygiene; 
Hospitals; Housing; Industrial Health; Mental Hygiene; 
Nursing; Recreation; Social Hygiene; Tuberculosis. 
Each Council is made up of representatives of the organi- 
zations interested in that particular problem and each 
Council elects its own chairman and may elect other officers 
if it chooses. 
The active work of the Federation is directed by the Co- 
ordinating Committee made up of the officers and the chair- 
men of the Divisional Councils. The District Health Com- 
missioner of Hamilton County has recently been made a 
member of the Coordinating Committee. The staff consists 
of the Executive Secretary, Educational Director and the 
Assistant Secretary. 
The Federation has affiliated with the American Public 
Health Association in the national field and with the Ohio 
Public Health Association in the state field. It also has 
membership in the national organizations doing health work. 
The Child Hygiene Division, selected as its most impor- 
tant piece of work for the year, a demonstration in protecting 
children against diphtheria. The Board of Health agreed to 
undertake the demonstration with the Public Health Federa- 
tion assisting by organizing a staff of pediatrists to supervise 
the demonstration and by financing the work. 
The urgent need of immunizing children from diphtheria 
will be understood from the fact that 700 children in Cin- APPENDIX E 
cinnati are reported every year suffering from this disease. 
The demonstration recently completed was carried on under 
the direction of the Board of Health in two public schools 
and in several child caring institutions. Some 800 children 
were given the Schick Test to determine whether or not they 
were susceptible to the disease. Those found susceptible 
were given three injections of toxin antitoxin at intervals of 
a week. 
A Day Nursery Association was organized in the fall of 
1919 as a subcommittee of the Divisional Council on Child 
Hygiene. Later it was organized into a permanent section 
of this Council. 
The purposes for which the section was organized are: 
1. To work out standards of admission for children. 
2. To provide proper investigation before admission in 
order to prevent children from being taken aimlessly from 
one nursery to another. 
3. To have each child receive a complete physical exam- 
ination and to have all remedial defects corrected. 
4. To promote the use of standardized records. 
5. To have all day nurseries provide adequate medical 
supervision. 
The membership is made up of four representatives from 
each of the nine day nurseries in the city. Representatives 
from the following organizations are also eligible to member- 
ship: The Public Health Federation, Child Hygiene Coun- 
cil of the Public Health Federation, Board of Health, Asso- 
ciated Charities, Bureau of Catholic Charities, Committee 
on Child Care and Boarding Homes, Negro Civic Welfare 
Committee, Babies’ Milk Fund Association, Cincinnati 
Kindergarten Association and the Anti-Tuberculosis League. 
The section has two standing committees, one on Program 
the other on Standards. The meetings of the section are 
held once each month and afford the members opportunity 
for discussion of common problems and hearing from prom- 
inent speakers on child welfare subjects. 
Standardized record forms have been adopted and when in 
use by all of the nurseries sufficient data will be available for 
a comprehensive study of day nursery problems. 
Bleecker Marquette, Executive Secretary 
249 APPENDIX F 
THE EXAMINATION OF SCHOOL 
BEGINNERS 
A COOPERATIVE DEMONSTRATION GIVING THE RESULTS 
OF THE PHYSICAL AND MENTAL EXAMINATIONS 
TO CHILDREN UPON REGISTRATION BEFORE EN- 
TERING SCHOOL 
A Report presented by the Committee on Education of the Civic 
Club of New York; the New York City Department of 
Health; the New York City Department of Education; the 
Health Service, New York County Chapter, American Red 
Cross; the New York State Association of Consulting 
Psychologists. 
Conclusions, by Ira S. Wile, M.D. 
1. Complete physical examination and individual intelli- 
gence tests should be given all children before admission 
to a school. 
2. Placing the registration time for new entrants to the 
kindergarten and first primary grades in the last or 
second last month of each term makes possible the sug- 
gested examinations. 
3. Follow-up work to secure the requisite remedial service 
should be intensified during the time period between the 
registration with examination and the opening of the 
succeeding school term. 
4. There is great need to transfer the emphasis placed upon 
. the medical inspection of school children to the medical 
inspection of pre-school age children with an increased 
emphasis at school registration. 
