SPECIAL NEEDS POPULATIONS

MENTALLY RETARDED CHILDREN AND ADULTS

<Medical Services>

MEDICAL CARE OF CHILDREN WITH MENTAL RETARDATION TO SOCIAL INTEGRATION

VANRUNEE KOMKRIS
Director, Rajanukul Hospital, Bangkok, Thailand

The basic needs of mentally retarded persons are love and understanding from their parents and society which are much different from those of normal persons. Hence, we must provide suitable services for promotion and development for better quality of life for these persons. It should be the simple means to make such services and opportunities available to them from birth, childhood and through adulthood, based on medical, educational and vocational training grounds.
The first important service is medical aspect interms of prevention and early recognition of such problems which will lead to early intervention consequently. Other services such as special education, rehabilitation and occupational training in the context of community basis should be emphasized such as day-care centres, group homes and sheltered workshops in order that they may have an opportunity to work like a normal person.
In 1986, WHO reported that mentally retarded persons all over the world were about 90-130 million persons and the surveillance rate of severely mentally retarded persons under 18 years was 3-4:1000. The surveillance rate of mildly and moderately retarded persons was approximately 20-30:1000.
In our country the figure came out as 1% of the population were mental retarded of various degrees, according to WHO and the Ministry of Public Health. That was 30 years ago, so one can imagine how many retarded persons we have at the present time.
The medical care for retarded children in Thailand started in 1957 when the Ministry of Public Health established the Rajanukul Hospital, Institute of Mental Deficiency, which served as a special hospital for diagnostic treatment and rehabilitation for the retarded persons, which remains as the first and the only hospital in Thailans whose functions are as follows -

1. To provide diagnostic, prevention and treatment services.
2. To provide rehabilitation in various aspects through medical, educational, social and vocational training.
3. To provide an early intervention programme.
4. To provide parent counselling.
5. To provide researches in the field of preventive measures against mental handicap.
6. To be a personnel training centre in the field of mental handicap for those who are interested and dealing with mental retarded persons.
7. To be a teaching center for student nurses and medical students.

Medical services for the mentally retarded persons are provided by -

1. The Ministry of Public Health through Rajanukul Hospital and Provincial Hospitals
2. Ministry of Interior through the Metropolitan Health Department.
3. Ministry of University Affairs through the University Hospitals.

Medical for mentally retarded persons must be provided since childhood, The Rajanukul Hospital started the early intervention programme in the International Year for Disabled Person (IYDP) in 1981. The basic aim is to stimulate the skills of mentally retarded persons in various skills such as cognitive motor skills, self helping skills, social skills, language and communication. This project is provided through the Department of Phychology in the out-patient clinic which received very good acceptance from the public, resulting in an increase in the number of patients attending this clinic. The hospital then expanded their services by opening 2 new centres in community -

1. Rajanukul Children's Rehabilitation Centre on New Road, Bangkok.
2. Dindaeng Community Based Rehabilitation Centre in Dindaeng, Bangkok.

Medical care for the mentally retarded persons is mostly available in the middle part of Thailand, however, it is very rare in other part of country which we are present trying to establist one more special hospital for the mentally retarded persons in Chiengmai in 1989. There are three community Based Rehabilitation Centres which provide early intervention programmes for the physically and mentally handicapped children belonging to the Daughter of Charity.

These centries provide early intervention programmes for children under age 0-3 years. Besides this a day-care centre was established for pre school mentally retarded children age 3-6 years to prepare them to get ready for school.

Apart from the medical services, the Rajanukul Hospital also provides special education for school-aged children by opening a special school in 1964. This school was lonated from H.M. The present King of Thailand through the Foundation for the Welfare of the Mentally Retarded of Thailand, but is being taken care by the Rajanukul Hospital Department of Medical Services, this school is available for educable and trainable mentally retarded person from 7-18 years old.

For the adult mentally retarded persons, the Rajanukul Hospital provides vocational training. There is one workshop in the hospital and the another two vocational centres are outside the hospital for male and female adult retarded separately.

In 1985, The Rajanukul Hospital developed community based programmes by forming teams of medical doctors, nurses, social service, staff and paramedical staff to visit the homes of severely and profoundly mentally retarded children who were not admitted into the hospital to provide counselling to their parents and to introduce to them the various methods of treatment of mental retardation.

From the above, you will notice that services for the mentally retarded resons in Thailand do not meet their demands and are still insufficient for the total mentally retarded population of 540,000 at present. The main services are mostly provided in Bangkok with very little or no facilities available in remote areas. This insufficiency is due to -

1. Lack of financial Assistance
2. Lack of qualified personnel
3. Lack of advanced knowledge in educational, occupational and rehabilitational for the retarded persons

In conclusion, the ministry of Public Health has already planned to incooporate whith the other 3 ministries including nongoverment organization to provide all kinds of services to the M.R. persons in a wide scale - to serve the demand of this group of population which is part of human resources development.

<Medical Services>

MEDICAL TREATMENT OF AUTISM - PRESENT AND FUTURE

HIROSHI KURITA
National Institute of Mental Health, NCNP, Japan

Introduction

Medical-research on autism for the last four decades has yielded diverse findings that suggest certain kinds of brain dysfunction to underlie the condition. These results corrected the initial misunderstanding that the cause of infantile autism was the disturbance or failure in the mother's care of her infant. As reflected in the transition of the understanding of the cause of autism, its first-choice treatment changed from a psychoanalytically-oriented playtherapy to behavior modification and educational methods. Attempts of medical treatment as represented by pharmacological therapy have also been increasing in keeping with the advancement in etiological studies on autism.

An Overview of Medical Research on Autism

Cognitiveandneurodevelopmentaldisturbances
Cognitive dysfunction in autism has been confirmed through comparative studies on the profile of intellectual functioning between autistics and controls (i.e., mental retardation, developmental language disorders). These results indicate that autistic children are relatively excellent in terms of rote memory and visuospatial skills, while they are inferior in reasoning and concept formations.
Autistic children also may show neuro-developmental problems (e.g., clumsiness, difficulty in imitating gestures) and clinical pictures fairly similar to those of minimal brain dysfunction or learning disabilities. The establishment of handedness of autistic children tends to be delayed.

Neurophysiologicalstudy
EEG abnormalities, which tend to increase with advancing age toward the end of adolescence, are believed to exist in 20 to 40% of autistics. Epileptic attacks emerge in 10 to 20% of autistic children by the end of their adolescence (5). The latency and transmission time of auditory brain stem responses may elongate in infantile autism (15).

Biochemicalstudy
Neurotransmitters have been the research focus in this area. Hyperserotoninemia in roughly one third of autism seems established, though some autistic children do show a low serotonin level (14). Results of studies on catecholamines are not so uniform as those on serotonin.

Neuropathologicalstudy
Neuropathological studies are scarce because of the difficulty in obtaining appropriate materials. A few such studies indicated no definite abnormality except for the result by Ritvo et al. (12) that the number of Purkinje cells is significantly lower in autistics than in controls.

Morphologicalstudy
Hauser et al. (9) demonstrated pneumographically a pathological enlargement of the temporal horn of the left lateral ventricle in autism. CT studies disclosed abnormalities in about 20% of autistic children (8). The results of PET scan on autism (13) were somewhat equivocal. A latest MRI study (4) suggests a possible structural maldevelopment of a part of vermis in autism.

Geneticstudy
Genetic factors are implicated as a part of multiple causations of autism. A high incidence of cognitive deficits among sibs of autistic probands in monozygotic twins suggest that autism per se is not inherited but a broader cognitive deficit could be an inheritable trait (6). In multicenter studies in the U.S.A. (2) and Sweden (1) showed that Fragile X syndrome existed in about 10% of male autistics.

Associationofotherdiseaseentities
Up to now, there have been sporadic reports that infantile autism is associated with various discrete disease entities, including single gene diseases, such as phenylketonuria. These facts suggest that infantile autism could not result from a common single causation.
The cause of autism is quite difficult to clarify in an individual case. Results of etiological studies on infantile autism suggest that it is reasonable to consider infantile autism as a behaviorally defined clinical syndrome emerged on the basis of certain kinds of brain dysfunction, the nature of which could differ somewhat among its subgroups.

Medical Examination

In view of diverse medical problems in infantile autism, detailed medical check-ups are the essential first step of medical treatment of autism. Neuropsychiatric and pediatric neurological examinations, developmental assessments, EEGs, CT, and screening of metabolic diseases and Fragile X syndrome are recommended to be adopted as routine procedures in every clinic for developmentally disabled children.

Medical Treatment

Historicaltreatment
Historically, even an electroconvulsive therapy and insulin coma therapy were tried on autistic children without avail. A combination of psychoanalytically-oriented playtherapy for autistic children and counseling for their parents was once a dominant remedy for autism. These treatments were based on the assumption that infantile autism is a an earliest form of schizophrenia. And they faded away with expanding knowledge about the nature of infantile autism and its difference from schizophrenia.

Pharmacologicaltherapy
In the light of the high incidence of epilepsy among infantile autism, the importance of antiepileptics for autistic children with epilepsy is apparent. However, other medicaments still appear equivocal in their effectiveness for infantile autism. To date, no medicine is demonstrated to be effective for mental development of autistic children. For example, fenfluramine, which appeared to improve intellectual functioning of autistic children theoretically through reduction of blood serotonin level in its earlier clinical trial (7), is turning out to be problematic through nation-wide trials in the U.S.A. The effects of megavitamins are not widely accepted despite the claim of their effectiveness by advocates. Pentoxifylline, effects of which for autism were once claimed by several prominent child psychiatrists in Japan, failed to demonstrate such action in multi-center double-blind trials. Naruse et al. (11) demonstrated an effect of tetrahydrobiopterin, which is a cofactor of tyrosine and tryptophan hydroxylases, to ameliorate autistic symptoms in a preliminary placebo-controlled double-blind trial, but their results must be replicated.
If a curative medicine for infantile autism is to be found, it must have a sound pharmacological rationale based on a certain biochemical alteration common in a subgroup of autism and must be by no means a panacea but a remedy only to that subgroup. Still there is a huge gap between the results of etiological studies and rationales of the effectiveness of medication as well as between the pharmacological basis of medication and its real effects.
As shown in the effects of some antipsychotic drugs (e.g., haloperidol, pimozide ), the majority of drugs so far proven useful for autistic children are in fact effective mainly for abnormal behaviors (3, 10). Autistic children usually have a lot of behavior problems, which hinder considerably educational and vocational training as well as their social adjustment. Autistic children are also likely to exhibit strong compulsive acts especially in adolescence. To control abnormal behaviors of autistic children and adolescents are undoubtedly beneficial for their education and vocational training. So long as medication is not curative for autism, it is best to be integrated with other types of therapy, especially remedial education.

