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British Red Cross Society maternal and child welfare manual no. 9
March 1957
Book Reviews Five Hundred over Sixlff. A Community.Survey on Aging. By BERNARD KtrrNER and others. (Pp. 345. 32s.L New Yorlc, Russell Sage Foundation. 1956. " A t Kips Bay:Yorkville Health Centre, in New York City, the health needs of 250,000 people in the area had been reasonably well met." But almost nothing was done for the great and growing number of old p e o p l e - - f o r the simple reason that knowledge was lacking as to what to do. It was'obvious that the medical aspect accounted for only part, of the need, in which, economic and social factors loomed large. So a committee was .formed, representative of university and "other organisations in the city, including the Russell Sage Foundation. T h e committee decided that the best way to learn o f the needs of old people was to ask them, personally and individually. Hence this survey, which considers-not only health, but patterns of adjustment in old a g e . One hears much nowadays of maladjusted children a n d the evil fate which awaits them ; but maladjusted among the elderly is no less a cause of trouble, as the investigators found. Morale and a due appreciation of the social self also count for much among them no less than among the young. A n d one should not forget that " t h e sixties are usually the most critical years for the older person." This book contains much factual information and has mubh of value to say of concrete services and programmes for work among the aged. It is inspired throughout by an u n d e r s t a n d i n g - a p p r o a c h to the problems O f - t h e individual human being and can be read with advantage by both doctor and social worker. It has an excellent bibliography extending to nearly thirty pages.
tion of new drugs has not abolished the need for other methods of treatment. The survey has brought together and analysed a mass of valuable information.
Psychology, Psychiatry and the Public Interest. Edited by MAURICE H. KROUT, PH.D. 6Pp. xv + 217. s 12s.) Minnesota University Press. London : Oxford University Press, 1956. The contributors to this book are 13 psychologists from various parts of the U.S.A. and one medical m a n - - P a u l E. Huston (M.D., YALE ; PH.D., HARVARD)who is Professor of Psychiatry in the College of Medicine at the State University of Iowa. They devote themselves to various aspects of the spheres a p p r o p r i a t e to those trained in psychology and psychiatry, and consider the way in which the public interest may best be served by their professional activities. The psychologists discuss the work that they do in collaboration with others not only in the medical, but also in the educational and other fields. They also deal with their position in the role of independent practitioners, in which capacity severa| of them have been working for years as psychotherapists-as apparently are hundreds of other in the United States. We are told that the main problems which "have to be dealt with in practice fall broadly into such categories as (i) marriage (or courtship), family, and sex, (ii) relations with those Outside one's family, (iii) " getting along with oneself," (iv) vocational and economic difficulties, (v) health problems, and (vi) religio----ethical problems. The orthodox position of the medical profession in regard to psychotherapy is put forward by quoting a statement approved by the American Medical Association and in a letter from the medical director of the Veterans' Administration. In greater detail the medical standpoint is dealt with in two articles by Dr. Huston. He sees a wide field of useful work for the psychologist in research of which there is great need. In psychotherapy also there is a place for the psychologist ; but Dr. Huston is at one with the American oPsychiatric Association in being strongly opposed to the independent practice of psychotherapy by psychologists. Clearly, the campaign now afoot in the U.S.A. to secure licensing of psychologists for this purpose is likely to meet determined opposition.
Minimal Pulmonary Tuberculosis found by Mass Radiography. A R e p o r t t o the Prophit Committee of the Royal College of Physicians of London. ]3y V. H. SPRINGETr & A. ;l. ELEY. (Pp. xiv + 233, with 16 charts and 65 photographs. s 2s.) L o n d o n : H. K. Lewis & Co. 1956, One of the aims of the original Prophit Survey was to ol6tain information concerning " t i m interpretation of certain x-ray appearances which are at present of doubtful import, and the question of spontaneous healing of tuberculous lesions even in the absence of treatment." In 1944, when that survey was concluded, mass radiography was beginning to reveal a large number of~such small foci in the apparently healthy; but there was no general agreement as to their correct management in regard to treatment. It was therefore decided to conduct a five-year follow-up of 500 persons of each sex found by mass radiography to have such abnormalities. Selection of cases took place between January 1946 and Ocl~ober 1948, and the.information obtained after a minimum of five years in each case was what was available in January 1954." These dates are in~portant because, as the authors point out, so far as treatment is concerned, previous measures have been rendered completely out-of-date by the new antibacterial therapy. The findings on the interpretation of x-ray appearances are, however, still valid ; and the introduc-
British Red Cross Society Maternal and Child Welfare Manual No. 9. Written at the request of the Society by DENNIS GEVFEN, O.B'.E.,M.D., D.P.H., & SUSANM.r TRACY,M.R.C.S., L.R.C.P~, D.P.H. Ninth Edition. (Pp. xi + 170, with 2 Plates and 48 Illustrations. 6s.) London, Cassell & Co., 1956. In a foreword to this manual, Lady Limerick expresses the hope that it will "be of great value not only to V.A.D. Members of the Society, but also to a much wider public. We certainly think that it will. It deals in a clear and interesting manner with the problems with which the expectant and (Continued on page 121) 117
PUBLIC H E A L T H
The Fountain Hospital* By L. T. H I L L I A R D , M.A., ra.a., D.P.M. Physician Superintendent, Fountain Hospital HE Fountain Group of hospitals for certified mental defectives consists of the main unit, the Fountain Hospital at Tooting with 600 beds for children of idiot and imbecile grade, and four smaller specialised units. The Ellen Terry Home at Reigate trains 50 blind mental defectives ; the South Side Home at Streatham provides a hostel for feeble-minded or high grade imbecile women ; Brooklands at Reigate is a small home for adolescent imbecile girls ; and Osborne House at Hastings prqvides training for boys of the same grade. Osborne House is also used as a holiday home for suitable patients in the group who each spend two weeks there during the six " s u m m e r " months, By specialising in the care of children the Fountain Hospital has been able to investigate the problems of young defectives and to provide an environment designed to cater for their needs. By agreement with the four Metropolitan regional hospital boards concerned the Fountain Hospital itself admits only mentally defective children under five years of age from the counties of London and Surrey. The average age on admission is under three years and consequently the mole obvious and serious cases with microcephaly, hydrocephalus, mongolism, cerebral palsy or epilepsy tend to be admitted. Such children need skilled nursing and owing to their liability to respiratory or alimen-
