1 January 1966 General Intensive Therapy Unit-Finn et al. MOURNAL 41

monitor showed the sudden onset of sinus tachycardia and rightaxis deviation. Gastric aspirate at this time showed no blood.Despite the normal aspirate it was considered that he was bleedingagain and laparotomy was performed. A duodenal tumour (abenign haemangioma) was found and removed after a long anddifficult dissection. The small bowel was full of blood. Recoverywas uneventful.Comment.-The cause of the electrocardiographic change is not

obvious, but it may have been due to pulmonary vasoconstrictionin the face of a falling blood volume. The close monitoring bythe nursing staff enabled us to diagnose further bleeding at a veryearly stage. He was therefore operated on while his general con-dition was still good and before a profound acidosis had beeninduced by multiple transfusions of stored blood. He was thuswell able to stand an extensive operative procedure.

Cor Pulmonale with Resistant OedemaA female, A. S., aged 43 years, with long-standing chronic

bronchitis, was admitted to the general ward in severe congestivecardiac failure. The oedema was resistant to all diuretic therapyand she gradually deteriorated, at the same time becoming drowsywith a raised Pco2 (150 mm. Hg). She was transferred to theI.T.U. and tracheostomy was performed. Positive pressureventilation was instituted and continued for one week. The massiveoedema resolved completely and the Pco2 fell to 65 mm. Hg (heraverage level during the previous two years). She subsequentlymade a satisfactory recovery and was discharged home.Comment.-This patient fits into the group of chronic bronchitics

known as " blue bloaters " in whom there is a noticeable absenceof dyspnoea associated with cyanosis and recurrent congestivecardiac failure. Before admission to the I.T.U. she was thought tobe in terminal cardiac failure with total resistance to diuretic therapy.The resolution of the massive oedema and her subsequent recoverywith assisted ventilation was impressive. Long-continued controlledventilation of this type would have been extremely difficult to carryout on a general ward.

Conclusions

There are several reasons why intensive therapy units of thistype should be considered by others-the more economic useof trained nursing staff, in increasingly short supply; theneedless expenditure in duplicating very expensive equipmentthroughout the hospital; and the building up of a team trainedin the use of complicated monitoring and therapeutic equip-ment.

It is our experience that one intensive care bed is required forevery hundred acute beds. Thus if the district hospitals ofthe future are large enough to carry all necessary services, theywill need possibly 1,000 beds and a 10-bedded I.T.U. Assum-ing an average stay of three days, which has been our experi-ence, this unit could admit approximately 1,000 patients ayear. It would of course have to carry a permanent staff andwe would suggest at least three registrars, one of whom woulddo night duty every third week and be relieved of day duties.The setting up of such units would be expensive in both man-power and money, but we believe that they will prove indispens-able in future hospital services.

We would like to thank the Matron of the Royal Southern Hos-pital, Miss A. M. W. White, and also Sisters J. Owen and A.Percival and their nursing staff; Dr. C. M. Ogilvie, Dr. C. A.St. Hill, and Dr. J. E. Riding, the consultants in charge of theunit, for their advice and criticism of this paper; and the staffsof the intensive care units at Whiston and Broadgreen Hospitals foradvice in the early stages of the unit. Dr. R. W. Brookfield, Dr.E. Sherwood Jones, and Dr. J. T. Robinson also advised in theplanning of the unit. We would also like to thank the UnitedLiverpool Hospitals for generous financial support.

REFERENCE

Cam, J. F., Grogono, A. W., and Lee, H. A., Lancet, 1964, 2, 1168.

Advisory Service for Parents of Mentally Handicapped Children*

BRIAN H. KIRMANt M.D., D.P.M.

Brit. med. Jt., 1966, 1,'41-44

There has been a reversal of attitude in regard to mental handi-cap. Previously institutional care was recommended and waslooked upon as almost inevitable. The emphasis now is onintegration into the community rather than on segregation inspecial colonies or hospitals. It should only be necessary toprovide residential care in those cases where the parent is unableto cope. The great majority of the mentally retarded in thefeeble-minded or subnormal range should, in any event, beincluded within the educational system and should go on toindependent employment.

