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Online archive 25 b (iii) Development of specialties – Learning disability psychiatry
Difficulty in learning can cause problems at two levels of severity. Those, once called feebleminded who can learn a certain amount but considerably less than their peers; and those who can learn virtually nothing, once called idiots or imbeciles. The latter were often associatedwith other physical handicaps and also symptoms from damage to the brain such as epilepsy. These handicapped people were generally cared for by their families. When this was notpossible, possibly because of severe behavioural problems, they might be placed in a workhouse or prison. When asylums were first built some would be detained there. A later development waswhat were called idiot colonies or idiot asylums. The latter eventually became hospitals for the mentally handicapped. With the closure of asylums those with learning disability are againlooked after in the community by their families. They should be helped by services in the community (day centres, special schools, training facilities, sheltered workshops). Those withthe most severe handicaps (including severe physical disabilities) may need total lifetime care in designated units. Those with learning disability may also have a superimposed mental orphysical disorder. The Medico-Psychological Society had a section for those doctors who dealt withmetamorphosed into the College Faculty of Learning Disability. The psychiatric specialisms of mental handicap patients, providing long term institutional care. This slowly mental handicap or learning disability were one of the first to be formally recognised.
The College and Association were involved with those with learning disabilities from their earliest years. Separate ‘idiot asylums’ which later became hospitals for the mentally handicapped were built. These eventually became overcrowded and were eventually closed down. Social care now occurs more widely in the community. When the terms idiot, imbecile and feeble minded (‘mental retardation’ in the USA where it is still used) were abandoned no less than six different terms were used in their place all subdivided into severe, moderate or mild varieties of the condition. This online archive outlines some of these changes and the development of a sub-specialism in psychiatry.
The conditions best known today as learning disability have been recognised from time immemorial but the titles for the conditions and the methods used to help have differed over time. When the Association (later to develop into the College) was founded in
1841 the terms in use were ‘idiot’, ‘imbecile’ and ‘feeble minded’ which covered three levels of handicap the first being most severe. Because the terms became pejorative they changed over the next 150 years. Mental defective was used for many years but was changed to mentally subnormal, followed by mental handicapped. Further terms used were mental retardation, mental impairment and finally learning disability. The majority of those with learning difficulties were looked after by their relatives or might end in workhouses. At the time lunatic asylums were first developed there was debate about the need for special units for such handicapped people (whether there should be special schools, asylums, colonies or help in the same way as those with mental illnesses).
The earliest references to these conditions in the Association journal often appear as short notes translated from foreign literature or reports in non medical journals. It was noted that:
the cost of the State. The Government of Wurtemburg had given its support to the^ ‘The Government of Saxony had been the first to found an idiot institution, at institutions of Mariaburg and Winterbach. The Government of the kingdom of Sardiniaissued in 1848 a Royal Commission to inquire into the nature and the causes of cretinism; Dr Kern, the Superintendent of an Idiot School near Leipzig, knew of no other Governments which had taken any steps in this matter. He distinguished betweencretinism, idiocy, and imbecility; and he defined imbecility as the psychical condition of weakness which prevented a human being, on account of its influence on his moral life,(innerhalb seiner Lebensphare,) from thinking and acting like healthy men. He distinguished imbecility into acquired and congenital forms. He doubted, however, theactual correctness of the last term, since the condition might have its origin in early infancy, before the mental functions had become active. He thought that there could beas little question of the congenitality of idiocy as of congenital quickness of the intellectual functions, since there could be little doubt that the nature of the intellect wasnot at birth what we see it after its development; that the cultivated intellect of man is indeed a product of education, and not an original endowment. The original, free, andcomplete, or the arrested psychical development depended on the normal or abnormal constitution of the brain and of the nervous system, the cause of which is to be soughtfor in the finer or coarser organization of the bodily organ. Mistakes in the intellectual and moral education could easily introduce false elements into the psychical formation.
that the last Report of the Commissioners in Lunacy shared the view they took about the provision of suitable asylum for the treatment of the idiot paupers who were either retained in the Union houses or, if found very troublesome or dirty, were sent to encumber the wards of the County Lunatic Asylum. In January 1888 the Journal returned to the topic in ‘Occasional Notes of the Quarter’.
