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Educability
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I'UBLIC HEALTH, November, 1954 " E D U C A B I L I T Y "* By L. J. BACON, M.D., D.P.H. D e p u t y P r i n c i p a l S c h o o l M e d i c a l Oj~cer, H a m p s h i r e
U n d e r this rather ugly, but brief and convenient title, I propose to discuss some of the problems that aris6 in trying to decide whether a child with a disability of m i n d is educable within the school system, or whether he shall be reported to the Mental Health Authority "under Section 57 of the Education Act. W h e n I chose this subject I was under the impression that in Hampshire the n u m b e r of appeals against report was increasing, and so also the n u m b e r of successful a p p e a l s - and that the p r o b l e m although not new was to that extent becoming more pressing. I should add that investigation did not support m y impression : the numbers of decisions to report, of appeals, and of appeals upheld has shown no consistent rise or fall in the last eight years. Nevertheless, I think the problem is worth discussing. T h e fact that one's opinion that a child is ineducable may be the subject of appeal by the parent, and that the deciding factor in such a case will be the opinion oZ one of the Medical Officers of the Ministry of Education, means that one's decision cannot be m a d e simply by a conscientious assessm e n t of what seems best for the child. T h e parent and the Minister's Medical Officer have to be satisfied too, which implies that there m u s t be some absolute standard other than the child's welfare. T h e Education Act sets out to provide education suited to the child's age, ability and aptitude---/.e., it aims to suit the education to the child : but it then provides for this one important exception in respect of the child with a " disability of m i n d . " It is hardly to be supposed that those who framed the Act believed that children fall into two clear g r o u p s w t h o s e who can and those who cannot benefit f r o m education. O n the contrary it is clear that the idea was to go to certain lengths to cater for the child of inferior intellect, but not all the way ; in fact " i n e d u c a b l e " means " not worth educating." Section 57(3) of the Act clearly relates the child's disability of m i n d to the education provided within the educational s y s t e m - - s o that " educability " is a function of two variables, the child and the education provided. But the Act gives no guidance as to the level d o w n to which education shall be carried. A clear exposition of the p u r p o s e of education would provide valuable assistance in deciding whether any particular child is worth e d u c a t i n g ; I know of no such exposition. One can readily " think up " a n u m b e r of different objectives in providing public education--e.g., to enable a child to earn its living, or to enjoy life, or to be a useful m e m b e r of the community, or to manage its own personal affairs, or to avoid breaking the law ! - - w h i c h call for widely differing qualities and levels of intelligence. W h a t is clearly n o t envisaged is that education is designed to develop to the full the capabilities of every child, for one has only to see the response of some of the children in the Occupation Centres provided by Mental Health Authorities, to realise that any child above idiot level is trainable. I have not yet succeeded in extracting f r o m any of m y colleagues in the Education D e p a r t m e n t any clear exposition of their own views as to what constitutes " educability." T h e nearest approach to an opinion in the matter appears to be that the child, to be educable, m u s t be capable of some progress in the " three Rs " - - w i t h particular emphasis on reading. T h e main criterion of success in our special school seems to be that the child's " reading age " shall have been brought up to his chronological age before he leaves school. T h e r e is, of course, a distinction to be drawn between mechanical reading and comprehension, and I believe there is gerleral acceptance in the educational world of the view that a " mechanical reading age " of less than 9 or 10 years * Paper read to the Southern Branch, Society of M.O.H., Winchester, 13th April, 1954.
at school-leaving age will mean i l l i t e r a c y : such a child will find reading too difficult and will quickly forget how to do so. A mental age of 989 at age 16 corresponds to an I.Q. of 63, so that we m u s t suppose that the Education Authority here sets its level of " educability " a great deal higher than we medical people have b e e n accustomed to do. T h a t this is so, and that Education Authorities in general adopt the same view in practice, is evidenced by the extraordinarily little provision made in special schools for the " low-grade " and educationally sub-normal pupils and border-line ineducables. Essentially this seems to be a matter to be thrashed out between the lay and medical personnel of the Special Services Branch of the Ministry : but if the result were a decision that future literacy is the proper criterion and that children w h o are not expected to achieve a reading age above about nine and a half years are to be regarded as ineducable, then Mental Health Authorities would need to reconsider the scope of training they are prepared to give in their occupation centres and h o m e training schemes. T h e emphasis on reading as a primary aim of education has led, in this county, to a policy of providing special schools only for children of secondary school age. T h e argument is that younger 9hildren of low I.Q. are not yet ready to receive teaching in reading, and that the ordinary schools can give t h e m as m u c h teaching as they are capable of benefiting from. T h i s seems to me very questionable in view of the large classes and consequent impossibility of giving individual attention ; and, of course, it does not permit o f a solution to the p r o b l e m before u s - - t h a t of testing educability by suitable special schooling. Of 10 children who have been the subject of appeal in this county in the last two years, six have been of infant school age. M a n y others of this age were reported during the same period as ineducable (without appeal) who were in fact " border-line " cases : these children did not have the benefit of trial in a special school. T h e provision of a special school, which in a county would of necessity be residential, for children aged five to seven, which would take the lowest grades of child w i t h the particular purpose of testing educability, would appear to be the proper solution of this problem. Criteria for A s s e s s i n g E d u c a b i l i t y Let us consider the criteria that we do in practice a d o p t - or rather the factors which may influence us--~n deciding whether a child is educable. T h e y appear to me to be as follows : - (1) T h e child's performance in school. (2) T h e child's behaviour in school and at home. (3) T h e child's performance on test. (4) T h e parent's reaction. (5) T h e special educational treatment available. (6) T h e training and care available if the child is " reported." P e r f o r m a n c e in school is probably the commonest first selection factor, and certainly the most apposite. I n every case where the child has attended schoOl at all we have our " 3 H . P . " - - 0 r should have : for m y part I regard it as indispensable. I cannot imagine that any School Medical Officer would ever d r e a m of reporting a child who has attended school as ineducable without wanting to know how he got on there. B u t , we well recognise that to have failed to progress in school is n o t final evidence of ineducability. W h a t was the school like ? Did the child get any special educational treatment ? H o w big were the classes ? H o w m a n y parallel streams were there ? H o w understanding, how conscientious, h o w intelligent, and h o w interested in dullards was the class teacher ? T h e criterion, then, is not to h a v e failed in school ; but to have failed with suitable special educational t r e a t m e n t - - a n d how often do we feel that the child has had that ? In practice, with children of border,line level, it means that the child should have been to a special school. T h e n there is the question of the child'g behaviour at school. F r e q u e n t l y the child is unacceptable at school less
PUBI,IC HEAI,TH, Nmcmbcr, 1954 on account of his failure to progress educationally t h a n because of his difficult behaviour. T h i s may be simply due to i m m a t u r i t y - - t h e relationship b e t w e e n the rates of intellectual a n d emotional d e v e l o p m e n t is an interesting subject to w h i c h I shall refer later. Or it may be positive b a d behaviour, due p e r h a p s to frustration or ridicule resulting f r o m the child's lack of success in his work. Inevitably we are i n f l u e n c e d by---or at least m u s t take account o f - - t h e teacher's r e p o r t that the child is unacceptable in school on behaviour grounds. But here again it seems i m p o r t a n t to ask oneself w h e t h e r the school was an appropriate one for g e t t i n g the best out of the child in spite of his behaviour a n d for r e m e d y i n g his behaviour : in fact, a suitable special school. An i m p o r t a n t g r o u p of these b o r d e r - l i n e children are those w h o have not a t t e n d e d school, but are b r o u g h t to our notice at or before s c h o o l - e n t r y age because it is believed that they are n o t ready for, or will not prove acceptable in, the infant school. T h e School Medical Officer is inevitably influenced b y the p a r e n t ' s account of the child at h o m e - - w h a t he can do and cannot do, and h o w amenable to control he is. It is our practice in H a m p s h i r e , if we t h i n k the child is not ready for, or acceptable in, school to defer a decision for six or m o r e m o n t h s ; a n d t h e n to try the child in school. (May I r e - e m p h a s i s e that I am speaking of b o r d e r - l i n e c a s e s - - I am n o t suggesting that every idiot or imbecile should be tried in school.) I f the child t h e n makes n o progress or proves unacceptable, he should then, of course, be tried i n a suitable special school : b u t as we all know the p r o b l e m in practice is the lack of s u c h schools for b o r d e r line ineducables o f infant school age, and s o m e t i m e s we are forced to r e c o m m e n d that the child be " r e p o r t e d " w i t h o u t a p r o p e r trial, or else to b o w d o w n in T h e H o u s e of Steiner ! . Performance
on
Test