It should, however, be frankly recognized that the care ofseverely mentally handicapped children does place a heavyadditional burden upon parents. The problems of suchfamilies have been set out by Tizard and Grad (1961). Theyhave also been expressed by parents themselves through theirorganizations such as the National Society for Mentally Handi-capped Children (formerly the National Association of Parentsof Backward Children), and in the United States by theNational Association for Retarded Children.

Some of the difficulties which the parents of a backwardchild have to face may be material; some are psychological;in others there is a combination of adverse circumstances inwhich the handicapped child occupies a central position. Onemother who came for advice has a malformed, crippled,mentally retarded child. During her pregnancy she had a lossof bloods which was thought to be aetiologically related to theabnormality in the child. She is now pregnant again. She hasagain had a loss of blood. She has been advised to rest, butthe care of her handicapped child involves carrying it up 60steps to her home. This is an example of an obvious physicaldifficulty. In other cases with professional parents it may bedifficult for them to reconcile themselves to the fact that theirchild is intellectually limited, and they may reject him. Amother with a child of low imbecile level may find that eachstep in development takes him some five times as long as thenormal child. She will be washing napkins for a very longtime, and may despair of progress.

Parents of backward children need help in two ways. First,they need material help in the way of training centres, daynursery accommodation, rehousing, and, in some cases,financial assistance. Secondly, they need advice and under-standing. To some extent this can be provided by the organ-

* Paper read at a meeting of the Paediatric Section of the Royal Societyof Medicine at Queen Mary's Hospital for Children, Carshalton, on29 May 1965.

t Consultant Psychiatrist, Fountain and Carshalton Hospital Group.

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ized efforts of local parents and through other voluntarychannels, but it is becoming increasingly obvious that what isneeded is expert guidance at an early stage. Existing localauthority child guidance and infant welfare clinics and hospitalpsychiatric and paediatric out-patients may have only a limitedinterest in or experience of the needs of the mentally retarded.For this reason it seems desirable, first, that special clinics foradvising the parents of retarded children should be set up, and,secondly, that other children's clinics should be in a positionto provide such advice.

Clinics for Retarded Children

A number of such special clinics have been organized bypaediatricians, psychiatrists, and by local authorities who haveshown a particular interest in the subject. Existing clinics donot satisfy the demand, and it seems in the present experimentalstage that efforts from all these three and other directions shouldbe welcomed. The composition of the team providing adviceis perhaps more important than the auspices under which-theclinic is organized. The best formula may be that it shouldbe available as part of the hospital service, but closely linkedwith the local authorities and possibly the result of joint effort.The advisory service which was instituted at the Fountain

Hospital after the second world war and which has sincecontinued at Queen Mary's Hospital for Children, Carshalton,provides for some 10 children weekly. The clinic is not con-fined rigidly to the, severely mentally retarded, and a numberof other problems in child psychiatry are considered, but theseare not included in the number mentioned. Cases are oftenreferred where there is some doubt as to normality-forexample, for investigation before adoption. Children are seenwho are the subject of an appeal against exclusion from schoolas ineducable and also children who present educational prob-lems. The numbers seen are kept small so that intensiveinvestigation can be carried out in each case, one of the objectsbeing to provide a service which, while strictly practical, canserve for training and for extension of knowledge about theproblems in this field.

Composition of Team

The clinics are staffed by a consultant psychiatrist or assistantpsychiatrist, junior medical staff, psychologist, and socialworker. A speech therapist also frequently participates. Oto-logical and neurological clinics are located in the same hospital.Laboratory services which are frequently drawn upon are thebiochemical and cytogenetic departments. As a result of along period of working together with out-patients and within-patients a highly integrated team has been developed. Theneuropathologist, biochemist, members of the teaching staff,the speech therapists, and others participate regularly in caseconferences, discussions, in the programme of teaching andresearch, as well as the psychiatrists, psychologists, and socialworkers. This facilitates a multi-disciplinary approach to theproblem. There is also constant exchange of knowledge andskill between members of different disciplines.

