nity for normal social contacts and giving a feeling of security in self, home, and community; (5) providing a chance to play; (6) training for jobs and finding employment; (7) conducting research and prevention; (8) public education toward understanding and action for a better life for all handicapped persons.

The society seeks to render and make possible health, welfare, educational, recreational, vocational, and employment services to all types of handicapped persons-regardless of which one or more of the 250 kinds of crippling diseases or conditions may be responsible.

All services of our society are established and carried out in a manner which supplements and extends but does not duplicate or compete with the services of any other agency, whether it be public or private, or at the National, State, or local level.

The society fosters the development of crippled children's programs in areas where none now exist it renders professional field consultation services in an effort to improve and expand the direct service programs already established-distributes through its Bureau of Information educational literature regarding prevention and treatment of various crippling defects, and encourages the use of its large library through an extended loan service.

To carry out these objectives, strong emphasis has been placed on the selection of a highly trained, efficient staff. The many projects and services of the organization are directed and supervised by professionally trained administrators, doctors, social workers, rehabilitation workers, nurses, occupational therapists, psychologists, and others. Our headquarters staff in Chicago is organized into:

(1) Professional field services which provide medical, social, nursing, psychological, and other therapeutic advice and guidance; (2) Administrative services including a national personnel registry and employment exchange, extension services providing research and reporting;

(3) Informational services including a lending library, publication of books, pamphlets, magazines, and bulletins, moving pictures and exhibit services;

(4) Easter seal services which conduct an annual Nation-wide appeal for funds for the support of the society through the 2,000 local units.

Our society actively participated in the White House Conference on Child Health and Protection and favored the adoption of the crippled children provisions of the social security law in 1935. Parenthetically, the personal experiences of Mr. Lawrence J. Linck, executive director of the society, have included 42 years of administration of the State Crippled Children's Service of Illinois through the University of Illinois, under the provisions of the Social Security Act, which has given him ample opportunity to discover the various strengths and weaknesses of the program. His present position gives him the opportunity to apply a critical viewpoint to the Nation-wide services for and needs of crippled children.

The national society supports the passage of the Maternal and Child Health Act and in connection therewith suggests for the consideration of your committee certain provisions which we think are

necessary.

We earnestly support this legislation for a number of reasons, not the least of which is that it provides for additional financial assistance to the States for work with crippled children. All who are actively at work in the field know that there are large areas of need in the field of services to crippled children which are not being met, chiefly because of lack of funds. Most important among these are medical care for and training of cerebral palsied children; speech therapy for the speech defective child; medical care, appliances for, and acoustic training of the child with defective hearing; medical and convalescent care for child victims of rheumatic fever; medical and surgical treatment for the visually defective child; and diagnostic services as well as medication for the epileptic child.

The changes which we suggest and the reasons therefor are the following:

The act as now drawn makes mandatory the requirement that crippled children's services be under the State health agency by 1950. We think this requirement is too broad and suggest an amendment which would make this permissive rather than mandatory. Other State agencies may be more logical administrators of the program in some States. For instance, even in the Federal Government, you find some bureaus which, although not a logical adjunct of their administering department, yet operate most efficiently under that department, whether for political expediency or other reason.

There are, according to report, approximately 85 Federal agencies that in one way or another participate in or provide public-health service. These are, either by necessity or by heritage, scattered. Without expressing an opinion as to whether and if so in what manner, all or some of them should be consolidated, it is clear that the withdrawal of funds from these agencies unless they be transferred to a common administrative head within 5 years might bring about a serious situation. Similar political and interdepartmental repercussions might quite possibly be experienced in many States in a forced transfer of crippled children's services from one State branch to another, with consequent deteriorated services to children in the interim. and no assurance of an improved program or extended services after the transfer.

We submit that uniformity of the kind proposed is not necessarily an advantage, and quite possibly might hold standards down instead of achieving the opposite effect. Full utilization of local and private resources with respect to existing facilities is essential, and it is open to question whether the State health agency is in a better position to achieve this than is the welfare, education, or some other existing department which is now concerned with child welfare.

