and the family without marked duplication of services and unnecessary examination.

I have seen facilities where staff have not been developed in such an interdisciplinary manner and where every child is subjected to the same examination. In such a setting, I have seen a child receive an extensive speech and hearing examination, even though his mental age is only two or three months. At the Kennedy Institute, the disciplines that can contribute to the particular case study the patient for a period of days. They then pool and compare their information in a major habilitation conference and the patient is assigned to a subsequent major discipline for therapeutic approaches which are monitored by other disciplines to ascertain the degree of improvement in relation to expectation. After a period of weeks, when specific therapeutic measures have been worked out, the family and repre entatives of community resources, such as community schools, social work programs, and day care facilities are brought in to learn the therapeutic approaches which can be applied specifically for that child in his home environment.

The Kennedy Institute has carried out a very substantial training program. Formal lectures and conferences are held regularly throughout each week rather than on a monthly or yearly schedule, as was the situation several years ago in the usual university environment. In the past year alone, we have trained over 175 nursing students, over 50 students in physical therapy, 5 psychiatrists, 4 psychologists, 17 special education teachers, 9 social work students, 30 medical students, 24 residents in pediatrics, 5 full-time pediatric fellows, and almost 75 students in speech and hearing. In addition, extensive course work has been given for clinical pathologists in genetic and biochemical detection; for graduate students in occupational therapy, rehabilitation, and for specialists in library sciences.

The numbers alone do not express the contributions which the universityaffiliated facility has made from the training point of view. Each discipline has had intensive technical training in its own area; but, in addition, as an example, the physcal therapist has learned how his or her activities can complement the activities of the psychologist, the behavior modification specialist, the neurologist, and so on. In this way, gains made by one therapist are not eradicated by the efforts of another. For instance, a child who is undergoing conditioning procedures for improved socialization-so that the family can live peacefully while the child is in the home-presents a particular problem if the personnel carrying out physical therapy of that child do not follow similar principles of behavior modification and reward.

In the process of learning, the psychologist learns the role of the speech therapist in the treatment of the handicapped so that, if he becomes the primary referral source, as may be the case in the community, he can wisely choose the appropriate specialist. The pediatrician must learn the contributions of the educator. Likewise, if a retarded child is brought to a special educator, he must have an appreciation of the disciplines to be involved.

The Kennedy Institute's impact on student attitude at present is in contrast to the experience of an instructor in public health after conducting field trips for medical students to an oversized residential facility for the retarded. I quote from his paper, "Part of the shock of students who visit this facility may be related to the experience of being confronted with so many problems at once. The physician is confident that he has certain specific measures to offer an individual patient in discomfort: when the student is faced with a large number in severe distress, he is extremely uncomfortable merely because of the numbers. When students are interested in such a facility, they go largely as spectators rather than as physicians." By comparison, over 25 percent of the students at Johns Hopkins, in the course of their medical school experience, choose work in the Kennedy Institute in preference to other exciting experiences in the care of acutely-ill patients or patients with other diseases than those with chronic disability.

In the research area, major emphasis has been on the development of new treatment strategies, new medical rehabilitation approaches, and new forms of special education with careful comparisons of treatment benefits. For example, we are interested in studying, in a given patient, whether or not behavior modification will produce greater social benefit or greater educational benefit than more conventional approaches. One study of particular interest and importance to education is that of the talking typewriter. This is an instrument that costs approximately $40,000 with several thousand dollars annually for soft ware. A

controlled experiment comparing this form of remedial reading for the handicapped with other forms has indicated the advantage, in the pilot program at least, of a human teacher over the machine—and at approximately one-fifth less cost. Other comparative treatment programs are underway which could have equally startling results.

The university-affiliated facilities have had an even more important role than simply these program objectives. Essentially, they have been unifiers of the university. They are a kind of mini-university: a meeting ground, a point of convergence for the medical sciences, the behavioral sciences, and the educational sciences. Unless these three areas concentrate their efforts in a coordinated manner, relatively little gain will be obtained by each carrying out his own independent efforts.

