'% ^" iim-i'vi-'' -# A^«'' C? ^ - -;^^r-!!y!vn?r/>. .^MW-mm^^ ^^ .■.l-'-fwj -T-'^-- '] -; 13J>1I -Xy 1 Wl? 'IFI'WIVF??/^ I t date stamped belc JTHERN BRANCH, .^'TY OF CALIFORNiAi -ES, CAUF, HEALTH EDUCATION and the NUTRITION CLASS HEALTH EDUCATION and the NUTRITION CLASS A Report of The Bureau of Educational Experiments Descriptive and Educational Sections By JEAN LEE HUNT Studies of Height and Weight and Mental Measurements By BUFORD J. JOHNSON, Ph.D. ; Report on Physical Examinations 1919-20 By EDITH M. LINCOLN, M.D. New York E. P. BUTTON & COMPANY 681 Fifth Avenue d 6 S S S Copyright, 1921 By E. P. BUTTON & COMPANY All Rights Reserved Printed in the "United States of America e TO ^lizabctli #pra0ue Caalibje WHOSE GENEROSITY HAS MADE POSSIBLE WHATEVER CONTRIBUTION THIS STUDY MAY OFFER TOWARD THE BETTER KNOWLEDGE OF CHILDHOOD, AND THE INCORPORATION OF SUCH KNOWLEDGE IN THE school's PRACTICE AND THINKING ACKNOWLEDGMENTS To recall the history of the Nutrition Classes at P. S. 64 is to recall devoted service and generous contributions of many kinds and from many sources. The text of our report in itself reflects the coopera- tive nature of the undertaking, compiled as it is from a diversity of special and partial reports made by different workers at various stages of the experi- ment. We desire to make special acknowledgment to the following: To Haeriet M. Johnson who as our General Sec- retary organized the experiment, secured the neces- sary facilities for it and the requisite permissions for its conduct from the school and city authorities, and who enlisted the cooperation of the chief workers and agencies identified with the undertaking. To Hareiet Forbes, at whose suggestion the ex- periment was first initiated and whose untiring efforts have been directed to the improvement of technique for the enlistment of cooperation from the children and from their parents. Miss Forbes has been responsible for the programs of class instruc- tion and home contacts in the second and third years of the work, and has contributed the social study used as the basis of Chapter 11. To Frederick W. Ellis whose reinterpretation of early results in the light of later findings has con- viii ACKNOWLEDGMENTS tributed greatly to the value of our report and whose advice and criticism have been invaluable throughout the experiment. To Dr. William R. P. Emerson who assisted in the organization of the work and directed it in its earlier stages and to his co-worker, Miss Mabel Skilton. To Dr. David Mitchell who made the computa- tions of statistical material gathered in the first and second years of the experiment, compiled the tables and devised the charts used in Chapters III and IV. To Miss Bessie Edwina Beckwith^ and Mis^ Louise Schriefer who as members of our staff have made individual contributions to methods employed and data submitted, and to Miss Mary Marot, our Educational Recorder, for the reports of class pro- cedure incorporated in Chapters III and IV. To Miss Margaret Vanderbilt and Miss Margaret Cobb who have given volunteer assistance of the greatest value. To Superintendent "William L. Ettinger of the New York City Schools and to Dr. Gustave Straub- enmuller, Acting Superintendent of Schools at the time our experiment was initiated, for the permis- sion by which we were enabled to conduct our classes in a public school. To Dr. Louis N. Marks, Principal, and those teachers of P. S. 64 who by their interest, sympathy and daily cooperation have made the experiment possible. ACKNOWLEDGMENTS ix To Dk. Josephine D. Baker and Dr. Leopold Marcus, of the New York City Bureau of Child Hygiene, through whose kind cooperation we ob- tained the special facilities of open-air class-rooms for many of the children under our care. To Dr. Howard Foster, and to Bellevue Hospital, the Metropolitan Hospital and the Post Graduate Hospital, for generous assistance in cases requiring special examinations or operation for tonsil and adenoid defects. To Dr. Harold A. Koonz and Dr. Louis A. Leichter for generous contributions of professional services in the correction of dental defects, and to the workers of the Stuyvesant Clinic and the Twenty- third Street Clinic for the assistance rendered by them. To the workers of Christodora House and to the New York School Lunch Committee of the Associa- tion for Improving the Condition of the Poor for their cooperation in the program of school feeding during the first term of the experiment. To Dr. Robert Kahn and his assistant, Mrs. B. G. Eeid of the New York City Department of Health Eye Clinic for their unfailing interest and coopera- tion during the entire period of our work, and to Dr. I. H. GoLDBERGER of the New York City Depart- ment of Health for the special physical examinations made by him of children under our care. FOREWOED By publishing this detailed study of our experi- ment with nutrition classes in a city school, it is our hope to place at the disposal of other workers such an account of the experience, of the questions raised by it, and of the varying degrees of success and fail- ure attending it, as may serve materially to further the success of other enterprises in the same 'field of service. The experiment has brought to us clearer understanding of the essential problems of health education, and better appreciation of its true scope and possible place in general educational pro- cedure. If our readers will consider with us the successive problems incident to our work at the dif- ferent stages of its development, we believe they will arrive with us at that inevitable conclusion of educational experiment, the beginning of further experiment, with enlarged knowledge and improved technique in prospect. Only thus may we account our undertaking successful and our record to have served its purpose. The Bueeau of Educational Experiments. New York Crry, June, 1921. CONTENTS PAGES CHAPTER I Place of the Experiment Premises — The General Health Problem — The Problem OF Malnutrition — Some Misconceptions — Inadequacy OF Attack — The Experiment Outlined 1-13 CHAPTER II The Social Backgroimd The School Population — Home Environment — School En- vironment 14-26 CHAPTER III The Initial Program Descriptive Report — Statistical Data and Interpretations — SlJMMARY 27-61 CHAPTER IV Development of Procedure — Grammar Grades Descriptive Report — Statistical Data and Interpretations — Summary 62-97 CHAPTER V Development of Procedure — Primary Grades Descriptive Report — Report on Physical Examinations. . . . 98-117 CHAPTER VI Growth in Height and Weight Distribution of Percentages Under and Overweight — Comparison of Underweight and Control Groups — Seasonal Variation — Comparison of Varying Degrees of Percentage Underweight — Variations in Type — Inter- pretations — Summary of Procedure 1919-20 118-158 xlii xiv CONTENTS PAGES CHAPTER VII Mental Measurements of First Grade Children Group Selection — Apparatus and Procedure — Tabulation OF Results — Comparison of Nutrition and Control Groups — Motor Coordination of Nutrition Group — Summary 15&-198 CHAPTER VIII Interpretations and Recommendations for a Program of Research Standards of Growth — Causal Factors and Response — Psychological Implications 199-220 CHAPTER IX Interpretations and Recommendations for an Educational Program Principles Determining Results — Criteria for Educa- tional Experiences in the Health Program — Impli- cations FOR School Procedure — Summary 221-257 Appendices 258 ILLUSTRATIONS Mid- morning Lunch at Christodoba House 28 Rest and Restlessness in the Gymnasium at Christodoba House 44 Comparing Progbess — Open-aib Boys of 1918-19 62 acv HEALTH EDUCATION and the NUTRITION CLASS HEALTH EDUCATION AND THE NUTRITION CLASS CHAPTER I PLACE OF THE EXPERIMENT PEEMISES The experiment here recorded was undertaken to explore the possibilities of the nutrition class in a public school, to determine how far a school can successfully employ the nutrition class procedure, and in particular how far the procedure itself can be expected to reinforce the school's general pro- gram of health education. Our classes at Public School 64, Manhattan, have constituted, we believe, the pioneer attempt to remedy malnutrition in a school population by employing the methods of the hospital nutrition clinic or class within the school. In conducting them, however, we have had broader educational interests very definitely in view, and our aim has been primarily the enrichment of general educational procedure rather than the development of special provisions for children needing particular care. The health program of the school, if it is to be developed in accordance with educational conceptions 1 2 HEALTH EDUCATION of the present day, must conform to the general thesis that the child's environment shall afford the conditions for certain necessary experiences, and that his intelligent cooperation with regard to these experiences must be secured; it must give to the school and to the individual child within the school a creative attitude toward the problem of health; it must function appreciably in better habits of health and in better individual well-being. Moreover, if such a school program is to be ade- quate as a health program, its development requires the services of the physician and of other specialists in several fields of science, for the school cannot be expected to take over and handle through its regular professional staff a serious attack on the technical problems involved. Thus the situation of the school in regard to health education is characteristic of its situation with regard to any supplementary activity involving a considerable body of specific knowledge or particular technique for its conduct. The great majority of teachers to-day are but inadequately equipped, so far as understanding of the science and technique of their own profession is concerned. To demand that the class-room teacher shall be conver- sant with any considerable outside body of scientific facts or any highly developed technique belonging to another profession, is to demand the impossible. It is only as specialists from other fields can enter the school, introducing their own techniques and adapt- ing them to the school's requirements, that their various contributions to the service of childhood can be successfully incorporated with school activities, PLACE OF THE EXPERIMENT 3 and the school's thinking and service correspond- ingly broadened. It is in this field of educational experience that the Bureau of Educational Experiments has been par- ticularly interested to work. The position of the school makes it the logical clearing-house for those members of the community who hold in their united thinking the community's available knowledge in regard to children and their needs, and the attempt to bring together cooperatively the school and the specialists best prepared to deal with children's problems, presents in our estimation an opportunity for educational experiment offering particular promise for the future. Thus a number of considerations led us to experi- ment with the nutrition class as a tentative proce- dure in a school program. It was in essential agree- ment with our educational thesis. It necessitated introducing within the school the services of the pediatrist and of his trained social service assistants and relating their special knowledge and techniques as closely as possible to the school's problems and the school's thinking. It offered an attack on health from the positive side. If by its adoption the school could secure a satisfactory procedure and appre- ciable gains for underweight children, we believed it would at the same time serve to demonstrate the essential features of a general program of health education much needed at the present time. THE GENERAL HEALTH PROBLEM We have had abundant illustration during the years just past of the importance of physical fitness 4 HEALTH EDUCATION to the national life. Attention has been increasingly focussed on problems of public health and it has been unnecessary to contemplate disasters in foreign lands for our own experience with such epidemics as those of ''polio" and ''flu" have brought into general public consciousness the importance of meas- ures for health conservation. We have all witnessed the dramatic sequence of events attending army re- cruiting, — the rejection of great numbers of young men because of physical defects, the raising to maxi- mum physical well-being of the men in training through the carefully regulated regime of the camp,* and to-day the third stage of the object lesson, the waning of that standard of well-being among the men mustered out as they go back to the daily occupations and ill-regulated regime of American private life. Possibly no circumstances less dramatic would have served to arouse public consciousness to the needs of the situation. Certainly there is throughout the country to-day a very general interest in problems of public health and a desire for betterment. The outstanding fact that must be evident to all is the need of a nation-wide program of prevention rather tljan correction, and the inadequacy of such limited lines of attack as military training and athletic pro- grams on the one hand, and the traditional activities of medical and welfare agencies on the other. THE PROBLEM OF MALNUTRITION The problem of malnutrition among school chil- dren plays an important part in this general health • Chamberlain, Col. Wm. P., Effects of Army Life on the Health of Men, Proc. Int. Conf. Women Physicians, Vol. I, p. 244. Womans Press, 1920. PLACE OF THE EXPERIMENT 5 problem. It is claimed to be largely responsible for after ills and weaknesses in later life. Its chief causes are main factors in the general public health problem, and a successful attack upon it in any group or community may be assumed to typify in miniature the kind of attack required in any comprehensive campaign on a nation-wide scale. Prevalent as the condition is to-day it was hardly recognized as a school problem ten years ago. We have only to examine the past reports of school medical inspectors to realize how little it figured in their thinking. Take for example the figures given for New York City Schools in 1911 * where malnu- trition is reported as affecting 2.57o of the total number of children examined, and compare them with the total of 17.77o similarly reported in 1920.t A survey of 43 schools in the poorer districts of the city made in 1918 revealed a percentage in one school population of 61% affected and 32% as the average found for the whole number surveyed.^ While these last figures represent extreme conditions and at once suggest questions as to the standards used in obtain- ing them, the testimony of school and health author- ities the country over, in rural as well as in urban communities, is unanimous in its emphasis on the prevalence of the condition. We may account for this astonishing increase only by taking into consideration two types of factors that have been working consistently toward it * Gulick and Ayres, Medical Inspection of Schools, Eussell Sage Foundation Monograph, 1913, Table p. 40. t Monthly Bulletin, Dept. of Health, City of New York, May, 1921. t Baker, Josephine D., Annual Report, Bureau of Child Hygiene, Dept. of Health, City of New York, 1918. 6 HEALTH EDUCATION in recent years. First among these is the grow- ing recognition of the condition as one of ill-health, or at least of ill-being. A few years ago only ex- treme cases were recognized. With greater knowl- edge, however, has come the emergence of standards for diagnosing malnutrition, among them the now generally accepted height-weight-age index. Such standards as we have are still most imperfect, yet, such as they are, they are widely accepted and play an important part in the rise of the percentage reported to-day as against that reported ten years ago. Developing standards of nutrition do not, how- ever, sufficiently account for everything. The lowered standard of living during the war period, when certain necessary commodities, as butter-fats, meats and sugar, became scarce and unduly expen- sive, and the increased cost of living exceeded in the majority of homes whatever increase to the family income was contributed by the rising wage-scale, has undoubtedly been an important factor. Yet, in this country where little actual want existed, where even in the greatest crises of the war food has been sufficient and employment general, the resulting drop in the standard of well-being among our children seems to demand further explanation. The theory that the average standard of living in American homes does not provide for the maximum well-being of the individual, and is indeed so near the margin of ill-being that it permits of no reduction without an immediate resulting drop below the safety line, probably offers the most satisfactory hypothesis and PLACE OF THE EXPERIMENT 7 one that the workers concerned in our experiment are ready to support. SOME MISCONCEPTIONS When during the winters of 1917 and 1918 the rapidly increasing percentage of malnutrition among children began to occupy the attention of the public, popular misconceptions in regard to its causes, remedies, and results to the individual, became evi- dent. First among these was the relation between malnutrition and hunger. It was claimed that our schools were full of hungry children whose parents were unable to supply them with necessary food. Popular discontent and alarm at rising prices added to this belief, and the obvious remedy seemed to lie in the general provision of school lunches at nominal prices, and at public expense for those unable to pay. In the brief time that has elapsed, there has been a considerable accession of popular knowledge on this subject, and it is almost difficult to look back to-day and understand the uncertainty with which such statements were met three years ago. As long as our chief sources of information in regard to the existing malnutrition in any community were the welfare and hospital agencies, no comprehensive view of the situation was possible, for their inquiry was, perforce, limited to those candidates for relief applying at their doors. The experience of the pri- vate practitioner with individual cases hardly car- ried over into the general picture of the community and its needs, and the conditions in middle class and 8 HEALTH EDUCATION wealthy homes were thus entirely excluded from the picture. Comparatively few as the community surveys of malnutrition through the agency of the schools have been, the light they have thrown on the relation of malnutrition to economic conditions has been clari- fying. Foremost among such attempts must be noted the survey of 1920 by the Elizabeth McCor- mick Memorial Fund in Chicago, where the height- weight-age index was applied to 10,000 children, rep- resenting several school populations from different sections of the city that presented wide contrasts in economic conditions. Among the statistics gathered, one school with a percentage of 57.7 of its enroll- ment underweight was reported from "a comfort- able semi-suburban neighborhood," as contrasted with 16.2% for one school of ''the stockyards dis- trict." This is undoubtedly the clearest answer yet returned to the misconception that confuses hunger with malnutrition.* Hungry children may be pres- ent in our public schools, but their problem does not explain the more general one of malnutrition. Another popular conception frequently voiced and less easily answered is that malnutrition results in dulling the mental faculties, and that such children are mentally handicapped. That hungry children are incapable of using their school opportunities with the same degree of profit as well-fed children, hardly needs demonstration. With a clear picture * Wood, Mrs. Ira Couch, Nutrition Classes in the Chicago Schools, Modern Medicine, May, 1920. See too, Bliss, D. C, Malnutrition a School Problem, El. Seh. Journal, March, 1921 — where a similar survey in the schools of Mont- clair, N. J., is described. The poorest section of this city made the best record. PLACE OF THE EXPERIMENT 9 of the facts before us, however, — that relatively few of the malnourished children in our schools are hungry cases, other questions arise, for another popular conception, still current in many sections, though not as general to-day as it was fifty years ago, is the idea that the child of full physical vigor is less likely to make a good student than one of lower vitality and less abounding activity. Inasmuch as science has been unable to return unmistakable answers to these and other theories, popularly held and confusing to the issue, the prog- ress of the nation as a whole toward better standards of well-being has been definitely retarded, and there still remains a considerable field of scientific en- deavor to be covered before replies can be presented in terms sufficiently popular and convincing. INADEQUACY OF ATTACK If the general conception of the problem has been obscured in the past because of the character of our sources of information, the attack on malnutrition has been subject to equally serious limitations, although the medical profession, social agencies, the school, have all contributed to the attempt. The medical profession and the social welfare agencies have of necessity focussed their efforts on the cor- rective side, working for immediate results to the individual. In recent years the development of social service departments in connection with our hospitals, and the emergence of the visiting nurse, the public health nurse, the hospital social service worker, have resulted in a closer relationship between the tech- niques of the social agency and of the medical pro- 10 HEALTH EDUCATION fession, and the development of the nutrition clinic is a pooling of their techniques and common experi- ence. The attack of the school, however, until a very- recent period, was a fairly isolated one. Recogniz- ing its essential function to be educational and pre- ventive it has been content for the most part to await long term results, and to make no attempt to evalu- ate its health procedure currently in terms of appre- ciable increase to individual well-being. The hygiene lesson of the physiology class, the work of the do- mestic science and home economics classes, with their instruction limited to girls, the school lunch service, too often existing where it existed at all, on a purely commercial basis, — none of these possible vehicles for health education can be proven (unless in some exceptional cases) to have functioned definitely in the community by the establishment of health habits and a better standard of physical fitness. Our de- partments of physical education at their best are concerned only with a limited portion of the whole field of physical education and, in our public schools at least, are for the most part entirely inadequate in their provisions for that portion of it that they do attempt to cover. The medical examiner and the school nurse, working it is true within the school building, can hardly be said to have affected educa- tional procedure. Their function has been rather to prevent the spread of infectious diseases, and, so far as malnutrition is concerned, to diagnose extreme individual cases and refer them to the private prac- titioner or the hospital clinic. Their work has con- stituted the school's attack on the corrective side and has been at best a negative one. Thus our PLACE OF THE EXPERIMENT 11 schools cannot be said to have developed an>^vhere a comprehensive educational procedure calculated to function appreciably in better habits of health, to develop a creative attitude on the part of the child towards his own health, or to lend itself to current evaluation in terms of individual well-being. THE EXPERIMENT OUTLINED It will be evident that a first requisite for success- ful experiment with nutrition classes as a school procedure is the cooperation of a pediatrist of stand- ing in his profession who can visualize the pos- sibilities of such an experiment and who in his own thinking emphasizes the educational attack. Dr. Wm. R. P. Emerson of Boston has been the pioneer among pediatrists in calling attention to the serious consequences of malnutrition among school children, and in recognizing its milder stages as a condition of ill-being if not of actual ill-health. He has long recognized the important part played by education in the successful treatment of such cases, and since 1908 has used a technique in the nutrition clinic of the Massachusetts General Hospital, now widely known as the ''Class Method," by which the work of the clinic is conducted along the lines of a class in school. A visit to one of these "nutrition classes" in the Spring of 1917 first suggested to a member of our organization the experiment subsequently tried by us, that of transferring the nutrition clinic or ** class" as developed by Dr. Emerson in the out- patient department of the hospital to a public school. In the fall of 1917 we enlisted Dr. Emerson's in- terest in our plan, and later when we accepted the 12 HEALTH EDUCATION offer of P. S. 64 as a school laboratory, we secured his services for organizing the work and training the necessary workers. From February, 1918, when the classes began, until June, 1919, Dr. Emerson was associated with us, at first in a supervisory, later in an advisory capacity. During the last year, 1919- 3920, the experiment was continued with our own staff. The original program as agreed on with Dr. Emer- son was an adaptation of the procedure used by him in the clinic of the Massachusetts General Hospital.* Our special interests in the educational and research aspects of the experiment led first to certain changes of detail, and later to substantial divergence as to the methods employed. In addition, certain modifi- cations and developments were made to meet condi- tions imposed by the school and community environ- ment, and by unexpected situations that developed in the course of the work. In June, 1921, when the classes were discontinued, we were using a procedure differing in many re- spects from the initial plan, though never approxi- mating a general health program. Indeed it may be well to realize at this point that the adoption of the nutrition class procedure, by confining our work to underweight children, proved confusing to our ulti- mate purpose for the entire period. To the workers actually engaged the tendency was always for the corrective procedure to become the all-important consideration, and as increasing public recognition of the problem of malnutrition further emphasized * For a description of this procedure see Standards of Child Wel- fare, Publication No. 60, Conference Series No. 1. Children's Bureau, U. 8. Dept. of Labor, 1919, pp. 238-241. PLACE OF THE EXPERIMENT 13 the existing need of corrective work, our experiment was naturally looked to for practical suggestions as to the conduct of a corrective program in the school. Thus the corrective aspect has always played a larger part in the experiment than was anticipated by us and has largely dictated the lines of develop- ment followed. It is probable, however, that the experience has gained in some respects by this fact, for the increased emphasis placed by the corrective procedure on the securing of results to the individ- ual, reinforces an educational program at its weak- est point. In addition to special provisions for physical diagnosis and care of individuals showing defects or morbid conditions, the nutrition class calls for a daily regime of good eating habits, abundant food, frequent rest, constant fresh air. To provide adequate conditions in respect to these essentials the cooperation of the adults responsible for the twenty-four hour environment of the child is de- manded. It seems desirable, therefore, before dis- cussing the procedure used in detail, to describe the environmental conditions of the community in which we worked, both in the homes and at the school. CHAPTER II THE SOCIAL BACKGROUND THE SCHOOL POPULATION The necessary arrangements preliminary to the experiment were not completed until January, 1918, for in addition to enlisting the interest and securing the necessary permission from the school authorities, the question of a suitable school plant was one for serious consideration. For years the City of New York has been behind in its school-building program, and the increasing shortage of labor and material since 1914 has greatly increased the problem. The consequent overcrowding of the school-buildings has made space for additional activities problematical in the majority of schools, and this factor in itself rendered opportunities for a pioneer undertaking very limited. Quite as important was the problem of school population. As our undertaking involved intimate questions of home surroundings and habits of personal hygiene, considerations of economic status, racial stocks and foreign customs assumed particular importance for it. The desideratum would have been a school population representative of the typical American home, but the New York schools can offer few such opportunities. Instead, there is a choice of districts predominately Italian, Bohemian, Irish, Jewish, as against more hetero- 14 THE SOCIAL BACKGROUND 15 geneous units. As to economic conditions, it was our purpose from the first to avoid the poorest districts. Obviously, those sections which furnish annually the greatest number of candidates for relief do not pre- sent an adequate opportunity for securing or evalu- ating results from an educational program. Public School 64, where we finally accepted the opportunity to conduct our classes, offered a fairly homogeneous Jewish population, in a section somewhat removed from the worst slums, though the neighborhood is crowded and unsightly. HOME ENVIRONMENT The social and home environment of the East side child has become fairly familiar through many care- ful reports* made in the general interest of child welfare, and for the purposes of this study it is prob- ably sufficient to discuss only those aspects which have particular bearing on the problem of nutrition. No thorough-going analysis of the economic situation is attempted, therefore, but rather a record of cer- tain problems reported by our home visitors, expe- rienced social workers who for years have studied life in the tenements and poverty in its varying degrees, and who in many cases have been admitted into the guarded confidence of the heads of families. That there is an abiding fear of want brooding over many homes where there is, at present, no acute distress is undoubtedly true, but there are also many families who regard their present surroundings merely as a * In particular see Dewey, Child and Ruml, Methods and Besults of Testing School Children, pp. 134 and 141-150, E. P. Button & Co., 1920 — where the results of an intensive social study in an adjoining district presenting similar features are given. 