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Mental health is public health
MENTAL HEALTH IS PUBLIC HEALTH* The New Look in Mental Subnormality By B. H.
K IRMA
N,
M.D., D.P.M.
Queen Mary's Hospital for Children, Carshalton, Surrey S o ~ dozen years ago, at the request of a women's organization, I visited a large city to speak on mental defect. 1 made bold to suggest to these good ladies that many of those detained at the public expense in institutions could, with good will and a little effort, be successfully adapted to life in the community. My audience promptly divided into two factions. Of these, the smaller, perhaps, but certainly the more vociferous, expressed suitable indignation and managed to convey the impression that such a rash action might lead to eminently respectable and valuable citizens, e.g. those on the platform, being murdered in their beds. Apart from this consideration, the nation would certainly be swamped by a flood of illegitimate morons. The spokeswomen of this faction were acquainted with the report of the Mental Deficiency Committee (1929) and were at pains to point out that the special provision recommended for defectives in that report had never been created. The need, in their opinion, was for more beds in institutions and for more stringent segregation. The other faction was more hesitant and prone to private disavowal o f the views of the other side; its views were co]oured by actual experience of, and work with, defectives. Contact with similar audiences at the present time finds the tables turned. The official emphasis is on informality, on rehabilitation and against legal detention except as a last resort. There is much more public understanding of the nature of mental backwardness and there is less tendency to confuse it with insanity and psychopathy. Even among authorities on the subject there are, however, wide differences of opinion. Reliable data are lacking on many aspects of the subject. Difficulties are also created by the fact that mental retardation is very much a social and cultural problem.
Definition I f we take the International Classification o f Diseases 1955 (1957), we find that moronity, feeblemindedness or mild mental subnormality is classified as referring, in the case of children, to a n intelligence quotient range of 50-65 on the Stanford revision of the Binet scale. In addition to this there is also a noman's-land of "borderline intelligence" which the experts have not had the temerity to define in terms of intelligence quotient! The 1948 edition of the *Lecture to Mental Health Group of The Society of Medical Officers of Health at "/'he London School of Hygiene and Tropical Medicine, January 3rd~ 1962. 108
MENTAL
HEALTH
IS
PUBLIC
HEALTH
109
international classification used a range of intelligence quotient from 50 to 69 and did not specify on which scale this was to be assessed. These limits, which are still widely used, enable 3 per cent. of the population, i.e. 1½ million on the basis o f 50 million to be regarded as mentally defective. Some 3 per cent. of children may score below the 70 I.Q. level on formal tests as in the Scottish survey (1949). On the school population of England and Wales this would give a figure of some 180,000 retarded pupils.
Present pro vision It becomes olzvious from these considerations that what has happened in providing for mental defectives under the 1913 Act is that a very limited number of individuals have been singled out for special attention, usually for social reasons. Thus the total numbers on the registers of local authorities in England and Wales in 1959 were approximately 145,000. But O'Connor and Tizard in 1954 showed that 58 per cent. of institutional cases could be cIassed as feebleminded and that, among this latter group, half had intelligence within the normal range. That is, roughly a quarter of ',the available institutional 'accommodation was being used for patients who were not intellectually defective. It appears possible that the situation in regard to institutional eases has still not changed very radically. Nearly one half of the cases admitted in 1958 were classified as feebleminded (Registrar-General, 1961). It seems likely that a very similar situation exists in regard to special schooling, a question which is obviously closely bound up with that of meo.tal subnormality in general. The number of children in classes for the educationally subnormal in 1950 was 1%000 and is estimated at 35,000 for the current year. The official estimate of the need is 54,000 (Howlett). Some 54 per cent. of education authorities draw more than a quarter of their children for special classes or schools from those with an intelligence quotient of over 70.
Need for different approach All of this reinforces the need for a radical revision of our attitude to the problem. There is no basis for regarding those individuals previously labelled as mentally defective as qualitatively distinct from the remainder of the population. They are but a small fraction of those with limited intellectual capacity and, indeed, include many of normal intelligence. It is essential to eliminate or make more flexible administrative classification and to make sure that normal social services are available to the handicapped individual, irrespective of test score.
Physical defect and social disability For practical purposes, the problem of mental retardation may be roughly divided under two heads: (a) reduction of cerebral capacity, and (b) social disability. All affected individuals suffer from a degree of the former but, by
110
PUBLIC
HEALTH
VOL.
