The
Report
of the
Joint Committee
on
The whole of the Report of the Joint Committee of the Board of Education and the Board of Control has now been published, and it is a great advantage to be able to view the Committee's conclusions and recommendations in respect of both children and adult defectives. The Report, as now published, appears in three small volumes. Volume i consists of Parts I and II, Part I being a general introduction to the whole Report and Part II dealing with the problem of the mentally defective children. Volume 2, which consists of Part III, deals with the mentally defective adults; whereas Volume 3, containing Part IV, is the report of the special investigation of the incidence of mental deficiency made on behalf of the Committee by Dr. E. O. Lewis. The Committee was, in the first place, appointed to advise the Chief Medical Officer of the Board of Education upon certain specific problems in regard to defective children, but at an early stage of its deliberations it became
9o
MENTAL WELFARE
clear that it was necessary to consider not only the problems of the defective children but also those of adults, and thus the inquiry became a most comprehensive one. Mr. A. H. Wood, C.B., who was at that time the Assistant Secretary in charge of the Medical Branch of the Board of Education, was appointed Chairman of the Committee, which included amongst its members persons who had expert knowledge of the administrative, medical, scientific, social and educational aspects of the problem of mental deficiency. In the initial stages of its deliberations the Committee decided that it necessary to make an investigation that would enable it to assess anew the magnitude of the problem. The only previous investigation on a large scale into the incidence of mental defect in this country was that of the Royal Commission on the Care and Control of the Feeble-minded, 1904-1908. It was thought that the legal and administrative provisions for the mental defective which resulted from the Report of the Commission and the important advances made in the scientific approach to the problem of mental defect during the last twenty years would enable a more reliable estimate to be made of the numbers of defectives. Therefore the incidence of mental defect in six typical areas, each with a population of about 100,000, was ascertained and the data thus obtained proved the wisdom of the Committee's decision. was
In Part I of the Report a chapter is given to review the legislation respectthe mental defective and in Part II another short chapter deals with the ing measures legal relating specially to adult defectives. These two chapters contain a concise but very clear summary of the most important provisions of Acts which apply to mental defectives in this country and of the principal methods devised by the legislature for dealing with these persons. The Committee discusses the legislative provisions in the light of the experience gained in applying them. Careful study of this discussion is essential if the reader is to appreciate the reason for some of the general recommendations which the Committee has made.
One important legal ambiguity which is treated with much frankness and with considerable insight of the difficulties it has presented to Local Auth" orities and Medical Officers, is that involved in the definitions of mentally " in Section 55 (1) of the Education Act, 1921, and of defective children " " in Section 1 (1) (c) of the Mental Deficiency Act, feeble-minded children in the Education Act stresses educational defect, The definition 1913-1927. whereas that of the Mental Deficiency Acts places the emphasis upon failure in social adaptation. The groups of children to whom these definitions apply are by no means identical. There are many children who are defective educationally but not socially, and there are some, a smaller number admittedly, who though not educationally defective prove to be conspicuous failures socially. It is the discussion of the disparity between these two definitions that gives point" and force to many of the statements in the chapter which deals The Committee urges the importance with the nature of mental defect." of having a single criterion of mental deficiency, namely, the social one, and
MENTAL WELFARE
defines
by
"
mentally defective individual, whether child or adult, as one who incomplete mental development is incapable of independent adaptation."
reason
social
91
a
of
The discussion of the effectiveness of the powers and duties allocated to Local M.D. Authorities deals with vital issues. The Committee reached the conclusion that the intentions of Parliament, when it passed the 1913 Mental Deficiency Act, have not been realised. This is attributed chiefly to the fact that Local M.D. Authorities' powers of ascertainment were limited to those defectives subject to be dealt with." The chief source of ascertainment, "
the notification of mentally defective children by the Local Education Authority, has been most disappointing, largely because of the limited number of Special Schools established. The special investigation revealed that no fewer than 77 per cent, of the educable mentally defective children in the six areas were in attendance at ordinary Public Elementary Schools. The other factor that has up to the present restricted considerably the scope of Local M.D. Authorities' activities in respect both of adults and children, is that Poor Law Authorities have power to maintain defective persons by outdoor or indoor relief. Over 40 per cent, of the whole number of adult defectives ascertained in the investigated areas were being dealt with by Poor Law Authorities and were thus for practical purposes outside the scope of the Local M.D. Authorities, and of the defectives receiving assistance from public funds no less than 75 per cent, were assisted by the Board of Guardians either in Poor Law institutions, in mental hospitals or by way of outdoor relief. These findings and conclusions obviously rendered it necessary for the Committee to make certain far-reaching recommendations for the modification of the present statutory powers of the Authorities that deal with mentally defective children and
namely,
adults.
