SPRI 1991) indicates that a little more than one-third of the clients are judged to have psychiatricproblems. About half of them could be handledwithin the ordinary service system. For the rest,some sort of support from specialized psychiatry isneeded. The most common request concerns drugtreatment. To a much lower extent, there is a needof psychiatric hospital care (in about one out ofthree contacts). Equally often, conversationaltherapy with client or supportive guidance forpersonnel is requested.

In a survey, of mentally retarded people whohad been referred to a psychiatric specialist duringthe 5-year period from 1985 to 1990 withinUppsala county, Gustafsson (1992) identified 50people. In the group, 27 had been in-patients at apsychiatric hospital, 12 of them for several periodsof time. Ten people had been seen by local psychi-atric teams and had been subject to ambulatingcare.

A majority of the group were mildly and mod-erately retarded. For several reasons, it was con-cluded that psychiatric disturbances for severaland profoundly retarded persons were underdiag-nosed.

The basic model in Sweden today — recom-mended by the National Board of Health andWelfare — is to establish continuous contact andconsultation between group homes or other formsof supported living on one hand, and the nearestmedical and/or psychiatric care centres on theother in order to achieve both personal acquain-tance and a knowledgeable staff.

Education and information are essential. Anorganized network of professionals from both careorganizations in a district meeting regularly inscheduled conferences has proven to be finiitful.

To meet the needs of in-patient care, i.e.duringacute periods of psychotic illness, different modelsare being tried out. The models are all based onthe existence of competent staff— both psychia-trists and other personnel — at county level withingeneric psychiatry. In one country, a special unitof six beds has been established.

'Dual diagnosis' calls for some sort of 'dualcompetence'. It is a challenge to establish the

The European services 65

necessary base of knowledge and organize thecooperation needed to apply it.

REFERENCES

Gustafsson C. (1992) Mental retardation and psychiatricdisturbances. Paper presented at The FUN Confer-ence, 'Research on Welfare', Turku, Finland, 19-20November 1992.

Granat K. & Granat S. (1973) Below-average intelli-gence and mental retardation. American Journal ofMental Deficiency 78, 1.

Grunewald K. (1979) Mentally retarded children andyoung people in Sweden. Integration into society: theprogress in the last decade. Acta Paediatrica Scandi-navica, Suppl. 27.

Kebbon L. (1987) Relation between criteria: case-fmd-ing method and prevalence. In: Studies in Mild MentalRetardation: Epidemiology, Origin and Prevention (edsK.H. Gustavsson, B. Hagberg, L. Kebbon & S.A.Richardson). Uppsala Journal of Medical Science,Suppl. 44.

Nirje B. (1969) The normalization principle and itshuman management implications. In: Changing Pat-terns in Residential Services for the Mentally Retarded (edsR. Kugel & W. Wolfensberger). Presidents Committeeon Mental Retardation, Washington, DC.

Nirje B. (1992) The Normalization Principle Papers. Cen-tre for Handicap Research, Uppsala.

Sonnander K., Emanuelsson I. & Kebbon L. (1992)Mildly mentally retarded pupils in the ordinary Swed-ish school: prevalence, objective characteristics andsubjective evaluations. American Journal on Mental Re-tardation 97, in press.

SPRI (1991) Cooperation between psychiatry and othercaregivers. SPRI-report 321. (In Swedish.)

Wolfesnberger W. (1972) Normalization: The Principle ofNormalization in Human Services. National Institute onMental Retardation, Toronto.

Wolfensberger W. (1983) Social role valorization: a pro-posed new term for the principle of normalization.Mental Retardation 21, 234-9.

L. KEBBONUniversity of Uppsala,

Ulleraker,S750 17 Uppsala,

Sweden

FranceINTRODUCTION

In France, children and adults with a mentalhandicap have a large number of services open tothem as a result ofthe 1975 law on integration andcare. The law allies itself closely to the integration

movement that has grown over the last 20 years inother countries in the European community. TheMinistries concerned with the specific roles andobjectives are the Ministry of Education and theMinistry of Solidarity and Social Affairs. The for-mer is concerned with the integration of the

66 France

mentally handicapped in schools or in specialclasses in schools, the latter with the treatment,care and education of mentally handicappedpeople in medico-social centres.

