community employment. Our experience in placing of the older boy, between 16 and 17 years of age, in employment upon his return to the community has not been consistent with his educational growth in the Village. During the past year (1958-59), 39 boys were placed in jobs in New York City. This was the result of the efforts of a trained specialist on our staff who works as a job placement and guidance counselor with boys leaving the institution. The problem of job placement has always been a difficult one from two standpoints. First, the reluctance of employers to take on an institutional youngster in gainful employment. Secondly, the process of preparing a youngster while in the institution for a particular trade placement is hampered by child-labor legislation aimed at protecting the average normal child, but not suited to the employment needs of children who fit into the category of delinquent and disturbed children with determined potential for learning and production. Union regulations regarding age in many situations prevent adolescents from developing apprenticeships and training. Unfortunately, too few employers have recognized the value of vocational on-the-job training, and many consider this to be a waste of time since the youngsters are subject to military service. They fail to recognize the potential of these youngsters to continue their trade training while in the service and to provide a resource of manpower to the employer upon his discharge.

CONCLUSIONS AND RECOMMENDATIONS

In consideration of the foregoing, as well as the task of this subcommittee, we would like to present the following proposals based on the experience of the Children's Village in the field of special education for disturbed children:

1. Provisions should be made by the Federal Government to provide grants-in-aid to institutions of higher education and private training centers, to provide specialized training programs for capable teachers, supplemented by on-the-job training in order to prepare qualified personnel to teach disturbed children. Such grants-in-aid should be a joint undertaking with the U.S. Department of Health, Education, and Welfare and under the supervision and control of the Children's Bureau.

2. Research moneys should be provided by the Federal Government, perhaps on a matching basis to those States willing to study the problems of this area of education. These moneys should be administered on the State level to those institutions, agencies, and school districts capable of establishing demonstration and research projects in this field.

3. The term "special education" should be expanded to include the "emotionally handicapped child" in its eligible categories so that any Federal assistance would include not only the physically handicapped and mentally retarded, but bring about an impact on other areas of exceptional children. 4. The Federal Government, through the Department of Health, Education, and Welfare, should undertake a study of existing Federal legislation regarding child-labor regulations and establish criteria for employment of these children under certain conditions and when certified by a public agency. This would serve as a guide to State legislatures. Contracts of financial assistance should be established to the effect that Federal appropriations for assistance would be contingent on meeting the definitions of this legislation.

5. Provisions should be made to grant Federal assistance to States on a matching basis for the development of more adequate programs of trade preparation and vocational training for special education categories of youngsters leaving institutions and schools for employment in the community. This would includes federally sponsored programs of vocational rehabilitation which should be open to emotionally disturbed adolescents. 6. Provisions should be made for the allocations of Federal funds to the various States for the purposes of establishing research and demonstration projects aimed at early detection and diagnosis of problem children requiring special education facilities.

The predominant needs as experienced by the Children's Village and other agencies involved in this problem is the acute shortage of qualified teachers, the lack of interest on the part of the public with the needs of children falling within this category, and, more precisely, the absence of a specified curriculum of training for such personnel. As an additional recommendation, we would suggest the establishment of a pilot project, perhaps under the direction of the Department of Health, Education, and Welfare and assisted by the National

Education Association to be conducted in a few of our institutions of higher education. Such a curriculum of training might include the following subject matter supplemented by field work experience at a recognized school or institution involved in the problems of special education:

1. Psychiatric concepts about human behavior;

2. Psychological understandings of learning disabilities and their relationship to emotional problems;

3. Group work concepts concerning the dynamics of group and peer leadership;

4. An understanding of the functions of community facilities available for disturbed and delinquent children;

5. Training in the use of concrete and creative nonverbal media, such as crafts, arts, music, visual aids, dramatics, etc.;

6. A 1-year educational field placement under supervision in a recognized treatment center for disturbed children. For supervisors and administrators additional courses in the process of supervision should be provided, based on experiences in those schools which conduct pilot educational programs for disturbed children.

The problems of special education for disturbed and delinquent children present complex and challenging tasks. Techniques and developments in the field of education have not kept pace with this growing problem. Unless the Federal Government and others interested in education provide adequately for these youngsters now, they will become the occupants of prisons and State hospitals tomorrow.

Mr. ELLIOTT. Our next witness is Dr. R. H. Manheimer, medical director, Arthritis & Rheumatism Foundation, Inc.

Do you have a written statement?

