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"Mental retardation refers to subaverage general intellectual functioning which originates during the developmental period and is associated with impairment in one or more of the following: (1) maturation, (2) learning, and (3) social adjustment". This is the definition on which the American Association on Mental Deficiency has based, its new "Manual on Terminology and Classification in Mental Retardation." Accordingly mental retardation will be used in this paper as encompassing all types and degrees of this disability.

It should be noted, however, that there is no common agreement on terminology. For instance in 1954, the World Health Organization proposed that the overall problem be termed "mental subnormality" with two major subdivisions reflecting causative factors: mental deficiency for those cases where biological factors have resulted in pathology of the central nervous system, and mental retardation for those cases where the causative factors are in the social, economic, cultural, and psychological realms. Many scientists and practitioners in this country, on the other hand, use the terms "mental retardation" and "mental deficiency" interchangeably while other English-speaking countries have terms of their own. This means that great care has to be taken to establish in discussions or in using literature what particular terminology is involved.

There are no exacting statistics available concerning the number of mentally retarded in the United States. A substantial portion of the scientists and practitioners in the field set the number of mentally retarded in this country in excess of 5 million, or 3 percent of the population. However, some writers give a substantially smaller figure down to as little as 1 percent of the population. While such discrepancies in estimates do constitute a problem, the source of disagreement does not lie with the main body of the supporting figures but with the point at which the upper limits of mental retardation are established.

The normal distribution curve provides for a rapid increment of the estimated number of individuals covered as one moves upward on an intelligence scale. Hence, if one writer uses as the upper limit of those called retarded a Binet IQ of 70, while another writer chooses to use a Binet IQ of 75, the second estimate would be about twice as large as that of the first one.

During the past 10 years a number of surveys and reports have been published which list in various ways the figures regarding the "known" mentally retarded. It is important to recognize the limitations of such figures. Relatively few preschool retarded children are "known" to agencies, yet we know they exist. Furthermore, the fact that no service is requested for them by parents does not mean that no such service is needed; recent studies (such as Kirk's) have indicated the advantage of early work with the very young retarded child, in other words, it is hazardous and misleading to base program planning mainly on statistics regarding known cases. Availability of good, accessible mental retardation services will result in distinctly more cases becoming "known, " and thus in increasing the estimates of future needs.

Causation

While, in general, there has been no inclination in this country to accept the terminology of the World Health Organization, there is general acceptance of the basic premise underlying it, namely the differentiation between mental retardation which is related directly to biological factors and mental retardation that does not indicate pathology of the central nervous system. It is in accord with the general status of knowledge in human affairs that we have far more exacting information about the biological than the sociocultural-economic causes. One of the outstanding leaders in the field, Dr. George Jervis, wrote in 1957 that "it would be easy to compile a list of some hundred diseases characterized by mental retardation, each one exhibiting its own etiologic determinants."

In general, the biologically conditioned and the sociocultural-economic types of mental retardation face each other in juxtaposition, qualitatively and quantitatively. The former encompasses a larger number of the severe cases but constitutes only a small percentage of all the retardates, while the latter is more typical of milder forms but numerically is by far in the majority.

A great deal of confusion exists with regard to so-called environmental influences in mental retardation, since this term is used in two entirely different frames of reference. The sociologist will use it with regard to cases where, for instance, lack of a minimum of stimulating influences and emotional deprivation have resulted in an individual's intellectual and social inadequacy. The biologist, on the other hand, uses this phrase to differentiate a genetic factor, such as is operative in gargoylism, from such prenatal environmental factors as effects of an infectious disease of the mother during pregnancy.

Another semantic problem in the etiology of mental retardation pertains to the use of the word "heredity." Not just the lay public but large numbers of professionals once held the belief that mental retardation to a large extent was directly inherited as a condition present in either the paternal or maternal side. To counteract this there has been a tendency in more recent years strongly to deny altogether the significance of hereditary factors. However, others presently use the term "hereditary" as synonymous with "genetic" (i. e. , transmittal through the germ plasm independent of the trait's manifestation in the parent). Used in this fashion, a statement "heredity plays a significant part in the causation of mental retardation" is not inaccurate.