5. The investigation indicates that there are no adminis- 
trative difficulties in accomplishing the program for all 
new entrants, though it requires a reassignment of work 
to medical inspectors, school nurses, and psychologists. APPENDIX F 
251 
6. A larger number of psychologists is required for studying 
the psychological problems existent in school systems. 
7. The program involves no increased expense where an 
adequate personnel already exists. 
8. Schools may be more intelligently organized, graded and 
supervised with an immediate knowledge of the physical 
and mental characteristics of the new entrants. 
9. District school organization with the requisite number 
and types of auxiliary classes is facilitated. 
10. The necessity of a dental and oral hygiene clinic as a 
school adjunct is evident. 
11. There is reason to believe that the introduction of the 
tested program will (a) promote the physical welfare of 
school children, (6) increase the benefits of mental hy- 
giene in schools, (c) advance educational standards in 
method and content, (<Z) lead to greater elasticity in the 
curriculum, (e) save the time and energy of teachers, 
(/) tend to decrease unnecessary retardation and elim- 
ination, (g) make each child an individual entity, instead 
of a fraction of a class. 
12. The result of the investigation clearly indicates the value 
of its adoption as a regular procedure by all far-sighted, 
progressive and cooperative Departments of Health and 
Education. APPENDIX G 
A MENTAL HYGIENE SERVICE FOR 
PRE-SCHOOL CHILDREN 
Paper read by Dr. Arnold Gesell at the convention of the Ameri- 
can Public Health Association, at Cleveland, Ohio, Octo- 
ber 16, 1922 
Only thirty years ago Dr. Budin established, in Paris, the 
first Infant Welfare Center. It was a simple but practical 
conception — a consultation center for the examination of 
babies and the instruction of mothers in child care. Infant 
welfare centers have since spread the world over. They have 
multiplied at a phenomenal rate during the last few years in 
England and America. Ambassador Jusserand, speaking 
in 1910 at the first annual meeting of the American Associa- 
tion for the Study and Prevention of Infant Mortality, said: 
“When its far-reaching results shall have been gauged, 
France will be as proud of Dr. Budin for his good work, as 
she is even of the discovery of the most startling inventions 
made by any of her sons in the realm of science or industry.” 
The ambassador spoke with characteristic French insight; 
for the child consultation center, simple as it is, represents 
a social device with unlimited possibilities of growth and 
elaboration. The grafting of a mental hygiene service on the 
consultation and health center organization is one of these 
possibilities. The center is nothing less than a vital point of 
contact, where child, parent, and the scientific social inher- 
itance of the race meet in order that lives should be saved 
and made more complete. 
In some respects this social device, the child consultation 
center, is of more significance even than the public school. 
Why? Because it copes directly with the most fundamental 
of all problems, the rearing of children. It makes health its 
undivided concern. It reaches the parent as well as the child. 
And it reaches the child before he has attained that stage of 
relative completion and superannuation — the school age! APPENDIX G 
253 
In a developmental sense, the child is indeed a pretty 
well-finished product when his sixth year molars begin to 
erupt. The pre-school years are incomparably the period of 
most rapid and most fundamental growth, whether physical 
or mental. Biologically, the pre-school period is the most 
important period in the development of an individual, for 
the simple but ample reason that it comes first. Psycholog- 
ically, the pre-school years are basic because the founda- 
tions of the structure of personality are then laid. It would 
not be dogmatic to say that no child mentally ever outgrew 
his first six years. Medically, the pre-school age is of critical 
consequence because it exceeds all others in mortality and 
morbidity. It is the strategic sector on which to concen- 
trate the defenses of preventive medicine. Most of the physi- 
cal defects of school children originated or preexisted in the 
pre-school period. To an astonishing extent, this is also 
true of mental defects and mental abnormalities. 
Let me attempt to prove the last statement. From the 
standpoint of mental hygiene we may recognize, broadly, 
three classes of exceptional or problematic children: (1) the 
mentally deficient; (2) children with special sensory or 
motor defects which have a tendency to handicap the indi- 
vidual in a mental as well as physical sense — the blind, the 
deaf, the crippled, and the speech defectives; (3) the men- 
tally abnormal — the psychopathic, the unstable, the de- 
linquent — children with conduct disorder. To what extent 
do all these problems demand a mental hygiene service in 
the pre-school period? 
