HMI: Matters for Discussion

Background notes

1 Ten Good Schools
2 Classics in Comprehensive Schools
3 Modern Languages in Comprehensive Schools
4 Gifted Children in Middle and Comprehensive Secondary Schools
5 The Teaching of Ideas in Geography
6 Mixed Ability Work in Comprehensive Schools
7 The Education of Children in Hospitals for the Mentally Handicapped
8 Developments in the BEd Degree Course
9 Mathematics 5 to 11
10 Community Homes with Education
11 A View of the Curriculum
12 Modern Languages in Further Education
13 Girls and Science
14 Mathematics in the Sixth Form
15 The New Teacher in School

The Education of Children in Hospitals for the Mentally Handicapped

The complete document is presented in this single web page. You can scroll through it or use the following links to go straight to the various sections:

Preface (page 3)
The survey (5)
Conclusions (19)
Appendix (21)

The text of The Education of Children in Hospitals for the Mentally Handicapped was prepared by Derek Gillard and upoaded on 16 Aug 2011.

The Education of Children in Hospitals for the Mentally Handicapped
HMI Series: Matters for Discussion No. 7

London: Her Majesty's Stationery Office 1978
Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.

[title page]

Department of Education and Science

HMI Series: Matters for Discussion 7

The Education of
Children in Hospitals
for the Mentally

A survey of educational provision in sixteen
hospitals for severely mentally handicapped
children carried out by Her Majesty's Inspectors
and a Medical Adviser during the autumn and
spring terms 1976-77.

London: Her Majesty's Stationery Office

[page ii]

The publications in this series are intended to stimulate professional discussion. They are based on HM Inspectors' observation of work in educational institutions and present their thoughts on some of the issues involved. The views expressed are those of the authors and are not necessarily those of the Inspectorate as a whole or of the Department of Education and Science. It is hoped that they will promote debate at all levels so that they can be given due weight when educational developments are being assessed or planned. Nothing which is said in this report should be taken as implying any commitment by the Government to the provision of additional resources.

Crown copyright 1978
First published 1978

ISBN 0 11 270447 6

[page 1]



The survey
Background information5
The children5
School holidays and hours9
Further education and training16
Supporting services16



[page 3]


Education for severely mentally handicapped children in hospital is nothing new. In the 1870s records show that 'patients' in the Royal Eastern Counties and in a few other Institutions were already being provided with a broadly based programme of educational activities, though the most severely handicapped were not usually included. 'Training', which at its best was virtually indistinguishable from education, was later provided for children living at home and attending Training Centres. Nevertheless, a recommendation of a Royal Commission, implemented in the Mental Health Act, 1959, left responsibility for the education of severely mentally handicapped children in the hands of Health rather than Education Authorities; 11 years were to pass before that decision was changed. The Education (Handicapped Children) Act 1970 transferred responsibility for mentally handicapped children from local health authorities to local education authorities. The Act came into force on 1 April 1971.

The consequences were far reaching. All mentally handicapped children were to receive education, however severe the nature and degree of their disabilities. Local Education Authorities became responsible for the provision of services and, later, of buildings comparable with those for other children. Guidance was given in a Joint Circular and in an Education Pamphlet.* New arrangements were made in teacher training establishments for specialised courses of initial teacher training for those intending to work with these children. These courses lead to the award of qualified teacher status, so that those who have successfully completed them are qualified to teach normal pupils in any maintained school.

Additional impetus was given by research into the learning processes of severely handicapped children, the results of which are gradually becoming available. The National Development Group (set up in 1975) has been active in promoting new developments in care and treatment. The recent publication Children living in long stay hospitals† also describes practices observed in some of them.

Though much remains to be done, much has been achieved. The survey undertaken in 1976 and 1977 by HM Inspectorate and a medical adviser to the Department of Education and Science was in the nature of a stocktaking exercise to assess what has been achieved to date and to attempt to define any difficulties still to be resolved, taking into account the rapid and extensive changes now taking place in services for the mentally handicapped.‡ The inspectors and the medical adviser looked at educational arrangements in 16 hospitals, and made individual reports on each hospital school. This publication draws together the findings of their survey in a way which it is hoped will further discussion and development in this important area of special education.

*DES/DHSS Circular The education of mentally handicapped children and young people in hospital, 21 May 1974 (DES Circular 5/74); Educating mentally handicapped children, Education Pamphlet No 60. HMSO. 1975.

Children living in long stay hospitals. Spastics Society 1978.

Better services for the mentally handicapped. CMND 4683. HMSO 1971.

[page 5]

The Survey

This survey was undertaken by a team of four inspectors with particular responsibility in respect of the education of mentally handicapped children, assisted by inspectors based in different parts of the country with special education assignments and by a medical adviser to the Department of Education and Science. Sixteen hospital schools were visited, two from each of the then inspectorate divisions, chosen to provide a wide diversity of size, type and circumstances. The sample represented about a fifth of the total number of hospital schools for mentally handicapped children.

