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General observations during the past year indicate a substantial lengthening of the lifespan of the mentally retarded who thus will in increasing numbers outlive their parents. This implies a need for some sort of simple residential facility, probably community based.

Finally, the presence of an ever-increasing number of retardates in the community highlights the need for the development of programs for spiritual guidance and for recreational activities.

Residential care

The least amount of progress in the field of mental retardation during the past decade was made in the area of institutional care. Some of the reasons for this unquestionably lie in the fact that brick-and-mortar have a tendency of forcing upon a program a "straitjacket". Another inhibiting factor has been a strong anti-institutional sentiment which expressed itself in low salaries, low allowances for maintenance, and a low esteem for the institution as a helpful agency.

With many progressive developments in community care one can expect during the next decade increasing pressure for upgrading and updating of residential facilities for the retarded. In the process the following issues will have to be met: Shall we continue to build large institutions serving thousands of residents? What is the measuring stick for the "economical size" of an institution -- the ease of maintenance, flexibility in classification, easy availability of supporting medical services, or the specific treatment and training potential for the individual residents ?

Is it advisable to combine in one facility groups as widely diverse as severely disabled young children needing full time intensive physical therapy and nursing care, inactive older retardates in need merely of protective shelter, and adolescents undergoing an intensive socialization and work training program preliminary to placement in the community?

Is it reasonable to set general limitations on the size of institutions for the retarded -- less than 1,500, less than 500, less than 50 -- or, must we begin to look at the problem of size in conjunction with specific functions which in turn must be related to the needs of the residents? Is there an upper limit in size beyond which the therapeutic and training potential for the individual resident is distinctly decreasing?

As far as the staffing problem is concerned, there has been widespread agreement that the basic employee group, the attendants, should receive a higher compensation to attract "better people". There has been disagreement, however, wherein this betterment was to be sought. Some point out that one should be aware of "overtraining" attendants as they would become less and less inclined to deal with what they may come to consider "menial" ward routines concerned with keeping patients tidy. On the other hand, better trained staff might indeed bring about some degree of improvement, even with the most severely retarded, and thereby decrease the need for the menial tasks.

Considerable staff improvements have taken place in the majority of the institutions during the past decade, but most of them focused on the addition of new types of professional staff and of strengthening existing professional staffs. However, a realistic appraisal will show that the weight of the rehabilitative effort rests with the attendant on the wards and in the work groups (if any), and that to a very large extent ward and work routines are far outside the knowledge and experience of the professional staff.

Several European countries have demonstrated the feasibility both of distinctly smaller housing units for institutional residents and of insistence on adequate training for the basic staff.

It has been customary in this country to speak of the more seriously disabled retarded in institutions as "custodial" cases, implying that "safekeeping" was with them the only objective. The experience of foreign countries and isolated experiments in this country call for serious consideration as to whether custodial care with its implied limited and limiting procedures can be justified.

Other problems which require attention are the degree to which the patient's family should be liable to carry the financial cost of institutionalization, the extent to which informal admission should replace present cumbersome, expensive and in many ways harmful commitment procedures, and the desirability of removing restrictions in visiting days and hours, correspondence, home leaves, weekend visits, and any other means of preserving an active relationship with the family.

The literature of the more recent years includes quite a number of articles debating the desirable qualifications for the superintendency, the core of the argument being whether this called for a physician, an educator or psychologist, or a specialist in administration of institutional management without training in one of the foregoing professions. Within the medical group there has been further argument as to whether or not it was essential for the superintendent to be a qualified psychiatrist.