Dental health is, of course, an integral and essential element of total health. The dental profession has become increasingly concerned over the problem of assuring that dental illnesses and dental diseases are not overlooked in the treatment and rehabilitation of patients afflicted with mental illnesses; mentally retarded children are of particular concern.

The President's Panel on Mental Retardation noted that the physical and emotional needs of the retarded frequently are neglected and that adequate treatment of these needs is essential to their total well-being. The panel noted further that:

"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."

The association believes that the President's panel was eminently correct in its assessment of this particular aspect of the problem and heartily concurs in the implied suggestion that in all cases the professional team approach should be fostered and utilized in the overall treatment and rehabilitation of retarded patients. There is no question that dental care must be viewed as an essential component of complete health care for these unfortunate individuals.

THE NEED FOR COMMUNITY CENTERS TO MEET THE DENTAL NEEDS OF THE MENTALLY ILL

The available evidence suggests that an increasing number of mentally retarded children are remaining at home with their families. This trend will create additional needs for community services for these handicapped children and adults.

One of the major needs will be providing dental care for the moderately and severely retarded child. Very few of these programs exist today, and, as a result, large numbers of retarded children cannot receive the dental care they need. Many of them suffer pain, infection, loss of teeth, malocclusion, loss of the ability to masticate efficiently, and impaired speech. As the number of retarded children in the community increases, the problem of providing dental care will become more acute.

There are two factors which make it difficult for retarded persons to receive adequate dental care. The first problem is that it is extremely difficult to perform dentistry on many retarded persons. In order to control body movements sufficiently to restore the teeth, it is often necessary to give the patient a general anesthetic. Even if anesthesia is not needed, the dentist must be equipped with special training to handle the unique problems of these patients.

The second complicating factor is an indirect result of the patient's intelligence impairment and accompanying physical handicaps. The financial resources of many families are exhausted by the additional expenses incurred in caring for retarded children.

If mentally retarded persons are to receive the dental care they need, community programs are necessary in order to make available and bring together trained personnel, special equipment and facilities and financial assistance for those families that cannot afford the services that are needed.

EFFORTS TO ASCERTAIN THE DENTAL NEEDS OF THE MENTALLY HANDICAPPED

Since 1957 and on an increasing basis, the Division of Dental Public Health and Resources of the U.S. Public Health Service has been making studies of the dental service needs of the mentally handicapped. Investigations and pilot projects were conducted in Nevada in 1957, in Idaho and Illinois in 1961, and in New Jersey, the District of Columbia, and Missouri in 1962. Preliminary evidence from these projects strongly indicated the feasibility of providing dental services to the mentally retarded who are not confined to institutions through the establishment of dental service programs in organized community programs for the handicapped.

The Division of Dental Public Health and Resources has indicated a continued interest in this subject and an intention to intensify its inquiries into the dental needs of the mentally ill. These programs complement the objectives of H.R. 3688 and H.R. 3689 and should continue to receive increasing support.

DENTAL SERVICES AS A PART OF THE OVERALL VIEW OF THE MENTALLY ILL

A basic objective of H.R. 3688 is to provide facilities for the overall treatment and rehabilitation of the mentally retarded. As indicated above, dentistry and dental services must be considered a part of this overall view and in the opinion of the dental profession no community mental health center would be able to care adequately for the needs of mentally retarded individuals unless their dental needs are serviced. The pain and discomfort of the person needing dental services cannot be ignored when one takes this view of the total needs of the mentally ill. It is the recommendation of the American Dental Association that community mental health centers constructed pursuant to H.R. 3688 contain adequate facilities for meeting the dental health needs of the persons to be served. This recommendation is reinforced emphatically by the following recommendation of the President's Panel on Mental Retardation: "To provide dental care for those who are so severely handicapped that they cannot be treated in an office, it is suggested to the American Hospital Association and local boards of general and special hospitals and other community services that complete dental care facilities be made available in a hospital or conveniently located institution, where the dental needs of mentally retarded children could be incorporated into the general rehabilitation program of the patient."