Background information

Only two of the schools visited served children's hospitals: the remaining hospitals provided for residents of all ages. In these, the proportion of beds allocated to children varied: in most cases they represented 7 or 8 per cent of the total. Most hospitals, naturally, provided for the most profoundly handicapped children, but a selection system in one group of hospitals seemed to lead to the placement in one of them of a group of less severely handicapped children who might elsewhere be found in day special schools.

Almost every hospital reported an ageing population. Fewer young children are admitted, but a widespread shortage of places for adolescents was leading to severe pressures on hospitals intended for children to retain young people beyond the age of 16. In addition to these two factors influencing the character of the hospitals there were two others: first, the policy of some hospitals of alleviating overcrowding by reducing the total number of beds; secondly, a growing awareness of the need to provide support for the family of the mentally handicapped child, leading to a policy of increased 'short-term care', though the extent of this tendency was difficult to show statistically. Two hospitals were providing 'phased care', that is, a planned sequence of periods of residence in hospital alternating with residence at home. The educational implications of this system are considerable and some of the problems inherent in it, particularly those of maintaining continuity in the educational programmes, were already becoming apparent. In a few hospitals children were admitted for a short period solely for comprehensive assessment; these children did not always attend the hospital school during their residence in hospital.

The children

Some statistics of the children referred to in the survey are given in the appendix. Of the resident children, 42 were below the age of five years, the largest group of these being resident in one children's hospital. Eighteen of these children were receiving education. Of the children within the statutory limits of school age, all appeared to be receiving some education with the exception of those excluded (often

[page 6]

temporarily) because of medical or severe behavioural problems. The educational arrangements, however, could not always be considered satisfactory. In one school, for example, there were nine children who were receiving only weekly visits from a teacher whose primary responsibility was to review their suitability for school attendance; in another hospital two children were visited for only the last half hour of each school day. These cases were, however, exceptional.

Of young people over the age of 16, about one in three received education in school; some of the others may have been attending classes provided under further education arrangements. In a number of hospitals a small number of pupils over the age of 19 were to be found in school, usually because of the lack of any alternative provision. However, in two instances it was the policy of the education authority to continue to provide education for young persons up to the age of 25. In only one school were 'leaving ages' adjusted to meet the observed needs and developmental maturity of individual pupils; elsewhere, a common leaving age had been decided upon, whether 16, 19 or 25.

In four hospitals an unsatisfactorily high proportion of resident children were receiving less than full time education, because of shortage of accommodation (even with some overcrowding), the use of school places by non-resident children or the retention of pupils over the age of 16 years. In only a very small minority of cases could a medical condition be said to be preventing a child from receiving full-time education.

Procedure for the admission to hospital schools of non-resident children varied from one hospital to another. A consultant psychiatrist often appeared to be involved in the admission of day pupils, sometimes, it would seem, without consultation with local education authorities. Children so admitted seemed usually to be those who had proved difficult or impossible to manage in day schools, or those referred direct by Social Services Departments or by parents expressing a preference for a hospital school.

Non-resident children in hospital schools rarely received specialised treatment other than education and physiotherapy.

The number of children resident in hospital attending day schools elsewhere was small - some 35 in all, though the figure may not be an accurate indication of the full extent of the practice, in that in some instances day school placements had been accompanied by arrangements made for children to live outside the hospital.

While it was difficult to categorise them precisely, children in hospital clearly constitute a very severely and, in many cases, a multiply handicapped group. In about a quarter of the cases severe mental handicap was accompanied by only minor additional disabilities; another quarter of the children presented severe behaviour problems and the remainder suffered from severe physical or sensory handicaps or both.


With two exceptions, heads in the hospital schools visited had all been appointed before 1971. Eight held the Diploma of the Training Council for Teachers of Mentally Handicapped Children: seven had qualified under teacher training arrangements for work with normal

[page 7]

children. One was without a teaching qualification.

Of the 208 teachers in these schools, 53 held no professional qualification. Of the remainder, 76 (of whom 20 were graduates) had qualified under teacher training arrangements for work with normal children, 38 under arrangements made by the Training Council for Teachers of Mentally Handicapped Children and 16 through specialised teacher training courses established since transfer of responsibility for the education of mentally handicapped children from Health to Education authorities. Details of the qualifications of the remainder were not available (eg in the case of supply teachers).

In all but two schools there was at least one unqualified teacher on the staff: in three schools at least half the staff held no teaching qualifications. Thirty per cent of qualified staff had taken courses of initial training which contained no specialist element concerned with severely mentally handicapped children. It was not without interest that teachers who had recently qualified under specialised courses were concentrated in a very small number of schools, perhaps because these schools had links with their local colleges of education.

