‘Patterns of Residential Care: Sociological Studies in Institutions for Handicapped Children’ by Roy D King, Norma V Raynes and Jack Tizard

Roy D King, Norma V Raynes and Jack Tizard Jack (1971) Patterns of Residential Care: Sociological Studies in Institutions for Handicapped Children London: Routledge & Kegan Paul ISBN 0 7100 7038 1

This study is unusual in focusing on the interactions between staff and children and in comparing children with very different needs and in different types of residential establishment and may for that reason have been ignored by those concerned with only one group of children or one type of establishment. Jack Tizard obtained the funding for, and then recruited, Roy King and Norma Raynes to undertake the research, first into child management practices in two large cottage homes and two hospitals, and then into child management practices in local authority, voluntary and hospital provision for children with learning disabilities.The conclusion, that there needed to be changes in nursing training to make it more child-centred, may distract from the many useful and sometimes unexpected findings on the way to that conclusion.

Key Ideas

  • There has been no pressure to change the situation of children with learning disabilities in residential care.
  • There has been no research on their situation in residential care.
  • Facilities and contact with the community were better in children’s homes than in hospital wards for children with learning disabilities.
  • Staff in children’s homes had more day-to-day responsibility for the children’s lives.
  • Children in hospitals almost never saw normal household activities such as food being prepared, had almost no personal items, did not receive birthday presents and were all in bed by 8 p.m..
  • Neither level of disability nor size of home accounts for differences in child care practice.
  • Deployment of staff to meet children’s needs and continuity of care are associated with positive child care practice.
  • Positive child care practice is associated with heads of units who share in the tasks of their staff and who interact positively with children.
  • Junior staff follow the lead of the head.
  • Heads who are given responsibilities have more time for children than those who do not, because the latter group spend more time passing messages to those who have the responsibilities than do those who can take the decisions themselves.


In Chapter 1 Introduction, the authors set out the context of the research which is to focus on the children’s immediate living environments and how they relate to the organisational structure and wider institutional context in which staff operate. While there had been some attempts to improve conditions, at the time children with learning disabilities experienced less favourable conditions than other children.

In Chapter 2 Children in Residential Care, they begin by outlining the situation in March 1963 when they began the first part of the research; there were about:

65000 children in local authority care
13000 children in voluntary homes
8000 children in private fostering
7000 children awaiting adoption
23000 children in special boarding schools
(c. 21000 boarders + c. 2000 day pupils)
10000 children in juvenile justice institutions
15-19000 children in institutions for children with physical disabilities

They note that Donnison and Ungerson (1968) had shown that, while the numbers in residential care in each age group had risen since the start of the century, the proportions in each group had declined and they show that, for children in the care of local authorities and voluntary organisations, this trend was continuing.

Also, while the Curtis Report (1946) had recommended greater use of foster care, scattered homes and breaking large homes into family groups, no similar changes had been made for children with learning disabilities in residential care.

As they were concluding their research in 1968, there were around 65,000 people with learning disabilities in hospitals, mostly large and overcrowded. The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, which had reported in 1957, had proposed more prevention, more short-term care, separate accommodation for children and adults, smaller living units, less sex segregation and the upgrading of older facilities.

In Chapter 3 Child Development and Methods of Upbringing, they survey the current literature on genes versus environment, ‘compensatory education’ as expressed in the Headstart programmes (and its critiques), the research on ‘deprivation’ in residential care by Bowlby (1953) and others and the literature of residential care.

In Chapter 4 The Sociology of Residential Institutions, they survey the available sociological literature on organisations noting that most research has been on institutions for adults, that there have been few studies of learning disability and even fewer comparative studies. They note that Goffman (1968) uses ideal types and that his book is not based on research.

In Chapter 5 Four Large Institutions, they describe the four institutions which were the focus of the first part of the research:

  • a cottage home for 340 children in 23 cottages of 15-20 children, with bedrooms for 1-5 children, having self-contained facilities on site,
  • a cottage home for 377 children in 6 detached and 30 semi-detached cottages of 12 children, with bedrooms for 1-4 children, and more integrated into the community,
  • a subnormality hospital for 307 children in 16 wards of 20 patients, on the same site and opposite
  • a paediatric hospital for 308 children in 16 wards of 20 patients (with some wards having cubicles).