16 HEALTH EDUCATION foothold till they become prosperous enough to move where air and sunshine do not command so high a price. In none of the homes has there been evidence of inflated incomes due to war industry. Eather has it been true that with the majority there has been added hardship, due to the increased cost of living and to loss of their wage-earning members. Few of the mothers work outside of the home and a rela- tively small percentage take in work. Many parents have their o^^^l small business, the wife being occu- pied much of the time in helping her husband. In a number of cases rent is reduced or given free in exchange for janitor's service, largely performed by the mother in addition to her home duties. Relief was received by only a few of the families concerned in our study, though many more had at some time been kno^\Ti to charitable agencies. Self- help and self-respect are highly prized and jealously guarded. In those cases under our observation where illness or misfortune had resulted in the ac- ceptance of temporary relief, speedy return to a position of independence was usual. These sterling qualities and their attendant reserve rendered infi- nitely difficult the task of the nutrition worker whose problem is to secure modification of many of the intimate details of family life. As has been said, the population of this quarter is almost entirely Hebrew, the great majority being of Russian origin, the remainder are principally from Austria, with a scattering of Galicians, Hun- garians and Rumanians and a few Italians. The older generation is fairly orthodox, consequently there is present the serious problem of family dis- THE SOCIAL BACKGROUND 17 integration and friction between older and younger members that obtains wherever such conditions are found. The public school is an important factor in this family problem for it is mainly through the school that the younger generation is Americanized. Our schools in the main have had but little under- standing of this situation in the foreign family, and few have developed a technique whereby the neces- sary instructions and messages to the home shall appear less like commands to the older from the younger generation, who are entrusted to deliver them. **You tell your mother," the usual teacher's formula, becomes an unthinkable medium for trans- mitting directions as to diet, sleep and clothing. The nutrition worker is keenly aware too of the impor- tance of strife and emotional disturbances in rela- tion to her problem.* A technique which will avoid any widening of this breach between parents and children must be hers if she would succeed, and her problem should otfer more than a suggestion for general school practice when the foreign home is to be reached. Since the diet is in the hands of the mother, it remains true to tradition and unaffected by the fac- tors which are in process of modifying the lives of the younger generation. The standards imposed by the Hebrew ritual are strictly adhered to, and there is little realization of other standards. Ceremonial ** cleanliness" is accepted as absolute cleanliness, with an acquiescence that is at times startling. Our workers found, however, no lack of food and of good * Cannon, Walter B., Bodily Changes in Fain, Hunger, Fear and Bage, D. Appleton & Co., 1915. 18 HEALTH EDUCATION food in the majority of homes. Insufficient knowl- edge of the properties of foods and faulty food habits were the evident factors militating against the adequacy of the home dietary. The long slow cook- ing which characterizes most of their dishes has its advantages in rendering food easily assimilable, but possibly results, too, in the loss of some of the essential vitamines with which the dietary as a whole is none too liberally supplied.* For years the public has been more or less aware that many children come to school mth- out adequate breakfast, very many with no break- fast, and much restlessness and inattention, with con- sequent lowering of school standing is attributed to this fact. Social workers and conservative members of our school boards alike seem unaware of a similar problem existing in the private school when they argue for, and against, the supplying of mid-morning lunches, on the basis of economic insufficiency and the pauperization of the working home. Private schools to-day frequently provide a light lunch of cocoa or milk, and crackers or bread and butter for those children who in spite of long hours of care- fully guarded sleep with open windows, the invigo- rating tonic of the morning bath, and the well- appointed breakfast table, are wdthout appetite for food in the early morning. On inquiry they T\ill be found in any school. In homes like those of the children of P. S. 64 we may well consider whether any but the most robust appetite can survive the conditions surrounding • Sohapiro, Mary L., Jewish Dietary Problems, Journal of Home Eeonomics, Feb., 1919. This article well describes the characteristics of the Jewish dietary as found by us in the neighborhood. THE SOCIAL BACKGROUND 19 breakfast time. In most instances every room in the flat including the kitchen is used for sleeping, and seldom has the individual child the common right of childhood to his own bed. Bed covering seemed adequate in all but a few instances, but the conti- nental fear of cold night air obtains, and windows are generally kept carefully closed, while for those able to afford it, the indoor air is further vitiated in winter by keeping the gas range burning through the night. In mild weather the conditions as to ven- tilation at night are but little better, as the rooms are small, and at least two out of the four-room apartment receive their air only from a narrow inner court, often foul with odors from adjoining apart- ments. The congestion within the flat makes breakfast a disturbed meal. The older wage-earners of the fam- ily who must needs start away early, are given pref- erence over the school children, who have been late to bed and for whom the longer rest is needed. When finally roused the little people are torn between their desire to sleep and their fear of being late at school. With barely time for a hasty toilet and breakfast often eaten standing or walking about, the result is inevitable haste and strife on the part of the child, or an apathy which a nervous and irritable mother attempts to overcome. The result in either case is a disastrous one. The habit of crowding the mouth and washing down the food which prevails with large numbers of school children is often begun in this way and is most difficult to break down. The unfinished mastication and consequent shortening of the process of mouth digestion is no doubt frequently 20 HEALTH EDUCATION the beginning of serious interference with digestion, and the accompanying hurry and irritation renders a thoroughly unsatisfactory meal even less desirable. The continental custom of serving only rolls and coffee for breakfast is the rule, and only occasion- ally does one find eggs or cereal added as a result of the propaganda for better feeding. In an appre- ciable number of homes, however, cocoa now replaces coffee for the children. The noon meal is usually a better one, though delay in its preparation or too great haste in its consump- tion because of the child's desire to have time for play is often the cause of friction at home. It is the habit in some cases to have only a ''snack" at this time, and to defer till school is over any attempt at a real meal. The three o 'clock meal of some sort is usual, and may or may not be a hearty one. In the main, convenience and economy urge that meals through the day be regarded rather as "stayers" until the wage earners shall return home, or the shop be closed, and the entire family can assemble for dinner, which is accordingly served late, often at eight or even nine o'clock. It needs little imagina- tion to realize that the children, after a long school day and hours of strenuous play in the street, are not able properly to digest this late meal, even were the menu planned with better regard for their years. The dinner consists usually of soup, which is re- garded as an essential dish, meat, frequently chicken, and such vegetables as potatoes, onions, beets and (cooked) cabbages. No salads or greens are found in the Jewish dietary and few puddings, though cakes of various sorts and pastry filled with fruit THE SOCIAL BACKGROUND 21 or cheese are used. High seasoning and condiments characterize almost all the dishes, and pickles and mustard in quantity are rated among the essentials of a satisfactory menu even for quite little children. Much soda water is consumed between meals as well as cheap candy. The homes were found fairly well supplied with the more usual fruits, apples, oranges and bananas. The amount of milk used in these homes is for the most part far below the daily pint per individual recommended by Dr. Sherman of Columbia and others, and cutting down of the customary supply is one of the first economies to which the family in straitened circumstances has recourse. The Jewish restriction on the use of milk and milk products at any meal where meat forms part of the menu, limits the consumption of butter as well as of milk, and this restricted use of butter plays an important part in making vegetables less savory and therefore less popular than they should be. While there is a gen- eral understanding that "loose milk" should not be used until ''boiled," ideas on the subject are far from clear. There is a general impression that all milk is unhealthf ul unless taken warm or hot, and that changes in its properties may attend heating is quite unknown. Even the best grade of bottled milk will often be placed immediately on the gas stove and allowed to heat indefinitely. It will be obvious that much of the dislike for milk found among the chil- dren may be traced to this method of treating it. Cold running water is supplied in these homes but bathing and toilet facilities are poor. In the majority of cases the occupants of the four or more 22 HEALTH EDUCATION flats on a floor share a single toilet, ill-lighted and poorly ventilated. Even where more modern ap- pointments exist and the flat contains a bathroom, family habits are but little affected by the added facility and the school weight-taking discloses only too many grimy little bodies, whose clogged pores have little chance to play their part in the man-build- ing process. At the age of six the sons of the orthodox must begin attendance at the rabbi 's school for instruction in the faith and in the Hebrew tongue. The sessions follow directly after dismissal from the public school and although the compulsory time is brief in the early years, at first only fifteen minutes a day, the little children are encouraged to stay after the ses- sions and, indeed, the younger ones are often sent by their mothers to be taken care of in the afternoons in the belief that they Avill be safer there than in the streets. Thus physical restraint in ill-ventilated sur- roundings is substituted for valuable hours of play in the open air, and the older boys who are prepar- ing for confirmation in the faith are often severely taxed by the requirements made of them in addition to the work and hours of their regular school day. It would seem as if, between the crowded home flat, the crowded school, and the after-school care of the rabbis, few stones were left unturned in the adult plan of this environment to cut the child off from activity in the open and a constant supply of fresh air. But were we to inquire as diligently into the environment provided by many ''typical American" homes far removed from any kind of slum surround- ings, there is at least a probability of their affording THE SOCIAL BACKGROUND 23 a fair parallel to the main features in this picture, — abundant food, inadequate dietary knowledge, poor eating habits, inadequate sleep and inadequate fresh air. SCHOOL ENVIRONMENT Public School 64 has one of the largest and best equipped school plants in the city and offers special facilities in its manual-training shops, auditorium, yard space, open air and ungraded classes. The principal, Dr. Louis Marks, is keenly interested in educational progress and has frequently cooperated with outside agencies in securing special activities and facilities for the school. Thus, the attitude, not only of the principal but of the teaching staff, is one of far greater interest, understanding and tol- erance for supplementary activities than is usually the case. Unusual opportunities for supplementing the school resources are to be found in the near proximity of Tompkins Square with its big play- ground and of such community agencies as the Boys' Club on Avenue A, the nearby branch of the city library, and Christodora Settlement House, which stands adjacent to the school. Because of its extensive shop equipment the school has for some years been used almost entirely for boys, girls being admitted only in the Terman classes. (See p. 29.) This predominance of boys in the school population has had its effect on the experiment in certain particulars. Much of our work was concerned with the fifth and sixth grade boys, whom we must assume to be at that stage of prepubertal development characterized by minimum 24 HEALTH EDUCATION growth when the individual is probably least able to respond to favorable conditions, and appreciable results from treatment are likely to be minimized. Food. — The time is not yet when the public school can gratify the small boy's native interest in food by admitting him to a cooking class, and domestic science equipment was, of course, entirely lacking as were lunch-room facilities. During the first year, when a mid-day meal was included in the nutrition program, it was supplied by the New York School Lunch Committee and served in Christodora House where special opportunities for rest periods were also provided. Fresh Air, — The importance of the air supply in relation to the processes of assimilation is too little understood, and public opinion in consequence too little informed, for school conditions generally to reflect the influence of scientific findings in regard to temperature, humidity and air movement. The equipment for heating and ventilation at P. S. 64 is of the forced-air type generally accepted as the best in modern school building but is none the less open to some serious questions on the score of healthfulness. The atmosphere of the class-rooms in winter is undoubtedly better than would be found in the majority of our city schools, as more intelli- gent use is made of the facilities the equipment affords than is often the case, but it is probably no exaggeration to say that the air is at all times too warm, too dry, too still for the health of those who must spend long hours there five days a week. If by fresh air we mean cool air, in motion, and of optimum humidity, it must be evident, that except THE SOCIAL BACKGROUND 25 for the groups in open-air rooms, the children of our nutrition classes did not receive a constant sup- ply during their school hours, nor probably at any other hours through the winter weather, save in their play time on the streets. Over-Fatigue and Bodily Activity. — ^By taking the children from active outdoor play for a considerable portion of the day and imposing the seated tasks and quiet of the class-room, there is no doubt that the school prevents much over-exertion on the part of the more delicate children. However, the probable loss to the average child resulting from the school's restraint of bodily activity and fixing of sedentary habits is of far greater importance for the general problem of health. Until the significance of this is more generally appreciated, however, school tradi- tion and equipment, together with the size of school classes, will continue to impose conditions where fatigue results from lack of bodily activity rather than because of it. There is, moreover, an inevitable nervous and physical stimulation for children in the mere presence of other children in numbers, and we may w^ell ask ourselves the significance in terms of nutrition of the scrambling crowds gathered about the doors of P. S. 64 before each session, and of the general tension that necessarily attends the school day where 3000 boys are housed under a single roof. It seems evident that such conditions demand an increased expenditure of energy that must have a direct bearing on the nutritional processes of the individual. Additional Facilities. — P. S. 64 is well provided with toilet facilities and with running water and 26 HEALTH EDUCATION drinking fountains. A fine gymnasium equipped with shower baths is available at the Boys' Club nearby and another is provided at Christodora House. These are used by many of the older children. CHAPTER III THE INITIAL PEOGRAM, FEBRUARY-JUNE, 1918 Basis of Selection- STANDARDS The children selected for our nutrition classes were first measured for height and weight, the Burk- Boas Height- Weight-Age Tables being used as standards.* Those found to be 7% or more under- weight became candidates for enrollment, although it was never possible to enroll them all because of the administrative difficulties involved. The use of 7% as a standard for determining malnutrition instead of the more usual 10% standard, was in ac- cordance with Dr. Emerson's opinion that 7% habitual underweight is indicative of a condition calling for attention. In our practice, however, because of the necessity the school was under of arranging definitely for the personnel of classes at the earliest possible date, the qualification " habit- ual" had to be disregarded and all children found 7% underweight were admitted if provision could be made for them. While we realized that the adop- tion of so high a standard, especially for Jewish children of middle European antecedents, was open to question, we employed it tentatively throughout * Burk, Fredoric, Growth of Children in Height and Weight, American Journal of Psychology, April, 1898. 27 28 HEALTH EDUCATION the experiment with a view to making an assessment of it, and of any special possibilities it might offer toward a program of preventive work. GROUP SELECTION Five classes were organized during the first year. A group of seventh grade, one of sixth grade, one of first grade children, a group of children from one of the regular open-air classes, and a group from the Terman or special classes, which existed as an experi- ment within the school, were included. In addition, a group of 20 fifth grade boys were selected and given a program of school feeding for purposes of comparison. The children from the upper grades were recruited in the belief that they were sufficiently advanced in school to cooperate intelligently in the experiment. The nutrition class procedure had been developed by Dr. Emerson with special reference to these older children, and the addition of the first grade group introduced problems of standards and of teaching methods not anticipated in his original plan. They were included because of an attempt on the part of the school to give particular care to mem- bers of the entering class, with a view to insuring individual adjustment to school life. It was believed that the nutrition class would supplement the school program effectively by affording special treatment for those showing need of physical attention. A program of health education carried out for six- year-olds seemed to offer, too, the logical beginning for a general health program in the school. The children of the open-air group were included partly because their condition as anaemic and pre-tuber- THE INITIAL PROGRAM 29 cular cases demanded every assistance the school was able to afford, partly because their inclusion was the best response the school could offer to Dr. Emer- son's request for open-air treatment and a lighter program of school work. The Terman classes were included because of special interest of the school in them, and the fact that a surprisingly large percent- age of underweight was found to exist among them. THE TEKMAN CLASSES These classes consist of gifted children whose devi- ation from the average intelligence quotient repre- sents about the same range above normal as that of the defective in the ungraded classes does below. As children showing an I. Q. of 75 or less are placed by the school in special classes for defectives, so those showing an I. Q. of 125 or above have special provision made for them in the Terman classes. This experiment was in its initial stages at the time the nutrition classes began and was at that time limited to the sixth, seventh and eighth grades. In all, 69 children had been withdrawn from these grades and placed in two groups, one of which graduated in the' spring of 1918, the other the following year. The average I. Q. was considerably beyond 125 and some individual ratings were much higher. The classes included girls as well as boys, and the age range was from ten to twelve years. The children in the more advanced group very generally exhibited the accelerated height increase, and consequent decrease of weight for height due to the approach of puberty. This factor undoubtedly contributed somewhat to the percentage of under* 30 HEALTH EDUCATION weight recorded among them, as the Burk-Boas Height- Weight- Age Index is based principally on the measurements of children of other racial anteced- ents, in whom pubertal development presumably takes place at a less early age. They were, however, at no greater disadvantage in respect to this factor than were the children of the regular sixth and seventh grades who showed by the same standard percentages of 15.9 and 14.4 respectively in compari- son with the 27.5 average of the Terman class. A corresponding contrast is presented by the percent- age of overweight found among the Terman and regular grade children, the sixth and seventh grades showing a percentage of 18.7 overweight and the Terman groups a percentage of only 8.6.* The general impression created by these gifted classes, however, was one of physical superiority rather than the reverse. Their relatively poor show- ing in the initial height and weight taking created considerable surprise; and even after the stripped examinations had revealed the usual characteristics — winged scapulae, poor muscle tone, prominent rib bones, etc. — their faces, alert and often rosy, seemed to contradict the evidence. Possibly three-fourths of them came from homes distinctly above the general economic level of the district. This was primarily due to the higher aver- age intelligence of their parents, for whom the diffi- culties of getting a foot-hold in America had been reduced by their exceptional ability. A number were children of East side physicians who combined • Seven per cent or above in excess of normal is the basis on which this overweight is computed. See Distribution Table, Appendix A., also Tables I and II, pp. 49-50. THE INITIAL PROGRAM 31 the advantages of education with those of superior intellect. The less prosperous represented families where some special factor, like relatively recent im- migration and consequent difficulty with a foreign language, kept the family fortunes at a lower level in spite of native ability. The members of the older class were looking for- ward to graduation in the spring, and were working under considerable pressure to prepare for the com- ing examinations. Ambition to excel was very gen- eral, and increased the high tension characteristic of the class as a whole. It is possible that over- stimulation had much to do with their condition of underweight and it is probably significant that 58% were borderline cases averaging less than 10% underweight. In providing for these children the school had not followed the usual rapid advancement plan by whicb^ gifted pupils are put through the standard curric ulum in the shortest possible period. The attempt had been rather to broaden the school experience for those, who by reason of superior ability could best afford time for additional activities, and could be expected to profit most from them. A careful can- vass of neighborhood facilities had resulted in secur- ing for them special opportunities for library, play- ground and gymnasium activities, and instruction in music and drawing. The usual school discipline was considerably relaxed in the conduct of their classes, and their attitude toward every new interest and opportunity that was secured for them, was one of eager participation. Thus there had been much in their previous experience to prepare them for 32 HEALTH EDUCATION benefiting from the suggestions of the nutrition class. Physical Care EXAMINATION AND DIAGNOSIS Every child enrolled in the class was given a care- ful stripped examination by one of the physicians to insure correct diagnosis and the prescription of treatment if conditions of disease were found to ex- ist, and to discover indications of physical defects calling for the advice and treatment of a specialist. Local legislation required that special permission from the parents must be obtained in every case before the stripped examination could be made, and this provision was always carefully followed. The nutrition worker secured the necessary permissions and urged the attendance of one of the parents at the examination in the hope of enlisting home inter- est and cooperation as far as possible from the start. The efficiency fetish which plays so important a part in public school thinking to-day, is only too likely to exert an undue influence on any program demanding the amount of individualization entailed by the nutrition class. Even our workers, who were under no necessity for observing standards other than thoroughness, and were free to expend time and care as the necessity of the individual required, felt keenly at first the desirability of making the experi- ment "efficient" from the school board viewpoint by limiting the time and effort expended to out- standing essentials, in the belief that the amount of time and work, and the consequent number of workers demanded, must be limited, so far as poe- THE INITIAL PROGRAM 33 sible, in order to commend the undertaking to the school as a practical one. As experience increased, however, and our workers became better aware of the complex factors involved, the fallacy of confus- ing expedition with efficiency became more and more apparent. The time required for the examinations was found to average from twenty minutes to a half hour. THE CORRECTION OF DEFECTS Naso-Pharyngeal Obstructions. — Children who ap- peared to be suffering from physical defects bear- ing in any way on the nutritional processes were taken by the nutrition worker to one of the available clinics for re-examination by a specialist. Naso- pharyngeal obstructions were the chief concern, as the presence of tonsil and adenoid growths definitely reduces the underweight's ability to gain, and the effect of their removal has been aptly characterized as rendering him ' ' free to gain. ' ' The ideal program is therefore, to have all cases recommended for operation treated at as early a date as possible after the formation of the class. The attempt to secure these operations for children needing them involved much expenditure of time and effort throughout the entire period. It was generally difficult to persuade the parents of the necessity for such treatment, and as the facilities afforded by the city hospitals were limited, operations had often to be delayed after the parents' permission had been secured. Both Belle- vue and the Post-Graduate Hospital treated cases for us. In the five classes organized during this first term, 69 children, or QQ% of the entire number en- 34 HEALTH EDUCATION rolled were recommended for removal of tonsils or adenoids or both, and operations were secured for only 20 children, or 29% of the number needing them. In the majority of cases the treatment was delayed until the term was considerably advanced. Dental Caries. — Second in importance was the treatment or removal of carious teeth. No such obvious results in weight increase attend the remedy- ing of this type of defect as follow the removal of tonsils and adenoids. It was, however, always given an important place in our program, as an essential of any general health program where preventive as well as corrective work is the aim. Eighty-eight of our children out of the total 105 were persuaded to undergo examination by the dentist and of these, 63 were found to have from 1 to 12 carious teeth. Treat- ment progressed slowly owing to the indifference of many parents, and the limited clinic facilities. The Stuyvesant Clinic and the Twenty-Third Street Clinic both treated dental cases for us. Eye Strain. — Examination for eye refraction was given in a few cases by request of the nutrition workers, but in general our staff did not assume responsibility for this type of defect as the Board of Health Eye Clinic, located in the building, provided excellent facilities for the children of the school. A strong prejudice against glasses, however, existed in the homes of the community and was shared by the children. Even after purchasing glasses few could be persuaded to wear them regularly in spite of strenuous efforts on the part of the nutrition worker and the class teacher to bring this about. THE INITIAL PROGRAM 35 Cooperation of the Home CONTKOL OF THE ENVIRONMENT The educational features of the nutrition class may be said to begin with the school and home en- vironment, and such opportunities as they afford for experience leading to proper intake of food, better digestion and increased assimilation. If children are to cooperate in a program of health experiences, certain conditions as to food, eating habits, fresh air, rest and sleep must be provided. How far the homes of the community could be enlisted to make necessary changes in customary habits, and how far they would be found able to do so, were therefore points of particular interest and importance for the experiment. By visits of the nutrition worker and the attendance of the parents at the weekly sessions of the class, we hoped to secure the necessary co- operation of the home in providing the following conditions : Food. — Adequate caloric intake averaging 2000 calories a day. — While individual needs must de- termine variation in the figure, it was believed this amount would be found to constitute an increase over what the average child was receiving. — Mid- morning and mid-afternoon lunches, designed to add from 250 to 300 calories to the amount received at the usual meals. — These lunches were not to consist of foods like sweets calculated to take away the appetite for the regular meal. They were advised by Dr. Emerson on the theory that undernourished children, like invalids, will assimilate better if food is taken in smaller quantities at briefer intervals. 