In four schools recruitment of teachers was said to be difficult for reasons which were said to include poor working conditions and the severity of the demands made by such severely handicapped and often behaviourally disordered children. Geographical isolation appeared to be a contributory factor in a few instances, adding further to the problems of attracting suitable candidates for senior posts.

The great majority of the 167 ancillaries employed in the schools visited held no qualifications. In one school, however, every ancillary held a certificate of the National Nursery Examination Board.

Many of the schools played a useful part in providing practical experience for both nurses and teachers in training. Twelve regularly accepted student teachers; eleven, student nurses. In only a small minority of cases did the training programme provided for student nurses appear to be well conceived.

Voluntary helpers were welcomed in 12 schools; in half of them some of the help was provided by secondary school pupils taking various kinds of community service courses. Adult help seemed usually to be forthcoming for swimming and riding lessons.

The ratio of adults (excluding voluntary helpers, but including head teachers) to pupils was usually at least adequate and in many cases generous. Teacher/pupil ratios varied from one to five at best to one to eleven at worst; those for ancillaries ranged from one to six to one to thirteen, with two exceptions where the ratios were one to twenty and one to fifty-two respectively. The mean ratio of teachers to pupils was one to eight and that of ancillaries one to ten.


Though some improvements have recently been made, the task of bringing premises up to good modern standards has yet to be undertaken. In almost every hospital, the school premises had shortcomings. In only five schools were there places for all the

[page 8]

children resident in the hospital; in two hospitals the number of children receiving education on the wards, often in less than ideal conditions, was substantial. In some instances hospital premises had of necessity been brought into use, though these were rarely suitable. Only four schools enjoyed the exclusive use of a hall; six others had shared use of a comparable space provided by the hospital. Six had no such provision.

The design of existing premises rarely met the needs of the increasing proportion of severely multiply handicapped children found in them nor did it, in general, enable teachers to adopt up-to-date educational approaches, even when recent extensions had been made. Poor toilet facilities and inadequate facilities for changing and cleaning children were common. Even where a sufficient number of toilets existed they often lacked privacy or were inconveniently sited. Several bathing and changing areas were cold and inadequately heated. Commodes or chamber pots were in use in classrooms in about one-third of the schools. Disposal of soiled napkins or tissues posed problems in several schools.

Small classrooms (often without sinks and running water), the lack of withdrawal spaces, inadequate storage space (particularly for large items of equipment) were features characteristic of about two-thirds of the schools. Facilities for practical work were to be found in only a few schools, though it must be recognised that the need for them is tending to diminish with the increasing severity of the conditions handicapping the children. However, where there were more able children, the lack of such facilities impeded attempts to provide a realistic training in the skills of daily living. Only two or three schools had fully satisfactory outdoor play areas.

In six schools, accommodation for the staff had been improved since 1971, but in at least as many toilet provision was extremely poor; in one school there were no toilet facilities for the exclusive use of the staff.

The standards of hospital school premises were generally felt to fall short of the quality of provision made elsewhere in the education service.


In all the schools included in the survey, equipment and materials were available on an adequate or even generous scale with, in many cases, considerable improvements made in the last few years. A number of schools recorded useful additions to their resources made by voluntary organisations, by the personnel of a local Royal Air Force station or by members of the staff themselves.

Capitation allowances were usually made according to age, with additional allocations, in some instances, for equipment for multiply-handicapped children, for cookery, library books or toys. Allowances averaged 18 a head but ranged from approximately 10 per head for younger children to an upper figure of 90, though the latter was exceptional and granted only for children in a 'special care unit'. Occasional references were made to shortages of materials, particularly for creative work, though these might possibly be attributed to limited imagination shown in requisitioning rather than to limited funds. Audio-visual equipment was usually provided on a

[page 9]

generous scale; in only one school could it be described as meagre. In eight schools equipment was unusually comprehensive; in two, lavish. One school had three television sets, slide and film strip projectors, record players, cassette recorders, radios, epidiascope, cine projector, overhead projector, Language Masters and both cine and instamatic cameras. Additional audio-visual apparatus was said to be available at a local teachers' centre if required. Two schools had the use of video-tape recorders. However, only in rare instances during the survey were aids seen in use, suggesting that much of the equipment available was seriously under-used. There could be various reasons for this: the fact that equipment was sometimes kept safely, but inaccessibly, in a central store, causing transport problems when needed elsewhere, the feeling of inadequacy experienced by many teachers when using such devices, failure to recognise their educational potential, or difficulties in using equipment with a group of difficult children unless ancillary help was available.

Apparatus or equipment designed especially for mentally handicapped children was found in a number of schools, some designed by teachers, some devised by physiotherapists and made in the workshops of local secondary schools. In one instance students at a local university had designed and made a number of technical devices. A few schools had the use of furniture and equipment or sophisticated apparatus designed and developed by the hospital authorities.