1. Practically every case of mental deficiency originates 
and is recognizable in the pre-school years. Feeble-minded 
children are frequently misunderstood, mismanaged, and 
maltreated during the pre-school age, because the parents 
have secured neither diagnosis nor advice. There should be 
opportunity for early diagnosis, systematic guidance in 
home care; and more provisions for supplementary nursery 
care and nursery training. The feeble-minded child of 
school age is receiving attention through auxiliary schools 
and special classes. In comparison the feeble-minded child 
of pre-school age is neglected. 
2. The sensory motor defectives in the aggregate consti- 
tute a very considerable group from the standpoint of public 254 
APPENDIX G 
hygiene; and here again the child of pre-school age has spe- 
cial claims upon us. An appreciable proportion of all cases of 
blindness occur in the pre-school period. Three fourths of 
all deaf individuals were so handicapped before their sixth 
birthday. Of all the crippled, one third became so before 
the age of five. Fully eighty per cent of all cases of speech 
defect, including the serious defect of stuttering, originate 
before the child goes to school. 
Now, in addition to purely medical attention, all these 
children need a special educational oversight and a super- 
vision of their mental welfare. They are entitled to a kind 
of mental hygiene service. Precious time is lost, injustice is 
done, by idly waiting for the school years and the institu- 
tional years. The blind child should acquire his elementary 
habits of deportment and personality during the nursery 
years; the deaf child should learn to talk in the nursery years; 
the health of personality in the crippled child should be safe- 
guarded from the first; and speech defects should be dis- 
covered and treated in their incipiency. 
3. We shall not go to any psycho-analytic extreme in es- 
timating the proportion of cases of mental abnormality 
which have their roots in the pre-school period. It is suffi- 
cient to say that the numerous cases of conduct disorder, 
perversions, behavior anomalies, which manifest themselves 
in the nursery years, are of too serious import to be ignored. 
They frequently are the symptomatic heralds of later delin- 
quencies and personality defects. From the standpoint of 
the public health nurse and public health official, it must be 
thought provoking that many of the typical conduct dis- 
orders of infancy express themselves as perversions of such 
apparently simple functions as eating, sleeping, elimination, 
speaking, and obeying. The extremely spoilt child, the 
morbidly silent, reserved, and timid child, the domestic 
tyrant, and many unnamed clinical varieties of behavior 
disorder need timely educational procedure if we wish to 
lessen some of the bulky burden of nervous and mental in- 
validism which society now bears. Educational authorities, 
through increasing applications of special educational, psy- 
chological, and psychiatric methods, have addressed them- 
selves to a program of prevention and amelioration. But 
the most essential and promising area for further operation APPENDIX G 
255 
lies in the domain of public health, in the pre-school field; 
and this demands the development of a workable technique 
which will render a mental hygiene service, not only to the 
more, but to the less, abnormal and to the normal pre- 
school child. Unless we achieve such a technique, pre-school 
mental hygiene will tend to remain in a tenuous state of 
aspirational nebulosity. 
What are some of the features of a mental hygiene service 
which are at least on the horizon? 
Periodic mental health examinations are a discernible 
possibility. The diagnostic and advisory functions of welfare 
and health centers should be gradually extended to include 
the hygiene of mental development. It will take much plan- 
ning and investigation to work out a proper procedure; but 
it is time to take conscious steps toward the goal. At the 
Yale University Psycho-Clinic, we have for some time, 
through the cooperation of the visiting nurses, paid special 
attention to the youngest age group of children. We have 
undertaken a program of research to determine the norms 
of mental or behavior development in children of pre-school 
age, with the hope of defining methods of clinical and social 
procedure in this field. We have examined some three 
hundred children at the 6, 9, 12, 18, 24, and 36 months age 
levels. These inquiries are directed toward personality as 
well as intelligence traits; and suggest the possibility of for- 
mulating concrete minimum standards for guidance in a 
more inclusive program of developmental supervision of 
pre-school children. I do not think it very urgent that we 
affix I.Q.’s to the babies at milk stations; but I would admit 
that public health administration and welfare agencies are 
headed toward a policy of pre-school health supervision, 
which will be as comprehensive as the best health work in 
public schools, and which will yet come to include a mental 
hygiene service from the cradle to the kindergarten. 