The university-affiliated facility is a meeting ground with a common concern for human beings in need of assistance. This need is strong motivation to effect cooperative and coordinated work. In this regard, the university-affiliated facilities have served as the major center of interest for the mentally and physically handicapped child in the academic community and in the general community along with the Kennedy Foundation and the National Association for Retarded Children, as government over the last four years has demonstrated a dwindling concern for the well-being of the retarded.

The university-affiliated facilities are also proving to be a focal point for educational approaches to difficult chronic problems in our society. They are also serving as proving grounds for the training of individuals in team practice.

Despite the serious financial limitations at the present time on medical institutions. The Johns Hopkins University as a private institution, though feeling very seriously the cutbacks in support by the present administration, is still giving considerable financial support to the Kennedy Institute. In one year alone, the Medical Institutions have contributed over one quarter of a million dollars in in-kind services and dollars to that facility.

More importantly even that this strengthening of internal university interest is the role that the university-affiliated facility is playing as a link to the community. It is essentially the bridge between the university academicians, and the community practitioners and families. It is a presentation of academics with relevance. First, it is a training resource for personnel from community programs, for public health nurses, and for black students in special education at Coppin State College who will provide the major special education resource to the City of Baltimore. It is a public information facility where activities for the retarded can be centralized, a meeting ground for parents' groups, and a center for State program planning. It is a training facility for the community with Neighborhood Youth Corps working on weekends and through the summer. It is the focus for a New Careers Program where poor people of Baltimore are given the opportunity to enter the health professions. These people are guided up a career ladder beginning as trainees to be a child life manager who is responsible for assisting the retarded in social skills. The next step for such workers is specialization in areas such as occupational therapy and physical therapy; or, working as psychology aides; or, in obtaining associate degrees through community colleges. Further educational progress may involve degreegranting colleges, and, eventually, professional schools.

It is a center for the training of day care workers and for pediatricians who come from practice to learn how they can better manage the retarded. It is a summer school for teachers who wish to learn more about the biomedical as well as educational aspects of the handicapped. And finally, it is a service facility for the community where children with severe educational problems may be brought to our school on a daily basis; where cerebral palsy clinics of charitable groups are conducted; and where the Cleft Palate Clinic of the Johns Hopkins Hospital meets as well as the child neurology clinics. In essence, it is a court of last resort for families seeking the most advanced medical, behavioral, and educational information for their child.

Our role, then, as we conceive it, is to develop new techniques of screening, new approaches to diagnosis, new methods of treatment, new ways to family education, new procedures in genetic counseling, new careers for personnel, and new disciplines to assist the retarded and handicapped. I believe the universityaffiliated facilities are succeeding in this role.

The second question which I raised is why should training be interdisciplinary? What are the advantages of this seemingly expensive approach? Actually, the advantages are largerly in the greater economy in the use of resources

for the family, patient, and community. It is to assure that there is greater efficiency in assisting the child. Interdisciplinary means that one discipline must learn how to use, to a degree, the tools of another discipline, and work with that other discipline to develop some optimal path for the treatment of the child. We, in now way, mean to disparage the efforts of others in training, but if one analyzes the experiences which a trainee at the Kennedy Institute receives in psychology, for example, one can see that he learns the role of the neurologist of the psychiatrist, of the educator, and the abilities and limitations of the physical therapist. He develops a realistic appreciation of what can and cannot be accomplished. This is absolutely essential since so many of the handicapped reach treatment facilities by way of singular members of the scattered health team. For example, a teacher may be the major source of referral, or, perhaps, a public health nurse.

Let me illustrate some of the problems associated with this approach. An eighteen year old child, the daughter of an important family in this country, is being admitted to the. Kennedy Institute this week. The child has a severe hearing disorder as well as some neurologic dysfunction. She was subjected to speech therapy for 81⁄2 years despite the fact that the major deficiences are in the prevocational and intellectual areas. Not only was this a waste of financial and human resources, but valuable time has been lost that could have been put to far better use if more realistic expectations on the part of the people making the earlier referrals had been carried out.

