8 THE JOURNAL OF SCIIOOI, HLALTlI -
education can be largely eliminated. The schools through a comprehenhive program of health education can build the foundation for a health- educated adult . Some of these young people will go on to colleges :d universities where continued education should be available as they cope with health problems unique to their environment and those of particular concern in the college age group. Eventually they will leave and he absorbed into the community. Such an integrated and continuing program of health education should, in less than a decade, begin to produce an intelligent, health educated, and self-directed population thal places a high value on optimal health as an essential ingredient in a productive, constructive, and creative way of life.
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FITNESS, POSTURE AND OTHER SELECTED SCHOOL HEALTH MYTHS
J. PHILIP KEEVE, M.D., M.P.H.
Most people, busy supplying health services, rarely have time to h i t back and look dispassionately at the product of their labors. This is especially true of people who work in the field of school health. We : i r ~ , very naturally, thoroughly convinced of the value of our own persoiinl efforls and the redeeming fact that we must be doing something wortl i- while since it has to do with childrens health. But when we really IooL at i t , this business of the school somehow doing something useful regar(\- ing its pupils health, what do we find? We find, first of all, ihat this looking-at is extremely difficult to do because were not quite certain i L l l / t l / to look for. Moreover, once weve decided what to look for, where do w find it. Let me explain.
Illness: When, Where, What Let us straight away agree that we do not usually concern oursel\.es
with Health. We are really talking about deviations from an ever- changing norm. One obvious and very clear-cut measure of this de1-i:~- tion is its extreme end-point; and we all agree that childhood mortdity figures have fallen sharply in the past century. Although medicine ha.: made a contribution to this decline, economic and hygienic adrnriccs cle- serve most of the praise for this accomplishment. Even success in thc changing pattern of child illnesses has been largely offset by higher abscuce rates for more modern causes. Illness figures, in fact, seem to be invc related to the quality of the health care of a particular school popula (1) Strictly speaking, the word illness itself is so broadly and individunlly defined that it is extraordinarily difficult to make comparison from oiic year to the next, let alone between schools. It would be equally t i n - sound to attempt to make similar comparisons for accidenk Alt lioiigli most stales have some kind of uniform illness and accident reportill::
*Associate Research Professor, Graduate School of Public Health, ITniv of Pittsburgh, Pittsburgh, Pennsylvania. This paper was presented at the S(wool, HEALTK EDUCATION WORKSHOP (H.E. 799) for the Ohio State ITniversity, C o l t u n l t r i ~ Ohio, June 29, 1966.
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system, the only solid facts to come out of it are the number of occupied seats counted daily during the official school calendar year. When we begin to probe for the reasons for the classroom vacancies, the pathway to truth becomes extremely tortuous. Absentee reporting becomes a forced-choice questionnaire for the teacher or the school nurse. At best, these figures reflect a resigned acceptance of whatever the parent. child, or physician chooses to report.
You might at this point, ask understandably, Who cares? If Mom decides to keep Johnnie home to watch the baby while she does an im- portant errand and returns him to school the following day with a note claiming illness because she knows the real reason would he illegal or unacceptable-why raise such a fuss? The unthinking, authoritarian physician who keeps a child out of school for two weeks for uncomplicated chicken-pox is a far worse offender. Actually the problem student-the chronic absentee is, more often than not, usually out of school for reasons other than the traditional medical ones, and these would make lively social-casework reading. The whole point of all this is to emphasize the notion that we really dont have very accurate information regarding the true causes of school absences and it may prove very helpful to begin searching for them.
When we turn our attention to the children who do show up, we face another morass of issues. We feel instinctively that if the child is to profit by being present then at least his learning equipment, should he in good order.
Health Defects and Correction We waste a great deal of time looking for things which, in fact, have
very questionable value, and neglect vastly more important matters. Solnit and Stark have stated this problem as clearly as anyone.