remain at home instead of being .institutionalised. This is becoming increasingly possible owing to the greater understanding which is developing both among parents and the general public of the problems of the mentally "retarded child. For many years there has been an increasing tendency for paediatricians, medical officers and others responsible for advising parents of merltal defectives to recommend institutional care. This has reached a point in the United States where many mothers of mongol children have been told as soon as their child is born that they should put it in an institution for defectives, never see it again, and tell their friends and relatives that it has died. The emotional stress which develops in parents who try for the rest of their lives to live this lie is very considerable and is not conducive to their happiness. Fortunately the parents of'retarded children in U.S.A. and in Britain are realising that the problem of mental retardation must be faced by both parents and public and not kept hidden away as a guilty secl:et. Hospital and Parents
T
Where a child has to be placed in an institution the parents should feel able to do this openly and without a sense of shame, just as they would let their child go to a sanatorfum or residential school for the blind if that was in his best interests. To encourage this feeling of-conscious co-operation, the hospitals concerned must not have rigid rules limiting visiting or making it difficult for the parents to have the child home on leave. The legal procedure, of certification and detention under a magistrate's order is quite outdated in the case of children and, pending the revision of the Mental
tary infections the death rate is relatively high among the newly a d m i t t e d patients, Admissiola Priorilies The demand for beds is very great and the less urgent cases have to wait several years. Priority of admission is given in relation to the medical, social and psychological needs of the families concerned. An incontinent defective child needs nursing care which the mother cannot provide in an overcrowded room on the top floor of a house with no water or sanitation easily accessible. Sometimes the mother is a widow who has to go Out to work and cannot give the
Deficiency Act procedure which is expected to follow the report of the Royal Commission, parents should be encouraged t o " place" their child in hospital under Section 3 and retain their feeling of responsibility for his welfare. All children admitted to the Fountain Hospital in recent years whose parents could be traced have been admitted under Section 3 and this has improved the relationship between
child supervision during the day and there is no one able or willing to help. A defective child's behaviour may be so disturbing to the family or to the neighbours that it is irapossible for him to remain at home. In such cases institutional care is at present the best and only alternative. It has been our experience, however, that the parents of some of the children admitted to the Fountain Hospital would have preferred to continue caring for their child if suitable facilities could be provided. In general a child develops better with family care than in a large institution. It is not possible to generalise and each case must always be considered individually. Most defective children will derive more intellectual stimulus and less emotional inhibition if they can
parents and hospital staff. Another recent facility which has been of help to parents is the temporary admission without certification for periods up to eight weeks under Ministry of Health Circular 5/52. This procedure can be used where a defectix~e normally cared for at home needs short term hospital care while the mother is ill or being confined or in need of a rest or holiday. It can also be used where the child is ill and needs in-patient treatment or requires admission for investigation or psychological assessment. 9 If permanent institution care is to be avoided in suitable cases, it will be necessary to increase the welfare services available to defectives in the community. Proper housing with sufficient rooms to accommodate the defective in a room of his own, and with modern sanitation and access to a garden
* During a refresher course for school medical officers, arranged by the Society of Medical Officers of Health, those taking part visited the Fountain Hospital, when Dr. HiUiard delivered these introductory remarks,
is essential. 1t8
Financial assistance is necessary if the child
March 1957
The Fountain Hospital
requires extra laundry and clothing owing to his dirty or destructive habits a n d also where the mother would otherwise have to go to work. Reasonable financial grarits of this nature would be a l e s s e r charge on public funds than permanent institutional care.
of educability is related t 9 the facilities available. There can be no sharp demarcation between the training given in occupation centres and educationally subnormal schools and the transition from one to the other should be as easy as possible. It is interesting to note that in a period of five years, 44 Fountain children certified as mentally defective, i.e. ineducable, have been discharged from the Mental Deficiency Acts and given places in special schools. One of the most difficult problems in the diagnosis of mental deficiency is the case of the doubly handicapped child where an apparent mental retardation is associated with another disability. This may be an early psychosis, or a behaviour disorder due to adverse home conditions, or emotional deprivation resulting from early institutionalisation. Physical disabilities include cerebral palsy, epilepsy, deafness and blindness. Although these conditions may usually be easily diagnosed, high tone deafness, poor sight, minor degrees of cerebral palsy and many behaviour disorders may be overlooked or be attributed to the mental deficiency. Even where the several handicaps are obvious the contribution which each makes to the total picture is often difficult to assess. One of the advantages of working in a mental deficiency hospital is that the staff have fairly close daily contact with patients over long periods and can observe the often considerable changes that occur in their mental capacity as time passes or the environment is changed. The lessons that can be learned from the ultimate achievements of some of our patients make one hesitate to be too dogmatic as regards the intelligence levels of young children or the social competence of the so-called high-grade adolescent defective.
