THE NEEDS OF MENTALLY RETARDED CHILDREN FOR CHILD PSYCHIATRY SERVICES

THE NEEDS OF MENTALLY RETARDED CHILDREN FOR CHILD PSYCHIATRY SERVICES

Howard W. Potter) M.D.

The aim of this communication is to promote the inclusion of mental retardation in programs for training in child psychiatry. There are five parts to this communication. Part I comprises a historical sketch of mental retardation so organized as to provide a realistic perspective and a corrective for the many distorted and biased notions that are so ' , prevalent about mentally retarded children and adults. Part II, like Part I, is historical but concentrates on a brief resume of published reports and articles of a psychiatric quality that have some direct or indirect bearing on mental retardation. Part III is devoted to a somewhat detailed examination of mild mental retardation. The thesis is promoted that mildly retarded children are normal children who fall a bit below a designated point on the distribution curve of tested intelligence. Part IV summarizes the information available to the writer about child psychiatry services currently available to the mentally retarded and a listing of some operational modalities for bringing .child psychiatry services to mentally retarded children. The paper concludes with Part V which presents the author's views on how mental retardation may be incorporated within the curriculum of training programs in child psychiatry.

Dr. Potter is Emeritus Professor of Psychiatry at the State University of New York. This -was a work paper prepared by Dr. Potter for the Conference on Training in Child Psy• .chiatry, held January 10-15,1963, in Washington, D.C.

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I

For the sake of clarity, a few comments on terminology are in order. Feeble-mindedness, Mental Deficiency, and Mental Retardation are generic terms inclusive of all persons whose cognitive functions are impaired and whose subnormal intelligence is congenital or was acquired during infancy or childhood. These generic terms mayor may not have clinical implications but are rather useful for administrative purposes. Feeble-mindedness is the oldest and first used of these generic terms; it began to appear in the literature during the latter half of the nineteenth century coincident with the establishment of tax-supported institutions for "idiots and other feeble-minded persons." Feeble-mindedness was not defined in terms of mental test scores until 1916, when Terman (1916) declared "all who test below 70 I.Q. should be considered feeble-minded." Mental Deficiency began to replace feeble-mindedness as a generic term in the 1920s and mental retardation began to replace mental deficiency during the early years of the 1950s. Mental deficiency carried with it the I.Q. 70 cutoff point that had been established for feeble-mindedness in 1916, while the cutoff point for mental retardation varies a point or two below I.Q. 70, depending upon which intelligence test is used (American Association on Mental Deficiency, 1961) . As early as 1672, a description of "degrees of stupidity," bearing a close resemblance to mild, moderate, severe, and profound mental retardation of today appeared in a textbook on mental disorders, De Anima Brutorum, by Sir Thomas Willis, one of the most astute physicians of seventeenth-century London. A quotation from this book, Chapter XIII, "De Stupiditate sive Morosis," follows: "Stupidity hath many degrees; for some are accounted unfit or incapable as to all things, and others as to some things only. Some being wholly fools in the learning of letters, or the liberal sciences, are yet able enough for mechanical arts. Others of either of these incapable, yet easily comprehend agriculture, or husbandry and country business. Others unfit almost for all affairs, are only able to learn what belongs to eating or the common means of living. Others merely dolts or driveling fools, scarce understand anything at all, or do anything knowingly." Idiocy (from the Greek Idioteia) meaning uncouthness) and Imbecility (from the Latin Imbecilitas) meaning weakness of mind and

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body) have appeared in medical writings since antiquity, were used interchangeably, and stood for some kind of gross pathology in body structure and gross distortions of behavior. However, neither Sir Thomas's recognition and brilliant description of degrees of intellectual subnormality nor the discovery of cretinism in the Swiss Alps by Paracelsus fifty years before (1616) aroused any active interest in idiocy among either the medical profession or the laity until the turn of the nineteenth century, when Itard undertook his epoch-making endeavor to cure Victor of his idiocy. Itard, an adherent of Locke's concept of the mind as a tabula rasa) directed his efforts toward "educating the mind" through the vigorous pursuit of a systematic program of sensory input and habit training. His report, De ['education d'un homme sauvage) was published in 1801. In 1837 Seguin, a former student of both Itard and Esquirol, founded in Paris the first school for the education of idiots. His book, The Moral Treatment) Hygiene and Education of Idiots and Other Backward Children) published in 1846, is a landmark in the literature on mental deficiency. Shortly before the mid-point of the nineteenth century, under, the leadership of Seguin, and his American counterpart, Samuel Gridley Howe, both of whom had had a rich and successful experience in the re-education of deaf mutes, widespread interest was focused on ways and means through sensory input and habit training to bring about some significant functional improvement of idiots and imbeciles. (And that this can be achieved is being rediscovered now, 100 years. later.) Causology attracted but little attention until the Parisian School of Neurology and Psychiatry turned its attention to searching clinical and pathological investigations of idiocy. The brilliant descriptions of the clinical and pathological characteristics of a number of neurological diseases associated with idiocy, published during the last two decades of the nineteenth century, are classics in the literature of neurology. Bourneville's (1893) reports received worldwide recognition and established beyond doubt that many cases of idiocy were' basically some form of brain pathology or anomalous development. Bourneville's case material did not include that which we call today mild mental retardation, for the simple reason that mild mental retardation (morosis) had not been generally recognized.

