Some Impressions of Mental Deficiency Work in the United States
By Evelyn Fox.
The Commonwealth Fund of America generously invited some ten oevsons- ,ot whom I had the pleasure of being one) connected with the new Child Guidance Council and interested in the prevention of delinquency amongst children, to visit the States. Their main object was to investigate the work of the Child Guidance Clinics and to report how far it was desirable or necessary to establish such clinics in England, and if so, how they could best be adapted to English conditions. Under these circumstances with a very full programme for the whole of my ten weeks in the States^ but little time could be spared to other enquiries. However, I tried to find out in each place what was being done for defectives but even so it was only possible to gain a few general impressions and to give a very brief time to the Institutions X actually did. visit. But I did come back with certain definite impressions which, though I realise they would most likely have been modified by fuller investigations and enquiry yet may be of some interest to us here.
Every facility was.given me to see all I could and my very numerous questions were answered with the greatest willingness, indeed nothing could exceed the ready kindness, the courteous consideration, the really true hosnit ality received from every one I met. , y nospit-
It is very generally held in this country that the States have taken the lead in recent years in the work for defectives. The world wide influence of Dr. Pernald based not only on his remarkable success in the training of defectives, but on the wisdom, originality and sound common sense of his views on the relation of the defective to the Community; the researches of men like Goddard, Healey, Terman; the rapid growth of mental testing originally so closely linked up with defectives, the enormous output of books and pamphlets emanating from the States, all have contributed to make us look to America as to a place where the problem of Mental Deficiency is kept wrell to the fore in the minds of all those engaged in public and social work. This view does not appear to be true of recent years as it was before the War. That those w7hose duty it is to care for -defectives and to safeguard their interests are doing a splendid piece of work is self evident but organisations for social work and even those connected with the various aspects of mental work did not appear to be giving particular attention to it themselves or directing public attention to it. The point of interest has shifted from the defective to the ‘ behaviour ‘ case, the maladjusted personality, and to all that they imply for the prevention of delinquency. Various factors ‘(at work here also) have contributed to this change. The tragic problems of war neuroses, the modern conception of psychology with its clinical develop- ments, the concentration of both lay and medical thought on preventive measures may be cited, but the determining factor is more probably the growth of modern psychotherapy with the hopes it holds out for prevention as well as for cure. The provision of clinics, the training of psychiatrists, the education of parents ?and the public in the necessity of early treatment, offer far more attractive and constructive aims to work for, than the more negative ones of the training and care of the defective whose capacity for improvement is limited. Herein lies a real danger both in the States and our own country. Without a powerful ‘ drive ‘ from the outside, a steady move forward in any branch of social service is hard to achieve, more particularly in work for defectives which is never ‘ popular,’ and in the States this ‘ drive,’ so potent in the past, had somewhat died down, nor did I hear hopes expressed of another big move forward. I have dwelt on this point as it should serve as a warning to us not to push on one side the problem of the care of defectives.
Another point of particular interest (one which is being actively con- sidered here), is the method of diagnosis or selection of children for Special Schools. The use of mental testing in the States is very highly developed. Where tests are well selected and are carefully correlated and where there is a recognition of their limitations, great advantages have been secured by their systematic use for passing children into special classes or schools. So far as I was able to ascertain, children were passed into Special Schools without any formal medical certificate whatever. ,In most areas the examination was based on mental and achievement tests, in all areas I believe a medical examination was also necessary but the examination by the School Medical Officer was not the determining factor in admitting a child to a special school. His general intelligence, his school attainments decided the type of class or school he was to attend. These were ascertained either by educational psychologists specially appointed or by teachers to whom pyschological training had been given. The medical ex- amination covered medical points, causations, type of defect, etc., but did not determine the kind of education required. This does appear to be more logical than our system and has much to recommend it, provided examination by a doctor is also required in every case.
Throughout I did not feel so much importance was attached by authorities and the public to certificates themselves ; there seemed to be less trouble in securing admission to Institutions on the ground of difficulties of certification than over here. This may be due to the fact that accommodation is so limited that cases involving a great deal of trouble or opposition are left and those, who whilst also urgently needing care, can be admitted with little trouble, are taken. This brings me to another interesting aspect of the question : ?the absence of organised effort for the protection of defectives in the Community. So far as I was able to ascertain no obligation is laid on the Authorities in the various States to find out if the defectives in the area are being adequately cared for. In New York and Massachusetts a certain amount of home visiting is carried out, but the number of officers employed is so small in proportion to the population, that obviously only a handful of cases can be visited. In some cases the Educa- tion Authorities employed officers to visit children leaving the Public Schools up to the age of 16 or 18 (according to the school leaving age of the area) but the officers were not persons specially trained for the supervision of defectives. Child- ren excluded from school might or might not be reported for Institution care, but that appeared to be very unsystematic. I heard of no provision made for the training of low grade children at home, and very little, if any, for giving parents advice on the subject of the care, control and training of such children. I heard of no handicraft centres for the training or occupation of older defectives. There were excellent clinics in several States where defectives could be taken for advice, but I gathered the work was mostly diagnostic, and little could be done to give prac- tical advice on home training, on suitable apparatus, manual work, etc. Even in the case of defectives coming before the Courts and put on Probation (which often only lasted a year), no system existed for caring for them afterwards because they were defective. It was left to parents and social organisations generally to press for institutional care for certain cases. These remarks apply only to the places I visited but they were fairly typical.