Within the framework of this brief paper, it is not possible to present a detailed analysis of the many diseases known to produce the symptom we describe as mental retardation. Suffice it to say that besides the genetic factors (classified as endogenous) we may identify three main categories of environmental diseases and injuries (classified as exogenous and ordered according to the time -- before, during, or after birth -- when they are operative); prenatal (e. g. , infection of mother, vitamin deficiency); perinatal (e.g. , hemorrhage during delivery, irregular oxygen supply); and postnatal (e.g. , meningitis, lead poisoning).

Classification

As indicated earlier mental retardation varies in degree; from those so severely impaired as to require permanent full-time nursing care, to those who manage to "get on" in a life situation with minimum demands, but who lack the intellectual resources to face new and more challenging situations.

The introduction of the intelligence tests facilitated originally a seemingly exacting classification of the mentally retarded into three groupings: the moron (IQ of 70-75 down to 50-55); the imbecile (IQ of 50-55 down to 25-30); the idiot (IQ below 25-30). Later, because of the unhappy connotations these words had assumed in the vernacular, the terms mildly, moderately, and severely retarded were introduced.

In the mid-fifties the terms marginally independent, semidependent, and totally dependent came into usage. At the same time, the educators tried to develop a terminology reflecting prevailing concepts of educative capacities of the retarded, and introduced the term educable corresponding to moron or marginally dependent, and trainable corresponding to imbecile or semidependent.

All these diverse efforts concentrated too much on the factor of intellectual inadequacy (in their dependence on the intelligence tests) and did not sufficiently consider the equally important factor of social adjustment or adaptive behavior. Furthermore the static concept of a classification based solely on intelligence test performance proved more and more inadequate as evidence accumulated that a given child might indeed substantially improve his rating on the intelligence test as a consequence of specific education and training or a generally enriched life experience.

Therefore, the new concepts of a behavioral classification combining "Levels of Adaptive Behavior" with "Measured Intelligence" developed in the Manual of Terminology and Classification in Mental Retardation published by the American Association on Mental Deficiency in 1959 must be considered as a real milestone. (1)

Unfortunately, however, the procedure suggested in the manual for implementing these new concepts can only create new confusion because it assigns the entire subaverage group to the realm of mental retardation including what in the past have been known as the slow learners, the borderline, and dull normal groups.

Obviously the challenge for the next decade will be to test out and develop further this new type of classification in order to provide a terminology which is conceptually sound as well as adequate to encompass prevailing programs and practices in the field

Whose Responsibility?

The problem of proper identification and classification does not just pertain to the individual afflicted with the condition but to the condition itself.

Not infrequently mental retardation is seen for instance simply as a mental health problem.

The comprehensive knowledge available today should make it clear that such unilateral identification will interfere with sound program developments -- whether in practice, teaching, or research. Educators, psychologists, social workers, sociologists, rehabilitation workers, and other professions are needed in the field of mental retardation along with the medical and paramedical personnel. The extent of their respective contribution hardly can be expressed in a generic rank order -- it depends on the given situation and the type of case under consideration. If we think of biologically conditioned mental retardation the psychiatrist has but little to offer compared with what the biochemist or obstetrician brings to prevention or the pediatrician to early diagnosis. But conversely the biochemist or obstetrician lacks the psychiatrist's competence to deal with adjustment problems of the retarded adolescent. Development of life skills in the severely retarded -- specific training in speech or perceptual skills, in reading or word recognition, in work training or play activities -- these are areas where the educator's skills are needed rather than the physician's. Similarly with regard to causation we have areas where the sociologist would be the prime investigator and interpreter.

We must be aware of the need for team work among the professions and for maximum flexibility in deploying their respective competence in the broad field of mental retardation.

