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EXPERIMENTAL UNIT FOR MENTALLY AND PHYSICALLY HANDICAPPED CHILDREN
1047
Letters
to
the Editor
EXPERIMENTAL UNIT FOR MENTALLY AND PHYSICALLY HANDICAPPED CHILDREN SIR,-In view of greater flexibility of hospital admissions under the Mental Health Bill, it seems useful to discuss the needs of a borderland group of childrenthose with severe mental and physical handicaps. These
handicapped mentally that they require training and education given in a mentaldeficiency hospital, and are debarred from education in hospital schools under the Education Act; so handicapped physically that they require the full range of medical services available in a children’s orthopaedic hospital not usually available in a mental-deficiency institution. They tend to be so handicapped that they require long-term inpatient treatment. are children the type of
so
Two such overlapping groups are (a) children with spina bifida associated with lumbosacral myelomeningocele, hydrocephalus, and mental defect; and (b) cerebral-palsied children with associated mental deficiency. We have been unable to find conclusive figures of the incidence of spina bifida with lumbosacral myelomeningocele and mental deficiency: there are figures 1-3 that suggest there are quite a number. We do know that the incidence of children with cerebral palsy is 1-2 in 1000, and that almost half of them would have I.Q.s below 70.4 No-one yet knows how much can be done for these children given (a) full clinical diagnosis followed by (b) treatment geared to their mental and physical handicaps. We quote 2 cases which suggest that such children may make a worthwhile,
though limited,
response to treatment: CASE 1.-A spina bifida with paraplegia and arrested hydrocephalus, certified mentally defective, was bedridden and incontinent, with flexion deformities of hips and knees on admission at age 5. Now aged 12, she is ambulant (with crutches and callipers) and continent (after an " ileal bladder " operation), LQ. 53 (borderline
educable). CASE 2.-A
spastic quadriplegia, admitted at 14 months with general retardation, certified mentally defective at age 8, !.Q. 485 and now awaiting transfer. But physiotherapy and corrective surgery have produced increasing mobilisation and he can now extreme
feed and wash himself.
We should like to suggest that an experimental unit for 15-20 young mentally and physically handicapped children could be set up in a children’s orthopaedic hospital, with occupation-centre or nursery-school staff to look after the social and educational side. Such a unit appears to have the following advantages over either a separate unit for these children or a unit attached to a mental-deficiency institution :
(1) Medically the children would receive the full range of expert services available to other children in the hospital suffering from the same physical disabilities. In spina bifida and cerebral palsy the physical disability cuts across the range of intelligence : therefore the hospital staff in a children’s orthopaedic hospital has experience and knowledge of the problems involved in physical habilitation of these conditions. A further point of some importance is that it may be easier to maintain a high level of staff morale where staff treat children of normal intelligence as well as mentally subnormal children. (2) Educationally and socially the mentally retarded children would be provided for as a separate unit, distinct from the hospital school attended by the other children. (3) There would be constant exchanges between hospital and teaching staff, and therefore this unit would be an integral part of the hospital. However, these children would not hold back the brighter children educationally and socially, and they 1. Hilliard, L. T., Kirman, P. H. Mental Deficiency. London, 1957. 2. The Health of the School Child; chap. IV, p. 133. Chief Medical Officer, Ministry of Education, 1956 and 1957. 3. Ellison Nash, D. F. Ann. R. Coll. Surg. Engl. 1957, 20, 350. 4. Illingworth, R. S. Recent Advances in Cerebral Palsy. London, 1958.
would not have to compete with the other children in fields which they would find hardest-namely, in educational and social life. (4) A last advantage would seem to be that in children with multiple handicaps accurate diagnosis is often difficult and needs time, and a unit such as this would allow for flexibility without major changes of personnel or environment. Such a unit should be an experiment. Our argument is that it is worth while to get these children as fully independent as possible, because it will increase their happiness and self-respect: any degree of social indepen-
dence lessens
nursing care, and is therefore important economically. The object of the experiment would be to find out whether one can achieve a useful degree of independence with such a prograrnme. The children would be carefully assessed initially and reassessed at intervals. It should be possible to obtain control groups from mental-deficiency institutions or occupation centres or
outoatient departments.
Chailey Heritage, Chailey, Sussex.