36 HEALTH EDUCATION Diet. — To increase the caloric intake, milk and ce- reals were recommended, as the best foods by which the home table could be supplemented for the under- weight child, with the least disturbance to family- preferences and eating habits. The elimination of tea and coffee, and of any other stimulants the home table might afford, was especially stressed, as well as the necessity for an adequate breakfast. Prevention of Over-Fatigue. — A half hour rest period before the mid-day meal and avoidance of un- due physical activity, as roller-skating and ball- playing for protracted periods, and the need for proper hours of sleep with open windows, were es- pecially emphasized. Personal Hygiene. — In addition, the intelligent supervision of the home was sought in habits of eat- ing, bathing and elimination. HOME VISITING Permission for the stripped physical examination and the gathering of information concerning birth and infancy, previous diseases, and general health habits, with other social data regarding members of the family was the primary cause of home visiting by the nutrition worker, and required at least two visits to each family. Arrangements for securing the removal of physical defects when recommended necessitated further visits. During this first school term, however, a definite attempt was made to limit the home visiting and to make the necessary contacts with the parents through their attendance at the weekly class sessions. This was especially urged by Dr. Emerson, who was accustomed to securing the THE INITIAL PROGRAM 37 attendance of mothers at hospital classes, and was anxious to develop the school nutrition class with as small a staff as was consistent with the demands of the situation. But the attempt to secure the mothers' attendance at the weekly class meetings was never very successful. The aversion of these foreign mothers to leaving their homes for any pur- pose outside the usual one of shopping and market- ing is very great, and their attendance as secured by the hospital clinic, is of itself indicative of their conviction that the children concerned are really ill. Where this is not obvious, it is often a slow process to convince either parent that any extra attention is needed. Cooperation of the School THE EYE CLINIC KOOM Through the courtesy of the Board of Health we were allowed to conduct our work in the one avail- able spot the crowded school building afforded. This was the eye clinic room, a class-room that had been set aside for that purpose. Sessions of the clinic were held here every morning, but after twelve the room was used only by the clinic nurse who worked at her desk, leaving the rest of the room free for the activities incident to the nutrition classes. Our equipment consisted of a Buffalo scale, a stadiom- eter, two screens, an examining table, and a cabinet file for records. Except for these, and the eye clinic desk and vision charts, the room presented no special features of equipment. Settees replaced the customary forms and desks, and offered certain ad- vantages in rearranging the room for our purposes. 38 HEALTH EDUCATION These, with blackboards, and a table and chair for the teacher, constituted the furnishings. A good north light was secured from large windows along one side. When the classes met the children's charts were ranged against the blackboards in the back of the room for discussion. The screens were used when physical examinations were made or stripped weights taken. How far the work of the eye clinic may have been embarrassed or impeded by this partnership ar- rangement, we were never informed, for at all times our work and our workers received the utmost con- sideration and sympathy both from Dr. Eobert Kahn, the oculist, and from Mrs. B. G. Eeid, the nurse. If our own workers felt seriously the restric- tions imposed by the situation we cannot feel very sanguine over the effect of our strenuous program on theirs. At no time was it possible for the room to be given over entirely to the nutrition work, and the nutrition staff was always conscious of the neces- sity for conducting its work of weighing and measur- ing, checking up and recording, with the least pos- sible disturbance to the others. During the first term when Dr. Emerson's visits were frequent and his lim- ited time perforce divided among several classes, preparation for the class instruction had to be made even before Dr. Kahn had finished his regular clinic sessions. When weights were taken the combined requirements imposed on the nutrition worker for accuracy in the records, quiet in a group of restless boys, and expedition, that the children might be re- turned to their class-rooms with the least possible loss of time, rendered the work particularly trying. THE INITIAL PROGRAM 39 The difficulty of taking stripped weights under these conditions will be apparent, but the regular weekly weight-taking without shoes was in itself a sufficient problem. The first grade boys at the beginning of the term could not take off their shoes nor put them on without assistance, and for all ages it was apt to be a relatively slow process. Shoe laces with frayed ends were common, and they were often wet and knotted. Shoes and stockings, too, were frequently water- soaked. Nor could the littlest boys manage to pull off and on the tight-fitting sweaters that were uni- versally popular. The location of the room, overlooking the play- ground and next to the metal workshop, rendered the work of recording particularly difficult because of noises from outside, especially the shouts and cries of the second session children gathered about the doors waiting for their classes to begin.* To add to the responsibility of these sessions rapid dismis- sal signals (fire alarm) which could not be disre- garded were frequent, and visitors came at all times to observe our methods. It mil be evident that whatever educational possibilities the experience of weight and height-taking might in itself have af- forded, were seriously impaired by the conditions under which these activities had to be conducted. CONTROL OF THE ENVEEONMENT In addition to furnishing headquarters for the work and facilities for the physical examinations, weekly weight-taking and class sessions, the school was asked to cooperate in the attempt at better con- ♦ See p. 112. 40 HEALTH EDUCATION trol of the environment. Compliance with Dr. Emer- son 's request for shorter hours of work and open- window rooms for all the nutrition class pupils, seemed quite beyond the possibility of the situation except in the case of a few children, 11 in all, who because of pre-tubercular or anaemic condition were enrolled in one of the school's regular open-air classes. Opportunities for additional food intake and for rest periods were arranged during school hours but, partly for purposes of comparison, partly because it was found impossible to secure like op- portunities for all, the school program was varied for the different groups. Three of the classes were given a mid-day dinner with a value of approxi- mately 1000 calories. For four classes a special mid- morning lunch was arranged. Three classes had opportunities for a half hour rest during the school session, and the little group in the open-air class received the regular mid-morning lunch provided in all the open-air class-rooms. They had in addition the special facilities of the open-air rooms for rest- taking and fresh air, as well as a lighter program of work. The group of 20 boys from the fifth grade, received only the mid-day dinner and was not in- cluded in the general program of physical care and instruction. This group therefore in some particu- lars resembled a control group. The chief considera- tion in making these special provisions for different classes was a desire to determine the relative value of school feeding in the program. It was through the generous cooperation of Christodora House and of the New York School Lunch Committee that we were THE INITIAL PROGRAM 41 able to secure the requisite facilities for this part of the work. MID-MORNING LUNCHES These were supplied and served by Christodora House to the children of the sixth grade, seventh grade, first grade, and Terman classes, and con- sisted of hot cocoa with crackers or bread and butter. The children enrolled in these groups went next door to the settlement to get this lunch beween ten and eleven o'clock every morning during ''out time" periods afforded by the school's double session schedule.* As the school was entirely without lunch room or domestic science equipment this appeared to be the only arrangement possible. It involved much extra time and loss of energy, especially in cold or stormy weather. Many of the children too were embarrassed and rebellious over other cir- cumstances attending it. The necessity of going for it when the other children did not, rendered them conspicuous, and ' ' different ' ' from their class- mates who did not fail to taunt them over their peculiarities. Thus many came only under protest after being ''rounded up" by the nutrition workers and "cutting" was frequent. Moreover, as no charge was made for the lunch, the stigma of "charity food" was attached to it at first, and many parents objected until its nature and purpose was fully explained to them. These difficulties became less as time progressed and most of the children came to understand and appreciate the significance of the nutrition program. The luncheon itself was * ' ' Out time, ' ' periods when the children are not in their class- rooms but are under supervision. 42 HEALTH EDUCATION always acceptable to them and taken with apparent enjoyment, even by those who protested most vigor- ously over going for it. MID-DAY DINNER The mid-day dinner was supplied by the School Lunch Committee and delivered at Christodora House where service and supervision were furnished. Sixty-five children from the Terman, the sixtli grade and the fifth grade groups received this meal. As the dining room capacity at Christodora House was limited to 35, the children were served in two groups. The menus were planned to provide 1000 calories and to broaden dietary habits with respect to vegetables, milk dishes, and cooked fruits. This deliberate at- tempt to supplement the deficiencies of the home dietary and develop a taste for new dishes, however excellent and important from the theoretical stand- point, presented very serious practical difficulties. In addition to the aversion felt by most children for un- accustomed dishes, the carefully inculcated prejudice of the Jewish child against strange foods, the fear that they may not be kosher, had to be reckoned ■v\dth. This fear conditions the attitude of the Jew- ish child toward any unaccustomed food and greatly increases the difficulty of persuading him to eat new dishes. The high seasoning to which his home cook- ing accustoms him presents another serious problem. Bland and relatively delicate flavors are unappetiz- ing to palates demanding pickles, mustard and spice as a matter of course. In addition it must be re- membered that few, if any of these children could be classed as ** hungry cases," and both the Terman THE INITIAL PROGRAM 43 and sixth grade groups were receiving mid-morning luncheon in addition to dinner. Under the circum- stances it is not surprising that the children were indifferent to the dinner. Indeed, many of them were never persuaded to eat much, although as time pro- gressed the general attitude was better, as in the case of the attendance at the mid-morning luncheon. In the beginning there was much disorder and even *' rough house" in the dining room. The intervals occasioned by the Easter vacation and the Jewish holidays at Passover broke up the continuity of the experiment, and during June, after the children had really begun to take the meal with some degree of satisfaction, the hot weather made serious inroads on appetite. Some concessions to the children's tastes, which the workers in charge felt could be made without sacrificing the nutritional and educa- tional value of the meal, were made. Such dishes as rice pudding and custards, for example, were given up, and desserts of cooked fruits substituted. Two sample menus reflecting this modification follow; as has been previously noted, they were planned to supplement deficiencies of the home dietary, not as model balanced meals.* Eice Soup (with milk) Potato Salad Mashed Potato and Turnip Eye Bread and Butter Eye Bread and Butter Prune Pudding Baked Apples Cocoa REST PERIODS These were taken in the gymnasium at Christo- dora House for a half hour before the luncheon period. The sixth and seventh grade groups were required to take this rest period. The Terman * See Appendix D. 44 HEALTH EDUCATION groups were advised to take it, and many of them did so. The children lay on the floor each wrapped in a blanket. There was always more or less diffi- culty in securing cooperation, especially from the older boys, and the task of supervising the rest period was not an easy one. The shouts and cries of their class-mates at play in the square outside could be plainly heard, and this made resting seem even more *' babyish" than it already appeared to restless spirits. Occasionally one or two of the more obstreperous would decide to endure it no longer, and would suddenly cut out of the room, and escape to freedom. In spite of these disturbing ele- ments, there is no doubt that the children whose interest had been enlisted, succeeded in getting bene- fit from the period, and learned to lie quietly relaxed without being seriously disturbed by their more rest- less neighbors. Enlistment of the Child's Cooperation INDIVIDUAL, INSTRUCTION To secure the second half of the educational program, the cooperation of the child within his en- vironment, both individual and class instruction were provided. Following the weekly measurements a brief interview between pupil and nutrition worker took place. Each child was given a specially devised booklet* containing a table of 100 calorie portions of common foods in which to record his food intake for 48 hours. He was asked to make a list of the actual food taken ; slices of bread, ounces * Emerson, Wm. R. P., A Record Boole for Measured Feeding, Pub. No. 3. Nutrition Clinics for Delicate Children, Boston, Mass. THE INITIAL PROGRAM 45 of milk, tablespoonfuls of cereal, etc. This 48-ho-ar record was returned each week and the caloric in- take figured by the nutrition worker. Further data were obtained by the nutrition worker on the entire week's record with regard to observation of the prescribed program, rest periods, lunches, hours of sleep, drinking of tea and coffee, water at meals, fresh air, breakfast habits, rapid eating, exercise, fatigue, colds, clothing and any other facts of significance in the week's history. Notes made at the time of this interview were used later as a basis for discussion of the individual charts at the class meeting. These charts were de- signed to record the outstanding features of the week's history. Gain or loss of weight, number of rest periods, mid-session lunches, use of tea and coffee, and caloric intake as well as progress in the correction of defects, were graphically indicated by this means.* CLASS INSTRUCTIOlSr During the first term the several nutrition classes met for weekly half hour class sessions in the eye clinic room. As several classes of the same grade exist in P. S. 64, each of the nutrition groups was recruited from children belonging in more than one class-room. Thus many members were strangers to each other and this fact, together with the unaccus- tomed room and special teachers, was partly respon- sible for the formality and restraint which char- acterized the class sessions at first. The average age range was sufficiently limited to make a similar pro- * See Appendix C. 46 HEALTH EDUCATION cedure feasible for all the groups with the exception of the first grade. For them, however, the type of class instruction employed was quite unsuited and beyond their ability to comprehend. Though they did acquire a conception of the chart and its meaning and a few outstanding facts concerning health habits, relatively little was accomplished during the term toward developing methods better suited to their years. At first the conduct of the class devolved on the physician, Dr. Emerson at the beginning, and later Dr. Henry J. Schreiber who assisted him. The individual charts were arranged on the wall facing the class, in the order of greatest gain for the week, and each child was seated before his own chart. Thus the distinction of "head" and ''foot" of the class was made prominent, and any mothers pres- ent were seated, each behind her oaati child, with the view of further emphasizing the idea of success and failure. The subject matter of the lessons was chiefly derived from consideration of the individual charts, and the conclusions to be drawn from the relative gain and loss they indicated. Interpreta- tions were supplemented by the nutrition worker's notes made at the time of the weekly weight taking. There was also discussion of related informational matter. Nutritional standards, the significance of measured feeding, the value of milk and cereals, the bad effects of tea and coffee, food habits and general health habits were thus presented to the children's attention in their direct bearing on their own phy- sical welfare. Special deductions and recommenda- tions in regard to individual children resulting from this class discussion were noted, and repeated later THE INITIAL PROGRAM 47 to the child or his mother by the nutrition worker. It will be evident that little opportunity was afforded the physicians for special planning of the day's discussion in advance, as they were under the necessity of receiving the material for discussion from the nutrition worker at the time the class as- sembled. Such a situation invariably results in much repetition, and relatively little opportunity for developing the possibilities of the subject matter. It is the usual procedure where the class method has been adopted for clinic use, and this first term might well be called the "clinic stage" of our class proce- dure. The problems arising as well as the techniques employed are, we believe, fairly characteristic of the usual clinic experience. The limitations disclosed, so far as they concern the enlistment of cooperation from the children, were inherent in the situation and arose first from the unequal physical endowment of individuals and consequent inability to accom- plish results in direct ratio with effort, secondly from the inequality of home facilities for coopera- tion which contributed in increasing measure to the workers' sense of injustice toward certain children. In addition, there was the inaccuracy of home rec- ords and the attendant difficulty of exercising proper judgment in regard to a child's veracity. Every at- tempt on the school's part to secure data from the home is more or less subject to this difficulty and the possibility of encouraging inaccuracy or even conscious deceit is a serious one. In addition to these difficulties others arising from faulty techniques should be mentioned. The use of competition was certainly questionable in view of the 48 HEALTH EDUCATION fact evident to all, that often conscientious children failed to gain as much as others who were careless or lacking in interest. The discouragement felt by the individual who could not approximate his normal weight line, was only increased by the introduction of the competitive idea, and the arrangement of the charts each week in the order of weight increase with the best record at the "head of the class." The appeal to future benefits to be secured, as a "place on the ball team in high school," was also employed, although generally recognized by the modem school of teaching as insufficient for enlisting continued cooperation from the average child. Half an hour for discussion of the kind involved, in a class of 20 to 25, led to hasty and occasionally to false deductions as to causes of failure, the injus- tice of which was deeply felt by the children con- cerned. But the didacticism and formality of the class procedure effectually prevented remonstrance or explanation in such cases, especially as the center- ing of attention on the chart made for self-con- sciousness. The impressions of a teacher who made a number of visits to the several classes may well be quoted here : ' ' The children clearly showed self-consciousness; their attitude was a listening one ; they seldom had a chance to say anything except in reply to direct questions. They were talked to rather than with; the latter takes more time, but does it not make for a greater feeling of responsi- bility, less direct adherence to direction and more thinking out, less mere cure and more growth of judgment? Moreover, much of the talk is for each child a repetition of what the nutrition worker has THE INITIAL PROGRAM 49 already gone over with him, when she weighed and measured him and made his diet list. It must seem to him unimportant, except to make him conspicuous, with the attention of the doctor and others focussed on him. Do we wish him to like this? The social element seems unnecessarily left out. Should not public discussion be reserved for topics of common interest, topics of an interest that is clearly common to all of them, something that cannot seem an ex- ploitation of individual ailments? After all it is not a difference of subject, but of approach. Health rather than cure should be the function of a class- room talk.*' Statistical Data and Interpretations GROUP SELECTION Eight hundred children of the four grades selected were weighed and measured with the results shown in Table I: TABLE I* ReSTTLTS of MEAStTREMENTS, CHILDREN OP FoUR GRADES Grade VII Grade VI Grade V Grade I Total Total number 7% or more imderweight. . . Per cent underweight 173 25 14.4 245 39 15.9 127 27 21.3 255 43 16.9 800 134 16.8 • The computations of statistical data and charts appearing in this chapter and the next were made by Dr. David Mitchell and pub- lished in The Pedagogical Seminary, March, 1919 and March, 1920. They are reproduced here by courtesy of the editors. 50 HEALTH EDUCATION At no time was the attempt made to weigli and measure the entire school population, as P. S. 64 enrolls approximately 3000 pupils and from the first it was our purpose to work intensively with a relatively small number of children. In so far as these four grades may be considered to represent a cross-section of the school population at the begin- ning of our work in February, 1918, the above aver- age, 16.8%, approximates the average of children 7% or more underweight throughout the school at that time. The children of the Terman and open-air group are not included in the above cross-section, as they cannot be considered representative of the average since they were drawn from two specially selected groups. Eesults of the initial weight-taking in these two groups and comparison with the results in the regular grades are shown in Table II. TABLE II * Results op Measubements, Special Classes and Regular Grades Terman Open-air Grades Total Total number 69 19 27.5 25 7 28 800 134 16.8 894 7% or more underweight Per cent underweight 160 17.7 * For distribution table of the total niunber weighed see Appen- dix A, THE INITIAL PROGRAM 61 COMPAKATIVE RESULTS IX WEIGHT INCREASE Of the total 160 children found 7% or more Tinder- weight, 105 were enrolled in nutrition classes. Twenty more were included in the group of fifth grade boys given the mid-day dinner. The results of the experiment in terms of weight increase for the several groups after nineteen weeks are given in Table III. TABLE III * Comparative Weight Increase of the Several Groups after 19 Weeks Nn Pounds Normal Net Gain Percentage Group Enrolled Total Expected of Normal Gain Gain Gain 7th grade 23 72 64.8 7.2 111.1 6th grade 28 109 89.9 18.1 120.1 1st grade 26 55.7 40.5 15.2 137.5 Terman 17 61.6 43.2 18.4 142.6 Open air 11 105 13.7 23.4 - 9.5 59.1 5th grade 20 6 23.2 -17.2 25.9 * The estimates of normal expected gain were calculated in the accepted way from the average yearly increase as given in the Burk- Boas table of normal weights. That is, a proportional increase for the period (19 weeks) was estimated on the basis of a supposed steady increment in weight from month to mouth throughout the year. Thus if the normal annual increase for a 12 year old boy of a certain height is 8 pounds, in nineteen weeks he would be ex- pected to gain approximately 3 pounds. In view of subsequent find- ings as to seasonal variation in weight increase (see p. 127) it will be apparent that the normal expected gain for fractions of a year cannot be so simply determined, and that the results in the given tables, except for the total number of pounds gained, have been seriously undercut. They are included here, however, because they still afford a basis for assessing the comparative results obtained in the different groups. 52 HEALTH EDUCATION Comparison of the weight increase for these groups with variations in their several programs is shown in Table IV. TABLE IV * Comparison of Variations in the Several Programs and Results IN Weight Increase Results in Group Physi- cal Care Instruc- tion Rest Lunch Dinner Fresh Air Lighter Pro- gram per- centage of Normal Gain Terman * * * * * X X 142.6 Ist grade * * X * X X X 137.5 6th grade * * * * * X X 121.25 7th grade * * * * X X X 111.1 Open air * * * * X * * 51. 5th grade X X X X * X X 25.9 (* = Yes. x = No. ) INTEKPRETATIONS While only tentative conclusions are possible owing to the small number of individuals in each of the groups discussed, certain interpretations can be offered in connection with these tables. The most striking fact recorded is the apparent failure to secure results in weight increase that are directly attributable to the school feeding program. From Table IV it is evident that some children, to whom the mid-day dinner of 1000 calories was served, gained considerably less than others in whose pro- gram it was not included. While the greatest aver- age percentage of gain was made by the Terman class who received both mid-day dinner and mid- morning lunch, the average gain made by the first grade was nearly as great, yet no dinner was at- tempted for them. The fifth grade children whose THE INITIAL PROGRAM 53 program was limited entirely to the mid-day dinner, show the least satisfactory results, as they lost weight steadily through the four months of the experiment. These results are not surprising in view of the problems attending the mid-day dinner. As has been already indicated (p. 42) the children were afraid of unaccustomed food and used to high sea- soning. Thus they did not find the meal appetizing and they were not hungry enough to eat what they did not like. Had the period of the experiment been a longer one, a greater degree of cooperation might have been secured from them as a result of the pro- gram of instruction. How far the results to weight increase would have been augmented, however, re- mains a speculation. Aside from demonstrating some practical difficulties of a school feeding pro- gram, our results for the mid-day dinner are quite inconclusive. As mid-morning lunches were served to all the children with the exception of the fifth grade, we must look to other factors for the interpretation of the relative gains shown by Table IV. The distinguishing feature of the Terman group is its intelligence (measured by a special standard) and this may be supposed to have made the instruc- tion given it more effective. An intelligent over- control of the environment by adults is one of the goals set by our attempted program. To such an over-control the intelligent self-control of the Ter- man group might be said to approximate. The eager-minded and participatory attitude of these children toward all their school activities, ensured 54 HEALTH EDUCATION better cooperation on their part than could be ob- tained from children of the regular grades. Thus intelligence in the group, or in direct application to the control of the group, is suggested as one ex- planation of the satisfactory results they achieved. It is also probable that as a group the chief causal factors of their underweight were of a nature cal- culated to permit ready response to an improved regime. It is quite possible that the Terman children were underw^eight largely because of an increased metabolism, and that their ability to respond to im- proved conditions of food taking, rest and fresh air was therefore proportionately better than that of individuals in the other groups.