The Role of Community Services

A well-rounded program for the mentally retarded requires a wide network of services and facilities because it must provide for the mildly as well as the severely retarded, and for many different age groups over the life span. During the past 10 years tremendous progress has been made in communities throughout the country through the establishment of specialized programs for the benefit of the retarded. Yet, considering the numbers of the potential users and considering that we are dealing with a lifetime problem these accomplishments are only a token effort.

Mental retardation clinics can serve as an example: Ten years ago there was no facility available to provide for a comprehensive evaluation of a retarded individual, and for guidance and counsel to his family. Today there are 77 such clinics, most of them initiated with funds provided for this purpose by Congress, 23 are located in hospitals, 17 in local and district health departments, 13 in special community centers for the retarded, 11 in medical schools, 8 in state health departments, 3 in private schools, and 7 in state institutions. The main focus of the work of all the clinics is on diagnostic studies, a secondary focus on parent guidance. The service is directed primarily at the preschool group and in 1958, 75 percent of the 7,000 to 8,000 cases seen by the clinics were under 9 years of age.

Because the Federal funds for the clinics come from the U. S. Children's Bureau to the state health departments, a particular effort has been made to establish close working relationships with other aspects of public health programs such as well-baby clinics, premature baby programs, maternity, and obstetrical care facilities. Through training institutes for professional workers, through clinical demonstration, and participation in efforts to educate the public the clinics have performed a major educational task.

However, throughout the country last year they were able to serve only 7, 000 to 8, 000 children. This points up the unmet need for these services in communities throughout the country. Without the availability of specialized clinical services in the field of mental retardation it is not possible to build a comprehensive, coordinated, effective system of community services for the retarded. While it was wise strategy to begin with pediatrically oriented clinics for the young child, clinical facilities must also be available for the school-age child and the young adult since experience has shown that periodic reevaluation is essential in view of the dynamic character of mental retardation which makes it impossible to assess with a single diagnosis -- however comprehensive -- the future of an individual's growth and development.

In this respect community planners will have to face important questions: To what extent will it remain necessary to have separate clinical facilities for the mentally retarded? Should broader gaged clinic facilities be developed for all handicapped children with appropriate specialized services? If so, what would be the respective roles for pediatrics and psychiatry? Will it be necessary to include in such clinics more representation from the educational profession since clinic recommendations will have to relate themselves in many cases to a considerable extent to educational needs and existing educational facilities?

In planning clinical facilities for early diagnosis of mental retardation, case finding becomes an essential prerequisite. In terms of direct services this points to the contribution public health nurses and child welfare workers can make along with the physician and hospital personnel in those cases where indications of serious damage are noticeable. Another aspect of case finding might be the maintenance by official agencies of special registries such as those maintained by public health departments for crippled children. However, in most carts of the country public health nurses and child welfare workers have access only to a limited number of homes, nor do most families have the services of a pediatric specialist.

Another aspect of early diagnosis pertains to the multiple handicapped children. In the past there has been a tendency to overlook the possibility of corrective physical therapy with the more retarded child and there are indeed still states which as a matter of law or regulation categorically exclude mentally retarded children from the crippled children's program. Once we begin to deny helping services to those who are deficient, who is to say which degree of deficiency shall justify such denials? Also, children with multiple handicaps are often left out as they do not fit properly into existing compartmentalized programs.

An immediate outgrowth of the increased diagnostic services has been the recognition of the importance of guidance for the parents of retarded children. One of the particularly aggravating factors in the problem of mental retardation has been the fact that even the diligently searching parent had great difficulty in getting helpful information regarding the retarded child's capacity and needs. During the past decade programs of parent education have been developing utilizing a variety of means such as lectures and film showings, parent discussion groups, and guidance pamphlets such as "The Mentally Retarded at Home" (U.S. Children's Bureau), "3 R's for the Retarded" (National Association for Retarded Children), and "Now They Are Grown" (Minnesota Department of Public Welfare). While these programs aim at giving the parent a general understanding of the meaning of mental retardation, the needs of the retarded child and the impact of the retarded child on the family, there is also need for counseling services providing help to parents in coping with specific problems. Few such counseling services are now available to other than the parent of the preschool child and there is uncertainty as to under which auspices they should be developed in the years to come.