The habit clinic sponsored by the Baby Hygiene Associa- 
tion of Boston has shown the possibility of doing preventive 
and corrective psychiatric work in this field. The new nurs- 
ery schools in Boston and elsewhere will no doubt develop 
a very useful auxiliary service for the mental hygiene of pre- 
school children. Both nurseries and kindergartens have an 
important contribution to make. 256 
APPENDIX G 
It is extremely indicative, that a few educational as well 
as public health leaders have begun to assert the social sig- 
nificance of the pre-school child. There is evidence that 
the foundations of the public school system will be dug a 
little deeper in the interest of public policy. This “no man’s 
land in the field of social endeavor” is being entered from 
the educational as well as public health camps. 
One of the most suggestive signs of the times is Clause 
19 of the famous Education Act of 1918, which confers upon 
local educational authorities in England “the power to 
supply, or aid in supplying, nursery schools for children over 
two and under five years of age whose attendance at such a 
school is necessary or desirable for their healthy physical 
or mental development.” 
Under this law over a score of nursery schools are now 
being supported by the State, and a greater number are 
maintained by voluntary organizations. In this country 
several experimental and demonstration nursery schools have 
been established, and there are signs of an interesting nursery 
school movement. One of these schools, the Merrill-Palmer 
School in Detroit, correlates its work in a most promising 
way with a practical course in child care for college students. 
There is, as yet, no reason to predict that the nursery 
school will displace the American kindergarten. It may be 
hoped, however, that this new movement will put the pres- 
ent kindergarten on its mettle and transform it into a more 
adaptive, health-promoting agency which will perform a 
bigger and more discriminating work in the field of pre- 
school hygiene. 
It appears, then, that a mental hygiene service for pre- 
school children can be realized if we extend and exploit 
the instruments which we have already at our disposal: (a) 
the consultation and health center to provide a more sys- 
tematic supervision of mental development; (6) conferences 
for the guidance of parents; (c) public health nurses, psychia- 
tric social workers, and pre-school visiting teachers to render 
more direct assistance in the home; (d) adaptations of nursery 
establishments, kindergartens, and special classes in behalf 
of the more exceptional, handicapped infants; (e) an active 
alignment of a reconstructed kindergarten with the public 
health and child welfare agencies of the community; (f) an APPENDIX G 
257 
effective type of pre-parental education dealing with the 
mental hygiene of child care. 
These possibilities are above the horizon. They will not 
all be realized to-morrow, but, perhaps, some day after to- 
morrow the agencies and movements mentioned may be co- 
ordinated to render a hygienic service — which will seek 
to conserve the mental health of the young child and which 
will increase his mental stamina APPENDIX H 
BIBLIOGRAPHY 
This bibliography consists mainly of titles referred to in 
the text. 
Annals of the American Academy of Political and Social 
Science. 
“Child Welfare’’ Number: Philadelphia, 1921. Vol. 98, 
No. 187, 222 pp. 
A very useful summary discussion of some twenty cur- 
rent child-welfare problems by as many different authors. 
Baker, S. Josephine. “Child Hygiene”; chapter xxv, p. 
698, in Park, W. H., Public Health and Hygiene. New 
York, 1920. 
Bibliography — Recent Literature on Mother and Child Wel- 
fare. 
A useful review and notice of books is printed in the 
monthly numbers of Mother and Child, published by the 
American Child Hygiene Association, Washington, D.C. 
Burnham, W. H. A Health Examination at School Entrance. 
Massachusetts Society for Mental Hygiene, 1917. Pub- 
lication No. 27. 
Chrisman, Oscar. The Historical Child, Boston, 1920. 471 
pp. 
Ideas and practices concerning child life among primi- 
tive, ancient, and medieval peoples. 
Cleveland Hospital and Health Survey. A Program for 
Child Health, Part m, Cleveland, 1920. 
Cobb, Margaret. “ The Mentality of Dependent Children 
in Journal of Delinquency, Whittier, California, 1922, vol. 
vri, No .3. 
Dealey, W. L. “Educational Control of the Pre-School 
Period”; in Pedagogical Seminary, vol. 24, pp. 125-140. 