Examples of what prevents the child with an adequate intellectual elidowmerit from learning include the following: defective percept u i l apparatus (for example, deafness) ; deviant visual-motor or auditory-motor co-ordination (for example, reading and writing disability) ; an inner state of excitement or anxiety that interferes with 1 he capacity to transform impulsive behavior into the psychic functions of perceptioii, thinking, remembering and so forth (over-stimulated or impulse-ridden child) ; overwhelming life experiences that ha1 e become associated with learning (for example, death of a parent); inhibitions in curiosity and intellectual activity that stem from parental prohibitions, especially in the spheres of sexual and aggressive thoughts; inhibitions that arise from the fear3 ot early childhood (for example, separation anxiety) ; and a home or school environment that interferes with the childs ability to concent rale nnd learn successfully (for example, a perfectionistic parent or teacher whose demands arouse resentment and discouragement) . . . . Just a5 a suc- cessful school experience prepares the child for assuming responsihilities in later life, one fraught with anxiety and failure leads to the 10s:: of *elf- esteem and to a self-defeating attitude. (2)
These kinds of defects, I submit, are not usually noted in school health records or annual statistical reports. Instead, we still find mis- guided concern with inappropriate trivia: flat-feet , enlarged tonsils, nor- mal developmental speech defects, runny noses, dirty fingernails, and
10 THE JOURNAL OF SCHOOL HEALTH
failure to eat an adequate breakfast. Another favorite rite we perform is the careful documentation of every decayed, missing, extracted and filled tooth in every mouth we can schedule to open during school hour>. We do this despite the fact that weve known for years that nearly every school child in this country has a dental defect. I t would be much more profitable to search carefully for reasons why some (abnormal) child reii lack dental caries, or to convince the dental profession that new ways must be sought to provide corrective services and oral hygiene education.
.hother favorite focus of misguided concern by school personriel and excessively worried parents, is the matter of posture and fitness. We still hold the notion, research findings to the contrary, that a healthy child should, somehow, perform his daily duties much more successfully if he tried to resemble an alert West Point Cadet-preferably at attention. There are no scientific facts to substantiate the benefits of this aesthetic ideal, yet a great deal of attention is devoted to correcting faulty pos- ture in many school systems. (3) In fact, the myths surrounding efforts to do something to or for the musculoskeletal system of children are stronger than ever today. I would like to use this subject of good and bad posture as a takeoff point for discussing some of the myths sur- rounding so-called modified or adapted physical education programs.
To begin with, lets dispel some of these myths by pointing out whal adapted physical education programs are, lets define our terms :
They are riot: 1. Physical-Therapy-Any attempt of treatment or therapy is patently denied to educational institutions by law. A child in need of these ser- vices should be referred to appropriate medical resources and they in turn will usually cheerfully co-operate with school authorities in mapping out an appropriate physical activity schedule for the patient while he attends school. 2. Character-Buildiizg or Psychotherapy-Physical educators, coaches and trainers have for years deluded themselves concerning the notion that participating in team or competitive sports will significantly modify under- lying personality disturbances. Repeated studies have shown that there is no positve correlation between athletic ability or fitness and a healthy, well-adjusted individual. (4) The more serious problems of physical and emotional disability which often accompany physical impairment require the professional services of those who are trained in the disciplines of psychotherapy. They, too, are happy to share responsibilities with the educator. 3. Corrective or Kenzedial Treatment of Medical Disorders-A coni- pendium of diseases found in current adapted or modified physical edu- cation texts (5 ) which are supposedly responsive to its services or remedies are :
Cardiac Defects, Cerebral Palsy, Seizure Disorders, Poliomyelitis, Vis- usal and Auditory Defects, Tuberculosis, Anemia, Diabetes, Malnu- trition, etc. Rarelv can these conditions be improved bv adapted or modified
physical kducation classes. may help strengthen muscles wasted through disuse. this is sheer charlatanism.
