Handicapped school leavers — The working party report and its implications

H A N D I C A P P E D SCHOOL L E A V E R S THE W O R K I N G PARTY REPORT AND ITS IMPLICATIONS J. D, K E R S H A W bl.D., bt.R.C.P.~ D.P.H.

Medical Officer of Health, Colchester I have been risked to take as my starting point for this paper the Report of the Working Party on the Handicapped School Louver, which has the distinction of being probably the most exhaustive study of the problems of handicapped adolescents ever carried out in this country. In the three years which have passed since its publication there have, of course, been opportunities for second thoughts. There has also been some change in the climate of opinion, with a growing realization that adolescents are now to be considered as a vulnerable group of the population whose problems present a challenge no less important than that of the very young and the ageing. It is amatter for regret that so few of the recommendations in the Report have been implemented, but perhaps the delay may carry the compensation that the whoJe st~bject may be a little better understood. Let us begin with a glance at the more purely medical aspects of disability in adolescence. From pubescence to the end or the physical growth period the youngster has years of physical instability. Growth itself proceeds in spurts with now one body system and now another tending to leap ahead. Growth of the long bones disturbs the mechanical efficiency of the museulo-skeletal system of simple levers on which physical activity depends. "/'he endocrine glands are now overactive and now underactive and commonly out of equilibrium. Emotional and social stresses produce a comparaNe emotional instability. The consequence is that disabilities themselves may worsen or become more handicapping in their effects. The stabilized diabetic may lose his stability, the epileptic improve or worsen dramatically, the "cured" stammer may recur and emotional maladjustment relapse or produce psychosomatic manifestations. Any or these may demand intensification of medical surveillance and treatment. It is, however, in the medico-social field that the difficulties are likely to be most evident, with the standard problems or adolescence more marked and, also, problems emerging which are not part of the hazards which have to be faced by the non-handicapped young person. The most important principle which has to be borne in mind is that of totality of effort. The individual's capacity for performance and his power to tolerate stress is limited; if he is required to expend extra effort in one field he has so much less capacity for effort in others. One of the essential consequences of/he possession of any disability is that the possessor, when undertaking various necessary

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activities, must give to their performance more time or more effort or suffer more strain and stress. Even some of the simple tasks of daily living, which the normal person carries through without thought, may require twice or thrice the time for performance or may involve careful and deliberate planning. In our present society, though ttle primitive rule that those who do not work do not eat has, happily, been superseded, it remains true that those who are unable to earn must forego some of the desirable things of life. The repercussions of this for the handicapped are plain. It is important that they should have and keep employme¢~t, but there is the risk that the efficient doing of their work may leave them too drained, physically or mentally, to enjoy the fruits of their labours. It can also happen that the effort which they have to put into activities of daily living may take so much out of them that their working efficiency is notably reduced. The finding of the most suitable job, having regard to both the job and the youngster's whole circumstances, is obviously a matter of the highest importance, and in this context one special disadvantage of the handicapped must be stressed. The normal young person may, and often does, find the employment that suits him best by a process of trial and error, moving from one to another over a period of mor)tbs and years. This process is not open to the handicapped in anything like the same degree. Not only does failure in his first employment have a damaging effect on his morale; employers are not philanthropists and they took somewhat askance at any handicapped applicant for work, so that the boy or girl who comes will1 a record of having already tried and failed at one or more jobs is substantially less likely to be found acceptable. It is now generally agreed that transition from life at school to life in the world at large can be a traumatic experience for a normal, healthy adolescent. It involves new physical stresses, the acceptance of unfamiliar responsibility, the change from senior status in the school world to very junior status in the factory or the eilice, exposure to z new set of social and ethical standards and, commonly, the need to learn, under pressure of urgency, a number of new skilts. It happens suddenly~virtually overnight. And it comes in the middle of one of life's most unstable periods. That most young people find their way through to adjustment is due to their possessing a substantial margin of resilience, adaptability and tolerance. The handicapped adolescent has less reserve strength and the disability which restricts his potentialities also restricts his adaptability. Furthermore, the process of transition can be considerably more brutal. In the day special school, and even more in tl~e boarding special school, he has achieved a more or tess precarious stability in art en,cironmertt carefully designed to minimize the stresses to which he might be subjected and to spare him unnecessary difficalties~ an environment, too, in which he has been in competition only with his peers. When he leaves, he goes out into a world where the path is not smoothed before him, w/lore be is not only in competition with his "superiors" in physical or