T h e I.Q. remains our s t a n d - b y - - a n d r i g h t l y - - b u t cannot provide an absolute s t a n d a r d of educability because (a) we do n o t k n o w precisely what we aro testing and are justified in a s s u m i n g only a generM correlation b e t w e e n I.Q. and educability, n o t an absolute one applicable to each individual child, (b) intelligence is p a t c h y and one cannot assume that a p o o r a c h i e v e m e n t in s o m e respects precludes the necessity to develop o t h e r faculties by education, (c) of physical limitations, (d) of emotional limitations. A p a r t f r o m difficulties of assessment; I.Q. is only a m e a s u r e of intelligence, not a m e a s u r e of edueability. Intellect varies f r o m child to child as a s m o o t h l y g r a d e d curve : there is no s u d d e n d r o p to indicate a distinction b e t w e e n the ineducable and the educable child. T r u e , we accept an I.Q. of s o m e w h e r e about 50 as the b o r d e r - l i n e - - s o m e m i g h t p u t i t at 45, s o m e at 55, b u t w h e r e v e r you p u t y o u r l e v e l you still recognise it to be only a r o u g h i n d i c a t i o n - - a centre p o i n t in a hazy b o r d e r - z o n e . A n d s u p p o s e w e say, as I suppose m o s t of us would, that (granted a confident assessm e n t and n o o t h e r handicaps) a child with an I.Q. of 35 is clearly ineducable and one with an I.Q. of 65 is educable, w h a t do w e m e a n by that ? W h a t qualitatively is the difference ? Quantitatively, the test boils d o w n to a check on the reliability of our first c r i t e r i o n - - a c h i e v e m e n t in school. It is merely a m e a n s of satisfying ourselves that the child's failure in school is genuinely due to a disability of m i n d a n d not to o t h e r causes s u c h as b a d teaching, or school abs~ence, or, of course (for the m e n t a l test m u s t n e v e r be dissociated f r o m the physical examination that accompanies it), to associated physical defects. It is t h e n a check on the existence and degree of disability of m i n d ; n o t a m e a s u r e o f educability. It is also of course an excellent way of getting to k n o w a great deal about the child in the s h o r t e s t possible time : for w h i c h reason I am strongly averse to the test being delegated to an Educational P s y c h o l o g i s t - - i . e . , disassociated f r o m the physical examination. It is sometimes claimed that the Educational Psychologist can learn far m o r e about the child as a result of his testing t h a n can a m e r e doctor, because of his knowledge of the
21 significance of success or failure in the different types of s u b - t e s t and of the different types of response. Certainly t h e y d o read an e n o r m o u s a m o u n t into the qualitative result of the test, a n d we find part of our p r o b l e m arises f r o m a t e n d e n c y of educational psychologists to say, in effect, " t h i s child's I.Q. is 68 but because of the quality of his responses he m u s t be d e e m e d ineducable." . I i n t e n d to come back t o this a~pect of the subject later on. I w o u l d not wish to be i n t e r p r e t e d as suggesting that n o t h i n g should be derived f r o m a b a t t e r y of mental tests except an I.Q. O n the contrary, I believe that a great deal can be learned about the child from the nature of his responses - - b u t I w o u l d emphasise that the p e r s o n t o q e a r n this is t h e p e r s o n who has the responsibility to advise as to educability. W e generally accept that a relatively high c o m p e t e n c e in p e r f o r m a n c e tests (as o p p o s e d to reasoning tests) augurs well for getting on all right in the w o r l d after leaving school : a n d to m e it seems logical to regard s u c h c o m p e t e n c e as evidence of e d u c a b i l i t y - - o n the g r o u n d t h a t the boy or girl w h o has a chance of h o l d i n g d o w n a job, however lowly, should not be " w r i t t e n off " by the E d u c a t i o n A u t h o r i t y : w h a t he n e e d s is education specially a d a p t e d to develop his own limited aptitudes. F o r m y part I w o u l d also give credit for cheerfulness, h u m o u r a n d co-operation. I do not m e a n by this that I w o u l d vary the I.Q. score on t h e s e grounds; b u t that it w o u l d influence m e in d e c i d i n g w h e t h e r a child is w o r t h educating (i.e., " educable "). Intelligence tests (of a sort) go back far b e y o n d the days of Binet. T h e folk-ballads of these islands indicate that s o m e sort of " intelligence test " was used on occasion in selecting o n e ' s spouse (and for what p u r p o s e could it m o r e p r o p e r l y be used ?). " Questions six ye'll tell to me, A n d that is three times twa, Afore I lie in your bed, E i t h e r at stock or w a ' . " T h a t was the lady. S o m e t i m e s the test was applied the next m o r n i n g w h e n it was the knight that was in a position to bargain and make conditions : - " I f t h o u canst answer questions three T h i s very day will I m a r r y t h e e . " A n d the tests were essentially tests of a ready wit. " O h w h a t is s h a r p e r t h a n the t h o r n ? " - - " H u n g e r ' s sharper t h a n the t h o r n , " " O h w h a t is d e e p e r t h a n the sea ? " - - " Hell is deeper t h a n the sea " - - a n d so on. C a t c h questions, if you like, such as are carefully excluded f r o m our batteries of tests nowadays. I w o n d e r if we are right ! T h e n we are p r o n e t o b e influenced by the p a r e n t ' s r e a c t i o n . T h i s is inevitable w h e n we know that if the parent appeals he will, in certain circumstances, win his appeal despite our own confident conviction that " r e p o r t " is in the child's interests. Parental reaction is interesting, a n d not always predictable. W e all know the complex range of ideas and e m o t i o n s that m a y govern the reactions of parents in these c a s e s - - g e n u i n e affection for the child or scarcely concealed h a t r e d ; a fear that the child will be taken away, or a fear that he will n o t ; over-protectiveness, or callous rejection ; intelligent studious balancing of the pros and cons, or an obstinate u n r e a s o n i n g prejudiced ignorance. M a n y parents of " i n e d u c a b l e " children arc, of course, i n t e l l i g e n t - particularly t h o s e of children whose defect of m i n d is n o t of an i n h e r i t e d nature, such as m o n g o l s and " spastics." Others w h o are of s u b n o r m a l intelligence will resent the suggestion t h a t t h e i r child is so lacking in intelligence as to be not w o r t h educating. I think we are p r o n e to assume t h a t their objection is based on the same belief that we ourselves hold, that the child lacking in intelligence is an inferior b e i n g : we assume that they resent this implication, and object to a " charge " of ineducability accordingly. But I w o n d e r if this really is so : w h e t h e r in fact their objection to their child being e x c l u d e d f r o m the educational s y s t e m is n o t b a s e d on precisely the reverse v i e w - - t h a t intelligence is an overrated, if not superfluous, quality. I do not m e a n that they actually reason in this f a s h i o n - - I am
22 speaking of p a r e n t s of low r e a s o n i n g ability. R a t h e r is it suggested that every one of us u n c o n s c i o u s l y regards h i m (or her-) self as a typical m e m b e r of the h u m a n race, alike in b o d y a n d miiad, a n d t e n d s to r e g a r d e v e r y o n e w h o is different, in any particular, as b e i n g to t h a t e x t e n t a slightly a b n o r m a l specimen. Y o u r tall p e r s o n regards tallness as n o r m a l a n d t h e little m a n as slightly deviating f r o m t h e n o r m a l ; y o u r little m a n m a y secretly e n v y the tall m a n - b u t in d o i n g so his w i s h is to d e p a r t f r o m t h e n o r m a l in t h a t r e s p e c t : his o w n small stature is still his yardstick of normality, i T h o s e of us w h o r e g a r d ourselves as b e i n g of average or superior intelligence r e g a r d the dullards as lacking in a quality necessary for o p t i m u m m a n h o o d ; w h e n we t u r n to consider those w h o s e intelligence exceeds o u r o w n we m a y admire, respect, a n d envy t h e m , b u t we n e v e r t h e l e s s regard t h e m as s o m e t h i n g in the n a t u r e of freaks : we are t h e yardstick f r o m w h i c h all w h o d e p a r t are a b n o r m a l . A n d this is m o r e a feeling, an e m o t i o n a l reaction, t h a n a rational o n e - - i n fact w h e n we start t h i n k i n g a b o u t it we b e g i n to realise the fallacy of the belief 1 I do n o t t h i n k we have a n y r e a s o n to suppose t h a t a dull or s t u p i d p e r s o n has any different reaction to his fellow m e n , i n this respect, f r o m o u r own. N o d o u b t he, too (you will n o t e t h a t I use t h e t h i r d p e r s o n - - f o r h o w e v e r s t u p i d I m a y be, m a y the L o r d preserve m e f r o m ever realising it ! " O h L o r d , we p r a y T h e e gie us a g u i d conceit o' ourset's " r e m a i n s essentially a p r a y e r for s a n i t y ! ) - - n o d o u b t he, too, considers his p a r t i c u l a r level of intellect, a n d t h a t of his child, to b e t h e " n o r m a l , " a n d regards t h e c h i l d r e n in t h e top t h r e e - q u a r t e r s of each school class as f r e a k s - - c e r t a i n l y n o t as t h e yardstick b y w h i c h his o w n child s h o u l d b e m e a s u r e d . A n d b y t h e same t o k e n n o d o u b t t h e School Medical Officer is to h i m also an o d d b o d y w i t h completely cock-eyed ideas a b o u t w h a t is really i m p o r t a n t in o u r make -up. I suppose t h a t t h e i n s t i n c t of m o s t p a r e n t s to p r o t e c t t h e i r c h i l d r e n f r o m b e i n g classified as " inferior " - - o r even d i f f e r e n t - - i s f u n d a m e n t a l l y s o u n d : a n d one w o n d e r s h o w m u c h of the " dullness " of t h e dull child m a y b e d u e , n o t to his or h e r inferiority of intellect, b u t r a t h e r to the c o n t i n u o u s dwelling u p o n t h a t inferiority w h i c h t e n d s to take place in school. Classically, y o u r s i m p l e t o n is a h a p p y soul : T h e Fool is also t h e J o k e r : you k n o w the r h y m e : - " T h e r e goes the h a p p y m o r o n . H e d o e s n ' t care a d a m n . I wish I were a m o r o n - My God--perhaps I am ! " B u t I suspect t h a t a s u r v e y of o u r lower grade E.S.N. c h i l d r e n w o u l d show a p r e p o n d e r a n c e of defensive a p a t h y a m o n g t h e m . Is y o u r h a p p y s i m p l e t o n a m y t h - - o r at least a n exception ? - - o r m i g h t it b e t h a t o u r educational system 9destroys his spirit i n t r y i n g to stimulate his m i n d ? W i t h o u r physically h a n d i c a p p e d c h i l d r e n we take it as a basic r e q u i r e m e n t t h a t e m p h a s i s s h o u l d b e laid u p o n t h e i r capabilities r a t h e r t h a n t h e i r d i s a b i l i t i e s - - u p o n w h a t t h e y can do r a t h e r t h a n u p o n w h a t t h e y cannot. Surely, this s h o u l d equally b e t h e a p p r o a c h to t h e child w i t h a disability of mind. I seem to have w a n d e r e d away f r o m m y t h e m e - - t h e criteria of educability. T h e p o i n t I w a n t e d to m a k e is t h a t we are b o u n d to take a c c o u n t of p a r e n t a l reaction, a n d t h a t this m a y be b a s e d u p o n s t a n d a r d s totally different f r o m o u r own.