Advising 'Parents Better facilities for advice to parents are needed. Suitably trained health visitors able to give practical guidance in the care of defective children, and assistance from home helps may reduce the mother's tasks to reasonable proportions. Mental deficiency out-patients clinics, such as those held at the Fountain Hospital and a few other centres, can give considerable encouragement and support to parents. Local parents' associations and branches of the National Society for Mentally Handicapped Children have given moral support to despairing parents and have also been able to make representations in official quarters for improved facilities for defectives. The Society's activity i n meetings, Press, radio and television has been one of the main factors in the recent more sympathetic attitude of the public to the needs of the defective in the community. The Friends of the Fountain, our parents' association, is one of the most active in the country and has raised more than s for additional buildings and equipment for the hospital which could not be provided out of national resources. Suitable training is essential for all defectives. With the lowest grade idiot the most elementary habit training is all that can be undertaken but this, if patiently pursued, will make his subsequent supervision and care less arduous. For the child of imbecile grade early access to occupation centres--better thought-of as training centres--is essential if his capacity is to be developed to the maximum. There is at present a very great deficiency of places in occupation centres, and official figures show that one-third of the children officially recognised as suitable for occupation centre training are unable to receive this. In fact if more training centres were available many more children would benefit from attendance. Some could start at an earlier age instead of waiting for a vacancy, others could remain at home and attend daily instead of having to be sent for residential care. A number of children previously requiring institutional care as the only alternative available have been discharged from the Fountain Hospital when appropriate provision has been made for them in the community by improved housing, financial grants or the opening of a local occupation centre.
Examples of Cases Examples which illustrate this are the following : 1. A boy admitted as an imbecile was discharged from the Mental Deficiency Act when given a trial in an educationally subnormal school. At 15 he was excluded as ineducable and recertified and sent to another M.D. institution. He is now under guardianship as he has no home and resides in a hostel but is able to earn his living by working in a plastics factory. 2. A blind boy at the Ellen Terry Home was at the age of five considered to be an idiot as he could do nothing for himself. He is now making good progress in an educationally subnormal residential school for the blind. 3. A deaf boy was certified as an imbecile and in spite of representation was for several years refused special education because his very disturbed behaviour was attributed to imbecility. He is now well above normal intelligence and is in a grammar school for the d e a l 4. A girl with severe cerebral palsy was certified as a n imbecile because her lack of response was attributed to a mental rather than a 'motor defect. She is now in a school for mentally normal physically handicapped children. With regard to adults who are certified as feebleminded usually for social reasons, our experience has been that many of these persons can adjust satisfactorily to community life if given friendly help and guidance in a suitable environment. Segregation in a mental deficiency institution against their
Temporary Care Another relevant problem is the question of ineducability. It should be realised that there is no clear cut level of educability and there are many anomalies when the assessed capacities of retarded children are compared, not only in different Counties but' also in different schools for the educationally subnormal under the same local education authority. The present provision of special schools is, as in the case of occupation centres, very much below the officially admitted requirements. Here again the criterion 119,
The Fountain Hospital
PUBLIC HEALTH
will does not usually help them to learn to live in t h e community. Parole conditions in a hostel with suitable employment is:usually a quicke~ and more effective form of rehabilita, t i o n . Of: 250 certified feel~leminded women admitted to the South Side Home, 'either as direct admissions or transferred from other institutions, 60~o have beeri discharge# from the Mental Defi~ienoy Acts and are self supporting in the community. These patients have been carefully followed up by our social worker and we have been surprised how well they have adjusted to normal life, some after many years in an institution. Fourteen per cent of these discharged women are now married. A psychological assessment of the children of our adult patients is in hand as a research project and preliminary results are contrary to the usual dictum that
many defective children will be born to allegedly feebleminded women. The Fountain Hospital is fortunate in having considerable research facilities.. The psychiatric, neuropathological, biochemical, psychological and social work depalkments collaborate in research projects and in the investigation of individual patients. There are also facilities for x-ray investigation, audiometry, speech therapy and physiotherapy. In these days of lack of nursing staff in mental deficiency hospitals the Fountain is also fortunate in having a relatively high c o m p l e m e n t . . Our nurse training school now has 44 student nurses and is one of the largest in mental deficiency hospitals. The five occupation centres in the group have a staff of 20 and accommodate 280 children.
A Residential Special Trainilig School for Blind Defectives By C. E. W I L L I A M S , M.n., cH.n.,
Senior Psychiatric Registrar, Fountain Hospital Group HE Ellen Terry Home at Reigate, Surrey, was founded by the Servers of the Blind League and was formally opened in 1926 by Ellen Terry. The Servers of the Blind administered the h6me until 1948 when it became part of the National Health Service and was incorporated in the Fountain Hospital Group. The home is for blind mental defectives. There are three teachers attached t o the home, one of whom-is a qualified teacher of the blind, and training is largely on the lines of that given in ordinary occupation centres (special training schools) but suitably modified for sightless children. Children are admitted from all regions of England and Wales. A t the present time nearly half of the 50 beds are oecupied by children of very low intelligence who, if not unaware of, are at least indifferent tb, their surroundings and are quite incapable of responding to simple training, These c h i l d r e n were admitted o n . a medical recommendation without preliminary assessment. To obviate this waste of good facilities the hospital now admits all applicants for a preliminary period of assessment and trial. This is done under the terms and conditions of the Ministry of Health Circular 5/52 and so does not require that the child should be ascertained or certified as mentally defective. The assessment period lasts from six to eight weeks during which all relevant information concerning the child is obtained and a thorough medical and psychological assessment made. -The child also attends the school and at the end of that period, the decision as to whether to admit the child or not is made by joint consultation of the staff involved. Where permanent admission cannot be recommended, advice about future treatment and disposal is given where necessary.
with an I.Q. of 45 to 50 will be. showing only those social responses that would be.expected of a normal child of two to two-and-a=half years, it is evident that ah attempt to assess that child for his capacity to respond to training before he is five years old is often impossible.