Equipment for physical education and home economics was limited, conveying the impression that resources were only slowly being accumulated. Cooking utensils and equipment in one school could only be described as primitive; in four schools limitations of space restricted the use of apparatus for physical education. There was frequently a deficiency of furniture designed for the use of pupils with severe physical disabilities. Difficulties were commonly experienced because furniture and equipment designed some years ago was proving unsuitable for the more severely handicapped children now using it.

School holidays and hours

In 11 schools the dates of school holidays conformed to those laid down by the education authorities for the rest of its schools. In two schools, staff holidays were arranged so as to enable the school to remain open for some 48 weeks a year; in two others arrangements were made to reduce the length of the summer holiday; in one school a four term year was in operation. Play schemes were in operation in seven hospitals during the summer holidays; in three of these, nurses, student teachers and voluntary workers provided the staff; in three, teachers were employed; in the seventh, a psychologist was in charge of a team provided under a 'job creation scheme'.

In at least a third of the schools, full use was not made of the educational opportunities available; children arrived late and were withdrawn before the end of both morning and afternoon sessions. In at least two schools, in order to relieve staff shortages on the wards, teachers were performing during school hours tasks normally carried out by nurses. In one school a considerable amount of school time was wasted while children returned to wards at every break in the school day.

[page 10]


Even apart from those instances where the organisation was dictated by hospital arrangements or by inadequacies of school premises, the principles employed to determine the organisation varied. Pupils in well over half of the schools were grouped according to one or other of the following factors, either alone or in combination: ability, maturity, attainments or the nature and extent of their disabilities, the object being to create manageable groups. Special classes for children with certain specific conditions were found in the majority of schools; there were those for blind, deaf, deaf-blind, multi-handicapped, chair-bound, immobile, physically handicapped, profoundly handicapped and those described as being in need of 'special care'. Age and maturity were the primary consideration in composing classes in some schools, in order to impart some sense of progression to the organisation as pupils grew older. Such progression was not easily achieved in classes where the nature of the handicap was the dominant factor. In two schools, at least, one with special classes for children with severe behaviour problems and the other with special classes for children with communication difficulties, the arrangements seemed counterproductive, accentuating rather than diminishing the problems of the group. In half the schools attention was paid, in composing teaching groups, to the degree of compatibility between a child and his teacher; this was considered of particular benefit to children with emotional problems. In such cases a child was often allowed to remain with the same teacher over a number of years.

In many cases, with other criteria overriding chronological age, the range of ages within some classes was wide. This was not a particularly serious problem when the nature and severity of pupils' disabilities virtually excluded group activities, but difficulties caused by a wide disparity in maturity were noted in six schools where classes with an age range of 5-15, 7-18, 7-21, 9-18, 5-16 (the last in two classes of children receiving short term care) and '11 years age range' were found. Not surprisingly, it was the youngest children, and to a lesser extent the oldest, who suffered most from such wide groupings.

Because of the absence of complete returns and the difficulty of taking into account, for example, changes in groupings for special activities, it was impossible to generalise with any accuracy about the size of classes. The two largest groups reported each consisted of 14 pupils taken by two teachers; the smallest, a class of three, was composed of particularly difficult hyperkinetic children. The average size of classes appeared to be about eight.

In some instances movement between groups was deliberately restricted in order to preserve a stable environment which would foster close personal relationships. Transfers from one class to another were usually made when it was considered in a pupil's interest ('according to pupils' progress'; 'where they will get most benefit'), but occasionally adjustments had to be made to accommodate new entrants or when older pupils moved out of the school. In some instances the organisation of pupils was dictated by the size of the classroom.

Where specialist subject teachers were available, some degree or specialisation within the timetable was usually found; and for such

[page 11]

activities, regrouping of children commonly occurred. Instances of this were reported in over half of the schools included in the survey for such activities as physical education, music, art, cookery, swimming or riding. In one school regrouping occurred every afternoon 'to help children integrate and spread difficult children'. In two others, classes were arranged in two major groupings with their own teams of teachers and a senior teacher in charge of each. In one of these the organisation permitted the amalgamation of classes whenever appropriate, so enabling one or more teachers to spend time with individuals or small groups. In the second, stress was laid on the organisation of different activities by each teacher in the team, so reducing the amount of contact any teacher had with individual children in her personal group. In yet another school, about half of the children had personal programmes offering individual teaching at certain times and membership of groups of varying sizes at others.

Individually programmed work is developing only slowly; in three schools this approach is firmly established, but not yet extensively implemented. In the majority of schools, teachers claimed to give individual help for at least some time every day within the class setting. Where an ancillary was available this was clearly possible; in three schools, teachers asserted that no individual work could be attempted as no assistant was present to supervise the rest of the group and to deal with contingencies.