T h e conscientious School M e d i c a l Officer, c o n f r o n t e d w i t h a " b o r d e r - l i n e " child, will ask h i m - (or her-) self " w h i c h is going to b e best for the child ? - - r e t e n t i o n w i t h i n the educational system, or exclusion f r o m it ? " A n d t h e answer will, of course, d e p e n d b o t h u p o n the facilities available for special educational t r e a t m e n t a n d u p o n those available for t r a i n i n g defectives. T h i s o u g h t n o t to b e so, of course ; for it m e a n s t h a t " ineducability " is a result n o t only of disability of m i n d b u t also of lack of educational facilities. I t m e a n s t h a t t h e same child is or is n o t excluded f r o m the educational system according to w h e r e h e h a p p e n s to live. Y e t - - h o w e v e r t h e
PUBI,1C IIEAI,Ttf, No~clubcr, 1954 m a t t e r ought to b e - - I t h i n k it is t r u e to say t h a t the only practical criterion of any value is the child's capacity to benefit f r o m t h e m o s t suitable special e d u c a t i o n a l t r e a t m e n t which is available to it. I f t h a t be accepted, it follows (to nay m i n d ) as a corollary that the onus of decision s h o u l d n o t fall upon. the School Medical Officer at all, b u t u p o n t h e C h i e f Officer of t h e Education Department. T h e responsibility of t h e School M e d i c a l Officer s h o u l d be t h a t of assessing t h e capabilities a n d disabilities, b o t h m e n t a l and physical, of t h e child ; a n d of p r e s e n t i n g a r e p o r t o n these u n d e r s t a n d a b l e b y the layman. T h e n , I suggest, it s h o u l d b e u p to the E d u c a t i o n Officer to decide w h e t h e r he can or c a n n o t educate a child w i t h those disabilities. I appreciate, of course, t h a t t h a t c a n n o t be done u n d e r the E d u c a t i o n Act as it stands. I t m a y b e c o n t e n d e d t h a t as things are n o w the decision is a n educational one, in t h a t it is the E d u c a t i o n C o m m i t t e e t h a t authorises the issue of a r e p o r t u n d e r Section 57(3), a n d t h e E d u c a t i o n Officer that issues it. T r u e , b u t so far as m y experience goes these are a u t o m a t i c p r o c e d u r e s following u p o n a r e c o m m e n d a t i o n for w h i c h t h e P r i n c i p a l School M e d i c a l Officer takes clear responsibility. If, as I c o n t e n d s h o u l d b e the case, the School Medical Officer w e r e m e r e l y to p r e s e n t a report, u p o n w h i c h t h e E d u c a t i o n Officer h a d to decide, t h e n every decision to r e p o r t u n d e r S e c t i o n 57(3) w o u l d b e a n a d m i s s i o n b y t h e E d u c a t i o n Officer of a failure in his own D e p a r t m e n t to provide e d u c a t i o n for t h a t child according to its age, ability a n d aptitudes.. T h e final criterion of " i n e d u c a b i l i t y " w h i c h I m e n t i o n e d was t h e availability of m e a n s of t r e i n i n g the child as a defective. H a r d i n d e e d is t h e lot of the child w h o is kept w i t h i n the e d u c a t i o n system, despite t h e lack of any suitable m e a n s of e d u c a t i n g him, for n o b e t t e r reason t h a n t h a t n o t h i n g can b e d o n e for h i m if h e is " r e p o r t e d " ! It is easy e n o u g h to see t h a t a sort of negative c o m p e t i t i o n can readily arise here. The Education Authority may default in p r o v i d i n g special educational t r e a t m e n t for b o r d e r line defectives in t h e hope t h a t the M e n t a l H e a l t h A u t h o r i t y will step u p its o c c u p a t i o n centre or h o m e t r a i n i n g a n d take t h e m off its h a n d s - - w h i l e conversely t h e M e n t a l H e a l t h A u t h o r i t y m a y feel t h a t e a c h t r a i n a b l e defective represents a r e p u d i a t i o n of its responsibilities b y t h e Local E d u c a t i o n Authority, a n d limit its o w n facilities accordingly. A r e m e d y for this, w h i c h has b e e n m o r e t h a n once suggested, is t h a t t h e Local E d u c a t i o n A u t h o r i t y s h o u l d b e responsible for t h e training, w h e t h e r at h o m e or i n centres, of m e n t a l defectives. T o m e this seems logical, t h o u g h one can see all sorts of practical difficulties : the m o s t i m p o r t a n t one b e i n g t h a t so long as a Local E d u c a t i o n A u t h o r i t y has less m o n e y t h a n it w o u l d like (which will always be t h e case) it will use its resources for t h e n o r m a l or superior c h i l d r e n a n d n o t the dull ones. So far I have b e e n speaking of c h i l d r e n w h o s e " disability of m i n d " is an inferiority of intellect u n c o m p l i c a t e d b y physical disability or deep emotional disturbances. But, as we all know, it is t h e c h i l d r e n w i t h m u l t i p l e h a n d i caps w h o create t h e h a r d e s t p r o b l e m s , b o t h of assessment a n d of disposal. O f the 10 c h i l d r e n w h o were the subject of appeal in this c o u n t y in 1952 a n d 1953, one only was physically n o r m a l ; two others were Mongols, a n d the r e m a i n i n g seven h a d each a physical d i s a b i l i t y - - t w o cerebral palsies, two epileptics, one deaf, one partially deaf, a n d one hydrocephalic. O n the physical side it is p e r h a p s the cerebral palsy cases t h a t are m o s t difficult. T h e y are, or seem to be, c o m m o n e r w i t h i n the last 10 or 15 years. A t a n y rate we hear a great deal m o r e a b o u t t h e m , p a r t l y because it was realised t h a t less was b e i n g d o n e for t h e m t h a n m i g h t be, a n d t r e a t m e n t s c h e m e s were s t a r t e d w h i c h w o n a lot of p u b l i c i t y ; a n d partly because of t h e d e v e l o p m e n t of central k n d local organisations of p a r e n t s a n d others particularly i n t e r e s t e d in these children. T h e cerebral palsied child can, of course, be extremely h a r d t o test as regards his intelligence, p a r ticularly if speech a n d h a n d - m o v e m e n t s are b o t h affected ;
23
PUBLIC HEAI,TH, November, 19.~4 a n d n o d o u b t some u n d e r - a s s e s s m e n t s h a v e b e e n m a d e . T h e s e have b e e n p u b l i c i s e d a n d have led to a n e r r o n e o u s belief a m o n g t h e laity t h a t a l l " spastics " are of n o r m a l or s u p e r i o r intelligence, a n d also t h a t o u r s t a n d a r d intelligencetests are inapplicable to " spastics." B o t h these beliefs are, of course, q u i t e u n t r u e , a n d I t h i n k we have to resist a n y a t t e m p t to shake o u r f a i t h in the reliability of o u r o w n tests. It may, of course, easily h a p p e n t h a t a child w i t h cerebral palsy can p e r f o r m only certain of the T e r m a n - M e r r i l l T e s t s because of physical disability, b u t t h a t does n o t detract f r o m t h e significance of t h e tests he c a n p e r f o r m . It m a y reduce t h e reliability of a n I.Q. assessment, because this is based o n a small n u m b e r of tests ; or i n d e e d it m a y m a k e it unwise to calculate an I.Q. at all ; b u t it does n o t detract f r o m the significance of failure of a 10-year-old child to p e r f o r m five- or six-year-old tests w h i c h are w i t h i n its physical capacity : n o r for t h a t m a t t e r does it detract f r o m the significance of a 10-year-old s u c c e e d i n g in tests at a 12-year-old level t h o u g h it m a y fail five-year-old tests because of its physical limitations. Personally, I a m a great believer in t r y i n g to m o d i f y the tests to suit t h e child's physical capacity, r a t h e r t h a n c u t t i n g t h e m o u t altogether. O n e has to b e a r in m i n d , of course, t h a t t h e test is n o longer a s t a n d a r d i s e d o n e - - b u t t h a t d o e s n ' t m e a n t h a t it can tell you n o t h i n g a b o u t t h e child's m e n t a l capacity. I t is a n i n t e r e s t i n g a n d instructive exercise, w h i c h n o d o u b t s o m e of you will have p e r f o r m e d , to list t h e various tests we u s e - - n o t only all the T e r m a n - M e r r i l l sub-tests, b u t also the various p e r f o r m a n c e t e s t s - - a c c o r d i n g to t h e p h y s i c a l capacities t h a t t h e y d e m a n d . I t will be f o u n d t h a t very few c h i l d r e n are c o m p l e t e l y u n t e s t a b l e . T h o s e w h o are for practical p u s p o s e s u n t e s t a b l e are likely to be t h e d e a f - m u t e - b l i n d , a n d t h e c e r e b r a l palsied c h i l d r e n w i t h n e i t h e r s p e e c h n o r h a n d control. T h e s e c h i l d r e n m a y , of course, have n o p r i m a r y a m e n t i a : t h e i r intelligence m a y at b i r t h h a v e b e e n potentially n o r m a l . B u t are t h e y educable? D o we n o t have to face t h e fact t h a t t h e r e are certain comb i n a t i o n s a n d degrees of p h y s i c a l defect w h i c h , if t h e y are irremediable, r e n d e r t h e child i n e d u c a b l e despite t h e fact t h a t t h e r e is strictly n o disability of m i n d ? C a n we i n d e e d say t h a t t h e r e is n o disability of m i n d w h e n t h e m i n d is p r e c l u d e d f r o m carrying out its f u n c t i o n s either b y lack of s t i m u l a t i o n or i n f o r m a t i o n due to sensory failure, or b y lack of executive capacity due to m o t o r paralysis ? A t t e m p t s to educate s u c h c h i l d r e n are, of course, colossally expensive, a n d for m y p a r t I d o u b t w h e t h e r t h e results ever justify t h e e x p e n d i t u r e - - a n d let m e a d d t h a t I a m t h i n k i n g less of t h e e x p e n d i t u r e of m o n e y t h a n of time, energy, skill a n d devotion. T o m e it seems t h a t o u r society has to t h i n k in t e r m s of r e t u r n for outlay ; a n d t h a t t h e onus u p o n a C h r i s t i a n w o r l d is to p r o v i d e n o t e d u c a t i o n b u t care for those 4r are so grossly defective t h a t t h e y can n e v e r b e c o n t r i b u t o r s to t h e c o m m o n weal. T h i s care can be b e t t e r provided by the Mental Health Authority than by the Education Authority. Emotional State and Mental Capacity Finally, a w o r d a b o u t t h e child w h o s e secondary defect is " m a l a d j u s t m e n t " ; b y w h i c h , in this p a r t i c u l a r context, I m e a n t h e c h i l d w h o s e emotional state is s u c h t h a t either h e c a n n o t use to t h e full w h a t intellectual capacity he does .possess, or his b e h a v i o u r m a k e s h i m u n a c c e p t a b l e for t e a c h lng. As w i t h physical defectives t h e first p r o b l e m is t h a t of assessment of m e n t a l capacity. I t h i n k we w o u l d all accept t h a t success in intelligence tests is very m u c h influe n c e d b y e m o t i o n a l state. W e t r y to indicate this in r e p o r t i n g o u r results, b y saying p e r h a p s t h a t we failed to establish a n effective r a p p o r t w i t h t h e child a n d c o n s e q u e n t l y believe t h a t the I.Q. m a y have b e e n under-assessed. F o r m y p a r t I r e g a r d it as t h e particular f u n c t i o n of the E d u c a t i o n a l Psychologist, so far as m e n t a l t e s t i n g is c o n c e r n e d , to b e able to m a k e a skilled assessment of t h e intelligence of a child w h o s e responses are o b s c u r e d b y d i s t u r b a n c e of b e h a v i o u r or emotion, O n e is a c c u s t o m e d to seeing reports