‘Provision for Indigent Idiots and Imbeciles families which have the misfortune to have an idiot child, know how utterly inadequate^ All who are acquainted with the demands made upon the Public Charities by is the provision made for this class in England. In the first place, there is a great mass ofpauper idiocy. Undoubtedly, counties and boroughs are obliged by law to admit cases of idiocy and imbecility into workhouses and asylums in the same way as lunatics. It isnot, however, necessary to prove that it is highly undesirable to mix this class with the insane in county asylums, or to retain them in workhouse infirmaries. It would bepossible, indeed, to erect separate buildings exclusively for idiots on the grounds of the asylum, and this course may be adopted if no distinct provision for the training and careof idiots be provided, as was proposed a few years ago by the Charity Organization Society. We will, however, assume that such provision will be made for pauper idiots asshall meet the objection of mixing them with the insane, and that they shall receive the special kind of education which they require. There still remains a not inconsiderablenumber of idiots who belong to a class socially above a very poor and strictly pauper class. In many instances a small weekly payment could be made, and, indeed, nothingwould be more painful to the parents of such a child than to have to seek relief and ask for the admission of their child into a pauper asylum through the relieving officer. Forpersons in this social grade, the charitable Institutions, Earlswood, the Royal Albert Asylum, Star Cross, &c., provide, but only to a very small extent, and everyone knowsthe extreme difficulty of obtaining votes by canvassing in order to procure admission. In short, the supply falls ridiculously short of the demand. We are brought, therefore, to the conclusion that increased efforts must be made to provide for the idiot children of non-pauper parents who can contribute a small sumtowards their maintenance and training. In some instances, no doubt, it would be difficult to pay anything, although it would not be fitting that the child should be treatedas a pauper. For the corresponding class of the insane, much larger provision, although still inadequate, has been made. Will the benevolent public come forward to increase the number of institutions like Earlswood, and free from the objectionable system of canvassing? It is time that aneffort was made in this direction. It must not be done by making exaggerated statements as to the educability of idiots, or by making sensational appeals founded on promises ofsubstituting able-bodied and able-minded workers for those who cumber the ground, but by taking the position that idiots must be removed from the families of the poor in theinterests of themselves and their families, that they can be improved up to a certain point, can be rendered cleanly in their habits, and in some instances even able to earn amodest livelihood.’
In 1886 the Idiots Act permitted the detention of the mentally impaired/handicapped in Idiot Asylums run by voluntary bodies, which were not intended to provide lifelong care, their aim being education and care.
In Dublin Dr Lalor of the Richmond Asylum did not disapprove of the presence of
education and recreative pursuits, he says: “I think it is right to state that they are^ ‘…idiot children in a county asylum. In connection with his system of carried out on the same principles, and with the same details that are applied, and haveproved so successful in special idiot asylums, and which are theoretically and practically suited to all forms of mental defect. The association thus carried out of idiotswith other classes of insane is not found to have injurious effect on either class; and I am convinced, from long experience, that, on the contrary, it is rather useful thanotherwise, and, everything considered, it appears to me that there is no necessity or advantage in having the treatment of the two classes of the insane carried out in separateasylums, and the experience of this Institution rather supports an opposite view.” commend his continuous efforts to carry out his system of teaching in the asylum. The^ Though we venture to differ from Dr Lalor in this point, we cannot too highly interest of the Richmond Asylum Schools does not consist so much in the education ofidiots as in the mental occupation of the insane.’
Edouard Seguin of the Bicêtre Hospital in Paris was one of the first psychiatrists who endeavoured to ameliorate the condition of those in this group. In his time efforts to ameliorate the condition of the congenitally imbecile were regarded with absolute hopelessness by psychologists and physicians at the period when he commenced his labours at the Bicêtre. The standard Dictionnaire de Medicine , published in 1837, had broadly stated, ‘It is useless to attempt to combat idiotism. In order that the intellectual exercise might be established, it would be necessary to change the conformation of organs which are beyond the reach of all modification.’ And even Esquirol himself had penned these desponding words: ‘Idiots are what they must remain for the rest of their life; everything in them betrays an organisation imperfect or arrested in its development.