T
In a child under four years who is of imbecile level, assessment" rarely reveals whether the child is trainable and it is necessary to refer the child for further assessment.at a later date. Furthermore, if the child of four or under appears trainable it is highly suggestive that he is of higher intelligence and therefore in the educationally subnormal range requiring opportunities that are afforded at the Sunshine Homes. A number of children who are admitted to the Ellen Terry Home prove to be above the imbecile level of intelligence. They have frequently failed at educationally subnormal or similar schools and the most frequent reason for this is a degree of emotional maladjustment or some additional handicap, such as deafness. Other cases are admitted and have the appearance of gross mental defect but under kindly care develop surprisingly. An example of this is Stephen, who on admission four years ago was described as an idiot and unable to do anything for himself. He soon began t o progress and has recently left us to go to Condover Hall School for the blind who have an additional handicap. The latest report from the school states that there is a reasonable chance of his going to a normal school for the blind. There a r e other instances of this very great degree of improvement and the Fountain Hospital is ever prepared to review its assessment of any case. It is not unusual for some defective children .to reach the age of seven or eight years before they begin to sho~; evidence of" being trainable.
Assessment Childl'en of all ages up to i2 are admitted for assessment. However in view of t h e fact that a child aged five years
120
M a t d a 1957
,4 Residential Special Training School for Blind Defectives
Since the Home became a unit of the Fountain Hospital Group it has been possible to transfer six children to educationally sub-normal schools,, while three have gone to normal schools. The helpful co-operation and advice of medical officers of health and school medical officers that has made this possible is gratefully acknowledged.
There is a need for a unil~ for the care and training of adult blind who are of high grade imbecile or feeble-minded level. Such a unit would eater for people who are below the level of the sheltered workshops for the blind, but who are yet capable of simple industrial activities if given adequate training. It would be envisaged that a proportion of such people might ultimately prove employable in the community but the majority would require care throughout their lives. Much effort would "be needed to discover the tasks which would be best adapted to their limited capacities but this is not an insurmountable problem. The advantages on humanitarian grounds from the patient's point of view would be considerable. However, the success of slJch a scheme would depend to a considerable extent on the Medical Officers of the Local Authoritj, who would be concerned in the referring of suitable cases, and it would be valuable to have their opinion on the establishment of such ~1unit.
Admission The names of those accepted for admission are placed on t h e waiting list. Vacancies at the home occur principally from transfers from the home to other hospitals or by death. The latter is very infrequent and so admission is most el~sily effected by returning one of the unresponsive children to a hospital in the same region as the child on the waiting list. A few vacancies occur as the result of transferring a child to a school for the blind educationally subnormal, and in a few other cases it happens that a ,child is discharged from the Mental Deficiency Acts to the care of his parents. Unfortunately, vacancies for low grade defectives are difficult to obtain in most regions and so it is that there are 24 or so such cases at the Ellen Terry Home, while there are a similar number of children able to respond to training on the waiting fist. Parents are encouraged to visit their children as often as possible and may call at the home at any time, but are encouraged to give the matron in charge of the home some notice if they intend to visit. Outings of all kinds are arranged for the children. They go for walks, shopping expeditions, and coach tours. Some have swimming lessons. Local associations entertain the children to parties and at the pantomime and simple concerts at the home. The children also give a party from time to time and put on an entertainment for their young guests. Excitement runs high on such occasions. The visitors to the home soon distinguish the sense of security felt by the children in belonging to a small homogeneous group, and frequently remark on the happy atmosl~here of the home.
Application f o r admission tO the Ellen Terry J-1ome should be made to the Physician Superintendent, The Fountain Hospital, London, S.W.17.
BOOK REVIEWS
(Continued from page 117)
nursing mother has to deal ; and with the care Of her own health and that of the infant. There is also a chapter on the toddler, and other chapters on common ailments, infectious diseases a n d other problems affecting children of all ages. The authors have brought to their work a wide knowledge and a sympathetic understanding. They are to be congratulated on producing a book which will be valuable.
In their Early Twenties. A study of Glasgow Youth. By T. FERGUSON & J. CUNNISON. (Pp. vi ~ 110. 12S. 6d.) London : Published for the Nuffield Foundation by the Oxford University Press. 1956. This book continues the study of over 1,300 Glasgow boys who left school in 1947 at w h a t was then the earliest permitted age of 14 years. In a previous book (The Young Wage-Earner, 1951) the same authors dealt with the same group at an earlier stage ; and in 1952 the senior author considered some of them in " The Young Delinquent in his Social Setting." This latest book is of great interest for the light which it sheds on factors which mould the adolescent and the young man. Individuals are followed into different types of employment, into factories and to National Service. Some of them are followed into the police court, into prison, and into what, in a few cases, promises to be a life of crime. Apprenticeship is considered; and also the drift from skilled employment, with the loss o f human capital thereby entailed Once again one is called to reflect on fundamentals; and not least on the paramount importance of a sound family and social background as a firm foundation for future development. From the strictly medical standpoint, the figures given for rejection for National Service on grounds of physical unfitness are disquieting and suggest the need for further detailed investigation of wide range.