f r o m E d u c a t i o n a l Psychologists to the effect t h a t a c h i l d has an I.Q. of, shall we say, 60 or more, b u t owing to some q u a l i t y of m i n d is u n a b l e to make full use of its intelligence a n d is ineducable. T h e defective quality of m i n d m a y b e of a type obvious in school c l a s s - - e x t r e m e restlessness, distractability, apathy, or lack of c o n c e n t r a t i o n , for instance - - w h i c h w o u l d lead a class t e a c h e r to say " I c a n ' t teach this boy (or girl) " : either because the child is u n c o n t r o l l a b l e in class or because the teacher c a n n o t secure a n d maintain. a d e q u a t e c o n t a c t w i t h him. At o t h e r t i m e s the defective quality of m i n d m a y be m o r e s u b t l e - - t h e child lacks j u d g m e n t , n o t in a wholly intellectual sense, b u t to appreciate its o w n relationship w i t h t h e world a b o u t it, or the significance of its o w n acts or those of others. A m a r k e d degree of this type of defect, w h i c h appears to a m o u n t to a d i s p r o portionate deficiency in a single c o m p o n e n t of intelligence, has f r e q u e n t l y led to a suggestion t h a t the child is p r e p s y c h o t i c - - t h a t we are dealing n o t j u s t w i t h m e n t a l deficiency b u t w i t h i n c i p i e n t dementia. A m o n g those c h i l d r e n w h o m E d u c a t i o n a l Psychologists r e p o r t as i n e d u c a b l e despite a fairly h i g h I.Q. are m a n y w i t h b e h a v i o u r p r o b l e m s , a n d one of t h e c o m m o n e s t diagnoses is t h a t of e m o t i o n a l immaturity. T h i s c o n c e p t o f " emotional d e v e l o p m e n t " as s o m e t h i n g t h a t proceeds i n d e p e n d e n t l y of intellectual d e v e l o p m e n t is, I think, an i m p o r t a n t one. T h e E d u c a t i o n a l Psychologist says in effect, " this child's e m o t i o n a l d e v e l o p m e n t is n o t c o m m e n s u r a t e w i t h its m e n t a l d e v e l o p m e n t , therefore it is n o t educable. Is t h e r e a " n o r m a l " p a t t e r n of e m o t i o n a l d e v e l o p m e n t ? Does it proceed at a steady pace ? Is it n o t possible t h a t a child w h o at six is so lacking in selfcontrol t h a t it is n o t educable (in spite of a n I.Q. well above t h e b o r d e r - l i n e ) m a y make big strides w i t h i n the next couple of years a n d b e c o m e at the age of eight capable of receiving e d u c a t i o n a c c o r d i n g to its m e n t a l age ? I f in fact o u r j u d g m e n t as to e d u c a b i l i t y has to take a c c o u n t of b e h a v i o u r a n d e m o t i o n a l control, have we a n y yardstick b y w h i c h this can be m e a s u r e d ? H e r e again we come u p against t h e fact t h a t t h e M i n i s t r y ' s assessors, so far as m y experience goes, do n o t recognise the existence of a child w h o is incapable of b e i n g t a u g h t u p to its m e n t a l age ; a n d it is a safe b e t t h a t a n y case going to appeal o n a n I.Q. of 60 will find t h e M i n i s t e r s u p p o r t i n g the appeal. I n this c o u n t y we have u s e d one of t h e R u d o l f Steiner " schools " occasionally for b o r d e r - l i n e ineducable chiI~ren w h o s e effective intelligence is, or is believed to be, d i m i n ished b y e m o t i o n a l p r o b l e m s . W e argue firstly t h a t s u c h c h i l d r e n will n o t suffer b y b e i n g m i x e d w i t h definitely i n e d u c a b l e c h i l d r e n (as h a p p e n s in these " schools " ) ; secondly t h a t t h e fact t h a t t h e y will get n o education (as t h e C o u n t y E d u c a t i o n Officer u n d e r s t a n d s t h a t t e r m ) will do n o h a r m for a t e r m or two ; thirdly, t h a t if they really possess an e d u c a b l e s t a n d a r d of intelligence w h i c h t h e y are precluded from using by their emotional disturbance, then t h e loving care which, w i t h some o d d e r ingredients, we believe t h e y get in these " schools," will give t h e m t h e i r best hope of r e t u r n i n g to emotional n o r m a l i t y ; a n d fourthly, t h a t if t h e y h a v e b e e n tried, a n d have failed to progress, e v e n in a R u d o l f Steiner " school " t h e A u t h o r i t y will be in a far s t r o n g e r position to resist appeal against an u l t i m a t e deeis.ion to " r e p o r t . "
Conclusions I a m conscious that this address has bccn somewhat diffuse, a n d w o u l d like in conclusion, a n d b y way of s u m m a r y , to repeat certain suggestions w h i c h will p e r h a p s serve to focus discussion. (1) T h e Act p r o v i d e s for exclusion f r o m t h e educational system on a c c o u n t of disability of m i n d b u t gives n o g u i d a n c e as to t h e degree of disability w h i c h is i n c o m p a t i b l e w i t h education. (2) T h e only p r o p e r criterion of i n e d u c a b i l i t y is failure to r e s p o n d to suitable special education. (3) E d u c a t i o n A u t h o r i t i e s t e n d to e q u a t e educability w i t h f u t u r e literacy, a n d to provide special schools o n l y for those
24
PUBI9
who it is hoped may learn to read usefully (I.Q. approximately 60 to 65). (4) T h e Ministry's Medical Officers appear to adopt a similar standard to School Medical Officers in general, and to support appeals with respect to children at a considerably lower level (I.Q.s about 50). T h e r e is thus a significant group who cannot readily be brought within the Mental Health law nor provided with suitable education. (5) T w o alternative solutions are suggested : - (a) T h e Local Education Authority to be responsible 9 for training of mental defectives (outside institutions), with suitable safeguards to see that they get their fair whack of education funds. (b) T h e C o u n t y Education Officer to decide, on the basis of, inter alia, a report from the School Medical Officer, whether the child is educable--i.e., whether he can provide it with education according to its ability and aptitudes. Neither of these alternatives is compatible with the present law. (6) T h e ascertaining Medical Officer at present has his hand forced by certain factors which ought not to a p p l y - i.e., the lack of suitable special education, the parent's reaction, and perhaps the lack of training facilities for mental defectives. Special schools for border-line children of Infant School age, where edueability can be put to the test, are particularly needed ; and not least schools which will cater for " low-grade " children with in addition physical or emotional handicaps. (7) A problem of ascertainment and disposal is presented by those children who, owing to associated disabilities of m i n d such as abnormalities of temperament, emotion, or bebaviour are not educable to a level corresponding with their assessed I.Q. THE ROLE OF THE PUBLIC HEALTH DEPARTMENT IN THE PREVENTION OF MENTAL AND NERVOUS DISEASE ~ By I. A. G. MAcQUEEN,M.A., M.D., D.P.H.,
Medical O~cer of Health, City of Aberdeen Mental diseases and mental deficiency between t h e m now take up m o r e hospital beds than do all general medical cot~ditions. T h e neuroses constitute the c o m m o n e s t cause of absence from work. T h e amount of suffering and distress occasioned by stress diseases and psychosomatic diseases (if these concepts can be differentiated) is incalculable. A n d in addition to the enormous known volume of disease of mental and emotional origin, there is the even greater portion that is u n k n o w n - - " hidden behind the aspidistra," in the words of an eminent sociologist, x It is fair to say that at least one half of all h u m a n disease and suffering has its origin in faulty emotional relationships, especially in childhood. T r e a t m e n t of a fully developed case of psychoneurosis involves the expenditure of m u c h time and m u c h money. W e in Britain have not enough doctors, not enough nurses, not enough hospital beds, not enough m o n e y for the effective treatment of even the visible portion of this vast iceberg. Unless we can reduce the prevalence of these conditions by preventive measures, the outlook is dismal indeed. For the neglect of mental health work to date both health officers and psychiatrists are to blame. T h e medical officers of health have been so engrossed in the eradication of formerly c o m m o n infectious diseases and in the improvem e n t of the physical health of children that they have not yet accepted the challenge of a menace even graver than the typhoid and smallpox that confronted the public health pioneers of last century. T h e psychiatrists, experts in a young and rapidly developing science, have tended to interest themselves 'in curative measures rather than in *Address to a joint meeting of the Scottish Branch, Society of M.O.H. and Scottish Division of Royal Medico-Psychological Assor 10~h April~ 1954,
HEALTH, November, 1954
prevention, and in the full-blown psychoses rather than the numerically c o m m o n e r psychoneuroses and psychosomatic diseases. Let me quote f r o m one psychiatrist who has some inkling of the truth : Hadfield, late of the Tavistock Clinic, s a y s " It is generally agreed by psychopathologists that the psychoneuroses such as Hysteria, Sex Perversions, Anxiety States, Obsessions, Depression, and many Behaviour Disorders are traceable in their origin to abnormal conditions in the early years of life. If this is so, it should be possible by providing the right conditions in childhood to prevent the occurrence of these disorders.' '~ Available Forces F o r the benefit of those unfamiliar w i t h the lay-out of health departments let m e briefly describe their staffing. T h e main h u m a n tools available to the health departments for preventive work are medical officers and health visitors. T h e medical officers---about one for every 13,000 population in the best staffed areas and half of that in the worst a r e a s - are not experts in p s y c h o l o g y : they have the ordinarv undergraduate medical training with its smattering of psychology and psychiatry, followed (usually after two or three years of junior hospital posts) by one year of full-time study for the D.P.H., again with a handful of lectures on mental health. T h e health visitors--about one for every 2,500 people in the best staffed areas and one for every 5,000 in the worst areas--are again not experts in psychology : they have their general nursing training, with nowadays a slender introduction to psychology included, a subsequent midwifery training, a n d - - u s u a l l y after t w o or three years as hospital staff nurse and ward s i s t e r - - a course of full-time study for the health 'visitor's certificate, this course lasting at present from six m o n t h s to one academic year but likely in the near future to become standardised everywhere as an academic year, and including some six or seven lectures and lecture-demonstrations on m e n t a l health 9 Other people in the health d e p a r t m e n t - - d i s t r i c t nurses, sanitary inspectors, staffs of day and residential nurseries, even home h e l p s - may have a supplementary part to play, but for the present let us concentrate on the medical officer and the health visitor. I am deliberately ignoring the child guidance clinic, because, valuable t h o u g h it is, it begins to play its part after a faulty situation has a r i s e n - - n o t before. T h e medical officer works mainly in the child welfare clinic and the school. T h e health visitor, while taking part in the work of the ante-natal and child welfare clinics and while regularly visiting schools, does her most important work in the home. U n d e r the m o d e r n concept of the health visitor as the health counsellor and teacher of the family she takes the family as her unit, is generally accepted by the family as a skilled friend to w h o m they can turn for advice on any health matter, and is responsible for the welfare of anything f r o m 600 to 1,200 families. T h e weakness of both officers in undertaking mental health w o r k is that they are n o t - - a n d in general cannot hope to b e - - e x p e r t s in psychology. O n the other hand, they have certain concrete advantages : - - b o t h medical officer and health visitor are well educated, highly trained officers, w h o - - f r o m the very width and variety of their professional training should be capable of forming balanced j u d g m e n t s and of offering sound advice ; both are accustomed to look at problems from the angle of preventing disease and p r o m o t i n g health ; both have experience in the difficult art of persuasion ; and the health visitor has the additional advantage that, unlike any other worker in the field of health and disease, she is in the habit of visiting houses at h e r discretion without the necessity of waiting to be summoned. In any contribution that they can make to mental health the public health medical officer and the health visitor are best considered as a team, but, in so far as separate consideration is necessary, the emphasis should probably be placed on the health v i s i t o r - - t h e r e are four or five health visitors for every public health doctor and the health visitor can influence people in their own homes,