Before
shall give some of the more defective persons in England mentally and Wales, based the of the upon findings special investigation. The total number of children between the ages of 7 and 16 who are mentally defective within the meaning of Section 55 of the Education Act is approximately Io5>ooo, that is, three times the number actually ascertained and certified by the Local Education Authorities. The number of imbeciles and idiots under J6 years of age is estimated to be at least 30,000, whereas the total number of adult defectives of all grades is certainly not less than 150,000, making a total ?f 180,000 which is again three times as great as that given in the returns submitted to the Board of Control of defectives of all ages brought to the notice ?f the Local M.D. Authorities. The Committee makes another important estimate, namely, that of the total number of persons in England and Wales who are mentally defective in the sense in which this term is interpreted in the M.D. Acts, that is, of social inefficiency due to incomplete mental development. This number it estimates to be at least 300,000, which is equivalent to an incidence of about 8 per 1,000 of the population.
passing to
these
recommendations,
important estimates of the number of
we
MENTAL WELFARE
92
figures show that mental deficiency is a problem of much greater than most persons had hitherto realised, although the numbers will magnitude not surprise those persons who have been in intimate touch with the work during the last twenty years. The Chairman in his letter accompanying the Report when it was submitted to Sir George Newman and Mr. L. G. Brock, the Chairman of the Board of Control, refers to mental deficiency as one of the major social problems of our time, and in the light of these estimates this claim is not too extravagant. These
Children. We will first outline somewhat briefly the recommendations of the Committee in respect of the educable mentally defective children. The members of the Committee were obviously much impressed by the good work already done by the Special Schools and their recommendations are framed so as to extend considerably the facilities for similar educational provision. They were of the opinion, however, that a careful survey of the facts relating to the special system of education proved that it cannot well be extended appreciably beyond its present limits as long as the statutory conditions remain as they are now. There are large numbers of children in the ordinary Elementary Schools who require the form of educational provision given in the Special Schools, but for one reason or another do not receive this or any corresponding provision. The Committee recommends that a new educational unit, to be " " known as the retarded group of children should be formed. This group would comprise children hitherto known as educable mentally defective children and also those known as dull or backward children. For administrative purposes this new group should be regarded as part of the Public Elementary School system and Local Education Authorities should modify the organisation of the schools in their areas so as to provide suitable education for the whole group. The Committee recognises that no single form of provision will suit all areas and that the greatest elasticity, consistent with efficiency, is desirable. In the large towns the Committee's recommendations will make it possible to develop considerably the Day Special Schools already established, but in most of the provincial towns and rural areas probably provision in separate departments or classes will be found most suitable. The admission of children to these new schools, departments or classes will require no special certification as is now the case with children admitted to Special Schools. Medical Officers and teachers who deal with educable mentally defective children will no doubt welcome this bold recommendation. It would not be too much to say that certification in the past has kept many more suitable children out of the Special Schools than it has enabled Authorities to place in these Schools. The removal of certification will necessarily mean that the Local Education Authorities will lose their special power to insist that children should attend this particular type of school. This, however, is a question that bears closely upon the whole organisation of educational provision in the future, if the recommendations of the Hadow Report arc adopted.
MENTAL WELFARE
93
The number of cases in which parents and children will refuse to conform with the allocation of the Local Authorities will no doubt be small, but even so the Committee thinks it will be necessary to give Local Education Authorities a general power to enforce attendance in the last resort of individual children at a school regarded by their Officers as best suited to their educational
capacity.
To persons interested generally in the practical problems presented by mentally defective, the Committee's recommendation of the formation of a new educational unit and its corollary that educable mentally defective children of school should no age longer be certified unless they need the special protection afforded by the M.D. Acts, suggest important questions. It is in the large towns where the Special Schools have been established that Local M.D. Authorities have been able to function most efficiently, and this is to be attributed largely to the fact that their work has been based upon that of the Local Education Authorities. The teachers and doctors and administrative officers who are directly concerned with these Special Schools realise that most of the pupils will require some form of care or supervision by the M.D. Authorities after they leave school and therefore take steps to ensure that most of the children shall be notified either during school life or on leaving school. What will be the result of the change of status of these schools upon this link so essential to the efficiency of the work of the M.D. Authority? The proportion of children in the " retarded " schools or classes who will require permanent care and control will be the minority and not the majority as in the Special Schools now existing, and there is the possibility that teachers and Medical Officers will minimise the importance of notification. The Joint Committee obviously realises this danger and therefore has placed much emphasis upon the importance of the Local Education Authority fulfilling its duty of notifying all children who will require the protection of the Mental Deficiency Acts when they leave school or even before they leave, if this be necessary. " " Another recommendation relating to the retarded group of children is that the schools, departments or classes should be organised on a primary and post-primary basis in accordance with the scheme outlined in the Hadow Report. The experience of some of the largest Local Education Authorities in this country has proved that this form of organisation is most admirably suited for dealing with educable mentally defective children. This dual basis should facilitate considerably the organisation of provision for retarded children as an integral part of the public Elementary School system of the future. The workers and members of Voluntary Associations will be particularly interested in the Committee's recommendations concerning the provision to be made for those mentally defective children who are too low-grade to attend the classes for retarded children. These will be notified to the Local M.D. as at present, and this Authority will be financially responsible for .any provision made for them. The prospect of suitable provision being made is, however, greatly enhanced by the Committee's recommendation that it should
the
Authority
94
MENTAL WELFARE
