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In our medically oriented institutions we shall need in the future a far greater pediatric influence and less domination by the psychiatrist, that is to say a more diversified medical program including a far greater interest in a program for specific physical therapy. On this point, too, I am regularly challenged with reference to the existence of such specialized services in the institutions under discussion. The question, however, is not whether one or more pediatricians are listed on the institution's roster. The question is to what extent they actually do have opportunity for continuous adequate pediatric practice on behalf of the institution's residents. To have one physical therapist in an institution of almost two-thousand patients is certainly better than having none at all. But it hardly can be claimed that the institution as such has a program of physical therapy for those of its two-thousand charges who need it.

I would like to refer once again to the quality of medical services in relation to specific programs. Let me briefly make my point by citing an example: Recently in a mid-western state a small T.B. sanitarium that had been running at low capacity was relieved of its remaining T.B. patients and immediately thereafter received a group of adolescent girls from the state institution for the mentally retarded, all crib cases. The point of my story is that within an astonishingly short time the medical and nursing staff of that small institution achieved most remarkable progress with quite a number of these girls in terms of such elements of self-sufficiency as feeding, sitting up, etc.

The point of my story is, of course, that this staff was not oriented to mere "custodial" care in its old-fashioned sense. They were attuned to treatment, to therapy, to doing something for their patients' individual well being and ability to operate. And it took them no time at all to recognize that with their new charges the first order of business was to help them toward a greater independence in life, no matter how modest a degree. Let this one example suffice to make my point that above all else what we need in the institution of the future is not just a different orientation towards the patient, but an opportunity to act effectively on it.

But a new medical orientation meets only one of many needs. Another is for a new attitude toward general patient management. There is an urgent need to bring to our institutions for mentally retarded children knowledge of good common child care as practiced in many of our good children's institutions throughout the country (and I emphasize the word good because obviously not all of them could serve as an example). There is no reason whatever to assume that good child care practices, modified to be sure by their specific needs, cannot be applied to institutions for the mentally retarded. However, there is no doubt that this will mean a radical departure from the now traditional patterns of mass care from which we have liberated ourselves in only a few instances in our field and even there only to a partial extent.

One of the most serious problems facing us with regards to planning for the residential facilities of the future pertains to the building program itself. Two and a half years ago the NARC Board of Directors adopted the following policy statement: "Future planning of state institutions should include plans for housing no more than 1,500 persons in each institution and plans for establishing each such institution close to a population center within each state, preferably those centers in which there are universities or medical schools." Please keep in mind that this was a policy statement dealing with the here and now. My topic today calls for a look at the horizons of the future. From that vantage point I have no hesitancy to predict that the instituion of the future, though unfortunately the rather distant future, in most cases, will need to be distinctly small and should not exceed 500 to 700 residents.-sic- This parallels the considered opinion of mental health leaders, both in this country, and especially abroad, and it is interesting that already 25 years ago American prison wardens came to the conclusion that this was an optimum size for institutions where the main weight rested on the personal relationship between and among the staff and the residents.

Within these small institutions of the future we can expect to see radically different building design: no longer storage places but buildings of functional design. There is some belief that functional design has already been an objective of our institutional architects. However, I shall insist that in the past we have used this word functional as equivalent to smooth running of the institution, while in our present context it should be used in relation to the needs of the individual residents. Even our relatively new and progressive institutions can learn in this respect a great deal from our friends in Europe, particularly in Holland and in the Scandinavian countries.