Worcester, 1917. 
Dinwiddie, Courtenay. Community Responsibility, A Re- 
view of the Cincinnati Social Unit Experiment. New York, 
1922. 171pp. APPENDIX H 
259 
Federal Board for Vocational Education. Child Care and 
Child Welfare. Washington, October, 1921, Bulletin No. 
65, 502 pp. 
A collection of valuable outlines for study and of bibli- 
ographies. 
Gesell, Arnold. Exceptional Children and Public School 
Policy. Yale University Press, New Haven, 1921. 66 pp. 
Handicapped Children in School and Court. Report of 
the Connecticut Commission on Child Welfare. Hartford, 
1921. Vol. II. 
“Kindergarten Control of School Entrance”; in School 
and Society, vol. xiv, No. 364. New York, 1921. 
“Mental Hygiene and the Public School”; in Mental 
Hygiene, vol in, No. 1, pp. 4-10. New York, 1919. 
The Normal Child and Primary Education. Ginn & 
Company, Boston, 1912. 342 pp. 
Contains a bibliography; also a critical discussion of the 
Montessori Method. 
Goodwin, E. R. Tabular Statement of Infant-Welfare Work. 
Children’s Bureau Publication, No. 16, 1916. 
Hall, G. Stanley. Educational Problems. Two volumes. 
New York, 1911, 710 pp. 714 pp. 
Lane-Claypon, Janet E. The Child-Welfare Movement. 
London, 1920. 341 pp. 
A useful review of English legislation and administra- 
tion. 
McMillan, Margaret. The Nursery School. London, 1919. 
356 pp. 
Minot, Charles S. Age, Growth, and Death. New York, 1908. 
280 pp. 
Misawa, Tadasu. Modern Educators and their Ideals. New 
York, 1909. 304 pp. 
Newsholme, Sir Arthur. Public Health and Insurance: 
American Addresses. Johns Hopkins Press, 1920. 270 pp. 
Owen, Grace. Nursery School Education. New York, 1920. 
176 pp. 
Payne, G. H. The Child in Human Progress. New York, 
1916. 400 pp. 
Report of the Children’s Bureau. Standards of Child Welfare. 
Washington, 1919. 459 pp. 
Report of the Commission on Child Welfare to the Governor. 260 
APPENDIX H 
A Children’s Code and Studies and Surveys. Two vol- 
umes. Hartford, 1921. 
Terman, L. M. The Intelligence of School Children. Boston, 
1919. 317 pp. 
Waddle, Charles W. An Introduction to Child Psychology. 
Boston, 1918. 317 pp. INDEX 
Abbot, Julia Wade, 203. 
Adler, 113. 
Adolescence, 3. 
Adoption of children, 147 ff. 
Baby farming, 139. 
Baby Hygiene Association, Bos- 
ton, 240. 
Baby Week, 157. 
Baker, Dr. Josephine, 39, 200. 
Baldwin, Bird T., 240. 
Barton, Eleanor, 40. 
Birth-rate, 21. 
Blindness, in infants, 30; in 
school children, 89 ff.; in pre- 
school children, 105 ff. 
Bolt, Dr. Richard, 15. 
Breckinridge, Sophonisba, 25. 
Brend, 179. 
Brockett, Myra, 39. 
Budin, Dr., 26. 
Burcklin, Lydia, 41. 
Camp-Fire Girls, and child care, 
168. 
Carstens, C. C., 243. 
Casa dei Bambini, 47 ff. 
Child Health Special, 187; 235. 
Child hygiene, historical develop- 
ment of, 12 ff.; departments of, 
35; 181 ff. See also Infant wel- 
fare. 
Child welfare, minimum stand- 
ards of, 36, 218-22; list of 
agencies, 224; activities and or- 
ganization of agencies of, 226 ff.; 
exhibits, 157. See also Infant 
welfare and Child hygiene. 
Child Welfare Association, Que- 
bec, 234. 
Child Welfare League of Amer- 
ica, 243. 
Child Welfare Research Station, 
Iowa, 238. 
Children bom out of wedlock, 
143 ff.; statistics of, 144; stand- 
ards of care of, 147. 
Children deprived of parental 
care, 130 ff.; mothers’ aid for, 
40, 132; causes for institutional 
commitment, 134. 