Guidance alone is obviously not enough, particularly for the parent of the severely retarded, often also physically disabled, child. The past several years have seen the development of pioneering programs in day care to provide relief to the family from the 24-hour care of the child and in nursery school programs to provide for the often isolated retarded child group contacts as well as group learning. Here again a variety of state agencies and private organizations have set up the demonstration projects and no agreement exists as to auspices, staffing, and financing.

Speaking quantitatively and qualitatively, no other service has as much to offer to the total group of mentally retarded as has the public school system. It is therefore encouraging that the last decade has seen spectacular progress in this area but also challenging for the decade ahead that special education facilities are as yet available for only one-quarter of the retarded who can avail themselves of them.

A particular controversy developed a few years ago as to whether the trainable child was a proper responsibility of the public schools or whether his training should rather be entrusted to welfare or mental health departments. While divergent opinions are still being expressed, the fact that 37 states authorize such classes either by mandatory or permissive legislation or administrative regulation and interpretation speaks for itself. In some cities classes for the trainables are fully integrated and in the same school buildings serving all other elementary classes, while elsewhere segregation is seen as the more desirable policy.

One of the arguments made against public school programs for trainable children is that this group sooner or later will find their way into public institutions. A study by Saenger, "The Adjustment of Severely Retarded Adults in the Community," contains convincing documentation that this is a false assumption. Following up a large sampling of pupils who between 1929 and 1956 had attended New York City classes for children with IQ's of between 40 and 50 he showed that only 26 percent were subsequently institutionalized. Twenty-seven percent of those who resided in the community worked for pay at the time of the study, an additional 9 percent had worked for pay previously. Obviously, such individuals should have the benefit of specialized public school education.

A new development pertains to secondary schools for the retarded. In a few communities this is now being extended to the trainable group. During the next decade further attention must be given to test out and develop prevocational programs for these pupils. This is all the more urgent because of the encouraging developments of sheltered workshops, of which more than 100 offer specialized services for the mentally retarded.

The experience of these workshops indicates that a sizable group of the retardates eligible for public school services is capable of sustained productive work. This should result in reexamination of public school curricula to determine whether they are designed to develop this vocational potential. An even greater challenge must be faced in the community: sheltered workshops are dependent on production contracts from business and industry. Also vocational training of the retarded for work in the community is useless unless the community, and in particular employer and employee groups, are receptive. It remains to be seen whether education of the public will create as favorable a climate for the young adult and adult retardate as now exists for the retarded child.

The success of vocational training centers and sheltered workshops will depend to a large measure on proper screening. Facilities must be developed for those individuals who can make a limited adjustment in the community but are incapable of sustained productive effort. They will require a simple type of activity center which in some measure is akin to the day care programs for the younger children.

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.

In general, this question has been put on an "either-or" basis, but consideration would seem in order whether this should be related to the proposals for breaking up the present large institutions into more functionally cohesive units.

As in other areas of mental retardation care should be taken not to assume that future planning can be done on the basis of present service statistics, because they are more likely to reflect present practices than present needs, or future potentials.

There will have to be considered a multiplicity of seemingly opposing trends: On the one hand, the lengthened lifespan of the institutionalized retarded is resulting in longer occupancy of institutional beds, but the greater availability to families of facilities assisting in the community care of the retarded is diminishing the demand partially. Reduction in infant mortality and the introduction of such lifesaving measures as antibiotics increase the number of severely disabled and retarded children, but the greater availability of community services and employment opportunities facilitate return to the community of a greater number of adolescent and young adult retardates. And finally the trend toward greater use of residential facilities for intensive training of those who for various reasons are unable to profit sufficiently from community education and training must be taken into account.