Otherissuesinmedicaltreatment
Autistic children are by no means immune to various physical diseases as their non-handicapped peers. Autistic children, especially severely retarded ones, don not complain adequately pains and discomfort. Instead, they may express their sufferings in the form of disruptive behavior (e.g., self-injurious behavior, aggressive behavior, temper outbursts). Their physical diseases tend to be overlooked. Caretakers of autistic children must be keen to notice even a subtle change in behavior or mood of their autistic children, because such a change can be an early sign of a serious physical disease.

Conclusion

In view of the status quo of medical treatment of autism, we still have a long way to go before we obtain an effective medication for autism, even though the future of medical treatment of autism may be promising. In addition, such a medicine could be useful not for all autistic children but for a subgroup of them that shares a common biochemical alteration, on which the rationale of the drug is based. As to symptomatic treatment, we have already had several medicaments to deal with problem behaviors of autism. It seems sensible to integrate such a medical treatment with remedial education to build a broader framework of treatment of autism.

References

1. Blomquist, H. K., Bohman, M., Edvinson, S. O. et al.: Frequency of the fragile X syndrome in infantile autism. A Swedish multicenter study. Clin. Genet., 27:113-117, 1985.
2. Brown, W. T., Jenkins, E. C., Cohen, I. L. et al.: Fragile X and autism: A multicenter survey. Am. J. Med. Genet., 23:341-352, 1986.
3. Campbell, M., Anderson, L. T., Small, A. M. et al.: The effects of haloperidol on learning and behavior in autistic children. J. Autism Dev. Disord., 12:167-175, 1982.
4. Courchesne, E., Yeung-Courchesne, R., Press, G. A. et al.: Hypoplasia of cerebellar vermal lobules VI and VII in autism. N. Engl. J. Med., 318:1349-1354, 1985.
5. Deykin, E. Y. and MacMahon, B.: The incidence of seizures among children with autistic symptoms. Am. J. Psychiatry, 136:1310-1312, 1979.
6. Folstein, S. E. and Rutter, M. L.: Autism: Familial aggregation and genetic implications. J. Autism Dev. Disord., 18:3-30, 1988.
7. Geller, E., Ritvo, E. R., Freeman, B. J. et al.: Preliminary observations on the effect of fenfluramine on blood serotonin and symptoms in three autistic boys. N. Engl. J. Med., 307:165-169, 1982.
8. Gillberg, C. and Svendsen, P.: Childhood psychosis and computed tomographic brain scan findings. J. Autism Dev. Disord., 13:19-32, 1983.
9. Hauser, S. L., DeLong, G. R. and Rosman, N. P.: Pneumographic findings in the infantile autism syndrome: A correlation with temporal lobe disease. Brain, 98:667-688, 1975.
10. Naruse, H., Nagahata, M., Nakane, Y. et al.: A multi-center double-blind trial of pimozide (Orap), haloperidol and placebo in children with behavioral disorders, using crossover design. Acta Paedopsychiatr., 48:173-184, 1982.
11. Naruse, H., Hayashi, T., Takesada, M. et al.: Therapeutic effect of tetrahydrobiopterin in infantile autism. Proc. Jpn. Acad., 63:231-233, 1987.
12. Ritvo, E. R., Freeman, B. J., Scheibel, A. B. et al.: Lower Purkinje cell counts in the cerebella of four autistic subjects: Initial findings of the UCLA-NSAC autopsy research report. Am. J. Psychiatry, 143:862-866, 1986.
13. Rumsey, J. M., Duara, R., Grady, C. et al.: Brain metabolism in autism. Resting cerebral glucose utilization rates as measured with positron emission tomography. Arch. Gen. Psychiatry, 42:448-455, 1985.
14. Takahashi, S., Kanai, H. and Miyamoto, Y.: Reassessment of elevated serotonin levels in blood platelets in early infantile autism. J. Autism Child. Schizophr., 6:317-326, 1976.
15. Tanguay, P. E., Edwards, R. M., Buchwald, J. et al.: Auditory brainstem evoked responses in autistic children. Arch. Gen. Psychiatry, 39:174-180, 1982.

<Medical Services>

EPIDEMIOLOGY AND COMMUNITY CARE OF THE SEVERELY MULTIPLY HANDICAPPED IN JAPAN

KITOKU OKADA
Sapporo Ayuminosono Training School & Hospital, Sapporo, Japan

1. INTRODUCTION

The severely multiply handicapped children in Japan are defined by the Child Welfare Law as those who have double handicaps of severe mental retardation and severe motor dysfunction. There is an exclusive system of institutionalization for them which includes the specially designated residential institution and the expenditure responsibility of National and Prefectural Goverments.
This special institution might be very exceptional among countries in the world. In most advanced countries in social welfare, such handicapped people have been accepted at the hospital care units or the intensive care units of the ordinary institutions designed for the mentally retarded.
In the past time, until about 25 years before, it was very difficult in Japan to accept such severe individuals neither at their homes, nor at any traditional institutions for the mentally retarded or the physically handicapped. There were often sad occasions that parents killed their retarded child, or that a mother committed suicide after killing her handicapped child. The affairs attracted the attention of the public. Some TV companies and newspapers took up the problem and campaigned for administrative establishment so that the severely and profoundly handicapped children could be accepted in the specially designated residential institutions.
Prior to then, there was a pediatrician who had been fighting for those handicapped children at the Red Cross Maternity Hospital in Tokyo. He was Dr. Teiju Kobayashi, chief of pediatrics and director of the attached baby-nursing home. He moved there just after the World War II from Keio University Hospital, where he had had many children with various disabilities before the War. His first inpatient at the baby-nursing home of the Red Cross was a severely handicapped baby, that was the same situation when he accepted the first inpatient at the pediatric ward of hospital. Soon later, he began special clinic for the handicapped, since a lot of disabled children were coming to him for consultation. There were always 25 to 30 children with various severe handicaps admitted to his hospital or baby-nursing home.
In 1956 an administration office gave a notice to Dr. Kobayashi that the medical treatment for the handicapped children would not be approved since it seemed non-effective to them. He protested against the dicision and made up his mind to appeal to the public opinion concerning the existence and the real situation of the children. The National Congress on Social Welfare held in 1958 adpoted Dr. Kobayashi's proposition, and then decided to organize a special committee in order to investigate how to serve these children. At this congress, "severely muItiply handicapped children" was determined as an official term.

2. ADMINISTRATIVE ESTABLISHMENT

The National Government decided to start a policy for these handicapped children in 1963, although it was not based on legislation. Since medicare-provided residential facilities were considered as the only way to solve the problem, the new institution was determined to have functions of hospital which should be controled by the medical acts. Two institutions were first authorized by the Government in 1963, SHIMADA RYOIKU-EN in tokyo and BIWAKO GAKU-EN in Shiga Prefecture. Subsequently, the Ministry of Health and Welfare decided in 1966 to put habilitative wards in National Sanatoriums in order to accept the severely multiply handicapped.

3. LEGISLATION OF RESIDENTIAL FACILITIES

In 1967 August, the Child Welfare Law was amended. The definition and the residential institutions of the severely multiply handicapped children were just specified in the law. According to the amendment, "the severely multiply handicapped children" was defined as those who suffer from both severe mental retardation(IQ below around 35) and severe physical disabilities(nonambulation). Individuals above 18 years of age with the same impairments, who had been assumed to be exceptional in existence because they were supposed to die by the middle of teenage, were determined to be treated by the same law.
The legislation had an effect on the spread of the private or public institutions throughout the country.

4. EPIDEMIOLOGY AND CAPACITY OF INSTITUTIONS

At present, 59 institutions and 80 National Sanatoriums are available for the severely multiply handicapped, which include about 14,560 beds. An exact population of those people in Japan is still unknown. However, it could be estimated at about 30,600 due to the investigation of the Child Consultation Centers in Aichi Prefecture that an appearance rate in the general population was 0.0253 %. Aichi Prefecture is presumed to be best in detection of the severely multiply handicapped.
Recently, the residential institutions for those children have not always been fully occupied. About 90 percent(approximately 13,100) of the total beds are used because of various reasons concerning institution management. In addition, 30 percent of the institutionalized individuals are not identical to the definition, who are ambulatory or mild/moderate in mental retardation. Therefore, the number of institutionalized severely multiply handicapped persons in the precise criteria might be considered as about 9,100(30 % of the total). Thus, nearly 70 percent(approximately 21,500) are living at their homes.

5. HOME-BOUND INDIVIDUALS

The surroundings of the severely multiply handicapped have markedly changed in these 10 to 15 years. Most of the home-bound individuals have no significant problems today, as far as their own daily lives. Now it is a general trend that parents and families want to care for them at homes as far as possible. The reasons why such change of situation has been made might be considered as follows,

1. The social recognition and the neighborhood cooperation have been better.
2. The various facilities in community-base have progressed.
3. Social aid systems for home-care(special child rearing allowance, exemption of medical expence, delivery of home-helpers, short-term care in urgent need, income tax exemption, etc.) have been widely established.
4. The standard of living has been better owing to the increase of the national income.
5. The informations, techniques, instruments and supplies for home-care have extremely progressed.
6. The concept of normalization has been widely supported, and people believe that the handicapped persons should be living as far as possible at their homes.

However, parents cannot deny the need of residential institutions. According to our investigations on the home-bound handicapped, their parents and families are labouring hard to support the daily life of the handicapped. Therefore, the system of institutionalization for the severely multiply handicapped will be very important when;

1. intensive medical care needed.
2. some special training or therapy needed.
3. residential facilities needed because of various familial reasons.
4. parents or family need a short-term stay care for vaccation, leisure, recreation, or cultivating a taste, etc.

6. THE ROLE OF INSTITUTIONS

Today's institutions for the severely multiply handicapped should expand their own function in order to accept the needs of home-bound individuals. For this purpose, the institutions are expected to possess such function as the out-patient clinic, day-care services, community services, tentative administration, and short-term stay for the mother-and-child, etc. The trials for this reform have already been promoted at the most institutions during these several years, which are called "socialization of institution" or "institution-opening toward the community".
The recent progress of perinatology and its related technology has been bringing a big change in the appearance of handicapped children. The handicaps caused in the perinatal period have been markedly reduced in ratio, and those caused by congenital abnormalities or various pathological processes after the childhood have been increased instead. It is often pointed out that the recent handicapped children have been apt to separate into two contrastive categories; the first is the children with a very mild symptom, the other is those who have severe and often multiple handicaps. The latter usually suffer from serious damages of the central nervous system, and most of them reveal the similar disabilities to those of the severely multiply handicapped children.
The role of the specially designated institutions for them is respected to become increasingly important hereafter.

<Educational Services>

INTERNATIONAL TRENDS IN SPECIAL EDUCATION OF PERSONS WITH INTELLECTUAL DISABILITIES

PETER MITTLER
Professor of Special Education, University of Manchester, U.K.

