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This claim is quite unjustified. We do have of course residents in our institutions who in addition to their long standing mental retardation have acquired a psychosis, a mental disease not organically connected to their original handicap. We have residents with a type of Retardation that typically or at least frequently involves behavior disturbances. And, finally, as has been brought out by prominent psychiatrists themseleves, our institutions have created behaviour disturbances in residents, by the very type of program (or better lack of program) offered them.

But the severe mongoloid child with associated physical handicaps is not a problem of psychiatric care, nor is the hydrocephalus or the early detected phenylketonuric child. These are problems of pediatrics with all its subspecialties such as pediatric neurology, and my efforts during the past year have been directed at recognition by the public authorities, the professional associations and the citizen groups, of the most urgent need for greatly expanded medical departments in our institutions for the retarded, directed by competent pediatricians, and staffed with an adequate number of related specialists, in order to initiate an aggressive medical rehabilitation program. Some small beginnings of such a program I have been able to observe in a very few institutions -- but it stands to reason that one physiotherapist for an institution with 3,000 patients, while surely to be welcomed, is at best a mere "teaser".

Again, let me be clear: I do not mean to imply that all mentally retarded children need such a comprehensive pediatric program or else will suffer serious damage. But there can be no question that a very considerable number of our trainable children in the institutions are doubly handicapped because they did not get pediatric restorative care to the extent our medical knowledge of to-day makes possible. The extent to which the life span of the mongoloids and indeed of all severely retarded has been lengthened in recent years is now common knowledge and underlines the contribution medicine and in particular pediatrics has to make.

It must be stressed that in this connection the focus of the institutional program for any one individual may change to a considerable extent. It may be medical in the early stages, with emphasis on physical therapy, orthopedic surgery or some other procedures and thereafter may become primarily an educational program or may develop problems requiring a psychiatric setting.

Some people have advocated that it would be more efficient and more economical to have smaller and specialized institutions. For instance, separate pediatric hospitals for mentally retarded children requiring extensive medical care, residential schools for those who for various reasons cannot live with their family but need primarily an intensive program of training and education (many of this latter category of course should eventually be accommodated in the kind of foster care program we heard about yesterday from Mr. Pichey of the Southbury Training School.) Others feel that the large multiple-function institution will remain indispensible. The main point I would want to stress here is that the institutional structure should be such to facilitate meeting the various needs of the various types of residents. One thing is certain: the old-style institution fashioned after the mental hospital with the rigid hierarchy from medical superintendent to ward physician to charge nurse to attendant has outlived its usefulness if indeed it ever had much in the field of mental retardation. For this we not only have some interesting sociological studies but the testimony of some eminent medical people, some of it published in the American Psychiatric Association's own journal, "Mental Hospitals".

Let me be quite clear, I do by no means advocate that we should change over the leadership of our retardation institutions to educators, for instance. To be specific I am not so much concerned with the position of superintendent as with the broad structure of the institution's program, which, it seems to me, falls into three functional areas: first, the diagnostic and clinical program under a medical director, second, the training (and domiciliary) program which should be directed by a person with professional background in this area, and thirdly the business administration. To the extent that social work and psychology contribute to the diagnostic process and also participate with the psychiatrist in the treatment of disturbed patients, they should be in the clinical department, which of course would also carry the responsibility not only for hospital and dispensary but for all units where we deal with a nursing program, such as the so-called infirm cottages.

The training department, on the other hand, should have full control not only of academic, vocational instruction and recreation but also for what is either referred to as ward supervision or "home life".