Address delivered at Tennessee Conference on Handicapped Children, April 8, 1957. ADDRESS: 167 Armory Street, New Haven 11, Connecticut.
EDUCATION
1088
Grover F. Powers, M.D., Contributing Editor
PROFESSIONAL
EDUCATION
AND
MENTAL
RETARDATION
I
T IS said that Martin Luther considered mentally retarded children as persons possessed of the devil.That rash diagnosis was made nearly 500 years ago. But even 22 years ago the super-intendent of an institution for netandates advised me as follows when I requested
guidance on a program for mentally handi-capped persons : “All they need, doctor, is a bench on which to sit and a lolly-pop to keep them quiet.”
In contrast, consider the humanitarian
and enlightened climate of our own day as demonstrated by a few news items:
Just over a year ago, officials of the Federal Department of Health, Education
and Welfare sponsored a conference on mental retardation with representatives of national, nongovernmental organizations
in-terested in the subject. This, I believe, is the first conference of its kind.
Also, just oven a year ago, the Josiah Macy Jr. Foundation at the request of the Federal Interdepartmental Committee on Children and Youth sponsored a conference on “New Directions in Community
Plan-ning for Mentally Retarded
Children”-an-other first of
its
kind.And less than 6 months ago the Ross Laboratories sponsored a “Symposum on Etiological Factors in Mental Retardation.”
Actively participating were some 20 out-standing scientists who are working in the fields of the chemistry and metabolism of
the nervous system, genetics, inborn errors of metabolism, the fetal environment and fetal-maternal interaction. Another first!
Two years ago (1955) the United States Congress appropriated $750,000 specifically for research in mental retardation. Still
an-other first! And for the fiscal year 1957 Congressional appropriations’ for several
aspects of this problem, including
educa-tion, are $4,121,000!
This list of encouraging activities in ex-plonation of the subject of mental
retarda-tion is only illustrative and far from corn-plete, I am happy to say.
If one takes a fleeting glance at the ne-tardate in history as did Dr. Lloyd Dunn,2 the story might be dramatized somewhat as follows : In Sparta, total disregard ending
in expected death; in the Middle Ages, Royal Court buffoonery; at the time of the
Reformation, “possessed of the devil”; at a little later period, forlorn bed and board, in asylums supported by ecclesiastical char-ity; then government supported custodial hostels of the past century-schools and
hospitals in name often but too rarely in fact; and, in more recent decades, the starved day schools and special classes.
This very drab background, with only occasional illumination by the imagination
of an Itand on Segumn and the devoted senv-ices of a relatively few dedicated souls,
fur-nished the soil in which some good but many evils flourished. There grew up pa-rental shame and guilt, social and
educa-tional ignorance and neglect, quarantine in the home for the “skeleton in the closet” and-as with the early asylums for the in-sane-institutional isolation somewhere off
in the Styx. Until less than a decade ago, taking the country as a whole, the retardate
was indeed “the forgotten child”!
The awakening to responsibility and en-lightened concern, the amelioration of
pa-rental shame and guilt, the attainment of a greater measure of professional prestige for senior personnel, and increasing intellectual interest by scientists are due in large degree
EDUCATION 1089
This kind of movement, of course, is not limited to the parents of retarded children.