Legal Status of the Mentally Retarded Child

Insufficient attention has been given in the past to the legal status of the mentally retarded child and adult, particularly with reference to the degree of legal protection required as related to the degree of the mental handicap. A large number of retarded, by far the majority, are capable of moving about in the community, attending school, being employed or participating in formally organized or informal activities, yet by virtue of their being considered mentally retarded, are considered not to have the minimum endowment for an independent life. Conflicting views come into evidence concerning the ways in which this situation is being approached in various ways by our states. The existing sociolegal instrumentality of guardianship is a complicating factor since it does not allow for any limited personal guardianship but results in complete denial of independent legal status.

Minnesota has been a pioneer in working out a system of state guardianship for the retarded, administered through the state and county public welfare departments and proposals of this nature are now under discussion in several other states. At least one authority raises serious question whether such agency guardianship (public or private) does not violate the spirit and purpose of the guardianship concept as a rather personal relationship. (2) Objection also has been raised to legislation which provides for the appointment of a public agency as guardian for retarded children living with their parents in the community. Most recently the State of Washington enacted legislation providing for the informal appointment by parents, of "Parental Successors" whose task it is to look after the welfare of retarded individuals after the parents' death. However, Washington also has a formal guardianship appointment through the courts which would supersede the parental successor.

Other more specific questions need to be explored: What restrictions are justifiable regarding the marriage of mentally retarded individuals? Since an increasing number of retarded young people are earning some wages, what situation should pertain to their property rights?

A serious problem regarding the legal status of the mentally retarded has long been the question of criminal responsibility. Present law and court practice does not recognize mental retardation under any name as grounds for legal defense, hence even severely mentally retarded young people have to stand for criminal trial. In this frame of reference it is again crucial to recognize the wide range covered by the term mental retardation and to develop different approaches based on a realistic appraisal of the individual's total capacity.

The Role of Government in Mental Retardation

Because the problem of mental retardation has been neglected for so long, there is in many areas no clear precedent for governmental responsibility, as between local, country, and state responsibility, and as between public and private responsibility. As a lifetime disability, mental retardation requires long-term services usually considered most appropriately as the State's responsibility. However, with the growing emphasis on community services, with residential care as a secondary measure, the participation of the local and/or county government has increasingly been under discussion and in various places already activated. This brings up a point of vital interest to the community planner: What tax base will be used for the various mental retardation services?

The fact that at this time almost 20 states have legislative or gubernatorial commissions or committees active, specifically concerned with mental retardation is an indication of the urgency of some of the problems posed by the developments of the last decade in the field. Considerable debate is taking place in many states as to which particular state department should be charged with the administration of a given service, a question that is not always easily determined due to the comprehensive nature of such services for the retarded with frequent overlapping into several areas.

This has led to proposals that one state department be designated as having major or overall responsibility for the welfare of the retarded. Some states have already taken or are considering this step, and significantly three different departments have so far emerged as appropriate for the overall responsibility: public welfare, public health, or mental health. Other states have organized or are working toward interdepartmental committees, but there is no unanimity as to composition and function of these bodies.

The problem of appropriate governmental organization is particularly difficult regarding services for the young adults. There is ample precedent as to how services should be handled for the preschool and school-age child, but who should manage sheltered workshops or the activity centers needed for those unable to work? Which department should arrange for community residences for young people deprived of their parental home, or for their recreation programs, or for counseling services for young adult retardates for whom existing services would not be adequate or appropriate?

In this connection the question arises as to how services to retarded children should relate to general childrens' -sic- services.

Private agencies have an opportunity to pioneer in the experimental new services which will have to be developed to find solutions to the many new problems posed in this field.

The Impact of the "Parent Movement"

Any appraisal of the present status of the problem of mental retardation, the role and function of the various institutions within our society, and the availability and effectiveness of services offered, would be incomplete and indeed incomprehensible without an assessment of the so-called "Parent Movement".