We know our own weakness here, how little we have really accomplished in the Community care of defectives but in comparing the conditions here with those in the States I was impressed by the fact that we had the legal powers and active organisations for the Community care of defectives. What we need is the money for developing them. Here the principle has been recognised, the machinery created, but the facilities we possess must be developed. The question of After-Care from Institutions I will deal with later.
Efforts are being made all over the States to secure the building of sufficient Institutions for defectives but everywhere I visited (and I travelled from New York across the Middle West to California and back to the Eastern States) there was the same familiar cry of lack of accommodation. Case after case in urgent need of training as well as of the protection of an Institution could not be admitted owing to lack of space. New Institutions were being opened or contemplated but even then it seemed impossible to keep up with the demand. The tremend- ous increase of recent years in population from immigrants from abroad and the shifting of the population within the States creates a problem not only more acute but less calculable than ours. We can give some rough estimate of the number of places required for defectives, but in certain of the States even this is impossible Nor did I, in spite of the great wealth of the country, gather any indication that Public Funds could be secured for the building of Institutions with much greater facility than here.
Generally speaking, I felt that even with our very inadequate efforts we had m this country a real contribution to make in our organisations for the commun- ity control of defectives, and the training of low grade cases not in Institutions I visited a very limited number of Institutions and these very hurriedly, so I can only refer to a few things which struck me.
I spent a night at Rome, when Dr and Mrs. Bernstein made me welcome and I was shown the Institution itself and a large number of the colonies for boys and girls. It is difficult to estimate how far principles of Rome could be trans- ported elsewhere. It is the creation of one man with a strong personality, with fresh and original ideas, with very clear cut views as to the problems his Institution is there to meet. I have seldom met the head of an Institution who visualised so clearly the relation between the defectives he has to care for and protect and the just claims of the Community which is paying for that care and protection. His colony system is the outcome of these views. The colonies afford not only a wider and a freer life to the defectives, but by enabling them to contribute to their own maintenance lessens the financial burden on the Community. The colonies I saw were of three types :
(1) Small homes for girls and for boys still of school age, where they re- ceived the ordinary training given to defective children. The majority appeared to be of the feeble-minded grade. They were selected as being likely to benefit by the more home-like environment of a small house (about 20 to 25) than by the more artificial surroundings of the large parent Institution. They did not differ materially from small residential schools in England, except that the type of building equipment, etc., were on rather simpler, homelier, lines than some I have seen here, and were I think, the better for that.
(2) Farm colonies for boys. Land is cheap in the neigbourhood of Rome and several farms varying in extent from 30 to 200 acres had been rented and were being run by the boys. Each farm had its farmhouse with a varying number of boys under the charge of a man and his wife, the former being responsible for the farm work, the latter for the care of the house. There was great liberty as to the way in which each home was managed, food, domestic details of all kinds varying in each home as they would have done in different private house- holds. The Institution gave the necessary market for the produce from the farm. Here again the arrangements did not differ materially from those of a small home for boys in England, but as in the other colonies there was a greater simplicity, less formality, than we seem to demand. One felt that the boys were living under the same conditions as ordinary working boys, much more so than in our more elaborately organised regulated homes.
(3) Colonies, one for boys and several for girls in which the inmates went out to daily work. Owing to local unemployment the home from which the girls went to work in a mill was no longer being carried on and the girls I saw were practically all in domestic work. The boys worked in gardens in the summer (this means mainly mowing grass), feeding furnaces in winter, cleaning gar- ages, etc. They appeared happy and contented. So did the girls. Those I saw were for the most part, high grade feeble-minded. The houses were all in Rome itself and were ordinary small houses very simply adapted for the purpose. The Staff consisted of one Matron, and between several homes there was a supply Matron for off hours, holidays, illness, etc. I spoke to a great many girls who described their work to me. The houses differed very much in atmosphere and apparently in the amount of training which was given to the girls to fit them for outside work.
All these colonies are near enough to the Institution for the inmates to be able to go there for treats and also to benefit by some of the special staff of the Institution, such as the ” Story Teller,” who visits the girls’ colonies on certain evenings in the week.