It is part and parcel of general folk interest and of group activity in matters of health and disease, which arose to heights in the
1930’s. The movement grew in part from the great increase in the number of pre-ventable and curable diseases and the con-responding unfavorable prominence of old age and chronic afflictions for which
pre-vention on cure were not available and ne-glect seemed inevitable. Also, germinating factors for group interest were the expand-ing information services in regard to
mat-tens of health through the media of the
popular press, radio and television. And also there arose widespread concern, along with financial resources, of various
govern-mental agencies, federal, state and munici-pal. People as never before were getting
data, often fallacious, to be sure, on health and disease and were forming groups for collective study, for developing services and for exerting pressures for action on vol-untary and governmental organizations. These groups supplied in part the fertile soil for the growth of rehabilitation
pro-grams in general which came after World War II. In 1955 an article on “Rehabilita-tion”3 offered 208 bibliographical references
of which only 3 are dated prior to 1953. Rehabilitation is in the very air we breathe now, sometimes, as of old, referring largely
to physiotherapy for panalytics but more and more frequently to broadly inclusive programs of long-term patient care what-even the nature of the handicap. The
physi-cian of the present should be and of the future must be qualified to deal with the chronic disabilities and diseases which at
both ends of life’s spectrum are increasing in incidence both actual and relative. The malformations of childhood and the
dis-abilities of extending old age are yielding more and more, but often slowly, to the ministrations of modern medicine. As
re-search points the way and alters the course, the nature of clinical material has changed; this means that the milieu in which gnadu-ate medical education functions must
per-force change. I say “graduate medical
edu-cation” to emphasize my old fashioned
be-lief that undergraduate medical education
should stick as far as possible to the basic sciences and to the fundamentals which un-derlie
all
divisions of clinical medicine. As Dr. Alan Gregg4 wisely said: “Since thereis too much factual knowledge and
practi-cal skill to impart in so short a period of time as 4 years, the part of wisdom seems to me to lie in training the student’s
capa-cities rather than stuffing his memory. What capacities? The capacity to observe, to reason, to compare his observations and
reasoning with those of others, and the capacity to put himself in his patient’s place -compassion. With such abilities trained,
sharpened, and refined, the graduate of a medical school would find in his fifth on intern year, and later as assistant resident
and resident, the opportunities to use and refine those capacities to the immediate and
the infinite advantage of his patients and himself.” These matters-not mental ne-tandation, not cerebral palsy, not any other special clinical domains pen se-constitute, in my opinion, the prime business of
under-graduate medicine! But in the graduate ex-perience, the newborn M.D. must find out the newer content of the clinical material
with which much of his professional life
will have to deal. I refer to mental retarda-tion, human ecology, psychology, geriatrics, rehabilitation in its broad ramifications,
re-parative surgery (in respect, particularly, to malformations). And just as important, one should include social service and
nuns-ing and team work in general in attacking
the manifold problems in these areas whose
complexities require many diverse skills.
Parents and friends of mentally retarded children began to organize in groups dun-ing the early 1930’s. Collectively, they were better able to work for their children’s
wel-fare. During the postwar period, the move-ment expanded widely. In October, 1950, representatives of 13 states met in
1. To secure for all retarded children and adults the benefit of cane, treatment and training appropriate to their disability; and
to encourage the development of integrated community and residential programs in
their behalf.
2. To develop a better understanding of
the needs of the retarded and their families
by the general public, professional groups
and legislative bodies; and to work co-op-enatively with all agencies and media, pub-lic and private, toward that end.
3. To promote and stimulate research into
causes, cure, and prevention of mental
re-tardation, the development of rehabilitation
techniques, and personnel training and re-cnuitment.
It is this latter item to which I especially
wish to address myself-in a broad way, medical education and rehabilitation with illustrative emphasis on the area I know
best, mental retardation.
In this matter, there are certain obvious facts which too often, nevertheless, escape comprehending observations and effective action. Such is the fact that what is most needed in illuminating mental retardation and the handicapped generally are inter-ested, imaginative and experienced
person-nel in medicine, psychology, sociology and special education. An area of scholarly con-cern is not glamorous so much in its content
as in the illumination which a creative, focused mind bestows upon the subject. Without necessarily making a single
dis-covery the very fact, publicized far and wide, that a Nobel laureate in chemistry-Linus Pauling-sees the intellectual chal-lenge of the field of mental retardation and
with his great gifts is planning to work therein, has thrilled and inspired thousands of parents and professional personnel and scientists. I sincerely trust Pauling’s
appne-ciation of the potentialities of research here will stimulate to action medical professors and senior teaching personnel in other
dis-ciplines who have regarded the domain of the handicapped as a dead end and have been laggards in encouraging student in-tenest. For an essential requirement for
meeting the great deficit in gifted
profes-sional personnel is contact of appropriate students at the university level with
teach-ens who are basically trained and are also
inspired with intellectual curiosity and pen-ception of potentialities to encourage work
with the handicapped. There are other fac-tors to be considered in getting competent senior personnel but, I repeat, without ex-posure of junior learners to this
multi-faceted problem under wise pedagogical leadership, there can be no adequate
ad-vances.
The most forthright way by which
learn-ens can get contact with problems of mental retardation and the handicapped is by some sort of affiliation between educational
in-stitutions and (1) residential schools for
re-tandates and (2) community evaluation or rehabilitation centers or institutes. The resi-dential schools, public and private, in which only about 10% of retardates live,
offer a controlled situation with special op-pontunities and facilities. But such institu-tions lack certain other opportunities and
facilities and are too often cut off from a variety of intellectual contacts by virtue of
geographical isolation. A combination of the opportunities offered by each type of
organization is very desirable.