Physical thkrapy under medical supervision To claim more t!hari
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4. Physical Culture or Training-The cultist approach to medical problems is often taken when generally accepted treatment methods fail. We know that the medical quack arid cult-practitioners will always IN with us. Unfortunately, much of physical education and training ha.; (unknowingly) incorporated the tenets of cult medicine with its eniphasi.: on body mechanics and posture. Kinesthesiology, spinal alignmen(- examples: Goldthwaite is convinced of a strong relationship bet ween faulty body mechanics and chronic illness, (6) while Rathbone believes that posture reflects the general state of physical and mental health. (7) Daniels and Davies state that good body mechanics promotes optimum growth and development, decreases fatigue and that poor mechanics ma). cause structural malalignment and possibly lead to chronic conditions. (S) It is almost beyond belief that educators are exposed to the following incredible nonsene: ailments such as backache, constipation, eyestraio , chronic fatigue, varicose veins, enlargement of the prostate gland arid many others have been shown to result in some persons from faulty posture and are often considerably improved or completely cured by correction of the posture. (9) Nor is there any scientific basis for the statement that exercise (may) prevent serious conditions from becoming surgical cases (10) or that faulty posture habits, sight and hearing problenis cause spinal scoliosis. (I 1) If adapted or modified physical educnt ion i.: not those things previously categorized what, then, is it?
The usually accepted special aims of the adapted physical educatioit programs are : 1. Correct or improve conditions which respond to physical-educat ioii
programs. 2. Aid the personal and social adjustment of permanently impaired
students. 3. Explore and develop the physical capacities of the impaired individual
student within the supervised environment of the school. How feasible or realistic are these goals of public education? Hon
appropriate are they in relation to the aims of the regular physical-educa- tion program? Perhaps a brief glance at these overall objectives might also help clarify the issues at hand.
Two of the major goals of most physical education programs aiv widely accepted and have generally unquestioned value; they provide B natural energy and socially useful aggression outlet, and supply healthy peer-group activity. These goals are not really challenged by physical- fitness skeptics. The means of achieving these goals are however the sill)- ject of controversy between the medical profession and the educator.
Honest and critical reappraisal of some traditional stone-images of physical education, has, in fact been the driving force of some of today? innovation in the field. One of these sacred-cows is the subject of Yitnes? tests. The current interest in fitness testing came about through two sources: one was the Kraus-Weber proximal muscle test findings in which Americans were unfavorably compared with European children. (12) Mi+ interpretation of these tests produced extensive overconcern with fitness testing in this country. The other source of anxiety concerning the health of young people was the mistaken widespread notion that a majority of our armed-forces rejectees had defects which might have been corrected by early medical and physical fitness intervention. Both these issue5
12 THE JOURXAL OF SCHOOL HEALTH
st iniiilated heated debate and superheated programs but failed t o provide any \uhstantially clearer definition of what physical fitness itself WLS all about.
If we may set aside ethical, aesthetic, moral and religious question5 for the moment, and consider the physical components only, fitness be- come\ a human attribute which may be more readily defined and me%- wred. Several major authorities fail to make this distinction and main- t n i i i that any clear definition of physical fitness is almost impossihle be- cause the concept itself is too complex and elusive.
Gsllagher and Rrouha categorize physical fitness, not total fitness, a. eitlier medical, functional or motor fitness. (13) The important, questioii is whether functional or motor-skill fitness bears any relation to longevity or individual level of physical health. There are some clues that physical fitness and good health may be causally related but much more research ih needed to prove it. (14)
Testing for motor or functional fitness presumes the existence of ac- curate and generally accepted national norms which are presently lacking. Cureton defines motor fitness as a limited phase of motor ability which emphasizes the capacity for vigorous work or athletic effort. (13) Consolazio defines physical fitness as quantitation of the ability to per- form a specific task requiring muscular effort in which speed and endurance are the main criteria. (16) He goes on to add, however, that at the present time, there is 110 single test that can measure more than a few kinds of fitness. Appropriate to this discussion then, would be 1 he question of which kinds of fitness are we interested in? Answers to this quest ion require imaginative, almost visionary thinking.