Since 1971, most of the schools have benefited not only from significant improvements in staffing ratios, but also from the establishment of posts of special responsibility and the introduction of deputy head teachers. Teachers appointed to these senior posts were not always wisely deployed. In five schools their duties were almost exclusively administrative and occasionally trivial, so preventing them from making a major contribution to educational planning and development and to in-service training.


The concern of the schools to enable their severely handicapped pupils to lead a satisfying life within whatever adult society they might find themselves in is reflected in the emphasis given to social competence in the formulation of their educational aims. "To improve pupils' lives by developing the skills which increase adaptability, autonomy, acceptability, with emphasis on self-help, social and linguistic development" was one expression of purpose which could stand for many. A number of schools also expressed more generalised aims such as "the development of children by means of a curriculum which is emotionally satisfying, intellectually stimulating, socially valuable and individually planned"; "to develop intellectual powers to their fullest extent"; "to develop potential to the fullest extent". The concept of normality was clearly influential. One school claimed to provide, somewhat ambitiously, "as near normal an education as possible". Only one school staled that one of its specific aims was to enable pupils to transfer to schools within the community by decreasing the severity of behavioural disorders. The aspirations of the schools were often summarised in terms which might have been applied to any type of school, as for example, "to

[page 12]

enable each child to develop his potential so that he can, as far as possible, become an acceptable member of society".

Aims expressed in these general terms were the only basis for curricular planning in most schools. It was apparent from the survey that modern theories of the curriculum had hardly begun to influence these schools. The formulation of precisely defined objectives (particularly important to the teaching of mentally handicapped children) was to be found in only two schools and even so only to a limited extent. The curriculum was usually conceived in terms of a programme of activities designed in accordance with what were generally considered to be the needs of severely mentally handicapped children in general.

Record keeping was widely developed though there were variations in quality as well as style. In some instances teachers recorded their observations in ways based on their knowledge of individual children's developmental sequences; more commonly, the Gunzberg Progress Assessment Charts were used. In other cases only broad descriptive impressions were recorded.

The concept of precise and comprehensive assessment used as a basis for the construction of programmes designed to meet the priority needs of each child was growing only slowly. This practice was fully operative in only two schools and on a limited scale in four or five others. In one school, individual assessments were used to prescribe treatment in the 'special care clinic', but had still to be extended to planning classwork elsewhere in the school. In another school where precise assessments were made (in one instance by the Head in conjunction with a medical officer) little use was made of them for planning educational strategies. In yet another school there was some reason to question whether comprehensive assessment had been carried out at any stage; certainly no information reached teachers.

The help given to individual children was, with a few exceptions, given as part of a group activity within the regular classrooms. Even in the six or seven schools where individual programmes were being developed, there was only limited understanding of 'short-term objectives'. The frequent findings that "no programmes are defined in writing" must give rise to concern. A commercially produced individual programme was found in use in one school. The more precise programmes which were in use were proving beneficial to the children and rewarding to their teachers; because they were more carefully defined they helped teachers to perceive over a short period of time small but positive signs of progress which otherwise might have been imperceptible.

An interesting example of work was seen in one hospital school where a selected group of children were being taught by one teacher and an aide. This group of children between the ages of 11 and 17 were all able to speak and understand simple language. The classroom was colourful with well-displayed pupils' work and well-presented teaching materials. There were three activity/resource areas: a social area in which cookery was possible; an area with tables and desks for educational and training activities, and a more open area where art and craft activities were carried on. Within each area materials for different activities were neatly arranged in view

[page 13]

and readily accessible.

The programme of activities was realistic and practical. A good deal of time was spent on educational visits in a minibus to see something of the world outside the hospital, and, where appropriate, to engage in normal activities such as shopping, visiting the swimming baths, playing in the park. Within the hospital school time was spent on developing gross and fine motor activities, on swimming, on elementary communication, personal hygiene and the acquisition of acceptable eating habits. The work inside and outside the school was characterised by careful planning and a sense of purpose. Both teacher and aide had immediate access to records which charted individual progress and indicated the next step, together with methods by which it might be achieved. Three types of record were kept in the classroom: a record of events in diary form, a developmental check list, and a record of overall development which described the individual in the round. The role which records played was important. They did not simply register achievement; they defined teaching objectives, described appropriate learning experiences and gave an indication of methods which might be helpful. Recording and planning was a joint process for teacher and aide: consequently both had a sense of direction and were able to take positive action towards agreed ends. The use of bar graphs to mark off progress was found to give a quick indication of a child's current achievement, and to facilitate decisions about objectives and activities. The records also served as an aid to memory, to ensure that essential items had not been overlooked.