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By the last decade of the nineteenth century and the earlier years of the twentieth century, less seriously handicapped retardates were coming to be recognized and filtering into the institutions in increasing numbers. Their limitations in the "learning of letters" was selfevident and most came to the "idiot asylums" as social misfits, neglected children, or both. In terms of I.Q. levels, they were probably high-grade imbeciles or low-grade morons. It was not until the second decade of the twentieth century that mild mental retardation came to be recognized in any significant numbers. Henry H. Goddard of the Training School, Vineland, New Jersey, had introduced the Binet-Simon scale for testing intelligence to America in 1908. Immediately the test was applied to increasing numbers of school children and, based on the test results, Goddard introduced the Moron (the mildly retarded) to America in 1910. (Moron, from the Greek Moron) meaning foolish.) By 1916 Lewis M. Terman, professor of education at Stanford University, had modified the Binet-Simon test and the Stanford Revision of the Binet-Simon Intelligence Scale became the standard test for many years. In the introduction to The Measurement of Intelligence) Terman (1916) stated: "Only very recently ... have scientific workers begun to appreciate fully the importance of intelligence tests as a guide to educational procedure." It has now long since been recognized that nomenthetic tests of intelligence are indeed indispensable guides for the educator. But in this same book, Terman goes far afield from the pragmatic application of his test to the operational aspects of educational programs. After explaining how an Intelligence Quotient is calculated, he goes on to say: "All who test below 70 I.Q. by the Stanford Revision of the Binet-Simon Scale should be considered feebleminded." Thus by an edict and a stroke of the pen, the category feeble-mindedness (mental deficiency, mental retardation) was defined in terms of the I.Q. and gained wide acceptance with little or no debate. Terman's magical cutoff point-I.Q. 70-has been written into the laws of many states or is incorporated into regulations of Bureaus and Commissions in defining mental retardation and regulating the placement of children in institutions and "special" classes in the public schools.

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A second quote from the same book: "Of the feeble-minded, those between 50 and 70 I.Q. include most of the morons [mild mental retardation] ..., those between 20 or 25 and 50 are ordinarily to be classed as imbeciles [moderate and severe mental retardation], and those below 20 or 25, as idiots [profound mental retardation]." Thus by a second pronouncement, Terman placed mildly retarded children and the most profoundly retarded ones, and all the retardates in between these two extremes, in one and the same category. Five years before Terman published his book, Charles B. Davenport reported on his genealogical studies of mental defectives. When Davenport made this study, the Binet-Simon test had been employed for some two years or more and Goddard had introduced the moron; it was this group of institutionalized subjects whose ancestral records Davenport explored. Davenport's study was a highly biased one; sociopathy, alcoholism, criminality, prostitution, ineffective or irregular employment, and other social transgressions among the subject's ancestors were interpreted asprima-facie evidence of mental deficiency. In his monograph Heredity in Relation to Eugenics (1911), Davenport came to the conclusion that "low mentality is due to the absence of some factor that determines normal development.... Two mentally defective parents will produce only mentally defective offspring." It is likely that both Davenport (1911) and Goddard (1912, 1914) closely followed and subscribed to Morel's (1857) theory of degeneration which has long since been disproven. By the end of the second decade of the twentieth century, most clinicians viewed all feeble-mindedness as representing some known or unknown pathological deviation from "normality." It came to be generally accepted that morosis (mild mental retardation) was undoubtedly an attenuated form of idiocy; the superb clinical blunder of the agesl It was hypothecated that most morons were feeble-minded because of bad heredity expressed in some degree of cerebral agenesis and that the rest were feeble-minded because of some encephalopathy due to infection, trauma, or toxic agents. The ghost of these 1920 concepts about morosis still hovers over mild mental retardation in some quarters todayI Since the moron was a relatively new recruit to the ranks of feeblemindedness in 1920, and in alarming numbers, too, institutionalized morons became the focus for dozens of "researchers," and the subject

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matter of hundreds of publications and reports over the next two decades or more. The moron supply was a dependable one, too, for ever since the Davenport report it had become public policy to get the moron into an institution whenever possible and to keep him there lest he propagate more of his own kind if released to the community. Social investigators swarmed over the countryside eagerly recording both fact and "old wives' tales" about the families of institutionalized morons. Brains of morons were scrutinized for gross and histological anomalies. Hundreds of morons became subjects of neuroendocrine explorations and tons of endocrine substances were fed to the point of satiation. The moron's body fluids came in for biochemical tests and assays extant at that time. All this, and more too, ended up as "negative"; the moron proved out to be just like his "normal" control in his brain structure, his body chemistry, and his metabolism. More recently the cellular geneticists and the experts in intermediary metabolism have taken a look at mild mental retardation and have had nothing exciting to report. But with all of this, there survives in too many places a lurking suspicion that all is not well with the mild retardate's physiology, metabolism, brain structure, or chromosomes. Of course it has long since been proven, and additional scientific proof is being discovered in recent years, that encephalopathy, cerebral agenesis, and deviant metabolism are responsible for the pronounced and more serious forms of mental retardation. There is, indeed, no valid reason to argue the point. PART

II

There are relatively few articles and reports in psychiatric literature that bear on mental retardation, but some of them merit attention. A hint at psychogenic causology is found in Thomas Willis's textbook, De Anima Brutorum (1672). "Stupidity or Morosis, or Foolishness ... signifies a defect of the intellect and judgement ... this eclipse of the superior soul proceeds from the imagination and the memory being hurt and the failing of these depends upon the faults of the animal spirits and the brain itself." A thoughtful reading of Itard's report (1801) convinces one that he recognized the significance of motivation, needs, and transference in