With the end of the century only 12 years away, it is time to look to the future, and to ask what changes would we like to see and are prepared to fight for in the next half century for all disabled children but particularly for those with severe intellectual disabilities?

First, we would expect that all children will attend schools, no matter how severe their disabilities. This goal does not seem so far off to those who live in countries in which education is compulsory for all children. UNICEF estimated that of the 140 million disabled children in the world, 120 million live in developing countries - 88 million in Asia, 18 million in Africa, 13 million in Latin America, 11 million in Europe and a mere 6 million in North America. In the 20 year period between 1980 and 2000, the total number of disabled children and adults of all ages is likely to rise from 400 to 600 million. Rough estimates from UNESCO and other international agencies suggest that less than one per cent of disabled children in Eastern and Southern Africa are going to school.

Despite these stark contrasts of scale, some positive trends can be found. A recent UNESCO survey showed that in 48 out of 58 countries responsibility for the education of all disabled children now lies with Education Ministries both at national and state levels, rather than with health or social welfare authorities, or with no one at all, as in the past (UNESCO 1988). But school attendance was not always either possible for families or enforced by the authorities. Secondly, an increasing number of countries have passed legislation specifically concerned with the admission of disabled children to schools. Thirdly, there is growing evidence of a commitment to educate children with disabilities in ordinary schools.

These developments should be seen as part of a world wide movement in the direction of greater emphasis on primary health care and community based rehabilitation. Community based rehabilitation builds on the basic training of local health workers in order to help families and local communities support and assist children and adults with disabilities to learn skills which are essential to independence and survival in the community. David Werner's masterly manual Disabled Village Children, (Werner, 1987) is likely to become highly influential.

SCHOOL AGE CHILDREN: THE CHALLENGE OF INTEGRATION

It has been said that what children need is not integration but education. Integration is now the central issue of special education and indeed of education itself. Furthermore, the integration of children with intellectual disabilties represents perhaps the most difficult educational challenge of all, given the disabilties of the children and the attitudes and expectations of adults.

Developing countries wishing to plan educational facilities for disabled children therefore face a difficult dilemma. Some experts advise them not to repeat the mistakes of the West by building special schools; they tell them they have a golden opportunity to start with integration in the first place. On the other hand, the ordinary schools in most of these countries are hopelessly overcrowded, the teachers are not adequately trained and the curriculum is centrally prescribed and does not lend itself to indidividualisation.

Priority in most countries goes to children with visual, hearing and physical impairments; children with intellectual impairments are nearly always the last to be considered either by governments or schools. Many special schools claiming to provide for 'mentally handicapped children' in fact admit only those with mild or moderate levels of intellectual disability and only then if they are toilet trained and have no major behaviour problems. Those with severe and above all profound and multiple disabilities are the most frequently excluded, even in some countries with advanced systems of education or special education.

STEPS TO RESPONSIBLE INTEGRATION

In our zeal to open ordinary schools to disabled children, we should not assume that special education necessarily means a either a poor quality education or even a segregated education. Closing special schools and simply placing children in ordinary schools is not integration or mainstreaming; it is maindumping.

A responsible integration policy would seek to ensure that every intellectually disabled child attended either their nearest neighbourhood school or at least a specially chosen ordinary school with additional staffing and resources and a staff with proven commitment to meeting the needs of all children. A study of the literature suggests that successful integration is certainly possible (Hegarty, 1987; Mittler and Farrell, 1987). The ingredients of success can be summarised in one word - support.

Support is needed for the children to ensure that they can participate in the learning activities of the classroom and the social activities in the playground and in the neighbourhood. Support is needed by teachers in the ordinary school from specialists with experience of children with special needs in general and those with intellectual disabilities in particular. These support teachers can work with the class teacher to assess what the child can already do and decide jointly with the parents about priorities for teaching, about methods and techniques which may help the child to learn without segregation from other children. Support from other children is another prerequisite of success. The view that "children are cruel" is not borne out by research. Children are supportive of those who have obvious difficulties; they tend to mock those who are most like themselves. Children have been encouraged to help those with difficulties.

Support from the community is also essential. Sometimes, a parent or relative will not only accompany the child but stay in the classroom and act as an assistant to the teacher - not just with the child who is disabled but with the class as a whole.

Support from and to the child's family is vital. If the family and the school are both committed to the child attending the local school, successful integration is much more likely.

Full integration in the ordinary classroom will not be practical or in the interests of all children with intellectual disabities. However, it is quite possible to create one or more special classes for such children in a small number of carefully selected ordinary schools. Such a plan involves the transfer into these ordinary schools of two or three whole classes of children, together with their teachers and teaching assistants and a guarantee of a high level of support from both teachers and therapists. Such classes can provide a starting point for a step by step plan for individual integration into the ordinary class.

AFTER SCHOOL, WHAT?

In Western countries we are used to thinking about young people leaving school at around 16. An increasing proportion of young people continue in full time education until they are in their early 20s or beyond. But even in the West, most young people with intellectual disabilties leave school at around 16, although this is the very time when many of them are just beginning to show a real interest in learning and to make progress in mastering basic educational skills. This is not surprising, since the level of intellectual maturity of many school leavers corresponds in some respects to that of a non-handicapped child of five or six.

People with intellectual disabilties need to be helped to learn and to take advantage of opportunities for life long continuing education for the whole of their lives, if that is what they would wish. Here again, they should not be segregated from other adults but should be helped to participate in community educational projects. These may be in community centres or colleges, in adult education institutes, in pre-vocational or vocational training, in any setting in which people meet together to develop their knowledge and skills. This is the giant task that confronts us in the decades to come.

REFERENCES

Hegarty, S. (1987) Meeting Special Needs in Ordinary Schools. London: Cassell.

Mittler, P. and Farrell, P. (1987) "Can children with severe learning difficulties be educated in ordinary schools?" European Journal of Special Needs Education, 2, 221-236.

UNESCO (1988) Review of the Present Situation of Special Education. Paris: UNESCO (in press)

UNICEF (1981) "The disabled child: a new approach to prevention and rehabilitation". Assignment Children 53/4, Geneva: UNICEF

Werner, D. (1987) Disabled Village Children. Palo Alto, Calif.: Hesperian Foundation.

<Educational Services>

DEVELOPMENT AND PROBLEM OF THE LIFE-CENTERED EDUCATION IN JAPAN

SUSUMU KOIDE
University of Chiba, Chiba, Japan

(1) Education for mentally retarded children after the Second World War

In August of 1945, our country lost the Second World War. After the war, our edutation for mentally retarded children started from scratch. During the post war, special classes (in Primary, Junior High School) were the center of the education for the mentally retarded children.
New education system started under bad conditions such as socially, economically and culturally after the war. Obviously, these children as a whole, began to show a declin in scholar. To make an emergency measures for the decline in scholars, schools tried to gather those who were not able to follow the subject matter taught in clases, and make a class for them. And children who were not able to follow it were gathered in a group which was known as a special class.

(2) Farewell to water-down curriculum

If there are classes for children who are not able to follow it, then the classes had to aim at making them understand the subject matter. By doing so, the studying materials were made teaching in lower levels, preparing carefully and using repeat technique. This is so called "water-down education", which was to be afford.
In those days, those children who couldn't follow it and mentally retarded children were thought to be same to educate. So, they tend to teach those children in a class, without separating them exactly, with teaching method based on ordinary teaching method used in ordinary classes.

(3) Intending for the life-centered education

But, to realize the way of thinking or the method was not correct through personal experience did not take many days and years. They recognized specific characteristics of the mentally retarded children, then began to look for the original way to educate them.
The teaching method they tried to find would be a quite new way what had never been adapted in the school in the past. In other words, education without worring about the subject, studies which are not find in the textbooks and away from classrooms and desks were aims. As a result, "life-centered education " were found.

(4) Influence of American empiricism education

Life-centered education in Japan for mentally retarded children are to educate them through practical experience, which were put into action. But after the war, American empiricism were not able to be ignored. And this influenced Japanese education. In 1947. starting of a new education system under the cooperation from the GHQ, lectures and meeting from researchers were held. At the same time, many related materials from America were introducted, many proffessors came to Japan and at times they gave direct guidance. In 1952, Mr. Kaoru Yamaguchi and others translated "Martens, E. H. (ed.); Currilculum Adjustments for the Mentally Retarded, 1950" which had a great influence on Japanese education.

(5) Realization of the life-centered education

The educational goal for the life-centered education for the mentally retarded children were to make them independent by making them have the ability to earn one's living. This was important. And as a final goal, it was to make them socially independent. Therefore the matter of education is to predict the future, find what is needed at most for their future and select the studying matter. As the result, they must be able to take care of themselves, able to live in their social environment, and able to earn ones' living by mastering skills needed for one's occupation. These were found to be important.
How to instruct them were to emphasis the practical needs in their daily life. That is to have them study actual life. The word "level of actuality" is often used to measure how will it can provide good education to live in the acutual world. So the basis of teaching for good education is to improve "level of actuality".

(6) Spread of vocational education

The life-centered education for the mentally retarded children was strongly thought to be related to vocational education. The education goal for "social-independent" is "social adjustment" also "economical independent" is "working place adjustment". This is the way it was understood. Until above 1965, mentally retarded children thought to be the subject for education were those who had slight disability. With these people, and this kind of education, it's goal were complished.
After finishing from Junior High School, practical work training was given within the school. Also in other working place in the society.

(7) Establishment of the course of study

About 15 years after the war, there was the needed to make an adjustment in the system. So the course of study for the special school (for the mentally retarded children) was estalished. But from the life-centered education point of view, it was greatly opposed.
First of all, if there is the course of study legal basis from the government, then teachers who used one's own free will to device original ways and schools' having it's own education system would be destroyed and unified. And second of all, the educational way in which subject matter is decided by the course of study is inconsistent with the "life-centered" education. Also there is suspicious to go back to the water-down eduation.

(8) Degeneration of the life-centered education

According to the course of study instruction point, subjects and others for matter of education had to be choosen and organized were denied from every point of view. This idea had weaken. High spirit were among the people to look for more desirable subjects for the mentally retarded children. Subjects had to be expanded due to lower levels of mentally retarded children. Just studying subject in school may not connect with daily life. But through special instruction one may learn to live in the actual world.

(9) Education for the severely retarded

Around 1965, school education began to focus on children who are severely mentally retarded. For this reason, one part of the life-centered education had to be corrected.
Social-independent was important in the goal for mentally retarded education. But the meaning for "independent" had to be broaded. Instead of "independent", it would be "self-supporting life". Therefore, "self-supporting life" which means to try his best to support himself with least help from others.
In the past life-centered education was to aim on children's social-independence for their future. Prediction were made about their future. So that they can get education according to it. But after caring for the severely mentally retarded children, present needs must be taken care as well. In school life, playing is also necessary.