In these affiliations, the areas where ties are closest are special education, psychol-ogy, and the biologic, medical and social
sciences. The liaison is currently most
read-ily and frequently attained in research pro-grams. Some residential schools have
re-search directors who hold university
ap-pointments and under their guidance in
some instances screenings before
admis-sions are processed in medical school
din-ics. Some residential schools have inde-pendent research programs with on without
consultation services from universities. Whatever be the method of affiliation and whether formal on informal, the essential requirement is that research be carried out
in the many areas of intellectual concern
EDUCATION 1091
mental retardation and rehabilitation in
general lies in research not only in medicine but whenever the questing mind finds
stim-ulation for investigation. The junior learner may be stimulated to abiding interest in re-habilitation by acting as associate in a
re-search project. Of all facets of medical edu-cation in relation to mental retardation, liaison in research has progressed farthest at this time. I might cite as examples
de-velopments at the Children’s Hospital in Philadelphia,6 at the Departments of Pe-diatnics and Biochemistry of the University of Utah’ and at the several universities in
Los 12 A number of important
studies relative to poliomyelitis, virology, fluoridation, phenylketonuria and genetics, for examples, have been carried out in resi-dential schools for retardates, and these
could hardly have been performed so satis-factonily elsewhere. There is an ever grow-ing realization that the handicapped, in one
scientific domain or another, offer a worthy challenge to the qualified investigator and in fields which are now fertile. May I ne-mind you here of my earlier comment on
the Ross Pediatric Research Conference on Etiological Factors in Mental Retardation
and its orientation to basic science. There are many professional persons who find the
greatest challenge in research rather than in service alone, and I believe that many
opportunities are now open to them.
I now call attention to what I believe is the most valuable type of teaching program
designed to interest medical personnel in mental retardation. This is the tour of duty
y the graduate student in pediatrics as in-tern and later as resident in a diagnostic
clinic and day center and in a residential training school. This type of rotation is applicable to other university services than pediatrics-e.g., psychology, education,
psy-chiatry, internal medicine, neurology. As an example I cite the educational program at
Southbury Training SchooP#{176}where the
pe-0 The liaisons are with the Woods Schools, Utah State Training School and Pacific State Hospital, respectively.
diatric interns of the Yale Medical School
spend 6 weeks at the Training School, and selected assistant residents 6 months, all
working under a chief resident and a senior staff. Since 1943, 117 interns and since 1949, 12 assistant residents have received this
training. Similar pediatric programs are in
existence at the College of Medical
Evan-gelists,h1 in association with the Pacific
State Hospital where also there are notating residences in psychiatry; and at New York
Medical College and Jewish Hospital of Brooklyn. I hope there are others but I do
not know of them. I would like to empha-size that these training-school experiences
are in comprehensive medicine dealing with children and adults-not just in mental
retardation; this is thrown in as a bonus,
so to speak!
Regarding the teaching of undergraduate medical students in the subject of mental retardation, I think this is best accom-plished by giving them experience not only as it comes on the usual pediatric service
but also as clinical clerks in a community diagnostic and day care center. I believe this is the plan at St. Christopher’s Hospital,
Philadelphia, under Dr. Bantram1’ and en-visaged by Dr. Arden Miller” at the Uni-versity of Kansas and by Dr. Deisher” at
the University of Washington. I would not expect this to be a course, so to speak, in mental retardation primarily but rather a
responsible clinical experience in compre-hensive medicine of which mental retarda-tion is one part. What I would hope the student would learn, so that the special
les-son is never forgotten on neglected, is that mental retardation is one of the great areas of humanitarian and educational concern
and that its impingements are extensive in many scientific directions. Something of this type ought to be increasingly possible as the Children’s Bureau’s community
pro-grams in mental retardation develop and increase. Dr. Lesser’6 tells me as of January 24, 1957, that “grants have been made to 13
PEDIATRICS DECEMBER 1957
are in the process of being approved.”0 These clinics, and similar privately sup-ported ones, would provide splendid teach-ing facilities, especially when combined
with day care centers and small residential infirmaries.