I'UBLIC HEALTH, November, 1954 " E D U C A B I L I T Y "* By L. J. BACON, M.D., D.P.H. D e p u t y P r i n c i p a l S c h o o l M e d i c a l Oj~cer, H a m p s h i r e
U n d e r this rather ugly, but brief and convenient title, I propose to discuss some of the problems that aris6 in trying to decide whether a child with a disability of m i n d is educable within the school system, or whether he shall be reported to the Mental Health Authority "under Section 57 of the Education Act. W h e n I chose this subject I was under the impression that in Hampshire the n u m b e r of appeals against report was increasing, and so also the n u m b e r of successful a p p e a l s - and that the p r o b l e m although not new was to that extent becoming more pressing. I should add that investigation did not support m y impression : the numbers of decisions to report, of appeals, and of appeals upheld has shown no consistent rise or fall in the last eight years. Nevertheless, I think the problem is worth discussing. T h e fact that one's opinion that a child is ineducable may be the subject of appeal by the parent, and that the deciding factor in such a case will be the opinion oZ one of the Medical Officers of the Ministry of Education, means that one's decision cannot be m a d e simply by a conscientious assessm e n t of what seems best for the child. T h e parent and the Minister's Medical Officer have to be satisfied too, which implies that there m u s t be some absolute standard other than the child's welfare. T h e Education Act sets out to provide education suited to the child's age, ability and aptitude---/.e., it aims to suit the education to the child : but it then provides for this one important exception in respect of the child with a " disability of m i n d . " It is hardly to be supposed that those who framed the Act believed that children fall into two clear g r o u p s w t h o s e who can and those who cannot benefit f r o m education. O n the contrary it is clear that the idea was to go to certain lengths to cater for the child of inferior intellect, but not all the way ; in fact " i n e d u c a b l e " means " not worth educating." Section 57(3) of the Act clearly relates the child's disability of m i n d to the education provided within the educational s y s t e m - - s o that " educability " is a function of two variables, the child and the education provided. But the Act gives no guidance as to the level d o w n to which education shall be carried. A clear exposition of the p u r p o s e of education would provide valuable assistance in deciding whether any particular child is worth e d u c a t i n g ; I know of no such exposition. One can readily " think up " a n u m b e r of different objectives in providing public education--e.g., to enable a child to earn its living, or to enjoy life, or to be a useful m e m b e r of the community, or to manage its own personal affairs, or to avoid breaking the law ! - - w h i c h call for widely differing qualities and levels of intelligence. W h a t is clearly n o t envisaged is that education is designed to develop to the full the capabilities of every child, for one has only to see the response of some of the children in the Occupation Centres provided by Mental Health Authorities, to realise that any child above idiot level is trainable. I have not yet succeeded in extracting f r o m any of m y colleagues in the Education D e p a r t m e n t any clear exposition of their own views as to what constitutes " educability." T h e nearest approach to an opinion in the matter appears to be that the child, to be educable, m u s t be capable of some progress in the " three Rs " - - w i t h particular emphasis on reading. T h e main criterion of success in our special school seems to be that the child's " reading age " shall have been brought up to his chronological age before he leaves school. T h e r e is, of course, a distinction to be drawn between mechanical reading and comprehension, and I believe there is gerleral acceptance in the educational world of the view that a " mechanical reading age " of less than 9 or 10 years * Paper read to the Southern Branch, Society of M.O.H., Winchester, 13th April, 1954.
at school-leaving age will mean i l l i t e r a c y : such a child will find reading too difficult and will quickly forget how to do so. A mental age of 989 at age 16 corresponds to an I.Q. of 63, so that we m u s t suppose that the Education Authority here sets its level of " educability " a great deal higher than we medical people have b e e n accustomed to do. T h a t this is so, and that Education Authorities in general adopt the same view in practice, is evidenced by the extraordinarily little provision made in special schools for the " low-grade " and educationally sub-normal pupils and border-line ineducables. Essentially this seems to be a matter to be thrashed out between the lay and medical personnel of the Special Services Branch of the Ministry : but if the result were a decision that future literacy is the proper criterion and that children w h o are not expected to achieve a reading age above about nine and a half years are to be regarded as ineducable, then Mental Health Authorities would need to reconsider the scope of training they are prepared to give in their occupation centres and h o m e training schemes. T h e emphasis on reading as a primary aim of education has led, in this county, to a policy of providing special schools only for children of secondary school age. T h e argument is that younger 9hildren of low I.Q. are not yet ready to receive teaching in reading, and that the ordinary schools can give t h e m as m u c h teaching as they are capable of benefiting from. T h i s seems to me very questionable in view of the large classes and consequent impossibility of giving individual attention ; and, of course, it does not permit o f a solution to the p r o b l e m before u s - - t h a t of testing educability by suitable special schooling. Of 10 children who have been the subject of appeal in this county in the last two years, six have been of infant school age. M a n y others of this age were reported during the same period as ineducable (without appeal) who were in fact " border-line " cases : these children did not have the benefit of trial in a special school. T h e provision of a special school, which in a county would of necessity be residential, for children aged five to seven, which would take the lowest grades of child w i t h the particular purpose of testing educability, would appear to be the proper solution of this problem. Criteria for A s s e s s i n g E d u c a b i l i t y Let us consider the criteria that we do in practice a d o p t - or rather the factors which may influence us--~n deciding whether a child is educable. T h e y appear to me to be as follows : - (1) T h e child's performance in school. (2) T h e child's behaviour in school and at home. (3) T h e child's performance on test. (4) T h e parent's reaction. (5) T h e special educational treatment available. (6) T h e training and care available if the child is " reported." P e r f o r m a n c e in school is probably the commonest first selection factor, and certainly the most apposite. I n every case where the child has attended schoOl at all we have our " 3 H . P . " - - 0 r should have : for m y part I regard it as indispensable. I cannot imagine that any School Medical Officer would ever d r e a m of reporting a child who has attended school as ineducable without wanting to know how he got on there. B u t , we well recognise that to have failed to progress in school is n o t final evidence of ineducability. W h a t was the school like ? Did the child get any special educational treatment ? H o w big were the classes ? H o w m a n y parallel streams were there ? H o w understanding, how conscientious, h o w intelligent, and h o w interested in dullards was the class teacher ? T h e criterion, then, is not to h a v e failed in school ; but to have failed with suitable special educational t r e a t m e n t - - a n d how often do we feel that the child has had that ? In practice, with children of border,line level, it means that the child should have been to a special school. T h e n there is the question of the child'g behaviour at school. F r e q u e n t l y the child is unacceptable at school less
PUBI,IC HEAI,TH, Nmcmbcr, 1954 on account of his failure to progress educationally t h a n because of his difficult behaviour. T h i s may be simply due to i m m a t u r i t y - - t h e relationship b e t w e e n the rates of intellectual a n d emotional d e v e l o p m e n t is an interesting subject to w h i c h I shall refer later. Or it may be positive b a d behaviour, due p e r h a p s to frustration or ridicule resulting f r o m the child's lack of success in his work. Inevitably we are i n f l u e n c e d by---or at least m u s t take account o f - - t h e teacher's r e p o r t that the child is unacceptable in school on behaviour grounds. But here again it seems i m p o r t a n t to ask oneself w h e t h e r the school was an appropriate one for g e t t i n g the best out of the child in spite of his behaviour a n d for r e m e d y i n g his behaviour : in fact, a suitable special school. An i m p o r t a n t g r o u p of these b o r d e r - l i n e children are those w h o have not a t t e n d e d school, but are b r o u g h t to our notice at or before s c h o o l - e n t r y age because it is believed that they are n o t ready for, or will not prove acceptable in, the infant school. T h e School Medical Officer is inevitably influenced b y the p a r e n t ' s account of the child at h o m e - - w h a t he can do and cannot do, and h o w amenable to control he is. It is our practice in H a m p s h i r e , if we t h i n k the child is not ready for, or acceptable in, school to defer a decision for six or m o r e m o n t h s ; a n d t h e n to try the child in school. (May I r e - e m p h a s i s e that I am speaking of b o r d e r - l i n e c a s e s - - I am n o t suggesting that every idiot or imbecile should be tried in school.) I f the child t h e n makes n o progress or proves unacceptable, he should then, of course, be tried i n a suitable special school : b u t as we all know the p r o b l e m in practice is the lack of s u c h schools for b o r d e r line ineducables o f infant school age, and s o m e t i m e s we are forced to r e c o m m e n d that the child be " r e p o r t e d " w i t h o u t a p r o p e r trial, or else to b o w d o w n in T h e H o u s e of Steiner ! . Performance