What, then, should these centers be? They must be administered in a way that permits them to inter-relate as much as possible with the community Developmental Disability Facilities. They must be consultation centers for the satellite groups in the community which will carry out a large part of the service programs for the handicapped. They must be community training centers which train personnel for the satellite units and provide subsequent in-service training. They must be community research centers that can develop the essentials of better treatment and pass on this information to community programs for immediate application.

From a cost benefit standpoint, there is impressive evidence of what can be accomplished for the handicapped through these university-affiliated facilities. Yet, for those members of our society who are skeptical of the value of any efforts made for the handicapped, it is appropriate to point out what may be accomplished in terms of real benefit for the normal child.

Historically, medicine has learned a great deal of what is important for the normal from the study of disease. For example, the study of diabetes has contributed a great deal of information concerning normal carbohydrate metabolism. The study of cretinism, a bizarre form of retardation studied many years ago in Switzerland, demonstrated the role of the thyroid gland in normal people. The study of inborn errors of metabolism has provided information on the normal chemical pathways of the body. The study of Mongolism, or Down's Syndrome, I believe, will contribute very significantly to our understanding of the aging process.

Likewise, in the study of learning problems of the handicapped, much information can be obtained which will be valuable in understanding the normal child. For example, an appreciation of the existence of individual variation in learning abilities is absolutely critical to the most effective use of our educatonal resources. Individual variation is a concept which has not been fully appreciated by education and which comes from the study of individuals with disability. Conservative estimates of so-called normal school children with unusual profiles of intellectual capabilities vary from 15 to 25 per cent. Optimal education of these normal children requires individual teaching methods-the development of what might be called prescription teaching-to exploit the child's areas of strength and to attempt to bring his areas of weakness up to a normal level. It is essential that adequate scientific epidemiologic approaches in the description of learning disabilities be developed so that communities can plan and experiment with different types of resource allocations which ensure that our educational dollar buys a maximum education for all pupils over the spectrum of abilities ranging from the mentally handicapped to the child who is quite intelligent but has only specific learning disabilities.

Another example is in the area of psychiatry. The study of the basis for the strength of a family facing severe adversity can lead to improved ways of assisting the normal family to be prepared for hardship. Likewise, in the area of behavior modification, the use of conditioning procedures to remove unacceptable

behavior has obvious application for normal child-rearing practices in determining the importance of rewards.

I should like to make sure that, within the legislative history of this bill, there is concern for the financial support of these centers. The construction funds should be allocated in a way that will permit optimal support of community resources. This will entail a careful programming to ensure that there is adequate geographical distribution of the university-affiliated facilities. Facilities must be built in locations and at university centers which will provide maximum support for regional or State community programs. In addition, the funds which are authorized for support are absolutely minimal and are a long way from being optimal.

I believe that the support of these facilities must be in four categories. First, sustained dollar support over a period of five to ten years for direct cost and administration. This would provide for core activities to ensure that there is continuity of staff from year to year which can lead to progressive improvement in programs. Second, there should be dollar support for specific programs which come from established agencies awarding funds in competition with other training, demonstration, and research activities. It is extremely important to assure that these centers are not excluded from such support programs because of the core support to which I referred. Third, support of indirect costs must be adequate to ensure universities and their affiliated facilities are not depleted of resources in the process of maintaining the high cost of the programs I have indicated. Fourth, there must be money for development so that emphasis can be placed on new methods of operation. I believe these funds should come from the efforts of the university-affiliated centers themselves through the recovery of monies for services performed, and should be used only for professional research and teaching just as universities use new funds to develop new programs. Such a mechanism will provide incentive for the acquisition of appropriate funds for services rendered.