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his therapeutic work with Victor. Much of his effort, too, was directed toward fostering ego development and the strengthening of ego controls through the use of identification. Itard's monograph might well be called the first published report on relationship psychotherapy. To demonstrate that even a severely mentally retarded subject such as Victor was responsive to psychotherapeutic efforts was a momentous achievement. In 1860, Griesinger published the second edition of his textbook, Mental Pathology and Therapeutics. In his chapter, "Idiocy in Genera!," he introduces the concept of psychogenic causology in mental subnormality: "Cases where the mental development remains stationary from want of any external impulse-from extreme neglect and inattention-associations with other dements, unfavorable outward relations, etc., finally in certain cases where the mental development does not progress, because in weakly children there exists such an excessive degree of emotional irritability, of timidity and fear, that a state of passionate excitement is awakened by every attempt at mental influence, even by any lively sensorial impression, so that development of the normal process of perception is rendered impossible. Although few of the latter cases originally belong to the idiotic states, still they have the same practically important result-arrest of mental development." The earlier annals (1876-1900) of the American Association on Mental Deficiency are rich in their references to training and education procedures based upon the dynamics of modern psychotherapy. In 1922, both Potter and Wallace published articles on the significance of personality structure in the social adaptation of mildly impaired young adult retardates. Potter (1927a) reported on a study of the erotic behavior of idiots and suggested that most were fixed at an infantile level of psychosexuality characterized by diffuse forms of autoerotism. In the same year Potter stated in another paper, "in certain instances there may be such an overwhelming narcissism in the infant as to prevent the outflow and onflow of that portion of the libido which perhaps furnishes at least a part of the urge needed for the development of intelligence and as a result the intelligence becomes fixed at an incomplete level of development" (1927b). In 1933, L. Pierce Clark, in his monograph on The Nature and Treatment of Amentia} states: "If we say that mental deficiency con-

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sists of some failure in the process of acquiring, absorbing and using knowledge for an adaptive mastery of reality, what are the specific defects behind this failure? Brain lesions or defects, a pathological variation in the germ cell, arrested neuron development, etc., have been indicated as the basis for mental arrest. None of these can indicate, however, just how the fundamental cause leads to the difficulties which the ament is seen to have nor do they contain possibilities for understanding the individual in such a way as to help him in his problem of getting along in the world.... There is found in all mental defectives a weak ego structure in association with an impounding of libido within the personality and an inbinding of primary narcissism, thus limiting the psychic energy available for object relationships which in turn dilutes the motivation for learning or acquisition." In 1933, Potter identified childhood schizophrenia and noted that schizophrenic children are commonly found in institutions for mental defectives where they are usually regarded as "excitable imbeciles" or "idiot-savants." In more recent years and especially since World War II, perhaps stimulated by the unique maternal deprivation studies of Rene Spitz (1946, 1959), a wealth of material directly or indirectly bearing on mental retardation and of particular interest to the child psychiatrist has been appearing in the literature. Many studies are reported by. pediatricians, psychiatrists, educators, and psychologists showing that the infant's development and functioning may be affected physically, intellectually, emotionally, and socially by maternal or sociocultural deprivation (Kirk, 1958; Bowlby, 1952; Bakwin, 1942, 1949; Ribble, 1943; Brodbeck and Irwin, 1946; Rheingold, 1933; Levy, 1947; Goldfarb, 1945a, 1945b; Simonsen, 1947; Sarason and Gladwin, 1958; Skeels and Dye, 1939; Theis, 1924; Bornstein, 1930; Clarke, 1958; Despert and Pierce, 1946; Kanner, 1952; Mundy, 1957) . In a recent study of 159 mentally retarded children, ages three to six, three quarters of whom "had evidence of organic brain disease," T. G. Webster (1963) reports that all had some clinical evidence of retarded emotional development. Some psychoanalytic studies have been reported by Woodward, et al. (1958), Menninger and Chidester (1936), Green (1961), and a few others (Stacy and DeMartino, 1957) showing substantial improvement even in tested intelligence. Perhaps a hundred or so reports (Stacy and DeMartino, 1957) have

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been published on the technique and effect of group therapy with mental retardates. Follow-up studies (Camp and Waite, 1932; McKay, 1942; Davies, 1930, 1959; Kennedy, 1948; Saenger, 1957; Fernald, 1919; Storrs, 1929; Wolfson, 1956; Windle, 1962) have shown that not only do , most of the mildly retarded make excellent social adjustments in adult life but that also in some, tested intelligence has risen to well within normal ranges. Odd though it may seem, there is a dearth of communications in the literature on the problem of anxiety in mental retardates and the role that anxiety plays in the psychodynamics of the adaptational problems so common in those handicapped by subnormal intellectual endowment. In reviewing the literature, it again is obvious that child psychiatry has been especially remiss in meeting its responsibilities to the intellectually handicapped child. With remarkably myopic vision, the intrapsychic aspects of adaptative problems of these children have been ignored. Little or no thought has been given to psychogenic causology in mental retardation. Child psychiatrists and psychoanalysts preoccupied with ego development have ignored an area of human pathology or deviation which might well be a rewarding area of investigation. PART