Source of Referral

As the availability of the service becomes known the numberof cases increases and there is in particular a tendency forgeneral practitioners to refer children direct in contrast withthe previous position where work with the mentally subnormalwas often looked upon as primarily the province of the localauthority. Since the new Mental Health Act was introducedin 1960 arrangements have become more informal. Parents,voluntary organizations, teachers, and others are not dis-couraged from referring patients direct, but wherever possible

BomMMDCAL JOURNAL

the general practitioner is informed beforehand and a reportis sent to him with any necessary copies to the school medicalofficer, medical officer of health, referring consultant, or other-wise as indicated. The source of a series of 100 referrals toone consultant is shown in Table I.

TANLz I.-Source of ReferralPaediatrician .35General practitioner 18Psychiatrist .15School M.O. or M.O.H. 10Suregeon ...... .. . .. . .. 7

Parent or relative 4Voluntary bodies 3Health visitor.1

Total .100

Reason for ReferralParents' difficulties with backward children vary very much

according to age. The age distribution of 100 referrals is shownin Table II. In young babies there may be a physically recog-nizable syndrome such as Down's syndrome. Somewhatsurprisingly even this well-known condition is not alwaysrecognized at birth, but the parents themselves may realizethat the child is abnormal and seek advice. In another groupof cases the condition has been established but the parentswish for a second opinion; they may be unable emotionallyto accept the diagnosis, or they wish for much more detailedinformation and advice than they have had. In other casesit is a question of a young baby "at risk" after perinatalinjury, jaundice, maternal rubella, or other hazard. Wherechildren have an established motor lesion or infantile convul-sions or spasms the question of concomitant limitation of intel-lectual capacity may be raised.

TABLE II.-Age and Sex

TABLE III.-Reason for Referral

Retarded .. 55 Cerebral palsy . ..3Overactive . . . 7 ?Infantile psychosis .. .. 2Second opinion . 6 Deterioration- - -1Educational advice 5 Fatigue.. . 1Delayed speech 5 Genetic advice...1General advice .. . 4 Encopresis... 1Epilepsy... 4 Enuresis...1For admission .. . 3 Adoption. .. 1

Total .. .. 100

The time of most acute stress for parents in the group abovecomes soon after the birth of the child. In other cases motherand baby are discharged from hospital, the infant is reported ina satisfactory condition but fails to make progress. The parentsor grandparents, however, gradually realize that all is not well.They often report that their doubts are dismissed with heartyreassurance, but eventually specialist advice is sought, perhapsbecause at 1 year the child is still not attempting to sit ordoes not respond to speech and is thought to be deaf.A third and usually less severely retarded group of children

are referred when they are at or approaching the age of attend-ing school. At 5 years a child may still be incontinent ofurine, have limited speech, or be insufficiently biddable in classto conform to group discipline, though previously accepted asnormal in the home. A fourth group is made up of teenagersof feebleminded level of intelligence showing behaviour dis-orders, usually associated with unfavourable domestic and socialcircumstances. Table III shows the chief reason for referralof 100 cases.

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Assessment and DiagnosisIn a majority of cases no clinical diagnosis can be made,

though with the severely subnormal a gross encephalopathycan be assumed. This is also the cause of the secondary dis-abilities of epilepsy and cerebral palsy when these are present.Table IV shows the main diagnosis of 100 cases, and Table Vshows numbers with major secondary handicaps. Thoughprecise diagnosis is important for genetic advice and occa-sionally for treatment, also ultimately for prevention, the parentsare more likely to be immediately interested in prognosis inregard to schooling and eventual employment, or in severe casesin regard to life. Such an assessment calls for careful,standardized, and often repeated psychological examinationcoupled with due consideration to the social history and theclinical findings. A long-term prognosis in a very younginfant is always hazardous and is usually based on somethingother than behaviour, since the repertory of the baby under3 months is limited. For example, in Down's syndrome it isoften difficult to demonstrate any developmental deviation fromthe norm at 3 or 6 months, though retardation' becomesapparent at a later stage. Certain generalizations may be per-mitted which are useful guidance for parents. In Down'ssyndrome the average expectation is that the child will do aswell intellectually as his peer of about one-third the age. Inother words, he will stay a baby three times as long. He willseldom succeed in competitive- employment. If the headcircumference of a young child is more than three standarddeviations below the mean for age and sex it will probably beseriously retarded. If the placing reactions are absent in ababy of normal birth weight this may suggest a degree ofabnormality of the brain incompatible with normal mentaldevelopment (Zappella, 1963, 1964; Zappella et al., 1964). Inphenylketonuria and cretinism much will depend on the ageat diagnosis. A summary of intellectual assessment of 100patients is shown in Table VI.