Children’s health center, 199. 
Children’s year, 34. 
Cobb, Margaret, 136. 
Compulsory education, 101. 
Connecticut Commission on 
Child Welfare, report of, 131. 
Corcoran, Mrs. Julia, 41. 
Crippled children, of school age, 
92 ff.; of pre-school age, 112 
ff. 
Cubberley, E. C., 183. 
Darwin, 17. 
Day nursery. See Nursery and 
nursery school. 
Deafness, in school children, 91 
ff.; in pre-school children, 109 
ff. 
Dealy, 160. 
Delinquency, 96 ff.; 121 ff. 
Dependent child, 131. See also 
Children deprived of parental 
care. 
Dinwiddie, C., 189. 
Diphtheria, 18. 
Dodge, Mrs. Arthur, 243. 
Education Act of 1918, 9, 44. 
Educationally exceptional chil- 
dren, 87. 
Eliot, Abigail, A., 53, 245. 
Emerson, Dr. W. R. P., 115. 
First Grade, repetition in, 68; re- 
lation of to kindergarten, 82. 
Fisher Act. See Education Act. 
Freud, Dr. 8., 120. 262 
INDEX 
Froebel, Friedrich, 47, 62, 154. 
Habit clinic, 241. 
Hall, G. Stanley, 62, 152. 
Handicaps of children, of school 
age, 85 ff.; of pre-school age, 
104 ff.; classification of, 87; 
blind, 89, 105; deaf, 91, 109; 
crippled, 92,112; physically de- 
fective, 93, 114; psychopathic, 
94, 118; delinquent, 96, 121; 
speech defective, 97, 122; men- 
tally deficient, 98,125; depend- 
ency and neglect, 130 ff.; ille- 
gitimacy, 143; social control of, 
100 ff. 
Harvey, 17. 
Health center, New Haven, 236. 
Holt, Dr. E. L„ 6, 18, 21. 
Home-making education, 169 ff. 
Home, placement of children in, 
137; and pre-school hygiene, 
151 ff., 209; education in, 
152; visitation of, 160; relation 
to economic factors, 209. 
Infant depravity, doctrine of, 15. 
Infant mortality, 4; and diphthe- 
ria, 18; and smallpox, 18; rate 
in England and Wales, 20; in 
other States and cities, 22; re- 
lation to income, 24; of chil- 
dren born out of wedlock, 145. 
Infant schools, 46. 
Infant welfare, historical develop- 
ment, 12 ff.; influence of World 
War, 27; stations, 30; confer- 
ence, 198. 
Infanticide, 14. 
Intelligence ratings, in kinder- 
garten, 74; in First Grade, 75; 
limitations of, 75; of dependent 
children, 136. 
Jenner, 17. 
Johnson. Harriet, 51. 
Jusserand, 27. 
Kindergarten, origin, 47; relation 
to nursery school, 56; functions, 
57-67. 82-84, 205-09; profes- 
sional training for, 62; reorgan- 
ization, 65; and school en- 
trance, 68—84; as a health 
agency, 73; psychological ob- 
servation in, 74-81; relation 
to handicapped children, 120, 
207; speech correction work of, 
125; and pre-parental educa- 
tion, 176 ff.; and social unit 
plan, 195; attendance on, 203; 
and parental guidance, 207. 
Lathrop, Julia, 146, 167. 
Liebig, 17. 
Little Mothers’ League, 168. 
Mackenzie, Dr. W. Leslie, 145. 
Marquette, Bleecker, 250. 
Maternity Center Association, 
247. 
Maternity, hygiene of, 30; 36; 
198; 221. See also Sheppard- 
Towner Law. 
Maxwell, W. H., 184. 
McMillan, Margaret, 49. 
Measles, 6. 
Mendel, 17. 
Mental deficiency, of school chil- 
dren 98 ff.; of pre-school chil- 
dren ; 125 ff.; of dependent chil- 
dren, 135. 
Mental growth, 7. 
Mental hygiene, 7 ff.; 19 ff.; and 
psychological observation, 77 
ff.; of handicapped school chil- 
dren, 85 ff.; of handicapped pre- 
school children, 104 ff.; rela- 
tion to physical inferiority, 
113; of children deprived of 
parental care, 141; for pre- 
school period, 200 ff.; 252 ff. 
