Table Of ContentPatterns of Care
for the Subnormal
BY
MICHAEL CRAFT, M.D., F.R.C.P.E., D.P.M.
Consultant, North and Mid Wales Hospitals for the Subnormal
AND
LEWIS MILES, M.SC, A.A.P.S.W.
Sturer y Department of Social Theory and Institutions,
University College of N. Wales
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First edition 1967
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Foreword
IN recent years some of the most exciting advances in psychiatry
have occurred in the field of subnormality. This is all the more
surprising and gratifying when one remembers the Cinderella
like status of this specialty within psychiatry.
The pattern of care for the mentally subnormal in England and
Wales has not, however, undergone the striking metamorphosis
which has recently overtaken that for the mentally sick.
A remarkable opportunity has been afforded for operational
research based on the epidemiological approach. This has been
seized in England and Wales during the past 10 years by Tizard,
O'Connor, Kushlick, Susser and by the present authors.
The determination of the pattern of prevalence of subnormality
and the way in which this relates to existing medical, educational
and social services is the first step. The present study reveals
striking variations in these patterns both within Wales and
between Wales and England.
The second step—more difficult and more controversial—
involves a series of judgements as to how services should be re
fashioned to meet the evident need. The authors do not shirk this
exercise and have produced a blueprint for a comprehensive intra-
and extra-mural service for the subnormal.
A third step—controlled experiments designed to evaluate new
approaches to treatment—has been employed by Craft and also
by Tizard and Kushlick. This is not, however, the concern of
the present work.
The empirical data presented in this enquiry and the implica
tions for the development of subnormality services will be of
vii
Vili FOREWORD
great interest to doctors, psychologists, educationalists and
administrators far beyond the boundaries of Wales. The issues
raised are perennial and universal.
Professor K. Rawnsley,
Department of Psychological Medicine,
Welsh National School of Medicine,
Cardiff.
22nd September, 1966
Acknowledgements
THE authors would like to thank the Consultants in Subnormality
of the Welsh Hospital Board, Drs. T. B. Jones, T. S. Davies and
D. C. W. Jenkins for the data they have provided, particularly
the survey in Chapter 6. Without their help this book could not
have been written.
The Welsh Hospital Board has made information available,
given us financial assistance through its Clinical Research Fund,
and Dr. Alwyn Smith, the Board's S.A.M.O. has given us every
support.
The Welsh Board of Health has also given considerable
support, and we would like to thank Dr. A. R. Culley and his
colleagues for this. The seventeen Local Authority Medical
Officers of Health contributed enthusiastically in providing data.
We hope the results will be of interest to all.
Finally, to our typists, particularly Mrs. Lowe, our thanks go
for their untiring help and attention to detail.
Michael Craft, M.D., F.R.C.P.E., D.P.M.,
Consultant, North and Mid Wales Hospitals
for the Subnormal.
Lewis Miles, M.Sc,
Lecturer, Dept. of Social Theory and Institutions,
University College of North Wales.
ix
51.830
Anglesey'
174.680
120,560 \ Denbighshire
I Caernarvonshire >
ζ Merionethshire é
38.390
43.660
Montgomeryshi re
Radnorshire
Cardigan
18.370
53,260
166,560 Brecknockshire
Carmarthenshire 55,180
, Monmouthshire
342.660
Glamorgan
752,250
Seal« 1:1.000.000
0 5 10 15 20 25 mile·
Principality of Wales and Monmouthshire
Local Authorities with 1963 Population
x
CHAPTER 1
The Term Subnormal
THE term subnormal came into common use in Britain following
the 1944 Education Act which introduced the term educationally
subnormal children. This group of children included the brightest
fraction of those previously covered by the Mental Deficiency
Acts, excluded from formal education and "trained" in hospitals,
or the few training centres available. The term subnormal was
thus a new label for a new approach to an old problem. The 1959
Mental Health Act of England and Wales continued this trend,
repealed the official use of the term mental defect using the new
terms severely subnormal and psychopathic disorder as suggested by
the Royal Commission into the Law Relating to Mental Illness
and Mental Defect. The Act also added the category subnormal.
Following the statutory lead, doctors gradually dropped the term
defective, using the new label subnormal to refer generally to the
same group of clinical problems. Teachers, lawyers and physicians
each have an interest in what the 1959 Act termed "a state of
arrested or incomplete development of mind which includes
subnormality of intelligence, and is such a nature or degree ..."
that the severely subnormal cannot look after himself alone, and
the subnormal needs help or training to do so. Sociologists are
interested in those who cannot help themselves, as are psycholo
gists, due to their development of tests rating intellectual and
personality development, whilst administrators need calculations
of prevalence and incidence in order to forecast demand for ser
vices. Unfortunately, because none of the definitions in the new
Act describe accurately the degrees of subnormality of intelligence
(indeed there is evidence that this is not possible with present
1
2 PATTERNS OF CARE FOR THE SUBNORMAL
tests—Clarke, and Clarke, 1958; Craft, 1959), and clinical
definitions are notoriously inconsistent, new labels can be even
less helpful than the old, about which a body of knowledge has
accumulated with the course of time.