STATEMENT OF DR. R. H. MANHEIMER, MEDICAL DIRECTOR, ARTHRITIS & RHEUMATISM FOUNDATION, INC.

Dr. MANHEIMER. Yes; I do.

Mr. ELLIOTT. Will you summarize it, please, in about 6 or 7 minutes and let us ask you questions?

Dr. MANHEIMER. Yes, Mr. Chairman.

Mr. Chairman, I am honored to appear here today, and hope that my statement will be useful to the Subcommittee on Special Education. I shall confine my remarks to two aspects of the rehabilitation of arthritis patients, vocational rehabilitation and the rehabilitation of the homebound.

Arthritis, as you know, is a widespread chronic disease which often disables and cripples. It affects 10 million Americans, with more than 32,000 otherwise able persons rendered unemployable for an entire year by arthritis and other rheumatic diseases.

The need for vocational rehabilitation, therefore, is evident. To continue earning, many disabled arthritics must change the kind of work they do. This requires skilled help, particularly for the patient who is 40 or older. Each year we estimate it costs $125 million in taxes to provide subsistence allowances for arthritics who cannot work.

To get as many of these men and women back to work as possible, therefore, makes good sense. We believe that the subcommittee should be prepared to encourage vocational rehabilitation activities in view of the results obtained by recent programs.

For 6 years the New York Chapter of the Arthritis & Rheumatism Foundation has been providing vocational rehabilitation for unemployed arthritis victims. This back-to-work program is run jointly by the foundation and the Institute for the Crippled and Disabled, one of the country's leading rehabilitation centers.

Each year 40 percent of the patients who enter this program do go back to work. They get jobs in regular business and industry, working side by side with nonhandicapped employees. To date, 200 men and women, some of whom had been out of work for 20 because years of disabling arthritis, have jobs which they perform efficiently despite their arthritis and without injury to their health.

To find out whether these handicapped people could sustain employment, we got in touch with 99 who had been placed on jobs at least 6 months earlier. Sixty-nine percent of these 99 persons were still working. Many had gotten wage increases; some had been working for over 2 years since their vocational rehabilitation. Not all these people gave us full information about their earnings, but 28 reported wages since they went back to work which totaled, over the 3-year period, $79,000, more than twice what the project had cost the Arthritis Foundation up to that time.

Instead of subsisting on welfare, these men and women have become taxpayers and were contributing to the cost of running their city and country. We therefore believe that vocational rehabilitation of the unemployed arthritic is practical, realistic, and good economics.

The money spent brings concrete returns. It appeared necessary to demonstrate that not only can vocational rehabilitation for arthritics be provided in a large center like New York, but that effective services can also be devised for our widespread and growing suburban communities.

The Arthritis & Rheumatism Foundation, with the cooperation of the Long Island Jewish Hospital, and a generous 3-year grant from the Office of Vocational Rehabilitation, recently started a vocational program on Long Island to serve not only arthritis patients, but all community residents with orthopedic handicaps which now keep them from working.

This new program, unlike the back-to-work project, does not depend on the existence of a large, specialized rehabilitation center. Rather, it is located in and uses the resources of a good general hospital, such as many communities throughout the Nation also have. Although the project is barely a year old, it also presents good evidence that a community's hospital facilities are well adapted to providing the varied services required in vocational rehabilitation. Already a number of patients have been retrained and placed on appropriate jobs in their home communities, and the number of patients coming to the project for help has been significantly larger than our original estimate.

Mr. ELLIOTT. Dr. Manheimer, let me ask you this question: Has much progress been made in eradicating the pain from arthritis? Do the people that you speak of who are rehabilitated sufficiently to go back to their jobs remain free of pain as they go back to work? Have we gotten that far yet?

Dr. MANHEIMER. They are reasonably free. Those who have a great deal of pain are not in condition to go back to work. Most of the patients whom we deal with, actually, are under medical treatment and require constant medical treatment. Yet they are able to get back to work. This has been our experience.

In most cases they have had to had some changes in their previous experience with work. They have had to learn a new kind of job. At times it only had to be to modification of their previous job.

For about 50 percent of those we got back to work, they had to learn a new trade altogether. The opportunities of developing a vocational rehabilitation center that can train and test these people in new jobs that they didn't consider that they had any capacity for or didn't have any comprehension about is what makes this kind of a program desirable and practicable.

Mr. ELLIOTT. Is cortisone still one of the main medications?

