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Another group that would benefit from an intensive temporary residential training program are certain of our adolescents, who during that period of contradictory growth patterns, hard enough for the average youngster, will respond better to a specialized education program woven into a pattern of group living. Please note that I am not suggesting this as a proper step to take with all retarded adolescents, but once again only for a group with special management needs which cannot be met adequately at home and in community programs.

That severely retarded adults can make an adjustment in the community has certainly been demonstrated by Dr. Gerhardt Saenger in his now famous study for the New York State Interdepartmental Health Resources Board. But even though Dr. Saenger showed that of all the former pupils of the original classes for the trainable in New York City the older group, then in their thirties and the forties, made the best occupational adjustment, we must foresee that the time may come for many of these older severely retarded individuals when the pressures of community living become too much for them and they would wish for a more sheltered environment with others like themselves. In contrast to the other programs I have mentioned, they will require neither intensive medical care nor specialized educational or training efforts.

One might gather from my enumeration of categories for whom we need to provide specialized programs (and I certainly have not made this an exhaustive listing) that I foresee a tremendous increase in institutional facilities. However, it must be remembered that several of them were presented as temporary programs providing for eventual and in some cases early return home. Furthermore, long-range planning for residential care must take into account that certain new community programs, such as day care centers, can bring sufficient relief to the parent so as not to make it necessary for them to ask for care in an institution. These comments apply in varying measure to all the age groups of the mentally retarded, but time does not permit me to go into more specific exemplification of these trends. Let me merely state that in the context of these considerations we must be mindful of the Independent Living Rehabilitation legislation and its projected help for the homebound, most severely retarded individuals.

Finally the fact that for the convenience of the audience I have brought you here today several specific categories for whom a new type of residential facility might be applicable, does not mean of course that I naively assume all cases will conveniently fall into these and other categories. There undoubtedly will always be certain children and young people who for various and sundry reasons, inherent in their own or their families situation, need the protective care and training of an institutional setting.

In summary then, it stands to reason that so many different types of needs call for a number of clearly differentiated types of residential facilities, of different sizes, with different staffs, different buildings, different programs, even in our smaller States.

And who will staff these institutions of the future? I am aware I am treading on dangerous ground here. Any suggestions for radical changes in institutional staffing can easily be and usually are mistaken as attacks on those who now perform their duties diligently and faithfully. This is decidely not my intention.

But if we consider that during the past ten years the field of mental retardation has undergone what can only be characterized as a revolution, it is a natural consequence that the staffing in our institutions needs to undergo a rigorous scrutiny to determine what changes need to be made in the light of newly gained knowledge. As community services, including schooling, are showing an even greater readiness to provide for new programs and new staffs specifically for the needs of the retarded, the admittedly less flexible institutions should feel greatly challenged to keep in step with these developments.

I do not want to include here a long recital of the many jobs we need in institutions and in which ways we need to improve the personnel standards pertaining to each. Rather I would like to emphasize here a general problem which has impressed itself on my mind as being a number one priority as I have traveled from state to state visiting public institutions and the departments administering them. This problem relates to the social structure we find in our institutions, or, as the sociologists call it, the power structure.

Some excellent studies have recently been published showing how, in our state hospitals for the mentally ill, this power structure from the superintendent down to the ward physicians, down to the nursing staff, and then on down to the lowly attendant, very effectively interferes with the main purpose of these state hospitals, namely to cure the patient. In other words, it is the institutional organization which is in the center of things, rather than the patient whom the institution is to serve. In the course of these studies, the researchers found that particular problems were created when an attempt was made to strengthen the hospital's program by the addition of specialized personnel, such as clinical psychologists, educators, occupational and recreational therapists, psychiatric social workers, and the like.