In 1913 the Mental Deficiency Act empowered local authorities to build their own establishments for those with learning difficulties. Rampton Hospital was opened in 1920 as the first state institution ‘for defectives of dangerous or violent propensities’.
In 1933 Dr Frank Turner, Medical Superintendent of the Royal Eastern Counties Institution, was President of the RMPA He was the first Chairman of their newly established Mental Deficiency Committee. Turner believed that the great majority of those with learning disability were very much improved by the training and stabilisation they received in institutions and that many could reform to earn their living or, with some supervision, to be cared for at home more simply and less expensively than in an institution. He realised however ‘that although great improvement was possible, yet life long care of some kind would be necessary for a large number’.
Dr A.F. Tredgold had published the first edition of his textbook Mental Deficiency (Amentia) in 1908 and in 1931 the RMPA its Manual for Mental Deficiency Nurses (The Red Book: see Chapter 11).
In 1946 the Mental Deficiency Committee became one of the RMPA’s specialist sections and with the passing of the National Health Service Act in 1946 the responsibility for the provision and maintenance of institutional accommodation for mentally defective people passed to the Ministry of Health.
In 1949 Lionel Penrose published the first edition of the Biology of Mental Defect following his clinical and genetic study of 1280 cases at the Royal Eastern Counties
Institution. His work in the field of mental handicap produced a similar clarification as the work of Kraepelin in the field of mental illness.
In 1957 a Royal Commission Report The Law relating to Mental Illness and Mental Deficiency proposed abolishing the term ‘mental defective’ and replacing it with the terms subnormal and psychopathic. The definition of the former stressed the criterion of social incapacity the latter the person’s therapeutic ‘need’. The Act introduced also the term ‘psychopathic disorder’ to include both those of subnormal or normal intelligence. The Act also made it possible for the first time to admit mentally defective persons to hospital on an informal basis.
In the 1960s the patterns of admission to institutions for long-term care were of two main types: young severely subnormal children, usually multiply handicapped with disturbed behaviour, and subnormal adolescents with behaviour disorders of suspected psychiatric illness.
Following a series of reports of hospital enquiries into mental handicap hospitals, they were gradually closed down by governments anxious to have more care in the community and less in institutions. The 1983 Mental Health Act replaced the term mental subnormality with mental impairment. A little over ten years later the College’s Section of Mental Handicap became the section (later the Faculty) of Learning Disability.
were only 5 senior registrars completing their training in this specialty each year and 10 consultant vacancies occurring annually. Inquiries such as the South Ockendon Hospital Inquiry were seriously undermining staff morale. The responsibilities and role of the Consultant in Mental Handicap were debated with some members advocating that specialists should provide total and ongoing care while others thought that they should be aware of their own shortcomings and not try to be so holistic. Another unpopular view was that their primary role was as psychiatrists without full responsibility for every aspect of care and treatment. It was suggested that there should be a greater presence in the community where the majority of those with mental deficiency lived, by offering more outpatient services.
In the 1970s there was development of the profile of mental handicap within the College with more relationships with external organisations such as the national Development Group for Mental Handicap (NDG) and the Jay Committee (reporting on mental handicap nursing and care). The upholding of standards in relation to consultant appointments was of particular concern to the Association. There was also concern about the failure of Local Authorities to provide community services as proposed by Government. Through this time the specialty remained under threat and further inquiries such as Normansfield (with the suspension of a Consultant) added fuel to the fire. The difficulty in recruitment was of great concern. There was a dearth of senior registrar posts leading to consultant posts not being filled and consequent overload of existing consultants. This made the specialty unattractive. However by 1976 the number of Consultants in Mental Handicap had increased from 90 to 130 in the previous ten years.