CHILDREN AND ADOLESCENTS:COMMISSIONS AND SERVICES

Several commissions and services have been setup to supervise the care of children such as thecentre for early medico-social action(C.A.M,S.P,) and the commission for pre-schooland elementary education (C,C,P,E,), The latterexamines the case for placing children in ordinaryclasses and 'improvement' classes, or special edu-cation sections (S.E.S.). The decisions are takenafter examination of the child's scholastic level,personnel difficulties, state of health and familyenvironnient, A similar commission (CC.S.D,)exists for handicapped students at the secondarylevel. For the more severely handicapped, theC,D,E,S, Departmental Commission of SpecialEducadon (there are more than 90 administrativedepartments in Erance) orients these people towardsmedico-social educational centres and attributesspecial education allocations. In order to complywith the 1975 law on integration, several types ofservice for preventive treatment and care havebeen created as well in order to take care of chil-dren in their family and school environment; forexample, the G,M,P,P, or groups for medico-psy-chological and educational aid. The services withteachers in an attempt to follow children withlearning disabilities and to find solutions to theirspecific educational difficulties. Other servicessuch as aid at home and day hospitals have alsobeen established.

ADULTS: COMMISSIONS ANDCENTRES

Handicapped adults have access to employmentthrough protected workshops and special work aidcentres as well as through professional re-educa-tion centres. Some of these centres have residendalfacilities for adults. The coordinadng commissionis the COTOREP or the technical Commission forOrientation and Professional Reclassificadon.

Other types of centres are available for adults,such as the special welcome homes and foyers(M.A,S,—^Maison d'Accueil Specialise, Eoyer deVie), Centres for professional re-education andfamily placement centres exist as well.

STATISTICS

Children and adolescents

It is difficult to obtain valid statistic in this field asthere are several data sources, each with its owncollecdon system. As mentioned above, the twoministries involved may use different criteria, di-verse categories defining handicap, various meth-ods of collecting informadon and different periodsfor collecdon, resulting in data which is not easilycomparable. Further obstacles to a comprehensiveoverview lie in the fact that transition periods fi-ominfancy to childhood and then fi-om adolescenceto adulthood lead to 'care overlap' by the differentcommissions and centres. Nonetheless, some ofthe data can be used to obtain a general impressionof government policies carried out for the intellec-tually disabled and mentally handicapped.

As a result of improved living condidons, medi-cal progress and care, the overall situation for thehandicapped has improved. However, the objec-tives of the integration concept have not entirelybeen achieved. The greatest discrepancies are inthe fields of social and educadonal integradon, andthe Creadon of residential facilities for severely andprofoundly handicapped children and adults.

Some progress has been made in maintainingmentally handicapped children in a regular schoolenvironment, but a sdll greater number are beingdirected towards special medico-social educa-tional centres. In 1966-1967, these centres served27 781 mentally handicapped people; 10 yearslater, four dmes as many people have been admit-ted. During this same period of dme, the type ofmentally handicapped person has changed in thesecentres: they are now 15% less moderately toseverely handicapped, Integradon in the main-stream of the school system remains primarilyavailable for those children with motor or sensorialhandicaps, whilst the severely intellectually dis-abled are excluded fi-om it. Furthermore, childrenthat would have formely remained in the regularschool system are now finding themselves in spe-cial needs or improvement classes (73 021) chil-dren in 1986), According to the Minister of SocialAffairs and Solidarity, only a minority of children(32 000 handicapped students) are considered 'in-tegrated'. There are 180 000 mentally handi-capped in special needs classes and over 110 000in residendal medico-educational centres.