It is suggested that further weight might be given to this recommendation by providing in H.R. 3688 for the appointment of a dentist to the Federal Hospital Council.

CORRELATION BETWEEN DENTAL DISEASE AND MENTAL ILLNESS

Some studies have indicated that there is some correlation between mental illness and the dental needs of the patient. One authority on the subject, speaking before a 1958 workshop on dentistry for the handicapped, reported that "One of the most serious health problems in the mentally subnormal child is the high incidence of periodontal disease." This was based upon a survey of approximately 1,500 institutionalized mentally ill people. This authority stated that some of the factors contributing to the high incidence of periodontal disease in the mentally retarded were lack of dental care, lack of oral hygiene, lack of routine prophylactic treatment, lack of functional stimulation derived from mastication of food, lack of muscular coordination of the mouth, and nutritional and vitamin deficiencies. The prevalence of periodontal disturbances in the mentally retarded creates a serious problem of both dental care and treatment. There is no substitute for periodontal treatment when the integrity of the periodontal tissues is disturbed or destroyed by the formation of calculus, or by the occurrence of gingival infection from local or systemic factors. It can be accepted as fact that periodontal treatment is an example of dental treatment which is not always available to a large segment of the mentally retarded.

There is some evidence, although by no means conclusive, that the mentally retarded child is less susceptible to dental caries. This susceptibility to periodontal disease and favorable experience with dental caries tends to indicate that the dental problems of the mentally retarded are unique.

SUMMARY ON THE CONSTRUCTION OF COMMUNITY MENTAL HEALTH FACILITIES

The American Dental Association supports the concept of serving the dental needs of the noninstitutionalized mentally handicapped through community mental health facilities for the following reasons:

1. Many mentally retarded patients cannot be treated in the environment of a private dental office. This may be due to the lack of special training of the dentist, lack of special facilities and equipment, or the need to give the patient a general anesthetic.

2. The dental needs of the mentally retarded are not being adequately met at the present time.

3. The dental needs of the mentally retarded are unique and frequently require the care and treatment of dentists experienced and trained in the problems of mental retardation.

4. There cannot be an adequate overall treatment and rehabilitation plan unless the dental health needs of the mentally retarded are included within the community mental health center.

RESEARCH CENTERS

As indicated above, the association supports strongly the concept that preventive measures brought about through research offer the greatest promise for the

ultimate prevention and control of the diseases that afflict mankind. The portion of H.R. 3689 providing construction grants for research centers is limited to research which "may assist in finding the causes, and means of prevention, of mental retardation, or in finding means of ameliorating the effects of mental retardation." The dental profession assumes that all areas of research related to mental retardation are intended to be included. The need to engage in research on the dental aspects of mental retardation should not be ignored in these research centers. As pointed out earlier, there is much we need to learn about the special dental needs of the mentally retarded, and the methods to be used in treating these persons.

An example of the possible tiein between mental retardation and oral malformations is seen in an article which appeared in the British Medical Journal* a few years ago. Clinical evidence indicated a correlation between cleft palate and mental retardation. This tendency for children with cleft palate to be below normal intelligence had been indicated by earlier research. In a study involving some 17,000 mentally defective children, cleft lip or cleft palate was found three times as often as can normally be expected in a group of this size.

FACILITIES FOR THE MENTALLY RETARDED

H.R. 3689 provides for construction grants for facilities to provide adequate services for mentally retarded persons. It is noted that these facilities are to be designed for the diagnosis, treatment, education, training and custodial care of the mentally retarded and that the construction grants include grants for the expansion and remodeling of existing facilities.

The American Dental Association recognizes the commendable objectives of this portion of H.R. 3689 and wishes only to add its recommendation that the dental needs of the institutionalized be recognized as being a significant part of the overall care and treatment plan of the mentally retarded.

In conclusion, the American Dental Association supports the general purposes of H.R. 3688 and H.R. 3689 and again wishes to commend the chairman and members of this committee for their attention to the problems of the mentally ill.