As to the question of residence requirements, the national society is in favor of eliminating any provision making such requirements. It has been found in the welfare field that residence requirements are expensive to administer so they frequently work severe hardships upon helpless people.

The fact of the matter is that families in general are sedentary and restricted to limited territories in travel by force of habit, and are not inclined to shop hither and yon for various types of free services. The number of persons who might secure services outside of State residential limits would be so far exceeded by the number who would

find their applications simplified and who would receive service otherwise denied to them by reason of nonresidence, that we believe the suggestion for omission of residence requirements should receive serious consideration.

I know in this printing of the Maternal Child Health Act that there are no residence requirements, and the National Society wishes to offer support to this omission of such requirement.

Lastly, we firmly believe that the act can be most economically and effectively administered if the means test is not included. Any financial saving incurred by eliminating financially responsible applicants might be more than overbalanced by the excessive administrative cost of such a provision. Reviews would have to be repeated frequently in cases where family incomes were close to the margin. In view of the fact that 85 percent of our families have incomes of less than $2,500 per year, and 92 percent have incomes of less than $3,000, there should not be many children receiving care to which they were not financially entitled. Under a means test, many children would go untreated, since service offered as a charity would be repugnant to their families.

We wish at this time to reaffirm the excellent working relationship which has consistently been maintained between the national society and the staff of the Children's Bureau. The excellent professional training of members of the Children's Bureau staff together with their sincerity and diligence, have resulted in a continuous improvement of service which warrants the warm appreciation of all who are in a position to know of the tremendous strides which have been made in the short years since the inception of the program.

Believing that they may be helpful, we are setting forth herein some observations which may be of assistance in more clearly appraising some needs. Of the more than 250 crippling diseases and conditions, some, like infantile paralysis, have been the focus of public attention and the subject of expenditures of millions of dollars, while others have received but scant attention. Therefore, it is especially important to provide for expansion of services to include these hitherto neglected groups.

Cerebral palsy (more commonly termed "spastic paralysis") ranks second only to infantile paralysis as a cause of crippling in childhood. In fact, an outstanding authority in the field, Dr. Winthrop Morgan Phelps, has stated that "the number (of cerebral palsy cases) is as great, if not greater than the number of cases of infantile paralysis throughout the country." This would mean that in the United States there are from 175,000 to 200,000 or more. This estimate is constantly being revised upward as more cases come to light. The further estimate of Dr. Phelps that 70 percent of cerebral palsy cases are educable indicates the importance of salvaging these thousands of handicapped children.

Let us take the State of Illinois, for instance: on the basis of authoritative estimates, approximately 10,000 cases of cerebral palsy would be expected in the State's child population. The central registry maintained by the Division of Services for Crippled Children of the University of Illinois (which is by no means complete) itself had data on 2,738 cerebral palsied children in 1940. Yet facilities in the State for the needed training of these children are pathetically

meager. Still more difficult to secure is specialized training, such as is available at St. John's Crippled School and Hospital (which_can accept only about 20 children), and Michael Reese Nursery for PreSchool Cerebral Palsied Children (which has room for only 12 preschool children) and the Illinois Children's Hospital School which is about to open for approximately 100 severely handicapped children (some of whom will be cerebral palsy cases).

The need is tremendous if we are to pick up the backlog of untreated cases, and maintain services for new cases which come to our attention each year. The education and training of these children is expensive and must be continued for a long time. Good residential care for the cerebral palsied generally costs not less than $5 to $6 a day, which is a sum to stagger the low and medium-income families faced with a medical bill of this proportion for an indefinite number of years.

To complicate the problem, only a few training centers for professional and medical personnel are to be found, which further emphasizes the urgency of the situation, since the specialized training needed by these children cannot be given without competent, welltrained staffs.

