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While the principles of dispersal and specialization recommended throughout this book would lessen the problem of multidisciplinary leadership, the process of regionalization will definitely bring this problem increasingly to the forefront, because the regions will encompass a wide array of services under different professional auspices. Already we have witnessed that in spite of an initial recognition at top level of the separate needs of mental retardation and mental health (mental illness), the procedure adopted in several states has been to make the regional mental retardation director subject to the supervision and direction of the regional mental health director, even though the latter in most instances has little or no working knowledge of or interest in the field of mental retardation,

Regionalization and the Traditional Institution. A considerable problem in effecting a reorientation from the large central institutions to small, dispersed, specialized residential centers derives from the fact that the large institution exists and occupies a position of strength, while the new structures, i.e., the regional and community centers, in most cases must be newly developed and are too small and too informal to counterbalance the large institution. Eventually, of course, the network of community services will constitute a major force, but in the meantime there is danger that the reality and convenience of the existing large institution will suggest unsound modifications of the plans for regionalization, dispersal, and specialization. For instance, it may appear expedient to develop smaller community residences as "satellites" of the large institution, or, similarly, to use the accommodations of the institution as bases for the development of regional services. Obviously it will be difficult to effect the necessary changes toward regionalization and dispersal in a state where the large state institution has for many years been the focal point for services to the mentally retarded.

The absence of effective or appropriate state regulations, standards, and controls of and for state residential services for the mentally retarded has been a serious problem throughout the country. It certainly would be foolish to assume that the greater visibility of the smaller facilities recommended throughout this work and by many previous commissions and reports would obviate the need for regulatory supervision. While regionalization, dispersal, and specialization will assure greater benefits to the mentally retarded, they will create serious problems of management and coordination as compared with the large centralized institution. The mere fact that there will be a large number of residences of differing sizes serving a distinct variety of clients will make it essential to develop standards which will assure programs capable of meeting the needs of the individual residents, proper management, and the needed cooperation with governmental and voluntary agencies within the framework of the continuum of "available care." Therefore, the standards must address themselves not just to the facilities (as is now the case in many states in similar situations), but must include the program and the resident.

Notwithstanding the development of a large variety of smaller residential centers, states with large population concentrations will most likely continue to have for the foreseeable future large institution complexes. This last term is used to indicate the desirability that there be established functional units which could operate with a considerable degree of independence. However, in order to develop toward the necessary balance between the major types of services, state governments (and in terms of its granting programs, the federal government as well) should recognize and adhere to the principle that i money be appropriated for any type of residential facility without concurrent consideration of and appropriation for essential related nonresidential services in the community. Owing to the striking differences in structure, organization, function, and extent of mental retardation services and related other services in the various states, it is quite impossible to think of any set formula for the proportion of expenditures for residential to nonresidential services; however, there can be no question that this is one of the most crucial issues faced at this time.

Finances

The various proposals which have been made in this volume and before that by innumerable committees and commissions in regard to improvement of mental retardation programming suggest any number of fiscal proposals and solutions.

However, of immediate and paramount importance must be an all-out effort throughout the country to recognize the indisputable need for immediate adjustment of appropriations to make sure that in the future, institutions for the mentally retarded can buy enough clothing so that no resident needs to be naked, no child need be kept from playing out of doors for want of a pair of shoes or a sweater, no resident need freeze at night for lack of a blanket, and that essentials such as soap and toilet paper are available. Each of the examples just cited refer to actual situations in the recent past in the two richest states in this country, and in each case, the official explanation was lack of funds.