III

The author maintains that mild mental retardation is unrelated to the more disabling forms of intellectual deficits except that it has been assigned an ordinal position on the one and same I.Q. ladder. Many biological structures and functions including intelligence are susceptible to mensuration by some relatively precise measuring or quantifying instrument. The "normal ranges" of pulse rate, blood pressure, blood sugar level, coagulation time, brain weight, body weight, stature, and a host of other functions and structures are a matter of record. The "normal range" is a serviceable guide for clinicians, but the extent to which a deviation is an indicator of "abnormality" is a matter of clinical judgment. Sixty years of experience of competent psychologists has gone into the construction of mental tests and in measuring intelligence. For

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classification purposes, the intelligence quotient has long since been adopted as the unit for measured intelligence. Whatever the defects and inadequacies of the test may be, and the experts are well aware of these, experience has demonstrated the intelligence quotient to be a useful guide and certainly one that most clinicians would not willingly discard. Mild mental retardation is a classification based exclusively on the intelligence quotient computed from the responses to the various items in a standardized nomenthetic type of intelligence test. In the Manual on Terminology and Classification in Mental Retardation, Second Edition, published by the American Association on Mental Deficiency in 1961, mild mental retardation is defined as greater than minus two standard deviation units of measured intelligence but not more than three; this range of minus deviation units represents an intelligence quotient, based on the use of the Stanford-Binet test, Forms Land M, ranging from 52 to 67 inclusive. Mild mental retardation, in terms of its defined I.Q. range, is essentially synonomous with "moderate retardation" as defined in the Diagnostic and Statistical Manual, published in 1952 by the American Psychiatric Association, and closely approximates the moron as defined by Terman (1916). As a general proposition, mildly retarded children closely resemble rather than differ from "normal" children and significantly differ from, rather than resemble, more seriously handicapped and limited mental retardates. Unlike the latter, mildly retarded children seldom . have any evidence of retarded development in infancy and the preschool years; encephalopathy and inborn errors of metabolism are but rarely encountered; and all of them are potentially capable of independent living, self-support, and socially effective behavior in their adult years. It seems to be the consensus of most sophisticated clinidans that "mild retardation" represents a normal physiological variation in the minus direction on the distribution curve of tested intelligence for any population group. In fact, the only difference between mildly retarded children and children who are not retarded is that the former are, relatively speaking, slow learners in structured educational situations (the classroom) and their capacity for abstract thinking, limited. At a conservative estimate, 75 of every 100 children classified as mentally retarded are within the category of "mild retardation." In

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other words, three quarters of all retarded children closely resemble "normal" children. Ordinarily one would expect to find somewhere in the neighborhood of 250 mildly retarded children in each 10,000 school children in the U.S.A. Only some 2 or 3 per cent of mildly retarded children are admitted to residential centers for retardates. According to the statistical data about Patients in Public Institutions for the Mentally Retarded (1960), published by the U.S.P.H.S., there are some 164,000 patients in these institutions throughout the U.S.A. However, an estimate based on a scrutiny of a number of statistical tabulations places the number of the mildly retarded who have not reached their fifteenth birthday at only 4 Y2 per cent (7,000) of the total institutional census. There are 108 such institutions in the U.S.A., and about 90 per cent of these carry a patient census not in excess of 2,000. Thus one might reasonably expect to find, at the most, 90 mildly retarded children in the great majority of these residential centers. It is highly probable that all institutionalized mildly retarded children are anxiety ridden in one way or another since either their .disturbed behavior, or broken, disorganized homes, or both, precipitated their admission. The proportion of mildly retarded children who are never institutionalized but are emotionally disturbed or socially maladjusted is probably not less than 10 per cent. But this is merely an educated guess. The prevalence of adaptational difficulties and emotionally disturbed personality is probably greater among mildly retarded children than in "normal" children for the following reasons: a. A large share of the mildly retarded come from the culturally and socially deprived strata of society where emotional deprivation is a common experience, where motivation for intellectual achievement is at a low ebb, and where opportunity for identification with intellectual proficiency is rather meager. b. Those from middle- and upper-class homes, where scholastic achievement has great prestige in our culture, are commonly subject to parental repudiation and rejection or frantic coercion. c. Their limited intellectual capacities often go unrecognized, and as a result demands are made upon them both at home and in school which they are unable to fulfill. d. Mildly retarded children are particularly apt to erect an anxiety-burdened self-image of exaggerated inadequacy and in-

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eptitude. Many develop a sense of futility and build up a significant element of repressed hostility and guilt. PART

IV

In discussing operational modalities for bringing child psychiatry services to mentally retarded children I shall focus upon the mildly retarded child who would ordinarily come within one or another subcategory of Section VIII of the Medical Classifications as set forth in the Manual on Terminology and Classification in Mental Retardation, Second Edition, published in 1961 by the American Association on Mental Deficiency. This section "is used for the classification of those numerous instances of mental retardation occurring in absence of any clinical or historical indication of organic disease which could reasonably account for the retarded intellectual functioning." The subgroups in this section are five in number: Cultural-familial mental retardation; Psychogenic mental retardation associated with environmental deprivation; Psychogenic mental retardation associated with emotional disturbance; Mental retardation associated with psychotic disorder; and Mental retardation due to uncertain cause with the functional reaction (retardation) alone manifest. In view of the particular competence the child psychiatrist has acquired through his training in the psychodynamics of anxiety, its impact on personality growth and development, its uneconomical impacts on effective personal and social function, the common defenses of the ego for mastering anxiety, and the effectiveness of ego structure in dealing with internal and external conflicts, he is well prepared1. To identify the extent to which anxiety, ego pathology, and narcissistic inbinding of libido embarrass the effectiveness of learning behavior, distort perception, impair associative and abstract thinking, and block executive function in the mildly impaired retardate. 2. To come to grips with the dynamics involved in the social and behavioral maladaptations of the individual retarded child. 3. To evaluate the conscious and unconscious impacts of the retarded child on his parents, sibs, teachers, and others in whose care he may be, and how these personages meet or frustrate his basic needs.