Physical education might consider one of its goals in addition to energy and peer-group activity outlets, the ability to survive in CUII- temporary and future society. What are todays survival needs? W h t mag be the survival needs of the future? And pertinent to these que+ tions is the need to survive under predictable stressful condit,ions includ- ing the handicap of personal physical and mental impairment. At first glance this seems like an impossible task, yet all of us at some time hale had to face this problem in one way or another. Most of us have had the temporary functional loss of an extremity or one of our sensory organs. ~ J J - not start teaching simulated functional loss or impairment a t an appropriate age? Anibi- dexterity may have many kinds of usefulness in addition to enhanced rehabilitative capability after a cerebrovascular accident. The same can be said for learning to function in total or semi-darkness. Survival techniques would also include the ability and skill to adapt to a variety of environments : water, heat, cold, confined space, increased or diminished atmospheric pressures, high-speeds and gravitational stresses, radiation, and heights and depths. Here again, the kind of experiences which mag be offered to children and youth is limited only by the imagination of the personnel administering the physical-education program.
Another aspect of survival now commanding more attention is the need to make the so-called non-productive portions of our life more worthwhile. I purposely avoided using the terms meaningful or en- joyable because the former is meaningless and the latter too narrowly confining. Here again, the physical-educator whether he likes it or not,
This suggestion is not as radical as it sounds.
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will be involved as a resource person in offering advice and instruction 011 the personal and individual use of leisure time. Our technologic skills now provide vicarious pleasures ranging from synthetic flavors and psychedelic drugs to live television and wide-screen, three-dimensional cinema. It would appear that the need for first-hand experience is almost anachronistic. The argument here is not a clarion-call to return to Thoreau and the innocent pleasures of natural-man but an appeal t o public-policy makers to consider the importance of searching for creative and useful outlets for the total range of life itself. We shall need to explore all sorts of new group and individual recreational and play activi- ties, and direct the need to create, to compete, exert and endure in such ways as to provide these satisfactions to a greater number of people than has ever been possible in the past. Physical education must free itself of the Fonds of traditional recreational games and have the courage to pioneer and innovate in un-thought-of directions. This same kind of ap- proach has a direct bearing on the needs of the individual student in the school physical-education program. To be doing an appropriate and justifjable job, we must prepare the child for leisure activities which may be piirsued, enjoyed and developed throughout his lifetime-not just his youth. One of the aims of the so-called modified or adapted physical- education program is to enable all children, including the different or exceptional one, to maintain his identity with the group. If this aim is desirable then the target population must be identified. Who are thew children?
Suggested candidates for an individual physical-education program are : 1. I egally or Reportable Physical Handicaps-Most states now re- quire an annual census of physically handicapped residents and schools often maintain their own rosters of these students. It would be difficult to catalog physical impairments which any child attending public school might have that would preclude some kind of useful recreational or physical education activity. For that matter, most people with physical impair- ment often require more energy expenditure to maintain normal weight than the non-handicapped. The program should, of course, be planned at a joint conference of teacher, parents, student and medical advisor. There is little need for exotic or elaborate equipment or facilities for these students but there is a need for additional supervisory and teaching personnel for them. 2. School-Reportable Conditions Including Physical Education Excuses- Most convalescent patients would benefit from an individualized physical education program. This includes students who are excused from the program for psycho-social reasons. 3. Mental-Retardatioia Classes-These students obviously require special attention and many specially designed programs are available for them. 4. Juvenile ObesitySince most obesity is due to food-intake and energy- imbalance problems-this group would also require individualized or small group sessions. Close cooperation and planning with parents, personal physicians and school-cafeteria personnel is essential for a suc- cessful attack on this, the second most common health problem in school- age populations.