be the duty of Local Education Authorities in return for payment by the Local M.D. Authorities, to provide facilities for training in occupation centres of all lower grade children between the ages of 5 and 11 who are capable of attending the day class, and that the same Authority should have the power, at the request of the Local M.D. Authority, of making similar arrangements for children of this grade of defect who are over 11 years of age. Such a scheme as the Committee outlines we believe would begin a new era in the development of occupation centres. The transfer of the organisation of these centres to the Local Education Authorities should go far to assure that all children suited for the type of training given in these centres would be provided for, and the securing of efficient trainers, suitable premises and an adequate supply of apparatus and material should no longer present the difficulties they have hitherto. One other general principle as to the allocation of responsibility of mentally defective children which the Committee enunciates is that residential provision should generally be made by the Local M.D. Authority. At the same time the Committee recognises that there will also be instances when the Local Education Authorities will have to provide boarding schools for selected " " children who are not likely to require permanent care and conretarded trol. Again, with regard to the admission to these residential institutions, colonies and boarding schools, the Committee pleads for elasticity and urges that it should be open to either Authority to send children for whom they are responsible to institutions provided by the other Authority. Adults. In reading the section of the Report that relates to adults, we realise how unfortunate it was that the completion of the Committee's deliberations practically coincided with the passing of the recent Local Government Act. Had this part of the Report appeared a few months earlier it would probably have influenced materially those sections of the Act relating to the mentally defective; or, if on the other hand, the Committee had been able to write its report in the light of the new legislative conditions consequent upon the passing of this Act, it would have been able to give further valuable guidance to Local Authorities concerning the new statutory conditions. this unfortunate synchronisation, Local Authorities Notwithstanding will find that the Report contains much that is most applicable to the administration of mental deficiency in work in the near future, for the simple reason that the Committee has laid great stress upon the principle which, to say the least, is implied in the Local Government Act, and which this Act, for the first the time, makes it possible for Local Authorities to adopt as a basis, namelv, " unification of responsibility for adult defectives. The Committee considers it to be a fundamental condition of any comprehensive scheme for the care, training and control of defectives that every practicable step should be taken to concentrate all existing powers in regard to adult defectives (as well as lower grade and other notified mentally defective children) in the hands of a single Authority, namely, the Local M.D. Authority." The repeal by Section 14 (4) of
MENTAL WELFARE
95
the Local Government Act, 1929, of the latter half of Section 30, Proviso (ii) of the M.D. Act, 1913, removes the chief legal obstacle that stood in the way of
the unification of responsibility, and Section 5 of the Local Government Act carries the process one step further as it empowers County and County Borough Councils to declare by scheme that any assistance that can be provided either by way of Poor Law relief or by virtue of the M.D. Act, 1913, shall be provided under the latter Act. It is to be hoped that this principle will be adopted as the basis of schemes formulated by the Local Authorities. The figures of the special investigation indicating the incidence of mental deficiency prove that the problem is one so large and important that it should be dealt with by a single Authority. It is inconceivable that this problem, which is so vital to national welfare, should in the future be dealt with by the piecemeal and somewhat chaotic methods that have hitherto statutory prevailed. Most of the other recommendations relating to adult defectives depend upon the adoption of this fundamental principle. Thus, a general scheme of institutional administration comprising a central colony, hostel branches and simpler institutions, each suitable for some particular class of defective is outlined, based upon the assumption that in the future there will be a system of unified control for all mental defectives requiring institutional care. The Committee emphasises the great and urgent need for additional accommodation in institutions. The investigator in his Report (Part IV) points out that most of this new accommodation is required for the children and younger defectives. He also gives detailed calculations (Tables 25-27) of the relative numbers of each group of defectives requiring institutional care for the urban and rural areas respectively. Local Authorities will find in these Tables the most reliable data available for calculating the institutional accommodation they should provide for defectives in their respective administrative areas. There is one picturesque phrase in the Report which suggests that the Committee envisages the institution of the future as one that will be much more intimately associated with the general administration of mental deficiency than has been the case in the past, namely, that " the institution should no longer be a stagnant pool but become a flowing lake, always taking in and always sending out." Adopting this view of the function of the institution the Committee has given much attention to the question of licensing defectives from the institutions, a question which bristles with difficulties. One of the most suggestive and helpful sections of the Report is that which deals with the care of defectives who remain in the general community. The Committee obviously realises that this aspect of the problem is second to no other in its importance. It is estimated that there will be at least 175,000 defectives of all If a ages in England and Wales living in the general community. scheme of unified control is adopted it is obvious that the number of defectives who will require some measure of care, training or supervision by the statutory authority will be considerably increased. One large and important new group will be the defective adults who are at present in receipt of outdoor relief. The
96
MENTAL WELFARE
Committee have made very interesting suggestions that additional powers be to Local M.D. Authorities to enable them to give financial assistance in cases to which the present conditions of guardianship can scarcely be said to be applicable. For instance, it recommends that (i) power be given to Local M.D. Authorities to grant financial assistance to defectives placed under supervision, and (2) that the magistrate, when making an order on petition, should be enabled to place a defective under the guardianship of the Local Authority, that the Authority should be given the power to exercise its guardianship through specially trained and appointed guardianship officers, and that these officers should be responsible for making all arrangements subject to the direction of the Local Authority for the care of the defective while at home or boarded out or when living with other people. These powers would greatly enlarge the scope of the activities of the Local M.D. Authorities in regard to defectives outside institutions and would enable this branch of the work to take its place as one of the foremost of all social services.