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4. To evaluate the role of the culture (family and peer group especially) in terms of the retardate's ~otivation for learning (especially in school). 5. To evaluate the retardate's activities and life situation in terms of his frustrations and satisfactions. 6. To assess the extent to which his realistic needs for dependency, support, control, and identification favor or impair the development of a healthy ego formation. 7. To formulate, plan, and recommend a program of management, treatment, and habilitation calculated to strengthen security systems and ameliorate anxieties in the individual case. This may involve or encompass(a) appropriate placement; (b) counseling with parents, sibs, teachers, or others in whose care the child may be; (c) individual or group psychotherapy; (d) appropriate educational and training programs and stimulating or rewarding social and recreational activities. Whenever feasible, the mildly retarded child (the more seriously retarded one, too) should remain in his own home and a program planned for him according to his needs. In addition to whatever counseling or psychotherapy is employed, use should be made of community resources such as preschool groups, recreational groups, settlement house programs, day care centers, etc., as well as the special class in the public school. The teacher and public health nurse as well as the social worker and the clinical psychologist are invaluable allies. The great majority of mildly retarded r'lildren respond remarkably well to supportive or relationship psychotherapy on either a "one-toone" basis or in a group therapy program. It seems advisable to point out that mild mental retardates ate just as suitable subjects for psychotherapy and as rewarding as are those with "normal" intelligence. If the home situation is highly unfavorable and beyond reconstruction, an appropriate boarding or foster home placement should be tried before institutionalization is resorted to. One should recognize, however, that appropriate boarding homes for disturbed children of any mental level are somewhat of a rarity. In recent years, criticism has been leveled at institutionalizing the mentally retarded. Much of this criticism is timely, but some of it is

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ill advised. There are many, many, instances in which the care, training, and treatment provided in well-organized institutions, directed by sophisticated staff, is far superior to what the community can offer, especially to those retarded children coming from deprived neighborhoods and distraught, poorly integrated homes. When a mildly retarded child, or even a more seriously retarded one, is socially maladjusted or emotionally disturbed, the assumption is too often made, in the community as well as in the institution, that these unhappy behaviors are by-products of "subnormality" and that the appropriate restitutive measures are time, training, rigid control, and regimentation. When and if subservient compliance and selfeffacing passivity take over, the restitutive measures employed are deemed to have been justified; the traditional erroneous image of the moron as stupid, affectively obtuse, devoid of a sense of responsibility, and lacking in initiative has been perpetuatedl Casual inquiry and observation show that whatever is being done within the operational framework of too many institutions in the way of restitutive or corrective modalities is rather naive, unsophisticated, and pro forma. Even consultative services from a child psychiatrist are indeed a rarity. Although most of these institutions have excellent educational and activities programs, provide well for the physical needs and comforts, and give humane care to their patients, there is only minimal scrutiny or grasp of the child's inner needs such as could be achieved by child psychiatry services. The record shows, too, that child psychiatry services are not available to most institutionalized mildly retarded children prior to their admission. There is indeed need to bring the structured environment and "way of life," especially in residential centers, in line with the dynamic needs of these children. It is time that we recognize that emotionally starved and conflicted mildly retarded children need and can benefit from appropriate psychotherapeutic measures. All of this is inescapably the responsibility of the child psychiatrist. It is my personal impression as well as that of some of my colleagues that but little is being done to provide emotionally disturbed or bereft community-based retarded children with child psychiatry services. Although there are recognized child psychiatry clinics in this country, there are no nation-wide figures that show the number of mildly retarded children accepted for diagnostic and/or continued treat-

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ment services. I suspect that the best most child psychiatry clinics offer to even mildly retarded children is "the revolving door" treatmentl Perhaps the training in mental retardation provided in child psychiatry training centers can be taken as an index of the services offered in their clinics to the mentally retarded. Of sixty-eight training centers responding to a questionnaire, three give "supervised intensive training," and twenty-two make available "some training" in a residential center for the retarded.! It is my belief, based on experience with literally hundreds of individual cases, that it is the policy of most child psychiatry clinics to offer, at the best, a brief diagnostic service even to mildly retarded children. If there is any validity in this belief, then we can estimate that there are some 50,000 mildly retarded children in the V.S.A. in need of child psychiatry services most of whom are denied these needs by virtue of an administrative edict. I have a conviction that such a policy is based on the gratuitous assumption that the mentally retarded do not and cannot materially benefit from child psychiatry services I In the special statistical report on Outpatient Psychiatric Clinics (1961), issued by the V.S.P.H.S., it is reported that 1,161 clinics terminated an over-all total of 227,522 cases of which 7,685, or nearly 3.4 per cent, below the age of fifteen were classified "mental deficiency." How many of these classified as "mental deficiency" were but mildly retarded is not recorded. Only 10 per cent received more than a brief diagnostic evaluation (Chandler, et al., 1962; McCarty, et al., 1961) . There are some 100 or more special clinics for mentally retarded children throughout the V.S.A., but there are no data available that show break-down of case load or even total case load. It is my impression that the case load of these clinics is largely made up of the very young more seriously retarded group. One report (Chandler, et al., 1962) indicated that psychiatrists contributed 7 per cent of the total professional man hours of such clinics. In responding to a questionnaire, 736 psychiatrists claiming an interest in child psychiatry saw 28,000 children in their private offices 1 Personal communication from Public Information Officer, American Psychiatric Association, Washington, D.C.