After Care The problem of disposal of patients who have reached mature years but who have no relatives or friends to care for them when the time comes for them to leave Ellen Terry. Home has not been satisfactorily solved. In some cases it has been necessary to transfer such patients to other mental deficiency hospitals. - I t frequently happens that they are then l~laced in large wards with sighted patients because it is not possible to provide a unit for the blind in each mental deficiency hospital. Patients who have to be dealt with in this way find t h e transition to this kind Of life very difficult after the more individual care given at Ellen Terry Home. In addition, facilities do not generally exist for the continuation of their training towards socially useful activities. Some of the patients have good homes to return to and are better able to fit. into them as a result of their basic training at the Home. While in need of care, supervision and financial support they are at least able to look after their basic needs, to behave in socially acceptable ways, and to discover interests and occupations for themselves. 121
Book Reviews Five Hundred over Sixlff. A Community.Survey on Aging. By BERNARD KtrrNER and others. (Pp. 345. 32s.L New Yorlc, Russell Sage Foundation. 1956. " A t Kips Bay:Yorkville Health Centre, in New York City, the health needs of 250,000 people in the area had been reasonably well met." But almost nothing was done for the great and growing number of old p e o p l e - - f o r the simple reason that knowledge was lacking as to what to do. It was'obvious that the medical aspect accounted for only part, of the need, in which, economic and social factors loomed large. So a committee was .formed, representative of university and "other organisations in the city, including the Russell Sage Foundation. T h e committee decided that the best way to learn o f the needs of old people was to ask them, personally and individually. Hence this survey, which considers-not only health, but patterns of adjustment in old a g e . One hears much nowadays of maladjusted children a n d the evil fate which awaits them ; but maladjusted among the elderly is no less a cause of trouble, as the investigators found. Morale and a due appreciation of the social self also count for much among them no less than among the young. A n d one should not forget that " t h e sixties are usually the most critical years for the older person." This book contains much factual information and has mubh of value to say of concrete services and programmes for work among the aged. It is inspired throughout by an u n d e r s t a n d i n g - a p p r o a c h to the problems O f - t h e individual human being and can be read with advantage by both doctor and social worker. It has an excellent bibliography extending to nearly thirty pages.
tion of new drugs has not abolished the need for other methods of treatment. The survey has brought together and analysed a mass of valuable information.
Psychology, Psychiatry and the Public Interest. Edited by MAURICE H. KROUT, PH.D. 6Pp. xv + 217. s 12s.) Minnesota University Press. London : Oxford University Press, 1956. The contributors to this book are 13 psychologists from various parts of the U.S.A. and one medical m a n - - P a u l E. Huston (M.D., YALE ; PH.D., HARVARD)who is Professor of Psychiatry in the College of Medicine at the State University of Iowa. They devote themselves to various aspects of the spheres a p p r o p r i a t e to those trained in psychology and psychiatry, and consider the way in which the public interest may best be served by their professional activities. The psychologists discuss the work that they do in collaboration with others not only in the medical, but also in the educational and other fields. They also deal with their position in the role of independent practitioners, in which capacity severa| of them have been working for years as psychotherapists-as apparently are hundreds of other in the United States. We are told that the main problems which "have to be dealt with in practice fall broadly into such categories as (i) marriage (or courtship), family, and sex, (ii) relations with those Outside one's family, (iii) " getting along with oneself," (iv) vocational and economic difficulties, (v) health problems, and (vi) religio----ethical problems. The orthodox position of the medical profession in regard to psychotherapy is put forward by quoting a statement approved by the American Medical Association and in a letter from the medical director of the Veterans' Administration. In greater detail the medical standpoint is dealt with in two articles by Dr. Huston. He sees a wide field of useful work for the psychologist in research of which there is great need. In psychotherapy also there is a place for the psychologist ; but Dr. Huston is at one with the American oPsychiatric Association in being strongly opposed to the independent practice of psychotherapy by psychologists. Clearly, the campaign now afoot in the U.S.A. to secure licensing of psychologists for this purpose is likely to meet determined opposition.
Minimal Pulmonary Tuberculosis found by Mass Radiography. A R e p o r t t o the Prophit Committee of the Royal College of Physicians of London. ]3y V. H. SPRINGETr & A. ;l. ELEY. (Pp. xiv + 233, with 16 charts and 65 photographs. s 2s.) L o n d o n : H. K. Lewis & Co. 1956, One of the aims of the original Prophit Survey was to ol6tain information concerning " t i m interpretation of certain x-ray appearances which are at present of doubtful import, and the question of spontaneous healing of tuberculous lesions even in the absence of treatment." In 1944, when that survey was concluded, mass radiography was beginning to reveal a large number of~such small foci in the apparently healthy; but there was no general agreement as to their correct management in regard to treatment. It was therefore decided to conduct a five-year follow-up of 500 persons of each sex found by mass radiography to have such abnormalities. Selection of cases took place between January 1946 and Ocl~ober 1948, and the.information obtained after a minimum of five years in each case was what was available in January 1954." These dates are in~portant because, as the authors point out, so far as treatment is concerned, previous measures have been rendered completely out-of-date by the new antibacterial therapy. The findings on the interpretation of x-ray appearances are, however, still valid ; and the introduc-
British Red Cross Society Maternal and Child Welfare Manual No. 9. Written at the request of the Society by DENNIS GEVFEN, O.B'.E.,M.D., D.P.H., & SUSANM.r TRACY,M.R.C.S., L.R.C.P~, D.P.H. Ninth Edition. (Pp. xi + 170, with 2 Plates and 48 Illustrations. 6s.) London, Cassell & Co., 1956. In a foreword to this manual, Lady Limerick expresses the hope that it will "be of great value not only to V.A.D. Members of the Society, but also to a much wider public. We certainly think that it will. It deals in a clear and interesting manner with the problems with which the expectant and (Continued on page 121) 117
PUBLIC H E A L T H