on
Test
T h e I.Q. remains our s t a n d - b y - - a n d r i g h t l y - - b u t cannot provide an absolute s t a n d a r d of educability because (a) we do n o t k n o w precisely what we aro testing and are justified in a s s u m i n g only a generM correlation b e t w e e n I.Q. and educability, n o t an absolute one applicable to each individual child, (b) intelligence is p a t c h y and one cannot assume that a p o o r a c h i e v e m e n t in s o m e respects precludes the necessity to develop o t h e r faculties by education, (c) of physical limitations, (d) of emotional limitations. A p a r t f r o m difficulties of assessment; I.Q. is only a m e a s u r e of intelligence, not a m e a s u r e of edueability. Intellect varies f r o m child to child as a s m o o t h l y g r a d e d curve : there is no s u d d e n d r o p to indicate a distinction b e t w e e n the ineducable and the educable child. T r u e , we accept an I.Q. of s o m e w h e r e about 50 as the b o r d e r - l i n e - - s o m e m i g h t p u t i t at 45, s o m e at 55, b u t w h e r e v e r you p u t y o u r l e v e l you still recognise it to be only a r o u g h i n d i c a t i o n - - a centre p o i n t in a hazy b o r d e r - z o n e . A n d s u p p o s e w e say, as I suppose m o s t of us would, that (granted a confident assessm e n t and n o o t h e r handicaps) a child with an I.Q. of 35 is clearly ineducable and one with an I.Q. of 65 is educable, w h a t do w e m e a n by that ? W h a t qualitatively is the difference ? Quantitatively, the test boils d o w n to a check on the reliability of our first c r i t e r i o n - - a c h i e v e m e n t in school. It is merely a m e a n s of satisfying ourselves that the child's failure in school is genuinely due to a disability of m i n d a n d not to o t h e r causes s u c h as b a d teaching, or school abs~ence, or, of course (for the m e n t a l test m u s t n e v e r be dissociated f r o m the physical examination that accompanies it), to associated physical defects. It is t h e n a check on the existence and degree of disability of m i n d ; n o t a m e a s u r e o f educability. It is also of course an excellent way of getting to k n o w a great deal about the child in the s h o r t e s t possible time : for w h i c h reason I am strongly averse to the test being delegated to an Educational P s y c h o l o g i s t - - i . e . , disassociated f r o m the physical examination. It is sometimes claimed that the Educational Psychologist can learn far m o r e about the child as a result of his testing t h a n can a m e r e doctor, because of his knowledge of the
21 significance of success or failure in the different types of s u b - t e s t and of the different types of response. Certainly t h e y d o read an e n o r m o u s a m o u n t into the qualitative result of the test, a n d we find part of our p r o b l e m arises f r o m a t e n d e n c y of educational psychologists to say, in effect, " t h i s child's I.Q. is 68 but because of the quality of his responses he m u s t be d e e m e d ineducable." . I i n t e n d to come back t o this a~pect of the subject later on. I w o u l d not wish to be i n t e r p r e t e d as suggesting that n o t h i n g should be derived f r o m a b a t t e r y of mental tests except an I.Q. O n the contrary, I believe that a great deal can be learned about the child from the nature of his responses - - b u t I w o u l d emphasise that the p e r s o n t o q e a r n this is t h e p e r s o n who has the responsibility to advise as to educability. W e generally accept that a relatively high c o m p e t e n c e in p e r f o r m a n c e tests (as o p p o s e d to reasoning tests) augurs well for getting on all right in the w o r l d after leaving school : a n d to m e it seems logical to regard s u c h c o m p e t e n c e as evidence of e d u c a b i l i t y - - o n the g r o u n d t h a t the boy or girl w h o has a chance of h o l d i n g d o w n a job, however lowly, should not be " w r i t t e n off " by the E d u c a t i o n A u t h o r i t y : w h a t he n e e d s is education specially a d a p t e d to develop his own limited aptitudes. F o r m y part I w o u l d also give credit for cheerfulness, h u m o u r a n d co-operation. I do not m e a n by this that I w o u l d vary the I.Q. score on t h e s e grounds; b u t that it w o u l d influence m e in d e c i d i n g w h e t h e r a child is w o r t h educating (i.e., " educable "). Intelligence tests (of a sort) go back far b e y o n d the days of Binet. T h e folk-ballads of these islands indicate that s o m e sort of " intelligence test " was used on occasion in selecting o n e ' s spouse (and for what p u r p o s e could it m o r e p r o p e r l y be used ?). " Questions six ye'll tell to me, A n d that is three times twa, Afore I lie in your bed, E i t h e r at stock or w a ' . " T h a t was the lady. S o m e t i m e s the test was applied the next m o r n i n g w h e n it was the knight that was in a position to bargain and make conditions : - " I f t h o u canst answer questions three T h i s very day will I m a r r y t h e e . " A n d the tests were essentially tests of a ready wit. " O h w h a t is s h a r p e r t h a n the t h o r n ? " - - " H u n g e r ' s sharper t h a n the t h o r n , " " O h w h a t is d e e p e r t h a n the sea ? " - - " Hell is deeper t h a n the sea " - - a n d so on. C a t c h questions, if you like, such as are carefully excluded f r o m our batteries of tests nowadays. I w o n d e r if we are right ! T h e n we are p r o n e t o b e influenced by the p a r e n t ' s r e a c t i o n . T h i s is inevitable w h e n we know that if the parent appeals he will, in certain circumstances, win his appeal despite our own confident conviction that " r e p o r t " is in the child's interests. Parental reaction is interesting, a n d not always predictable. W e all know the complex range of ideas and e m o t i o n s that m a y govern the reactions of parents in these c a s e s - - g e n u i n e affection for the child or scarcely concealed h a t r e d ; a fear that the child will be taken away, or a fear that he will n o t ; over-protectiveness, or callous rejection ; intelligent studious balancing of the pros and cons, or an obstinate u n r e a s o n i n g prejudiced ignorance. M a n y parents of " i n e d u c a b l e " children arc, of course, i n t e l l i g e n t - particularly t h o s e of children whose defect of m i n d is n o t of an i n h e r i t e d nature, such as m o n g o l s and " spastics." Others w h o are of s u b n o r m a l intelligence will resent the suggestion t h a t t h e i r child is so lacking in intelligence as to be not w o r t h educating. I think we are p r o n e to assume t h a t their objection is based on the same belief that we ourselves hold, that the child lacking in intelligence is an inferior b e i n g : we assume that they resent this implication, and object to a " charge " of ineducability accordingly. But I w o n d e r if this really is so : w h e t h e r in fact their objection to their child being e x c l u d e d f r o m the educational s y s t e m is n o t b a s e d on precisely the reverse v i e w - - t h a t intelligence is an overrated, if not superfluous, quality. I do not m e a n that they actually reason in this f a s h i o n - - I am
22 speaking of p a r e n t s of low r e a s o n i n g ability. R a t h e r is it suggested that every one of us u n c o n s c i o u s l y regards h i m (or her-) self as a typical m e m b e r of the h u m a n race, alike in b o d y a n d miiad, a n d t e n d s to r e g a r d e v e r y o n e w h o is different, in any particular, as b e i n g to t h a t e x t e n t a slightly a b n o r m a l specimen. Y o u r tall p e r s o n regards tallness as n o r m a l a n d t h e little m a n as slightly deviating f r o m t h e n o r m a l ; y o u r little m a n m a y secretly e n v y the tall m a n - b u t in d o i n g so his w i s h is to d e p a r t f r o m t h e n o r m a l in t h a t r e s p e c t : his o w n small stature is still his yardstick of normality, i T h o s e of us w h o r e g a r d ourselves as b e i n g of average or superior intelligence r e g a r d the dullards as lacking in a quality necessary for o p t i m u m m a n h o o d ; w h e n we t u r n to consider those w h o s e intelligence exceeds o u r o w n we m a y admire, respect, a n d envy t h e m , b u t we n e v e r t h e l e s s regard t h e m as s o m e t h i n g in the n a t u r e of freaks : we are t h e yardstick f r o m w h i c h all w h o d e p a r t are a b n o r m a l . A n d this is m o r e a feeling, an e m o t i o n a l reaction, t h a n a rational o n e - - i n fact w h e n we start t h i n k i n g a b o u t it we b e g i n to realise the fallacy of the belief 1 I do n o t t h i n k we have a n y r e a s o n to suppose t h a t a dull or s t u p i d p e r s o n has any different reaction to his fellow m e n , i n this respect, f r o m o u r own. N o d o u b t he, too (you will n o t e t h a t I use t h e t h i r d p e r s o n - - f o r h o w e v e r s t u p i d I m a y be, m a y the L o r d preserve m e f r o m ever realising it ! " O h L o r d , we p r a y T h e e gie us a g u i d conceit o' ourset's " r e m a i n s essentially a p r a y e r for s a n i t y ! ) - - n o d o u b t he, too, considers his p a r t i c u l a r level of intellect, a n d t h a t of his child, to b e t h e " n o r m a l , " a n d regards t h e c h i l d r e n in t h e top t h r e e - q u a r t e r s of each school class as f r e a k s - - c e r t a i n l y n o t as t h e yardstick b y w h i c h his o w n child s h o u l d b e m e a s u r e d . A n d b y t h e same t o k e n n o d o u b t t h e School Medical Officer is to h i m also an o d d b o d y w i t h completely cock-eyed ideas a b o u t w h a t is really i m p o r t a n t in o u r make -up. I suppose t h a t t h e i n s t i n c t of m o s t p a r e n t s to p r o t e c t t h e i r c h i l d r e n f r o m b e i n g classified as " inferior " - - o r even d i f f e r e n t - - i s f u n d a m e n t a l l y s o u n d : a n d one w o n d e r s h o w m u c h of the " dullness " of t h e dull child m a y b e d u e , n o t to his or h e r inferiority of intellect, b u t r a t h e r to the c o n t i n u o u s dwelling u p o n t h a t inferiority w h i c h t e n d s to take place in school. Classically, y o u r s i m p l e t o n is a h a p p y soul : T h e Fool is also t h e J o k e r : you k n o w the r h y m e : - " T h e r e goes the h a p p y m o r o n . H e d o e s n ' t care a d a m n . I wish I were a m o r o n - My God--perhaps I am ! " B u t I suspect t h a t a s u r v e y of o u r lower grade E.S.N. c h i l d r e n w o u l d show a p r e p o n d e r a n c e of defensive a p a t h y a m o n g t h e m . Is y o u r h a p p y s i m p l e t o n a m y t h - - o r at least a n exception ? - - o r m i g h t it b e t h a t o u r educational system 9destroys his spirit i n t r y i n g to stimulate his m i n d ? W i t h o u r physically h a n d i c a p p e d c h i l d r e n we take it as a basic r e q u i r e m e n t t h a t e m p h a s i s s h o u l d b e laid u p o n t h e i r capabilities r a t h e r t h a n t h e i r d i s a b i l i t i e s - - u p o n w h a t t h e y can do r a t h e r t h a n u p o n w h a t t h e y cannot. Surely, this s h o u l d equally b e t h e a p p r o a c h to t h e child w i t h a disability of mind. I seem to have w a n d e r e d away f r o m m y t h e m e - - t h e criteria of educability. T h e p o i n t I w a n t e d to m a k e is t h a t we are b o u n d to take a c c o u n t of p a r e n t a l reaction, a n d t h a t this m a y be b a s e d u p o n s t a n d a r d s totally different f r o m o u r own.