TABLE IV.-Main Diagnosis

No specific diagnosis 38 Cretinism. 1Developmental encephalopathy 21 Franceschetti's syndrome .. 1Perinatal damage 11 Thalidomide embryopathy .. 1Down's syndrome (mongolism) 10 Carbon monoxide encephalo-.Deafness .2 pathy .. .. 1Head injury .. 2 Sj6gren's syndrome .. .. 1Infantile psychosis 2 Klinefelter s syndrome .. 1Acquired encephalopathy 1 Post-encephalitic syndrome .. 1Hydrocephalus .. 1 Educational retardation .. 1Pertussis encephalopathy 1 Maternal rejection .. .. 1

,, vaccine encephalopathy 1 Poor social circumstances .. 1

Total .. 100

TABLE V.-Major Secondary Handicap

Nil . . 48 Speech defect. 3Emotional disturbance 13 Congenital dislocation of hip 2Cerebral palsy (hemiplegia) 7 Heart lesion. 2

(spastic diplegia) 6 Cataract 2(minimal) 5 Ptosis .1

Deafness . 6 Hypospadias. 1Epilepsy. 5

Total .. .. 100

TABLE VI.-Intellectual AssessmentSuperior ...2Average .. . 22Dull normal . . .11Educationally subnormal 31Imbecile ...25Idiot ...9

Total .100

Recommendation

An interview with parents of backward children and withthe child has a therapeutic quality and purpose. Our pro-cedure involves a series of interviews and subsequent groupdiscussion with the psychiatrist, psychologist, and socialworker, possibly with other members of the staff. Wherever

BRMSnMEDICAL JOURNAL 43

possible the father is seen as well as the mother. Sometimesother relatives, grandparents, siblings, take part. Formalrecommendations emerging from interview do not alwaysreflect the exchanges which took place or alteration of attitudewhich may have occurred. The social worker carries out ahome visit before the clinic appointment. This also has atherapeutic role, and practical suggestions may be made at thesame time in regard to clothing, bedding, use of sleeping accom-modation, housing, independence, visits to shops, local con-tacts, and membership of a local branch of the National Societyfor Mentally Handicapped Children, etc. Major recommenda-tions are shown in Table VII.

TABLE VII.-Main Recommendations

Waiting-list for institutional careAdmit to unit for disturbed

childrenAdmit to paediatric unitResidential unit

,, nurseryDay nurseryNursery school ..

,,1 ,,.(deaf) .Ordinary school(Remedial classSchool for educationally sub-normal (day)

Ditto (residential)School for physically handicappedSchool for the deaf

Open air school

Training centre (day)Special care unit (day)Further assessment

5

411331011

93121843

Suitable employmentMore stimulationReassurance

Speech therapy .

Physiotherapy.Hearing aidSpecial chairOrthopaedic helpEnuresis alarm.LodgingsMore independence .

Patient to join children'sorganization.

AdoptionGenetic advice.Parents to join National Society

for Mentally HandicappedChildren

RehousingNil specific

Total

3

1

42

11,

1

.31

4

221

ObjectivesIt is possible to make some generalizations as to the role of

such a service. Acceptance and integration in the communitycan be promoted by means of parent guidance. Parents maybelieve that they are wrong in wishing to keep a retarded childat home, and that he would do better in a specialized institu-tion. In fact, institutions are overcrowded; there is a shortageof beds. The waiting-list in this' hospital is 120, mainly youngchildren. This may imply a three-year wait. Furthermore, allthe evidence suggests that children do better at home, providedthe family is able to carry the burden.