LXXVII1
NO.
2
and large, those who have come to the notice of the authorities have done so because of the latter. The impact of social factors varies with the social environment. In times of economic crisis, job-finding and rehabilitation are naturally more difficult so that the demand for institutional care may increase. On the other hand, with improvement in 13ousing conditions it becomes easier even for tlae severely subnormal to remain at home. It was formerly the custom to divide backwardness into sub-cultural and pathological types but there is no justification for this. The brains of many people of normal intelligence show evidence of pathological factors and almost all the syndromes producing backwardness have minor variants which allow of normal in|elligence.
Single factors In recent years, the role of single factors in influencing cerebral function has become clearer. Instead of the mystique of the "ncuropathic diathcsis" or the "'submerged tenth" an increasing number of hereditary and environmental deletcrious influences are being recognized. The way in which these agents work is, however, subtle and always conditional upon all the other factors which go to make up the individual. The study of mental defect has suffered more than other branches of science from dogmatism and oversimplification. Two examples may bc drawn from the fields of enviromnent and heredity respectively. Gregg's (1941) classical discovery o f the role of rubella in congenital malformation re-awakened interest in maternal health and the possible noxious influence of early environment. It was also followed by a gross over-estimate of the risk arising from German measles in pregnancy. Some countries even changed their laws to adapt to the situation. More recent careful observation such as that of Pitt (1961) have shown that the risk is not so a/arming as was thought and certainly not such as to call for wholesale abortion. The other example derives from the work of Sj6gren published in 1935. He drew attention to the fact that cataract occurs not uncommonly in association with mental defect. He listed examples occurring in 30 Swedish families and showed that in 9 of the families more than one case of the condition was found. There was no direct inheritance, unlike other forms of cataract, and he thought that many of the cases could be accounted for by a single recessive genetic factor. Whilst this may be so, it seems likely in the light of present knowledge that some of the single cases may have been due to maternal rubella, possibly some were the result of galactos,'emia and perhaps the remainder were not all due to the same genetic abnormality. Both of these examples raise the possibility of prevention. It is sometimes possible for the woman in the early months of pregnancy, who is aware of the risk, to avoid contact with rubella. Deliberate exposure of young girls m a y reduce the risk, whilst attempts at
MENTAL
HEALTtt
IS
PUBLIC
HEALTIt
111
passive immunization on exposure may be helpful. In galactos,'emia, recognition at an early stage should prevent brain damage (Holzel et al., 1957) which, when established, is very marked (Crome, 1962), consisting of widespread gliosis and loss of cclls. It is also now possible to recognize carriers of the disease, i.e. heterozygotes (Kirkman and Bynum, t959). Such recognition is becoming increasingly feasible in a number of diseases responsible for mental defect. Whereas it is true that at present this may be something of an academic exercise, since most people are unlikely to take such considerations into account when marrying and having children, there is little d,oubt that more attention will be directed to this aspect in the future. Already the siblings of patients with this and similar diseases tend to be interested. With increasing public knowledge and awareness, more are likely to seek guidance.
Multil#iciO, of causes There are many hundreds of diseases which may cause damage to the brain and hence mental defect. Of these a big proportion are as yet undefined. Many of them are exceedingly rare. This applies to a large number of genetic conditions. Even such a now well-known and relatively common condition as phenylketonuria is found at most in some 1/20,000 ,of our population. If the metabolic anomaly is to be treated successfully, it is important that it be diagnosed before irreversible damage has been done to the brain. One approach is by routine examination of the newborn. As has been pointed out by Harding and Shaddick (1961), such a survey, if it is to be complete, entails much work and yields a very limited result. None the less, experimental surveys for this and other disease increase our knowledge of incidence and distribution. They will also provide a base line for future assessment of any alteration in incidence. Much more could be done in this field on the basis of already diagnosed cases. This should be coupled with a thorough survey of metabolic anomalies in all suspected cases of mental retardation. Surprisingly little has been done in this direction even with the limited technical resources at our disposal. The readily available institution population has been little examined, whilst there is an almost complete lack of information about subnormal patients living at home and about the populations of schools for the educationally subnormal. Difficulties may arise from lack of co-ordination of information and it is even possible that, in sibships where one case has been affected by, for example, phenylketonuria, siblings born subsequently may escape diagnosis if the family moves to another area. Similarly, an extensive survey of cousins and other potentially affected relatives is not always made. Refinement of techniques for establishing heterozygosity in phenylketonuria will make the task easier in that disease. It will then be possible to state with confidence whether a sibling, an uncle or an aunt is a carrier and also to ascertain the state of the spouse. In this way, the birth of some babies with hereditary metabolic disorders
112
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
2
o f this type could be anticipated. This work would, however, be greatly facilitated if some form of national register of this kind of error could be compiled, or possibly some inter-regional arrangement could be made. Any difficulties which might arise in the way o f public suspicion of such a measure could be met by asking such a body as the National Society for Mentally Handicapped Children to co-operate and to accept a large share of responsibility for ascertainment. The existence o f this information would greatly assist research into metabolic errors.
