Dr. TRAMONTI. This will indicate why we are in complete agreement with the statement found in the report of the President's Panel on Mental Retardation as follows: All professional personnel should be oriented to the special needs of the retarded. Physical and emotional handicaps are common among the retarded and require early detection and competent treatment. The retarded child is subject to all of the diseases and health hazards to which the intellectually normal child is heir. In addition, his problems of retardation are frequently complicated by such serious conditions as cerebral palsy or epilepsy, speech, hearing, visual disorders, and dental defects. Based on my own experience there is no question but that mental and visual or perceptual development are directly related. It is therefore essential that at an early age a child who has a visual problem should be given attention in order to improve that child's visual capabilities even before school age. We all realize the importance of vision but may overlook its importance to the preschool child. At birth the infant's eyes and visual mechanism are far ahead of any other pattern of growth and develop ment. His eyes are 75 percent of adult size at the time of birth. Seven years later the visual apparatus is its adult size while the remainder of the body continues in growth for almost 15 more years. Vision leads the child's growth pattern. As he mouths an object, bangs it to hear the sounds, pokes at it, feels it in the palm of his hands and tips of his fingers, as he throws it into space and feels it with his whole body, he is exploring the world and the space about him. Soon he learns to discriminate primarily with his vision. A child is born with the mechanism for vision but he must learn to use it. Dr. Arnold Geselle, formerly of the Geselle Institute of Child Development, New Haven, Conn., with which our association has worked closely, said "to understand the total child you must understand vision, to understand vision, you must understand the total child.” I like to put it this way: The child unable to experience a normal visual perceptual growth pattern will not experience normal growth patterns; a child unable to experience normal growth pattern is not able to experience a normal visual perceptual pattern. In other words, the two go hand in hand. In other words, vision and growth are simultaneous. For the last 7 years, I have been closely associated with medical and medically allied professional disciplines related to child development, primarily in the field of cerebral dysfunction, with manifestations of impaired neurological function such as neuromotor, intellectual, sensory, behavioral and perceptual disorders. These may be found singly or in combination, and in varying degrees. There can be a combination of physical and intellectual impairment. There are many children with slight subtle signs of neurological impairment and normal IQ but functioning at such a low level of performance and school achievement as to be regarded as retarded. I think that sentence is so important, I would like to repeat it. There are many children with slight subtle signs of neurological impairment and normal IQ but functioning at such a low level of performance and school achievement as to be regarded as retarded. My interest and work in these fields has been in the investigation of the visual perceptual problems of retarded children. It is said that vision is the result of a very simple eye and a very complex brain. A visual sensation is that which the eye sees but the mental modification of this sensation is visual perception. Formal and informal experimentation in this area has been carried out. At the Meeting Street School, Children's Rehabilitation Center, and also with private patients from the pediatric practice of a prominent physician in Providence, R.I., we worked with children who were greatly retarded in school performance and were showing achievement considerably below their intellectual potential. Both with cerebral palsied children and with children who showed no signs of gross organic pathology, in a high proportion of cases we found significant improvement in school performance following a period of visual perceptual training. In considering preliminary findings, it appeared essential that at least one phase of our problem be conducted in the Bradley Hospital setting where all the patients are seen in individual psychotherapy. A pilot study has been carried out in the attempt to discover if the visual-perceptual diagnostic procedure could predict which of the patients were school problems. On the basis of this procedure the children were classified into groups labeled "perceptual problem" and "no perceptual problem." The testing and diagnosis were done completely independently of knowledge of such factors as IQ, psychiatric and neurological diagnoses, personality testing, or school record. When the visual perceptual findings were related to school performances, it was found that in the "perceptual problem" group 55 percent were at least 2 years retarded in reading, according to formal school tests, and only 26 percent of the "no perceptual problem" group were retarded in reading to such an extent. A more striking finding was that 50 percent of the children in the "perceptual problem" group were at least 2 years retarded in arithmetic, while no cases in the "no perceptual problem" group were so retarded in arithmetic. Another interesting finding was that between the results of psychological testing and the perceptual capabilities of the patient. On the basis of the overall psychological test, the psychologists made the diagnosis of "signs of organic impairment." Of the former group, 50 percent were independently diagnosed on the basis of visual perceptual tests, as being in the "perceptual problem" group, while only 11 percent were found to be in the "no perceptual problem" group. This work has brought me into a team of dedicated workers-pediatricians, neurologists, orthopedists, psychologists, psychiatrists, otologists, social workers occupational, speech and hearing, physical therapists, teachers, and other professional personnel. I cannot overemphasize the importance of this total team approach for dynamic goals in the diagnoses and treatment of these children. Diagnostic and treatment centers, outpatient or resident, are a physical necessity which you can help to supply. It is in the public interest that all professions should work together. The important contribution which our profession has made to improving the mental development of a child through visual training and the use of lenses is frequently overlooked and sometimes even denied. We are pleased to note that the National Institute of Child Health and Human Development, which was authorized by the 87th Congress, is beginning to function and that its program will provide "an additional resource for attacks on