given
In this discussion of the care of defectives living in the community, the Committee emphasises two points in particular. The first is that the guardianship and supervision officers of the Local Authority and the officers employed by Voluntary Associations should (a) be trained social workers and (b) subsequently have special training for and experience in this particular work. The second is the importance of making adequate provision both for the training and the occupation of defectives. Authorities are urged to make the provision of Section 30 (cc) of the M.D. Act, as amended, a reality by seeing that so far as it is practicable no defective under supervision or guardianship is left without suitable training or occupation. The Committee makes one general recommendation concerning the coordination of the mental health services. "With a view to the ultimate concentration of responsibility for the care of all forms of mental ailment, whether mental deficiency or mental disorder, we suggest that further consideration should be given to the question of the amalgamation of the functions of Local Authorities, visiting and M.D. Committees and of the institution of a post of specialist officer of mental health in each area." The adoption of this recommendation would obviously carry the unifying process one step further and if this could be done much of the overlapping that now exists in our methods of dealing with the mentally unfit would be obviated. The last chapter of the Report consists of a very interesting though somewhat academic discussion of mental deficiency as a genetic and social problem. The Committee makes it clear that it knows of no preventive or ameliorative " panacea. In one of the earlier paragraphs of this chapter it is stated that inasmuch as mental defect is in the main due to germinal variation, its elimination or even its appreciable diminution must be a very gradual process which we certainly do not claim to have found any effective means of accelerating." It is urged that sterilisation, segregation, and other methods that have been proposed, if they are to be effective preventive measures, would have to be applied
MENTAL WELFARE
97
to persons who are mentally defective but to the whole marginal of sub-normal persons from which group the large majority of the group mentally defective spring. When discussing the sterilisation of mental defectives from the standpoint of enabling as many as possible of them to live with the general community, the Committee states that it is not prepared to deny that this measure might, under adequate safeguards, prove of value in a very limited number of individual cases selected from among the most stable type of defective with no anti-social tendencies." It then proceeds to state that there is not sufficient evidence at present to justify the general adoption of sterilisation of defectives and that even if it were adopted, no great alleviation of the burden of mental deficiency would follow." The members of the Committee obviously have more faith in the efficacy of the segregation of certain types of defectives, in the efficient training, care and control of those living in the general community and in the gradual raising of the cultural level of the sub-normal group of the population by improved educational treatment and social care of the group of children classed as dull. In this review we have endeavoured merely to focus the reader's attention upon some of the general recommendations of the Joint Committee. No attempt has been made to criticise or even to comment upon these recommendations because wre feel it is impossible in the limited space given to this review to discuss critically the many important issues raised by the Committee's proposals. The Committee has dealt with the problem in a comprehensive manner but at the same time there is abundant evidence in the Report that the members were thoroughly conversant with the practical difficulties and with the details of the work relating to the mental defectives in all its aspects. Some of the more important recommendations, especially those dealing with children, will require new legislation before they can become effective, but there are many recommendations and suggestions v/hich could be adopted by the Local Authorities without delay. From this point of view alone the Committee's Report is a document of no small importance and one that may well lead to many and great improvements in the provision for the care of defectives. In two respects, however, we believe that the publication of this Report will in the future be regarded as one of the landmarks in the history of the mental health services of this country. First, because it contains a full account of an investigation into the incidence of mental defect which was probably more thorough and within its limits more complete than any which has been previously made in this or any other country; and secondly, because the Committee's Report contains an ordered review of the situation in regard to the problem of mental deficiency in this country as it is in the third decade of the twentieth century, a review v/hich, whatever may be its immediate results, must serve as a stepping-off ground for future enquiries and for future legislation and administrative action. not
only
"
"
Report
of the
Joint Committee
on