(10) Amendement and restoration of the life-centered education

Life-centered education means to take good care of childrens life. To have desirable children's life, prepare children life and help out is the meanings of education. It's not right to teach children through living,or to relate children's life to teach them. We should prepare children's life so that they can have a better living.
To prepare children's life, we must follow the first rule which is to prepare children's most desirable life. Second most important rule is to prepare the children's future after graduation school. Schools must help life for these people to adjust naturally into the world.
How can we make the most desirable life for these mentally retarded children adjust to the outside life is something we must think about in our school system and help. This is the main purpose in life-centered education is to think in a concrete form.

<Social Welfare Services>

THE AGING OF MENTALLY RETARDED PEOPLE IN INSTITUTIONS IN JAPAN

TAKEO KANETSUKI
Mizunokiryoh, Rehabilitation Facility for Mentally Retarded Adults, Kyoto, Japan

In general, people with mental retardation is said to age faster, at about the age of forty. However, this is a vague argument based on experiences and lacks scientifical grounds.
The researches conducted by the Japanese Association for the Care and Training of the Mentally Retarded between 1984 and 1986 ("The Aging Process of Mentally Disabled People" - Findings from the Research on the Actual Conditions of the Elder Mentally Retarded People - May 1987) has made clear some points which were unconfirmed up to then. Here I would like to introduce some of these points and go on further with the arguments on the actual conditions and the problems of the mentally retarded.

1. Outline of the research
This research consisted of three investigations on the population living in rehabilitative institutions for the mentally retarded.

1. First investigation (1984)
   On 3,123 institutionalized people above 40 years old (59 institutions, cross research)
2. Second investigation (1986)
   On 1,424 institutionalized people above 20 years old (10 institutions, cross and vertical research)
   The population under 40 years old was set as the control group and comparisons were made with that above 40. Individual changes over the two years from the first investigation were also observed.
3. Third investigation (1986)
   5 institutions from the second investigation were selected and on-the-spot examinations were conducted on 599 institutionalized people. (Mostly vertical research)

2. Findings from the research
After summarizing and analyzing the three investigations, the following was made clear regarding the aging of mentally retarded people.

1. Activities of Daily Life (ADL)
   Looking across, a trend to decline from around the age of 50 can be observed. (fig. 1) However, the results of the 2nd and 3rd investigations which observed individual changes with time was that for the population above 40, those who showed improvement or no changes in ADL was nearly 85%, while those who showed decline was 15%. For the population above 60, the ratio was 88% to 12%.
2. Social Adaption (SA)
   The relationship between the degree of SA and aging was the following. An upward trend from the mid-40's to around 50, no significant changes thereafter until around 60 to the mid-60's when a downward trend begins to be observed. (Fig.2)
3. Mental functions
   Mental functions reaches its peak around 50 in general, and continues to decline thereafter.(Fig.3)
4. Physical strength (standing on one foot and grip)
   1. Standing on one foot
      I will not comment on the details of the test to observe the equilibrium functions, for it was impossible to measure 40% of the population. However, a sharp decline was observed after 60.
   2. Grip
      The changes of grip with age differs considerably according to sex. Males showed almost no change until 60, but a sudden decline after that. Females showed a gradusl decline from the late 40's. (Fig.4)
5. Health conditions
   There is a notable trend to decline after60. The number of people that need special health care such as periodical medication increase with higher age.
   However, looking at the individual changes with time, the number of people who lessen their need for health care is large until around 40, but from the late 50's to 60's and thereafter, the need increases with each age gained.(Fig.5)
   Summarizing the above, 60% of the people are almost completely healthy even in their late 50's. After 60, the situation changes and on entering the 70's, the population is divided into two poles. 70% are ill and need special care, 30% are still very healthy. Great indivisual differences can be assumed regarding health conditions. Looking further into the individual's changes with time, an increase in the speed of decline of physical functions with age gained can be observed.
   Also, when the percentage of mentally retarded people above 40 who are ill was compared to the national health survey, the risk of mentally retarded people becoming ill was 4-5 times greater.

3. Services in live-in institutions and the aging of the mentally retarded
Recent researches in the US reports that mentally retarded people who receive services directed toward the community have a higher degree of adaptive activity compared to those living in institutions. However, here the differences in size and quality of the services between American "institutions" and Japanese "institutions" must be made clear.
Looking at the research findings reported in this paper, activities of daily life shows improvement in the late 50's overall. A positive interaction of institution services can be assumed behind this progress.
According to on-the-spot research reports, there were many examples where people in their 50's and 60's worked outdoors among young people, and also took the leadership. The grip of such people were superior even when compared to healthy people. There are individual differences in people's physical strength and abilities given at birth, but the changes which occur with aging seems to be affected by how the environmental factors work upon such natural abilities and conditions. The same could be said of the degree of social adaptivity. Mental functions are observed to develop until around 50. This can be said to be due to the positive stimulates given by institutional functions. The percentage of mentally retarded people with illness increase with age, but for some types of illnesses, the trend is to decrease. Although the percentage of those who are ill is high, it can be said that people are un-expectedly leading a happy life in institutions where health, medication, nutrition and excercise are well-supervised. At the least, for mentally retarded people up to the age of 60. Japanese live-in institutions can be said to be a meaningful exsistence.

4. Points of notice regarding the services of live-in institutions
There is an indication that "the life expectancy of mentally retarded people depends upon the degree of disability on one hand, and the quality of the various elements/conditions of daily life and care on the other". There exists peculiar phenomenons of early aging due to therapy-resistant epilepsy and chromosome disorders such as Down Syndrome, and the need for health supervision, e.g. geriatric disease examinations and medication need not be mentioned.
Here, I would like to comment on some points of notice in providing institutional services for the prevention of senility.
The securing and preserving of a "life worth liging" is important from a psychological point of view. From a physical point of view, care for meal and nutrition, health and medical measures, securing of an adequate amount of excercise can be given.
The sense of being needed is the greatest factor in making a life worth-while for humans. To make this possible in live-in institutions, the following should be noted in providing services.

1. The maintaining and elevation of cultural standards within the institution,
2. that the institution and community be directly tied together and social interaction be preserved and encouraged on a daily basis,
3. that by the above conditions being realized, those in the institutions gain a sense of belonging to the society,
4. that each individual have a hobby or job they can seriously lend themselves to, and their accomplishments be valued and enjoyed by others. Commenting on hobbies and jobs, creative activities are very effective in stimulating the will to live of mentally retarded people.

5. End
The problems which occur at old age are coupled with the aids and services at each previous stage of life - infant, child, adolescence, manhood.
It is necessary to acknowledge the problems of aging as the terminal stage of the life cycle and to make it consistent with the aids and services in each stage of life.
Hereafter, practices and researches on the question of the position and role of institution's aid services in this life cycle should be deepened.

<Social Welfare Services>

THE RIGHTS OF SEXUALITY AND SEX EDUCATION FOR PERSONS WITH MENTAL RETARDATION IN JAPAN

KATSUHIRO YAMASHITA
Makibito-Kai (Social Welfare Juridical Person), Japan

1. Introduction:

Recently, the rights of sexuality and sex education for persons with mental retardation in Japan has become a major problem for discussion from the point of view of human dignity and basic human rights.

This report is a brief summary of both where we now stand on the current situation and what are the most important actions which should be taken on this problem.

2. The definition of sexuality:

The right of sexuality is used in this presentation is defined as follows.

The right of sexuality for persons with mental retardation is the right to live in society as male or female according to their biological age, intellectual ability, and degree of development. They also have the rights to decide choose by themselves regarding their roles and functions as male or female concerning their daily lives including in their homes, at their working place, and in society. Therefore, sex education for persons with mental retardation is defined as supporting activities by the educational program and methods for them to acquire the abilities which are mentioned above.

3. The current situation of sexual problems and sex education for persons with mental retardation in Japan:

I have send out questionnaires to both superintendent and staff members of residential facilities and day-centers for the mentally retarded peoples to collect date on this subject. The main conclusion that I have drawn from these situations and the questionnaires is as follows.

1. The sexual problems of persons with mental retardation. 80 percent of residential facilities and day-centers for the mentally retarded in Japan are faced with sexual problems of the resident. These problems belong in the field of their daily life such as "Dating" (34%), "Masturbation" (31%).
2. The job training for staff members in connection with sexual problems. 95 percent of residential facilities and day-centers for the mentally retarded in Japan take the necessary actions about on the sexual problems of the resident after it has happended. This shows us that sex education is provided after problems, not before. Regarding these matters, 72 percent of residential facilities and day-centers do not have any supervisors in the field of sex education.
3. Supporting activities in the residential facilities and day-centers. As a specific example in the case of the residential facilities and day-centers, 80 percent of the resident who have been married have not received any lessons or guidance about sex.

4. The consciousness and opinion of staff members on sex education for persons with mental retardation:

The main conclusion which the questionnaires have lead to is as follows.

1. The purpose of sex education for persons with mental retardation.
   68.5 percent of staff members are now gaining a clear understanding concerning of the importance of sex education for persons with mental retardation, 55 percent of staff members, however, think that the main purpose of sex education is to prevent sexual wrongdoing by persons with mental retardation before it happens, 75 percent of staff members find it difficult to agree to implementing sex education for persons with mental retardation if their parents or family are opposed.
2. Factors obstructing the development of sex education:
   The lack of mutual understanding and agreement on the purpose and activities of sex education (29.4%), the negative attitude of staff members with regards to sex education (16.6%) and the lack of teaching experience concerning sex education (10.8%). All are factors which obstruct the development sex education in the institutions and day-centers.
3. Factors promoting the development of sex education:
   The mutual understanding and agreement of staff members on the purposes and activities of sex education (35.5%), the cooperation and understanding of the family members (24.6%), the progress of the staff's teaching skill (12.7%) are the major factors.

5. The trends and prospects for sex education for persons with mental retardation in Japan:

The date and current situation which has been presented supports the need for implementing daily training programs and activities. It is a natural tendency that the contents of programs or activities in field of the sex education are now being consolidated according to the ADL (activities of daily living) training and behavioral training in social adaptation.

Therefore, the top priority should be given to the mutual understanding and agreement on the following matters to respect the rights of sexuality of persons with mental retardation in Japan. We must also have the responsibility to put them into practice in daily lives for persons with mental retardation.

1. Accept the sexuality of persons with mental retardation as basic human rights.
2. Establish the staff and family members the mutual understanding and agreement about the purpose and content of the sex education for persons with mental retardation, especially at residential facilities and day-centers.
3. Improve and promote not only the social environment, but also the service system for persons with mental retardation who can use their rights of sexuality in their daily lives.