* Second only to the gain made by the Terman class is the record of the first grade children, yet their pro- gram included only the provisions for physical care and instruction and was considered by members of the staff the least satisfactory of any afforded. Because the program of instruction was ill-adapted to their age period, increased necessity for co- operation from the home was felt by the staff, and therefore much greater effort was made to interest the mothers and secure their attendance at the class sessions. Our efforts were reinforced by the greater readiness of parents to maintain intelligent control and lend cooperation to special efforts on behalf of young children. Thus better environmental control was secured for this group than we were able to secure for the others, and the special factor of in- * See Burnham, Wm. H., The Metabolism of Childhood, Pedagogical Seminary, Dec, 1920, pp. 304-322. Where the hypothesis is pre- sented that the curve of learning is correlated with the curve of metabolism. THE INITIAL PROGRAM 55 telligence in the Terman group was paralleled, in the case of the first grade, by the factor of adult supervision. In addition, we must consider too, the readier response of little children to conditions affecting them for good or ill. This better ability of their age period to respond, again parallels the probable better ability to respond on the part of the Terman group. Intelligent control of the environment was less easily secured for the children of the sixth and sev- enth grades. It was not only more difficult to secure cooperation from the homes but, with children of their age, home cooperation was less effective, as many of them were quite beyond parental control. Moreover, it was far more difficult to enlist their own cooperation. This was especially true of the seventh grade in which there were a number of over-age boys, who had lost all interest in school activities, and were merely marking time, and waiting to take out their working papers. These big fellows consti- tuted an unruly element, and to a certain extent w^ere leaders because of their years and daring. Obvi- ously, their level of intelligence was inferior. Their cooperation w^as never successfully enlisted. The nutrition program w^as regarded by them as ''baby- ish," and the difficulties in discipline experienced in the lunch room and during the rest period emanated for the most part from them. The sixth grade group had also its quota of retarded boys, but they were proportionately fewer and the greater differences in physiological age existing between them and the younger members of their class rendered their influ- ence less disturbing. The comparative results ob- 56 HEALTH EDUCATION tained in these two groups, 120% for the sixth grade group and 111% for the seventh grade, seem to de- pend in the main on this factor of their personnel. The failure of the fifth grade to make gains is easily explained in view of the circumstances sur- rounding the mid-day dinner, and the additional fact that no attempt to enlist their cooperation by a pro- gram of instruction was made. It will be noted (Table I) that this grade showed the largest num- ber of underweights and as individuals they may have represented more serious problems of malnu- trition or of physical defect than did the other classes.* In addition, the age period of the average fifth grade boy offers a possible contributing cause. (See p. 23.) The only fact established by their place in the experiment is the failure of the school lunch to compete with a more comprehensive program. Like the fifth grade, the open-air group of this first year cannot be considered comparable to the others. It undoubtedly included incipient cases of disease and its members were probably candidates for a far more controlled regime than could be sup- plied through the school procedure. As it seemed impractical to send the members of this group to the eye clinic, class instruction was given them in their own room. As the rest of the class did not share in this, there was always a consciousness among them that they were on a different basis from the others, and a resulting lack of cooperation was probably a factor in their poor record. Although the program of school feeding plays no * No physical examinations were made or social histories taken for this group. After the initial height and weight taking they were merely given the mid-day dinner. THE INITIAL PROGRAM 57 part in our interpretation of relative gains made by the several groups, there can be little doubt that the actual gains made by the Terman, sixth, seventh, and first grade classes were due in considerable part to the mid-morning luncheons. It is also probable that the mid-day dinner afforded some re- sults for the Terman group, because of probable better and more intelligent cooperation on their part in this, as in other features of the program. PHYSICAL DEFECTS Naso-pJiaryngeal Obstructions. — A comparison of the 49 children who were recommended for tonsil and adenoid operation and failed to secure treat- ment, with the 32 children who were free from such defects appears in Table V. As the groups were not of equal size the percentages best indicate the rela- tive results. TABLE V Comparative Gains op Children without Naso-Pahryngeal Obstructions and Those Recommended for Operation With Obstructions Without Obstructions No. Per Cent No. Per Cent Lost weight 4 IS 24 3 8.2 36.7 49 6.1 1 9 12 10 3.1 Gained less than normal 28.1 Gained more than normal, 100% 1 to 37 Gained more than normal, 100% over 31.3 49 100 32 100 From this table it is evident that 55.1% of the children from whom these defects were not removed 58 HEALTH EDUCATION made gains in excess of normal while 68.8% of the children without such defects gained in excess of normal. The relative amount of gain must be noted, however, and the record of gains showing over 100% in excess of normal is only 6.17o for children having defects as against 31.3% for those without defects. A study of the gains made by 19 * of the cases operated for a period of five weeks before and five weeks after the operation is given in Table VI. In practically every case the child lost weight at the time of the operation and recovered it in about a week. The five-week periods are therefore separated in each case by a few intervening days in which this recovery was taking place. TABLE VI Per Cent Gain of 19 Children for Period of Five Weeks before AND Five Weeks after Tonsil and Adenoid Operation No. Before After No. Before After 1 2.4 1.4 11 -1.3 2.5 2 3.6 8.2 12 1.1 3.3 3 1.7 1.0 13 0.6 1.9 4 5 5.6 14 -0.9 3.4 5 -0.3 1.5 15 3.3 4.6 6 -1.3 3.4 16 5.8 -1.3 7 0.6 2.5 17 0.9 4.0 8 -2.8 5.8 18 -0,3 4.7 9 2.8 3.9 19 -1.7 1.5 10 0.9 6.4 Carious Teeth. — Of the entire group 88 were ex- amined for dental caries and 63 were found to have * One child of the 20 operated is not included owing to an attack of influenza following his operation. THE INITIAL PROGRAM 59 from 1 to 12 carious teeth. An attempt was made to correlate this defect with the degree of under- weight found, but this was unsuccessful. The re- sults of the study are given in Table VII. TABLE VII Comparison of Dental Caries and Average Percentage Underweight No. of Carious Teeth No Record 1 2 3 4 5 6 7 8 9 10 11 12 No. of children Average per cent un- derweight 17 10 25 10 21 9 12 S 9 13 8 9 3 10 3 10 2 16 2 10 1 13 1 9 1 13 Summary At the end of the first school term no spectacular gains had been made by the children enrolled in our nutrition classes. On the contrary, progress had been slow and discouraging. The results achieved in *' percentage of normal gain" fell far short of our attempted goal, and of the entire number en- rolled (105) only two had '^ graduated" by reaching the standard weight for their height and age. In the light of subsequent experience these results appear less disappointing and we can appreciate to- day that the standards used in making our evalua- tions were too high, as they were based on an '' ex- pected gain" in the determination of which no allow- ance for the factor of seasonal variation had been made. Not until two years later did our staff become aware of the importance of this seasonal factor and of its effect on previously accepted standards. But the complexity of our problem, and of the underlying 60 HEALTH EDUCATION causes and contributing factors of malnutrition had been pretty well revealed to us by June of the first year. The outstanding facts of the first five months' experience may be briefly stated as follows: The wide variations in response shown by the individual records had emphasized the importance of the child's physical status and home conditions in determining results. At the same time the relative gains of the several classes had brought into relief the depend- ence of success on the child's own cooperation and the necessity of better techniques for enlisting it. In comparison with these essential factors the dif- ferences in the various programs arranged were shown to be negligible. Better cooperation from the home, better progress in the correction of defects, more careful physical examination and diagnosis and a better class procedure were felt to be neces- sary lines of development, if we were to cope suc- cessfully with the problems involved. Certain limitations, too, were apparent in the chart forms and other records used during the first term. These had been copied from those in use at the Massachusetts General Hospital and were better adapted to gathering the type of material needed for purposes of clinical diagnosis than for collecting data for statistical treatment.* As a result of our experience in the first term's work we developed an * For similar difficulties experienced with physical examination records see Dewey, Child and Ruml, op. cit., p. 160, and Heron, The Influence of Defective Phi/sique and Unfavorable Home Environment on the Intelligence of Children, Galton Laboratory Memoirs VIII. 1910. ' THE INITIAL PROGRAM 61 individual record blank resembling in some re- spects that used by the visiting teachers of the city. The weight chart was somewhat modified as well to suit our particular needs.* * See Appendix B and C. CHAPTEE IV DEVELOPMENT OF PROCEDURE— GRAMMAR GRADES— SEPTEMBER, 1918— JUNE, 1919 Basis of Reorganization In organizing the classes for the second year, an attempt was made to develop our program in direc- tions calculated to secure better control of the envi- ronment and added opportunities for enlisting the children's cooperation, since the experience of the first year had emphasized the importance of these factors in securing weight increase. As no convinc- ing results in favor of the mid-day dinner had been afforded, it was decided to give up this feature of the experiment and to work more intensively along other lines. The work of the New York School Lunch Committee had been discontinued at the end of the previous term and their cooperation was no longer available. Without their aid an attempt to secure a hearty meal at school for any of our classes presented many difficulties beyond the increased ex- penditure of money and service involved. Dr. Emerson's belief, that such a meal though advan- tageous is not necessary to the success of the nutri- tion class program, was an influential factor in reach- ing the decision to discontinue it, especially since his opinion appeared to be confirmed by our data. 62 o DEVELOPMENT OF PROCEDURE 63 Viewed in the light of our subsequent experience and with the statistics for three consecutive years available, the decision to discard entirely so im- portant a feature of the program at so early a stage of the experiment now appears question- able. More serious, however, was the basis on which the new classes in the fall of 1918 were organized. Not one of these will be found strictly comparable to any of the groups organized in the previous year. Thus the advantages to be gained by continuing to set up really comparable groups within a single experiment, and at the same time incorporating new features of treatment, were largely lost at P. S. 64, and the statistics gathered in the three successive years hardly lend themselves for purposes of comparison. Two types of influence were responsible for the changes which so seriously affected our program of research : on the one hand the advisability of conforming to the practical situ- ation and modifying plans in accordance with ad- ministrative and financial considerations, on the other the temptation to sacrifice the statistical re- quirements for possible benefits to the individual child. The organization of the classes in the fall of 1918 exhibits the latter influence very clearly. Any such undertaking as ours must inevitably experience the pressure of influences in these two directions, and workers should realize that so far as they find it inadvisable to carry out a consistent program on the basis of verifying and expanding previous experi- ence and accumulating comparable data, the possi- bilities for much-needed research are endangered. 64 HEALTH EDUCATION GROUP SELECTION From the viewpoint of benefit to the individual our first need in the fall of 1918 appeared to be pro- vision for those children who had been in our classes the year before and were still underw^eight. With a view to securing the best environmental conditions available for them Dr. Louis Marks, the Principal of P. S. 64, arranged for two open-air classes, one for sixth and seventh grade children, the other for those of the fourth and fifth grades. In these were enrolled members of the nutrition groups from the fifth, sixth and seventh grade and open-air classes of the previous year. To these were added a number of boys from the same grades, selected at the open- ing of school as conspicuously underweight. There were also a few pre-tubercular cases for whom the school had to provide open-air facilities. Thus the two open-air classes presented the special problems of a higher average underweight, and a more or less chronic condition of malnutrition, as shown by fail- ure to respond to previous treatment. A third class w^as recruited entirely from fifth grade boys whose average condition as to under- weight was not serious. This group was selected with a view to developing an educational procedure under usual class conditions, and determining how far the borderline and low percentile cases would respond to such a procedure. It was hoped results w^ould show that by making special provision for the more serious cases, a school could secure satisfactory results for the majority of its underweight children, through further development and adaptation of the nutrition class program to typical school conditions. DEVELOPMENT OF PROCEDURE 65 The choice of fifth grade children for this ex- perimental group was determined partly by the un- satisfactory showing of the fifth grade in the pre- vious year, partly by considerations of administra- tive convenience. ADMINISTRATIVE ADJUSTMENT Dr. Marks' decision to form entire classes of un- derweight children was a distinct gain to our pro- cedure, as it made possible the development of an esprit de corps among the class members that was impossible as long as they were distributed amon^ the different classes of their grade, and assembled only for the weekly sessions in the eye clinic room. Class instruction for the open-air groups was of necessity given in their own class-rooms, and at mid- year the same plan was adopted for the fifth grade boys. Thus the eye clinic came to be used only for measurements, examinations and individual in- terviews. The conduct of the weekly class sessions was given to the two nutrition workers who now as- sumed this responsibility in addition to their pre- vious duties.* Physical Care This change made for efficiency in the program of physical care, as the physician's time could now be devoted entirely to the physical examinations and diagnosis, and to individual interviews, when it seemed necessary to true up the findings of the nutri- tion worker or give special advice. The added au- * The subsequent developments in teaching methods, and techniques for better enlistment of cooperation from the children and from the homes, were made under the direction of Miss Harriet A. Forbea. 66 HEALTH EDUCATION thority of any recommendation from the doctor was always evident and could be relied on for securing additional emphasis when necessary. Results obtained in the correction of defects showed an appreciable gain over those of the first year.* Tonsil and adenoid cases were treated at the Metropolitan Hospital. The treatment of dental caries was continued conscientiously but progressed slowly owing to the inadequate provision of clinics for the purpose. Had it not been for the interest and kindness of a skillful and busy dentist in prac- tice, Dr. H. A. Koonz, who treated many of our children without a fee, it would have been impossible to secure dental treatment for them. Cooperation of the Home In spite of the failure of parents to attend the class meetings of the previous year, we continued to urge them to be present in the belief that our work would gradually enlist interest and better coopera- tion, as the individual families and the community at large became more fully aware of its significance. Our attempts to secure their attendance continued all through the second year of the experiment, but as time wore on and our realization of the need of home cooperation increased, we were led to increase the number of home visits considerably. The better to enlist the mother's interest a miniature copy of the child's weight chart was taken by the nutrition worker on these visits and carefully explained to her. Frequently during such a visit the nutrition * See p. 87 (statistical data). DEVELOPMENT OF PROCEDURE 67 worker was able to persuade the mother to prepare cereal and to serve smaller portions when trying to establish the habit of eating more nourishing food; or she was encouraged to make greater effort to pre- vent late hours, and in various other ways to give her aid to the experiment. Almost invariably we found her keenly interested in her boy's health, and fre- quently the cooperation given was invaluable. A spe- cial problem of the nutrition class program is the difficulty of assessing the accuracy of the children's statements concerning their home regime. Facts gathered during the home visits served as a check on the child's reports as to his habits and were used to corroborate them or the reverse. Where testi- mony was conflicting, that bearing the best indica- tion of good faith and accuracy was taken. Fifth Grade Class ENVIRONMENT Except in the extreme winter weather the windows of the fifth grade room were kept open. The boys wore their outdoor sweaters and coats, and enjoyed the fresh air. Rest periods were arranged during the morning session, the children remaining seated with arms and heads on the desks before them. In- struction in relaxation was given in connection with these attempts at conserving energy, and a certain success was achieved, though with boys of this age the problem was difficult, and five minutes of real relaxation was almost as much as could be secured in a fifteen minute period. The children were urged to bring mid-morning lunches from home and a reg- ular time was arranged for eating them. The at- 68 HEALTH EDUCATION tempt to secure home cooperation in the provision of these hmches was never more than partially success- ful. Failure to supply them was frequent, and those brought averaged much below the caloric value pre- scribed (250-300 calories). Often a small apple or an unappetizing roll would be their only constituent. MOTIVATION Every effort was made to enlist a spirit of coop- eration among the children sufficient to ensure the carrying out of the health program at home. As has been stated, the change in class organization was a gain in this respect, and a further advantage resulted from the decision reached at mid-year, to hold the class instruction sessions in the regular class-room instead of the eye clinic room. The familiarity of the surroundings, better acquaintance between the members of the class and the presence of the class teacher, the resulting informality and closer identi- fication of the procedure with usual school interests and attitudes, all contributed to establishing a class spirit. The idea of competition between individual members of the class was dropped, and children were urged to exceed their own previous record instead. A significant change, too, was made in the chart where the normal weight line was supplemented by the ''line of expected gain" for the individual, the two together forming a zone within which progress could be considered achievement.* By this device some discouragement on the part of those who could not approximate the standard of normal weight for height was avoided. At the same time the use of * See Appendix C. DEVELOPMENT OF PROCEDURE 69 the colored markers in connection with the charts became more evidently one of records rather than rewards. The familiarity of the nutrition worker with the weekly records, and the facts of home en- vironment and individual history, made possible more careful interpretation of the charts, at the same time that discussion of them was made briefer and more impersonal. These changes in class-room technique made for increased effectiveness in securing the cooperation of the children. An additional stimulus was furnished by giving the boys some realization of the meaning of the class as an experiment. They were interested to feel themselves part of a serious investigation of the means by which the percentage of underweight in their school could be reduced. That they really grasped something of their own place in the experi- ment and of its social significance, was evidenced by the increased care with which they made their weekly reports as this conception became clearer. The question may well be raised how far such a special appeal can be regarded as legitimate in an educational experiment. Certainly any successful results obtained are less convincing for a general program because of its use. Whatever response may be secured from an individual group by keeping before them the fact that they are pioneers, and that the future of others depends on their record of suc- cess or failure, the necessity of securing no less active cooperation from succeeding classes must be kept in mind. The work was started late in November. By mid- January an attitude of habitual participation and 70 HEALTH EDUCATION ease of manner during discussions was manifest, and there was no sign of the self-consciousness noted the previous year nor of the clinical atmosphere. SUBJECT MATTER If the teaching of the nutrition workers was less authoritative than that of the physicians, it was also less didactic and more stimulating to the child's own thinking. An aim kept constantly in view was to lead discussion away from the individual records and consideration of the charts, to topics emphasiz- ing health and constructive suggestions for living habits, not only for the class but for their families and the community. This resulted in the develop- ment of a considerable program of subject matter which proved full of interest for the children. The content involved is shown in the f ollomng summary, derived from the class discussions for a period of 28 weeks. Subjects were reviewed repeatedly with no apparent loss of interest, and a new fact was re- ceived with absorbed attention by the majority of* the class. Correct weighing and care of scales. The nature of an experiment — its social value — the scientific atti- tude of mind. What constitutes good nutrition. The calorie — a unit of heat. The uses of food: As fuel — for heating the body. As fuel — for maintaining the internal activities (respiration, cir- culation, etc.). As fuel — to produce energy for all kinds of work and play. As fuel — for reserve energy, storage for emergency uses. For repair. The significance of measured feeding. DEVELOPMENT OF PROCEDURE 71 The value of certain foods — milk, cereals, vegetables, fruits, meat, eggs. The nature of habit formation. Food habits. Other factors in promoting good nutrition — fresh air, rest, exercise. Prevention and treatment of physical defects. Care of the teeth. Effect of tonsil and adenoid obstructions. Eye strain. It took several weeks for the children to get a working knowledge of caloric values, and to under- stand not only the term but the significance of the body's fuel needs. The dramatic storj- of the college boys whose willing immolation in the calorimeter made them heroes in the minds of the class, was used as the starting point of this interest. The idea of measured feeding followed naturally, with the con- ception of food as fuel and a source of energy for the human machine. The need to regulate the supply as the engineer does for his monster of iron and steel was also evident. Then followed special uses of dif- ferent foods and the relative values of those found in their own dietaries or available for them. Wax models showing 100 calorie portions of suitable breakfast dishes were secured, to assist in the inter- pretation of caloric values in terms of daily experi- ence, and to demonstrate a few menus for the ideal breakfast. On one occasion several children from the open-air classes were taken for a trip to the Post-Graduate Hospital, where a very complete ex- hibit of this kind is to be seen, with a view to helping them estimate more accurately the caloric value of the food portions served them at home. Samples of real food were occasionally used in 72 HEALTH EDUCATION conjunction with the wax models for this type of illustration. Mention was made of acquiring proper food habits, and at one lesson a psychologist was present, and explained habit formation to the class. This talk was frequently referred to by the children afterwards. Incidentally, some important conceptions of the value and interest of work done in the scientific spirit, and of the exactness required in carrying out the details of scientific work were gained. In the study of pure milk, for example, each child could get a picture of the interrelationship of the processes involved in getting milk from farm to child consumer, and could feel the disastrous effect of failure on the part of any individual to perform his part conscientiously. Their interest in facts and changes recorded on charts other than their own was indicative of this budding scientific spirit, and as the year progressed the class discussions increasingly reflected it. The boys would gather around the charts eagerly talking about the gains and losses in a surprisingly impersonal tone. The assertion of a boy on one occasion, "When I drink milk I don't gain ; when I drink coffee I do, " was met by a chorus of exclamations and demands for an explanation. During a discussion of the plan to give a demon- stration in the auditorium, one boy volunteered the suggestion that all charts should be shown whether good or bad. This was talked over pro and con as to its usefulness, and no one suggested that his chart should be omitted. This auditorium program took place late in the year and was arranged by the class at the sugges- tion of the principal. It was sufficiently successful DEVELOPMENT OF PROCEDURE 73 to bring a request from the teachers that a regular auditorium period be taken over by the nutrition classes. The wax food models were shown and ex- plained by the boys, as well as several of the weight charts, two from the fifth grade, and two from each of the open-air classes. The boys who had secured treatment for physical defects then marched on the stage in two groups, and a spokesman explained what they had done to become better fit. The few stories introduced in the class work were true ones. Interest in Roosevelt and his determina- tion to overcome his weakness of body was keen, and Horace Fletcher, w^ith his ideas about eating, w^as well received. On several occasions a visitor re- corded portions of the class discussion to which she listened, and the following quotations from her note book are of interest in connection with the problem of home environment : ' ' My baby leaves out his milk, but now I make him drink it. " ' ^ My sister goes to bed earlier. " " My big brother didn't believe in eat- ing slowly, but he tried it and he gained." "Now I get my brother and sister to eat the same things.'