Dr. MANHEIMER. Cortisone, as such, is really rarely used today, but many advances have been made in cortisone derivatives so that there are now many drugs which are much less toxic than cortisone and which are really useful.

That doesn't mean that every doctor must not be aware of the cautions in using the drug. There is not a journal of rheumatic diseases that does not come out emphasizing the dangers inherent in this drug. But really, I believe it, as with many drugs, has a very useful place.

In our experience, we find that at least an important percentage of the patients who go back to work are able to go back to work, in part, at least, because they are on drugs such as the cortisone and its derivatives.

Mr. ELLIOTT. Thank you.

Dr. MANHEIMER. We are convinced that programs like this one can and should be encouraged throughout the United States so that patients afflicted with arthritis and other handicapping conditions may return to self-respect and self-support.

In analyzing how such metropolitan and suburban programs may be developed throughout our country, it would appear that Federal support would be of material help. I would like to touch on this and on how such help would be most useful in just a moment. Meantime, there is another group of arthritics equally in need of help. These are the men and women who are confined to their chairs or beds by their rheumatic disease.

A measure of the scale of this problem is the fact that of all the beneficiaries under the Federal program of aid to the permanently and totally disabled, one-tenth require such aid because of arthritis. In 1956, 258,279 persons in the United States were receiving such aid. No one knows how many other arthritics not receiving care under the APTD are, nevertheless, confined to bed or chair, nor how many family members who would otherwise be able to earn must stay at home all day to care for them.

It has been the experience of the Arthritis Foundation that the homebound arthritic can also be helped significantly. To reach the homebound arthritic, the Arthritis and Rheumatism Foundation turned to the visiting and public health nurses who are already going into the homes of many patients too handicapped to get to doctors' offices or to clinics.

We submit that the visiting-nurse organizations are ripe and eager to assume some of the responsibility for making homebound patients more self-sufficient, more capable of the ordinary activities of everyday life. With appropriate help and encouragement, the visiting nurses are in an ideal position to do this. As evidence of what can be done, I offer the Arthritis Foundation's 3-year experience in cooperation with the District Nursing Association and the Westchester

Public Health Department. To their joint nursing staffs we added a full-time physical therapist and regular consultations with the physicians specializing in rehabilitation.

This cooperative program cared for over 120 patients. Some were bedfast, some chairbound. Others could walk, but were limited in other ways, in washing themselves or doing simple household activities. On careful analysis of the 120 case records, we found that 80 patients had improved significantly in their capacity to perform ordinary everyday activities.

This 66-percent improvement is all the more striking when I add that most of these patients were at least 60 years old and many had two or more serious diseases. Some of these 80 patients learned how to wash and dress, to shift from bed to chair, or to feed themselves without the help of another person. Some began to go out of doors or to do light household chores. In a few cases the improvement was such that a family member could go to work, thus improving the family's economic situation.

The cost per patient was about $99, which seemed reasonable. How can the Federal Government aid in developing effective programs of home and vocational rehabilitation programs throughout this country? Two aspects of the programs I have described merit special consideration by your subcommittee:

First, both programs use existing and I repeat, existing-highly skilled agencies to develop new rehabilitation services to meet urgent, unmet needs. Thus, the organization of our programs were simple, their operation flexible, and their costs moderate.

In considering ways and means of improving our Nation's rehabilitation services, I suggest that the subcommittee consider the value of adapting and expanding existing agencies, already well established in their communities and, as evidenced by our experience, eager to develop new ways of serving their local communities.

Second, the vital element in both home and vocational rehabilitation proved to be the highly skilled professional workers who did the work. In vocational rehabilitation our success depended in overwhelming measure on the well-trained vocational counselor. Inherent in such personnel is the developed capacity to utilize all the resources at their command, to fully evaluate the patient's limitations and needs, to develop the residual resources, to determine the exact demand of the jobs locally available, to plan training programs suitable to the patient's capacities and the community's job resources, and to carry through until the patient is actually placed at work.

In home rehabilitation, the essential factor was the physical therapist. His skill in evaluating the extent of the patient's handicap and of his residual resources, in devising self-help devices and training the nurses to plan an appropriate role in the whole enterprise, these qualities were the heart of the program.

Well trained personnel for vocational and home rehabilitation are exceedingly scarce. Time and again arthritis programs have been delayed for months because competent personnel to staff them could not be found. The growing activity in all areas of rehabilitation, welcome though it is, places a demand for personnel on the training schools which they have been unable to meet.

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