The programme placed great emphasis on social development, with attention to language and the skills of literacy and numeracy as essential aspects of social competence. Within this programme, however, a substantial amount of time was given to artistic and creative activities. These included music and the exploration of a wide range of media in art and craft. The artistic and creative work not only reinforced verbal learning (which pupils found difficult), but seemed to act as a spur to communication. It was impressive to see even those children with a very limited command of language attempting to talk about their work. The pattern of working also promoted independence, since pupils were encouraged to select for themselves within the activity areas the equipment and materials they needed. Teacher direction of the small groups in these areas was discreet and unobtrusive, inducing in the pupils the idea of doing things for themselves.

In a few schools, behaviour modification was an approach being used with individual children. In three schools it was being employed with selected children under the guidance of a clinical psychologist. In one instance a developmental check list had been prepared by the psychologist; this was being used as the basis for systematic planning and evaluation. The method was proving of value in helping teachers to plan suitable educational approaches and to see at a glance how a child was progressing. Even in the early stages of its use the method was said to have given work in these schools a new direction and a sense of purpose. In one school, in particular, this method had been employed without impoverishment of the children's educational activities, for a skilful balance had been maintained between this aspect of tile work and group and creative activities.

[page 14]

The role of head is generally regarded as crucial. In this respect, the survey gave cause for concern, for it clearly showed the degree to which administrative responsibilities had come to exclude educational oversight. In only three schools in the survey could the head be said to be closely concerned with detailed planning of the curriculum and with devising programmes of work for individual children, including the most profoundly handicapped. In two schools the head arranged regular courses of in-service training (including workshops) for the staff, in one instance involving other interested professionals. In many schools, however, the head teacher appeared to exert little influence on the curriculum apart from determining broad areas of activity. In about a quarter of the schools, responsibility for the curriculum was delegated to members of staff; detailed planning was usually left to individual teachers, any coordination between classes being achieved largely through informal discussions in the staff room. Administrative responsibilities clearly cannot be ignored, but the evidence from this survey suggested that some of these, at least, might be better delegated to enable heads to undertake a more direct responsibility for educational planning and innovation.

At a time when hospitals have attracted attention on account of the deprivation they can inflict on the lives of the residents, the efforts made by teachers to extend and enrich the lives of the children in these schools are worthy of note. Eleven of the schools combined a range of interesting experiences in school with a programme of varied activities outside. Cookery, music, swimming, painting and creative work of several kinds were included in the curriculum of most schools, supplemented by riding, membership of local youth clubs or playgroups, visits to shops, parks, cafes, motorway service areas and other places of interest to the children. One school claimed "a pronounced outward orientation", with the professed intention of involving the children in the community to the greatest possible extent. A private dwelling house had been made available and regular visits were paid to it to give older pupils experience of living and working in a house rather than an institution. Regrettably, not all schools were so fortunate in their resources or so imaginative in their outlook. In four schools, the children had only weekly or fortnightly outings in the minibus; in three instances comments such as "little beyond the school premises" tell their own story of limited horizons.

Though teachers and nurses enjoyed friendly relationships in most schools and in some shared recreational activities, instances of a joint professional approach to meeting the manifold and complex needs of these severely handicapped children were rare. One or two instances were recorded of a coordinated approach to feeding and toilet training; in one hospital, nursing staff were said to take part in group activities on the wards. In a number of hospitals, teachers and nurses shared the responsibility of escorting children to and from the wards. Instances of fuller professional cooperation, however, seemed to depend not upon any deliberate policy, but upon the enlightened attitudes of individuals who were prepared to work closely together to a common end. But these instances were exceptional. "Hardly at all", "not at all" were the commonest phrases used to describe the degree of cooperation observed.

[page 15]

In a number of hospitals teaching takes place in the ward in which the pupils live. An example of promising practice in one such hospital illustrates the need for very close collaboration between medical, nursing and teaching staff.

In this hospital 13 pupils aged between 8 and 16 years were placed in the same ward on medical criteria. They were ambulant, and disturbed in their behaviour, varying from marked withdrawal and passivity to impulsiveness and hyperactivity. Bizarre behaviour was commonplace and the teacher was faced on the one hand with eliciting a minimal response and on the other with containing wildly uncontrolled behaviour. The group presented a diverse and complex array of educational need, varying with ages and with degree of handicap.

A genuine multi-disciplinary approach was adopted, and the organisation encouraged teachers, nurses and aides to work as a team. Joint in-service training sessions gave all the staff concerned a chance to state their views and to form a common policy based both on the developmental schedule drawn up by the hospital's psychologists and on the educational objectives set by the teachers.

The accommodation was not good. It consisted of three substandard verandah-type rooms, together with shared use of a large partitioned classroom/playroom. There were inadequate storage facilities. There was however enough space to allow the group to be split and to allow areas to be set aside for different activities.

The nature and duration of work with these pupils was very much conditioned by their emotional states: planned activities often had to be abandoned when a child became uncooperative. Opportunities had to be seized as they presented themselves, and activities suited to the needs of the pupil had to be offered spontaneously.