Generally the facilities were better in the children’s homes than in the subnormality hospital though it was better than other subnormality hospitals. There were more boys than girls in all the institutions and at least 88% had been in the institution for more than two months.

The children in the children’s homes attended many different schools (to keep numbers in any one school down) and there was a high level of behaviour problems.

The children in the subnormality hospital were split into eight ‘low grade’ wards where the children had physical and learning disabilities and eight others. The children in the paediatric wards had disabilities midway between those in the subnormality hospital and those in the children’s homes. In both hospitals there were high levels of incontinence.

In Chapter 6 Administration, Staffing and Patterns of Responsibilities, they note that both hospitals were below establishment; they were jointly managed to the level of medical administrator and matron, below which each had four assistant matrons, a night superintendent and a night administrative sister. There was also a nurse training school.

Though the children’s homes had fewer staff, there was no separate administrative hierarchy and little specialisation. The children’s homes staff worked longer hours and most lived in the cottages, whereas no hospital staff lived in the wards. There was no spare capacity in the children’s homes for illness or holidays. 23% of the staff in the first home and 31% in the second home had done the one-year Home Office course.

All establishments shared two things: decisions about the future of the children were not the responsibility of the head of unit and staffing allocation was left to the head of unit. However, the actual daily routine was in the hands of children’s home staff, but not of the ward staff, who did no purchasing and had no petty cash, whereas most routine purchasing was done by the children’s home staff.

In Chapter 7 Patterns of Care, they describe the children’s day, noting that the children in the hospitals almost never saw food being prepared and that toileting dominated their routine.

Most of the children in the children’s homes went to outside school or nursery school on site.

In the hospitals bathing followed toileting and then bed whereas in the children’s homes bathing was an individual experience with staff. Most children in the hospitals were in bed by 7, with a few staying up to 8; bed times in the children’s homes ranged from 6.30 to 10.

In the hospitals the only personal item all children had was a toothbrush; many had no other personal items; clothes were washed and given to different children. In the children’s homes, children had personal clothing, toys and pocket money and they celebrated special occasions. In the hospitals they might get extras on their birthdays but no present.

To supplement these observations, they looked at a voluntary home for children with severe learning difficulties and a local authority hostel; in both, life for the children was much closer to life in the children’s homes than to life in the hospitals.

In Chapter 8 Child Management: Some Preliminary Conclusions, they note that none of the establishments was a ‘total’ institution as defined by Goffman (1968) and describe the development of a Child Management Scale to assess how child-oriented an establishment is, where the lower the score the more child-oriented it is. The cottages in the children’s homes all scored between 0 and 6 while the paediatric hospital wards scored between 17 and 22 and the subnormality hospital wards between 23 and 30. The local authority hostel score fell within the same range as the children’s homes while the voluntary home had a higher score than the children’s homes but lower than the hospitals.

The key difference they noted at this stage was the kind of training the staff had received.

In Chapter 9 Child Management Policies and Institutional Organization: Some Hypotheses, they set out thirteen hypotheses which they wanted to test in a second research project.

In Chapter 10 Research Design and Methods, they describe the sixteen establishments in which they carried out the research: eight local authority hostels, five hospital wards and three voluntary homes. The number of residents ranged from 12 to 41 in the hostels, 121 to 1,650 in the hospitals and 50 to 93 in the voluntary homes. However, they focused only on those residents between 5 and 16 years old who were ambulant but had a severe learning disability.

The voluntary homes had the worst facilities and the children in the hospitals were more handicapped overall.

They looked at information on the children and examined staff activities through:

  • interviews and records
  • time sampling, that is, observing staff interactions for fixed periods of time.

In Chapter 11 Child Management Practice in Hostels, Hospitals and Voluntary Homes, they report on the findings relating to the first four hypotheses.

In relation to the first, they found large and characteristic differences between the hostels, the hospital wards and the voluntary homes.

In relation to the second, they found that differences in the children’s handicaps did not account for these differences.

In relation to the third they found no association between child management practice and the size of the unit.