T h e conscientious School M e d i c a l Officer, c o n f r o n t e d w i t h a " b o r d e r - l i n e " child, will ask h i m - (or her-) self " w h i c h is going to b e best for the child ? - - r e t e n t i o n w i t h i n the educational system, or exclusion f r o m it ? " A n d t h e answer will, of course, d e p e n d b o t h u p o n the facilities available for special educational t r e a t m e n t a n d u p o n those available for t r a i n i n g defectives. T h i s o u g h t n o t to b e so, of course ; for it m e a n s t h a t " ineducability " is a result n o t only of disability of m i n d b u t also of lack of educational facilities. I t m e a n s t h a t t h e same child is or is n o t excluded f r o m the educational system according to w h e r e h e h a p p e n s to live. Y e t - - h o w e v e r t h e
PUBI,1C IIEAI,Ttf, No~clubcr, 1954 m a t t e r ought to b e - - I t h i n k it is t r u e to say t h a t the only practical criterion of any value is the child's capacity to benefit f r o m t h e m o s t suitable special e d u c a t i o n a l t r e a t m e n t which is available to it. I f t h a t be accepted, it follows (to nay m i n d ) as a corollary that the onus of decision s h o u l d n o t fall upon. the School Medical Officer at all, b u t u p o n t h e C h i e f Officer of t h e Education Department. T h e responsibility of t h e School M e d i c a l Officer s h o u l d be t h a t of assessing t h e capabilities a n d disabilities, b o t h m e n t a l and physical, of t h e child ; a n d of p r e s e n t i n g a r e p o r t o n these u n d e r s t a n d a b l e b y the layman. T h e n , I suggest, it s h o u l d b e u p to the E d u c a t i o n Officer to decide w h e t h e r he can or c a n n o t educate a child w i t h those disabilities. I appreciate, of course, t h a t t h a t c a n n o t be done u n d e r the E d u c a t i o n Act as it stands. I t m a y b e c o n t e n d e d t h a t as things are n o w the decision is a n educational one, in t h a t it is the E d u c a t i o n C o m m i t t e e t h a t authorises the issue of a r e p o r t u n d e r Section 57(3), a n d t h e E d u c a t i o n Officer that issues it. T r u e , b u t so far as m y experience goes these are a u t o m a t i c p r o c e d u r e s following u p o n a r e c o m m e n d a t i o n for w h i c h t h e P r i n c i p a l School M e d i c a l Officer takes clear responsibility. If, as I c o n t e n d s h o u l d b e the case, the School Medical Officer w e r e m e r e l y to p r e s e n t a report, u p o n w h i c h t h e E d u c a t i o n Officer h a d to decide, t h e n every decision to r e p o r t u n d e r S e c t i o n 57(3) w o u l d b e a n a d m i s s i o n b y t h e E d u c a t i o n Officer of a failure in his own D e p a r t m e n t to provide e d u c a t i o n for t h a t child according to its age, ability a n d aptitudes.. T h e final criterion of " i n e d u c a b i l i t y " w h i c h I m e n t i o n e d was t h e availability of m e a n s of t r e i n i n g the child as a defective. H a r d i n d e e d is t h e lot of the child w h o is kept w i t h i n the e d u c a t i o n system, despite t h e lack of any suitable m e a n s of e d u c a t i n g him, for n o b e t t e r reason t h a n t h a t n o t h i n g can b e d o n e for h i m if h e is " r e p o r t e d " ! It is easy e n o u g h to see t h a t a sort of negative c o m p e t i t i o n can readily arise here. The Education Authority may default in p r o v i d i n g special educational t r e a t m e n t for b o r d e r line defectives in t h e hope t h a t the M e n t a l H e a l t h A u t h o r i t y will step u p its o c c u p a t i o n centre or h o m e t r a i n i n g a n d take t h e m off its h a n d s - - w h i l e conversely t h e M e n t a l H e a l t h A u t h o r i t y m a y feel t h a t e a c h t r a i n a b l e defective represents a r e p u d i a t i o n of its responsibilities b y t h e Local E d u c a t i o n Authority, a n d limit its o w n facilities accordingly. A r e m e d y for this, w h i c h has b e e n m o r e t h a n once suggested, is t h a t t h e Local E d u c a t i o n A u t h o r i t y s h o u l d b e responsible for t h e training, w h e t h e r at h o m e or i n centres, of m e n t a l defectives. T o m e this seems logical, t h o u g h one can see all sorts of practical difficulties : the m o s t i m p o r t a n t one b e i n g t h a t so long as a Local E d u c a t i o n A u t h o r i t y has less m o n e y t h a n it w o u l d like (which will always be t h e case) it will use its resources for t h e n o r m a l or superior c h i l d r e n a n d n o t the dull ones. So far I have b e e n speaking of c h i l d r e n w h o s e " disability of m i n d " is an inferiority of intellect u n c o m p l i c a t e d b y physical disability or deep emotional disturbances. But, as we all know, it is t h e c h i l d r e n w i t h m u l t i p l e h a n d i caps w h o create t h e h a r d e s t p r o b l e m s , b o t h of assessment a n d of disposal. O f the 10 c h i l d r e n w h o were the subject of appeal in this c o u n t y in 1952 a n d 1953, one only was physically n o r m a l ; two others were Mongols, a n d the r e m a i n i n g seven h a d each a physical d i s a b i l i t y - - t w o cerebral palsies, two epileptics, one deaf, one partially deaf, a n d one hydrocephalic. O n the physical side it is p e r h a p s the cerebral palsy cases t h a t are m o s t difficult. T h e y are, or seem to be, c o m m o n e r w i t h i n the last 10 or 15 years. A t a n y rate we hear a great deal m o r e a b o u t t h e m , p a r t l y because it was realised t h a t less was b e i n g d o n e for t h e m t h a n m i g h t be, a n d t r e a t m e n t s c h e m e s were s t a r t e d w h i c h w o n a lot of p u b l i c i t y ; a n d partly because of t h e d e v e l o p m e n t of central k n d local organisations of p a r e n t s a n d others particularly i n t e r e s t e d in these children. T h e cerebral palsied child can, of course, be extremely h a r d t o test as regards his intelligence, p a r ticularly if speech a n d h a n d - m o v e m e n t s are b o t h affected ;
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PUBLIC HEAI,TH, November, 19.~4 a n d n o d o u b t some u n d e r - a s s e s s m e n t s h a v e b e e n m a d e . T h e s e have b e e n p u b l i c i s e d a n d have led to a n e r r o n e o u s belief a m o n g t h e laity t h a t a l l " spastics " are of n o r m a l or s u p e r i o r intelligence, a n d also t h a t o u r s t a n d a r d intelligencetests are inapplicable to " spastics." B o t h these beliefs are, of course, q u i t e u n t r u e , a n d I t h i n k we have to resist a n y a t t e m p t to shake o u r f a i t h in the reliability of o u r o w n tests. It may, of course, easily h a p p e n t h a t a child w i t h cerebral palsy can p e r f o r m only certain of the T e r m a n - M e r r i l l T e s t s because of physical disability, b u t t h a t does n o t detract f r o m t h e significance of t h e tests he c a n p e r f o r m . It m a y reduce t h e reliability of a n I.Q. assessment, because this is based o n a small n u m b e r of tests ; or i n d e e d it m a y m a k e it unwise to calculate an I.Q. at all ; b u t it does n o t detract f r o m the significance of failure of a 10-year-old child to p e r f o r m five- or six-year-old tests w h i c h are w i t h i n its physical capacity : n o r for t h a t m a t t e r does it detract f r o m the significance of a 10-year-old s u c c e e d i n g in tests at a 12-year-old level t h o u g h it m a y fail five-year-old tests because of its physical limitations. Personally, I a m a great believer in t r y i n g to m o d i f y the tests to suit t h e child's physical capacity, r a t h e r t h a n c u t t i n g t h e m o u t altogether. O n e has to b e a r in m i n d , of course, t h a t t h e test is n o longer a s t a n d a r d i s e d o n e - - b u t t h a t d o e s n ' t m e a n t h a t it can tell you n o t h i n g a b o u t t h e child's m e n t a l capacity. I t is a n i n t e r e s t i n g a n d instructive exercise, w h i c h n o d o u b t s o m e of you will have p e r f o r m e d , to list t h e various tests we u s e - - n o t only all the T e r m a n - M e r r i l l sub-tests, b u t also the various p e r f o r m a n c e t e s t s - - a c c o r d i n g to t h e p h y s i c a l capacities t h a t t h e y d e m a n d . I t will be f o u n d t h a t very few c h i l d r e n are c o m p l e t e l y u n t e s t a b l e . T h o s e w h o are for practical p u s p o s e s u n t e s t a b l e are likely to be t h e d e a f - m u t e - b l i n d , a n d t h e c e r e b r a l palsied c h i l d r e n w i t h n e i t h e r s p e e c h n o r h a n d control. T h e s e c h i l d r e n m a y , of course, have n o p r i m a r y a m e n t i a : t h e i r intelligence m a y at b i r t h h a v e b e e n potentially n o r m a l . B u t are t h e y educable? D o we n o t have to face t h e fact t h a t t h e r e are certain comb i n a t i o n s a n d degrees of p h y s i c a l defect w h i c h , if t h e y are irremediable, r e n d e r t h e child i n e d u c a b l e despite t h e fact t h a t t h e r e is strictly n o disability of m i n d ? C a n we i n d e e d say t h a t t h e r e is n o disability of m i n d w h e n t h e m i n d is p r e c l u d e d f r o m carrying out its f u n c t i o n s either b y lack of s t i m u l a t i o n or i n f o r m a t i o n due to sensory failure, or b y lack of executive capacity due to m o t o r paralysis ? A t t e m p t s to educate s u c h c h i l d r e n are, of course, colossally expensive, a n d for m y p a r t I d o u b t w h e t h e r t h e results ever justify t h e e x p e n d i t u r e - - a n d let m e a d d t h a t I a m t h i n k i n g less of t h e e x p e n d i t u r e of m o n e y t h a n of time, energy, skill a n d devotion. T o m e it seems t h a t o u r society has to t h i n k in t e r m s of r e t u r n for outlay ; a n d t h a t t h e onus u p o n a C h r i s t i a n w o r l d is to p r o v i d e n o t e d u c a t i o n b u t care for those 4r are so grossly defective t h a t t h e y can n e v e r b e c o n t r i b u t o r s to t h e c o m m o n weal. T h i s care can be b e t t e r provided by the Mental Health Authority than by the Education Authority. Emotional State and Mental Capacity Finally, a w o r d a b o u t t h e child w h o s e secondary defect is " m a l a d j u s t m e n t " ; b y w h i c h , in this p a r t i c u l a r context, I m e a n t h e c h i l d w h o s e emotional state is s u c h t h a t either h e c a n n o t use to t h e full w h a t intellectual capacity he does .possess, or his b e h a v i o u r m a k e s h i m u n a c c e p t a b l e for t e a c h lng. As w i t h physical defectives t h e first p r o b l e m is t h a t of assessment of m e n t a l capacity. I t h i n k we w o u l d all accept t h a t success in intelligence tests is very m u c h influe n c e d b y e m o t i o n a l state. W e t r y to indicate this in r e p o r t i n g o u r results, b y saying p e r h a p s t h a t we failed to establish a n effective r a p p o r t w i t h t h e child a n d c o n s e q u e n t l y believe t h a t the I.Q. m a y have b e e n under-assessed. F o r m y p a r t I r e g a r d it as t h e particular f u n c t i o n of the E d u c a t i o n a l Psychologist, so far as m e n t a l t e s t i n g is c o n c e r n e d , to b e able to m a k e a skilled assessment of t h e intelligence of a child w h o s e responses are o b s c u r e d b y d i s t u r b a n c e of b e h a v i o u r or emotion, O n e is a c c u s t o m e d to seeing reports