Value of pooled records Tuberous sclerosis is another example of a potentially hereditary disease which causes serious mental defect. In fact, the majority of sporadic cases are probably due to new mutations (Corlett and Kirman, 1957) though familial cases tend to be more often reported. Central recording of this disease would have double value. It may bring to light mild cases with a 50 per cent. risk o f transmission, and it would afford some index of the mutation rate which is obviously of topical importance in regard to radioactivity. Although we know that this defect can be directly transmitted as a Mendelian dominant trait, we do not know what causes the mutation, its exact nature, its site, nor do we know what enzyme systems, if any, are disturbed in this disease, so to work havoc with the developing nervous system. Light would be shed on some or all o f these matters if cases were systematically recorded. Incidental to all such research on mental defect, vital information is gleaned about normal h u m a n development.
Prevention In most cases of severe subnormality and to a lesser degree in feeblemindedness, there is gross anatomical abnormality in the brain. It is to some extent a function of the high degree o f specialization o f function in the brain that it has limted capacity for recuperation. This very fact emphasizes the importance o f prevention o f cerebral abnormality. Although progress in this direction is to be expected from some o f the types o f measures outlined above and from any general improvement of the environment, we have not yet exhausted the possibility of relatively simple methods of prevention. Assessment of the role of such factors as maternal health and birth injury is always a difficult subject (McDonald, 1958) but there is still r o o m for improvement in regard to obstetric care. A recent survey of cases of defect due to meningitis (Berg, 1962; Kirman, 1958) which we carried out, shows that the various forms of this disease still make a considerable contribution to the total of brain defect, all of which is now technically completely preventable. Similar considerations apply to kernicterus due to jaundice. It seems, however, that the biggest contribution to a reduction in the number of retarded persons needing special help is likely to come from very
MENTAL
HEALTH
IS
PUBLIC
HEALTH
i13
geeeral improvements in the environment and in social facilities. At a simple phys~,:al level there is some evidence (Edwards, 1958) that certain forms o f congenital neurological defect are related to such factors as social class, urbanizm.:on and geographical situation. There is ample animal work to demonstrate the importance of maternal nutrition for integrity of the fcetal brain (Millen and Woollam, 1956, 1957).
Change hz public attitude Changes in the measure of private and public support are, however, likely considerably to influence the size of the problem. It is significant that the demand for institutional beds for the mentally subnormal has continued to increase o f recent years, whilst that for the mentally il~ has declined. In part this may be due to better survival. In part it may reflect a changing attitude in that some families are no longer willing to carry a burden which they have previously accepted without question. It seems reasonable to suppose, however, that if the great unsatisfied demand for day centres were met, the pressure on hospitals might be eased. There is still plenty of scope for more vigorous rehabilitation. The work of pioneer centres (O'Connor and Tizard, 1956; Hilliard and Mundy, 1954) has shown large numbers of institutionalized cases can be placed in jobs and become self-supporting without a great expenditure of effort. Experience in the Fountain group suggests that in a considerable number of cases, guidance, assistance from an experienced social worker, knowledge of suitable employment and, where necessary, short hostel residence, make it possible to avoid institutional care altogether. Apart from the fact that many of those in institutions have not been intellectually defective, there seems no reason why the mildly subnormal should not remain integrated in the community.