* In the month of May the boys were asked to write compositions on the value of the Nutrition Class and urged to tell exactly what they thought of it, ''for and against. ' ' About one-half of the 33 papers were against the class, largely because of the ''bother of tonsil operations." Rest was also referred to many times as perhaps the greatest "bother" of all, re- quiring much self-control and resolution to put through. The compositions in general are note- worthy for their sincerity and freedom of speech, in decided contrast to what is usual in the class-room. 74 HEALTH EDUCATION Even where disapproval is expressed, as in the fol- lowing excerpt, we can realize that the writer had gained something from the experience: '*I like to go to bed late and I like to eat fast. I donH like the idea of the calories. The nutrition class is good for those who like it." A more submissive spirit tells us: *'I used to take a roll and run out in the street and play. Now I learned to eat a roll and sit down by a table and have more a joyable time." The following quotation shows the common attitude of the boys when they were in the class-room : ''I am in the nutrition class and I think I am here long enough to know whether it has helped me or not. When I was not in the nutrition class I did not know that I ought not to drink tea or coffee. I know enough to go to sleep early and try to take rest periods or lunch periods and know nearly everything that Avill make me gain." ESTIMATE OF METHODS It will be recalled that the program developed for this group was undertaken to determine how far results could be secured from the nutrition class under typical school conditions. For this reason the type of class instruction used presents several fea- tures for special consideration, and well illustrates the possibilities and limitations of health teaching under the conditions imposed. It will be evident that the socialized recitations with their appeal to group psychology, effectively secured the interest of the children, whose enjoyment of the weekly discus- sions, and increased facility of expression and ease of manner as the year progressed, were noted DEVELOPMENT OF PROCEDURE 73 by all who observed them. Partly because of these conditions, partly because of the natural interest nearly all children feel for the subject matter covered, it was possible to present it always in its scientific aspect and from the ''work level '^ approach. The class instruction used will be recognized as the best of its kind and, as an informational procedure, was highly suc- cessful. The subsequent record of the children affords evidence that it was fairly successful also, in establishing a creative attitude on their part toward the problem of health. As a weight-getting and habit-forming program, however, it undoubt- edly left much to be desired, and in this respect its limitations were the limitations incident to the usual public school environment, when equipment and fa- cilities for radical readjustment of existing condi- tions are not provided. We may well ask ourselves what might have been the results in weight increase, had mid-session luncheons or a mid-day dinner and rest facilities, similar to those provided for groups in the previous year, been arranged for these chil- dren, whose cooperation and interest had been so effectively appealed to, and the causal factors of whose underweight were, for the most part, of a less serious nature than in the case of other groups con- sidered. Open-Air Classes ENVIRONMENT The open-air classes throughout the school system are designed to provide special conditions to meet the needs of children handicapped because of tubercular 76 HEALTH EDUCATION diathesis, anaemia or serious malnutrition. Children suffering from various other maladies of a nature which does not exclude them from school, easily drift into these classes, so that in the minds of many chil- dren they have become identified with the idea of sickness and ill-health and to a certain degree carry a resulting stigma. As existing in P. S. 64 they presented the follow- ing points of distinction from the rest of the school: a sunny room with windows adjusted in order to swing and be open the year around, army cots with blankets or sleeping bags for daily rest periods, movable desks and chairs, mid-morning luncheon, a bonus for the teacher in order to secure a woman with special social and technical qualifications. With such a modification of the school environment, and with health rather than school progress the goal before the class, there is an inevitable slowing down of the usual speed in class-room procedure, with a consequent gain in informality, all of which is obvi- ously of benefit to the child, and in close accord mth the ideal program for the nutrition class. In the two rooms placed at our disposal, therefore, we had only to make use of features already existing, the daily rest period with the children lying flat on the back for three-quarters of an hour, sleeping when possible, but always remaining quiet in a recumbent position, and the mid-morning lunch which was served in the class-room. In the open-air rooms the need of extra nourishment, especially in winter weather, is always recognized, and lunches for them have been regularly supplied at P. S. 64 through outside subscription. DEVELOPMENT OF PROCEDURE 77 During the coldest weather oatmeal or farina with milk was served and taken generally with relish, although appetites for the most part needed tempt- ing in these particular groups, and it was found necessary to vary the luncheon as circumstances per- mitted. Hot cocoa was sometimes substituted for the cereal and milk. The cooking was done by one of the teachers on a small gas stove in the teachers' lunch room; and a fireless cooker was available, thanks to the teacher of one class, who had been suf- ficiently energetic to have it made by one of the boys in the school shop. In warm weather a good grade of bottled milk was served, also bread and jelly sandwiches, or bread and jam. With the facilities at her disposal the serving of even these simple lunches was something of an achievement for the class teacher Any educational possibilities incident to the selection, purchase, and preparation of them could not be made available for the children under the circumstances. The actual serving and eating, however, presented opportunity for a certain training in food habits, and for discus- sion of caloric intake and food values, while the group example doubtless played its part in helping individuals to cultivate a taste for milk and cereals. INSTEUCTION The open-air groups offered less opportunity for the development of class discussions and subject matter content, because of the shorter lesson periods arranged for them. A special feature used by the nutrition worker in these classes was a small indi- vidual chart which the child himself prepared at his 78 HEALTH EDUCATION desk and took home with him, being thus enabled to discuss his record with his family from week to week. A unique use of stories was made by this worker, who finding the boys in the lower class familiar with and fond of some of the wonder book tales, retold The Golden Touch and the story of Penelope, the boys maldng their own applications, in the case of Midas sufficiently evident. Penelope, who unravelled at night the work of every day, was compared td those children who undid the benefits of fresh air during their school day by sleeping with closed win- dows at night. Statistical Data and Interpretations GROUP SELECTION Open-Air Classes. — Of the 48 children enrolled in the open-air classes, 29 had been carried over from the nutrition classes of the previous year for failure to respond to treatment. Of this number 12 presented special problems and, although they were seriously underweight, no satisfactory diagnosis of the causes for their condition was made in the two years they remained under our care, nor did. they make gains in spite of their own sincere efforts at cooperation, the enlistment of their parents' interest, and the best efforts of our staff. Sixteen of the class, one-third of the total enrollment, were pre-tubercular cases and, while a number of these were not seriously underweight, they contributed their quota to the difficulties of securing gains. The remaining mem- bers had been enrolled because they were conspicu- ously underweight. Table VIII shows the distribution DEVELOPMENT OF PROCEDURE 79 of percentages underweight for these groups at the initial weighing in September, and again at the final weighing in June. It will be seen that just half of them were seriously underweight, above 11% for height, and only 13 of the 48 were low percentile cases. The results at the final weighing show a slight approximation to normal. Open-air Classes: TABLE VIII Distribution of Percentages Underweight AT Different Dates First Weighing Final Weighing - 3 - 5 5 - 5 - 7 2 - 7 - 9 13 7 - 9 -11 11 11 -11 -13 6 « -13 -15 10 7 -15 -17 3 5 -17 -19 2 2 -19 -21 3 1 48 48 Fifth Grade Classes. — ^Five classes of fifth grade boys, 223 pupils in all, were weighed and measured and of the total number 74, or 23.19% were found 7% or more underweight. Of this number 13 were placed in the lower open-air group, and 39 were enrolled in the fifth grade nutrition class, measure- ments being taken with indoor clothing and without shoes. Owing to various delays, the Liberty Loan drive in which the older children were active, and the epidemic of Spanish influenza, which disorgan- 80 HEALTH EDUCATION ized the schools for a period, this class did not begin its sessions until nearly seven weeks after the initial weighing, when it was found that 22 of the number were no longer 1% underweight. Table IX gives the distribution of their percentages underweight at the initial weighing in the latter part of September, and again at the first class meeting in November when, as may be seen, 12 individuals were found to be between 5 and 7% underweight and 10 more were from 1 to 5% underweight. TABLE IX Fifth Grade Class: Distribution of Percentages Underweight AT Different Dates Percentages First Weighing First Class Final Weighing 3 1 1 1 - 1 - 1 - 3 1 1 - 3 - 5 9 - 5 - 7 12 2 - 7 - 9 19 8 8 - 9 -11 11 4 5 -11 -13 4 1 6 -13 -15 4 2 7 -15 -17 1 6 -17 -19 1 1 5 -19 -21 2 Total.... 39 39 43 These unexpected graduates afforded the spec- tacular element in the year's record. It will be re- called that of the total enrollment (105) in the pre- vious Spring, only two were ''graduated" in the course of 19 weeks of serious effort to provide a DEVELOPMENT OF PROCEDURE 81 corrective program. Now by contrast, we had 22 ready to "graduate" from a group of only 39 after a term of seven weeks and before any program of care or instruction had been begun. Not until the publication, eighteen months later, of Dr. Porter's* statistics on seasonal variation was a satisfactory interpretation offered. For although the fall has long been recognized as the probable season of maxi- mal weight increase, no previous study has shown how large a percentage of the total annual incre- ment is involved in such variation. In the light of Dr. Porter's investigation our spectacular feature appears easily accounted for. Heavier under-cloth- ing at the second weighing in November probably proved a contributing factor, but it is not sufficient of itself to provide an explanation. Since it was impractical to reorganize the class, all school arrangements for the term having been made, and the usual school program being more or less seriously delayed already by the unusual con- ditions attending the influenza epidemic, these 22 children remained in the class. The final approxi- mation to normal weight and its distribution is shown in the last column of Table IX. Here the effect of Dr. Porter's season of minimal weight in- crease seems as apparent as that of the season of maximal increase in the results for the period of the first seven weeks. Less spectacular perhaps, it proved far more disconcerting to the workers con- ducting the experiment. Comparing the first weigh- ing with the final weighing, the cases are found to * Porter, Wm. T., Seasonal Variation in the Growth of Boston School Children, American Journal of Physiology, May, 1920. 82 HEALTH EDUCATION be more uniformly distributed but no decided ap- proach to normal is shown. Control Group. — A Control Group of 35 children who were approx- imately of average weight for their height was selected at the time of the first weighing, with a view to studying the variability exhibited by normal chil- dren, for the light it might throw on problems of CoNTEOL Group: TABLE X Distribution op Weight Percentages at Different Dates Percentages First Weighing Second Weighing Third Weighing 12 1 11 10 9 1 8 1 7 1 6 4 6 2 1 4 1 1 3 4 3 2 2 3 3 4 1 4 4 6 5 6 -1 4 3 3 -2 7 1 3 -3 7 3 -4 1 -6 1 1 -« 3 -7 1 -8 1 -9 1 8 5 35 27 DEVELOPMENT OF PROCEDURE 83 underweight, especially in regard to the discrimina- tion of temporary and chronic cases. A study of mental ability in underweight children which formed part of our program demanded similar data derived from well-nourished children for purposes of com- parison. Table X shows the results of the measure- ments for this group taken in the fall, in February at the beginning of the second school term, and in the first week of May. Unfortunately, at this third weighing 8 of the children could not be secured, so our results are for 27 instead of 35. At the first weighing all the children were within 3% of aver- age weight for their height, at the second weighing they varied from 97c under to 12% overweight, and at the final weighing the 27 children measured ranged from 8% underweight to 5% overweight. A marked variability is thus apparent, first in the general direction of gain, only two falling below the original minimum (—3%) for the entire group, later a very general trend in the direction of loss is apparent. It will be seen that the history of the Control Group exhibits the same general features as to variability shown by the Nutrition Groups and further confirms Dr. Porter's findings. EESIILTS IN WEIGHT INCREASE The comparative results achieved by the open-air and indoor groups are shown by Chart A, where the shaded column represents the fifth grade classes and the plain column the open-air classes. The base line indicates the periods for which results were cal- culated: A the first seven weeks, B the first twelve weeks, C after nineteen weeks, and D the final re- 84 HEALTH EDUCATION 380 ' .a«o 93Q 300 480 1 160 1 140 1 i 130 IDA .......... i i m ////// 1 m i i P i y//A P 1 13 B 19 C 30 D CHART A Comparative Gains, Fifth Grade and Open-air Classes DEVELOPMENT OF PROCEDURE 85 suit, after twenty-seven weeks for the fifth grade and thirty-two weeks for the open-air classes. The height of the columns shows the average per cent of gain. It will be seen that the open-air classes in the first twelve weeks increased 274:% of the nor- mal gain, whereas in nineteen weeks their increase was 125%, and in the entire period 111%. The first and final difference is not so great for the children of the fifth grade classes. In the first seven weeks between the original weighing and the first meeting of the class, the average gain in relation to normal was 208%. In the first twelve weeks it had decreased to 156% and was approximately the same at nine- teen weeks, but for the entire period it was only 106%. The percentage of gain for the fifth grade class from week to week is shown in Chart B, the base line indicating weeks, and the figures at the left percentage of gain. The chief interest of this record is the fluctuation shown in parade week and again in promotion week. The loss incidental to the ex- citement and strain of examinations is approxi- mately 0.6%. The gain for the entire period of twenty-seven weeks is approximately 9%. Our attempts to find correlation between the per- centage of gain and such features of our procedure as caloric intake, the number of rest periods ob- served, the number of lunches taken, were unsuccess- ful. With data gathered from a larger number of individuals it might have been possible to establish clear cut correlations but even so the evidence as to the value of any one of these taken by itself would hardly be convincing — such testimony would indi- 86 HEALTH EDUCATION 10 to so 40 3.0 XHAS TTIO MOTION 10 15- 20 2? CHART B Percentages of Gain from Week to Week — Fifth Grade Class Note. — The fluctuation sJwvni in the eighteenth week coincides with the date of tht parade by which the return of the city troops was celebrated. DEVELOPMENT OF PROCEDURE 87 cate rather their value as contributing factors to the results obtained by the general regime. PHYSICAL DEFECTS Naso-pharyngeal Obstructions. — Thirty children, or 35% of the 87 enrolled, were recommended for re- moval of naso-pharyngeal obstructions, and of these 23, or 76.6% of the number recommended, had opera- tions arranged for them in the course of the year, although the conditions incident to the influenza epidemic delayed the treatment in all but two cases until early Spring. Any resulting benefits therefore cannot have played an appreciable part in the class record of gains for the year. Of the 30 children recommended for operation, 13 were from the open-air group and represented 27% of their total enrollment. This relatively low per- centage of naso-pharyngeal defects among the group of high percentile, chronic underweights was partly accounted for by the enrollment among them of chil- dren operated on the year before. The indoor groups also presented a better condition in respect to these defects than had been the case the previous year, only 17 children, or 44% of their enrollment being recommended for operation. Only 10 of the 23 cases operated secured treat- ment at a date early enough to permit a five weeks* period of observation after the necessary interval for weight recovery. Chart C shows the curve of gain for these 10 cases for five weeks previous to the operation, as well as for the five weeks following their recovery of weight. The intervening period, 4.6 weeks, during which they were recovering from 88 HEALTH EDUCATION ♦3. ♦1 -1 4.6 ffaeks Raoovary from Operation S Waok» Ton«lf Ope r a. t ion CHART C Progress op 10 Children before and after Operation fob Naso-pharyngeal Obstructions DEVELOPMENT OF PROCEDURE 89 the effects of the operation, is indicated by the dotted line. The percentage of gain is —.4% for the period before and 2.1% for the period after the defects were removed. MENTAL ABILITY The results of the comparative study of mental ability in underweight and normal children under- taken this year * were briefly as follows : In tests of motor control there was no marked difference shown between the Nutrition and the Control Group either in the separate series of tests as given at the beginning and at the end of the Nutrition Class period, or in improvement as shown by the differ- ences between the first and second results. When the combined scores for the two series are considered we get a slight difference in favor of the Control Group in the two tests measuring physical endurance — Eapidity of Movement (Tapping) and Strength of Grip (Dynamometer). In the Steadiness Test the Nutrition Group has a little advantage. Tapping Dynamometer Steadiness R. H. L. H. R. H. L. H. R. H. L. H. Nutrition 298.5 306.7 269.4 265.6 32.0 32.6 29.6 30.4 4.8 4.45 3.55 Control 3.4 In the following tests of mental processes the averages of the combined scores for both trials show * For a more complete report of this study see Mahmtrition and Health Education, by David Mitchell and Harriet A. Forbes, Peda- gogical Seminary, March, 1920. 90 HEALTH EDUCATION superiority of the Nutrition Group in five of the seven tests. Trabue Completion Memory Span Association Reaction Time Directions Cancellation Knox Cubes Dearborn Reconstruction . . Nutrition Control 10.05 8.85 6.4 6.05 2.6 3.1 3.5 3.3 6.95 6.95 6.9 7.3 151. 148.5 The Trabue Completion Scales which give a high correlation with standardized intelligence scales show similar distributions of scores. Superiority of the undernourished children is indicated. These average scores differ so little and the sampling is so small, one is not justified in asserting that sig- nificant differences are found between the two groups. It can be claimed that these undernour- ished children are equal in mental ability if not superior to the well-nourished children. INTERPRETATIONS Evaluation of procedures in this second experi- ment is more difficult than in the case of the preced- ing one, where groups were established on a fairly equal basis and with definite variables as points of comparison. It will be apparent, however, that the advantage in gain shown by the open-air classes is of significance in view of their personnel. The variety of retarding factors they exhibited must be borne in mind when we contrast the year's record DEVELOPMENT OF PROCEDURE 91 made by tliem with that of the fifth grade. When allowance is made for the physical disparity between the two groups, and especially when we recall that of 48 open-air boys, 12, or 25% of the number, failed to respond at all owing to unknown factors pre- sumably of disease or organic deficiency, the facts of their relative response become emphatic. It would appear that the special factors determining this response must have particular significance for the efficient health program, if on analysis they can be isolated. It will be recalled that special emphasis was laid on fresh air in the fifth grade class-room and that their windows were kept open except in extreme weather. Thus it is evident that the results for the first twelve weeks shown at B (Chart A) were for gains made in a season during all, or nearly all of which the windows were kept open. In the interval between B and C, however, we may assume that the fifth grade was conducted as a closed-window class, with frequent changes of air by direct ventilation and temperature lower than that of the average class-room. During the greater part of the interval between C and B this arrangement must have ob- tained as the final determinations were made for the fifth grade early in May. Comparison of results at B, C and B, therefore, gives no evidence that open windows were a determining factor, as the superior gains of the open-air groups at B were made when the fifth grade was conducted as an open-window room, the superior gains of the fifth grade at C and its inferior gains at B seem to argue the dependence 92 HEALTH EDUCATION of the results obtained on factors other than open air. The food experiences arranged for the open-air groups were much better calculated to influence gains than those given to the fifth grade. The hot mid- morning luncheons of cereal and milk or cocoa were admirably calculated to supplement the home diet- ary and educate a taste for the milk and cereals so lacking in the Jewish bill of fare. The meagre cold lunches brought from home by the fifth grade boys added little to the actual caloric intake and nothing to the broadening of dietary habits. But there is probably an added reason for the greater effective- ness of the lunches served to the open-air groups in the undoubted stimulation to metabolism and conse- quent better assimilation resulting from out-of-door atmosphere. We may go further in making our com- parison here and infer that the inadequate lunches brought by the fifth grade boys were less adequate during the period of open windows, when metabo- lism and assimilation were thus stimulated, and more adequate in the period preceding the determinations made at C, after a season of closed windows.* Comparison of the rest periods for both groups of children is obviously greatly in favor of the open- air classes. Indeed it is hardly an exaggeration to say that the rest periods in the fifth grade provided a dramatic rather than a real experience of rest, although a certain conception of relaxation and how to secure it was doubtless gained by the children. * See Hill, Leonard, special report, English Medical Eesearch Com- mittee, The Science of Ventilation and Open Air Treatment, Part I, 1919. A series of observations on heat production of man in- and out-of-doors is discussed. DEVELOPMENT OF PROCEDURE 93 Again, we cannot isolate the factor of rest from that of temperature, but must consider the combined effects of both in estimating the open-air environ- ment. That the physiological effects of rest and sleep in cold air with warm body coverings are of particular tonic value, is a fact well recognized in therapeutics although as yet not fully explained by science. That blood pressure is thereby increased, heart action strengthened, and nerves steadied, has been demonstrated in some cases of acute illness, notably pneumonia.* How far data on the blood pressure and heart action of well children under similar conditions may serve to reinforce the open-air program has yet to be ascertained. It seems apparent, however, that the significance of the open-air class does not lie in any one of its special provisions but rather in the physiological effect resulting from the interaction of all three. The factor of sunshine like that of ''fresh" air evidently played no determining part in securing results, as the open-air class-rooms both had a south- ern exposure and were flooded with sunshine, while the fifth grade was in a north room until mid-year or during the two periods A to B and B to C, when their gains were successively less and greater than those of the open-air boys. Cooperation on the part of the children and of the homes was fairly comparable in both groups, although interest was probably established some- what earlier in the open-air classes, because of their * See Discussion of Papers on Fresh Air Schools by Dr. John W. Brannan — Transactions Fourth Int. Congress on School Hygiene, 1913, Vol. II, p. 171. 94 HEALTH EDUCATION special significance in the minds of both parents and children, and because of the number of children in them carried over from the experiment of the year before. The longer period of educational influence to which these had been subjected may well have re- sulted in better cooperation at the outset, and greater gains during the period of maximal weight increase may also have resulted from a previous im- provement in their home regime. The removal of tonsil and adenoid defects during the preceding year probably proved a contributing factor too, but we must assume that these possible advantages could hardly offset the failure on the part of 25% of their total enrollment to gain at all. Rather it seems rea- sonable to accept the difference between the gain of 274% and 156%' shown at B, as the probable increase resulting from the combined environmental factors of lunches, rest, fresh air and lighter school pro- gram at the season specially favorable to increase, over and above the gains to be expected from the seasonal period itself and the program of instruc- tion. The results shown at C suggest that the sea- sonal period of minimal growth may retard gains for the high percentile underweight rather more than for the low percentile and normal child, and that the advantageous factors of environment for the open-air classes were insufficient to compensate for the better resistance to winter conditions offered by the fifth grade, who were now probably beginning to show the results of educational influences and im- proved home regime, in addition to their better physical endowment. DEVELOPMENT OF PROCEDURE 95 The determinations at D demand a special word of explanation. As all but two of the children oper- ated for tonsil and adenoid obstructions during the school year were treated in the period between G and D, results for weight increase in both groups are correspondingly lowered. In addition the gen- eral discouragement felt by children and parents as the year drew to a close and it became obvious that the promised results of the nutrition program were not being realized, resulted at last in lessened efforts and frequent lapses in regime. Thus the lessened results at D are really not representative and a final estimate of the year 's work should not be based on them.* So far as the results shown by Chart A lend them- selves to analysis, we may conclude their testimony is to the importance of environmental factors for securing early results, and to the better ability of the low percentile and normal child to gain, even under less favorable circumstances of environment, during the period of minimal weight increase. Summary In June, 1919, after a full school year of intensive work our results in terms of weight increase ap- peared so slight as to be almost negligible. Appre- ciable improvement in our procedure had not brought corresponding gains to the children in our classes. In spite of more adequate physical care, increased control of the environment and better teaching technique, we seemed as far from our goal as we had been in the previous June. The facts of * See later showing of fifth grade boys, pp. 146 aud 149. 