The corporate structure of this "movement" is the National Association for Retarded Children. It was founded in 1950 as the National Association of Parents and Friends of Mentally Retarded Children, i.e., as an organization that from the beginning did not limit its membership to parents, but invited participation from the community at large. The form, scope, and effectiveness of "NARC's" activities on the local, state, and national level constitute a new phenomenon. Originally a "do-it-yourself" organization, it has now incorporated in local, state, and national offices paid professional staff, but has kept the character of a volunteer organization, with continued independence of the 750 local groups. There is a definite resemblance in spirit to the cooperative movement and, more specifically, to the parent-cooperative nursery schools which have sprung up in so many parts of the country since World War II. It is interesting that NARC got its start in 1950, the year of the Midcentury Conference on Children and Youth, which laid such stress on citizen participation, but it is still more interesting that parallel associations sprang up at the same time in some European countries, and are now to be found on all continents.

As this national movement enters now on its second decade questions will arise as to its future role in community planning and in conducting pilot projects; in research and training; in relationship to other public and private agencies and in public education.

Research

The 10 years since the Midcentury White House Conference witnessed a sudden spurt of research activities in the field of mental retardation. Outstanding among them were: the assessment of research needs in the biological and social sciences undertaken for the National Association for Retarded Children by Doctors Masland, Sarason, and Gladwin and published under the title "Mental Subnormality", a widespread diversified research program supported by the U. S. Office of Education with initially earmarked funds from its new Cooperative Research Program; a group of inquiries and studies undertaken by the Project on Technical Planning in Mental Retardation established by the American Association on Mental Deficiency in 1956 with Federal mental health funds; and finally the "Collaborative Project on Cerebral Palsy, Mental Retardation, and Other Neurological and Sensory Disorders of Infancy and Childhood" sponsored by the National Institute of Neurological Diseases and Blindness with 16 medical centers throughout the country participating.

All this reflects the increasing availability of public and private funds for mental retardation research. In view of the many years of neglect of the field there is urgent need for acceleration of this research activity on all fronts.

In the medical field the importance of environmental factors whether inherent in the physiology of the mother herself, or upon the circumstances and situations in which she finds herself, can undoubtedly be clarified by epidemiological studies, particularly longitudinal studies of the prospective type. Many forms of retardation are due to congenital malformation of the central nervous system; more accurate classification of these malformations is a necessary step.

The recent discoveries relating to "inborn errors of metabolism" of genetic origin point up the need for further studies of the nature of gene action and interaction with the prenatal or postnatal environment, especially where manipulation of this environment can lead to the suppression of undesirable characteristics to which a genetic defect may predispose the individual.

Such studies of both genetic and environmental factors are basic to attempts to identify the specific causes of the various clinical entities such as mongolism and microcephaly. The discovery, in England and France, of an abnormal chromosome complement in mongoloid children (47 as against the normal 46 chromosomes) undoubtedly will lead to greatly accelerated research activity into this particular condition.

Those causes of mental retardation associated with the birth process which appear to require particular emphasis at this time fall in three classifications. First, the relation between prematurity and mental retardation, although positive, is not understood. Secondly, the possible damage to the brain due to delays or other interference with the infant's proper breathing in the first minutes and hours of independent life also require considerably more study. Finally, there is substantial evidence that abnormalities in the composition of the blood in the neonatal period are important determinants of permanent damage resulting in mental retardation.

Among the possible sources of damage to the brain after birth diseases of the circulatory system require more study. A number of common and uncommon childhood diseases may result in inflammation of the immature nervous system of the child which will leave permanent residual damage. Many different viruses may produce such effects, but do not necessarily do so. This fact very much complicates the research picture, while at the same time pointing up the importance to the field of mental retardation of the study and control of many types of viruses.

Such a broad program of medical research reemphasizes the need for parallel activity in sociological and psychological areas. Yet, remarkably little attention has been given to the fact that all cases of mental retardation, regardless of etiology, present a continuing social problem. This problem is multiplied when one recognizes the compelling factor that mental retardation poses a severe social problem not only for the retardate himself but for the entire family group, and in many ways the problem extends into the community at large.