6. Conclusion:

Today, the philosophy, policy, and supporting system of social welfare for persons with mental retardation in Japan are based on the principle of normalization. It makes it clear that all persons with mental retardation have dignity as human beings and are entitled to the same guarantees as other citizens. We must, however, establish basic guidelines and concrete plans for sex education to be put into operation as soon as possible. If this is done in all places where persons with mental retardation live they will be able to live their lives as human beings with the right of sexuality.

<Vocational Rehabilitation Services>

JOB SUPPORT PROCEDURES FOR WORKERS WITH SEVERE INTELLECTUAL DISABILITIES IN OPEN EMPLOYMENT

G. M. LEWIS
Project Employment (Perth) Inc, Australia

INTRODUCTION
Project Employment (Perth) Inc has operated as an employment agency for job seekers with an intellectual disability for more than four years. In the past two years the agency has expanded its operations to provide services for job seekers with any disability - including physical, sensory and psychiatric. More than 300 job seekers with disabilities, of whom some 200 have an intellectual disability, have secured award (prevailing) wage open employment as a direct result of Project Employment's activities. Approximately two thirds of all people placed continue to work in open employment.
An analysis of workers with an intellectual disability revealed that one-fifth had an IQ in the borderline range, one-half had an IQ in the mild range and one-third had an IQ in the moderate to severe range. The age of workers with an intellectual disability ranged from 14 to 45 with a mean of 18 years. Two-thirds of workers were male and one-third female. The great majority (80 percent) of workers lived at home with their families with the remainder spread equally across shared houses (staffed), shared houses (unstaffed), with spouses or alone. One-third of all workers with an intellectual disability entered open employment directly from a special class or special school, one-fifth from a sheltered workshop or activity therapy centre and most of the remainder were unemployed at the time of securing employment. (Lewis, Robertson, Lawn and Roberts, 1987).
An analysis of the performance of workers with an intellectual disability placed by Project Employment (Perth) Inc revealed that the vast majority of workers were performing at or above the levels of their non-disabled co-workers in the critical areas of productivity, safety, absenteeism and turnover. These levels were sustained irrespective of the workers' individual IQ, age, sex, transportation, communication, computation, reading or writing skills (Lewis, 1987).
JOB SUPPORT PROCEDURES
The long term success of these workers in the open workforce under normal competitive conditions is due in large part to the comprehensive Job Support system that has been developed and documented by Project Employment. (Moore and Lewis, 1985; Lewis, Lawn and Navarro, 1987).
This system is an extension of the principles and techniques pioneered by Marc Gold (Gold, 1980) and Tom Bellamy (Bellamy, Horner and Inman, 1979; Bellamy, O'Connor and Karan, 1979) in the area of supported employment for people with severe intellectual disabilities. In essence, the system is based on a place-then-train model where a targeted job for the respective job seeker is first located and secured and the agency's training resources are committed to on-site support. The sequence of operations entailed in on-site support is described in the following sections.
The Employer
Two days prior to the job commencing, the Work Trainer approaches the company and arranges to meet with key personnel with whom the worker is likely to come into contact in the course of his duties. This might include supervisors, leading hands and/or proximal co-workers. It is likely that these individuals were not involved, nor consulted, with respect to employing a worker with an intellectual disability. This, in itself, may result in some resentment and resistance from company personnel who may, in addition, harbour negative stereotypes about people with an intellectual disability. For example, staff may assume that the worker will not be able to safely operate machinery. They may wonder how they are going to communicate with the individual or relay instructions. They may fear that they will have to assume additional "chaperoning" duties as a result of the individual's presence in the company or work harder to make up for under-productivity on the part of the new worker. All these misconceptions will need to be identified and discussed.
Next the Work Trainer must clarify with the manager, supervisor and/or leading hand the worker's duties. The following information will need to be collected: What duties will the worker be expected to perform? Are these duties likely to change in the near future? How frequently will each task be performed? How will the worker know when to perform each task? Who will give directions to the worker? Who will check the quality of work? Are certain tasks of higher priority? What should the worker do in the advent of having insufficient work?
Once these questions can be answered adequately the Work Trainer is in a position to formulate a precise Duty Statement which can be agreed to by all parties. The Work Trainer will also use this opportunity to explain his role in the workplace. He will make it clear that he is not just an "extra pair of hands", he is not a surrogate supervisor, he is not a company "efficiency expert" and he is not a welfare officer for all company employees with personal problems. As a Work Trainer dedicated solely to the successful placement of the worker he has undertaken to: work through the worker, not for the worker; act upon supervisor instructions, not to take over the supervisor's role; and facilitate worker/co-worker interactions, not substitute for them.
The Job
Once the Duty Statement has been formulated the Work Trainer undertakes an ergonomic analysis of the duties - which involves the scientific application of principles of speed and safety. The ergonomic system utilized by Project Employment is called Modapts Plus (Heyde 1978; 1981). Once the ergonomic analysis is completed and any job modifications discussed with management, a task analysis of all duties is undertaken. Task analysis serves multiple purposes in on-the-job training of workers with an intellectual disability. It breaks the job down into easy-to-teach and easy-to-learn steps.
It enables the Work Trainer to accurately gauge the worker's specific strengths and weaknesses - ensuring proper focus of training effort. It guarantees that task presentation is consistent. It permits the efficient and accurate collection of quality and quantity data. It allows an alternative Work Trainer to pick up training at the correct point using the correct method.
These task analyses are transferred to Project Employment's production forms which include also a job layout, equipment and materials lists, quantity and safety controls and quality and quantity assessment charts.
The Employee
Armed with the Duty Statement and Production Forms the Work Trainer next arranges to meet with the worker's key support group (be it parents, spouse, hostel staff). The exact nature of the worker's duties and conditions of employment are discussed and any misconceptions held by the key support group addressed. The important message to deliver to the family is that the worker has been hired on the understanding that he will perform like any other worker and, in return, will be treated and remunerated like any other worker. This implies that minor ailments should not automatically constitute a day off, medical appointments or visits to relatives should be scheduled out of work hours and employers should not be harangued over every minor problem that arises at work. Indeed, the Work Trainer will seek an undertaking from the key support group that any extraordinary communication between them and the employer should be relayed through the Work Trainer.
Having established the ground rules for family/company communications the Work Trainer next turns to transport - how the worker will get to and from work reliably and safely. If public transport is to be used the Work Trainer will map out the most efficient route and accompany the worker to and from work until he is satisfied that the worker can travel reliably without support. If the worker is planning to use his own transport (e.g. car, bicycle) an appropriate route will be devised and the Work Trainer will follow the worker in his own vehicle until he is satisfied that the worker can get to and from work confidently and independently.
Finally, the Worker Trainer will enlist the aid of the key support group in ensuring the worker gets up on time, is appropriately attired, has a proper breakfast and packs a suitable lunch. The Work Trainer will undertake to contact the key support group on a daily basis with updates on how the worker is settling into the workplace. This will continue until the worker is performing to company expectations independently of Work Trainer support.
The Work Environment
An important determinant of a worker's likelihood of retaining his job in open employment will be his motivation to continue working. Given that 50 percent of the workers who have separated from jobs found by Project Employment have done so of their own volition (Roberts, 1987) the importance of maintaining worker motivation cannot be understated. Robert Schalock has made the observation that the only two predictors of a successful outcome in competitive employment for workers with an intellectual disability are worker motivation and family support (Schalock, personal communication).
Many variables associated with the job, the co-workers, the management, the workplace or the outside world can act as powerful motivators or, conversely, job-threatening de-motivators. For example, the menial tasks (such as cleaning the toilets), that are normally the lot of the newest employee, may be taken by the worker as a personal affront and a subversion of his new found status as a regular employee in a regular job. The Work Trainer will explain to the disillusioned worker that all the regular employees performed these demeaning duties as part of their initial employment and to not do it would be tantamount to receiving "special" treatment. Occasionally a worker will run across an antagonistic co-worker. The Work Trainer will diffuse this situation as a matter of urgency and ensure that the co-worker does not become a de-motivating influence on the worker. Supervision styles of line supervisors can affect motivation to work and these will need to be analysed and acted upon. Workplace conditions such as heat, dust, light, noise and draught can act as de-motivators. Cheap and simple remedies can often be found by an experienced Work Trainer. As a corollary, workplace personalisation, such as the addition of a few photographs or a radio can make the workplace more attractive and, thus, a more motivating, friendly environment in which to work. The outside world can play a part in motivating the worker as well. Telling the worker that in just five pays he can buy that racing bike he has always wanted can do wonders for worker staying power.
Reinforcing is another critical aspect of the work environment. The types of naturally occurring reinforcers that might normally be available to regular employees include material reinforcers (pay cheque, company car, Christmas bonus), symbolic reinforcers (key to premises, not signing on, "cushy" jobs) and social reinforcers (supervisor praise, reputation as a good worker, positive social interaction). Few of these natural reinforcers will be available to the worker in the first few weeks of work - and some not for a very long time. The Work Trainer will be aware of this and ensure that he substitutes alternative reinforcers until natural reinforcers come into play. He will also work actively to bring forward those normal reinforcers so as not to make the worker unnecessarily dependent upon artifical reinforcement. With respect to production training, the early focus of reinforcement should be on worker input (attention to task, initiation, perseverence, responding to directions, accepting prompts and learning from mistakes). The later focus should shift to worker output (quality of work, quantity of work).
The Training Environment
Production training proceeds in two relatively distinct and sequential phases: quality training and quantity training. That is, the worker is taught first to perform his assigned duties at the required standard (quality) and, having attained that, is then taught to produce that standard of work at the required speed (quantity). The rationale underlying sequential training is that slow accurate workers are generally more valued by employers than fast, inaccurate workers (especially where material costs are high). Also it is normal practice in industry and, consequently, possesses face validity. From a training standpoint, it reduces the frequency of worker error early in training (a potential de-motivator), it reduces the frequency of work trainer intervention to error correct (a dependency trap) and it demands less over-the-shoulder surveillance.
The quality aspects of a job can be partitioned into two controlling factors: steps (the correct performance of each task analytic step) and chains (the correct sequencing of each task analytic step). Step and chain training are taught simultaneously using a total task presentation format. When the worker can independently perform all steps in the correct sequence over three probes on three consecutive days he is deemed to have met the quality demands of that task.
The worker then proceeds to quantity training. The Work Trainer utilises various techniques, called pacing prompts, to increase worker speed. First, it is necessary that the Work Trainer isolates where the production delays are residing. These delays could result from certain steps being performed too slowly, too much time being wasted between steps or unnecessary additional steps being inserted into the step sequence. The site of the production delay will determine the appropriate remedy. Once the worker can perform the task at the industry standard speed over three probes on consecutive days he is deemed to have mastered that duty. Once all tasks identified in the duty statement have been mastered according to the above criteria the worker is deemed to have mastered his job.
The Post-Training Environment
Until the point of job mastery on-site support has been provided full-time by the Work Trainer. Full-time support continues until several criteria are met. The worker must be performing at the appropriate quality and quantity levels. He must be sustained by naturally occurring reinforcers. He must be integrated into the company social network. He must be reporting satisfaction with his job and the employer must be reporting satisfaction with the worker.
Withdrawal of support then proceeds on a planned and gradual basis. The supervisor is asked to report back if the worker's production level slips away when the Work Trainer is off-site. If this does occur it is clear that the worker is still dependent on the Work Trainer's presence to perform at company standards. This will need to be resolved prior to the Work Trainer again contemplating work site withdrawal.
The Work Trainer will reduce his site visits to one per week for the six months subsequent to withdrawal from full time support and one visit per fortnight thereafter. In the alternate weeks the Work Trainer will make contact with the key support group. This frequency of contact with the workplace and home continues for as long as the worker remains in employment - in other words, indefinitely in the majority of cases. Follow-up schedules less frequent than once per fortnight have been found by the agency's Work Trainers not to give them sufficiently current information concerning issues or problems that may be surfacing on a job site.