96 HEALTH EDUCATION Dr. Porter's investigation, it will be remembered, were not available to our workers until nearly twelve months later, and we were therefore without the key- by which our apparent failure could be properly in- terpreted. The initial gains of the fall were for- gotten, in view of the inexplicable failure to gain through the second term of school, and as the year progressed and the discouragement of the season of minimal increase was felt by all, the educational fallacy of holding out to the children promises of results that were not to be realized, however well informed or willing their cooperation, was keenly appreciated by the members of our staff. While the conviction remained with those who had observed the fifth grade class, that such a subject matter program as had been developed for them was a valuable addition to the procedure, the statistical data for the year brought into relief the better show- ing of the open-air classes, and emphasized the im- portance of more adequate provision in the school environment for the actual practice of health-mak- ing activities by contrast with class discussion of them. As a natural corollary the importance of parental cooperation to provide increased opportu- nities for a health-making regime at home received corresponding emphasis. But the development of a subsequent program planned to secure further enlistment of home co- operation, and to permit greater emphasis on ac- tivities and environmental conditions in the school, hardly promised a solution of our major problems, even though the general efficiency of our procedure should be increased thereby. Our experience with DEVELOPMENT OF PROCEDURE 97 the ** graduates" of the early fall who later fell back into the ranks of underweight, and the fluctuations shown by the control group had raised serious ques- tions as to the standards we were using. The failure to secure response from, or even to diagnose the twelve cases transferred from the groups of the previous year to the open-air classes, indicated the insufficiency of our knowledge in regard to certain types of malnutrition. The need for a program of study involving more detailed observations of height and weight increment, and more careful physical ex- amination and diagnosis had become apparent, if we were to make real progress in solving the problems raised by our experience. Moreover, the negative results from our study of mental ability called for further investigation in this field, where we had ob- tained findings so much at variance with precon- ceived opinion. CHAPTER V DEVELOPMENT OF PROCEDURE— PRIMARY GRADES— SEPTEMBER, 1919— JUNE, 1920 Basis of Reorganization In planning our work for the next school year it was decided to experiment with first grade children and to concentrate our efforts on developing a pro- cedure suited to their needs. It mil be recalled that our initial program in 1918 included a first grade class and that they had shown surprising gains in comparison with the other classes, in spite of the fact that little attempt had been made to adapt our procedure to the special demands of their age period. In the belief of our workers the great solicitude felt by the parents for children in their first school year, and the type of home cooperation afforded in conse- quence, offered an explanation of our relative suc- cess with the first grade class; and it was believed that by development of a program further enlisting home cooperation for such a group, proportionally better results could be secured. At the same time, the first grade was felt to be the logical beginning for any program of instruction depending in the main on activities rather than subject matter. If school tradition still confuses the teacher who is trying to think in terms of activity rather than in- formation, the same is equally true of the nutrition DEVELOPMENT OF PROCEDURE 99 worker. But in classes where the possibility of in- formational content is reduced to its lowest terms by the limitations of the age period, it would seem possible to carry out such a change in class proce- dure to the best advantage. The immaturity of the six-year-old makes equally impossible the reduction of the educational program to informational mate- rial, and the shifting of responsibility for gains from the adults in control of the environment to the child himself. In addition to our program for first grade children, the boys of the previous year's fifth grade class were weighed and measured monthly, with a view to studying their record and determining, if possible, any long term results that might have been afforded by the nutrition class procedure. Careful measure- ments of control groups for both classes, the first grade and the previous year's fifth grade were planned, more thorough physical examinations were arranged, and a more extensive program of mental measurements was included. GEOUP SELECTION Forty first grade children ranging from 8 to 20% underweight were enrolled in the nutrition class organized in September, 1919. The group was seg- regated and an experienced class-room teacher who was interested to cooperate with the nutrition staff was assigned them for the school year. Owing to the early transfer of 2 boys the class was reduced to 38 members. Of this number 8 were replaced later in the school term because of transfer to other schools or failure of promotion at mid-year. 100 HEALTH EDUCATION In February, 14 children from 7 to 22% under- weight for height, were found among the mid-year entrants to the first grade.* These formed a second nutrition group. Associated with them were 5 boys not promoted with the September group. ScJiool Procedure. INDrVTDUAL INSTRUCTION Weights were taken weekly in the eye clinic room and the results written on a report slip for each child to take home. These slips created much inter- est at home and among the children. Every other week individual instruction was given in connection with the weight taking. The child's chart was used and his progress marked by a red crayon dot placed on it in his presence, the black line being filled in by the nutrition worker afterwards. Neither the "nor- mal weight line" nor the line of "expected gain" appeared on the charts,! and the boys were not con- scious of being underweight, they were simply en- couraged to form health achieving habits, to try to make gains and if possible to beat their own pre- vious records. In the beginning the charts were meaningless to them, as thoy could not read their own names nor follow the figures; but they soon grasped the significance of the "up and down" weight line. CLASS INSTRUCTION On alternate weeks class instruction was given by the nutrition worker for a period of fifteen minutes * See " Growth in Weight and Height, ' ' p. 119, t See Appendix C. DEVELOPMENT OF PROCEDURE 101 and included a story. The chart showing the best progress for the fortnight was displayed on the wall and attention called to it as a recognition of achieve- ment. Except for these best records the children saw only their o^\^l charts, and discussed their indi- vidual progress only with the nutrition worker, or at home. A special subject for class discussion was selected for each month, and the short stories told at the end of the session were chosen to emphasize the subject under consideration. Each contained an obvious and simply expressed lesson on health habits, and a feature was made of repetitive and rhythmical para- graphs in which the class could join and thereby secure the active sense of participation so important for holding interest at this age period. '^What the Milk Told Me," ''The Pig Brother," ''How Bobby's ■Food Turned into More Bobby," "The Rain-drops," "Little Potato," were the stories successfully used for these children.* Their recital was followed by informal discussion and by the spontaneous dram- atizations characteristic of modem story telling for the primary grades. The particular content covered by the series involves the importance of cleanliness, of water drinking, of milk and vegetables in the diet, and a conception of the processes of digestion, re- duced to very simple terms. The class dramatiza- tion of "The Story the Milk Told Me" was given by 12 of the boys at the Grand Central Palace during the week of the New York Milk and Child Health Campaign. The breakfast food models were shown *"What the Milk Told to Me," by Gertrude Noyes, from the collection In the Child's World, by Poulsson; "The Pig Brother," by Laura E. Eichardsj the other three stories are unpublished. 102 HEALTH EDUCATION in connection with class discussion, and were supple- mented by specimens of fresh green vegetables brought by the nutrition worker. ENVIRONMENT Lunches. — The attempt to have mid-morning lunches provided by the homes was definitely aban- doned and an 8-ounce glass of good milk substituted for the uncertainties of home catering. This was served at the Nathan Straus Milk Station in Tomp- kins Square at 10:15 every day, when the children went over to the square for their playground period. Later, when severe weather made this impracticable, the milk was delivered at the school by special ar- rangement and served by the class teacher. Each child brought his own cup from home, and these were kept in one of the class-room cupboards, and washed after school by one of the janitor's assistants. This cooperation on the part of the Nathan Straus milk depot made it possible to serve really delicious milk at a nominal cost. The expense was partly met by the children who paid a cent a day for it. For many this was their first experience with milk as a cool and palatable beverage. Several of the mothers had fears as to its safety and healthfulness, and were reassured only with difficulty; but it soon became popular with the children. Although adding only about 150 calories to the daily intake, it proved a most satisfactory solution of the mid-morning lunch problem for this group of children. Mid-afternoon nourishment was provided at home by the mothers. Rest. — As in the fifth grade class of the previous year, rest periods were taken in the seats for a DEVELOPMENT OF PROCEDURE 103 few minutes each day under the class teacher's supervision. The double session schedule necessitated a noon period of an hour and a half for children of the X-school, to which the nutrition class belonged, and as all the children lived in the near neighborhood, rest periods of from twenty to thirty minutes at home were advised. Owing, however, to congested home conditions mothers found this too difficult a task to accomplish with any degree of regularity. FEBRUARY ENTRANTS The group of 19 children recruited from those found underweight among the entrants to the first grade at the beginning of the second term, was not segregated as the September group had been be- cause, even after the addition of 5 boys from the September group who failed of promotion, their total number (19) was too small to organize an entire class for them. They were divided between the two first grade classes enrolled in February, and the nutrition worker was assigned a weekly period in each class. On alternate weeks when the group in- struction w^as given and stories told, all the pupils in the room shared in the experience. Thus, for the first time the children of the control group, and members of the class who were not subjects of special care or study, were included in this part of the nutrition program. Mid-morning milk was provided for the children of the nutrition group only and they were excused from their owti class-rooms for a fifteen-minute period each morning to get it. It was served in 104 HEALTH EDUCATION one of the open-air class-rooms at the same time that the open-air boys received their mid-session luncheon. Home Cooperation The attempt to secure the attendance of mothers at the weekly class sessions was definitely abandoned at the beginning of the year, as we felt that without far more energy and time than we had at our dis- posal, we could not present a claim sufficiently im- portant to outweigh the pressure of work for a large family, the demands of the shop or push-cart, or the inertia incident to a foul environment. A monthly mothers' meeting was tried as a substitute, in the belief that the greater convenience and attractive- ness of a meeting, arranged at less frequent inter- vals, and entirely with a view to adult interests, would make a stronger appeal, but the relative suc- cess that followed this change was due to other fac- tors as well. It seems reasonable to believe that results of our attempts in the two previous years to enlist interest and confidence were beginning to be felt in the community ; in addition, the general health propaganda stimulated by the war may have perme- ated the neighborhood sufficiently to have had an efifect. Then too, the mothers of first grade children form, in many respects, an ideal group to be ap- proached. Many of them have small families and are launching a child for the first time on his school career. Some, through the kindergarten, have already made social contact ^^ni\\ the school a fa- miliar experience. Moreover, the type of mother represented in this group has not yet resigned her DEVELOPMENT OF PROCEDURE 105 child to outside influences to any such degree as she tends to do later on. Many still hold rather freshly in mind the precepts received through the baby clinic and the prenatal work of welfare workers, and it is thus relatively easier to get attention on mat- ters of growth and development at this period than later on. The factors working for increased cooperation were apparent early in the fall when parents were asked to be present for the physical examinations. Twenty-one mothers and two fathers responded, 60.5% of the thirty-eight requests sent out at that time. Later in the term when stool and urine ex- aminations were undertaken, 34 specimens or 58.6% of the number requested were brought to the school at the appointed time. mothers' meetings Postal cards sent to all the mothers of the first grade nutrition class announced the first mothers* meeting, and stated that the school desired to see present every mother who was interested to cooper- ate with us in a special health program. The re- sponse was felt to be encouraging, as nearly half the number were present at the first meeting. It was held in the eye clinic room. The large individual charts were hung against the black-boards, and these were explained to each mother separately before the meeting. This gave a pleasant informality at the start. As it seemed important for the mothers to realize that our work held a real place on the school program. Dr. Marks, the Principal, was pres- ent at this first meeting and at our request outlined 106 HEALTH EDUCATION for them the need for the work, the opportunity that the school was offering, and their responsibility for any success that the new class might achieve. This he did skilfully and aroused a sense of pride in the venture that carried throughout the entire year. The nutrition worker in charge then pre- sented a few of the specific objectives for which we expected to work, and for the attainment of which the help of the home was essential. As a result there was a promise to stand by us, and we felt at the end of the year that the interest stimulated at this initial meeting had been really well-sustained throughout the period. The meetings were held each month from October to June with an average attendance of a third of the group. The women responded to notifications with very little special pleading on our part. Dr. Marks or his assistant usually attended, and the class-room teacher was always present and met the mothers informally after each session. Attendance cards were distributed and consider- able pride Avas shown in presenting them to be punched. At the last meeting several prizes were given to those having the best showing on the cards. In formulating a program for these meetings we aimed to create a background of knowledge regard- ing bodily processes explaining the reasons for our concern with the underweight child. We took up for discussion simple matters of personal hygiene, more or less familiar in the abstract, but which we knew often failed to function in action, because of entire lack of understanding of the body mechanism and the laws governing growth. The exhibit of food DEVELOPMENT OF PROCEDURE 107 models was used, and the stories told the children were occasionally retold to the mothers, with a view to informing them in regard to the class-room in- struction. We were careful to attack only one im- portant matter at a time, and much important ground was thus left uncovered at the end of the year. The following topics were discussed with the mothers' group: Milk: an essential food for the growing child. Sleep: why the young child needs more sleep than the adult; the conditions most advantageous for sleep, and their value to all the family. Food: what kinds are best for children; how best prepared and served; purpose of the different kinds of foods. Health Habits: water drinking, its use and abuse; need of establishing slow eating and thorough chewing; elimination of worry and emotional disturbance at table; need of daily rest period, with emphasis on its desirability before eating; need of securing regu- larity of stool, and conditions necessary to obtain this, bad results of depending on the use of cathartics or enemata; results of stool and urine examinations explained. Dental Care: the need for — emphasis on the treatment of the first teeth. As the year progressed the members of our staff became increasingly aware of appreciable results due in part at least to these discussions at the mothers' meetings, among them the following: (1) Increased interest in milk-drinking. The frequent remark which we had at the beginning, ''My child won't drink milk," was very soon replaced by the announcement that ' ' Maxie must have his penny now every day for milk," or ''He loves now to drink milk; I must buy." (2) More use of cereal foods and green vegetables. (3) Attempts in a few cases to supervise a daily rest-period and in general an 108 HEALTH EDUCATION increase in the number of children put earlier to bed. (4) The excellent returns in securing the stool and urine specimens. Throughout the year home visiting was continued and no attempt was made to curtail this part of the nutrition worker's program. The average number of visits paid each family was five, but when children were recommended for the correction of defects, the number was often considerably increased. Data on family measurements of weight and height were gathered during the home visits. This was a matter of interest to all members of the family, and 24 fathers, representing 41% of the families, were in- terviewed on the subject in their homes by the nutrition worker. The considerate attention paid the mother by the Bureau physician at the time of the physical examination did much to establish con- fidence at the outset, and the weekly slips sent to the homes reporting the results of weight-taking, con- tributed materially to sustaining interest. CORRECTION OF DEFECTS Twenty-one of the 58 children given physical ex- aminations, or 43.5% of the total enrolled, were recommended for tonsil or adenoid operations. Ten cases were recommended for operation in the fall. At the same time eleven more were recommended for observation and of these, all were recommended for operation in March. These recommendations came too late, however, to secure necessary arrange- ments before the end of school and therefore the total number operated, 8 cases, was relatively small, DEVELOPMENT OF PROCEDURE 109 only 38% per cent of the number recommended. The Post-Graduate Hospital received them. The record for dental work was far better, as 45 of the 48 children enrolled in the September group were examined and 38 or 65.5% were treated, 10 by the family dentist. The remainder were taken to the Stuyvesant Clinic or were treated by Dr. L. A. Leichter, a dentist, whose office adjoined the school and who generously offered to give his ser- vices, but in accordance with a suggestion from our staff decided to ask a nominal fee. A developing disposition on the part of the parents to pay the fees was one of the most encouraging features of the year's experience. Fourteen mothers paid the fees for dental treatment in full; others paid in part. The total work done amounted to 76 fillings and 74 extractions. It was found impossible to carry out recommenda- tions for correction of defects found among the little group enrolled in February. As we were unable to begin the nutrition procedure for them until March, the period available was too brief to secure the necessary permissions from parents, and obtain appointments at the various crowded clinics. Physical Examinations Of the 58* physical examinations, 43 were done by the Bureau physician and 15 by Dr. I. H. Gold- berger, a physician of the Board of Education. * Of the total number (62) enrolled during the year, 4 were trans- ferred before physical examinations had been made; thus the tabu- lations in Dr. Lincoln's report are for a total of 58. 110 HEALTH EDUCATION Partial reexaminations were done by the Bureau physician on 11 cases. The mother was usually present at the examina- tion and was encouraged to ask questions regarding the child, and a short interview was usually given at the close of the physical examination, giving re- sults of the examination and recommendations. Occasionally, in order to stimulate the confidence of the mother, advice about her own condition was given when requested. As complete a general physical examination as possible was given to each child, consuming on the average half an hour, including otoscopic examina- tion and rough hearing tests. No eye examination beyond the usual routine was done, as all these chil- dren were examined in the eye clinic of the Board of Health in whose room the physical examinations took place. No attempt was made to diagnose tuberculosis except on physical signs. The only case suspicious of pulmonary tuberculosis was referred to the chil- dren's tuberculosis clinic at Bellevue Hospital, and was taken there by one of the nutrition workers for x-ray and the von Pirquet test. No other tuberculin tests were made. Besides the routine examinations of the heart, exercise tolerance tests were occasionally done on suspicious cardiacs. One case diagnosed as cardiac, and one suspected case were cardiographed at Belle- vue Hospital by Dr. Kelley. Stool examination was done on 47 cases and urine examination on 49 out of 58 children. These were added in the first place as further means of diag- DEVELOPMENT OF PROCEDURE 111 nosis, and proved of particular value for convincing the mother in cases where corrective dietetic meas- ures were indicated. An undernourished child, whose mother is concerned about his condition, is apt to receive extra rations of food considered fat- tening, especially carbohydrates, but often in the cases of the Jewish children studied, an attempt is made to add to the diet by giving cream with food, or even as a beverage. Obviously where there is faulty digestion of any one food component and particularly in the case of fats, no good and pos- sibly harm can be done by overfeeding this element of the food. In addition to the large number of cases of con- stipation, 22 out of 47, 5 cases of fermentation were found, large numbers of undigested starch cells in 11 cases, of undigested muscle fibres in 8 cases, and a large amount of neutral fat in 3 cases. Since no second examinations were made, it is recognized that these results are not unimpeachable ; but at least they are very suggestive, and corrective dietetic measures were instituted in the cases of fer- mentation and fatty indigestion and constipation, because of the large proportion of cases confirmed by stool examination. It was decidedly a surprise to find all the stools negative for ova and parasites on routine examina- tions. Oscar M. Schloss * in consecutive examina- tions of the stools of 280 children found parasites or ova in 28.5%, 78% of the positive cases being in children over five years of age. For this reason a * Schloss, Oscar M., American Journal of Medical Science, May, 1916. 112 HEALTH EDUCATION second examination was made in 10 cases taken with- out selection from the nutrition group. Stools from these cases were examined by the Loop Flotation Brine method of Kof oid and Barber,* this being the method used in the army in search for parasites and ova.f All these stools were again negative. Urine examinations were negative in 48 out of 49 cases, albumen being present on one occasion in one specimen. They were therefore not nearly so suggestive nor helpful as stool examinations. Owing partly to the difficulties encountered in the examining room, due to its size, proximity to street noises, and numbers of mothers and children wait- ing for examination, a good many discrepancies and omissions occur on the charts. They cannot there- fore be used to obtain exact statistics regarding presence or absence of abnormalities in this group of undernourished children. In some instances, how- ever, the records are fairly complete, as on teeth, where note of some kind has been made on each child examined, even if the number of decayed teeth has not been mentioned. No. of Muscle Tone: Cases % Firm 13 22.4 Fair 19 32.7 Flabby 21 36.2 Very flabby 1 1.7 Not noted 4 7.0 No. of General Condition :Cases % Good 13 22.4 Fair 14 24.1 Poor 8 13.8 Not noted 23 39.7 Total 58 100.0 Total 58 100.0 * Kofoid and Barber, Journal of the American Medical Society, Vol. LXXI, p. 1557. t Kantor, Journal of the American Medical Society, July, 1919. DEVELOPMENT OF PROCEDURE 113 No. of Breathinq: Cases % Obstructed 9 15.5 Partially obstructed ... 2 1 36 . 2 Free 22 38.0 Not noted 6 10.3 Total 58 100.0 No. of Cases . 2 . 12 % 3.4 20.7 Tonsils: Complete removal. . . Apparently normal.. . Moderate enlargement only 8 13.8 Very large or with evi- dences of disease ... 36 62 . 1 Total 58 100.0 No. of Teeth: Cases % One or more decayed . . 52 89 . 7 None decayed 6 10.3 Total 58 100.0 No. of Approximation Cases % Good 27 46.6 Fair 8 13.8 Poor 9 15.5 Bad 1 1.7 Not noted 13 22.4 Total 58 100.0 No. of Ears: Cases % Drums— Normal 22 38.0 Thickened... 17 29.2 Otherwise dis- eased 7 12.1 Not seen 7 12.1 Not noted... 5 8.6 Total 58 100.0 No. of Glands: Cases % No enlargement of glands 4 7.0 Moderate enlargement 38 65.4 Marked enlargement . . 16 27.6 Total 58 100.0 Note. — Marked enlargement in- cludes both general glandular en- largement and marked enlarge- ment of a single group of glands. Thyroid was palpable in one case only. No. of Eyes: Cases % Normal 30 51.7 SI. conjunctivitis 14 24.1 Conjunctivitis 3 5.2 Marked conjunctivitis. 2 3.4 Strabismus 2 3.4 Stye 1 1.7 Blepharitis..! 3 5.2 Sluggish reaction to light 1 1.7 Not noted 3 5.2 114 HEALTH EDUCATION No. of Heart: Cases % Normal 50 86.2 Poor muscle sounds ... 2 3.4 Organic murmurs 3 5.2 . Enlargement 3 5.2 Diag. of cardiac disease 2 3.4 No. of D'EspiNB Sign : Cases % Negative 35 60 . 3 Positive 23 39.7 Total 58 100.0 No. of Abdomen: Cases Normal 36 Prominent 13 Hernia or enl. ring. ... 10 Umbilical hernia. 2 Inguinal hernia. . 8 Lax muscles 1 No. of Extremities: Cases Normal 22 Enlarged epiphyses ... 1 Knock knees 23 Bowing of tibiae 1 Hyperactive reflexes. . 17 Ejiee jerks 16 Upper reflexes. . . 1 Babinski 2 Edema 1 % 62.1 22.4 17.3 1.7 % 37.9 1.7 39.7 1.7 29.3 3.4 1.7 No. of Lungs: Cases % Normal 52 89.7 Bronchitis 4 6.9 SI. impairment 2 3.4 Total 58 100.0 Note. — D'Espine Sign has been considered positive where in- creased whispered voice was heard at or below the third dor- sal vertebra. There were 5 cases not heard below the third. No. of Genitals ; Cases % Normal 45 77.6 Undescended testicles .10 17.3 Phimosis 2 3.4 Other condition 1 1.7 Total 58 100.0 V No. of Skin: Cases % Normal 50 86.4 Pediculosis 2 3.4 Scabies 1 1.7 Alopecia areata 1 1.7 Not diagnosed 2 3.4 Not noted 2 3.4 Total 58 100.0 DEVELOPMENT OF PROCEDURE 115 No. of Mucous Membrane :Cases % Good color 19 32.7 Fair color 12 20.7 Pale 20 34 . 5 Not noted 7 12.1 Total 58 100.0 No. of Chest: Cases % Normal 26 44.8 Harrison's groove: Slight or moderate.. 20 34.5 Marked 4 6.9 Depressed sternum. . . 11 19.0 Rosary 3 5.2 "Rachitic" 1 1.7 Flat 2 3.4 Narrow 1 1.7 No. of No. of No. of Spine: Cases % Feet: Cases % Posture: Cases % Kyphosis . . 5 Scoliosis . . 3 Lordosis. . . 3 Normal. . .47 8.6 5.2 5.2 81.0 Normal.. Weak... 33 25 56.9 43.1 Poor 11 Good 5 Not noted 42 19.0 8.6 72.4 Total. 58 100.0 Total. . 58 100.0 Total... 58 100.0 No. of Stool Examination: Cases Not examined 11 ' Normal 15 Constipated 22 Fermentation 5 Many imdigested starch and vegetable cells . 11 Many undigested meat cells 8 Much free fat and many fatty acid crystals . 3 Ova and parasites not found. % 19.0 25.9 38.0 8.6 19.0 13.8 5.2 No. of Urine: Small amount of mucus 6 Albumen on one occa- sion 1 Not examined 9 No. of Cases % Electrocardiograms: Cases % 1 1 Normal 48 82.8 Slight left preponderance. 1 Right preponderance with poor muscle tone 1 1.7 15.5 Total 58 100.0 116 HEALTH EDUCATION Recommendations No. of Cases Per Cent Dental care Removal of jaw polyp Tonsillectomy and adenoidectomy or ade- noidectomy alone Observation of nose and throat Eye examination Treatment scabies Cardiac precautions X-ray chest advised Circumcision Observe testicles Observe hernia Foot exercises Other corrective measures Attention to posture, including exercises Dietetic advice Tonics given General hygiene Hygiene for eneuresis Observe for achondroplasia 52 1 20 20 9 89.7 1.7 34.5 34.5 15.5 1.7 2 3.4 1 1.7 1 1.7 4 6.9 1 1.7 20 34.5 1 1.7 4 6.9 3 5.2 2 3.4 1 1.7 1 1.7 1.7 DEVELOPMENT OF PROCEDURE 117 September and February Nutrition Groups Per Cent Underweight of Children xoith Physical Defects First Weighing Last Weighing No.of Cases Av. % Under- weight P.E. Av.