The Fountain Hospital* By L. T. H I L L I A R D , M.A., ra.a., D.P.M. Physician Superintendent, Fountain Hospital HE Fountain Group of hospitals for certified mental defectives consists of the main unit, the Fountain Hospital at Tooting with 600 beds for children of idiot and imbecile grade, and four smaller specialised units. The Ellen Terry Home at Reigate trains 50 blind mental defectives ; the South Side Home at Streatham provides a hostel for feeble-minded or high grade imbecile women ; Brooklands at Reigate is a small home for adolescent imbecile girls ; and Osborne House at Hastings prqvides training for boys of the same grade. Osborne House is also used as a holiday home for suitable patients in the group who each spend two weeks there during the six " s u m m e r " months, By specialising in the care of children the Fountain Hospital has been able to investigate the problems of young defectives and to provide an environment designed to cater for their needs. By agreement with the four Metropolitan regional hospital boards concerned the Fountain Hospital itself admits only mentally defective children under five years of age from the counties of London and Surrey. The average age on admission is under three years and consequently the mole obvious and serious cases with microcephaly, hydrocephalus, mongolism, cerebral palsy or epilepsy tend to be admitted. Such children need skilled nursing and owing to their liability to respiratory or alimen-
remain at home instead of being .institutionalised. This is becoming increasingly possible owing to the greater understanding which is developing both among parents and the general public of the problems of the mentally "retarded child. For many years there has been an increasing tendency for paediatricians, medical officers and others responsible for advising parents of merltal defectives to recommend institutional care. This has reached a point in the United States where many mothers of mongol children have been told as soon as their child is born that they should put it in an institution for defectives, never see it again, and tell their friends and relatives that it has died. The emotional stress which develops in parents who try for the rest of their lives to live this lie is very considerable and is not conducive to their happiness. Fortunately the parents of'retarded children in U.S.A. and in Britain are realising that the problem of mental retardation must be faced by both parents and public and not kept hidden away as a guilty secl:et. Hospital and Parents
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Where a child has to be placed in an institution the parents should feel able to do this openly and without a sense of shame, just as they would let their child go to a sanatorfum or residential school for the blind if that was in his best interests. To encourage this feeling of-conscious co-operation, the hospitals concerned must not have rigid rules limiting visiting or making it difficult for the parents to have the child home on leave. The legal procedure, of certification and detention under a magistrate's order is quite outdated in the case of children and, pending the revision of the Mental
tary infections the death rate is relatively high among the newly a d m i t t e d patients, Admissiola Priorilies The demand for beds is very great and the less urgent cases have to wait several years. Priority of admission is given in relation to the medical, social and psychological needs of the families concerned. An incontinent defective child needs nursing care which the mother cannot provide in an overcrowded room on the top floor of a house with no water or sanitation easily accessible. Sometimes the mother is a widow who has to go Out to work and cannot give the
Deficiency Act procedure which is expected to follow the report of the Royal Commission, parents should be encouraged t o " place" their child in hospital under Section 3 and retain their feeling of responsibility for his welfare. All children admitted to the Fountain Hospital in recent years whose parents could be traced have been admitted under Section 3 and this has improved the relationship between
child supervision during the day and there is no one able or willing to help. A defective child's behaviour may be so disturbing to the family or to the neighbours that it is irapossible for him to remain at home. In such cases institutional care is at present the best and only alternative. It has been our experience, however, that the parents of some of the children admitted to the Fountain Hospital would have preferred to continue caring for their child if suitable facilities could be provided. In general a child develops better with family care than in a large institution. It is not possible to generalise and each case must always be considered individually. Most defective children will derive more intellectual stimulus and less emotional inhibition if they can
parents and hospital staff. Another recent facility which has been of help to parents is the temporary admission without certification for periods up to eight weeks under Ministry of Health Circular 5/52. This procedure can be used where a defectix~e normally cared for at home needs short term hospital care while the mother is ill or being confined or in need of a rest or holiday. It can also be used where the child is ill and needs in-patient treatment or requires admission for investigation or psychological assessment. 9 If permanent institution care is to be avoided in suitable cases, it will be necessary to increase the welfare services available to defectives in the community. Proper housing with sufficient rooms to accommodate the defective in a room of his own, and with modern sanitation and access to a garden
* During a refresher course for school medical officers, arranged by the Society of Medical Officers of Health, those taking part visited the Fountain Hospital, when Dr. HiUiard delivered these introductory remarks,
is essential. 1t8
Financial assistance is necessary if the child
March 1957
The Fountain Hospital
requires extra laundry and clothing owing to his dirty or destructive habits a n d also where the mother would otherwise have to go to work. Reasonable financial grarits of this nature would be a l e s s e r charge on public funds than permanent institutional care.
of educability is related t 9 the facilities available. There can be no sharp demarcation between the training given in occupation centres and educationally subnormal schools and the transition from one to the other should be as easy as possible. It is interesting to note that in a period of five years, 44 Fountain children certified as mentally defective, i.e. ineducable, have been discharged from the Mental Deficiency Acts and given places in special schools. One of the most difficult problems in the diagnosis of mental deficiency is the case of the doubly handicapped child where an apparent mental retardation is associated with another disability. This may be an early psychosis, or a behaviour disorder due to adverse home conditions, or emotional deprivation resulting from early institutionalisation. Physical disabilities include cerebral palsy, epilepsy, deafness and blindness. Although these conditions may usually be easily diagnosed, high tone deafness, poor sight, minor degrees of cerebral palsy and many behaviour disorders may be overlooked or be attributed to the mental deficiency. Even where the several handicaps are obvious the contribution which each makes to the total picture is often difficult to assess. One of the advantages of working in a mental deficiency hospital is that the staff have fairly close daily contact with patients over long periods and can observe the often considerable changes that occur in their mental capacity as time passes or the environment is changed. The lessons that can be learned from the ultimate achievements of some of our patients make one hesitate to be too dogmatic as regards the intelligence levels of young children or the social competence of the so-called high-grade adolescent defective.