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in the year 1961; 2,400, or 8~ per cent, of these children were mentally retarded. 2 Although it is clear that mildly retarded children, their parents, teachers, and others responsible for structuring their care, training, and way of life are the rational focus for child psychiatry services, the child psychiatrist should not be unmindful of the unfulfilled needs of some of the more seriously retarded children and especially their families. Although only 15 or 20 out of every 100 mentally retarded children are quite seriously handicapped, about two thirds of them are cared for at home. It is self-evident that their care is no easy matter. Some, of course, are emotionally disturbed and the emotional disturbance is by no means necessarily an expression of their "organicity." Even the emotionally "tranquil" severely retarded child in the home poses adaptive problems for the family group. Mothers, fathers, brothers and sisters of these badly handicapped children not infrequently need help for their adaptive problems and emotional conflicts, especially when the seriously retarded child is in the home and sometimes even when he is being cared for in an institution. In 1961, 102 public institutions responding to a questionnaire reported 7 certified and "board-eligible" child psychiatrists and an additional 93 certified and "board-eligible" psychiatrists on their collective staffs. s At first glance, these figures are heartening, but additional data indicate that these 100 psychiatrists contribute but 7 per cent of the total medical staff man-hours in these institutions. Undoubtedly most are on a relatively inactive consultant basis. In the current list of members of the American Association on Mental Deficiency I was able to identify three or four child psychiatrists as fulltime staff members. There is nothing novel to be done about making child psychiatry services available to the mentally retarded. If intake policy of child

psychiatry clinics was liberalized only to the extent of including mildly retarded children in the ongoing case load, child psychiatry services would thus become available to a substantial segment of the mentally retarded group. Although there are always enough disturbed children 2 Personal communication from Public Information Officer, American Psychiatric Association, Washington, D.C. • Personal communication from Public Information Officer, American Psychiatric Association, Washington, D.C.

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of normal intellectual capacities to more than fill the rolls of any child psychiatry clinic, a policy to accept even a small number of mildly retarded children would be a rewarding educational experience for the clinic staff. Child psychiatrists who function as consultants to child welfare and child-caring agencies, adoption agencies, and school systems should have ample opportunity to serve the needs of mentally retarded children. Certainly the child psychiatrist should provide services to retarded children and their families in his private practice. There are many residential institutions accessible to those centers of population where child psychiatrists practice or teach. Although it is unlikely that any significant number of child psychiatrists will enter upon a professional career as a full-time staff member of an institution, it is realistic to expect many of them to provide service on a part-time or consultative basis. As a part-time staff member or consultant, a child psychiatrist could indeed achieve a good deal for the best interests of at least the relatively few mildly retarded children in the institution. His skills and sophistication would be most effectively and economically used were he to function as a preceptor and teacher rather than as a clinician working directly with the children. With the case seminar as the basic teaching modality, supplemented by counseling pertinent professionals on the institution staff, meaningful life histories could be secured, illuminating material adduced in interviews or through playroom techniques with the child or in interviews with attendant personnel. Psychologists would employ projective as well as nomenthetic tests, and teachers and others would learn how to use their skills and contacts with the child for support, stimulation, constructive control, self-realization and many other needs, all serving to strengthen the child's security system and modulate his anxieties. The need for research in mental retardation is crucial. The child psychiatrist, by virtue of his particular competence in the dynamics of personality growth, psychological functioning, motivation and reaction formation, is in a position to make some significant contributions. With the use of the exploratory tools of psychodynamics much can be learned about ego development and structure from the mentally retarded. Little or nothing is known about the self-image of the retarded. What is the roleof identifications in impaired learning? To what extent does psychosexual maturity parallel tested intelligence?

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Does narcissism impair learning and is it a psychogenic cause of mental retardation? Mental retardation is indeed a rich field for psychodynamic exploration. PART

V

I would neither promote nor support the proposition that the basic training of a child psychiatrist should prepare him to be a specialist in mental retardation. Nor would I endorse any child psychiatrist as a specialist in mental retardation unless he had spent not less than two years in intensive training under the guidance of a qualified supervisor. To qualify as a specialist in mental retardation, like qualifying as a specialist in child analysis, is a matter of postresidency training and preparation. Although Parts II and III and much of Part IV of this communication are largely focused on mild mental retardation, training programs in child psychiatry should provide an orientation to the entire spectrum of mental retardation. Based on conversations I have had with some of my colleagues, I feel impelled to state emphatically that a guided tour through an institution, even including a kaleidoscopic demonstration of clinical "specimens," does not constitute a meaningful orientation. In planning for the inclusion of mental retardation in a child psychiatry training program, the program director is confronted with five basic questions: Who should teach it? What or how much should be taught? How should it be taught? When should it be taught? Where should it be taught? Who? It is highly desirable, but perhaps not essential, to vest the responsibility for planning, directing, and supervising this segment of the student's training in a member of the faculty who is especially knowledgeable in mental retardation. Perhaps a staff member of a nearby institution, one who has acquired a broad sophistication about all aspects of mental retardation, could be added to the faculty. Perhaps an interested member of the faculty could be prepared for this