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mental ability but is judged by the standards which they achieve. These who have worked in his care have tried, very properly, to make him feel that though different from normal young people he is not necessarily inferior to them; now everything conspires to make him feel inferior and under the special stress of this appearance he has to start his search for relationships and for his place in the community. Even the handicapped child who has attended an ordinary school has been in some degree sheltered there and though the change may for him not be quite so radical it is nevertheless fraught with risk. Indeed, it may be that only when he leaves school does he realize for the first time that he is handicapped. It was,with these things in mind that the Working Party made its many recommendations. Inevitably, the question of employment had to have a prominent place. The importance of adequate facilities for vocational assessment and guidance was realized, but it wa~; evident that knowledge in this field is sadly limited and that the most that could be done at present was to express pious hopes that progress, especially in regard to job-analysis in the light of the restrictions imposed by disability, might soon be made. To some extent it was considered that special schools might be able to introduce a sufficient variety of activities to give pupils a chance to reveal aptitudes in a fairly general way. There was, however, strong criticism of the tendency to over-optimism shown by some enthusiastic teachers, who failed to realize fully that a tad who could do certain things well but slowly in the school could not expect to do them equally well ~t the speed which a factory or an office might demand. The key role of the Youth Employment Officer was stressed, with special emphasis on adequate communication between the School Medical Officer and the Y.E.O. It was essential that communication should be not only direct and timely but should be comprehensible and an important appendix to the Report was a suggested scheme for functional assessment. The Department of Education and Science has taken this up with enthusiasm and has devised an experimental scheme which is now being operated in a number of selected areas. The further recommendation that the Y.E.O. should automatically receive essential medical information has been less enthusiastically received in certain quarters. The View of the Working Party, that for this purpose the Y.E.O. is in the same position as a medical auxiliary and is thus entitled to eov_fidential information, will surely be shared by most School M.O.s. The Central Ethical Committee of the B.M.A., however, would appear to regard such procedure as unethical. Surely, the fact that the information is to be used by the Y.E.O. in the child's interests must be the governing consideration. One must agree that to give it to the employer without the parents' consent would be wrong. To allow a Y.E.O., however, to try to find a job for a school teaver in complete ignorance of the fact that he is, say, an epileptic or a diabetic, would be grossly unfair to the Y.E.O. and might well lead to the Ieaver's placement in a job for which he was quite unsuitable or; even worse, a job which caused him to imperil his own wellbeing and even the health or safety of fellow workers.

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In times past, a strong case has been made out for the inclusion of vocational education in the special school curriculum; the case tlas been based mainly upon the idea that since the handicapped child is at some disadvantage in job-seeking his chances are improved if he can be presented to a potential employer as already lrained in the sort of work for which he is applying. Most members of the Working Party accepted this argument in part, but the evidence received made it plain that changing conditions had greatly reduced its validity, It is clear that as the range of employments open to the handicapped widens, the less a school will be able to provide vocational training in all of them. The most convincing argument against vocational education, however, arises out of the change in the character of many employments with the advance of technology. Witness after experienced witness made it plain that the types of work which were best suited to a youngster of average or high intelligence suffering from a motor or sensory handicap required a high level of general education before jobtraining could start. Many young people in this category had had their education impeded or interrupted because of their handicap and, on leaving school, had to accept an artisan's job when they were actually capable of working as technicians at a substantially higher level. For this group, to spend on elementa~ vocational training valuable school time ~,hicb could have been used to advance their general education would tend to make bad worse! The Working Party's considered view, therefore, was that vocational training or education as such should be confined to such generalized "vocational exposure" as might explore the pupil's technical aptitudes and inclinations and that true vocational training should wait until he left school. It went even further--conscious of the fact that for the reasons mentioned the pupil might still, at the age of sixteen, be educationally below the level of normal school leavers, it stressed the need for better facilities for further education for the handicapped in technical colleges and also for including general education in the programme of vocational training establishments and, even, assessment centres. The most one can say in regard to progress is that while the basic idea is gaining some acceptance it is not yet making much impact on practice. Progress in this field, when it comes, will probably increase the number of handicapped young workers who can be accepted in ordinary industry, but there will remain some who will need employment in sheltered conditions. Rather disturbed by, bat accepting as a fact, the apparent reluctance of Remploy workshops to take in adolescents, the Report recommended that local authority sheltered workshop provision should be expanded. It may be that the expansion which most authorities seem to be making in their development plans is purely coincidental, but it is welcome and I hope that possibly the recommendations,have helped local authorities to strengthen their case. How adequately one can meet any kind of stress depends, inter alia, on how well one has been prepared for it and clearly the special school must prepare its pupils for the change before them. The inevitable question to be asked is