However, the current method of teach-ing, so fan as mental retardation is con-cerned in undergraduate medical educa-tion, is by clinical lectures and by one or two demonstration visits to residential training schools, private as well as public,
conducted by a staff physician or by a per-son holding joint appointments in the
insti-tution and in a university. I think a clinical clerkship is a fan more effective educa-tional tool and I hope that with increasingly available clinical facilities and competent senior personnel it will supplant the didactic
methodology and casual visiting. I believe the Committee on the “Handicapped Child” of the American Academy of Pediatrics un-den the able Chairmanship of Dr. Eric Den-hoff’7 has data on this matter indicating that most medical schools teach the subject, if at all, in this latter manner.
I might point out that teaching by under-graduate clinical clerkships and by gradu-ate residencies is considered highly
satis-factory in the educational programs devel-oped by medical schools and veterans hos-pitals as a joint enterprise; such programs are mutually advantageous.
Another form of promoting medical
edu-cation in the area of mental retardation is the symposium or seminar on the subject sponsored jointly by a university and a training school or a parents’ organization.
These functions serve a very important purpose of enlightenment of practicing physicians and other relevant personnel. I
know of at least four such institutes held during the past year-at New York Medical College,22 the University of Minnesota,”
Indiana University,’ and Winfield, Kansas -these were excellent in quality, broad in
0 As cf June 13, 1957, grants have been made
to 24 state health departments for programs for mentally retarded persons.
scope and much appreciated by those in attendance from many different profes-sional fields and by parents.
Finally, I would call attention to the splendid training fellowships available to interested and qualified graduate students
through various divisions of the U. S. Public Health Service. It is also hoped that from private sources endowed support for senior
investigators in basic research will become available in universities.
Although my comments have dealt pnin-cipally with medical education and mental retardation, the fundamental philosophy
of joint educational endeavor is sound re-ganding many relevant disciplines of
uni-vensity responsibility and corresponding
in-terests and activities involved in dealing
with handicapped persons and with re-habilitation broadly conceived. In addition to medicine, much progress has been made in the area of special and vocational edu-cation. First off I would cite here the excel-lent programs at the George Peabody Col-lege for Teachers in Nashville and at the
Institute for Exceptional Children in
Un-bana. The Southbury Training School’8 in conjunction with the New Haven Teachers College has for several years conducted 6-week summer work shops for teachers of
exceptional children; the participants re-ceive official credits for attendance and satisfactory work. Also, some students in
the Teachers College come to the training school for 6 weeks’ supervised practice teaching.
I cannot comment so favorably on liaison
between university departments of psychol-ogy and training schools. Professor
Sey-mour Sanasonl9 of the Yale Department of
Psychology confirms the comment of Dr.
Leonard Duhl’#{176}of the National Institute of Mental Health as follows:
“Psychologists who several decades ago played an important role in both research and service for the retarded have generally
EDUCATION 1093
nature, which have programs to train their
psychologists for work in mental retarda-tion. However, in no way is this adequate to the need.”
There are hurdles to be overcome in
con-summating affiliations between universities and residential training schools and per-haps other centers for the handicapped. I shall list the most serious as I see them.
1. In universities and in training schools there must be administrative, political and professional personnel who really see the
importance of the problems and the oppon-trinities and the needs for co-operative efforts to solve them. Of these enlightened
persons there are now too few. To develop these liaisons, imaginative interest and dy-namic leadership and hard work are
re-quined.
2. There is usually need for some special financing and for housing of changing grad-nate student personnel, often including a family. Expenses and honoraria for con-sultants also must be provided.
3. A very difficult hurdle is the frequent geographical isolation of training schools
from the parent institution with which basic contact should be maintained. This is not
only applicable to graduate students but
also to consultants who cannot be expected
to waste time and energy in travel. In 5ev-enal places efforts are now being made to build new units for these special patients near established medical centers#{176}’21; this would obviate many serious frustrations in-henent in distance. An affiliation is
impossi-ble for some training schools no matter how sincere the desire for it may be, either
be-cause there is no university available or it is too distant. But it is an inexcusable
edu-cational crime against society now to build new residential schools, private or public, isolated from educational centers.
4. Another hurdle is the lack in some in-#{128}titutions of adequate laboratory
equip-ment and facilities to meet the require-ments of modern science. Such equipment
along with qualified operating personnel is absolutely essential.