Advising 'Parents Better facilities for advice to parents are needed. Suitably trained health visitors able to give practical guidance in the care of defective children, and assistance from home helps may reduce the mother's tasks to reasonable proportions. Mental deficiency out-patients clinics, such as those held at the Fountain Hospital and a few other centres, can give considerable encouragement and support to parents. Local parents' associations and branches of the National Society for Mentally Handicapped Children have given moral support to despairing parents and have also been able to make representations in official quarters for improved facilities for defectives. The Society's activity i n meetings, Press, radio and television has been one of the main factors in the recent more sympathetic attitude of the public to the needs of the defective in the community. The Friends of the Fountain, our parents' association, is one of the most active in the country and has raised more than s for additional buildings and equipment for the hospital which could not be provided out of national resources. Suitable training is essential for all defectives. With the lowest grade idiot the most elementary habit training is all that can be undertaken but this, if patiently pursued, will make his subsequent supervision and care less arduous. For the child of imbecile grade early access to occupation centres--better thought-of as training centres--is essential if his capacity is to be developed to the maximum. There is at present a very great deficiency of places in occupation centres, and official figures show that one-third of the children officially recognised as suitable for occupation centre training are unable to receive this. In fact if more training centres were available many more children would benefit from attendance. Some could start at an earlier age instead of waiting for a vacancy, others could remain at home and attend daily instead of having to be sent for residential care. A number of children previously requiring institutional care as the only alternative available have been discharged from the Fountain Hospital when appropriate provision has been made for them in the community by improved housing, financial grants or the opening of a local occupation centre.
Examples of Cases Examples which illustrate this are the following : 1. A boy admitted as an imbecile was discharged from the Mental Deficiency Act when given a trial in an educationally subnormal school. At 15 he was excluded as ineducable and recertified and sent to another M.D. institution. He is now under guardianship as he has no home and resides in a hostel but is able to earn his living by working in a plastics factory. 2. A blind boy at the Ellen Terry Home was at the age of five considered to be an idiot as he could do nothing for himself. He is now making good progress in an educationally subnormal residential school for the blind. 3. A deaf boy was certified as an imbecile and in spite of representation was for several years refused special education because his very disturbed behaviour was attributed to imbecility. He is now well above normal intelligence and is in a grammar school for the d e a l 4. A girl with severe cerebral palsy was certified as a n imbecile because her lack of response was attributed to a mental rather than a 'motor defect. She is now in a school for mentally normal physically handicapped children. With regard to adults who are certified as feebleminded usually for social reasons, our experience has been that many of these persons can adjust satisfactorily to community life if given friendly help and guidance in a suitable environment. Segregation in a mental deficiency institution against their
Temporary Care Another relevant problem is the question of ineducability. It should be realised that there is no clear cut level of educability and there are many anomalies when the assessed capacities of retarded children are compared, not only in different Counties but' also in different schools for the educationally subnormal under the same local education authority. The present provision of special schools is, as in the case of occupation centres, very much below the officially admitted requirements. Here again the criterion 119,
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PUBLIC HEALTH
will does not usually help them to learn to live in t h e community. Parole conditions in a hostel with suitable employment is:usually a quicke~ and more effective form of rehabilita, t i o n . Of: 250 certified feel~leminded women admitted to the South Side Home, 'either as direct admissions or transferred from other institutions, 60~o have beeri discharge# from the Mental Defi~ienoy Acts and are self supporting in the community. These patients have been carefully followed up by our social worker and we have been surprised how well they have adjusted to normal life, some after many years in an institution. Fourteen per cent of these discharged women are now married. A psychological assessment of the children of our adult patients is in hand as a research project and preliminary results are contrary to the usual dictum that
many defective children will be born to allegedly feebleminded women. The Fountain Hospital is fortunate in having considerable research facilities.. The psychiatric, neuropathological, biochemical, psychological and social work depalkments collaborate in research projects and in the investigation of individual patients. There are also facilities for x-ray investigation, audiometry, speech therapy and physiotherapy. In these days of lack of nursing staff in mental deficiency hospitals the Fountain is also fortunate in having a relatively high c o m p l e m e n t . . Our nurse training school now has 44 student nurses and is one of the largest in mental deficiency hospitals. The five occupation centres in the group have a staff of 20 and accommodate 280 children.
A Residential Special Trainilig School for Blind Defectives By C. E. W I L L I A M S , M.n., cH.n.,
Senior Psychiatric Registrar, Fountain Hospital Group HE Ellen Terry Home at Reigate, Surrey, was founded by the Servers of the Blind League and was formally opened in 1926 by Ellen Terry. The Servers of the Blind administered the h6me until 1948 when it became part of the National Health Service and was incorporated in the Fountain Hospital Group. The home is for blind mental defectives. There are three teachers attached t o the home, one of whom-is a qualified teacher of the blind, and training is largely on the lines of that given in ordinary occupation centres (special training schools) but suitably modified for sightless children. Children are admitted from all regions of England and Wales. A t the present time nearly half of the 50 beds are oecupied by children of very low intelligence who, if not unaware of, are at least indifferent tb, their surroundings and are quite incapable of responding to simple training, These c h i l d r e n were admitted o n . a medical recommendation without preliminary assessment. To obviate this waste of good facilities the hospital now admits all applicants for a preliminary period of assessment and trial. This is done under the terms and conditions of the Ministry of Health Circular 5/52 and so does not require that the child should be ascertained or certified as mentally defective. The assessment period lasts from six to eight weeks during which all relevant information concerning the child is obtained and a thorough medical and psychological assessment made. -The child also attends the school and at the end of that period, the decision as to whether to admit the child or not is made by joint consultation of the staff involved. Where permanent admission cannot be recommended, advice about future treatment and disposal is given where necessary.
with an I.Q. of 45 to 50 will be. showing only those social responses that would be.expected of a normal child of two to two-and-a=half years, it is evident that ah attempt to assess that child for his capacity to respond to training before he is five years old is often impossible.