% Under- weight P.E. P.E.D. D FED. Fermentation Poor general condi- tion 5 9 22 17 10 36 22 24 14.40 10.88 11.77 9.41 10.40 10.64 10.09 11.04 1.232 .4284 .5415 .4946 .4061 .3040 .3394 .3329 10.20 9.00 8.95 6.59 5.70 7.33 5.82 5.58. 1.568 .5510 .5974 .5676 .7067 .4743 .5600 .5198 1.994 .6979 .8062 .7528 .8150 .5633 .6547 .6172 2.106. 2.693 Poor muscle tone . . Hyperactive re- flexes 3.495 3.750 Decayed teeth .... Diseased tonsils . . . Constipation Harrison's groove. 5.766 5.876 6.527 8.843 Sept. and Feb. nu- trition groups. . . 58 11.20 .2880 7.37 .3769 .4743 8.077 CHAPTER VI GROWTH IN WEIGHT AND HEIGHT First Grade Children SELECTION The total number of entrants to the first grade classes of Public School 64, in September, 1919, were weighed and the height measured. One hundred and twenty-three of these boys were measured be- tween September 9th and September 24th. Two entered in October and one in November, making 126, from whom the Nutrition Class was selected. Forty boys, ranging from 87c to 20 7o underweight for height, and with an average per cent underweight of 11.6, were segregated in this class. The early transfer of 2 boys reduced the group to 38. Of the boys weighed after September 18th, ten were found to be more than S% underweight. By the first of December, four of these had entered the Nutrition Class to replace members who had been transferred to other schools, and in February, 1920, four more entered to replace boys who were not promoted with the group. The other two underweight boys are tabulated with the general group. A Control Group was formed of those nearest the normal standards for height-weight index at their ages. There were found 41 boys who ranged from 4% above to 4% below normal weight for height, 118 GROWTH IN WEIGHT AND HEIGHT 119 and 6 boys from 5% above to 87c below normal. The last case was included in the Control Group through error in first calculation. The average per cent underweight of this group was 0.83. Measurements were taken without shoes or coats. The Nutrition Group was weighed weekly from September to June, and the height was measured monthly. The Control Group was measured every two months and the others of the general group, not included in these two classes, were measured again in May, 1920. The chronological age of the Nutrition Group ranged from 5.25 to 7.39 years, with an average of 6.3 years. The range for the Control Group was 5.96 to 7.54 years, mth an average of 6.3 years. The nationalities represented were as follows : Nutrition Grodps September 1919 Group Russian 25 79|% Russian and Austrian Austrian 10 Italian 2 Galician 1 Hungarian 4 Rumanian 1 German Jew 1 (Born N. Y. C.) February 1920 Group Russian 6 79% Russian and Austrian Austrian 5 Hungarian 1 German American 1 Irish American 1 In February, 58 boys entered the first grade classes. They were measured and a group of 14, ranging from 7% to 22% underweight, was formed 120 HEALTH EDUCATION on March 2. Five boys of the September class, who failed of promotion, were placed with this group. Twenty-three entered school during March and April, and of these 7 ranged from 8% to 12% under- weight. Twenty-two boys of the February entrants formed a Control Group, ranging from 4% above to 4% below normal standards. These mid-year en- trants were not segregated into groups, but divided between two class-rooms. DISTRIBUTION OF PERCENTAGES OVER AND UNDERWEIGHT Chart I represents the distribution of the percent- ages over and underweight for all the children who entered the first grades in September, 1919. Of 126 children, measured at entrance in the fall, 8 were of normal height and weight ; of the remaining 118, 25 or 21% were from 1-24% overweight and 93 or 79% were from 1-24% underweight; 55 children or 43.7% were from 8-24% underweight, 6 children or 4.8% were from 16-24% underweight. Contrasted mth these we have only 6 children or 4.8% who were from 8-24% overweight, 2 children or 1.6% who were from 16-24% overweight. There were 81 boys entering in February and March. Of these 10 were of normal w^eight for height, 29 were from 1-24% overweight, 16 were from 1-6% underweight, and 26 were from 7-22% underweight. If we take a seven per cent standard for select- ing the undernourished child, and if we consider this general group a typical one for the age, sex, stock and social group studied, we find nearly 50% GROWTH IN WEIGHT AND HEIGHT 121 is w o l-H CO O < o o o M H M H CO w 04 o 05 3 a H - overweight. The wide variation between these two averages and the fact that the average percentage underweight of the Control Group so nearly approximates zero would seem to indicate that likenesses or differences be- tween these groups are significant ones and are not due to faulty selection from the standpoint of nu- tritional status. However the demarcation of 8% under for a Nutrition Group is not established, and the nutritional behavior of the children in both groups near this borderline should help to deter- mine standards of malnutrition. The accompanying tables, la and lb, show the per- centages underweight of the September Nutrition and Control Groups for October, December, Febru- ary, April, and June, according to the Burk-Boas norms of weight for height. These percentages are derived from a height and a weight taken on the same day, this day falling for a given month between the GROWTH IN WEIGHT AND HEIGHT 123 8th day of that month and the 8th day of the preced- ing month. For example, the percentages underweight for October are based on a height and a weight meas- ured for any one individual on the same day, this day falling between September 8th and October 8th, etc. COMPAEISON OF UNDERWEIGHT AND CONTROL GROUPS The total gain in weight is reckoned from the time the individual entered the Nutrition or the Control Class until approximately June 1st, when the last weighing was made, and includes those individuals who missed not more than four weekly weighings either at the beginning or the end of a period of eight months, during which the class was conducted. The deviations from normal gain are given for these same individuals and are obtained by subtracting the total gain in weight from the normal gain for eight months, as given by Burk and Boas. Similarly, Table II contains percentages for the minor groups, selected in the following February, for February, April and June, the measurements being made between the 20th of the given month and the 20th of the preceding month. The gains in weight are given for the children who missed not more than two weekly weighings either at the begin- ning or the end of the class period. The deviation from normal gain is obtained by subtracting the total gain for the class period from the normal gain for four months, as given by Burk and Boas. The Total Gain for the Nutrition Group (Table la) during the class period shows an average of 3.69 124 HEALTH EDUCATION TABLE I a Percentage Underweight September Nutrition Group No. October December February April June Total Gain (lbs.) Dev. from Normal Gain + - + - + - + - + - + - + - 1 10 5 5 8 8 2.7 0.1 2 11 7 4 3 10 3 5 5 4.2 1.4 4 11 7 7 4 8 4.0 1.1 b 9 6 8 4 2 4.8 1.9 7 7 4 7 8 11 4 2 6 4.0 1.0 9 12 10 8 6 6 3.9 0.8 10 12 7 2 7 7 3.6 0.6 11 9 12 14 7 7 7 9 2.7 0.2 13 12 7 9 7 7 4.1 1.2 14 16 9 5 7 9 3.8 1.0 15 17 9 10 12 2.1 0.7 16 8 8 8 10 17 8 4 2 4 5.4 2.5 18 20 14 10 6 9 6.3 3.3 19 12 5 5 2 7 1.7 1.2 20 8 6 2 5.8 3.0 21 12 4 6 4 4.6 1.8 22 13 11 9 10 3.1 0.2 23 12 11 9 9 12 3.2 0.2 24 10 2 5 2 3.0 0.2 25 13 9 7 10 12 2.0 1.0 26 14 7 11 9 9 3.1 0.1 27 10 7 2 2 7 1.4 1.5 28 8 6 6 2 5.1 2.0 29 12 2 2 30 8 2 6 2 6 4.4 1.6 31 9 7 4 8 3.4 0.4 32 15 5 2 2 5 2.6 0.2 33 10 10 7 9 9 1.9 0.9 34 10 12 7 2 35 16 7 9 7 11 2.2 0.9 36 9 4 2 5.1 2.1 37 14 12 11 9 38 12 7 5 4 7 2.7 0.3 39 9 2 2 2 5.7 2.9 40 12 6 6 6 4 5.5 2.3 41 14 42 12 12 10 4 9 43 10 8 10 44 8 4 6 Av. -11.56 -6.60 -5.68 -4.4 -6.54 3.69 0.769 a 2.691 3.330 3.670 3.217 3.811 1.305 1.250 P.E .2725 .3029 .40 .3667 .423 .1552 .1487 GROWTH IN WEIGHT AND HEIGHT 125 TABLE I b Pebcentage Under or Over Weight September Control Group No. October December February April June Total Gain (lbs.) Dev. from Normal Gain + - + - + - + - + - + - + - 1 4 6 6 4.4 1.6 2 4 2 4 4.6 1.6 3 6 2 2 2 4.0 1.1 4 2 2 2 2 2.8 0.0 5 5 10 7 7 1.2 1.8 6 2 2 7 5 2 3.5 0.7 7 2 4 4 3.3 0.5 8 4 2 2 3.6 0.8 9 5 4.0 1.1 10 2 11 8 4 2 2 5.4 2.4 12 2 5 2 7 2 5.7 2.8 13 4 2 2 4.7 1.9 14 2 2 4 6.9 4.1 15 2 9 2 2 3.1 1.3 16 4 2 4 6 2 4.7 1.7 17 7 2 2 7 7 3.0 1.2 18 2 5 5 2 2 3.5 0.7 19 5 9 7 11 4 5.1 2.3 20 2 7 7 12 7 4.5 1.7 21 2 7 7 2 8 7.0 4.1 22 2 2 2 2 4.5 1.7 23 5 5 7 24 2 5 7 7 7 4.3 1.5 25 2 7 2 3.7 0.8 26 4 4 2 3.5 0.7 27 2 2 2 4 5.5 2.6 28 4 4 2 4.3 1.4 29 2 2 5 5 5 1.9 0.9 30 4 9 9 4 6 4.2 1.4 31 2 2 7 2 3.2 0.1 32 2 2 4 3.1 0.0 33 4 4 2 34 11 11 4 35 2 4 3.2 0.2 36 2 5 10 2 3.7 0.8 37 4 2 6 2 6.6 3.6 38 2 12 4 7 3.6 0.8 39 4 4 4 3.5 0.7 40 2 5 41 2 4 8 10 8 4.7 1.8 42 4 2 4 4.4 1.2 43 3 5 2 1.9 1.1 44 8 10 4 8 6.5 3.4 45 2 2 4 4.7 1.9 46 4 2 2 3.9 0.9 47 2 2 6 2 6 4.8 1.7 Av. .826 2.50 3.21 2.79 2.17 4.16 1.3 105... {h) T.Q.< 90... (c) Entire group. No. of Cases 9 32 Av. in Lbs. 4.54 3.22 3.69 1.247 1.216 1.387 P.E. 0.2967 0.2736 0.165 Difference between (a) and (b) is 3.271 times its Probable Error; (a) and (c), 2.504; (6) and (c), 1.464. 176 HEALTH EDUCATION 1— t o K O hJ z W o < H H « o <: O -^OiOOCC^OSfNOOSOiCCKNC^ OilOOCOOOOOi-IOOJOMfOO W P>^' =2 pi (u T3 13 O W fe W rH .-( i-H CDi-Hi-Hr-t i-l oooioiooioioioooiceo iOOOOO'-iTta5eo(Nt^»oi^Oi MENTAL MEASUREMENTS 177 e?C0Tj<(MTHf0(NT-lC0C0'*k0(N»-lO'*f0i-HC. »C CDIM (N »-HOifOt^-*OCOi-HCOOt>fO'-Ht- CO 00 C5 CD a> 0Si0OOOOO00t^OO»OO(MOOO>OOiCO«0Olr^ OC005-rt<05'-lOO'*i|>.005t>0'-<0"*iMC01>'-it^05(NC<) I— I 1— I C<1 r-( 1-M ,— I I— ( I— I I— I T-l 1—1 CO 0>OOC00005rt*>OCOt^OOO>00-*CO C-05l>'Xia500i05(Ni— ICOOOiOtH tHi— li— It— li-Hi— I ,-H C<> CO I— I t-ItH i-Hi— I OOOiCiCOOiOOOOiOiOiOiOiOtQiOOiCOiOiOiClOkO COOiOOOOIr^O'+iOi(Mr^0500G005>-liOC^OO:QOt^03 r-l i-( rH Ca r-< »-l rH lO CO T-t i-* t-t r-( 01 (N C<) "* (M l— I CO CO CO "* ooco CO T-l ,—1 ^H O'-iO-*(M(N'-h(Ni- o -d »— 1 o .H s h3 o ^ ^ o 1 o O eo»Ci-H'-iTHOO'-Jco W O m OOiOiOOOOOiCcOOcOt^O l>CDO-*COOCO-*Ot^LOOOcO o H' H' (Nt^OOtMCOOOi-i^-^tNiO 1—1 T-HrHi— ( 1— ( I— lrHT-l(Nt— I (McD-*COiCt^OOOOOOiO 1— iCOCOOlCOTjHt^iOCSiOGOOCO (M rH i-H 1-H CO CO CO CO 1-H Ttl lO CO 'T3 w ID o aa> fe w H q T-tCOOcC>i-(Ni-lC0'-l.-<.-H OeO»OCiC05* Tf rH 1-H CO (M CO CO T-t i-l i-H CDOOCOiOCC(NOOiO'-Ht:^T-((MTt<(MOcOTH(NcDiOCO T-H ,-1 .-H CO IN '-I (M (N >-l iM rH Til T-H(N »CiOiOOOiCiOOCOI>-iOO>OOkOOOOOOOO OOt^t^,— (C0i-Ht>.iOt^iCiCOt:^C5"*'l^OiCi0O>OOOO'*iOOc000C0'*f0O »0001>»I>'--OOt>COOO'— Ii0l>-CDO>1>-0-^0'— I rH (M T-H (N CO (M T-l COi-H ,-H T-( i-H ,-( eoiM«iO'-HOOooiot^cocoo-*t^r^oi^ioio CDCOOOCOCOCC>CDa2t^CO(N(M>0'^000-*Ot>»-HC005 l-H T-H CO CO 1-1 r-l (N (N (M '^ (N T-H rH CO lO 00 o CO lO CO J-l OOcOiOOLOOOiMOOO^iOOOOiOOiOiOOCI iO«OCOi— tiOr-it^iOOOOOOlfMI^OO^DC^-^T-HCOt^CO •<*(NT-4T-HrH.-l -cJIIMt-I OCOCO'*(MI>C0000iOtO'OCOi:Ci-<*lCO'* 00'-*00 •w :z;<: b^. 180 HEALTH EDUCATION Card sorting. — The time and errors in Card Sort- ing were reduced in the second trial by both groups, but the Nutrition Group has better averages in time required and has fewer errors in both trials. Probable Error of Difference (P.E.D.) between Scores of THE Nutrition and Control Groups Card Sorting P.E.D. D. P.E.D. Time — First Trial 5.307 2.915 0.2557 0.2750 0.158 Second Trial 1.585 Errors — First Trial 2.335 Second Trial 1.673 The difference between the Nutrition and Control Groups in time required for the first trials seems insignificant. More absolute improvement in rate is shown by the Nutrition Group on the second trial. The difference between the averages is much larger, and is 1.585 times its Probable Error. The differ- ence of 1.27 in average number of errors on the first trial is 2.335 times its Probable Error, and for the second trial this is only slightly less. This aggre- gate of differences in favor of the undernourished group indicates a slight superiority over the Control Group. Cylinders. — A study of the results in the Cylinder Test from the standpoint of the total time required and of the practice effects from one trial to another shows a more marked superiority of the undernour- ished group. MENTAL MEASUREMENTS 181 Probable Error of Difference (P.E.D.) between Scores of THE Nutrition and Control Groups Cylinder Test P.E.D. D. P.E.D. Time — First Trial 19.740 16.386 10.471 2.051 Second Trial 1.276 Third Trial 0.829 Probable Error of Difference between Trials Nutrition Control Cylinder P.E.D D. P.E.D. P.E.D. D. Test. P.E.D. T1-T2 T,-T, 17.317 14.071 14.178 4.464 1.137 6.582 18.93 13.42 17.28 5.12 2.10 7.24 The time required decreases rapidly from first to second trials for both groups with a smaller differ- ence between second and third trials. There is a greater absolute gain for the Control Group, which has a much larger initial time score, but the percent- age of reduction shows greater improvement by the Nutrition Group. The differences in the learning process as shown by these averages are significant, since they are more than four times the Probable Error except between second and third trials. The differences in averages of the two groups for time required are not so significant, for the second and 182 HEALTH EDUCATION third trials, though the difference on first trials is more than twice the Probable Error, which is cer- tainly suggestive. CancellaUoyi. — The Nutrition Group has a faster rate in Cancellation and makes fewer errors. Cancellation P.E.D. D. P.E.D. Time 13.410 1.508 1.748 2.514 Errors — First Half 2.029 Second Half 1.865 The difference in the averages of time required for the two groups is two and a half times the Prob- able Error of this difference. The difference in the average number of errors in the first half of the sheet is twice its Probable Error. The Nutrition Group shows no more inaccuracy in the latter half of the sheet than in the first half, but the Control Group has a slight increase in the average number of errors. Action- A gent. — In the test of controlled associa- tions there is but little difference between the two groups in accuracy. The errors for both groups were with a few words, as gallops, growls, stings, which were unknown to them. The Nutrition Group has a longer average reaction time. The scores range from 1.8 seconds to 9.8 seconds, with an aver- age reaction time of 4.5 seconds. This is 0.9 seconds MENTAL MEASUREMENTS 183 longer than the average for the Control Group, and this diiference is 3.378 times its Probable Error. There are five in the Nutrition Group with slower reactions than the longest reaction time for the Con- trol Group, two of them exceeding it by 2 seconds. Among these are three who had low intelligence scores. The longest reaction times for the Control Group were made by those having lowest intelligence scores. The inequality within the groups as to intel- ligence makes group comparison for a study of the undernourished child far less valuable. A group of 50 Italian boys of the same age range from another public school of New York had an average reaction time of 5.9 seconds for the same list, which is longer than that for the Nutrition Group. Their accuracy score was 8.44 in compari- son with 11.62 for the Nutrition Group. This group of undernourished boys makes fewer errors and has a quicker reaction time than a group in the same city having somewhat similar home conditions. We do not know, however, how many of the Italians were also underweight. Ship Test. — In the Ship Test the time scores in- clude so many variables that the average is of little value. Some took 6 minutes and made a very good score, others made a score of zero but completed it in a very short time. The average score of 7.26 coin- cides with the Pintner-Paterson norm of 7 to 8 for six-year-olds, so the performance of these under- nourished boys is considered normal. The low scores correlate more closely with Intelligence Quo- tients than with index of undernourishment. 184 HEALTH EDUCATION SB 5 a e MENTAL MEASUREMENTS 185 Substitution. — In the Substitution Test no norms are available for half sheets, which seemed to be a desirable length to give these young children in com- bination with the other tests used during the period of time available for testing. There was wide varia- tion in the time scores. The last line used as a memory test for 31 individuals was free from errors in 23 cases, or 74.2% of the group; 3 or 9.6% made 1 error; 2 or 6.5%^ made 2 errors; 2 or 6.5%? made 4 errors; 1 or 3.2% made 5 errors. We find that under conditions of work demanding maximal attention for the best records as to speed and accuracy, appreciation of relationships, and the control of associational responses, the group selected as undernourished make better scores than the Con- trol Group. They also show greater improvement in reducing the amount of time required for repeated performances together with a higher degree of accu- racy. Chart 14 shows the significance of difference between scores of the two groups. Motor Coordination of Nutrition Group Tapping. — In the Tapping Test on Single Plate there are marked individual variations as to total output and fatigue effects. The difference in actual taps between the first and third periods of 30 sec- onds averages 12.3 or a fatigue index of 4.3%, when this loss is compared with the total number of taps. This can not be directly compared mth an index of fatigue determined by Gilbert for eight-year-olds, or by Wells for adults because of varying factors in 186 HEALTH EDUCATION TABLE V Nutrition Group First Grade A. B N.C B. D S. Fa J. Fa S. Fi J. Fr N. G P. G A.G B. H I. H P. K J. K A. K E. L L. Le J. L H. L I.L L. Lu L. M M. M L. P J. P M.R S. R N. R I.S H. Sa N. S D. S H. Sk M. T H. U N. W J. Y No. of cases Average . . . cr P.E Ship Substitution Walking Target Score Board Total Steps Off Time Score Time Errors m sec. m sec. 67 4 274 48 70 240 1 45 5 55 8 690 1 21 5 110 12 604 3 35 1 28 6 329 1 43 45 263 11 4 120 15 612 1 67 3 60 8 290 41 80 8 342 46 6 40 6 290 78 1 62 6 255 2 75 10 25 295 4 43 1 57 10 500 18 25 5 90 7 435 3 41 1 63 8 273 45 7 80 15 385 11 11 13 45 12 358 4 34 23 360 13 302 41 14 150 10 240 1 57 50 285 2 48 6 85 332 4 15 6 133 8 550 3 49 8 60 10 325 S 39 1 67 6 315 68 65 18 230 1 47 4 122 18 315 36 1 43 5 285 1 21 5 30 339 49 3 35 4 306 1 64 3 85 16 333 4 29 12 50 8 443 5 72 2 95 7 212 27 98 435 1 59 2 72 6 311 11 38 45 249 5 52 8 35 35 35 35 35 35 78.34 7.26 349.8 2.31 43.43 4.57 57.32 5.31 114.71 3.95 17,10 4.97 6.534 0.6053 13.077 0.450 1.949 0.5668 MENTAL MEASUREMENTS 187 the procedure. The average total output for the first 30 seconds — 99.8 taps — is 12.2 taps less than the score of 112 for 268 six-year-old city boys given by Pyle in the 1920 revision of his manual for the ex- amination of school children.* The loss from the first to the second period and from the first to the third period is a valid difference, being more than three times the Probable Error in each case. Probable Error of Difference between Averages for Tappinq Single Plate P.E.D. D. P.E.D. First 30 seconds — Second 30 seconds Second 30 seconds — Third 30 seconds .... First 30 seconds — Third 30 seconds 3.269 3.117 3.373 3.319 0.465 3.646 In Tapping on Double Plate the same loss is shown and again the differences are significant. Probable Error op Difference between Scores for Tapping Double Plate First 30 seconds — Second 30 seconds . . . Second 30 seconds — Third 30 seconds . . First 30 seconds — Third 30 seconds. . . . 2.537 2.436 2.522 D. P.E.D. 3.532 0.472 3.096 * Miles, W. E., Journal of Nervous and Mental Diseases, 1919. Eeduction in neuro-muscular activities is noted in subjects on low diet with loss of weight. 188 HEALTH EDUCATION Six children of the same age from a private school averaged 138 taps in one minute or a score of 12 more taps than the average of 126 made by the Nutrition Group. No other data are available for comparison. The fatigue effects as shown in the Single Tap- ping test were compared with the percentages under- weight at the time of the test, and with the gains in weight during the period of the Nutrition Class from October to June. The five cases showing most fatigue made an average gain of 4.42 lbs., while the six cases showing least fatigue made an average gain of 3.43 lbs. The difference between these averages is 1.816 times its Probable Error. At the time of testing seven boys in the most fatigued group had an average of 7.3% under- weight, w^hile the six in the least fatigued group averaged 6.3% underweight. The difference between these averages is 1.15 times its Probable Error. The total output in the Tapping tests for Single and Double Plate forms was reckoned for groups having specific physical defects. Comparing these averages with those of the contrasting or normal group we find the differences shown in table on op- posite page. In each case those of firm muscle tone and without hyperactive reflexes make better averages than those defective in these respects. The variability is so great, however, the differences are of little signifi- cance. Primarily to obtain some check upon the Double MENTAL MEASUREMENTS 189 Muscle Tone Reflexes Tapping — Single Plate Poor Firm Hyperactive Not Hyperactive Number of cases Aver, number of taps in 1 ^ min 10 280 45.15 9.616 9 285.44 52.45 11 801 9 275.89 45.75 10.293 26 290.42 (7 63.42 P.E 8 . 371 P.E.D.-''^^'^ D. — = 1.0951 P.E.D. Tapping — Double Plate Number of cases Aver, number of taps in 1 min 10 117.8 24.28 5.171 D. P.E.D. 9 125.44 20.462 4.603 = 1 . 103 13 124.54 21.307 3.984 D. P.E.D. 22 126 91 0" 26 37 P.E 3 796 =0.4307 Form of Tapping, correlation coefficients were com- puted. Tapping— Single Plate with Double Plate, r=0.436 Tapping — Single Plate with Intelligence Quotient r=:0.316 Tapping — Double Plate with Intelligence Quotient t^^O.204: Target Test. — In the Target Test the boys of the Nutrition Group made a better score than nine chil- dren of same age in the private school. 190 HEALTH EDUCATION 6 s fe, "I CO o rQ Plh .g a Eh HO §" I I ocs^oco'*(N>-ir>i'«*coo>'Tj< coooi-^cooiot^ooc^rooo OOi-HcDCOOOC200500cO-^i— i(M (N(N'-HCO(NIM(N(N(N(N(M(NCO MENTAL MEASUREMENTS 191 C5CO(NOO'*iOO»OCOeOOiM'-li-iCCOOt^T}HTjcoooiMeoou:)Ocoi>cD COiOOiOOI.-HiOOOOO-^iOO'-iOOajT-HiMO^CCCO •w !Zi made. Even so there is much opportunity for error, many parents being as inaccurate as the children in regard to specific de- tails. Moreover the additional expense and labor attending such verification makes it prohibitive un- less undertaken as in our experiments, for special classes and for children needing a corrective pro- gram. Under the circumstances any system of re- wards or credits based only on reports from the children appears distinctly undesirable, and to be avoided as placing a premium on inaccuracy, and very possibly on hypocrisy. It would seem that effective relationship between community and school in the health program must be developed along other lines. Adjustments within the School. — Within the school the health program demands provision for continuous supervision and record-keeping for every child, provision for the greatest possible number of advantageous factors within the school environment, provision for enlisting the intelligent cooperation of all children in respect to advantageous factors both at home and in school. To effect a continuous supervision of individual condition in regard to health, the best available provisions for physical examinations and medi- cal inspection should be supplemented by fre- quent records of height and weight. In addi- tion to its importance as a record from which cur- rent results may be evaluated, the individual 242 HEALTH EDUCATION growth chart is a device of undoubted educational value. It presents a graphic record of facts to be interpreted by relating the child's experiences at first hand directly to the necessary informational material. As a means of enlisting interest and hold- ing it, it is without doubt the best device we have, and the only one of its kind. Like all other devices in educational procedure, it is susceptible of misuse. The successive modifications adopted by us in regard to its use reflect the more serious possibilities of this kind.* Weight and height measurements present many opportunities for inaccuracy and the keeping of the current records must be in the hands of care- ful and experienced adults, if they are really to ful- fill their function in affording the necessary data for evaluating the health procedure. For this reason the responsibility for taking measurements cannot be relegated to the children themselves and undertaken as a class activity, excellent as such an experience might be from the educational standpoint. It is a question how far the class teacher may be relied on for such measurements. In our work all measurements and records were made by the nutri- tion workers who had been carefully instructed as to methods. Under the supervision of trained workers the experiences incidental to height and weight tak- ing may well be made to yield their quota of par- ticipatory activities for the children. The conditions obtaining in the eye clinic room a P. S. 64, how- ever, effectually prevented the development of the educational possibilities the measurements should have afforded, beyond informal discussion with the • See Appendix C. AN EDUCATIONAL PROGRAM 243 child of his own gains or losses in relation to his daily regime. The provision of advantageous factors within the school environment should be such as to supply con- tinuous experiences that will be health building and habit-forming. How can this be accomplished? Obviously the school's function in regard to facilities for feeding, sleeping and bathing must always be limited. Whatever provision it may make in these directions must be of value rather as they afford suggestions for the home or supplement its provi- sions. The conditions obtaining in the average homes of any school community must determine the relative need for such experiences and, to an extent, the method of supplying them. Thus the comparative failure of the mid-day luncheon to function in the program of P. S. 64 is inconclusive as to its possible advantages in a dif- ferent community. Properly conceived and executed, the school lunch could be made an ideal educational vehicle. Examples of a carefully planned lunch- room service may be found in several of our welfare agencies, combining a program of full feeding, with opportunity for the broadening of dietary habits, and the inculcating of healthful table habits. It is, however, a long step from the commercially con- ducted lunch-rooms of our city schools to the educa- tional ideal. The difificulties concerning the administration of the school lunch are, indeed, so many, that it is a serious question how far it can be considered a prac- tical undertaking if carried out in the ideal way, which involves not only the careful selection and 244 HEALTH EDUCATION preparation of the food supplied, but also the super- vision of the children in their selection of food and eating habits. The noise and confusion generally found in the school lunch-room, the haste that so often prevails, are questionable attendants to a satis- factory meal. It is only too evident that our large public schools cannot provide a substitute for the home in these particulars, although much can be done to improve the conditions usually found, if the value of serenity and of desirable eating habits can be fully established in the minds of the teaching staff. The results claimed for improvement in the condi- tion of the children where the usual system prevails, and the luncheon is served on the cafeteria plan, with the stipulation that one essential dish, generally a thick soup with bread and butter, must be purchased by every child before he can secure sweets, cannot be said to establish the value of the school lunch as an educational factor nor even as a health-making fac- tor, the inference to be draA\Ti is rather against the unsatisfactory conditions obtaining in the average home of the community concerned. The desirability of the mid-session luncheon of milk or cocoa as an educational experience seems evident aside from the probable existence in any school population, of children whose breakfast has been inadequate.* When it is recalled that much of the difficulty over the eating of breakfast, and of the hurried conditions attending luncheon in many homes as well, is directly related to the penalties imposed by the school on late-comers, the desirability of better adjustment between the schedules of the school and * Sec Appendix D. AN EDUCATIONAL PROGRAM 245 home with relation to this particular point suggests itself. Lengthening of the noon hour to include a rest period at home for the younger children would probably be attended in many communities with bet- ter results than we were able to secure at P. S. 64. Except for the special provisions at Christodora House during our first term and in the open-air classes, the conditions we were able to provide with regard to rest periods were really little better than those attending dramatic experiences. As such they served a purpose but their functioning as true advantageous factors is to be questioned. The possibilities and responsibilities of the school in regard to the advantageous factors related to bodily activity, habits with respect to ventilation, and emotional attitudes, are probably of greater importance to health than those attending any routine experiences it may supply as to food and rest. Indeed we cannot properly estimate the part these might play in the establishment of health habits and increased vigor, unless we first conceive of a school environment successfully affording optimum conditions in regard to each, continuously throughout the school day, the school year, and the years of school attendance. If the total influence to be exerted appears a fairly con- siderable one viewed in this perspective, what is to be said for the present general adherence to seden- tary traditions, questionable winter atmospheres, and frequency of nervous tension and worry in our school-rooms? Unfortunately science has not yet spoken on these matters with sufficient definiteness to make her message to the school an unmistakable 246 HEALTH EDUCATION one. Comparable experiments carefully planned with a view to ascertaining comparative results in gro'wi:h under differing school environments are evi- dently needed before general progress in these directions can be expected.