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assignment; the Letchworth Village 4 Graduate Course in Mental Retardation is one such preparatory modality. What? The content of the course material should be broad, but not necessarily deep, in its scope. Child psychiatrists should be as knowledgeable about the encephalopathies, metabolic and genetic factors commonly responsible for the more severely retarded states as they are about similar problems associated with behavior disorders in some bright children. They should be informed about the "way of life," the training programs, and the care and treatment provided by residential facilities for the mentally retarded. They should be aware of community facilities for retardates of all levels such as are provided in public schools, day care centers, work shops, etc. They should know in general what retardates of different levels can do, as well as what their limitations are. They should be given some idea about the repertoire of different behaviors of retardates and how these vary in reference to causology and I.Q.level. Just as child psychiatrists are conversant with psychopathology in adults so they should be informed about the adult retardate, his adjustments and his ability or inability to live independently. How? When? Where? When instruction in mental retardation is best introduced will depend on the content and timing of the curriculum and the locale of the training center. It would seem that supervised clinical work leading to the diagnostic formulation of the problems of mildly retarded children could be easily integrated with an already-established program in clinical evaluation in the teaching clinic. Likewise, follow-through on long-term case management, parent counseling and psychotherapy in the case of mildly retarded children should offer no instructional problem. It is obvious that these activities are best carried out in the teaching clinic ·of the training center. Sufficient knowledge about the clinical aspects of a variety of causological types of retardation can be acquired through attending a series of planned demonstration clinics. As a general rule these clinics are best conducted at a facility where there is a wealth of clinical material. Adjunctive to supervised diagnostic and therapeutic work in the training clinic and clinical demonstrations at some other facility, • Research Foundation for Mental Hygiene, Inc., Letchworth Village Branch, Thiells, N.Y.

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trainees should make leisurely, well-planned tours or visits to both residential and community facilities to see, at first hand, a number and variety of programs for the retarded in actual operation. These visits should be supported by relevant seminar discussions. CONCLUDING COMMENTS

The tenor of this exposition of mental retardation is set, hopefully, to capture the interest of the child psychiatrist. A rather extensive bibliography has been appended so that the interested reader may pursue at his leisure and in greater detail those topics briefly presented or merely alluded to. Part I is a sketch of the historical background of mental retardation interspersed with annotations on the derivation of some misconceptions about mental retardation that are currently prevalent. Part II pursues the application of modern concepts of psychodynamics to mental retardation, especially in its milder forms. It proposes that virulent anxiety depresses cognitive function and thus has a causological role in some forms of mental retardation. It also emphasizes that anxiety, rather than the intellectual deficit, is the operative factor in adaptational problems of mildly retarded children. A brief review of the psychiatric literature on mental retardation is included to show that psychodynamic considerations were current, although perhaps unpopular, throughout the past 150 years. Part III is comprised of a rather extensive discussion of mild mental retardation and advances the thesis that mildly retarded children are but normal variants in the minus direction on the distribution curve of measured intelligence. The "normalcy" concept of mild mental retardation is vigorously pursued. In Part IV some data on the extent to which child psychiatry services are available to mildly retarded children are presented. The data are sparse and inconclusive, but I could find nothing to contravert my opinion that there is but minimal effort on the part of most of the experts in child psychiatry to bring their skills to assist unhappily adjusted mildly retarded children to realize their potentials for productive independent living in their adult years. My frustrating search for these data leads me to hope that sometime soon a nation-wide system of clinic bookkeeping will be adopted for

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child psychiatry clinics and that a file on the professional activities of child psychiatrists will be established in the office of the American Academy of Child Psychiatry. The last few paragraphs of Part IV comprise a discussion of ways and means by which child psychiatry services may be made available to mentally retarded children. Part V is dedicated to promoting the inclusion of mental retardation in child psychiatry training programs. Ways and means of achieving this and course content are discussed. It is suggested that the aim of such instruction is to provide a meaningful orientation rather than to create specialists in mental retardation. REFERENCES AMERICAN ASSOCIATION ON MENTAL DEFICIENCY (1961), A Manual on Terminology and Classification in Mental Retardation, 2nd ed. Willimantic, Conn. AMERICAN PSYCHIATRIC ASSOCIATION (1952), Diagnostic and Statistical Manual: Mental Disorders. Washington. BAKWIN, H. (1942), Loneliness in infants. Amer. ]. Dis. Child., 63:30-40. - - (1949), Emotional deprivation in children. ]. Ped., 85:512-521.

BORNSTEIN, B. (1930), Zur Psychogenese der Pseudodebilitlit. Int. Z. Psychoanal., 16:378399. BOURNEVILLE, D. (1893), Recherches sur l'idiotic. In: Recherches cliniques et therapeutiques sur l'hysterie et l'idiotie. Paris: Bureaux du Progres Medical. BOWLBY, J. (1952), Maternal Care and Mental Health. Geneva: World Health Organization Monographs. BRODBECK, A. Be IRWIN, O. (1946), The speech behavior of infants without families. Child Develpm., 17:145-146. CAMP, B. Be Waite, T. (1932), Report of four cases of mental deficiency on parole. Amer.