The whole of the Report of the Joint Committee of the Board of Education and the Board of Control has now been published, and it is a great advantage to be able to view the Committee's conclusions and recommendations in respect of both children and adult defectives. The Report, as now published, appears in three small volumes. Volume i consists of Parts I and II, Part I being a general introduction to the whole Report and Part II dealing with the problem of the mentally defective children. Volume 2, which consists of Part III, deals with the mentally defective adults; whereas Volume 3, containing Part IV, is the report of the special investigation of the incidence of mental deficiency made on behalf of the Committee by Dr. E. O. Lewis. The Committee was, in the first place, appointed to advise the Chief Medical Officer of the Board of Education upon certain specific problems in regard to defective children, but at an early stage of its deliberations it became
9o
MENTAL WELFARE
clear that it was necessary to consider not only the problems of the defective children but also those of adults, and thus the inquiry became a most comprehensive one. Mr. A. H. Wood, C.B., who was at that time the Assistant Secretary in charge of the Medical Branch of the Board of Education, was appointed Chairman of the Committee, which included amongst its members persons who had expert knowledge of the administrative, medical, scientific, social and educational aspects of the problem of mental deficiency. In the initial stages of its deliberations the Committee decided that it necessary to make an investigation that would enable it to assess anew the magnitude of the problem. The only previous investigation on a large scale into the incidence of mental defect in this country was that of the Royal Commission on the Care and Control of the Feeble-minded, 1904-1908. It was thought that the legal and administrative provisions for the mental defective which resulted from the Report of the Commission and the important advances made in the scientific approach to the problem of mental defect during the last twenty years would enable a more reliable estimate to be made of the numbers of defectives. Therefore the incidence of mental defect in six typical areas, each with a population of about 100,000, was ascertained and the data thus obtained proved the wisdom of the Committee's decision. was
In Part I of the Report a chapter is given to review the legislation respectthe mental defective and in Part II another short chapter deals with the ing measures legal relating specially to adult defectives. These two chapters contain a concise but very clear summary of the most important provisions of Acts which apply to mental defectives in this country and of the principal methods devised by the legislature for dealing with these persons. The Committee discusses the legislative provisions in the light of the experience gained in applying them. Careful study of this discussion is essential if the reader is to appreciate the reason for some of the general recommendations which the Committee has made.
One important legal ambiguity which is treated with much frankness and with considerable insight of the difficulties it has presented to Local Auth" orities and Medical Officers, is that involved in the definitions of mentally " in Section 55 (1) of the Education Act, 1921, and of defective children " " in Section 1 (1) (c) of the Mental Deficiency Act, feeble-minded children in the Education Act stresses educational defect, The definition 1913-1927. whereas that of the Mental Deficiency Acts places the emphasis upon failure in social adaptation. The groups of children to whom these definitions apply are by no means identical. There are many children who are defective educationally but not socially, and there are some, a smaller number admittedly, who though not educationally defective prove to be conspicuous failures socially. It is the discussion of the disparity between these two definitions that gives point" and force to many of the statements in the chapter which deals The Committee urges the importance with the nature of mental defect." of having a single criterion of mental deficiency, namely, the social one, and
MENTAL WELFARE
defines
by
"
mentally defective individual, whether child or adult, as one who incomplete mental development is incapable of independent adaptation."
reason
social
91
a
of
The discussion of the effectiveness of the powers and duties allocated to Local M.D. Authorities deals with vital issues. The Committee reached the conclusion that the intentions of Parliament, when it passed the 1913 Mental Deficiency Act, have not been realised. This is attributed chiefly to the fact that Local M.D. Authorities' powers of ascertainment were limited to those defectives subject to be dealt with." The chief source of ascertainment, "
the notification of mentally defective children by the Local Education Authority, has been most disappointing, largely because of the limited number of Special Schools established. The special investigation revealed that no fewer than 77 per cent, of the educable mentally defective children in the six areas were in attendance at ordinary Public Elementary Schools. The other factor that has up to the present restricted considerably the scope of Local M.D. Authorities' activities in respect both of adults and children, is that Poor Law Authorities have power to maintain defective persons by outdoor or indoor relief. Over 40 per cent, of the whole number of adult defectives ascertained in the investigated areas were being dealt with by Poor Law Authorities and were thus for practical purposes outside the scope of the Local M.D. Authorities, and of the defectives receiving assistance from public funds no less than 75 per cent, were assisted by the Board of Guardians either in Poor Law institutions, in mental hospitals or by way of outdoor relief. These findings and conclusions obviously rendered it necessary for the Committee to make certain far-reaching recommendations for the modification of the present statutory powers of the Authorities that deal with mentally defective children and
namely,
adults.