* Provision for enlistment of the children's coopera- tion with regard to advantageous factors must in the last analysis depend on the attitude of the school's teaching staff, and especially on the class teacher's appreciation of their essential values for health, and of their scientific and social interest. Constant contact with an adult whose o^^^l attitude tow^ard health is informed and creative, must ever be the most potent of influences the school can bring to bear on the development of a health program, and of a tradition of health within the school. Under such influence the facts of daily environment and routine deliver their true message, and are raised to their true dignity. So far as the experiences offered by advantageous factors lead on to wider fields of interest, an educa- tional program of very special value may be de- veloped, although it may have little increased signifi- cance as a health program. The more modern types of school curricula where subject matter is definitely organized about the child's natural interest in food, shelter, and clothing, thus present special possibili- ties for supplementing the health program and will in turn be reinforced by it.f * See Appendix D — where an experiment of the kind is outlined. t For illustration see Goodlander, Mabel B., Education through Experience, Bui. No. X, Bureau of Educational Experiments, 1921 — where a number of class projects in food study (fourth grade) are described. AN EDUCATIONAL PROGRAM 247 This will be especially true of those age periods chosen for the more intensive health programs. Food experiences offered by the school can probably be provided to the best advantage in connection with such programs. When necessary adjustments can be made to permit such first-hand experiences as the selection, purchase, preparation and serving of food by the children themselves, the informational con- tent incidental to such activities will greatly enrich the experience and the children's cooperation will be easily enlisted. Such activities should be organized from a viewpoint somewhat different from that usually held by the Domestic Science Department, in that the specific object should be, not so much the technique of cookery, as the study of foods, their values and place in the dietary. The content of such a series of lessons should be determined principally by the recognized need for broadening the dietary of the young child, and there- fore the emphasis should be placed chiefly on fresh vegetables, cereals, milk dishes and eggs, as the types of foods with which the home generally experi- ences the greatest difficulty in establishing satisfac- tory dietary habits. Simple equipment and simple methods of preparation are all that should be con- sidered in such a course of instruction for elemen- tary grade children. A most important factor how- ever is the provision of opportunity for the class to serve and eat their dishes, and thus secure the effects of the group appeal in acquiring a taste for new foods. In connection with such experiences we must appreciate that the program that educates to the importance of caloric intake, ivithout special em- 248 HEALTH EDUCATION pJiasis on conceptions of balanced feeding and vita- mine intake, is inadequate. Our initial program for diet and school feeding especially emphasized the importance of caloric in- take and in this followed the general lines prescribed by Dr. Emerson. Insistence on the elimination of tea and coffee, and on milk as an essential of the child's dietary, however, adds to his program some additional elements of importance, and the emphasis on cereal foods is a particularly practical method of supplementing the dietary with inexpensive carbo- hydrate foods, with the least possible danger to interference with the family budget and customary menu. Our experience seems to indicate the insuffi- ciency of this simple program, for a community of the kind in w^hicli we were working. Acquaintance v/ith the dietaries of the homes shows lack of knowl- edge as to balanced diet, lack of knowledge as to vitamines, their place and importance, as to fats and the ability of young children to digest them, as to the peculiar properties of milk, and as to the undesir- ability of condiments especially in the diet of the child. Incomplete as present knowledge in regard to food properties must be admitted to be, very con- siderable progress in this field of science has been made in recent years, and any program of health undertaken in the school must take cognizance at least of the best authenticated facts of recent labora- tory experiment. THE CORRECTrVTE PROGRAM While the true starting point for an educational procedure is the development of the general health AN EDUCATIONAL PROGRAM 249 program with prevention as its aim, the school can- not ignore those children whose physical condition indicates the need of corrective measures and special care. For them a corrective program supplemen- tary to the general program must be arranged, but many of its details and provisions Avill of necessity vary with the varying conditions offered by the homes of the school community, and the adequacy of the health provisions incorporated by the school in its preventive program. In general we must antici- pate that special provisions affording advantageous factors ivill he a necessary part of the corrective program inversely to the proportion in which the home and school environments afford them. There are still many questions to be answered, however, as to the relative value of differing provisions especi- ally those relating to food intake and air, before our use of advantageous factors can become scientific and correspondingly efficient. Further experiment is needed to establish the place and character of the school lunch in the corrective program, and special research as to the effect of varying conditions of temperature and ventilation on the nutritional proc- esses and growth, must determine the place of the open-air class and the open-window room.* Whatever the special needs of a given community, the essential provisions of the corrective program must concern the extension of the school medical ser- vice to provide special examination, diagnosis, and observation, for children whose nutritional status is in question, as well as for those presenting obvious defects or symptoms of infections and diseases. In * See Appendix D. 250 HEALTH EDUCATION addition to underweight for height and age, over- weight for height and underheight for age must be included in our conception of defective nutritional status if the program is to be in any sense complete. The first function of the school medical staff, then, will be to determine cases needing special physical care, improved regime or medical treatment, and to inform the home of its findings. Where the home cannot supply the necessary medical care, the school medical staff must be prepared to assume the re- sponsibility for arrangements with the various hos- pital and other agencies in the community, as was so generally done at P. S. 64. Here again the character of the community must largely determine the actual relationships to be established. THE STAFF When we review the foregoing implications for school procedure with the necessary members and personnel of an adequate staff in mind, the following conclusions force themselves to attention: The positive health program demands a con- siderably increased school staff. Its success must depend on a personnel capa- ble of coordinating the requisite knowledge and techniques from several professional fields. The relative importance of special types of technical training Avill not be the same for the preventive as for the corrective program. Numbers. — It will be realized that at P. S. 64 our staff were entirely concerned with problems of corrective work, and our experiment amply testi- fies to the size of the corrective program in that school community. The work, as reported, in- AN EDUCATIONAL PROGRAM 251 eluding physical examinations, weekly measure- ments, individual and class instruction, home visiting and parents' meetings, and arrangements for cases needing special consultations, examina- tions or treatment of defects, with, in addition, the measurements of the control groups, consti- tuted a really arduous program for our nutri- tion workers, who were able to care for an average of but 40 children each, and who felt keenly the need of more extensive provisions for medical care throughout the experiment. Moreover, the de- mands on the physician's time were relatively in- creased. Because of the diversity and importance of the causal factors underlying malnutrition, diag- nosis of the condition requires care and experience on the physician's part. Thus, in any adequate plan for a corrective procedure, physical examinations ar- ranged for the children found to be underweight must be given a longer time allowance than is customarily provided in schools, and the number of under- weights that can profitably be examined in succession is limited by the tendency for the procedure to be- come a mere routine, where one child after another presents no clearly defined symptoms beyond those of poor general condition. Six or eight under- weights probably represent as many cases of this kind as one physician can profitably undertake to diagnose in succession. Beyond the mere statement that an increased personnel is required, however, it is hard to draw just inferences as to the probable number of workers needed in a different adminis- trative situation, where the corrective program is in the hands of the regular school medical staff and 252 HEALTH EDUCATION is supplementary to an adequate preventive pro- gram. It will be evident, too, that the initiation of any health program will inevitably demand more time and effort than should be necessary subse- quently. After physical defects have been largely corrected, parental cooperation established, and community understanding secured, the proportions of the program will be correspondingly reduced. We may conclude from our experience, however, that unless an adequate staff is provided for the cor- rective program, its demands ^\all absorb the atten- tion of the workers, and overshadow the claims of the preventive program. Thus, although our pro- visions for health should start with those for pre- ventive work, practically, the existing need for cor- rective work must always be supplied before the time and thought of the workers engaged can be given to very much else, and our personnel there- fore must be definitely planned to cover the correct- ive work in addition to the general program. Personnel. — The principal techniques employed in the nutrition class are those of the physician and nurse, of the social case worker, and of the teacher. While the contributions of other technically trained workers are also essential, success in the main de- pends on provisions for the combined medical, sociological and educational attack, and the organi- zation of the work to permit the most effective con- tribution from workers in each of these fields. If we analyze the chief provisions of both the cor- rective and preventive programs, we will find these techniques represented with somewhat differing emphasis. AN EDUCATIONAL PROGRAM 253 The preventive program must provide for (1) or- ganization of the school's resources for health; in respect to physical examinations and record-keep- ing ; environmental conditions and equipment ; effect- ive cooperation of the class teachers and of special teachers, especially in the departments of physical training, of home economics, and science; (2) en- listment of the community and cooperation of the homes, through publicity, adult education, parent- teacher programs, and organization of the forces influencing public opinion. The corrective program must provide for (1) spe- cial examination, observation and diagnosis, with individual instruction and advice, for children whose physical examination indicates specific problems or lowered general condition; (2) individual follow- up to secure special provisions for care from the family physician or hospital agency, in the homes and at school. That is, the preventive program is primarily a teacher's program, dependent on physiological knowledge and the physician's advice to be sure, but essentially concerned with problems of school organization and teaching techniques, and with a supplementary program of adult education that calls for community social work rather than for social case work. It is evident that professional and tech- nical qualifications for corrective work will not in themselves constitute the necessary qualifications for the personnel of the school's general health pro- gram, and the subtle differences of temperament, in- terests, and attitudes that characterize the worker in the medical field, in sociology, and in education, must 254 HEALTH EDUCATION be considered in addition to any practicum for train- ing. The starting point of interest for the physician and nurse is, in the great majority of cases, ill- health. Pathology rather than hygiene absorbs their attention, and similarly, the interest of the sociolo- gist is, for the most part, centered on poverty and its problems. At the same time the physician, the nurse, the case worker, as a rule, have but little understanding of recent developments in education- al techniques, and, like most of the community, base their conceptions of acceptable procedures on the experiences of their own school days, 15, 20, 30 years ago as the case may be. The modern teacher has some very good grounds for instinctive reservations toward the "educational programs" suggested by outside enthusiasts, whose ideas of teaching in nine cases out of ten will be found to consist in the di- dactic presentation of additional subject matter. Physicians in particular seem, as a profession, to lack the necessary attitude for teaching children, possibly because their consciousness of the great body of subject matter incident to their own pro- fessional training renders them especially suscept- ible to the temptations of didacticism as a "short cut" to knowledge. Our nutrition class for the first term clearly showed the educational limitations and fallacies incident to a school procedure in the hands of specialists untrained in educational techniques. It seems evident that our positive health program must be entrusted to a new type of worker who shall be at once ahygienist and a teacher, who shall as such cooperate mth the teaching staff on the one hand, and with the medical staff on the other, supplement- AN EDUCATIONAL PROGRAM 255 ing each without superseding either. The advisa- bility of freeing such a worker entirely from respon- sibility for corrective measures, and thus ensuring individual effort and attention for the development of a constructive health program will be evident. The organization of the school's total resources for health, and the resulting modifications in the exper- iences afforded to all children, should relieve the corrective program from the necessity for class in- struction, and modify the requisite qualifications for its personnel accordingly. If the preventive program is primarily a teacher's jjrogram, the corrective program, on the other hand, is primarily the physician's and should be directed by him. The great variety of the causal factors in- volved and the serious nature of many of them argue the importance of the physician's services here, and the danger of entrusting the responsibility for diag- nosis, or advice as to remedial measures, to any worker of narrower experience or less thorough training. It will be evident that the services of the visit- ing case worker are necessary, to supplement the work of the physician and school nurse, and that the demands of the situation offer a distinct status for a medical social worker. In a community like that of P. S. 64, a dietitian's training is of undoubted advantage for the home visitor. Success, however, is primarily dependent on the case worker's attitude and technique, and in such a community the dieti- tian without these can hardly be expected to succeed. The place of the case worker and dietitian in school communities where better economic conditions ob- 256 HEALTH EDUCATION tain has yet to be defined, but development of the school health program in such communities will probably modify our present conceptions as to the scope of such work, and the necessary qualifications and training of the worker. Summary The health program that shapes itself from the foregoing interpretations must not discourage by reason of its proportions. It should lead rather to a new realization that "public health is purchas- able," and that the purchase price must include as always initiative, ability, and continued conscien- tious effort. So far as the experiment at P. S. 64 has broken ground by uncovering problems and pos- sibilities, we believe its record will prove service- able to the cause of public health and public educa- tion. The chief points in our thinking to-day as we bring this study to a close may be briefly summar- ized as follows : The efficient program of health education must recognize the primary importance of nutritional status as a basis for estimating general physical condition among children. Such recognition in- volves a considerable program of scientific research, community enlightenment and school adjustment. Results of the health program should he evaluated currently through individual records of groivth in- crement and nutritional status. Not merely pre- vention of lowered phj^sical condition and approxi- mation to currently accepted "norms" should be the aim, but physical vigor and height and weight in- AN EDUCATIONAL PROGRAM 257 crease in excess of our present standards for race and stock. The resources of the school for supplying the chief provisions essential to the success of an educa- tional health program are greatly superior to those at the command of any other agency. Great as the initial task may be, the school can eventu- ally transmit the necessary conceptions to the community and enlist the cooperation of both child and home, and it is the only agency organized to reach every child and every home. It is the only agency, therefore, that can advantageously secure the data necessary for research from all sections of the community, and present a true cross-section of child development from every type of home, and from adequate numbers of well children, of differing racial strains and differing economic levels. The preventive program of health education must he basic, an integral part of the school's general thinking, administration and equipment. It cannot be successfully developed merely as a procedure to supplement the corrective program. The school can greatly strengthen its educational practice by making the adjustments in its equipment and procedure demanded by the health program. On analysis these will be found consistent ^^ith successful educational experience. Indeed our health program well exemplifies what has been called "the normal estate of effective learning, namely that knowledge-getting be an outgrowth of activities hav- ing their own end."* * Dewey, John, Democracy and Education, The Macmillan Co., 1916, p. 229. APPENDIX A Distribution Table of Percentages Over and Underweight This distribution table was compiled from the re- sults of measurements taken in February 1918. It therefore reflects the comparative status of children in the several grades represented at a season when the period of maximal weight increase is over and before effects from the period of minimal weight increase have become appreciable. 258 APPENDIX A 259 Distribution Table op 894 Children According to Percentage Over- and Underweight * Percentage Grade VII Grade VI Grade V Grade I Terman Open Air 67 1 49-44 1 1 44-39 39-34 2 1 34-29 1 1 1 29-24 4 24-19 3 2 1 1 19-17 1 2 17-15 4 2 1 1 15-13 3 8 3 2 13-11 7 5 3 2 2 11-9 3 8 4 6 2 9-7 14 9 7 13 1 1 7-5 8 11 9 24 2 2 5-3 17 19 11 24 12 3-1 13 23 13 27 3 3 1-1 16 31 6 35 9 2 -1-3 23 28 13 24 8 1 -3-5 22 24 16 29 3 4 -5-7 11 30 11 22 6 5 -7-9 8 12 10 14 11 1 -9-11 6 10 4 13 2 2 -11-13 7 6 5 11 2 2 -13-15 3 2 2 2 -15-17 1 5 1 3 2 1 -17-19 4 3 2 -19-24 .... 1 -24-29 1 -29-34 1 Total. .. 173 245 127 255 69 25 * Computations for this table were made hj Dr. David Mitchell and the figures originally published in his article, Malnutrition and Health Education, Pedagogical Seminary, March, 1919. They are reproduced here by permission of the Pedagogical Seminary. APPENDIX B Individuul Record Sheet The record form used by us at P. S. 64 is a single sheet, 8"Xl4i/2", folded twice to make a six page folder of 5"X8" filing size. It may thus be used to hold supplementary sheets or correspondence rele- vant to the case history but is definitely planned to cover the essential facts of the physical history and examination, social history and class record on a single form and thereby avoid as far as possible the necessity for additional records. While further ex- perience has suggested a few changes of detail in this record, space for some additional notations, as for stool and urine examinations, and elimination of some non-essential details, it has been found fairly satisfactory for our purpose and of particu- larly convenient size for filing. The fascimile of page 1 shows at the right the items for identification, name, address, etc., printed on page 5 but appearing at the top when the record is folded and filed. Page 1 contains the final summary and weekly record for 19 successive weeks and this is extended to include 44 weeks, the spacing for the last 25 weeks covering page 6 when the record is folded. 260 APPENDIX B 261 W n3 93 , -II iii^i I ii'MMil ! I I i- I .1 M I p4i M I I I I I I A I ill 1 M I » I ( I I ( 1 M I ( t i Si I Mil 1 I 0|b V\^i>.i.i^:iA-i:i :i:i:>:i^^-:^^^ ^■\ 111 I U , 1 I 1 ( Cl M I I I 1 M I I I I f I tr» fO "* r>y t^ ♦S d /• v> ^ i cT a — ~ ^ N.c^t^ f«»t^/-«.c-^ r>»c-^s. ts.f^ f*»rs,^»^i»»i>-t^ev. >8 f>«w^ ^ ^ — ^^p-vS'^sa v9 t«* Nfif v9 r**v3 n3' ^ ^v. I I 1 V? I » / 1 'S M I ' I 1^1 I ■' -i I bLU K I ^- I C^ cr-^^^i^O^ >. (T "i.. iSiSiiiS 262 HEALTH EDUCATION PHYSICAL EXAaiNATION INSTBCnON: BrllM i/ dull frerroui l/ pld«tra«llo DSVKLOFMKNT: Good ttlu •^ poor UUSCLES: rre ••»» flKNI&U. CONDITION: Ceod r>lr 4^ poM BXAD: NonoAl • • IkMia promlnflnt Pedtcull t^ STBS: fMpOi (no •' nemct to ll>li»-UDea i/ UoUou: a«r l/omm. Bi«ta.1 KAlOl: Oear ^ matM Hunxu dlichui* Scar 0«llatedl«MB MOOTB: K«aal wot V^Cowk Banto Miina MOk. xmit WU •'<• TUNUUB: Kormtl nwlat t/^ tfry tL whlfffcoat fB&OAT: Koratl eonjcateil grtoulir ^. RracCM T0N8IL8; Konsal Iftrro bulled eryptio yC* laflUMd OLANDB: Norad cnlmal Ant-«rTlci] 'f— f Fort-oan. -f- TKBT^: Good No. dccaysd Appitoxlmatlon food \/^ poor Stalaod ■Alts: BUbtdnin: Konnil l^ dull ntractod bulilnc Omvam Un drum: Nonnd dull l/^ retracttd bultklf Cama nVAItT: Arat dttBuM io'S" c. m. left m]d-«t«nnl ttM / • ^ t m. right " • Ap« 4tb em 1/ eui n>K< is nippi* im «: D. outild* •• •• a m. iDjlda ** * , Action: nma Imsnlu *^ Boundi; dMi ia**m Tbrlll: pnaaot nooa b^ A3 'PI Bnnmui; nona tr. la •nt oinair I old. " aagia of sois •oft era. >^ ( cva v^ toud era. at J pulrponla dloatollo I aortic LDKOB: Raaonanco food throustiont V^ D'Eapina 10 / dor. f«lt«bf« ZlceplraUoo " •• \/^ ABOOMBN: Normal y^ lanra |u dlatended muf lllc aaftr Eerala LlTer: dulfaieaa U? apace rib to eootal toider olxM ■■• EVIeen: telt not felt l^ CBMITALS: Norma] ^^ Pr«vuco: loaf tdharcDl drvoaateai #^^ CXTItEMITIES: K J.r praent and eoual ^ aljaeot Edema " •• %^ eKlN: Sraooti 0~yw»*i dear s^-tra Vacdnaaoei: praaaol j/ atMM Facsimile of page 2— Individual liecord Sheet.— Nota- tions on Physical Examinations, APPENDIX B 263 PHVSICAt EXAMINATION (Ciatllind) BrtNE: Konntf I/' Latanl currattu*— riibl lJKf^^ M 3^ «» S(m*lIh -t 13 h-^-^ 13. iJL k«cs. 'Ificlude gtm-bont and miscarrlves tn order. DTPOBiUTION BEGilUJtNO BIBTH AND INFANCY Bora tl fuU term \x " " a<». Dreut-fed ) ) jy^^BoiUe Libor /I Oondiaoii tt MrUx |f^> Ulzad IstToothit lMj^W>lltal» V3 apotott|X| rnsTioua diseases (with DATES) «~i" l&-lA>-«r». Cblclnn-pox — TbuUlUi — Msmix ^— « RhsoniftUsio ,^^^ Ooonltkxtt ^^^ 8e>rl«t-fe»« — UnlDflUi — '■ Cbm* — DllfaUialt — PiiRiiiiaiili OptnUou _ Whooirtr-ff-eowtl — - Bnmchltlf — — ' OENEIUI. HEALTH AND HABITa Ainwaw <«peclaUj for breikfut) P^^|>Jj K»U-MtlBl "~* Il4fulAr1l7 of meaJ* f< ^ci « Bed'Wettmt -«*• Bovtli U> Seadsche FftqtieQi eoU< ^ COKDITION OF FLAT ana i/*" FuraiAhJfio '^ Va Is looa. ^^ - - b.d i^ lau) oa booi* /© -— 8'- 30 No. Boom* 3 Gv.^«vUtXt S.S.S^. /I^O./fcjur-C 1?./^ Facsimile of page 4 — Individual Record Sheet. — Social facts and health habits are recorded on this page. APPENDIX C 265 •OPPLEHEMTARY JHFO HATIOM PtXAAALltc. UAA.tA< <4_- -L*-erU»jUC -^-'-i^4- pXAO-* OAxf."^ ^O^Xaa, -tXJL<-Jl==> CJL^AJ-*-*. *r.i8-.l7;^. U-0^>v.>OU 1)~A(Vl. FoUJLuM. 4: r I i o ^ ^j> t Facsimile of page 5— Individual Record Sheet. — Sup- plementary information recorded on this page covers social facts and miscellaneous details. APPENDIX C Specimen weight charts with adaptations made during the course of the experiment. The weight charts used at P. S. 64 were of heavy white paper 24"X19". Charts Xa and Xb * show the original form used during the first school term. The name of the child is placed in large letters across the top and dates of the weekly class meet- ings are recorded jast below in the first two rows. Stars appearing in the third and fourth rows fol- lowing the words ''Lunches" and "Best" indi- cate that the child has followed his prescribed regime in regard to lunches and rest on each day of the week so marked. Figures in the left- hand column indicate pounds and are determined by placing at the bottom of the column a number two or three pounds below the actual weight of the child at the time of enrollnaent. Figures in the last row following the word ' ' calories ' ' indicate the num- ber of hundred calories averaged per day as esti- mated from the 48 hour record taken weekly. The heavy irregular line running across the chart is the record of the weekly weight taking showing the suc- cessive increments and losses of the individual for whom the chart is kept. Dotted lines indicate holiday periods and absences. The heavy straight line above is the "Line of Normal Expected Gain" and repre- • Eeproduced by permission of the Pedagogical Seminary. 266 APPENDIX C 267 sents the week to week weight increment for a child of normal weight and of the same height and age. (For»compiitation of this line see footnote p. 51). Xa shows a satisfactory record. The child in question was 8 pounds, 9%, underweight when en- rolled and in 13 weeks gained 9I/2 pounds, bring- ing him within 2% of normal. It will be readily appreciated that where the individual makes this kind of response, the line of normal expected gain acts as an incentive to effort, and it will be equally clear that for the child Xb the effect of the line of normal expected gain is discouraging to effort. This child was I31/2 pounds, 17%, underweight when enrolled and at the end of 19 weeks had gained but 3 pounds and was still 13i/^ pounds, 16%, under- weight. Charts Ya and Yb * show the form used for the fifth grade and open-air classes during the second winter and have the line of normal expected gain paralleled by a line of '' Individual Expected Gain'* that starts from the point indicated by the child's actual weight at enrollment and progresses by the same weekly increments. The two lines thus form a zone within which progress may be considered achievement. Ya is a low percentile case showing satisfactory progress: He was 5 pounds, 8%, un- derweight when enrolled, gained 8 pounds in 30 weeks and was then within 1% of normal. Yb on the other hand, is a high percentile case, whose re- sponse is unsatisfactory. He was 12 pounds, 17%, underweight when enrolled and after 30 weeks was 14 pounds or 18% underweight. It will be appar- • Reproduced by permission of the Pedagogical Seminary. 268 HEALTH EDUCATION Date lib .March April May dunQ 22 I & IS 22 Z9 3 \Z i9 26 J /o J7 2413/ "^ 14 2) ^ ^ ^ ^ ^ J^:** 2J J-f 20 2^9a9SS 26Z9Zt CHART Xa. Showing Line op Nokmal Expected Gain — a Satisfactory Record. APPENDIX C 269 Datcfcbruory March April May dune S IZ 19 ze 5 IZ 19 Z6 2. 9 W^ 2J JO 7 1^ Zf ZS -^ /I /& Ll/nch»t Rest 85 84 83 82 61 80 79 78 77 76 75 74 73 72 II 70 69 63 61 60 65 * * * * * * 3^ * * * ^^ ^" ^ ^v ^^ '^» ^ liohJi n .Z2. Z6 Z3 23 CHART Xb. Showing Line op Normal Expected Gain — an Unsatisfactory Record. 270 HEALTH EDUCATION M^X w^65 lb a::: P« Cau. Uulaw^ki fTT1^tt t ?tt ^n t ttl j^HT^t^ ilitl!^ n 1318 25 S' 17 1*12 13 14 18 15 17 19 I»ir8sei262ff 22 «a M 2988 II I31S 2° 8' 71 70 57 iMiMMMiMiiM l ii^i) AWEUN!' U-l '- ^, University Of California, Los Angeles L 007 449 463 4 REGIONAL LmRARVgiyjf J. J^QO^o?>^^^^ °