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how far can one, in an essentially protective environment, prepare a pupil for the ~tresses o f competitive life in industry and in society generally, Three main possibilities were considered. An obvious and practical one was to give older pupils practice and training in activities of daily living, A second one was to provide a kind of "hardening off" period by which the special school pupil might J'eturn to an ordinary school for his last year before leavizag, or at least spend part of his time learning certain subjects in a neighbouring ordinary school. Some progressive schools were already moving in this direction and it would seem that others are slowly following their lead. Part time introduction to employmenL though highly desirable, carries its difficulties. Opportunities of part time weekend and out-of-school hours employment cannot, for obvious reasons, be provided in industry. Part time release to employment in industry during school hours is not at present permissibte for children within compulsory school age and it would carry the disadvantage of impeding general education. The Working Party's view was that every encouragement should be given to handicapped children to stay on at school after the age of sixteen but to be released to part time employment for increasing amounts of time until they gradually found their feet in full time work. Incidentally, it was felt that for handicapped youngsters to do this in their seventeenth year would be much better than raising the leaving age for the handicapped to seventeen when the general leaving age goes up to sixteen. (Such a course would probably be/nore acceptable to the handicapped and their parents when the general leaving age goes up--at present some of those who could most profit by it insist on leaving at sixteen.) A substantial number of handicapped adolescents fail to find and keep the employment which would suit them because of factors outside the work itself. One of these is inability to get to and from work by public transport. Another is difficulty in moving around in the factory to use canteen ~ sanitary facilities. A third is the point I have already mentioned, namely excessive fatigue and strain in the ordinary business of daily living. The second difficulty may be insuperable or may be partly overcome by co-operation on the part of the factory management--better education of employers, not merely of the managing director in his office but of the foreman or charge hand on the shop floor, in understanding of the problems of the handicapped is desirable. Special transport provision may also be indicated to deal with the first difficulty, but some employers are enlightened enough to adjust the working hours of handicapped employees so that they can travel by public transport outside the peak rush hours. The provision of more hostels was recommended as something which would not only reduce travelling difficulties but would cut down travelling time and provide an adjusted and less stressful living environment, More hostels are envisaged in most development plans, but two questions remain to be answered: is it a good thing to mix adolescents with adults in

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hostels and, if not, are there sufficient handicapped adolescents in need to justify the provision of special hostels for them ? The Working Party considered that too little use was being made of the supportive services which the Welfare Departments could supply. It appeared that housing adaptations, for instance, were considered as something for the handicapped breadwinner or housewife rather than for the adolescent son or daughter. Stress was laid on tlae potential value of the advisory and counselling role of the welfare offxcer in helping the handicapped youth to live with his disability and upon the quite Jntolerable caseloads which prevented him from playing this role to the full. Staff augmentation in this field ought to be a priority matter, and there are indications that the point is being taken. So many and diverse are the special skills and techniques required in helping the young handicapped that it is inevitable that a considerable number of people will be invt3ved in the field work. The Working Party considered that to bring together in a single agency workers who now work within three or four local authority departments and severat statutory and voluntary organizations outside local government was a manifest impossibility, but that co-ordination of the work was essential. The local authority, with its responsibility for health services (including general health, school health and mental health), education services and welfare services was certainly in the best position to initiate coordination, and new functions in this field of work should be, wherever possible, allocated to the ]oca] authority. In the light of recent events it is interesting that the Working Party did not see fit to recommend any specific plan for the amalgamation of the various local authority services. Though impressed by the results obtained in some places by combining health with welfare it preferred to leave matters flexibie to meet varying local circumstances. At field work level it regarded the ease conference technique as the most effective means of getting co-ordination. It was obvious that localities where this system was well established were getting results. That there should be a large scale case conference to discuss every school leaver's problems in detail is as unnec,ezsary as it is unpractical, but the Working Party favoured a slight shift from the common emphasis. In many fields, case conferences are called only to discuss cases where there is special need; in other words, they are called only wher, substantial multiple problems have already arisen. When dealing with handicapped school leavers the function of the case conference is preventive rather than curative and the recommended approach is that a ease conference should be held unless all the parties involved are satfsfied that none is necessary. This ensures that in every case there will be a multi-disciplinary review. It is al~o emphasized that the review, and the case conference when called, should concern itself not only with the pupil's employability and work prospects but with the totality of his need. The corollary is that all the workers involved should get to know something about the pupil as a whole and that not only the Schoot M.O. and the Y.E.O. should have good continuing contacts with the