These four support efforts must be for all elements of the center, not just the biomedical, or the educational, so that maximum balance can be obtained and maximum flexibility in the use of funds can be made possible. At the present time, there is a very serious imbalance which compromises the interdisciplinary approach. Either the biomedical support in some facilities is grossly underdeveloped and under-supported, or the educational support is seriously compromised, as is the situation in most of the facilities. Indeed, what has developed is competition instead of cooperation in acquiring funds for the major areas of the program, and this competition has seriously limited development. Methods must be found to reward joint activities so that divisions with educational responsibility and divisions with biomedical responsibility can be encouraged to work together. Likewise, centers with major emphasis on one or the other can also be encouraged to cooperate.

In conclusion then, I feel this legislation has great merit. It seems that the only way community programs, which are demanded by society, can be effectively implemented and improved on a year-to-year basis is through the parallel development of the university-affiliated facilities. As a way of illustrating the particular accomplishments in a somewhat graphic manner, I have asked some of the staff of the Kennedy Institute to accompany me to present very briefly, a few case examples of the kind of service programs upon which the framework of training and research are built. Accompanying me is Dr. Arnold Capute, who is Deputy Director of the Kennedy Institute, and he will present these cases. I appreciate the opportunity to appear before the Committee and I hope that the legislation will be successfully enacted.

Senator KENNEDY. The subcommittee will reconvene at 2 o'clock this afternoon.

(Whereupon, at 11:50 a.m. the subcommittee recessed, to reconvene at 2:00 p.m. the same day.)

AFTERNOON SESSION

Senator KENNEDY. The subcommittee will come to order. First of all I want to express my appreciation for the patience of the witnesses today. This is a busy day for all of us. I know this is a busy day for

you, and so I particularly appreciate your understanding and patience. Our next witness is Dr. Charles D. Barnett, from Columbia, S.C. I understand that South Carolina was the first State to set up a separate department of mental retardation, the department which Dr. Barnett now heads.

Prior to his present position, Dr. Barnett served as deputy commissioner of mental health and mental retardation in Texas. He has had extensive experience with State problems in the area of planning and coordinating comprehensive programs for the retarded, and we look forward to his testimony.

STATEMENT OF CHARLES D. BARNETT, PH. D., COMMISSIONER, SOUTH CAROLINA DEPARTMENT OF MENTAL RETARDATION, COLUMBIA, S.C., AND PRESIDENT, NATIONAL ASSOCIATION OF COORDINATORS OF STATE PROGRAMS FOR THE MENTALLY RETARDED

Mr. BARNETT. Thank you, Senator.

It is my pleasure and privilege to represent here today the chairman of the South Carolina Mental Retardation Commission, Dr. James B. Berry, of Marion, S.C., and our personable and dynamic Governor, Hon. Robert E. McNair, in basic support of S. 2846. The Developmental Disabilities Services and Facilities Construction Act of 1969.

Additionally, and in the capacity of president, I have the honor of representing the National Association of Coordinators of State Programs for the Mentally Retarded. Our association consists of a single individual from each of the several States representing the State agency heretofore appointed by the Governor to generally coordinate mental retardation planning within the State. Our association's purpose is to forward mental retardation services in the several States by promoting mutual assistance, cooperation, and the exchange of information and ideas in the administration of public mental retardation programs.

"Public mental retardation programs" as used here is meant to encompass the total programs dealing with institutional (residential) and community care in order to meet the needs of the mentally retarded and their families insofar as these programs are the responsibility of the individual States. The executive committee of our association unanimously endorses in principle and philosophy the content of S. 2846.

My purpose here today will be to comment briefly on S. 2846 and in so doing, I will put aside the inclination to share with you in any great detail the enormous needs which have accrued relative to mental retardation services in the various States. I will also set aside the perhaps even stronger inclination to verbalize the great bewilderment and concern that many of us in the States have felt for the past year or two regarding what is actually happening in Washington relative to the coordination and funding of mental retardation services and programs. Suffice it to say that we have often wondered who was doing what to whom and why? I must add that our confusion was often shared by Washington leaders themselves. Yet, despite this and despite sometimes outmoded communications and decision-making processes which have often excluded consumers and firing line admin

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