RESOLUTION ADOPTED BY THE PSYCHIATRIC SOCIETY OF WESTCHESTER COUNTY, INC., BY DR. SAMUEL ROSMARIN, PRESIDENT

The Psychiatric Society of Westchester County endorses President Kennedy's proposals in the field of mental health. In his message to Congress on February 5, 1963, the President advocated new subsidies for the development of community mental health services. In his message, the President has taken the first major step in implementing the chief proposals of "Action for Mental Health," the final report of the Joint Commission on Mental Illnesses and Health which was empowered by Congress in 1955 to make a thorough analysis of the Nation's mental health needs.

The Commission recommended a planned system of professional community services for the care of the mentally ill which would stress prevention, research, and the training of an adequate number of professional personnel. In order to accomplish the goal of intensive preventive and treatment efforts centered in the community in which the patient lives, the Commission recommended that Federal, State, and local government expenditures for mental health be increased appropriately.

It is the goal of this program to reduce by 50 percent the hospital admissions for mental illness through the prompt and efficient use of outpatient and day care treatment centers, integrated with family, educational, and vocational rehabilitation services. It is also expected that hospital treatment where indicated will be more effective as well as briefer. There is emphasis in the program on followup treatment and rehabilitation services.

We endorse the President's program as constituting a sound long term financial investment as well as on humanitarian and scientific grounds. As representing the psychiatrists of Westchester County, we, therefore, urge our fellow citizens and elected representatives to support the President's enlightened mental health program.

*British Medical Journal, No. 5016: 454, Feb. 23, 1957.

STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION, PRESENTED BY HYMAN M. FORSTENZER, CHAIRMAN, MENTAL HEALTH SECTION

I appreciate the opportunity to submit to you via this statement the views of the American Public Health Association. We respectfully direct the attention of you and your subcommittee to the views expressed hereafter relative to legislation proposing assistance in the construction and operation of community mental health centers, H.R. 3688, and that legislation relating to increased activities for programs directed toward improved services for the mentally retarded, H.R. 3689.

H.R. 3688-Community mental health centers

1. The motives and objectives of this bill merit the fullest support. The size and scope of the problems involved in the control of mental disorders make it apparent that an adequate control program is beyond the fiscal capacity of State and local government. The final report of the Joint Commission on Mental Illness and Health pointed this up, and one of its principal recommendations was large-scale Federal support of efforts to control mental disorders.

2. An amendment to the bill should be requested to link it to the federally initiated and supported program for State planning of comprehensive mental health programs. The 87th Congress appropriated $4.2 million for a grant-inaid program to the States to be administered by the National Institute of Mental Health and to be utilized exclusively for the support of comprehensive mental health program planning. Nothing in H.R. 3688 links the support which it seeks to provide for one particular type of mental health facility to this essential development of comprehensive State plans. The amendment should relate this proposed legislation administratively and from a time sequence point of view to the planning which is now being undertaken by each of the States under the stimulation of the National Institute of Mental Health and with the support of Federal funds. It should be pointed out that it is inconsistent to ask States to spend 2 years in an assessment of their resources and needs and the development of priorities, and to prejudge the outcome. There should be a clear requirement that plans for community centers be closely integrated with the State's overall planning process.

3. For the past two decades all efforts to develop an adequate control program in this field have been directed, at the Federal level, by the Institutes of Health under the Surgeon General. In this bill in section 103 of title 1, no mention is made of the Institutes of Health in connection with the establishment of regulations. The section requires only that the Secretary consult with the Federal Hospital Council. Membership of this Council, to the best of our information and belief, does not include specialists in mental health facilities. This point is further confused by section 205 of title 11 which requires the Secretary to consult with the National Advisory Mental Health Council in prescribing regulations for support of centers after they are constructed. This group is not by the terms of the bill involved in the regulations for constructing the mental health centers. Construction and operation should not be dichotomized.