SUMMARY
Project Employment's experiences in placing more than 200 people with intellectual disabilities into award wage open employment has led it to the following conclusions. A successful career for people with intellectual disabilities in open employment is predicated on a desire to work, the support of key persons in the job seekers life, realistic career choice, accurate job match and access to on-the-job training. On-the-job training must be planned, disciplined, high density and involve a four-way partnership between the worker, his key support group, the employer and on-site support staff.
REFERENCES
Bellamy, G.T., Horner, R.H. and Inman, D.P. (1979). Vocational Habilitation of Severely Retarded Adults: A Direct Service Technology. Baltimore: University Park Press.
Bellamy, G.T., O'Connor G. and Karan, O.C. (1979). Vocational Rehabilitation of Severely Handicapped Persons: Contemporary Service Strategies. Baltimore: University Park Press.
Gold, M.W. (1980). Try Another Way: Training Manual. Illinois: Research Press.
Heyde, G.C. (1978). The Sensible Taskmaster. Sydney: Heyde Dynamics Pty Ltd.
Heyde, G.C. (1981). Modapts Plus. Sydney: Heyde Dynamics Pty Ltd.
Lewis, G.M. Job Ready ... Who Isn't? Keynote Address to the 8th Asian Conference on Mental Retardation, Singapore, 1987.
Lewis, G.M., Lawn, R.W. and Navarro R.E. (1987). Rapid Entry Training: Field Manual. Perth: PE Publications.
Lewis, G.M., Robertson, S.K., Lawn, R.W. and Roberts, S.L. A Retrospective Analysis of Project Employment (Perth) Inc after Three Years Operation as an Employment Agency for Job Seekers with an Intellectual Disability. Paper presented at the 23rd National Conference of the Australian Society for the Study of Intellectual Disability, Perth, Australia, 1987.
Moore, R.E. and Lewis, G.M., (1985). Rapid Entry Training: A Manual for Training Intellectually Disabled Workers in Open Employment. Perth : PE Publications.

<Vocational Rehabilitation Services>

THE DEVELOPMENT OF VOCATIONAL REHABILITATION MEASURES FOR PEOPLE WITH MENTAL RETARDATION IN JAPAN

- THE PRESENT SITUATION AND PROBLEMS -

SHUSAKU YASUI
Japan Association for Employment of the Disabled, Tokyo, Japan

I. BRIEF HISTORY OF THE INTRODUCTION AND STRENGTHENING OF THE EMPLOYMENT QUOTA SYSTEM

Looking over the employment promotion measures for disabled persons, some countries have introduced an employment quota system (European countries) and some have not. Japan, following the example of European countries, adopted a direct means to place employers under an obligation (obligation to endeavour) to employ more than a certain percentage of physically disabled persons based on the Employment Promotion Law for Physically Disabled enacted in 1960. The above quota system greatly contributed to the promotion of employment of the physically disabled, in conjunction with brisk demand for labour due to high economic growth. At the same time, assistance measures such as re-inforcement of vocational guidance and job placement by Public Employment Security Offices (PESOs) and payment of employment incentives to employers were initiated.

Later, however, Japan's economy changed over to stable growth with no prospect for large expansion of employment opportunities. Due to this situation, the stengthening of employment measures including the employment quota system was examined. As a result, employers were placed under a legal obligation to always employ more than a certain percentage of the physically disabled. The amendment of the Law in 1976 legally requires employers to employ physically disabled people (private enterprises, 1.6%; corporations having special status, 1.9% government and public offices, 1.9%, or 2.0% as of April 1988).

In addition, the Levy and Grant system for the physically disabled was newly established to compensate for the added expenses incurred in employing the physically disabled. The System subsidizes employers hiring physically disabled workers and covers expenses for improving facilities required for their employment. The financial resource comes from the Levy which is collected from employers who have not attained the quota for employing the physically disabled. This provides an economic incentive for the quota system. (The amount to be collected is reduced in proportion to the number of physically disabled workers already employed.)

Up to this point, the mentally retarded were excluded from all this legislation. However, in the above revision process, heated discussions were held about how people with mental retardation should be included in these systems. The employment quota system was not applied to the people with mental retardation for the following reasons: 1. It is difficult to evaluate whether they are suitable for employment or not. 2. The occupational areas where they can be employed are limited. 3. Special consideration on the side of the employer is required to enable their vocational adjustment.

Despite such particular problems, the mentally retarded need employment opportunities just as the physically disabled do. Therefore, the Levy and Grant system for the physically disabled was adjusted to include the mentally retarded. However, the amount of the levy was reduced. Other special measures are payment of subsidies to employers who employ people with mental retardation.

According to the survey of the Ministry of Labour (Employment Situation of the Disabled in 1983), the employment situation of people with mental retardation has not improved in comparison to that of the physically disabled: 1. Enterprises which employ persons with mental retardation are 1.5% of all enterprises (In the case of the physically disabled, it is 14.6%). 2. The employment ratio in the large enterprises is low. 3. The length of employment is short compared with nondisabled workers.

II. IMPROVEMENT IN THE EMPLOYMENT QUOTA SYSTEM ACCORDING TO THE SPECIAL NEEDS OF THE MENTALLY RETARDED

In 1983 the ILO adopted a significant convention concerning vocational rehabilitation and employment (Disabled Persons) (Convention 159). The convention provides for the formulation and implementation of appropriate vocational rehabilitation. It also provides employment measures to enable a disabled person (an individual whose prospects of securing, retaining and advancing in suitable employment are substantially reduced as a result of a duly recognized physical or mental impairment) "to secure, retain and advance in suitable employment and thereby to further such person's integration or reintegration into society." The Convention is a new international standard related to employment measures for the disabled. It should provide guidelines for our country, too. Therefore, improved treatment of the mentally retarded under the employment quota system, which had been pending because of problems, was reexamined in the light of this Convention.

All employers should be placed under an obligation to employ mentally retarded workers in the same way as the physically disabled considering the fact that the mentally retarded have the same handicap as the physically disabled in finding a job. On the other hand, employers are also required to undertake vocational adjustment training for their mentally retarded employees, and this is difficult to ask. Considering these points, the Law was amended and enacted in April 1988 stating that people with mental retardation, if presently employed, are included in the employment quota like the physically disabled. For the time being, no legal employment obligation is imposed on employers.

III. STRENGTHENING OF VOCATIONAL REHABILITATION MEASURES FOR THE MENTALLY RETARDED

Many people with mental retardation hope to become employed after graduating from junior high school (at the age of 15). After that point, the education system is not suitable for their needs. The effective implementation of these improvements under the employment quota system requires the reinforcement of vocational rehabilitation services to enable mentally retarded people to move smoothly into the job market after graduation. Vocational training to improve their vocational and adjustment abilities for employment are even more important than with other disabled people.

(1) Vocational training for people with mental retardation

In Japan, the following two systems of vocational training are available: 1. On-the-job training entrusted to employers (Job Adaptation Training System) 2. Vocational training in the Public Vocational Training Centers for the Disabled

a) Job Adaptation Training System.

This system was established as one of the employment promotion measures for the physically disabled carried out by PESOs. Later, people with mental retardation were included in order to promote their employment. Basically, the office entrusts a company with the on-the-job training of mentally retarded workers for a period of six months to one year, selecting work according to the ability of the disabled person concerned. After this training is over, they are employed by this same employer with whom they trained. A training allowance is given to the worker, and a grant is given to the employer. This makes job adaptation easier and contributes to the solution of the mentally retarded person's problems. Satisfactory results in employment promotion are produced.

In addition to this job adaptation training system, ability development measures are promoted. These include orientation training and work adaptation training. Currently, ability development centers for the mentally retarded are being promoted on a third sector basis through joint investment of local public offices and enterprises which have know-how on the employment and training of such persons. (There are three centers as of 1987.) A subsidy, based on the Levy and Grant System, is paid to these facilities. In particular liberal financial assistance is provided for operation expenses, in view of the special needs of mentally retarded people. In order to foster these facilities in as many prefectures as possible, guidance is given to prefectures on how to establish them.

b) Vocational Training Centers for the Disabled

Vocational Training Centers have been established for the physically disabled, but basically people with mental retardation were not included as their clients, although a few centers tried to give vocational training services to the mentally retarded. Upon enforcement of the revised Law of 1988, the "Vocational Training Centers for the Physically Disabled" have been changed to "the Vocational Training Centers for the Disabled." Their aim is to implement flexible training related specifically to the characteristics of the mentally retarded and also the mentally ill. These centers are now preparing for their new training responsibilities.

(2) Work Preparation Training

It was soon noticed that some of the people with mental retardation had not acquired basic work-related skills necessary for vocational life. Therefore, job adaptation training or getting a job was difficult. To deal with these situations, Employment Rehabilitation Centers (ERCs) were established (There are 47 Centers throughout Japan.) which furnish vocational rehabilitation services in close cooperation with the PESOs. They began to provide prevocational training to people with mental retardation to cope with these problems. Since July 1985, some Centers have established "Work Preparation Rooms" with the purpose of helping mentally retarded people gain work skills through engaging in simple work. This gives them valuable work experience. This project was carried out on a trial basis by some Centers (The period of training was 5 weeks.). Training was given to about 200 mentally retarded people over a two year period and the results showed a high employment ratio (75% of those persons found work.). It proved that such pre-vocational training is an effective means of work rehabilitation. Since 1987, after improving procedures through trial implementation, training has been performed as follows:

a) Purpose of training for the mentally retarded:

1. To help them form a basic work routine and related skills.
2. To assist them in acquiring adequate attitudes toward work.
3. To help them develop basic work skills.
4. To help them understand appropriate attitudes toward other workers.

b) Details of implementation:

The curriculum includes three training stages which intend to form basic work routines (eight weeks at the longest).