In relation to the fourth, they found no status connection between child management practice and the size of unit.

In Chapter 12 Staffing and Child Management, they report in relation to the next three hypotheses. There was no relationship between the official child:staff ratio and child management practice but there was a relationship between the effective child:staff ratio and good child management practice, because the staff in the children’s homes were deployed at the times when children needed them.

They also found that continuity of care was associated with good child management practice, noting that Bettelheim (1950) had recommended the same staff member see a child last thing at night and first thing in the morning.

In Chapter 13 Staff Roles and the Way they are Performed, they describe how they collected the data relating to the next four hypotheses under the headings:

  • social child care
  • physical child care
  • supervision of children
  • domestic activity
  • administration.

They found that, while heads of units might spend the same amount of time in the presence of the children, those where there was good child management talked to them one and half times more and were three times less likely to ignore them.

They found that, while junior staff did substantially the same in all the units, the proportion of their activities which were also done by senior staff was much higher in those units where there was good child management practice.

Overall, junior staff in the hostels were more likely to talk to children and less likely to reject them.

They conclude that the unit head is the key to setting the style of a unit. They also noted that Downs’ syndrome children were significantly more able to feed themselves and to verbalise in hostels and voluntary homes than in hospitals.

In Chapter 14 The Responsibilities and Training of Senior Staff, they report that heads of units who were more involved in unit decisions were also more involved in personal care. This was very significant; in practice, giving responsibilities to heads actually released them from a lot of intermediary activity which they had to undertake when they didn’t have the responsibility.

Finally, they found that, across the local authority hostels and voluntary homes, child care trained heads were more likely than nursing trained heads:

  • to talk to children
  • not to reject children
  • to interact when doing domestic or administrative tasks.

In Conclusions, they summarise the above results and note that:

  • size of unit and
  • staff shortages

are not relevant to whether there is good child management practice but that the

  • responsibilities of staff, for example, whether they eat with the children, and
  • their interactions with children while carrying out their activities

are relevant to child management practice and they suggest that the content of nursing training needs to be examined.


These results were, and probably still are, unwelcome to those who believe that the best care is provided in small units with sufficient, well trained staff. The key factors in quality care are having a head who can take decisions about the daily life of the unit, who shares in the work of her/his staff and who interacts positively with the children, thereby setting an example which other staff follow. Size of unit and even having the unit fully staffed are not as important as these. At the time child care training was far more oriented to encouraging such behaviour than nursing training but arguably training today, with its emphasis on child protection, no longer emphasises such behaviour.

The fact that a positive environment could encourage rapid development in children with learning disabilities had been demonstrated over twenty years earlier by Skeels (1942) but this research had been overlooked by most researchers until Wolins (1974) drew attention to it a few years later.

But what is most important is that these results were discovered across a range of establishments from very large children’s homes and hospitals through a variety of voluntary sector and local authority establishments of different sizes and with very different physical provision for children with and without disabilities.

In the end it is the interactions of one person — the head of a unit for which s/he has full day to day responsibility — that will have most impact on the quality of care of that unit and the most important aspect of their training will be improving the quality of their interactions with their staff and with those for whom they are responsible. Perhaps that is just too simple for our sophisticated age.


Bettelheim, B (1950) Love is not enough: the treatment of emotionally disturbed children Glencoe IL: Free Press

Bowlby, E J M (1953) Child care and the growth of love: based by permission of the World Health Organization on the report “Maternal care and mental health” Abridged and edited by Margery Fry London: Penguin

Care of Children Committee (1946) Report of the Care of Children Committee Cmd 6922 London: His Majesty’s Stationery Office Chairman: Myra Curtis

Donnison, D V & Ungerson, C (1968) Trends in residential care, 1911-1961 Social policy and administration 2(2):75-91

Goffman, E (1968) Asylums: essays on the social situation of mental patients and other inmates Harmondsworth: Penguin

Skeels, H M (1942) A study of the effects of differential stimulation on mentally retarded children: a follow-up report American Journal of Mental De?ciency 46:340-350

Wolins, M (Ed.) (1974) Successful group care: explorations in the powerful environment Chicago: Aldine

Leave a comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.