The mapxinally educable In regard to the imbecile level of intelligence, similar considerations apply with modifications. Unfortunately the Mental Health Act (1959) did not do away with the concept of "ineducability" but even within the present administrative framework there is scope for easing of boundaries which are too sharply defined. There are many borderline cases (Kirman, 1958) which, with a little extra help, could be regarded as educable. Many of these suffer from additional disabilities. The case of the deaf child has now received very considerable attention and, with more audiometric facilities, is less likely to escape notice. The emotionally disturbed child is less well recognized and impaired capacity for social relationships is not uncommonly equated with defect of intelligence. If marginal cases of this type are given the opportunity of formal education in special schools, they will often adapt sufficiently well to be ultimately capable of earning their living and enjoying a full life.
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Undevelopedpotentialities The work of Lyle and his colleagues (Lyle, 1960, 1961a, 1961b) has shown the benefit which can accrue to the average institutionalized imbecile fi'om improvement in staff ratio, more individual attention, a small unit, greater contact with the general community and a liberal regime. It was possible to measure objectively the gain in vocabulary as compared with a control sample. The gain in happiness and self esteem is difficult to evaluate statistically but none the less important. It is too much to hope that a large proportion o f imbeciles will be capable of open employment but the great majority are capable of socially useful work in protected workshop conditions. In brief, it is reasonable to suppose that increased knowledge and improved social conditions will ultimately decrease the burden o f cerebral abnormality and limited mental ability. Meantime, there is a pressing need for fuller provision both in the community and in the institution for the cxisting handicapped population. Given a minimum of competent help, many more handicapped people can lead normal livcs. In planning for the future, we mast remember that officiousness and prejudice have often made formal provision a hindrance rather than a help in achieving this goal. REFERENCES B E R G, J. (1962). Proceedings of the London Conference on The Scientific Study of Mental Deficiency. London. C o n L E T T , K. and K I R,~ A N, ]3. H. (1957). Brit. med. J . , 2 , 1,174. C R O r,~ Z, L. (1962). Archives o f disease ht Childhood, 37, 415. K D w A R D S, J. H. (1958). Brit. J. prey. soc. ~led., 112, I t 5. G RE GG, N. M. (1941). Trans. ophtkaL Soc. Must.,3, 35. H a R D I N G , W. G. a n d S H A D D I C K , C. "W. (1961). ~'vled, Off'r., 106, 51. HILLIARD, L.T. and MuNDv, L. (1954), Lancet., 2, 644. H O L Z E L , A., K O M R O W E R , G . M. a n d S C H W A R Z , V. (1957). Amer. J. Med., 22, 703. H o w 1, E T T, R. (1961). Forward Trends hi the treatment o f backward ckildrem 5 (No. 4) 7. hzternational Classification o f Diseases t 955 (I 957). G e n e v a . Vol. 1 p. 123. KIRKMAN, H. N. a n d B Y N U M , E. (1959). Attn. hum. Genet. 23. 117. K J a M A N, B. H. (1958), Brit. reed. J., 2, 1,515. (1958a).J. ment. Sci., 104, 167. L Y L E, .1. G . (1960). J. ment. Defic. Res., 4, 14. (1961a). J. ment. Doric. Res., 5, 40. (1961 b). Amer. J. men!. Defic., 66, 69. M c D o N a L D, A. D. (1958). N. Eng. J. Med., 258, 767. Mental Deficiency Committee (1929). W o o d R e p o r t . L o n d o n . M I L L ~ N , J. W. and W O O L L A ~ v l , D. H. M. (1956). J. Neurol. Neurosure. Psychiat., 19, 17. M I L L F N , J. W. and W O O L L A M , D. H. M. (1957). Brit. reed. J., 2, 196. O'CoNNoR, N. a n d T I Z A R D , J. (1954). Brit. med. J., 1, 16. ~ - (1956). The Social Probh,m o f Mental Defi'cietlo,, P. 124. L o n d o n . P l T ~', D. B. ( 1961 ). Med. J./1 ustral., i, 8 81. Registrar General ( 1961 ). Statistic~:l Review of £)tgland arid l~?:h's 1957-58. S u p p l e m e n t o n Mental Health. L o n d o n . S,J 6 c; R E N, T. (1935). Z. ges. Nem'ol. PaTchiat., 152, 263. The Scottish Council for Rcse~-rch in Education (l 949). Yh,, Trend oJ" Scottish httelligence. London.