Before
shall give some of the more defective persons in England mentally and Wales, based the of the upon findings special investigation. The total number of children between the ages of 7 and 16 who are mentally defective within the meaning of Section 55 of the Education Act is approximately Io5>ooo, that is, three times the number actually ascertained and certified by the Local Education Authorities. The number of imbeciles and idiots under J6 years of age is estimated to be at least 30,000, whereas the total number of adult defectives of all grades is certainly not less than 150,000, making a total ?f 180,000 which is again three times as great as that given in the returns submitted to the Board of Control of defectives of all ages brought to the notice ?f the Local M.D. Authorities. The Committee makes another important estimate, namely, that of the total number of persons in England and Wales who are mentally defective in the sense in which this term is interpreted in the M.D. Acts, that is, of social inefficiency due to incomplete mental development. This number it estimates to be at least 300,000, which is equivalent to an incidence of about 8 per 1,000 of the population.
passing to
these
recommendations,
important estimates of the number of
we
MENTAL WELFARE
92
figures show that mental deficiency is a problem of much greater than most persons had hitherto realised, although the numbers will magnitude not surprise those persons who have been in intimate touch with the work during the last twenty years. The Chairman in his letter accompanying the Report when it was submitted to Sir George Newman and Mr. L. G. Brock, the Chairman of the Board of Control, refers to mental deficiency as one of the major social problems of our time, and in the light of these estimates this claim is not too extravagant. These
Children. We will first outline somewhat briefly the recommendations of the Committee in respect of the educable mentally defective children. The members of the Committee were obviously much impressed by the good work already done by the Special Schools and their recommendations are framed so as to extend considerably the facilities for similar educational provision. They were of the opinion, however, that a careful survey of the facts relating to the special system of education proved that it cannot well be extended appreciably beyond its present limits as long as the statutory conditions remain as they are now. There are large numbers of children in the ordinary Elementary Schools who require the form of educational provision given in the Special Schools, but for one reason or another do not receive this or any corresponding provision. The Committee recommends that a new educational unit, to be " " known as the retarded group of children should be formed. This group would comprise children hitherto known as educable mentally defective children and also those known as dull or backward children. For administrative purposes this new group should be regarded as part of the Public Elementary School system and Local Education Authorities should modify the organisation of the schools in their areas so as to provide suitable education for the whole group. The Committee recognises that no single form of provision will suit all areas and that the greatest elasticity, consistent with efficiency, is desirable. In the large towns the Committee's recommendations will make it possible to develop considerably the Day Special Schools already established, but in most of the provincial towns and rural areas probably provision in separate departments or classes will be found most suitable. The admission of children to these new schools, departments or classes will require no special certification as is now the case with children admitted to Special Schools. Medical Officers and teachers who deal with educable mentally defective children will no doubt welcome this bold recommendation. It would not be too much to say that certification in the past has kept many more suitable children out of the Special Schools than it has enabled Authorities to place in these Schools. The removal of certification will necessarily mean that the Local Education Authorities will lose their special power to insist that children should attend this particular type of school. This, however, is a question that bears closely upon the whole organisation of educational provision in the future, if the recommendations of the Hadow Report arc adopted.
MENTAL WELFARE
93
The number of cases in which parents and children will refuse to conform with the allocation of the Local Authorities will no doubt be small, but even so the Committee thinks it will be necessary to give Local Education Authorities a general power to enforce attendance in the last resort of individual children at a school regarded by their Officers as best suited to their educational
capacity.
To persons interested generally in the practical problems presented by mentally defective, the Committee's recommendation of the formation of a new educational unit and its corollary that educable mentally defective children of school should no age longer be certified unless they need the special protection afforded by the M.D. Acts, suggest important questions. It is in the large towns where the Special Schools have been established that Local M.D. Authorities have been able to function most efficiently, and this is to be attributed largely to the fact that their work has been based upon that of the Local Education Authorities. The teachers and doctors and administrative officers who are directly concerned with these Special Schools realise that most of the pupils will require some form of care or supervision by the M.D. Authorities after they leave school and therefore take steps to ensure that most of the children shall be notified either during school life or on leaving school. What will be the result of the change of status of these schools upon this link so essential to the efficiency of the work of the M.D. Authority? The proportion of children in the " retarded " schools or classes who will require permanent care and control will be the minority and not the majority as in the Special Schools now existing, and there is the possibility that teachers and Medical Officers will minimise the importance of notification. The Joint Committee obviously realises this danger and therefore has placed much emphasis upon the importance of the Local Education Authority fulfilling its duty of notifying all children who will require the protection of the Mental Deficiency Acts when they leave school or even before they leave, if this be necessary. " " Another recommendation relating to the retarded group of children is that the schools, departments or classes should be organised on a primary and post-primary basis in accordance with the scheme outlined in the Hadow Report. The experience of some of the largest Local Education Authorities in this country has proved that this form of organisation is most admirably suited for dealing with educable mentally defective children. This dual basis should facilitate considerably the organisation of provision for retarded children as an integral part of the public Elementary School system of the future. The workers and members of Voluntary Associations will be particularly interested in the Committee's recommendations concerning the provision to be made for those mentally defective children who are too low-grade to attend the classes for retarded children. These will be notified to the Local M.D. as at present, and this Authority will be financially responsible for .any provision made for them. The prospect of suitable provision being made is, however, greatly enhanced by the Committee's recommendation that it should
the
Authority
94
MENTAL WELFARE