Merrill-Palmer School, 54. 
Milk inspection, 31. 
Minimum standards for child 
welfare, 218 ff. 
Misawa, Tadasu, 155. 
Montessori, Dr. Maria, 47. 
Mulon, Dr. Clothilde, 40. 
National Federation of Day 
Nurseries, 234. INDEX 
263 
Neglected child, 131. 
Newsholme, Sir Arthur, 4, 20, 
21, 180, 185. 
Nursery Department, Henry 
Street Settlement, 245. 
Nursery school, origins, 45 ff.; in 
New York, 50; in Boston, 52; 
in Detroit, 53; in England, 42; 
in Italy, 47; law governing in 
England, 44; future possibili- 
ties, 55; Froebel and, 154 ff. 
Nutrition, 6, 115. 
Oberlin, Jean F., 45. 
Owen, Grace, 45, 49. 
Parental guidance and training, 
in care of handicapped, 127ff.; 
modern agencies for, 156-65; 
and the social unit plan, 194; 
and the kindergarten, 206. 
Parks, Helen, 234. 
Pasteur, 17. 
Peixotto, Dr. Jessica, 40. 
Pestalozzi, 26, 45, 152, 154. 
Phillips, W. C., 189. 
Physical growth, 3. 
Physically defective children, of 
school age, 93 ff.; of pre-school 
age, 194 ff. 
Platt, P. S., 238. 
Pre-natal hygiene. See maternity 
hygiene. 
Pre-parental education, 165 ff.; 
in relation to administrative 
problems, 12; 210-12; baby 
week campaigns and, 32; nurs- 
ery schools and, 53; college 
provisions for, 166. 
Pre-school child, physical growth, 
3; mortality, 4, 19; morbidity, 
5; mental growth, 7; nursery 
hygiene, 38-57; and the kin- 
dergarten, 57-68; and school 
entrance, 71-84; handicaps, 
104 ff.; adoption of, 147-50; and 
the home, 151 ff. 
Pre-school period, definition, 1; 
significance, 2-9; administra- 
tive aspects, 9-12; mental hy- 
giene. 19. 200, 252; social con- 
trol of, 10-12; 24-26; 115, 178- 
96; public hygiene of, 28-38; 
197-212; 224; relation to phy- 
sical and mental handicaps, 
104-30; chronology of hygiene 
of, 215-17. 
Project method, 78-81. 
Psychological observation, 74- 
81; relation to psychometry, 
75; methods of, 77; and the 
project, 78. 
Psychopathic children, of school 
age, 94; of pre-school age, 
118. 
Public Health Federation, Cin- 
cinnati, 248. 
Public health nurse, 160, 187. 
Rand, Winifred, 242. 
Rickets, in China, 16; in pre- 
school age, 116. 
Rogers, Jessie, 247. 
Rows, Dr. Richard, 119. 
Ruggles Street Nursery School, 
Boston, 244. 
Rural child hygiene, 103; 186- 
89. 
School beginner. See School en- 
trance. 
School entrance, 68 ff.; kinder- 
garten-control, 69-71; exam- 
ination at, 71-74; 250. 
School nurse, 162. 
Sheppard Towner Act, 221-23. 
Shick, 18. 
Smith Hughes Act, 169, 171. 
Snedden, David, 172, 202. 
Social control, of pre-school age, 
10 ff.; 24 ff.; 178 ff. 
Social unit plan, 189. 
Speech defective, of school age, 
97 ff.; of pre-school age, 122. 
Stevens, Anne, 248. 
Superior children, 138. 
Teeth, and pre-school hygiene, 
117. 
Terman, L. M., 136, 183. 
Uncared-for child, 131. 264 
INDEX 
Vesalius, 17. 
Vincent de Paul, 26. 
Visiting Nurse Association, 
Santa Barbara, California, 
232. 
Visiting teacher, 162. 
Vital statistics, 19. 
Whalen, Mary, 236. 
White House Conference, 132. 
Wile, I. S., 250. 
Wilson, President, 32, 36. 
Winslow, C. E. A., 161. 
World War, and child hygiene, 
27. RIVERSIDE 
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