Other parents reject a child at an early stage. They may havebeen influenced by an unsympathetic or brusque attitude onthe part of those around them. It is important that parentsshould be able to discuss their problems in relation to a retardedchild at some length, and that they should have patient andsympathetic hearing. A helpful, informed, and interestedapproach will encourage a positive response in the parent.Often the mother or father is anxious for information, and may

underestimate the developmental potential of a handicappedchild or may be worried about whether to have further children.A special clinic such as I have described is in a position tosupply information and to elicit parental difficulties andanxieties.

SummaryThe emphasis is now on community care of the mentally

handicapped. Institutions should be used only as a last resort.But the family with a mentally handicapped member is carryingan additional burden. In some cases material help is needed.In all cases advice should be available. Special clinics for thementally handicapped are very valuable. One such clinic isdescribed. A team of workers is needed who are in sympathywith and have experience of the needs of parents of mentallyhandicapped children. The team at Queen Mary's Hospitalfor Children comprises psychiatrists, junior medical staff,psychologists, psychiatric social workers, and speech therapists.Other specialist services are available. Children are most fre-quently referred by paediatricians on account of suspected

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44 1 January 1966 Mentally Handicapped Children-Kirman MEDIB OURNALmental retardation. In 38 % no specific diagnosis was made,52% have a secondary handicap. Thirty-one per cent. of out-patients are in the educationally subnormal range and 34%severely subnormal. The commonest specific recommendationswere for attendance at day nursery or nursery school, daytraining centre or special care unit.

REFERENCES

Tizard, J., and Grad, J. C. (1961). The Mentally Handicapped andTheir Families. Maudsley Monograph, London.

Zappella, M. (1963). Develop. med. Child Neurol., 5, 497.(1964). Proceedings of the International Copenhagen Congress

on the Scientific Study of Mental Retardation, p. 474.Foley, J., and Cookson, M. (1964). 7. ment. Defic. Res., 8, 1.

Medical Education Overseas[FROM A SPECIAL CORRESPONDENT]

The Medical and Technical Education StudyGroup of the International Co-operationYear held a symposium on "Methods ofTeaching Large Numbers of MedicalPersonnel in Developing Countries " at theCiba Foundation on 30 November, under theco-chairmanship of Dr. J. R. ELLIS (LondonHospital) and Professor K. R. HILL (RoyalFree Hospital).The symposium was opened by Sir ARTHUR

PORRITT, who gave an account of the recentCommonwealth Medical Conference at Edin-burgh. He outlined the proposed establish-ment of supernumerary appointments in thiscountry, at both university and regional hos-pitals, to enable doctors to visit developingcountries more easily on secondment, andstressed the importance of the general dutyofficer who was trained in environmental,preventive, and social medicine. Manydeveloping countries rejected the concept ofthe " medical assistant," and demanded fullytrained doctors.

Dr. S. GAUVAIN (London) discussed theresults of a small survey carried out withpostgraduate students on the relative meritsof the didactic lecture and the seminar. Theformer had been found to be the more popu-lar with students, but there seemed to be littledifference in the examination results achievedby either method.

Role of Textbooks

Mr. J. A. RIVERS (London) emphasizedthe importance of textbooks as an instrumentof individual study. The subject matter ofthe textbook was the responsibility of themedical and allied professions, who shouldtake into account the geographical pattern ofdisease when designing new books. He feltthat English was the best medium forinstruction, but believed that authorship byindigenous doctors was desirable. Unfor-tunately, textbooks published for local usehad a restricted market and tended to beuneconomic. This drawback might be over-come by introducing cheaper methods ofprinting and obtaining subsidies from outsideGovernments and agencies.

Dr. VALERIE GRAVES (Chelmsford)described the advantages of teaching bymagnetic tape, but stressed that the subjectmatter needed careful selection. Tapes weregreat savers of time and labour, in that onerecording could be used over and over againby many students, and they could also be sentto remote centres which were inaccessible toteachers. They were particularly useful incontinuing education, especially if combinedwith slides, film, or filmstrips.