SIR,-Your tion of
note
E. P. QUIBELL ELSPETH STEPHEN ELIZABETH WHATLEY. HOSPITAL DIET of April 18 about the recent
publica-
third memorandum on hospital diet is indeed The memorandum is so excellent a document timely. that it should receive the widest possible publicity for, were its recommendations to be fully implemented on a national scale, the standard of the hospital service would be immeasurably raised. a
As you emphasise, it is generally recognised that good food, well cooked and attractively served, is an important factor in the treatment and recovery of every patient. A well-balanced normal diet, no less than a therapeutic diet, requires trained personnel, including qualified catering officers, cooks, and dietitians. The catering department is as important as any other of the hospital service and yet often, especially in the periphery, catering for normal diets is quite inadequate while facilities for therapeutic diets are virtually non-existent. Moreover, kitchen hygiene is not always above reproach. Yet most hospitals, central or peripheral, can boast of, and indeed would not tolerate anything but, the best medical, surgical, or pharmaceutical services. What then is the cause for this lower standard of the catering department ? One of the answers lies in what Dr. Avery Jones, chairman of the Hospital Catering and Diet Committee, refers to in his foreword as the " structural inadequacy of kitchens in many hospitals which are not only poorly equipped but also badly designed ". In fairness, however, one must agree that the Ministry of Health have readily accepted the principle that catering departments are of key importancewitness the great improvements in some of the major hospitals, especially during the past decade. Not, however, until hospital capital expenditure is increased so that new hospitals can be built will their kitchens become satisfactory and some of the antiquities of today become no more than a sordid memory. The second most important problem to be solved is staff shortage. The national salary scales are far too low by comparison with current commercial levels to attract trained personnel, from catering officer down to kitchen assistant, not excluding the important dietitian whose role as therapist, teacher (to patients, nurses, and cooks), and nutritionist is so well outlined in the booklet. As a temporary measure to deal with the immediate problem, could not existing resources be and administrators and hospital management colllliÙtconsider more even distribution and sharing of catering personnel between two or more hospitals in a group rather than concentrating on the well-developed departments of some of the major hospitals ? This would help to promote a general uneradina- to an accented standard of efficiencv. PHILIP ELLMAN. London, W.I.
pooled tees
Letters
to
the Editor
EXPERIMENTAL UNIT FOR MENTALLY AND PHYSICALLY HANDICAPPED CHILDREN SIR,-In view of greater flexibility of hospital admissions under the Mental Health Bill, it seems useful to discuss the needs of a borderland group of childrenthose with severe mental and physical handicaps. These
handicapped mentally that they require training and education given in a mentaldeficiency hospital, and are debarred from education in hospital schools under the Education Act; so handicapped physically that they require the full range of medical services available in a children’s orthopaedic hospital not usually available in a mental-deficiency institution. They tend to be so handicapped that they require long-term inpatient treatment. are children the type of
so
Two such overlapping groups are (a) children with spina bifida associated with lumbosacral myelomeningocele, hydrocephalus, and mental defect; and (b) cerebral-palsied children with associated mental deficiency. We have been unable to find conclusive figures of the incidence of spina bifida with lumbosacral myelomeningocele and mental deficiency: there are figures 1-3 that suggest there are quite a number. We do know that the incidence of children with cerebral palsy is 1-2 in 1000, and that almost half of them would have I.Q.s below 70.4 No-one yet knows how much can be done for these children given (a) full clinical diagnosis followed by (b) treatment geared to their mental and physical handicaps. We quote 2 cases which suggest that such children may make a worthwhile,
though limited,
response to treatment: CASE 1.-A spina bifida with paraplegia and arrested hydrocephalus, certified mentally defective, was bedridden and incontinent, with flexion deformities of hips and knees on admission at age 5. Now aged 12, she is ambulant (with crutches and callipers) and continent (after an " ileal bladder " operation), LQ. 53 (borderline
educable). CASE 2.-A
spastic quadriplegia, admitted at 14 months with general retardation, certified mentally defective at age 8, !.Q. 485 and now awaiting transfer. But physiotherapy and corrective surgery have produced increasing mobilisation and he can now extreme
feed and wash himself.