This is well exemplified by a question that has been posed in the literature and in practice with increasing frequency in recent years: on what grounds can the physician (or other counselor) base his recommendation as to how a family should handle a problem of retardation once it has been diagnosed, particularly with regard to institutionalization? In this regard Bernard Farber's study "Effects of a Severely Retarded Child on Family Integration", published in 1959, has produced important findings of areas of sensitivity in the interpersonal relations of families so affected. From one point of view his findings can be used presently with appropriate caution in considering the question whether residential care should or should not be recommended in particular cases of severely retarded children or not. However, seen from another angle his findings and those of further more refined studies he has suggested, should provide important leads for community planners. If we can identity a growing number of tension producing situations involving the retarded child and his family we need not necessarily accept these passively as indicators for institutionalization but can proceed to consider and plan for appropriate community services which would tend to bring specific relief to families in these situations. Thus we would receive important clues as to needed functions, structure and administration of day care services, clinical consultation, leisure time programs, temporary residential care facilities and similar supportive programs for families with retarded children and young people.

There is needed a social and psychological appraisal of differentials in parental attitudes toward the problem of mental retardation as such, toward their own retarded child, toward treatment (in the broader sense, including medical, social, and educational measures) and the agencies providing the treatment, and toward their own continuing responsibility to plan for the future of this mentally retarded child during their own lifetime.

All of these factors become more complicated when the mentally retarded child is not an only child and the parents' relationship to the siblings must reflect on their planning for this retarded child.

We need experimentation in research in the area of the education and training of the mentally retarded. It is increasingly recognized that level of intellectual ability is but one of many factors affecting the quality of ultimate social and economic functioning. Secondary characteristics in the form of behavior and attitudes are as important in reference to the ultimate adjustment of the mentally retarded as they are in reference to the adjustment of the intellectually normal.

There is a need for expansion of research dealing with the effects of early childhood and preschool programs upon the later adjustment of the retarded. There is a need for experimentation in the area of curriculum development and teaching materials. Comparative studies of the effectiveness of a variety of curricula and materials are sorely needed.

In reference to the primary characteristic of intellectual development, the results of research point to increasing consideration of intelligence, not as a single unitary process, but rather one which is composed of many factors. There is a need for the development of new diagnostic instruments which will more effectively identify those factors as a basis for the development of specific instructional materials and methods designed to facilitate specific training in intellectual functions.

In the area of residential care there is need for a multitude of closely controlled studies to evaluate the effectiveness of present systems and of "improved" experimental services. Proposals have also been made for the use of institutions on the basis of intensive but temporary training periods facilitating the return of the child to his family whenever feasible.

Some excellent studies have recently been published showing how, in our state hospitals for the mentally ill, the inflexibility of the present power structure effectively interferes with the main purpose of these state hospitals, namely to cure the patient. Similar studies need to be undertaken in institutions for the mentally retarded to provide guidance for future developments in residential care.

One of the most significant studies undertaken in recent years is Dr. Gerhart Saenger's "The Adjustment of Severely Retarded Adults in the Community". Furthermore, intensive studies are needed with particular reference also to the social, economic, psychological, and cultural factors in causation.

Prevention

As we plan ahead for the next decade a new concept must be introduced which 10 years ago would hardly have been listed in the framework of a paper on mental retardation -- prevention.

By control of biochemical (metabolic) disorders, by surgical intervention, by improved techniques of delivery, and by eliminating damaging conditions during pregnancy medical science is slowly but steadily moving ahead on programs directed at preventing a condition that formerly were characterized by hopelessness. Mental retardation has thus become a promising new field for public health action.

To be sure the conditions in which preventive measures can now be taken represent only a very small numerical fraction of the mentally retarded. But as Dr. Richard Masland puts it succinctly in his summary of his study "The Prevention of Mental Subnormaljlty": "One cannot escape the conclusion that progress in the program for the prevention of mental retardation will take place by small advances along a broad front."