4. The bill permits the States to designate any agency to administer this grant-in-aid program. An amendment should be requested which would require interagency cooperation between the State's mental health authority and the agency responsible for administering Hill-Burton funds.

5. Support for operation of mental health centers should not be limited to those constructed with funds made available under title I of the bill. The need for Federal support of comprehensive control programs has been documented by the Joint Commission. Such a limitation militates against comprehensive planning and may lead to second-class citizenship status for existing facilities and services.

6. The effect on State participation of the time-limited support of staffing of centers should be evaluated. A major problem in program development is the fiscal inability of the States to support improvement and expansion. Does this bill signify an intent on the part of the Federal Government to restrict its involvement to pump-priming and stimulation, leaving permanent support entirely to the States?

7. For many years to come, integration of State hospitals and schools for the retarded with community services will be a major problem in developing comprehensive programs. Short-term care facilities must be related to those providing intermediate and long-term care if they are to be effective. How these are to be related should be a requirement of any State plan submitted under this bill.

8. Title 1 requires approval of the designated responsible State agency. Title 11 omits this requirement. Is it intended that individual applicants may by-pass the State agency in apply for support of staffing? What is the effect of this on comprehensive planning in each State?

H.R. 3689-Community mental retardation centers

1. All of the statements in respect to H.R. 3688 are applicable to H.R. 3689. 2. The need for a requirement of interagency coordination at the State level is even greater in mental retardation than in mental illness. In several States, services for the mentally retarded are under different administrative agencies than services for the mentally ill. Even in those States in which institutional and community care and treatment programs for both groups of disorders are in one agency, preventive and rehabilitative services are the responsibilities of other State agencies.

STATEMENT OF C. LEIGH DIMOND, CHAIRMAN, COUNCIL OF NEW YORK STATE ORGANIZATIONS FOR MENTALLY ILL CHILDREN

The degrees of mental illness or emotional disturbance vary in individual cases. The treatment and rehabilitation of mentally afflicted children involves specialized medical care coupled with therapeutic educational procedures and techniques. Treatment is incomplete without education. When therapeutic education is made available, the chances for rehabilitation are far greater, with many children eventually being able to participate in regular classes in the public school system. Education is a normal attribute of childhood; exemption from school attendance only adds to a child's disability. The member organizations of the Council of New York States Organizations for Mentally Ill Children provide essential therapeutically oriented educational programs for such children in Manhattan, Nassau, Queens, Rockland, and Westchester Counties of New York State.

The council heartily endorses the expansion of the Federal mental health program as embodied in H.R. 3688. This proposal constitutes an historical step forward in the solution of the problem of rehabilitation of the mentally afflicted. Since education is a fundamental, distinct segment of the general care and rehabilitation process, the council recommends that legislative authority governing the Federal mental health program specifically provide for the establishment of educational programs and required facilities for mentally afflicted children as an integral function of community mental health centers. To achieve this objective, the following specific action should be taken :

1. Section 301, title III, general, of H.R. 3688 should be amended to include the education of minors under paragraph (b) as a designated function of the community mental health center.

2. The Federal regulations required for implementation of the mental health program should include policies, criteria, and procedures covering the operation of educational programs and related facilities for mentally ill or emotionally disturbed children as an integral function of community mental health centers.

In the education of mentally afflicted children, certain children progress until they are capable of entering regular classes in the public education system. During this progress, many children reach an educational plateau where they are capable of assimilating academic and vocationl training in the environment of special classes; such children are not capable of entering regular classes in the public education system.

Local conditions and existing facilities may warrant the establishment of these specialized classes in either the community centers or the public education system or both. The council suggests that consideration be given to the establishment of such classes in the public education system as part of the State plans developed for community mental health centers. If such classes are established under the public education system, consideration should also be given to maintaining these classes through the use of Federal funds appropriated for the mental health program. The use of such funds should be limited to expenditures for only the specific objectives of the mental health program, e.g., staffing of such classes as provided under title II of H.R. 3688.