Assn. Study Feebleminded, 37:381-394. CHANDLER, C., NORMAN, V., Be BAHN, A. (1962), The mentally deficient in outpatient psychiatric clinics. Amer. ]. Ment. Def., 67:218-226. CLARK, L. (1933), The Nature and Treatment of Amentia. Baltimore: Wood. CLARKE, A. (1958), Genetic and Environmental Studies of Intelligence. Glencoe, Ill.: Free Press. DAVENPORT, C. (1911), Heredity in Relation to Eugenics. New York: Holt. DAVIES, S. (1930), Social Control of the Mentally Deficient. New York: Crowell. - - (1959), The Mentally Retarded in Society. New York: Columbia University Press. DESPERT, J. Be PIERCE, H. (1946), The relation of emotional adjustment to intellectual function. Genet. Psycho I., 34:5·56. FERNALD, W. (1919), Aftercare study of the patients discharged from Waverly for a period of 25 years. Ungraded,5:25-31. GODDARD, H. (1912), The Kallikak Family. New York: Macmillan. - - (1914), Feeblemindedness: Its Causes and Consequences. New York: Macmillan. GOLDFARB, W. (1945a), Effects of psychological deprivation in infancy and subsequent stimulation. Amer. ]. Psychiat., 102:18·33. - - (1945b), Psychological deprivation in infancy and subsequent development. Amer.

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GRIESINGER, W. (1860), Mental Pathology and Therapeutics, 2nd ed. London: New Sydenham Society. ITARD, J. (1801), The Wild Boy of Aveyron. New York: Century, 1932. KANNER, L. (1952), Emotional interference with intellectual functioning. Amer. ]. Ment. Def., 56:701-707. KENNEDY, R. (1948), The Social Adjustment of Morons in a Connecticut City. Hartford, Conn.: Mansfield Southbury Training Schools, Social Service Dept. KmK, S. (1958), Early Education of the Mentally Retarded. Urbana, Ill: University of Illinois Press. LEVY, R. (1947), Effects of institutional vs. boarding home care on a group of infants. ]. Personal., 15:233-241. MCCARTY, C., HENCH, C., NORMAN, V., & BAHN, A. (1961), Trends in outpatient psychiatric clinic sources. Ment. Hyg., 45:483-493. McKAY, B. (1942), A study of IQ changes in a group of girls paroled from a state school for mental defectives. Amer. ]. Ment. Def., 46:496-500. MENNINGER, K. & CHIDESTER, L. (1936), The application of psychoanalytic methods of the study of mental retardation. Amer. ]. Orthopsychiat., 6:616-625. MOREL, B. (1857), Traite des degenerescenses physiques, intellectuelles et morales de l'espece humaine. Paris: Bailliere. MUNDY, L. (1957), Environmental influence on intellectual function as measured by intelligence tests. Brit. ]. Med. Psychol., 30:194·201. POTTER, H. (1922), Personality in the mental defective with a method for its evaluation. Ment. Hyg., 6:487-497. - - (1927a), An introductory study of the erotic behavior of idiots. ]. Nero. t!f Ment. Dis., 65:497-507. - - (1927b), Mental deficiency and the psychiatrist. Amer. ]. Psychiat., 83:691-698. - - (1933), Schizophrenia in children. Amer. ]. Psychiat., 12:1253-1269. RHEINGOLD, H. (1933), Mental and social development of infants in relation to the number of other infants in the boarding home. Amer. ]. Orthopsychiat;, 13:41-45. RmBLE, M. (1943), The Rights of Infants: Early Psychological Needs and Their SatiSfaction. New York: Columbia University Press. SARASON, S. & GLADWIN, T. (1958), Psychological and cultural problems in mental subnormality: A review of research. Genet. Psychol. Monogr., 57:1-284. SAENGER, G. (1957), The Adjustment of Severely Retarded Adults in the Community. Albany: N.Y. State Interdepartmental Health Resources Board. SEGUIN, E. (1846), The Moral Treatment, Hygiene and Education of Idiots and Other Backward Children. New York: Columbia University Press. SIMONSEN, K. M. (1947), Examination of Children from Children's Homes and Day Nurseries by the Buhler-Hetzer Developmental Test. University of Copenhagen, Faculty of Medicine, 1947. SKEELS, H. & DYE, H. (19.39), A study of the effects of differential stimulation on men· tally retarded children. Amer. Assn. Study of Feebleminded, 44:114-l36. SPITZ, R. A. (1959), A Genetic Field Theory of Ego Development. New York: Interna· tional Universities Press. - - & WOLF, K. M. (1946), Anaclitic depression: An inquiry into the genesis of psychiatric conditions in early childhood II. The Psychoanalytic Study of the Child, 2:313-342. New York: International Universities Press. STACY, C. L. & DEMARTINO, M. F. (1957), Counselling and Psychotherapy with the Mentally Retarded. Glencoe, Ill.: Free Press. STORRS, H. (1929), A report on an investigation made of cases discharged from Letchworth Village. Amer. Assn. Study of Feebleminded, 34:220-232. TERMAN, L. (1916), The Measurement of Intelligence. New York: Houghton, Mifflin. THEIS, S. (1924), How Foster Children Turn Out. New York: State Charities Aid Assn., Publication No. 165.

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U. S. PUBLIC HEALTH SERVICE (1960), Patients in Public Institutions for Mental Defectives. - - (1961), Outpatient Psychiatric Clinics. WALLACE, G. (1922), A report of a study of 100 feebleminded girls with a mental rating

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WINDLE, C. (1962), Prognosis of mental subnormals. Amer. ]. Ment. Def., Monogr. Suppl., Vol. 66. WOLFSON, I. (1956), Follow-up studies of 92 male and 131 female patients who were discharged from the Newark State School in 1946. Amer.]. Ment. Def., 61:224-238. WOODWARD, K., et al. (1958), Psychiatric study of mentally retarded children of pre-school age. Amer. ]. Orthopsychiat., 28:376-393.