be the duty of Local Education Authorities in return for payment by the Local M.D. Authorities, to provide facilities for training in occupation centres of all lower grade children between the ages of 5 and 11 who are capable of attending the day class, and that the same Authority should have the power, at the request of the Local M.D. Authority, of making similar arrangements for children of this grade of defect who are over 11 years of age. Such a scheme as the Committee outlines we believe would begin a new era in the development of occupation centres. The transfer of the organisation of these centres to the Local Education Authorities should go far to assure that all children suited for the type of training given in these centres would be provided for, and the securing of efficient trainers, suitable premises and an adequate supply of apparatus and material should no longer present the difficulties they have hitherto. One other general principle as to the allocation of responsibility of mentally defective children which the Committee enunciates is that residential provision should generally be made by the Local M.D. Authority. At the same time the Committee recognises that there will also be instances when the Local Education Authorities will have to provide boarding schools for selected " " children who are not likely to require permanent care and conretarded trol. Again, with regard to the admission to these residential institutions, colonies and boarding schools, the Committee pleads for elasticity and urges that it should be open to either Authority to send children for whom they are responsible to institutions provided by the other Authority. Adults. In reading the section of the Report that relates to adults, we realise how unfortunate it was that the completion of the Committee's deliberations practically coincided with the passing of the recent Local Government Act. Had this part of the Report appeared a few months earlier it would probably have influenced materially those sections of the Act relating to the mentally defective; or, if on the other hand, the Committee had been able to write its report in the light of the new legislative conditions consequent upon the passing of this Act, it would have been able to give further valuable guidance to Local Authorities concerning the new statutory conditions. this unfortunate synchronisation, Local Authorities Notwithstanding will find that the Report contains much that is most applicable to the administration of mental deficiency in work in the near future, for the simple reason that the Committee has laid great stress upon the principle which, to say the least, is implied in the Local Government Act, and which this Act, for the first the time, makes it possible for Local Authorities to adopt as a basis, namelv, " unification of responsibility for adult defectives. The Committee considers it to be a fundamental condition of any comprehensive scheme for the care, training and control of defectives that every practicable step should be taken to concentrate all existing powers in regard to adult defectives (as well as lower grade and other notified mentally defective children) in the hands of a single Authority, namely, the Local M.D. Authority." The repeal by Section 14 (4) of
MENTAL WELFARE
95
the Local Government Act, 1929, of the latter half of Section 30, Proviso (ii) of the M.D. Act, 1913, removes the chief legal obstacle that stood in the way of
the unification of responsibility, and Section 5 of the Local Government Act carries the process one step further as it empowers County and County Borough Councils to declare by scheme that any assistance that can be provided either by way of Poor Law relief or by virtue of the M.D. Act, 1913, shall be provided under the latter Act. It is to be hoped that this principle will be adopted as the basis of schemes formulated by the Local Authorities. The figures of the special investigation indicating the incidence of mental deficiency prove that the problem is one so large and important that it should be dealt with by a single Authority. It is inconceivable that this problem, which is so vital to national welfare, should in the future be dealt with by the piecemeal and somewhat chaotic methods that have hitherto statutory prevailed. Most of the other recommendations relating to adult defectives depend upon the adoption of this fundamental principle. Thus, a general scheme of institutional administration comprising a central colony, hostel branches and simpler institutions, each suitable for some particular class of defective is outlined, based upon the assumption that in the future there will be a system of unified control for all mental defectives requiring institutional care. The Committee emphasises the great and urgent need for additional accommodation in institutions. The investigator in his Report (Part IV) points out that most of this new accommodation is required for the children and younger defectives. He also gives detailed calculations (Tables 25-27) of the relative numbers of each group of defectives requiring institutional care for the urban and rural areas respectively. Local Authorities will find in these Tables the most reliable data available for calculating the institutional accommodation they should provide for defectives in their respective administrative areas. There is one picturesque phrase in the Report which suggests that the Committee envisages the institution of the future as one that will be much more intimately associated with the general administration of mental deficiency than has been the case in the past, namely, that " the institution should no longer be a stagnant pool but become a flowing lake, always taking in and always sending out." Adopting this view of the function of the institution the Committee has given much attention to the question of licensing defectives from the institutions, a question which bristles with difficulties. One of the most suggestive and helpful sections of the Report is that which deals with the care of defectives who remain in the general community. The Committee obviously realises that this aspect of the problem is second to no other in its importance. It is estimated that there will be at least 175,000 defectives of all If a ages in England and Wales living in the general community. scheme of unified control is adopted it is obvious that the number of defectives who will require some measure of care, training or supervision by the statutory authority will be considerably increased. One large and important new group will be the defective adults who are at present in receipt of outdoor relief. The
96
MENTAL WELFARE
Committee have made very interesting suggestions that additional powers be to Local M.D. Authorities to enable them to give financial assistance in cases to which the present conditions of guardianship can scarcely be said to be applicable. For instance, it recommends that (i) power be given to Local M.D. Authorities to grant financial assistance to defectives placed under supervision, and (2) that the magistrate, when making an order on petition, should be enabled to place a defective under the guardianship of the Local Authority, that the Authority should be given the power to exercise its guardianship through specially trained and appointed guardianship officers, and that these officers should be responsible for making all arrangements subject to the direction of the Local Authority for the care of the defective while at home or boarded out or when living with other people. These powers would greatly enlarge the scope of the activities of the Local M.D. Authorities in regard to defectives outside institutions and would enable this branch of the work to take its place as one of the foremost of all social services.