K IRMA
N,
M.D., D.P.M.
Queen Mary's Hospital for Children, Carshalton, Surrey S o ~ dozen years ago, at the request of a women's organization, I visited a large city to speak on mental defect. 1 made bold to suggest to these good ladies that many of those detained at the public expense in institutions could, with good will and a little effort, be successfully adapted to life in the community. My audience promptly divided into two factions. Of these, the smaller, perhaps, but certainly the more vociferous, expressed suitable indignation and managed to convey the impression that such a rash action might lead to eminently respectable and valuable citizens, e.g. those on the platform, being murdered in their beds. Apart from this consideration, the nation would certainly be swamped by a flood of illegitimate morons. The spokeswomen of this faction were acquainted with the report of the Mental Deficiency Committee (1929) and were at pains to point out that the special provision recommended for defectives in that report had never been created. The need, in their opinion, was for more beds in institutions and for more stringent segregation. The other faction was more hesitant and prone to private disavowal o f the views of the other side; its views were co]oured by actual experience of, and work with, defectives. Contact with similar audiences at the present time finds the tables turned. The official emphasis is on informality, on rehabilitation and against legal detention except as a last resort. There is much more public understanding of the nature of mental backwardness and there is less tendency to confuse it with insanity and psychopathy. Even among authorities on the subject there are, however, wide differences of opinion. Reliable data are lacking on many aspects of the subject. Difficulties are also created by the fact that mental retardation is very much a social and cultural problem.
Definition I f we take the International Classification o f Diseases 1955 (1957), we find that moronity, feeblemindedness or mild mental subnormality is classified as referring, in the case of children, to a n intelligence quotient range of 50-65 on the Stanford revision of the Binet scale. In addition to this there is also a noman's-land of "borderline intelligence" which the experts have not had the temerity to define in terms of intelligence quotient! The 1948 edition of the *Lecture to Mental Health Group of The Society of Medical Officers of Health at "/'he London School of Hygiene and Tropical Medicine, January 3rd~ 1962. 108
MENTAL
HEALTH
IS
PUBLIC
HEALTH
109
international classification used a range of intelligence quotient from 50 to 69 and did not specify on which scale this was to be assessed. These limits, which are still widely used, enable 3 per cent. of the population, i.e. 1½ million on the basis o f 50 million to be regarded as mentally defective. Some 3 per cent. of children may score below the 70 I.Q. level on formal tests as in the Scottish survey (1949). On the school population of England and Wales this would give a figure of some 180,000 retarded pupils.
Present pro vision It becomes olzvious from these considerations that what has happened in providing for mental defectives under the 1913 Act is that a very limited number of individuals have been singled out for special attention, usually for social reasons. Thus the total numbers on the registers of local authorities in England and Wales in 1959 were approximately 145,000. But O'Connor and Tizard in 1954 showed that 58 per cent. of institutional cases could be cIassed as feebleminded and that, among this latter group, half had intelligence within the normal range. That is, roughly a quarter of ',the available institutional 'accommodation was being used for patients who were not intellectually defective. It appears possible that the situation in regard to institutional eases has still not changed very radically. Nearly one half of the cases admitted in 1958 were classified as feebleminded (Registrar-General, 1961). It seems likely that a very similar situation exists in regard to special schooling, a question which is obviously closely bound up with that of meo.tal subnormality in general. The number of children in classes for the educationally subnormal in 1950 was 1%000 and is estimated at 35,000 for the current year. The official estimate of the need is 54,000 (Howlett). Some 54 per cent. of education authorities draw more than a quarter of their children for special classes or schools from those with an intelligence quotient of over 70.
Need for different approach All of this reinforces the need for a radical revision of our attitude to the problem. There is no basis for regarding those individuals previously labelled as mentally defective as qualitatively distinct from the remainder of the population. They are but a small fraction of those with limited intellectual capacity and, indeed, include many of normal intelligence. It is essential to eliminate or make more flexible administrative classification and to make sure that normal social services are available to the handicapped individual, irrespective of test score.
Physical defect and social disability For practical purposes, the problem of mental retardation may be roughly divided under two heads: (a) reduction of cerebral capacity, and (b) social disability. All affected individuals suffer from a degree of the former but, by
110
PUBLIC
HEALTH
VOL.