Work with the pupils included artistic and expressive activities as well as more structured ones linked to developmental programmes. The work was mainly individual, even where a small group could be engaged in the same activity, such as painting or clay modelling. In the play area, however, children practised throwing, kicking and catching a large ball, in a successful small group activity with an adult. They were also grouped when they played percussion instruments.

In addition, pupils were working on such tasks as threading beads, completing simple form-boards, copying a model made of building blocks, and freer constructive building with plastic bricks.

Some activities were specifically programmed for individual pupils working with an aide. For example, within a structured language programme, which was followed with some rigour, the aide asked the pupil to select one toy from a group of toys.

Nurses, aides and the teacher showed themselves to be very adept at containing and redirecting a disruptive child. In order to engage such a child in a fresh activity, the adult had to know what the child could do and what would be likely to absorb his attention; she also had to have resources immediately available to support that activity.

Cooperation extended to the use by teaching and nursing staff of a shared record book. Bar graphs and written observations contributed to the usefulness of the records. Under these circumstances teachers, nurses and aides were able to adopt an effective team

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approach in the ward classroom with a very difficult group of pupils.

In many schools therapists were also evolving ways of coordinating their work more closely with that of the teachers. In several schools physiotherapists worked alongside teachers in the classroom and in others cooperated with the teachers in planning remedial programmes of physical education. In one or two instances, speech therapists prepared programmes for individual children which teachers helped to implement.

Further education and training

Though the survey was essentially concerned with the education of children of statutory school age, it proved impossible entirely to ignore what opportunities for further education and training lay ahead in the years immediately following school - years for which so much of the later schooling had formed a preparation.

In 11 hospitals, further training opportunities were said by heads to be limited, in three, non-existent; in only two were they reasonably extensive. Leavers' assessment conferences were held in some 30 per cent of the schools. Links with colleges of further education were rare: in five hospitals classes which were arranged or about to be arranged by local adult education institutes included reading, writing and arithmetic, cookery, physical education and creative work. A constructive working partnership to achieve continuity between schools and training units appears as yet far off. Some continuity between schools and adult education, however, was achieved, particularly where the same group of teachers was involved.

Though detailed evidence was hard to come by, the information available suggested that fewer than half of those leaving school received either further education or training in hospital workshops or elsewhere. In only one hospital had all school leavers during the last two years passed on to some other form of training; at the other extreme as few as two out of 37 had been given similar opportunities. Teachers in almost every school expressed concern at this situation and revealed a sense of frustration over the fact that these young people seemed likely to deteriorate immediately after leaving school for want of a suitable occupation.

Supporting services

In the education and management of severely handicapped children, teachers are more than usually in need of advice and support from consultant and advisory services. However, this survey of the services available showed them to be uneven, surprisingly uncoordinated and in some cases seriously deficient. Two schools reported no advisory visits from specialists of any kind. Two enjoyed comprehensive, but apparently unrelated, supportive help from psychologists employed by hospitals and from those employed by local education authorities, while three others had none. Visits from psychiatrists were not frequent, and made almost exclusively by hospital-based consultants: one school, however, received regular visits from a psychiatrist in the community health service as well as from a hospital consultant.

The major source of support in most schools came from hospital

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departments. Ten schools received advice from clinical psychologists who helped either in assessment, in formulating educational procedures or in evolving special approaches for children with severe behaviour disorders. Consultant psychiatrists were a source or support to some schools. The constructive help and advice given by hospital physiotherapy departments was referred to by teachers in appreciative terms in ten schools, in some of which a truly interdisciplinary approach seems to have been achieved. The paucity or speech therapists reflected the national shortage: only three schools enjoyed an adequate service, and in all three, teachers and therapists were said to work closely and harmoniously together.

Supportive services provided by local education authorities were less comprehensive and less intensive. Four schools reported visits by educational psychologists, but only two of them found the service provided adequate and effective. Three schools were highly appreciative of continuing and constructive advice provided by the local authority's adviser for special education; four others received only occasional visits. About a third of the schools recorded visits from other specialist advisers. One serious deficiency, in view of the substantial number of children with sensory impairments, was the absence of specialist advice in dealing with such problems. Only three schools reported regular visits from peripatetic teachers of the deaf.

The community health service appeared to play only a minor part in the oversight of mentally handicapped children in hospital schools. A school health service was operating in only four schools. In some, only the non-resident children were seen for medical inspection, visual and audiology screening and immunisation. There was for most resident children no routine screening for vision or hearing, but children with suspected sensory defects were referred by the school to hospital staff who arrange for further investigation. Only one school had easy access to the audiometric and ophthalmological services of the community health service. Three schools received regular or occasional visits from paediatricians or other doctors, one from a psychiatrist from the Child Guidance Clinic and one from a psychologist whose help was spoken of in appreciative terms.