1. Basic course (Orientation project, about two weeks).
2. Intensive course (Intends to promote work habits that support long-term employment, about 2-4 weeks).
3. Practical course (to acquire basic abilities required as employed workers through actual work experience in a work place, about two weeks).

c) Types of work

Clerical and/or non-clerical work are provided in accordance with the person's ability. This work preparation training is being conducted at 12 Centers, and implementation at all Centers (47) is being planned.

(3) Vocational Rehabilitation Research

The employment situation of the disabled in Japan has steadily improved through the implementation of the quota system, the incentive policy for employers, and various rehabilitation measures already mentioned. However, due to the recent increase in the number of persons with severe mental and/or physical disabilities, ERCs have to offer vocational rehabilitation services to those severely disabled persons for whom traditional types of rehabilitation are not so well suited. Also, systematic training for the vocational counselors in ERCs is necessary. Soon, a new National Institute of Vocational Rehabilitation will be established according to the amended 1987 Law mentioned above.

The aims of this Institute will be:

1. To develop research and innovative rehabilitation techniques for all kinds of disabled people based on the basic techniques and understanding concerning vocational rehabilitation. This will be done with the cooperation of related universities and institutes.

2. To offer systematic staff training to vocational counselors in ERCs and to other professionals. They, in turn, will be responsible for instructing and advising employers, etc., and will communicate the appropriate research results. It is expected that these efforts will contribute to the development of vocational rehabilitation in the whole of Japan. From now on, this National Institute will contribute to the innovative and expanded vocational rehabilitation techniques for all disabled people, and transfer them to ERCs and related facilties.

Various kinds of work rehabilitation services have been strengthened as well as the improvement in the employment quota system for mentally retarded people. It is strongly desired that employment of the mentally retarded will be earnestly promoted. This will be necessary to redress the lack of opportunities they have had in the past, compared to physically disabled people.

<Vocational Rehabilitation Services>

VOCATIONAL REHABILITATION OF PERSONS WITH INTELLECTUAL DISABILITY

KLAUS-PETER BECKER
Humboldt-Universitat zu Berlin, Sektion
Rehabilitationspadagogik, Berlin, D.D.R.

Intellectual competence has an important place in the general structure of the personality and is expressed not only in performance behavior but also in social behavior.
The resulting limitations of capability for being trained or educated serve for the subclassification into the educable intellectually disabled (Section I and II) and the trainable intellectually disabled.
The dominant disorder of the educable intellectually disabled is the disordered cognitive activity which has a more or less strong influence on all aspects of the personality.
Still intellectually disabled children and juveniles in Section I of the Hilfsschulen can develop performance and behavioral qualities which strongly promote their social independence and make them by and large indistinguishable from normal.
While children and youth in Section I may approximate those performances corresponding to their age group under rehabilitative educational guidance, in, for example, visual, auditory and kinesthetic perceptual processes, the perception quality of students in Section II is always characterized by marked disorders.
"Trainable are those children and youth who, because of considerable organically based intellectual reduction and disturbance of the entire personality, are incapable of meeting elementary educational requirements. However, they do possess physical and mental preconditions to acquire under systematic training elementary environmental knowledge as well capabilities, skills, customs and social behavior which would permit them with permanent assistance to participate in the life of socialist society and, under conditions of sheltered work, to perform tasks in the societal work process." (Grundsatze ... 1975, p. 14)
Graduates from the Hilfsschulen, because of their specific handicap, cannot be trained for skilled vocations or for activities which require the special demands of theoretical knowledge or special performance characteristics. Despite this, the educable intellectually disabled in the GDR have the right to vocational training, the right to work and the right to a place to work. Graduates of Section I of the Hilfsschulen receive a 2-year partial training in selected skilled vocations; graduates of Section II, a 1-year training for simple jobs. Regulations state that, "Graduates from the Hilfsschulen shall be provided with limited training. The training shall be offered within the framework of an apprenticeship. The vocational training period shall be 2 years. It must be ensured that the theoretical training will take place in a class room setting for graduates of the Hilfsschule.
Hilfsschulen graduates with considerable personality disorders shall receive training for simple jobs as a special form of limited vocational training. The training shall be provided within the framework of an apprenticeship. The training contract shall be applied analogously to this training. The training shall last one year. It shall be ensured that the theoretical training will be offered in class room setting for graduates of Hilfsschulen" (Durchfuhrungsbestimmung ... 1980, p. 2).
Appropriate vocational training of the students is already guaranteed by the fact that long term specific vocational counseling is provided by the organs of vocational training of the County Councils. The regulation specifically states, "Graduates from the Hilfsschulen shall be informed by the vocational counseling center together with the director of the Hilfsschulen in March of the next to last school year regarding apprenticeships in suitable vocational training possibilities" (Anordnung ... 1982, p. 101). Following a medical determination of vocational suitability, the factories can sign a training contract with the student. During the vocational training the students receive a stipend.
Neumuller determined that over 75 % of the Hilfsschule graduates adapt fully to vocational life, 15 - 20 % predominantly, and 10 % not at all. Overall they showed good adaptibility.
The trainable intellectually disabled in the GDR also have the right to work. This right is not granted because of materialistiosocial consideration, but rather from the point of view that work is an essential condition for personality development and the formation fo specific personality characteristics.
The trainable are continuously prepared in their educational rehabilitation institutions for socially useful and productive work. Such acquired skills and capabilities allow the person to the placed into the work process under certain conditions. A regulation sets the pertinent criteria. A person being rehabilitated under this regulation is someons with disabilities of the most severe degree (including the trainable), who cannot be exployed under conditions of the normal work process. They are ensured vocational work through sheltered work. Sheltered work means an activity under specifically established conditions, considering the person's guaranteed right to work.
The following requirements are significant with respect to the placement of trainable persons within factories: Improvement of understanding of the limited competence of the worker and preparation for his integration into the labor collective and taking measures for social support, such as adjustment of housing conditions, possible placement in residential schools, individual transport to and from the work place as well as cultural and sports activities" (Anordnung uber die Bildung ... 1978, p. 229).
Based on the above mentioned legal requirements, trainable persons perform good and recognized work in many factories of the GDR.

References

Anordnung uber die Bildung und Tatigkeit von Betriebsrehabilitationskommissionen vom 14. Juli 1978, Gesetzblatt Teil I, Nr. 18, S. 229.
Anordnung uber die Bewerbung um eine Lehrstelle - Bewerbungsordnung - vom 5. Januar 1982, Gesetzblatt Teil I, Nr. 4, S. 95.
Breitsprecher, A. (Hrsg.), Welches Kind mB sonderpadagogisch betreut werden? Berlin: Volk und Wissen Volkseigener Verlag, 1982.
Durchfuhrungsbestimmung zur Verordnung uber die Systematik der Ausbildungsberufe vom 15. Mai 1980, Gesetzblatt Sonderdruck Nr. 1036, 25. Juli 1980.
Grundsatze uber die Gestaltung der Forderung schulbildungsunfahiger forderungsfahiger Kinder und Jugendlicher vom 31. Dezember 1974, Verfugungen und Mitteilungen des Ministeriums fur Gesundheitswesen, Nr. 3/75, S. 14.

INTRODUCING THE SOCIETY FOR THE CARE AND EDUCATION OF THE MENTALLY RETARDED, BANGLADESH (SCEMRB) AND ITS PROGRAM OF REHABILITATION

MOMTAZ RAHMAN
Sheltered Workshop, SCEMBR, Dhaka, Bangladesh

Mental retardation is a common phenomenon. No country of the world, rich or poor, big or small is free from this problem. Bangladesh is one of the poorest Asian countries, having to support a population of nearly 105 million in an area of only about 56000 seuare miles. The poor state of the economy has naturally seriously affected the quality of life in general and as the literacy rate is very low, most of the people suffer from ignorance and age-old prejudices. Nearly 80% of the population live in rural areas and more than 60% of them depend on agriculture. The per capita income is around U.S$140 and two fifths of the people live below poverty line. Since there exists a strong correlation between mental retardation and malnutrition, disease, early marriage etc., the incidence of persons with retardation is logically considered quite high in Bangladesh. No exact statistics as to the exact number of the retarded persons in Bangladesh are yet available, as no systematic survey has been carried out by any authority, so far. However, taking the cue from the World Health Organization's estimate of 3% of the world population being disabled, it can easily be concluded that the percentage of mentally retarded persons in Bangladesh, under the present socio-economic condition, can not be less than 2%.

In the backdrop of the above situation, the Society for the Care and Education of Mentally Retarded Children (SCEMRC), later on re-named as the Society for the Care and Education of the Mentally Retarded, Bangladesh (SCEMRB) saw the light of day in 1977, in Dhaka, the capital of Bangladesh. A few determined parents, in cooperation with some distinguished professionals and dedicated social workers, launched the program for education and training of the mentally retarded. Despite the initial constraints of lack of community awareness, funds and other resources, like trained and experienced trainers, the Society gradually made headway and expanded its service. Work for identification of the mentally retarded, parent-counselling, guidance, setting-up of Special Education Classes in the premises of normal schools continued steadily both in Dhaka and outside of Dhaka. Now, the Society has a number of Special Education Classes, Vocational Classes in Dhaka and about 21 Branches with similar facilities in different parts of the country. Besides, there is one big Sheltered Workshop in Dhaka and 2 small Workshops, one each at Rajshahi and Chittagong (two major cities) where trained adult M.Rs of both sexes are engaged in producing various handicraft items for sale in the market. Nearly 1000 M.Rs could be brought under the direct service net-work of the society, so far while many more are being given some home-based service by the Counsellors engaged by the society; such services are being provided in some places through rural projects also. The aim of the Society is to undertake programs through out the country in a phased way. Availability of funds will of course determine the pace and extent of its work.

The rapid expansion of the organization has been possible through the generous support rendered by NFPU (Norwegian Society for the Mentally Retarded) and NORAD since 1982. An Institution for the M. R. has been set up at Dhaka with Norwegian support for providing direct services to the M.R. in Dhaka and for acting as a resource and training centre for the whole of Bangladesh.

Meanwhile, the Govt. has also extended its helping hand to the society. A National Institution for the M.R. is now under construction at Dhaka on a piece of land donated by the Govt. and with funds also provided by the Govt. When completed, the Institute will function as the nucleus of all programs for M.R. including research. The Government have also agreed to provide space in some Govt. schools; efforts are on to have the number increased. Efforts are also on to make the Govt. agree to bear part of the operating cost of the program. The National policy for economic development of the Govt. also recognises the need for providing some service to the M.R.