5. The greatest need and greatest
neces-sity is for basically trained and clinically
gifted teachers at the training schools and rehabilitation centers so that students will be inspired respecting the subjects. These
persons must hold joint appointments in university and training school and maintain serious contact with both institutions. It is
because I see this need as so urgent that I earnestly appeal for the only basic remedy -the joining of forces and resources now
between universities and the various kinds of rehabilitation units in the interest of edu-cation in medicine and in other relevant
fields and the elevation of professional standards in institutions. The situation just now is like a carousel-more good teachers to train more students to develop more
teachers to train better students-round and round it goes! In my opinion, professional
service in training schools would be greatly enhanced in the eyes of prospective
stu-dents, interns, residents and fellows if their superiors gave undivided attention to scien-tific and clinical work. As it is, many
insti-tutions are divided into units in which the physician is also administrative officer with
oven-all responsibility even for mainten-ance. Was it not Sir William Osler who admonished us that Medicine is a jealous
mistress!
CONCLUSIONS
In conclusion, I would point with en-thusiasm to the mounting interest and
effec-tive concern of top-level professional per-sonnel in various aspects of the problems of handicapped persons. The professors
must be interested if the students are to become interested-and both are now
be-coming interested!
The universities are gradually finding it of increasing value for research purposes to develop liaison with residential schools
and rehabilitation centers. Available finan-cial support for research in terms of proj-ects over a broad but relevant field are
rela-tively generous.
Also, there seems to be increasing
will-ingness of leaders in medical education and
utilization of training schools and other fa-cilities for handicapped persons to broaden
and enrich their programs with mutual ad-vantage to all parties. These programs will in time lead to the development of gifted leaders in research and teaching.
I repeat that specialized basic teaching belongs, in my opinion, largely in the years of graduate education and I believe clinical clerkships, internships and residencies and fellowships foster the most fruitful results
in medicine and similarly in other relevant
disciplines.
I repeat, also, that pediatrics and special
education are now the leaders in this essen-tial undertaking, but the need and the philosophy are present and appropriate in many other disciplines.
The growing number of Children’s Bu-reau and otherwise sponsored special Corn-munity Centers afford an encouraging out-look for developing future educational
pro-grams in accessible university settings. Let us even be alert to the fact, however, that our urgent lacks are not so much
avail-able clinical facilities as interested, top-flight investigators and teachers; for these the principal sources are the universities thus making educational and research
affil-iations imperative. Lest the cynical decry
humanitarian concern for, and scientific
study of, the handicapped, let there be
re-flection on the fact that truth recognizes no limitations for the heart, no boundaries
for the intellect! An environment propitious for the development of gifted children
sure-ly cannot but be enriched by offering
suc-con to those who are in any way handi-capped!
REFERENCES
1. A Balanced Approach toward Meeting the Needs of the Mentally Retarded. De-partment of Health, Education and
Wel-fare, Washington, D.C., January, 1957. 2. Dunn, L. : Services for Exceptional
Chil-dren. Proceedings of the 1956 Spring Conference of the Woods Schools, pp.
17-29.
3. Marks, M., and Green, L. B. : Rehabilita-tion. Progress Neurol. & Psychiat., 10:
619, 1955.
4. Gregg, A. : Challenges to Contemporary Medicine. New York, Columbia Univ. Press, 1956.
5. Aims and Purposes: Report, National As-sociation for Retarded Children.
6. Stokes,
J.,
Jr. : Personal communication. 7. Bray, P. F. : Personal communication. 8. Low, N. L. : Personal communication. 9. Bosma,J.
F. : Personal communication. 10. Yannet, H. : A pediatric intern and residenttraining program integrated with a train-ing school for the mentally retarded.
PEDIATRICS, 20:139, 1957.
11. Centenwall, W. R. : Personal communica-tion.
12. Wright, S. W. : Personal communication. 13. Bantram,
J.
R.: Personal communication. 14. Miller, C. A. : Personal communication. 15. Deisher, R. W. : Personal communication. 16. Lesser, A.J.
: Personal communication. 17. Denhoff, E. : Report, Committee on theHandicapped Child, American Academy of Pediatrics, and Liaison Meeting be-tween this Committee and the Research
Committee of the American Academy of Cerebral Palsy.
18. Schmickel, B. : Personal communication. 18. Sarason, S. B. : Personal communication. 20. DuhI, L.
J.
: Mental retardation: A reviewof mental health implications. Canad. Psychiat. A.
J.,
1: 107, 1956.21. Wilson,
J.
L. : Personal communication. 22. The Evaluation and Treatment of theMentally Retarded Child in Clinics. Pro-ceedings of a training institute
co-spon-sored by New York Medical College and National Association for Retarded Chil-dren. N. A. R. C. Inc., 99 University Place, New York City.