While most of the schools reported that case conferences were held, only two reported regular, multi-disciplinary case conferences resulting in defined targets; both found them of considerable value in enhancing their understanding of the children and in helping to indicate suitable educational approaches. One welcome instance of the interrelation of local education authority and hospital services has already been mentioned, in which a clinical and an educational psychologist collaborated in providing a course of in-service training for teacher and nurses together.

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In 1971 there were approximately 8,000 children resident in hospitals for the mentally handicapped; at the present time there are some 4,500.* This number is continuing to fall, partly because of a growing reluctance to admit young children and an understandable wish to avoid weakening the bonds between a child and his family; partly because of other factors. It seems likely that although there will, in the foreseeable future, still be a need for a certain number of places in hospitals for mentally handicapped children, they are likely to be occupied by the older and most severely handicapped children with complex disorders, and by others (an increasing number) admitted periodically either for medical treatment or in order to provide relief and support for their parents. Even now the children in hospital present complex problems both of education and management, demanding a coordinated approach to the alleviation of their difficulties. At the same time, there is growing awareness of the value of continuing education into adolescent and adult years.

The present survey shows that the years following transfer of responsibility have seen a number of changes and improvements in the educational provision made for severely mentally handicapped children in hospital, most of which might broadly be seen as prerequisites to educational advance.

In the first place every child, with the exception of those children withdrawn, sometimes temporarily, for medical reasons or on account of severe behaviour disorders, is now receiving some education, though this is not always adequate in extent nor provided in satisfactory conditions. Next, staffing ratios have been improved, in some cases dramatically, and there has been a substantial increase in the proportion of qualified teachers employed. The number of teachers who have qualified by taking a three year course of specialised training is gradually increasing, and many are making a valuable contribution to education in the schools in which they serve. Substantial improvements to the quantity and quality of equipment and materials have been made. These are all positive advances.

But a number of problems, some urgent and some long term, remain to be resolved. These may be summarised as follows:-

a) Some 25 per cent of teachers in post are still without qualifications. Many have served in their present capacity for many years; some by reason of their natural teaching gifts are giving good service. A substantial proportion of those who are qualified have not undergone training specifically designed for teachers of mentally handicapped children. Although a few education authorities and heads themselves have arranged courses of inservice training, the extent of the need for such training remains great.

b) In most hospitals, school premises have shortcomings, some of

*Mentally handicapped children: a plan for action. National Development Group for the Mentally Handicapped. Pamphlet 2. March 1977.

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them serious ones. A number of schools still have to attempt to provide education in difficult conditions on the wards, on account of a shortage of places in the school building: for the same reason some children cannot be provided with full-time education. But the main fact to emerge is that premises built some years ago no longer provide adequately for the far more severely handicapped group of children now using them; and the general impression is that standards of provision, particularly in toilet facilities, fall somewhat below those considered acceptable for children in other kinds of special schools. There is an urgent need for up-to-date reappraisal of needs in the light of changed circumstances, and for some priority to be given to carrying out a programme of improvements when the necessary financial resources become available.

c) The educational problems presented by these very severely handicapped children are in some ways new. While many schools have extended the range of the children's experience, have improved the quality of their life and are providing an admirably high standard of care, very few have made clear their objectives on the lines of recent developments in curriculum theory; equally few are providing specific programmes designed to meet the needs of individual children based on a continuing assessment of their progress.

d) If new approaches such as these are to become more widespread, teachers engaged in this exacting and often most exhausting field of work need far more help from local education authority advisory services than they at present receive. The evidence of this survey suggests that the services available are uneven, almost invariably uncoordinated and in some cases seriously deficient.

e) A truly inter-professional approach to the problems of these children appears to be elusive. While the schools in most cases seem well accepted in the hospitals, with teachers enjoying good social relationships with nurses and other hospital staff, only occasionally, and then only in individual instances, are nurses and teachers found to be adopting an agreed and consistent approach to meeting the developmental needs of the children.

Hopes for the future must be set in the context of changing attitudes towards residential care of mentally handicapped children. There are those who foresee the disappearance of the large hospitals for the mentally handicapped and their replacement by small residential units; others, stressing the importance of maintaining family relationships. would wish to retain the child in the family, strengthened by supporting services and by the assurance of short term residential care, if necessary, in hospital. Developments such as these, which are already taking place in some areas, will confront teachers with new challenges calling for new skills and changing professional attitudes to meet the needs of the very severely handicapped group of children now coming into hospital. Currently inadequate support services will have to be considerably strengthened, and greater efforts made to ensure that the teachers become a recognised and respected part of the professional team with frequent opportunities to maintain and extend their own professional skills.

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Table 1 Numbers of children receiving education in 16 hospital schools

Table 2 Numbers of children receiving education mainly on wards

Table 3 Numbers of non-resident children receiving education in 16 hospitals

Table 4 Number of resident children receiving education elsewhere than in the hospital