LXXVII1
NO.
2
and large, those who have come to the notice of the authorities have done so because of the latter. The impact of social factors varies with the social environment. In times of economic crisis, job-finding and rehabilitation are naturally more difficult so that the demand for institutional care may increase. On the other hand, with improvement in 13ousing conditions it becomes easier even for tlae severely subnormal to remain at home. It was formerly the custom to divide backwardness into sub-cultural and pathological types but there is no justification for this. The brains of many people of normal intelligence show evidence of pathological factors and almost all the syndromes producing backwardness have minor variants which allow of normal in|elligence.
Single factors In recent years, the role of single factors in influencing cerebral function has become clearer. Instead of the mystique of the "ncuropathic diathcsis" or the "'submerged tenth" an increasing number of hereditary and environmental deletcrious influences are being recognized. The way in which these agents work is, however, subtle and always conditional upon all the other factors which go to make up the individual. The study of mental defect has suffered more than other branches of science from dogmatism and oversimplification. Two examples may bc drawn from the fields of enviromnent and heredity respectively. Gregg's (1941) classical discovery o f the role of rubella in congenital malformation re-awakened interest in maternal health and the possible noxious influence of early environment. It was also followed by a gross over-estimate of the risk arising from German measles in pregnancy. Some countries even changed their laws to adapt to the situation. More recent careful observation such as that of Pitt (1961) have shown that the risk is not so a/arming as was thought and certainly not such as to call for wholesale abortion. The other example derives from the work of Sj6gren published in 1935. He drew attention to the fact that cataract occurs not uncommonly in association with mental defect. He listed examples occurring in 30 Swedish families and showed that in 9 of the families more than one case of the condition was found. There was no direct inheritance, unlike other forms of cataract, and he thought that many of the cases could be accounted for by a single recessive genetic factor. Whilst this may be so, it seems likely in the light of present knowledge that some of the single cases may have been due to maternal rubella, possibly some were the result of galactos,'emia and perhaps the remainder were not all due to the same genetic abnormality. Both of these examples raise the possibility of prevention. It is sometimes possible for the woman in the early months of pregnancy, who is aware of the risk, to avoid contact with rubella. Deliberate exposure of young girls m a y reduce the risk, whilst attempts at
MENTAL
HEALTtt
IS
PUBLIC
HEALTIt
111
passive immunization on exposure may be helpful. In galactos,'emia, recognition at an early stage should prevent brain damage (Holzel et al., 1957) which, when established, is very marked (Crome, 1962), consisting of widespread gliosis and loss of cclls. It is also now possible to recognize carriers of the disease, i.e. heterozygotes (Kirkman and Bynum, t959). Such recognition is becoming increasingly feasible in a number of diseases responsible for mental defect. Whereas it is true that at present this may be something of an academic exercise, since most people are unlikely to take such considerations into account when marrying and having children, there is little d,oubt that more attention will be directed to this aspect in the future. Already the siblings of patients with this and similar diseases tend to be interested. With increasing public knowledge and awareness, more are likely to seek guidance.
Multil#iciO, of causes There are many hundreds of diseases which may cause damage to the brain and hence mental defect. Of these a big proportion are as yet undefined. Many of them are exceedingly rare. This applies to a large number of genetic conditions. Even such a now well-known and relatively common condition as phenylketonuria is found at most in some 1/20,000 ,of our population. If the metabolic anomaly is to be treated successfully, it is important that it be diagnosed before irreversible damage has been done to the brain. One approach is by routine examination of the newborn. As has been pointed out by Harding and Shaddick (1961), such a survey, if it is to be complete, entails much work and yields a very limited result. None the less, experimental surveys for this and other disease increase our knowledge of incidence and distribution. They will also provide a base line for future assessment of any alteration in incidence. Much more could be done in this field on the basis of already diagnosed cases. This should be coupled with a thorough survey of metabolic anomalies in all suspected cases of mental retardation. Surprisingly little has been done in this direction even with the limited technical resources at our disposal. The readily available institution population has been little examined, whilst there is an almost complete lack of information about subnormal patients living at home and about the populations of schools for the educationally subnormal. Difficulties may arise from lack of co-ordination of information and it is even possible that, in sibships where one case has been affected by, for example, phenylketonuria, siblings born subsequently may escape diagnosis if the family moves to another area. Similarly, an extensive survey of cousins and other potentially affected relatives is not always made. Refinement of techniques for establishing heterozygosity in phenylketonuria will make the task easier in that disease. It will then be possible to state with confidence whether a sibling, an uncle or an aunt is a carrier and also to ascertain the state of the spouse. In this way, the birth of some babies with hereditary metabolic disorders
112
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
2
o f this type could be anticipated. This work would, however, be greatly facilitated if some form of national register of this kind of error could be compiled, or possibly some inter-regional arrangement could be made. Any difficulties which might arise in the way o f public suspicion of such a measure could be met by asking such a body as the National Society for Mentally Handicapped Children to co-operate and to accept a large share of responsibility for ascertainment. The existence o f this information would greatly assist research into metabolic errors.