We should like to suggest that an experimental unit for 15-20 young mentally and physically handicapped children could be set up in a children’s orthopaedic hospital, with occupation-centre or nursery-school staff to look after the social and educational side. Such a unit appears to have the following advantages over either a separate unit for these children or a unit attached to a mental-deficiency institution :
(1) Medically the children would receive the full range of expert services available to other children in the hospital suffering from the same physical disabilities. In spina bifida and cerebral palsy the physical disability cuts across the range of intelligence : therefore the hospital staff in a children’s orthopaedic hospital has experience and knowledge of the problems involved in physical habilitation of these conditions. A further point of some importance is that it may be easier to maintain a high level of staff morale where staff treat children of normal intelligence as well as mentally subnormal children. (2) Educationally and socially the mentally retarded children would be provided for as a separate unit, distinct from the hospital school attended by the other children. (3) There would be constant exchanges between hospital and teaching staff, and therefore this unit would be an integral part of the hospital. However, these children would not hold back the brighter children educationally and socially, and they 1. Hilliard, L. T., Kirman, P. H. Mental Deficiency. London, 1957. 2. The Health of the School Child; chap. IV, p. 133. Chief Medical Officer, Ministry of Education, 1956 and 1957. 3. Ellison Nash, D. F. Ann. R. Coll. Surg. Engl. 1957, 20, 350. 4. Illingworth, R. S. Recent Advances in Cerebral Palsy. London, 1958.
would not have to compete with the other children in fields which they would find hardest-namely, in educational and social life. (4) A last advantage would seem to be that in children with multiple handicaps accurate diagnosis is often difficult and needs time, and a unit such as this would allow for flexibility without major changes of personnel or environment. Such a unit should be an experiment. Our argument is that it is worth while to get these children as fully independent as possible, because it will increase their happiness and self-respect: any degree of social indepen-
dence lessens
nursing care, and is therefore important economically. The object of the experiment would be to find out whether one can achieve a useful degree of independence with such a prograrnme. The children would be carefully assessed initially and reassessed at intervals. It should be possible to obtain control groups from mental-deficiency institutions or occupation centres or
outoatient departments.
Chailey Heritage, Chailey, Sussex.
SIR,-Your tion of
note
E. P. QUIBELL ELSPETH STEPHEN ELIZABETH WHATLEY. HOSPITAL DIET of April 18 about the recent
publica-
third memorandum on hospital diet is indeed The memorandum is so excellent a document timely. that it should receive the widest possible publicity for, were its recommendations to be fully implemented on a national scale, the standard of the hospital service would be immeasurably raised. a
As you emphasise, it is generally recognised that good food, well cooked and attractively served, is an important factor in the treatment and recovery of every patient. A well-balanced normal diet, no less than a therapeutic diet, requires trained personnel, including qualified catering officers, cooks, and dietitians. The catering department is as important as any other of the hospital service and yet often, especially in the periphery, catering for normal diets is quite inadequate while facilities for therapeutic diets are virtually non-existent. Moreover, kitchen hygiene is not always above reproach. Yet most hospitals, central or peripheral, can boast of, and indeed would not tolerate anything but, the best medical, surgical, or pharmaceutical services. What then is the cause for this lower standard of the catering department ? One of the answers lies in what Dr. Avery Jones, chairman of the Hospital Catering and Diet Committee, refers to in his foreword as the " structural inadequacy of kitchens in many hospitals which are not only poorly equipped but also badly designed ". In fairness, however, one must agree that the Ministry of Health have readily accepted the principle that catering departments are of key importancewitness the great improvements in some of the major hospitals, especially during the past decade. Not, however, until hospital capital expenditure is increased so that new hospitals can be built will their kitchens become satisfactory and some of the antiquities of today become no more than a sordid memory. The second most important problem to be solved is staff shortage. The national salary scales are far too low by comparison with current commercial levels to attract trained personnel, from catering officer down to kitchen assistant, not excluding the important dietitian whose role as therapist, teacher (to patients, nurses, and cooks), and nutritionist is so well outlined in the booklet. As a temporary measure to deal with the immediate problem, could not existing resources be and administrators and hospital management colllliÙtconsider more even distribution and sharing of catering personnel between two or more hospitals in a group rather than concentrating on the well-developed departments of some of the major hospitals ? This would help to promote a general uneradina- to an accented standard of efficiencv. PHILIP ELLMAN. London, W.I.
pooled tees