f r o m E d u c a t i o n a l Psychologists to the effect t h a t a c h i l d has an I.Q. of, shall we say, 60 or more, b u t owing to some q u a l i t y of m i n d is u n a b l e to make full use of its intelligence a n d is ineducable. T h e defective quality of m i n d m a y b e of a type obvious in school c l a s s - - e x t r e m e restlessness, distractability, apathy, or lack of c o n c e n t r a t i o n , for instance - - w h i c h w o u l d lead a class t e a c h e r to say " I c a n ' t teach this boy (or girl) " : either because the child is u n c o n t r o l l a b l e in class or because the teacher c a n n o t secure a n d maintain. a d e q u a t e c o n t a c t w i t h him. At o t h e r t i m e s the defective quality of m i n d m a y be m o r e s u b t l e - - t h e child lacks j u d g m e n t , n o t in a wholly intellectual sense, b u t to appreciate its o w n relationship w i t h t h e world a b o u t it, or the significance of its o w n acts or those of others. A m a r k e d degree of this type of defect, w h i c h appears to a m o u n t to a d i s p r o portionate deficiency in a single c o m p o n e n t of intelligence, has f r e q u e n t l y led to a suggestion t h a t the child is p r e p s y c h o t i c - - t h a t we are dealing n o t j u s t w i t h m e n t a l deficiency b u t w i t h i n c i p i e n t dementia. A m o n g those c h i l d r e n w h o m E d u c a t i o n a l Psychologists r e p o r t as i n e d u c a b l e despite a fairly h i g h I.Q. are m a n y w i t h b e h a v i o u r p r o b l e m s , a n d one of t h e c o m m o n e s t diagnoses is t h a t of e m o t i o n a l immaturity. T h i s c o n c e p t o f " emotional d e v e l o p m e n t " as s o m e t h i n g t h a t proceeds i n d e p e n d e n t l y of intellectual d e v e l o p m e n t is, I think, an i m p o r t a n t one. T h e E d u c a t i o n a l Psychologist says in effect, " this child's e m o t i o n a l d e v e l o p m e n t is n o t c o m m e n s u r a t e w i t h its m e n t a l d e v e l o p m e n t , therefore it is n o t educable. Is t h e r e a " n o r m a l " p a t t e r n of e m o t i o n a l d e v e l o p m e n t ? Does it proceed at a steady pace ? Is it n o t possible t h a t a child w h o at six is so lacking in selfcontrol t h a t it is n o t educable (in spite of a n I.Q. well above t h e b o r d e r - l i n e ) m a y make big strides w i t h i n the next couple of years a n d b e c o m e at the age of eight capable of receiving e d u c a t i o n a c c o r d i n g to its m e n t a l age ? I f in fact o u r j u d g m e n t as to e d u c a b i l i t y has to take a c c o u n t of b e h a v i o u r a n d e m o t i o n a l control, have we a n y yardstick b y w h i c h this can be m e a s u r e d ? H e r e again we come u p against t h e fact t h a t t h e M i n i s t r y ' s assessors, so far as m y experience goes, do n o t recognise the existence of a child w h o is incapable of b e i n g t a u g h t u p to its m e n t a l age ; a n d it is a safe b e t t h a t a n y case going to appeal o n a n I.Q. of 60 will find t h e M i n i s t e r s u p p o r t i n g the appeal. I n this c o u n t y we have u s e d one of t h e R u d o l f Steiner " schools " occasionally for b o r d e r - l i n e ineducable chiI~ren w h o s e effective intelligence is, or is believed to be, d i m i n ished b y e m o t i o n a l p r o b l e m s . W e argue firstly t h a t s u c h c h i l d r e n will n o t suffer b y b e i n g m i x e d w i t h definitely i n e d u c a b l e c h i l d r e n (as h a p p e n s in these " schools " ) ; secondly t h a t t h e fact t h a t t h e y will get n o education (as t h e C o u n t y E d u c a t i o n Officer u n d e r s t a n d s t h a t t e r m ) will do n o h a r m for a t e r m or two ; thirdly, t h a t if they really possess an e d u c a b l e s t a n d a r d of intelligence w h i c h t h e y are precluded from using by their emotional disturbance, then t h e loving care which, w i t h some o d d e r ingredients, we believe t h e y get in these " schools," will give t h e m t h e i r best hope of r e t u r n i n g to emotional n o r m a l i t y ; a n d fourthly, t h a t if t h e y h a v e b e e n tried, a n d have failed to progress, e v e n in a R u d o l f Steiner " school " t h e A u t h o r i t y will be in a far s t r o n g e r position to resist appeal against an u l t i m a t e deeis.ion to " r e p o r t . "
Conclusions I a m conscious that this address has bccn somewhat diffuse, a n d w o u l d like in conclusion, a n d b y way of s u m m a r y , to repeat certain suggestions w h i c h will p e r h a p s serve to focus discussion. (1) T h e Act p r o v i d e s for exclusion f r o m t h e educational system on a c c o u n t of disability of m i n d b u t gives n o g u i d a n c e as to t h e degree of disability w h i c h is i n c o m p a t i b l e w i t h education. (2) T h e only p r o p e r criterion of i n e d u c a b i l i t y is failure to r e s p o n d to suitable special education. (3) E d u c a t i o n A u t h o r i t i e s t e n d to e q u a t e educability w i t h f u t u r e literacy, a n d to provide special schools o n l y for those
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PUBI9
who it is hoped may learn to read usefully (I.Q. approximately 60 to 65). (4) T h e Ministry's Medical Officers appear to adopt a similar standard to School Medical Officers in general, and to support appeals with respect to children at a considerably lower level (I.Q.s about 50). T h e r e is thus a significant group who cannot readily be brought within the Mental Health law nor provided with suitable education. (5) T w o alternative solutions are suggested : - (a) T h e Local Education Authority to be responsible 9 for training of mental defectives (outside institutions), with suitable safeguards to see that they get their fair whack of education funds. (b) T h e C o u n t y Education Officer to decide, on the basis of, inter alia, a report from the School Medical Officer, whether the child is educable--i.e., whether he can provide it with education according to its ability and aptitudes. Neither of these alternatives is compatible with the present law. (6) T h e ascertaining Medical Officer at present has his hand forced by certain factors which ought not to a p p l y - i.e., the lack of suitable special education, the parent's reaction, and perhaps the lack of training facilities for mental defectives. Special schools for border-line children of Infant School age, where edueability can be put to the test, are particularly needed ; and not least schools which will cater for " low-grade " children with in addition physical or emotional handicaps. (7) A problem of ascertainment and disposal is presented by those children who, owing to associated disabilities of m i n d such as abnormalities of temperament, emotion, or bebaviour are not educable to a level corresponding with their assessed I.Q. THE ROLE OF THE PUBLIC HEALTH DEPARTMENT IN THE PREVENTION OF MENTAL AND NERVOUS DISEASE ~ By I. A. G. MAcQUEEN,M.A., M.D., D.P.H.,
Medical O~cer of Health, City of Aberdeen Mental diseases and mental deficiency between t h e m now take up m o r e hospital beds than do all general medical cot~ditions. T h e neuroses constitute the c o m m o n e s t cause of absence from work. T h e amount of suffering and distress occasioned by stress diseases and psychosomatic diseases (if these concepts can be differentiated) is incalculable. A n d in addition to the enormous known volume of disease of mental and emotional origin, there is the even greater portion that is u n k n o w n - - " hidden behind the aspidistra," in the words of an eminent sociologist, x It is fair to say that at least one half of all h u m a n disease and suffering has its origin in faulty emotional relationships, especially in childhood. T r e a t m e n t of a fully developed case of psychoneurosis involves the expenditure of m u c h time and m u c h money. W e in Britain have not enough doctors, not enough nurses, not enough hospital beds, not enough m o n e y for the effective treatment of even the visible portion of this vast iceberg. Unless we can reduce the prevalence of these conditions by preventive measures, the outlook is dismal indeed. For the neglect of mental health work to date both health officers and psychiatrists are to blame. T h e medical officers of health have been so engrossed in the eradication of formerly c o m m o n infectious diseases and in the improvem e n t of the physical health of children that they have not yet accepted the challenge of a menace even graver than the typhoid and smallpox that confronted the public health pioneers of last century. T h e psychiatrists, experts in a young and rapidly developing science, have tended to interest themselves 'in curative measures rather than in *Address to a joint meeting of the Scottish Branch, Society of M.O.H. and Scottish Division of Royal Medico-Psychological Assor 10~h April~ 1954,
HEALTH, November, 1954
prevention, and in the full-blown psychoses rather than the numerically c o m m o n e r psychoneuroses and psychosomatic diseases. Let me quote f r o m one psychiatrist who has some inkling of the truth : Hadfield, late of the Tavistock Clinic, s a y s " It is generally agreed by psychopathologists that the psychoneuroses such as Hysteria, Sex Perversions, Anxiety States, Obsessions, Depression, and many Behaviour Disorders are traceable in their origin to abnormal conditions in the early years of life. If this is so, it should be possible by providing the right conditions in childhood to prevent the occurrence of these disorders.' '~ Available Forces F o r the benefit of those unfamiliar w i t h the lay-out of health departments let m e briefly describe their staffing. T h e main h u m a n tools available to the health departments for preventive work are medical officers and health visitors. T h e medical officers---about one for every 13,000 population in the best staffed areas and half of that in the worst a r e a s - are not experts in p s y c h o l o g y : they have the ordinarv undergraduate medical training with its smattering of psychology and psychiatry, followed (usually after two or three years of junior hospital posts) by one year of full-time study for the D.P.H., again with a handful of lectures on mental health. T h e health visitors--about one for every 2,500 people in the best staffed areas and one for every 5,000 in the worst areas--are again not experts in psychology : they have their general nursing training, with nowadays a slender introduction to psychology included, a subsequent midwifery training, a n d - - u s u a l l y after t w o or three years as hospital staff nurse and ward s i s t e r - - a course of full-time study for the health 'visitor's certificate, this course lasting at present from six m o n t h s to one academic year but likely in the near future to become standardised everywhere as an academic year, and including some six or seven lectures and lecture-demonstrations on m e n t a l health 9 Other people in the health d e p a r t m e n t - - d i s t r i c t nurses, sanitary inspectors, staffs of day and residential nurseries, even home h e l p s - may have a supplementary part to play, but for the present let us concentrate on the medical officer and the health visitor. I am deliberately ignoring the child guidance clinic, because, valuable t h o u g h it is, it begins to play its part after a faulty situation has a r i s e n - - n o t before. T h e medical officer works mainly in the child welfare clinic and the school. T h e health visitor, while taking part in the work of the ante-natal and child welfare clinics and while regularly visiting schools, does her most important work in the home. U n d e r the m o d e r n concept of the health visitor as the health counsellor and teacher of the family she takes the family as her unit, is generally accepted by the family as a skilled friend to w h o m they can turn for advice on any health matter, and is responsible for the welfare of anything f r o m 600 to 1,200 families. T h e weakness of both officers in undertaking mental health w o r k is that they are n o t - - a n d in general cannot hope to b e - - e x p e r t s in psychology. O n the other hand, they have certain concrete advantages : - - b o t h medical officer and health visitor are well educated, highly trained officers, w h o - - f r o m the very width and variety of their professional training should be capable of forming balanced j u d g m e n t s and of offering sound advice ; both are accustomed to look at problems from the angle of preventing disease and p r o m o t i n g health ; both have experience in the difficult art of persuasion ; and the health visitor has the additional advantage that, unlike any other worker in the field of health and disease, she is in the habit of visiting houses at h e r discretion without the necessity of waiting to be summoned. In any contribution that they can make to mental health the public health medical officer and the health visitor are best considered as a team, but, in so far as separate consideration is necessary, the emphasis should probably be placed on the health v i s i t o r - - t h e r e are four or five health visitors for every public health doctor and the health visitor can influence people in their own homes,