It is nothing less than a tragedy that this large segment of our child population has for so long gone ignored. Limited experiments in certain States, among them Illinois, have demonstrated the feasibility of establishing services for cerebral palsied children within the framework of the services for crippled children as it is now operated under the Children's Bureau. The only bar to expansion of this work and its establishment throughout the 48 States is insufficient funds. The additional funds provided for in the Maternal and Child Health Act would help to eliminate this barrier and give the go-ahead signal to the many workers in the field of crippled children's work who are anxiously awaiting the establishment of such

services.

A second problem of serious proportions involves children with epilepsy. Authoritative estimates of the number of such children in the United States range from 1 in every 500 to 1 in every 125, or from 95,000 to 380,000 up to the age of 21. Regardless of which figures are accepted, the problem is one of great magnitude, since these children are subjected to social ostracism, frequently excluded from schools, rejected as job applicants, and, because of the stigma of the condition, are prey to numerous types of medical quackery. Dr. Lennox, of Harvard Medical School, states that 75 percent of these children can be rid of 75 percent more of their seizures. Therefore, a crippled children's program which is designed for all types of handicapped children-as it should be-would include diagnostic and medical service for these children. At the present time almost nothing is being done for epileptics of normal mentality and who are not eligible for instutionalization. The greatest element of concern is that epilepsy is considered by many authorities to be essentially a defect of childhood.

In addition to the two groups mentioned are others equally neglected, namely:

Deaf and hard-of-hearing: Estimates of the number of children with hearing defects range from 5 to 14 percent. The United States

Office of Education states that 400,000 children have hearing so defective that they are in need of special educational procedures. The American Society for the Hard-of-Hearing estimates that 300,000 children are in need of lip-reading instruction, while only 20,000 are receiving it in public schools. Furthermore, it is pointed out that of the 250 cities and towns in the entire country providing for such instruction, over half are in only three States: California, Massachusetts, and New York.

The State-wide hearing program of the Division of Services for Crippled Children in Illinois demonstrates the feasibility of providing for this group of handicapped children through grants-in-aid under the Social Security Act. Through the Division Clinics, diagnostic tests are given throughout the State, and children with defective hearing are referred to their family physicians.

This, by the way, is the only State in the Union which has a Statewide hearing program through the division services for crippled children under the Children's Bureau.

Visually defective: The number of school children with serious uncorrected visual defects has been estimated by the United States Public Health Service as 1 in 8, or some 3,750,000 school children, a very small proportion of whom have had visual defects corrected.

Rheumatic fever: Rheumatic fever is the leading fatal disease of childhood, and each year many thousands of children are crippled or handicapped as a result. Yet only 240 of the 3,000 counties in the United States were reached by State crippled children's programs in 1945.

Speech defectives: Although a recent authoritative estimate indicates that 10 percent, or 3,000,000 of the school population of the country need speech training, only 6,000 to 8,000 are receiving such training.

Recommendations: The thousands of children suffering handicapping defects of one kind or another present a social tragedy as well as tremendous economic loss to their country. Therefore, the National Society for Crippled Children and Adults, Inc., wishes to be placed on record as urging the adoption of the Maternal and Child Health Act, in order to permit the development of State programs which will be broad enough to handle those problems which they cannot now handle, and to encourage the recruiting of staff members with the specialized skills necessary.

We sincerely hope that we may anticipate the opportunity in the near future for services to those thousands of children who so sorely need care but whom we cannot serve because of limitation of funds. Senator PEPPER. Any questions?

Senator DONNELL. A very few.

Mrs. Jacobs, have you made any study of the amount of money that would be required to provide the treatment and services that are contemplated by title I to the approximately 3,000,000 mothers and 40,000,000 children of this country?

Mrs. JACOBS. No, sir; we have not. We have, of course, been chiefly concerned with title II.

Senator DONNELL. Yes.

Mrs. JACOBS. Because of our specialization in the field of crippled children.