given
In this discussion of the care of defectives living in the community, the Committee emphasises two points in particular. The first is that the guardianship and supervision officers of the Local Authority and the officers employed by Voluntary Associations should (a) be trained social workers and (b) subsequently have special training for and experience in this particular work. The second is the importance of making adequate provision both for the training and the occupation of defectives. Authorities are urged to make the provision of Section 30 (cc) of the M.D. Act, as amended, a reality by seeing that so far as it is practicable no defective under supervision or guardianship is left without suitable training or occupation. The Committee makes one general recommendation concerning the coordination of the mental health services. "With a view to the ultimate concentration of responsibility for the care of all forms of mental ailment, whether mental deficiency or mental disorder, we suggest that further consideration should be given to the question of the amalgamation of the functions of Local Authorities, visiting and M.D. Committees and of the institution of a post of specialist officer of mental health in each area." The adoption of this recommendation would obviously carry the unifying process one step further and if this could be done much of the overlapping that now exists in our methods of dealing with the mentally unfit would be obviated. The last chapter of the Report consists of a very interesting though somewhat academic discussion of mental deficiency as a genetic and social problem. The Committee makes it clear that it knows of no preventive or ameliorative " panacea. In one of the earlier paragraphs of this chapter it is stated that inasmuch as mental defect is in the main due to germinal variation, its elimination or even its appreciable diminution must be a very gradual process which we certainly do not claim to have found any effective means of accelerating." It is urged that sterilisation, segregation, and other methods that have been proposed, if they are to be effective preventive measures, would have to be applied
MENTAL WELFARE
97
to persons who are mentally defective but to the whole marginal of sub-normal persons from which group the large majority of the group mentally defective spring. When discussing the sterilisation of mental defectives from the standpoint of enabling as many as possible of them to live with the general community, the Committee states that it is not prepared to deny that this measure might, under adequate safeguards, prove of value in a very limited number of individual cases selected from among the most stable type of defective with no anti-social tendencies." It then proceeds to state that there is not sufficient evidence at present to justify the general adoption of sterilisation of defectives and that even if it were adopted, no great alleviation of the burden of mental deficiency would follow." The members of the Committee obviously have more faith in the efficacy of the segregation of certain types of defectives, in the efficient training, care and control of those living in the general community and in the gradual raising of the cultural level of the sub-normal group of the population by improved educational treatment and social care of the group of children classed as dull. In this review we have endeavoured merely to focus the reader's attention upon some of the general recommendations of the Joint Committee. No attempt has been made to criticise or even to comment upon these recommendations because wre feel it is impossible in the limited space given to this review to discuss critically the many important issues raised by the Committee's proposals. The Committee has dealt with the problem in a comprehensive manner but at the same time there is abundant evidence in the Report that the members were thoroughly conversant with the practical difficulties and with the details of the work relating to the mental defectives in all its aspects. Some of the more important recommendations, especially those dealing with children, will require new legislation before they can become effective, but there are many recommendations and suggestions v/hich could be adopted by the Local Authorities without delay. From this point of view alone the Committee's Report is a document of no small importance and one that may well lead to many and great improvements in the provision for the care of defectives. In two respects, however, we believe that the publication of this Report will in the future be regarded as one of the landmarks in the history of the mental health services of this country. First, because it contains a full account of an investigation into the incidence of mental defect which was probably more thorough and within its limits more complete than any which has been previously made in this or any other country; and secondly, because the Committee's Report contains an ordered review of the situation in regard to the problem of mental deficiency in this country as it is in the third decade of the twentieth century, a review v/hich, whatever may be its immediate results, must serve as a stepping-off ground for future enquiries and for future legislation and administrative action. not
only
"
"