the causes and prevention of mental retardation in the context of the basic processes of human development" (mental retardation program of the U.S. Department of Health, Education, and Welfare, fiscal year 1964). This very excellent overall program of the Department also includes a demonstration training center for medical and allied professional personnel, as well as the development of a demonstration service center for a comprehensive community approach to mental retardation, through the Bureau of State Services. As far as we are aware, the optometric profession has not been brought into these programs, but we believe that eventually they will, and the sooner it is accomplished the better. This statement has dealt primarily with vision problems of children because that is the area in which I have specialized. However, our profession is also working extensively in providing vision care for the aged and the partially sighted. Even among adults and particularly among the aged, visual performance frequently has a direct bearing on mental health. By means of subnormal vision aids, such as telescopic and microscopic lenses, as well as by means of contact lenses, our profession has rendered an important service to adults and particularly to the aged and infirm, as well as to children. The bills as introduced, while they do not specifically provide for the utilization of the services of optometrists, are broad enough in their language to provide such services. We believe it would be helpful if the committee, in making its report, would deem it appropriate to mention the importance of vision in combating mental retardation and improving mental health and at the same time indicating the congressional intent that optometrists should be part of the team which will be organized to carry out the provisions of these two bills. While sitting here this morning and this afternoon I was aware of the fact that most of the speakers mentioned institutionalization. Dr. Pratt made a statement saying that by 1970 more than one-half of the mentally retarded persons in this country will be children. Now, when the time comes, are we going to appropriate more money to institutionalize these children, or are we going to do something to habilitate as well as rehabilitate them and prevent them from going into institutions, and to make them capable of going to normal schools and earning a normal livelihood? It has been my privilege to appear before this committee, for which I am grateful. If there are any questions you would like to ask, I will endeavor to answer them at this time. Mr. O'BRIEN (now presiding). Thank you very much, Doctor. 98493-63- -21 I take it it is your considered belief that faulty vision uncorrected can either cause a child to be retarded or to give the appearance of being retarded? Dr. TRAMONTI. No, that is not exactly right, Mr. Chairman. You notice that in my report I say visual perceptual difficulties and not vision difficulties. Visual perceptual difficulty as referred to is what the child or what the patient understands or the meaning he gets from what he sees. Many of the children we see and work with have perfect vision, if 20/20 vision is understood to be perfect vision. A child may have 20/20 vision and still have a visual perceptual problem. Correcting a vision problem is a very simple matter compared to correcting a visual perceptual problem in the mentally retarded. But the visual perceptual disorders and I am sure that anyone here dealing with children who has seen or who knows perceptual visual problems will agree that we do not know very much about it, and there is a great deal to learn. And there is tremendous room for research in this area. Mr. O'BRIEN. We are very grateful to you, Doctor. And I am sure the committee will give full consideration to the recommendations you give. And I would just like to say one more thing before adjourning this hearing and I apologize for Mr. Roberts, who had an emergency call that in my time here in Washington I don't think I have ever seen legislation supported by such a distinguished and unselfish group of our citizens, and I know that the full committee is most grateful to all who have testified. Thank you, Doctor. And the hearing is adjourned. (Whereupon, at 4:15 p.m., the subcommittee adjourned, to reconvene at 10 a.m., Thursday, March 28, 1963.) え MENTAL HEALTH THURSDAY, MARCH 28, 1963 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTH AND SAFETY OF THE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D.C. The subcommittee met at 10 a.m., pursuant to call, in room 1334, Longworth Building, Hon. Kenneth A. Roberts (chairman of the subcommittee) presiding. Mr. ROBERTS. The subcommittee will please be in order. Our first witness today will be the Honorable Mr. Farbstein, our colleague from New York, who has introduced H.R. 3939 and H.R. 3940, which are identical to H.R. 3688 and H.R. 3689. Mr. Farbstein we are indeed happy to have you with us. STATEMENT OF HON. LEONARD FARBSTEIN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW YORK Mr. FARBSTEIN. Thank you Mr. Chairman. I appear before your committee today to offer my unqualified support for H.R. 3688 and H.R. 3689, identical with my bills H.R. 3939 and H.R. 3940—in my estimation two top priority bills that deserve immediate consideration and passage to help the mentally ill and retarded of our Nation. In the last decade a great deal has been done to dredge up from oblivion the fact about the horribly debilitating conditions that these people are forced to subsist in through sheer neglect. Moreover, these facts, unlike the persons they describe, have not been relegated to oblivion or remained the secret of an inarticulate few, they have been the subject of articles in some of the country's major magazines, the basis of a fervent appeal by hopeful parents and relatives and finally, the last few years, the testimony of the President of the United States for the absolute need for change and a new approach toward treating the mentally ill and retarded. For example, on February 5, he said: This situation has been tolerated far too long. It has troubled our national conscience, but only as a problem unpleasant to mention, easy to postpone, and despairing of solution. The Federal Government, despite the nationwide impact of the problem, has largely left the solutions up to the States. The States have depended on custodial hospitals and homes. Many such hospitals and homes have been shamefully understaffed, overcrowded, unpleasant institutions from which death too often provided the only firm hope of release. But the President not only offered testimony, he also outlined a solution. And, as we all know, the two bills before your committee are an important part-the actual backbone of that solution. H.R. 3688, and my bill H.R. 3939, would provide for assistance in both the construction and initial operation and staffing of community |