As a result, some confusion has arisen between the different
disciplines noted above. In this book it is intended to review the
contribution to care of the subnormal made by each discipline,
note patterns of care used by societies outside Britain, and put
forward a suitable pattern for future British practice.
We start with the contribution of the educationalist.
1. The Educational Approach to Subnormality
As in other fields of endeavour, educationalists have improved
their methods over the years, and also expanded their field.
Indeed, education is felt by many to cover most aspects of pre
paration for adult life, including some formerly believed to be
the province of the family. Educationalists are now keen to teach
many with physical and mental handicaps who were regarded as
falling more within the sphere of medicine and often educationally
excluded. The deaf, the blind, the spastic, and the maladjusted
are examples of special needs just as the subnormal. As with the
subnormal, different diseases, injuries, and genetic endowments
contribute to each group of handicap, and medical treatment,
optimal environment and remedial teaching go hand in hand
towards improvement. Whilst societies in their own interest will
always pay special regard to the tuition of the intellectually
superior, it is also economically, as well as morally, advantageous
to advance the handicapped as far as possible. As the definitions
of earlier Acts show, defective children were excluded from
ordinary school as much to protect "normal" children from
handicapped colleagues as to help the defective. In England and
Wales it is really only since 1870 that education has been regarded
as a child's right and not a privilege to be won. It was a way
society rationed by finance a scarce commodity. In England and
Wales defectives were excluded from school, and it was only after
THE TERM SUBNORMAL 3
the development of techniques of special education for them, the
rebuilding of many out-of-date state schools, and an increasing
supply of teachers, that the needs of the subnormal were met to
any extent.
In Scotland the results were very much the same although the
road travelled differed somewhat. The retarded were not in
practice formally excluded from school, but facilities for special
education were poor, so that most of this group, although
theoretically at school, did not profit greatly. Now that new
techniques, new premises, and extra teachers are being made
available for special education of the handicapped, progress is
more rapid.
Despite the definition of educational subnormality in the 1944
Education Act there is still doubt as to how many of the subnormal
should be covered, for even the definition used in the Act is a
clinical one, seeming to vary with local medical opinion. The
current 1959 definition varying the 1944 Act defines subnorma
li ty as: "educationally subnormal pupils, that is to say pupils who,
by reason of limited ability or other conditions, resulting in
educational retardation require some specialized form of educa
tion wholly or partly in substitution for the education normally
given in ordinary schools" (our italics). In one residential E.S.N.
school in North Wales one may find a mongol with, for instance,
an I.Q,. in the 50-60 range, whilst 10 miles across the same
county one finds a maladjusted and parentally rejected boy of
Stanford Binet I.Q. 85, a test result which even his psychologist
knows to be an estimate more of his educational inadequacies
than his native abilities. When taxed, the principal school
medical officer can point out that although subnormal, both
children were given the best educational placements com
mensurate with (1) their educational needs, (2) availability of
community placements, (3) parental contact, and (4) county
finance. One might apply these arguments to cover the case of
any subnormal child, for if all these points are adequately met,
there is no need to stream rigidly according to legal categoriza
tion. As the current controversy on the 11-plus reveals, a single
4 PATTERNS OF CARE FOR THE SUBNORMAL
test or I.Q,. result only measures present function, that is on the
day the child is tested, and both children and their abilities
change with time. Flexibility is necessary in educational pro
visions both for the upper and lower ranges.
The Legal Viewpoint
Laws are necessary for the protection of both the individual
and the community. It follows that definitions should be as
accurate as possible. Nevertheless it is generally recognized that,
for treatment purposes, voluntary methods are better than
compulsory ones, and particularly for children should avoid
legalistic terms having a community stigma. One wonders
whether the new labels, severe subnormality and subnormality which
describe present function give any more comfort to parents than
old labels such as idiot and imbecile. Their main hope is that
the child's state will improve. Such terms may be necessary for
documentation and diagnosis, but should only be used in public
with adolescents and adults when the processes of law have to be
observed.
Where community resources are limited and have to be
rationed, the distribution of these rations, whether of food or
education, may have to be governed by law. Even when resources
become freely available, legal safeguards may be required to
govern excess accumulation by certain individuals or areas. This
is true in the field of teaching today. For the subnormal child
the best situation is that offering a choice of available placements.
At this point legal categorization can become unnecessary, for
most parents are sensible enough to appreciate that subnormal
children, of whatever grade, need teaching commensurate with
their ability and need. If all educational establishments are
termed schools, whether pre-literate nursery schools for normal
infants, or pre-literate training centres for the subnormal, and
teachers paid according to skill and qualification, then formal
school "exclusion" is superfluous. In Britain, Denbigh, Birming
ham and Monmouth education authorities have followed this