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In a child under four years who is of imbecile level, assessment" rarely reveals whether the child is trainable and it is necessary to refer the child for further assessment.at a later date. Furthermore, if the child of four or under appears trainable it is highly suggestive that he is of higher intelligence and therefore in the educationally subnormal range requiring opportunities that are afforded at the Sunshine Homes. A number of children who are admitted to the Ellen Terry Home prove to be above the imbecile level of intelligence. They have frequently failed at educationally subnormal or similar schools and the most frequent reason for this is a degree of emotional maladjustment or some additional handicap, such as deafness. Other cases are admitted and have the appearance of gross mental defect but under kindly care develop surprisingly. An example of this is Stephen, who on admission four years ago was described as an idiot and unable to do anything for himself. He soon began t o progress and has recently left us to go to Condover Hall School for the blind who have an additional handicap. The latest report from the school states that there is a reasonable chance of his going to a normal school for the blind. There a r e other instances of this very great degree of improvement and the Fountain Hospital is ever prepared to review its assessment of any case. It is not unusual for some defective children .to reach the age of seven or eight years before they begin to sho~; evidence of" being trainable.
Assessment Childl'en of all ages up to i2 are admitted for assessment. However in view of t h e fact that a child aged five years
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M a t d a 1957
,4 Residential Special Training School for Blind Defectives
Since the Home became a unit of the Fountain Hospital Group it has been possible to transfer six children to educationally sub-normal schools,, while three have gone to normal schools. The helpful co-operation and advice of medical officers of health and school medical officers that has made this possible is gratefully acknowledged.
There is a need for a unil~ for the care and training of adult blind who are of high grade imbecile or feeble-minded level. Such a unit would eater for people who are below the level of the sheltered workshops for the blind, but who are yet capable of simple industrial activities if given adequate training. It would be envisaged that a proportion of such people might ultimately prove employable in the community but the majority would require care throughout their lives. Much effort would "be needed to discover the tasks which would be best adapted to their limited capacities but this is not an insurmountable problem. The advantages on humanitarian grounds from the patient's point of view would be considerable. However, the success of slJch a scheme would depend to a considerable extent on the Medical Officers of the Local Authoritj, who would be concerned in the referring of suitable cases, and it would be valuable to have their opinion on the establishment of such ~1unit.
Admission The names of those accepted for admission are placed on t h e waiting list. Vacancies at the home occur principally from transfers from the home to other hospitals or by death. The latter is very infrequent and so admission is most el~sily effected by returning one of the unresponsive children to a hospital in the same region as the child on the waiting list. A few vacancies occur as the result of transferring a child to a school for the blind educationally subnormal, and in a few other cases it happens that a ,child is discharged from the Mental Deficiency Acts to the care of his parents. Unfortunately, vacancies for low grade defectives are difficult to obtain in most regions and so it is that there are 24 or so such cases at the Ellen Terry Home, while there are a similar number of children able to respond to training on the waiting fist. Parents are encouraged to visit their children as often as possible and may call at the home at any time, but are encouraged to give the matron in charge of the home some notice if they intend to visit. Outings of all kinds are arranged for the children. They go for walks, shopping expeditions, and coach tours. Some have swimming lessons. Local associations entertain the children to parties and at the pantomime and simple concerts at the home. The children also give a party from time to time and put on an entertainment for their young guests. Excitement runs high on such occasions. The visitors to the home soon distinguish the sense of security felt by the children in belonging to a small homogeneous group, and frequently remark on the happy atmosl~here of the home.
Application f o r admission tO the Ellen Terry J-1ome should be made to the Physician Superintendent, The Fountain Hospital, London, S.W.17.
BOOK REVIEWS
(Continued from page 117)
nursing mother has to deal ; and with the care Of her own health and that of the infant. There is also a chapter on the toddler, and other chapters on common ailments, infectious diseases a n d other problems affecting children of all ages. The authors have brought to their work a wide knowledge and a sympathetic understanding. They are to be congratulated on producing a book which will be valuable.
In their Early Twenties. A study of Glasgow Youth. By T. FERGUSON & J. CUNNISON. (Pp. vi ~ 110. 12S. 6d.) London : Published for the Nuffield Foundation by the Oxford University Press. 1956. This book continues the study of over 1,300 Glasgow boys who left school in 1947 at w h a t was then the earliest permitted age of 14 years. In a previous book (The Young Wage-Earner, 1951) the same authors dealt with the same group at an earlier stage ; and in 1952 the senior author considered some of them in " The Young Delinquent in his Social Setting." This latest book is of great interest for the light which it sheds on factors which mould the adolescent and the young man. Individuals are followed into different types of employment, into factories and to National Service. Some of them are followed into the police court, into prison, and into what, in a few cases, promises to be a life of crime. Apprenticeship is considered; and also the drift from skilled employment, with the loss o f human capital thereby entailed Once again one is called to reflect on fundamentals; and not least on the paramount importance of a sound family and social background as a firm foundation for future development. From the strictly medical standpoint, the figures given for rejection for National Service on grounds of physical unfitness are disquieting and suggest the need for further detailed investigation of wide range.
After Care The problem of disposal of patients who have reached mature years but who have no relatives or friends to care for them when the time comes for them to leave Ellen Terry. Home has not been satisfactorily solved. In some cases it has been necessary to transfer such patients to other mental deficiency hospitals. - I t frequently happens that they are then l~laced in large wards with sighted patients because it is not possible to provide a unit for the blind in each mental deficiency hospital. Patients who have to be dealt with in this way find t h e transition to this kind Of life very difficult after the more individual care given at Ellen Terry Home. In addition, facilities do not generally exist for the continuation of their training towards socially useful activities. Some of the patients have good homes to return to and are better able to fit. into them as a result of their basic training at the Home. While in need of care, supervision and financial support they are at least able to look after their basic needs, to behave in socially acceptable ways, and to discover interests and occupations for themselves. 121