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school but the mental welfare officer, the welfare officer fo~; the physically handicapped, tile D.R.O. and others who might be concerned or have something to contribute should be on "dropping-in" terms with both the special and the ordinary schools of a district. Some special schools reported good results from developing this sort of relationship with local employers who might have jobs suitable for their leavers. Clearly, neither case conference techniques nor good informal relationships can be enforced by law, nor can they even be assured by published codes of practice. They will come only from staff education, but it would seem that the Report has been widely enough discussed and understood to have already had some impact in this way. Continuity is perhaps even more important than co-ordination and the act of leaving school means that in present conditions the adolesce~lt is compelled to lace a break in continuity of care. That the "new" workers who take over responsibility for him are able and well trained must not obscure the fact that the youngster does not know them as well as he knows his former helpers, the School M. O., the school nurse and the teacher, and that in his bewilderment his first instinct is to turn to someone who is familiar to him. It must be accepted that it is natura~ and normal for an adolescent to lose his old contact with his parents at this stage and that they may well be the last people to whom he would go with an important problem. The same may be true of the family doctor; apart from the fact that the new-found independence &adolescence often shows itself in a reluctance to go to a doctor unless one is manifestly ill, the family doctor, precisely because he is the family doctor, may be regarded as "one of the enemy"! On this point the Working Party made several recommendations. One was that the statutory responsibility of the school health service should be extended to cover general surveillance of handicapped adolescents at least up to the age of eighteen. Another was that in the staffing of special schools allowance should be made to enable the staff to continue the informal contacts with old pupils which so many schools and so many pupils find worthwhile. No action has yet been taken in the matter and the present is a particularly important time to emphasize its importance because some forward-looking people see in the impending overhaul of the Appointed Factory Doctor Service a chance to link school health with factory health in the provision of a health surveillance service for adolescents in general. Perhaps ~he beginning of this might be through combined work for the handicapped. Running through at[ the Working Party's discussions was the recurrent realization that much more needs to be known about all aspects of the care of the young handicapped, and its Report included a plea for more research. Fundamental research into the nature of disability is a first requirement and [ welcome the recent tendency to expand it, particularly in the field of mental handicap. Research into problems of adjustment is moving more slowly; the standard work on adjustment of the physicMly handicapped is still the admirable

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book of Barker which is now fifteen years old ! Also neglected is research into the na tore of the needs of the handicapped. The Institute of Education in the University of London is starting to take a new and erkical look at educational needs, but social and emotional needs after leaving school need much more investigation, W/lether or not we like it, we must accept the fact that in most modem eomraurt~ties the handicapped are underprivihged. True, it is not legislation but the accident of disability tttat bars them from certain employments, prevents them from enjoying certain rights or compels them to abstain from certain activities. The effect however is the same; the notice on the door of a public building which prohibits entry to those of a particular race or colour is rightly condemtled, but what of the flight of steps outside the door which equally effectively bars the way to the wheelchair patient and turns him, too, into a second-class citizen ? Almost every problem the Working Party met would be easier of solution, and I suspect that more would have been done toward implementing the recommendations, if public understanding of the handicapped and their difficulties could be improved. Most public education in this respect has been in the hands of the voluntary organizations and the comparatively small measure of their success to date is mainly due to an ir~evitable dilemma. For their work--even their work in public education--they must have money. To raise funds they are compelled to present the handicapped as unfortunate creatures in need of charity, and it is exceedingly difficult to present this kind of public image simultaneously with that which shows the handicapped as desirable house guests~ fellow workers and companions in recreation: The handicapped mart or w~man who has succeeded in a career is thus too often made to zeern a freak or a prodigy rather than a person who has achieved whal: many others could achieve if they were but giveu the opportun.ity. We in the public services are substantially better situated than the voluntary organizations to bring about this public education, remembering not only that the better we do it tl~e better our services will become, but that the improvement of those services in the right spirit will itself tertd to make the climate of public opinion more favourable to those for and with whom we are working.