The attempt to maintain mentally handicappedchildren in the ordinary school system and theincrease in medico-social residendal centres areinterrelated, demonstradng the pracdcal limits ofthe law. Over 50% of cases presented for the firsttime to the C.D,E,S, redirect the child back toordinary schools, but following attempts often lead

The European services 67

to admission to the special medico-social educa-tional centres.

Adults

Valid statistical data concerning adults is evenmore difficult to obtain since many of them havenot gone through the channels of Commissionsand centres, some are integrated as a result of thefamily network, others are completely excluded. Itis estimated that nearly 100 000 people are to befound in specialized medico-educative residentialcentres for adults and there are over 2000 severelyto profoundly handicapped persons on a waitinglist for the Paris region.

The estimated number of people concernedand the number of people really being followed bythe medico-socio-educational services tends todiflFer. The estimated number is higher than thoseactually being cared for.

For the adult handicapped worker, other factorsinherent to any professional integration come intoplay, such as the economic dependence of womenand the employment priority for men, as well aseconomic recessions, increased unemployment

and the fact that positions are rarely reserved forthe handicapped regardless of the sector of activ-ity. However, a 1987 law stipulates the obligationof French employers to reserve 5% of the workforce for handicapped people but this figure isseldom attained.

Severely to profoundly mentally handicappedadults that are not integrated through the abovementioned work programmes are cared for in theirfamilies, by family placement groups or in special-ized residential centres. However, far too many arestill to be found in psychiatric hospitals. A greatnumber of private non-profit organizations haveopened more residential centres to accomodateand care for handicapped adults, as it becomesmore and more difficult for parents to keep aseverely handicapped adult at home.

N. Ross, O. ROBIN, A. BOGUOLOand A. DEVERNE

Association de Villepinte,27 rue Maubeuge,

75009 Paris,France

Republic of IrelandHISTORICAL BACKGROUND

In the late nineteenth century (Robins 1992),various religious orders began to take responsibiltyfor homeless children in Ireland. In the first half ofthe twentieth century, these religious orders tookincreasing responsibility for the care of personswith intellectual disability. Throughout the 1950sand early 1960s, with the involvement of Parentsand Friends Groups, public ftinds became avail-able and reports were commissioned which recom-mended a move from institutions to thecommunity, and the movement of all people withintellectual disability living in psychiatric hospitalsinto appropriate accommodation separate fromthe psychiatric hospitals. Services had been andcontinue to be provided by different groups (vol-untary and state run) and diis diversity is reflectedin approaches to management of people with dualdiagnosis, as outlined below.

AVAILABLE PREVALENCE FIGURESON PEOPLE WITH DUAL DIAGNOSISIN IRELAND

The 1971 Psychiatric Hospitals census (O'Hare&Walsh 1971) showed that 16% of the residents of

psychiatric hospitals were diagnosed as mentallyhandicapped. As only 3-5% of annual admissionswere accounted for by the diagnosis of mentalhandicap (O'Hare & Walsh 1972), many of the16% were probably long-stay residents. A series ofpapers in 1974 reported studies of the associationof psychiatric disability and mental handicapamong the in-patients and day-attenders at ageneral-hospital-based acute psychiatric unit(Clarke et al. 1974; Parton et al. 1974). It wasfound that 16-3% of in-patients and 23-5% ofday-attenders scored in the mentally handicappedrange on formal testing with the WAIS. This studywas repeated in 1987 (Kennedy etal. 1988) usingthe WAIS and the WAIS-R and showed littlechange in prevalence from the previous study.

The 1981 Census of Mental Handicap(Mulcahy & Reynolds 1981) enumerated a totalof 22 979 persons with some degree of mentalhandicap in the Republic of Ireland. Unfortu-nately, in 30% of returned cases, the individual'sclinical record contained no information on psy-chiatric diagnosis. For 53-9% of returned cases, itwas specifically stated that no psychiatric syn-drome was present. Some 15-8% of cases wereidentified with a psychiatric syndrome. The rela-tive proportion of the mentally disturbed increased