The Society is trying to mobilise resources from within the country by way of collecting contributions/donations from various sources, but the economic base of the country being low, the response is not that encouraging. The NFPU, the major contributor of funds for the Society will be phasing out by and from 1992. This has become a real cause of concern for the Society. Unless Govt. is fully involved, which is unlikely because of their other social and economic priorities, or alternative source(s) of funding from abroad is lined up, the program may be disrupted with disastrous consequences for the M.R. who have been given the prospects of a better and meaningful life. In addition to providing services to the M.R., the society during the short time achieved a good deal of success in terms of making the problem of M.R. visible and understood through holding seminars, workshops, conferences and other publicity and thereby indirectly benefitting many more people. Our people to-day are more aware of the problem of mentally retarded and the help and care they need.

In Bangladesh where the M.Rs come from various socio-economic groups and where job opportunities in the open market are highly limited even for the nondisabled persons, accepting an integrated approach for rehabilitation of the M.R. i.e. finding work for them in the open market and at home (on an out-work basis) will be extremely difficult and unsuitable. It is, therefore, felt that the best way to get work for the M.R. is to engage them in the Sheltered Workshops where they can work with full mental satisfaction and confidence. Effort may, however be made to find work for the trained or marginally retarded cases in the normal setting i.e. in competitive jobs. But this may pose a problem; the M.R.s may face rejection due to their disabilities; some may be ridiculed in the working situations and if they react towards the attitude of their colleagues they may be considered unfit and aggressive. Being placed in strange and hostile environment, a M.R. may himself leave his job. It will certainly need an enlightened and more understanding society that will offer the M.R. a place in the social frame-work. Absorption of the M.R. in their family business seems to be a feasible proposition but such scope will certainly be very limited.

Another possibility often suggested is to start small projects at home, such as back-yard gardening, poultry or farming on a small scale. While this may work in a rural setting, there is very little chance of its success in an urban area where space is a problem even for the comparatively rich section and family circumstances are also hardly congenial.

Although residential services are both expensive and difficult to organize and manage, arrangement of small group-homes for the severely retarded persons will be necessary.

In the rural area rehabilitation of the M.R. poses less formidable problems. There are many explanations for this. Rural M.R.s, are well integrated in their family as well as in their community compared to the urban M.R. persons; this is because families are closely knit and the traditional value system which still maintains some of its original character creates a congenial local environment for the disadvantaged group. An M.R. can easily form part of the family work-force and help the male and female working members in very many ways in field and house-hold work. He or she is also socially accepted. As a result the M.R. is not considered to be burden on the family in the way it is done in the urban areas. In a situation like this what is needed more is to teach the families of the M.R. basic skills for stimulation and training of their M.R. children. Of course, as in the case of urban areas, group-homes in small scale may be necessary in rural areas also to deal with the severe cases and for those M.R. who have none to look after them.

The Bangladesh Society (SCEMRB) also runs a week-end home at Dhaka as a help and relief for parents and also as part of the independent-living training of the M.R. During the week-end, the small group of M.R. can stay away from home for two nights and spend their time under supervised care. However, basically we believe that it might be the best idea for the retarded to stay in their own home, or close to their own family as far as possible.

Mentally retarded are a complex group of handicapped persons. Proper training for their welfare will require a lot of team-work of parents, professionals, educational institution and concerned voluntary and Govt. departments. It will never be possible for any single organization to shoulder the responsibility of undertaking programs for the mentally retarded through out the country; therefore, comprehensive programs at Govt. and nonGovt. levels will be absolutely necessary. It is hoped that such coordination of efforts will be forthcoming to promote preventive measures of the cause of the M.R. who are in no way responsible for their misfortune.

CLOSING CEREMONY

CLOSING REMARKS

Dkfm. Otto Geiecker
President of Rehabilitation International

The closing ceremony of the 16th World Congress is the moment for the Oresident of RI to say a few words of appreciation and thanks to our friends in Japan who made with their hard work and their efforts this Congress possible and gave us the basis for successful deliberations in our meetings. Whenever there was the slightest sign of growing difficulties, our friends reduced it with their human understanding, kindness and efficiency in practically no time to nothing. Therefore, I am certain to have the permission to speak on behalf of all the delegates when I especially express our deepest gratitude to the Japanese Society for Rehabilitation of the Disabled and to the Japan Association for Employment of the Disabled for sponsoring this Congress and to the Government of Japan for its support and for accepting that this World Congress was held under its auspices.

I also have to thank and to congrarulate the members of the Organizing Committee of the 16th World Congress under the Chairmanship of Dr. Naoichi Tsuyama for the excellent work they have done in preparing and planning this Congress and so giving us a solid basis for a successful meeting. But first of all it was the strong and enthusiastic leadership of the President of the 16th World Congress, Mr. Hirokuni Dazai who always encouraged the many hard working officers and volunteers, coordinated their activities and so huaranteed that they became a powerful team with one goal only - the 16th World Congress. The only thing that we can do now is to say thank you Sir and thank you dear friends, you have done a marvellous job. Since our arrival in Tokyo our respect for your work has constantly grown and I am sure it will be very hard for the organizers of the next World Congress of RI to achieve the same level.

Four years ago in Lisbon, when I was elected to the Presidency of RI I promised to do my best to strengthen RI as an independent federation of organizations working for disabled persons and to strengthen also the participation of disabled persons in the decision making bodies of our World Organization.

Today, looking back on these last four years with the 16th World Congress as climax of our activities I am happy to say that we have achieved many things and that I also have been able to fulfill my promise. But this was only possible because I have had the support from all our member organizations, from our headquarters with our Secretary General Mrs. Susan Hammerman and also the advice of the members of the Executive Committee and especially the wise counsel of our immediate Past President Dr. Harry Fang.

Therefore many thanks to all of you. I was lucky to have your friendship and I hope this friendship, growing out of our common work for disabled persons will last for many years to come.

My last duty as President of RI at the end of this World Congress is to introduce to you our newly elected President for the next term of office - our sistinguished friend Mr. Fenmore Seton. Mr. Seton has served RI for many years as Treasurer and is well-known for his outstanding work in the interest of disabled persons. He has devoted many years of his life to the social welfare of the members of our society and we are glad that he will now serve RI as President.

Congratulations to Mr. Seton, on your election. We shall support your activities for RI with all our strength.

And to all of you, my friends, thank you once again, good bye and God bless you.

ADDRESS OF THE INCOMING PRESIDENT

Mr. Fenmore R. Seton

Here we are at noon on Friday, in the very closing moments of this historic 16th World Congress of Rehabilitation International. As your new President, I have the privilege of officially offering the final thank you to the the Japanese Organizing Committee for their remarkable efforts which have made possible this convening of minds and cooperation of interested people and organizations that will in the future have a permanently beneficial effect on countless millions of disabled persons in every country of the world.

I am aware that for four days or more all of you have been subjected to a multitude of speeches and a torrent of words and ideas...so the last thing you wish now as you near the hour for departing, is a lengthy discourse from me. So I promise to make this presentation mercifully brief and to speak only concerning two of the most important issues to which I will devote emphasis during my term of office as RI President.

The first issue concerns UNIVERSALITY. Rehabilitation International's constant progress toward universality is its most unique characteristic. It is an organizational manifestation of the real meaning of those twin slogans with which the Rehabilitation community expresses its goals - "Full Participation and Equality" and "Integration of Disabled People and Society".

Rehabilitation International provides a forum for EVERYONE concerned with disability - for every nation, for every religion, for every race, for every profession and, perhaps most important, for every degree of ability and disability. This forum functions through our membership, through our standing Commissions, and through our cooperative relationships with the United Nations family, with other non-governmental organizations, and with many other entities.

I believe that, in the days to come, when our challenge is to bring the thinking of disabled people into every aspect of life, the Rehabilitation International model will grow into an ever more powerful influence. It must grow because it genuinely offers to everyone "Full Participation and Equality". Properly nurtured it will continue to lead the way to the genuine integration we all seek.

As we relish the magnificent experience we have had at this Congress in Tokyo, my second and final thought must concern the decision voted this past Saturday by the Delegates' Assembly of Rehabilitation International...namely to hold our 17th World Congress at Nairobi, Kenya in 1992.

To my mind, for I fully and wholeheartedly concur with the decision of the Assembly, there will likely be no single accomplishment of more significance achievable by RI during the next four years than to convene in Africa a World Congress. For such a Congress will serve to mobilize public attention to the forces necessary to bring to the African continent the medical and technical knowledge required to reach millions of disabled men, women, and children.

The distinguished Minister from Kenya, with the assistance of the Vice President and Deputy Vice President for Africa, will surely do all within their power to insure that the RI World Congress will be successfully convened again in Kenya in 1992.

I pledge to you, my dear friends, that I, as your new RI President, will do everything I personally can to assist in this noble task.

I hope and trust that each and everyone of you assembled here will, as you depart, have the feeling that our World Congress at Tokyo has contributed greatly to your supply of knowledge...and that you will safely return to your homes with a renewed sense of pride in your dedicated service to the disabled community.

Thank You.

CLOSING ADDRESS

Takashi Katoh
President, JApan Association for Employment of the Disabled

The 16th World Congress of Rehabilitation International is now drawing to a close. Standing as it is, at the mid-point of the United Nations Decade of Disabled Persons, there has been particular emphasis on the reinforcing of international cooperation in order to increase progress in such issues as prevention of disability and development of regabilitaion techniques.

There was an intense atmosphere over the five days of the Congress. It brought together over two thousand professionals - including disabled people - working in various disability fields, from ninty-three regions and countries. They had chance to discuss the latest information of the above matters, based on both experience and research. The various activities such as the Film Festival, Arts & Performance, Technical Exhibition and Facility Visits, also contributed greatly in giving participants a broader perspective.

As hosts, we were concerned to ensure that everyone at the Congress would be able to take home something of realistic value for themselves and their country. If you feel this was successfully achieved, then it was only made possible by the hard work, guidance and assistance of the RI Head Office, and many others involved internationally and nationally, including the volunteers. I should like to express my sincere thanks to all of them.

From tomorrow there will be several Post-Congress Seminars staged in various places throughout JApan. Every one is related closely to the ideals of this main Congress, and is a further opportunity to develop these aims through international exchange at a community level. We should be delighted if you were able to enjoy these Post-Congress Seminars, as well as the beautiful Japanese autumn.

Well, these days everyone is looking towards the coming 21st Century. There is need for us all to quicken our pace, that we may receive and achieve greater results regarding comprehensive rehabilitation world-wide, both appropriately and promptly.

I should like to conclude by wishing us all greater confidence and results as we go ahead.

See you at Nairobi in four year's time!

Thank you.

Title:
16th World Congress of Rehabilitation International No.14 P.591-P.633

Publisher:
The Organizing Committee of 16th World Congress of Rehabilitation International

Month,Year of Publication:
Jun,1989

To access/retrieve this document:
Japanese Society for Rehabilitation of Persons with Disabilities
1-22-1, Toyama, Shinjuku-ku, Tokyo 162-0052, Japan
Phone:03-5273-0601 Fax:03-5273-1523