A working party was established to consider the Future of Mental Handicap Services and its report was published in 1983. At that time there was noted to be a consultant establishment of 212.6 throughout the UK and Ireland. The Section had fought hard for academic credibility and now this was beginning to be achieved. The specialty began to strengthen and flourish. The executive committee set up a working party on recruitment and training and a joint liaison group with the NDG was established. The first appointment of regional representatives of the Specialty took place in 1981. The need to move from a generic specialty to a more focussed psychiatric specialty was recognised although hotly debated. The result was a ballot on the possible new title in 1982 as a result of which there was a change to Specialist Section for the Psychiatry of Mental Handicap in 1983, replacing Specialist Section for the Psychiatry of Mental Deficiency. There was development of specialist psychiatric services and memoranda were published in the Bulletin to this effect including the first guidelines for Regional Advisers on Consultant Psychiatric Posts in Mental Handicap and guidelines for registrar training. Section meetings focussed on presentations on the new relevant research and recruitment began to steadily improve.
The late 1980s was a challenging time because, although resources were being poured into community services for people with learning disabilities, the rationale for this was the closure of institutions. These were deprived of funding and their negative image was strongly associated with the psychiatry of mental handicap. Consultants had the difficult task of establishing their role in community services and some whole time posts were replaced by joint or special interest posts and other posts were left vacant. There was
Association for Mental Retardation and the International Association for the Scientific Study of Intellectual Disability.
The need for a specialty of mental handicap was being questioned both within and outside the College in the 1960s. Recruitment to the specialty was poor and there were only about 140 established consultant posts with many unfilled. Section numbers were about 80 with a few active members and a turnout of 20 at a scientific section meeting was regarded as good. The criteria for the selection of consultants and senior registrars enforced by the College had a beneficial effect on mental handicap services. This was achieved following the introduction of the MRCPsych examination and higher training in 1972 that included a substantial mental handicap component. One consultant often covered a population of 400 000 with a bed load of 450. There were only five senior registrars completing their training in this specialty each year and ten consultant vacancies annually. Inquiries such as the South Ockendon Hospital Inquiry were seriously undermining staff morale. The responsibilities and role of the Consultant in Mental Handicap were debated with some members advocating that specialists should provide total and ongoing care while others thought that their primary role was as psychiatrists without full responsibility for every aspect of care and treatment. It was suggested that there should be a greater presence in the community where the majority of those with mental deficiency lived, by offering more outpatient services. The outcome of the debate was to define more clearly the role of the health service and lead eventually to better recruitment and the improved overall strength of the specialty.
In the 1970s the specialty of mental handicap within the College developed with more relationships with external organisations such as the national Development Group for Mental Handicap (NDG) and the Jay Committee (reporting on mental handicap nursing and care). The upholding of standards in relation to consultant appointments was of particular concern. There was also concern about the failure of Local Authorities to provide community services as proposed by the Government. Through this time the specialty remained under threat and further inquiries such as Normansfield (with the suspension of a Consultant) added fuel to the fire.
The Section pressed for academic credibility which slowly began to be achieved with the establishment of academic posts, improved teaching and training at both undergraduate and post-graduate levels and in the development of research. The first Chair in the Psychiatry of Mental Handicap was established in 1980 at St George’s Hospital, soon followed by Birmingham University. There are now seven chairs in learning disability psychiatry in the UK.
There was much argument about what the specialty should be called – from mental deficiency through mental handicap to learning disability. This led to a ballot in 1994 after which and the Section became the Faculty of Learning Disability of the College. This maintained its role in influencing training, policy and the executive functions of the College. The pioneering developments in the Section and the College had a fundamental influence on developments in Europe and the USA. As well as having a key role in the founding of the International Association for the Scientific Study of Mental Deficiency in 1964 members of the Section and Faculty have also played a prominent role and held
References Harding, W. (1893) Mental Nursing: Lecture for Asylum Attendants. Scientific Press. Heaton-Ward, A. (1960) Mental Subnormality. John Wright. Heaton-Ward, A. & Wiley, Y. (1984) Mental Handicap. John Wright. Tredgold, A.F. (1908) Manual for Mental Deficiency Nurses. Ballière, Tindall & Cox. Tredgold, A.F. (1938)Tindall & Cox. Occupational Therapy. An addendum to the Handbook for Mental Nurses. Ballière,