14 THIS JOURNAL OF SCHOOL HEALTH
5. Late-Maturers-Recent long-term studies of late-mat uring children in- dicate that they are indeed handicapped by their tardy physical develop- ment. At age 33, men who were early maturers were still making better impressions, were more dominant and responsible and less impulsive than late-maturers. Mussen and Jones found that late maturing boys were much more inadequate, dependent and rebellious. (17, IS) Girls are simi- larly disadvantaged by late maturation. (19) This inferiority also has its impact on intellectual functioning as well as social accomplishments. If an individualized physical-education program could successfully over- come some of the handicaps of slow maturation by providing enhanced self-esteem, by increasing personal recreational and social skills, by con- trolling disadvantageous competitive group activities and other kinds of supportive and ego-building efforts, then this program may have some permanent and very important assets l o add to the curriculum. There is no evidence a t present that exercise alone will have any long-last irig affects on the student. We know too, that another desirable personal attribute like strength is strongly correlated with body build and niatura- tion. Motivation and training and other non-physical factors have a negligible effect on this genetic attribute. Like so many other aqxcts of school life, athletic success becomes a self-fulfilling prophecy-the child who studies more gets better grades and is rewarded and consequently continues to study more. The early maturing athlete practiceh more, becomes stronger and more skillful and practices even more. As usual, those in need of training most, become the spectators, not the performers in life. 6. The Potential Drop-Out, The Chronic-Absentee, The Scholastic Failurf- Most students in these categories would also profit from the ego-strength- ening aspects of individualized attention a t school. Any modality offering an opportunity to succeed, no matter how seemingly trivial will add to the Yecurity and trust they often lack in other areas of their lives at whool and nt home.
There are many ot,her current myths in school health which might he dispelled. 1. Special classes for handicapped students 2. Use of school nurses for non-nursing duties 3. Useless routine physical screenings or evaluations
These and many others are, for the most part, tolerated by people who do not wish to rock the boat or lose secondary gains offered hy the secure, time-tested, and traditional job-role. The new federal programs will force better ways of providing medical services in every commiinity. The nest phase, once this Ijurden of the school health program is relieved, mill he the hopefully inspired renaissance of health education and the creative aspects of life-physical, cultural and emotional-which the school will share in providing for from infancy to the halcyon d a ~ , \ ot old age.
REFERENCES 1 Price, B. School Health Services-A Selective Review of Evalunlive S m l z e \ ,
Childrens Bureau Publication #362, Washington, D.C., U.S. Dept. of Health, Education, and Welfare, 1957. Solnit, A. & Stark, RI. Pediatric Management of School Learning Probleniq of Underachievement, New Englund Journal of Medicine, 261: 988-993. Noveni- her 12, 1050.
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3. Asmuseen, E. & Heeboll-Nielsen, K. Back in Boys, T to 16 Years Old, Acta. 0,rthop. Scand., 28: 174-189, 1959.
4. Logan, G. Research Con erence, Columbus, Ohio: Ross Laboratories, 1958, page 65.
Itow, 1965. 6. Ibid., page 116. 7. Zbid., page 117. 8. Ibid., page 118. 9. Ibid., page 124.
10. Ibid.. iiaae 119.
Posture, Mobility and Strength of ( I N
Competitive Athletics and Physical Fitness, 26th Ross Pediu/ri(.
5 . Daniels, A. d . R Davies, E. A. Adapted Physical Edzication, New York: Harper tk
11. Zbid.; page 125. 12. Kraus, H. & Hirschland, R. P.
24: 17. 19.53. Muscular Fitness and Health, Res. Quart.,
I -. 13. Gallagher, D. & Brouha, L. Physical Fitness; Its Evaluation andSignificance,
Journal of the American Medical Association, 125: 834, July 22, 1944. 14. Norris, J. N. & et al. Coronary Heart Disease and Physical Activity of Work,
Lancet, 265: 1053, 1953. 15. Cureton, T. I