Value of pooled records Tuberous sclerosis is another example of a potentially hereditary disease which causes serious mental defect. In fact, the majority of sporadic cases are probably due to new mutations (Corlett and Kirman, 1957) though familial cases tend to be more often reported. Central recording of this disease would have double value. It may bring to light mild cases with a 50 per cent. risk o f transmission, and it would afford some index of the mutation rate which is obviously of topical importance in regard to radioactivity. Although we know that this defect can be directly transmitted as a Mendelian dominant trait, we do not know what causes the mutation, its exact nature, its site, nor do we know what enzyme systems, if any, are disturbed in this disease, so to work havoc with the developing nervous system. Light would be shed on some or all o f these matters if cases were systematically recorded. Incidental to all such research on mental defect, vital information is gleaned about normal h u m a n development.
Prevention In most cases of severe subnormality and to a lesser degree in feeblemindedness, there is gross anatomical abnormality in the brain. It is to some extent a function of the high degree o f specialization o f function in the brain that it has limted capacity for recuperation. This very fact emphasizes the importance o f prevention o f cerebral abnormality. Although progress in this direction is to be expected from some o f the types o f measures outlined above and from any general improvement of the environment, we have not yet exhausted the possibility of relatively simple methods of prevention. Assessment of the role of such factors as maternal health and birth injury is always a difficult subject (McDonald, 1958) but there is still r o o m for improvement in regard to obstetric care. A recent survey of cases of defect due to meningitis (Berg, 1962; Kirman, 1958) which we carried out, shows that the various forms of this disease still make a considerable contribution to the total of brain defect, all of which is now technically completely preventable. Similar considerations apply to kernicterus due to jaundice. It seems, however, that the biggest contribution to a reduction in the number of retarded persons needing special help is likely to come from very
MENTAL
HEALTH
IS
PUBLIC
HEALTH
i13
geeeral improvements in the environment and in social facilities. At a simple phys~,:al level there is some evidence (Edwards, 1958) that certain forms o f congenital neurological defect are related to such factors as social class, urbanizm.:on and geographical situation. There is ample animal work to demonstrate the importance of maternal nutrition for integrity of the fcetal brain (Millen and Woollam, 1956, 1957).
Change hz public attitude Changes in the measure of private and public support are, however, likely considerably to influence the size of the problem. It is significant that the demand for institutional beds for the mentally subnormal has continued to increase o f recent years, whilst that for the mentally il~ has declined. In part this may be due to better survival. In part it may reflect a changing attitude in that some families are no longer willing to carry a burden which they have previously accepted without question. It seems reasonable to suppose, however, that if the great unsatisfied demand for day centres were met, the pressure on hospitals might be eased. There is still plenty of scope for more vigorous rehabilitation. The work of pioneer centres (O'Connor and Tizard, 1956; Hilliard and Mundy, 1954) has shown large numbers of institutionalized cases can be placed in jobs and become self-supporting without a great expenditure of effort. Experience in the Fountain group suggests that in a considerable number of cases, guidance, assistance from an experienced social worker, knowledge of suitable employment and, where necessary, short hostel residence, make it possible to avoid institutional care altogether. Apart from the fact that many of those in institutions have not been intellectually defective, there seems no reason why the mildly subnormal should not remain integrated in the community.