In the discussions following these twopapers, opinions were expressed that the

standard textbook was out-dated, and thatshorter, instructional manuals should replacethem; reduction of " the vocabulary load"was advocated, so as to make the contentmore easily understandable in developingcountries, in which English was not the firstlanguage.

Use of Films

Professor J. K. RUSSELL (Newcastle) dis-cussed the advantages of films as an adjunctto other methods of teaching. He recom-mended the use of silent films of shortduration, accompanied by a commentary byan experienced teacher. Films could showmany aspects which could not be explainedverbally, but the preparation needed to bescrupulous and the co-operation of a pro-fessional photographer was a necessity.Long films were deprecated in subsequent

discussions, but loop films, which lasted avery short time and could be used over andover again, were recommended. Lanternslides or short films, accompanied by a com-mentary in English on a half-track magnetictape, were suggested; these could be added toby a commentator speaking in the locallanguage on the other half-track. It wasgenerally agreed that magnetic tapes andfilms tended to get out of date, and that theyshould be periodically revised or discarded.

Programmed Teaching

Dr. GRIFFITHS OWEN (Newcastle) dis-cussed the use of programmed teaching. Hereported that at Newcastle such teaching(using machines) had produced an overallresult as good as that by lecturers in the fieldof electrocardiography. He emphasized thatprogrammed teaching demanded active parti-cipation by the student. Recent work hadsuggested that scrambled textbooks were asefficacious as machines. If this were so, theymight be found to be the most economic andpracticable method for developing countries.

Closed-circuit Television

Mr. C. E. ENGEL (London) described thesuccessful use of closed-circuit television inteaching large numbers of students. This wasparticularly useful in allowing image magnifi-cation-e.g., of an anatomy dissection-and permitted much saving of the teacher'stime. As learning in medicine dependedconsiderably on visual experience, the tele-vision camera was a useful adjunct to theusual form of instruction, especially whenused for unobtrusive observation-e.g., inoperating theatres and psychiatric clinics.

Dr. S. CAMERON (London) said that open-circuit television for medical education was asyet in its infancy, and that the use of soundradio allied to visual material such as bookletsor slides should not be neglected. Televisionhad a part to play, but it must be realizedthat it was expensive and needed muchtechnical equipment and organization.Although the general opinion of the meetingagreed with this, it was pointed out that closed-circuit television was now relatively cheapand easy to use; this was illustrated by Dr.G. B. D. SCOTT, who described its use in theteaching of morbid anatomy at the RoyalFree Hospital for the past four years.Experience in the United States had shownthat large numbers of students could beefficiently taught in this way, despite shortageof teaching staff.The advantages of videotape were stressed,

not only as a method of record but also as ateaching medium which could be usedrepeatedly or put on film.

Types of Student

Professor G. MAcDONALD (London)pointed out that medical training in thedeveloping countries affected two classes ofstudent. The first comprised the greatmajority who had a relatively low standardof education; in the second were the few whowere at universities. In the first group werenurses, laboratory technicians, and auxiliariesof all types, and it should be recognized thatthey needed an accelerated form of training,which involved the teaching of techniques.This could be done by means of short filmsand magnetic tapes, provided such methodsof instruction inculcated the need to maintaina high standard of work. With the better-educated students the more elaborate forms ofvisual aid, such as television, might be usedto help to combat the teacher shortage, butit should not be forgotten that the main-tenance of elaborate equipment might posedifficulties in some developing countries.

In the general discussion there was agree-ment that a Teaching Services Centre shouldbe established in the United Kingdom (andalso perhaps others in the developingcountries). The centre should have severalfunctions: (1) to find out what was wantedin the way of audio-visual aids; (2) tocatalogue and locate material which couldbe used for teaching; and (3) to evaluatematerial. Consultations with the developingcountries would be necessary. Such centreswould not necessarily produce audio-visualaids, but rather act as coordinators andadvisers to universities and other institutions,who would do the programming.

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