The mapxinally educable In regard to the imbecile level of intelligence, similar considerations apply with modifications. Unfortunately the Mental Health Act (1959) did not do away with the concept of "ineducability" but even within the present administrative framework there is scope for easing of boundaries which are too sharply defined. There are many borderline cases (Kirman, 1958) which, with a little extra help, could be regarded as educable. Many of these suffer from additional disabilities. The case of the deaf child has now received very considerable attention and, with more audiometric facilities, is less likely to escape notice. The emotionally disturbed child is less well recognized and impaired capacity for social relationships is not uncommonly equated with defect of intelligence. If marginal cases of this type are given the opportunity of formal education in special schools, they will often adapt sufficiently well to be ultimately capable of earning their living and enjoying a full life.
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Undevelopedpotentialities The work of Lyle and his colleagues (Lyle, 1960, 1961a, 1961b) has shown the benefit which can accrue to the average institutionalized imbecile fi'om improvement in staff ratio, more individual attention, a small unit, greater contact with the general community and a liberal regime. It was possible to measure objectively the gain in vocabulary as compared with a control sample. The gain in happiness and self esteem is difficult to evaluate statistically but none the less important. It is too much to hope that a large proportion o f imbeciles will be capable of open employment but the great majority are capable of socially useful work in protected workshop conditions. In brief, it is reasonable to suppose that increased knowledge and improved social conditions will ultimately decrease the burden o f cerebral abnormality and limited mental ability. Meantime, there is a pressing need for fuller provision both in the community and in the institution for the cxisting handicapped population. Given a minimum of competent help, many more handicapped people can lead normal livcs. In planning for the future, we mast remember that officiousness and prejudice have often made formal provision a hindrance rather than a help in achieving this goal. REFERENCES B E R G, J. (1962). Proceedings of the London Conference on The Scientific Study of Mental Deficiency. London. C o n L E T T , K. and K I R,~ A N, ]3. H. (1957). Brit. med. J . , 2 , 1,174. C R O r,~ Z, L. (1962). Archives o f disease ht Childhood, 37, 415. K D w A R D S, J. H. (1958). Brit. J. prey. soc. ~led., 112, I t 5. G RE GG, N. M. (1941). Trans. ophtkaL Soc. Must.,3, 35. H a R D I N G , W. G. a n d S H A D D I C K , C. "W. (1961). ~'vled, Off'r., 106, 51. HILLIARD, L.T. and MuNDv, L. (1954), Lancet., 2, 644. H O L Z E L , A., K O M R O W E R , G . M. a n d S C H W A R Z , V. (1957). Amer. J. Med., 22, 703. H o w 1, E T T, R. (1961). Forward Trends hi the treatment o f backward ckildrem 5 (No. 4) 7. hzternational Classification o f Diseases t 955 (I 957). G e n e v a . Vol. 1 p. 123. KIRKMAN, H. N. a n d B Y N U M , E. (1959). Attn. hum. Genet. 23. 117. K J a M A N, B. H. (1958), Brit. reed. J., 2, 1,515. (1958a).J. ment. Sci., 104, 167. L Y L E, .1. G . (1960). J. ment. Defic. Res., 4, 14. (1961a). J. ment. Doric. Res., 5, 40. (1961 b). Amer. J. men!. Defic., 66, 69. M c D o N a L D, A. D. (1958). N. Eng. J. Med., 258, 767. Mental Deficiency Committee (1929). W o o d R e p o r t . L o n d o n . M I L L ~ N , J. W. and W O O L L A ~ v l , D. H. M. (1956). J. Neurol. Neurosure. Psychiat., 19, 17. M I L L F N , J. W. and W O O L L A M , D. H. M. (1957). Brit. reed. J., 2, 196. O'CoNNoR, N. a n d T I Z A R D , J. (1954). Brit. med. J., 1, 16. ~ - (1956). The Social Probh,m o f Mental Defi'cietlo,, P. 124. L o n d o n . P l T ~', D. B. ( 1961 ). Med. J./1 ustral., i, 8 81. Registrar General ( 1961 ). Statistic~:l Review of £)tgland arid l~?:h's 1957-58. S u p p l e m e n t o n Mental Health. L o n d o n . S,J 6 c; R E N, T. (1935). Z. ges. Nem'ol. PaTchiat., 152, 263. The Scottish Council for Rcse~-rch in Education (l 949). Yh,, Trend oJ" Scottish httelligence. London.