The Colony system as attached to one Institute has obviously many advan- tages other than the economic one ; the possibility of transferring inmates from the Institution to the Colonies, does give a greater feeling of hopefulness to the Institution itself ; it is an incentive to those capable of understanding it. A Colony is a good half-way home to greater liberty outside; and is a valuable method of sifting out those to whom complete liberty may be entrusted. But the disadvantages must be faced both as regards the colonies and the parent com- munity. The gradual drafting out of the higher grade, better trained inmates to Colonies tends inevitably to a preponderance of low grades in the Institution itself. Indeed it would seem that an Institution embarking on this scheme would be faced with the problem of catering for two main classes ( which it might not be desirable to mix) those of higher grade training for Colony life and the lower grades who would remain permanently in the Institution. I can hardly believe that an Institution with a very large number of adult low grades is suitable for the training of young high grades.
From the point of view of the Colonies and the Community, the difficulty of selecting a large number of cases to be grouped together and given a consid- erable amount of liberty must of necessity be great. With Colonies developed as a systematic part of an Institution and with the general feeling in the Institution that the Colonies are a step up, it must be difficult not to give everyone a chance. This would mean the inclusion of cases who need more adequate protection than a small staff can give, and thus involve considerable risk to the weaker colonists or a very heavy burden on the staff. At Rome the colonies are close together in a small town, and it has been suggested by outsiders that the fact of there being several homes for feeble-minded girls in one place and thus drawing atten- tion to them may make it more difficult to protect the girls. I am quite unable to say by personal observation if that be so, but obviously it is a point to be con- sidered. One must weigh on the one hand the greater happiness of a very considerable number of feeble-minded against the danger to these who are tried but cannot be protected in Colonies. In any case the data being gathered by Dr Bernstein’s pioneer work will be of the highest value to all those concerned in the care of defectives.
Another interesting point at Rome was the training of very low grades to fit them for simple manual work, with the result that many were employed who would otherwise be sitting about in the wards.
In the Ward for the young imbecile youths of a low grade a considerable number of large children’s go-carts were provided : the boys pushed these running after them and jumping on them. They were constantly charging about the room, bumping into the walls but were getting first class exercise without any trouble to anyone. Generally speaking they were of the grade who would have sat round the room listening to a gramaphone and rocking themselves about. Incidentally, the din was appalling but it was well worth while, as once roused and having gained the habit of movement the boys were trainable for the simplest forms of employment.
In the Ward for the very low grade women for most of whom employment was impossible, they marched round and round the ward, each holding the rung of a very long wide rope ladder led by one of the women beating a drum. This exercise was taken several times a day and the Superintendent was emphatic on 6 mental welfare.
the good results, in quiet nights and generally diminished restlessness and auto- matic movements which resulted from the muscular fatigue induced by the exercise.
I noticed here as at the Fernald Schools (the present name for Waverley) that great use is made of teachers of special subjects for the whole Institution, children and adults. There were in both places excellent gymnasiums and a first-class woman teacher with classes going all day for all sorts of exercises, ball games, folk dancing, etc. There were one or more music teachers taking orchestral and other classes. In one Ward (at Rome) where there were some very crippled as well as defective cases she was playing simple songs in which the patients joined in with real enjoyment. At Rome also I saw a specially trained teacher for story telling. Different classes came to listen to the stories suited to their intelligence : it appeared to develop their alertness and power of concentra- tion.
At Rome the nurse in charge of the Hospital wards trained the higher grade girls in nursing. They nursed under her in the maternity ward (they take in pregnant defective women here) as well as in the ordinary sick wards, and after two years of sound training were found to be very satisfactory. I was informed that some of them were in work outside, mainly I gathered in private families looking after bed-ridden or senile cases. These girls are willing to do house work as well as simple nursing so they do seem to fill a demand. In any case, it is an interesting piece of work.
In the Institutions I visited, there was an atmosphere rather different from that in most of our own Institutions. More ” homey ” in the sense of being more free and easy, more happy-go-lucky, less ” institutiony.” With- out greater experience it hardly seems possible to analyse it, but I should say the inherited traditions of institutional discipline were not so potent, the considera- tion of the patients and inmates was less trammelled by a desire for outward con- vention and orderliness and ” spick and spanness,” and that the general result was a feeling of greater happiness and contentment.
At the Fernald School (Medical Superintendent Dr Green), I was lucky enough to spend one morning when a clinic for outsiders was being held. In Massachusetts the examination of children in the public schools who are three years retarded is under the Department of Mental Diseases, and is carried out by speci- ally appointed members of the staff of the State Hospitals for the Insane. In the case of the Fernald Schools (which are also part of the State Department) they examine specially defectives from the area. A careful physical, psychological, educational and psychiatric examination is made and particulars of social history are also taken by the social worker. Apart from the advantage of securing exam- ination of cases for present or future admission to the Institution by those with experience, bringing the staff into contact with the conditions of defectives in the community has very obvious advantages. In addition, if the case is admitted, all information available is on the spot not far away at some central office. The number of cases evidently in need of training in the Institution but for whom there was no vacancy was one of the tragic features with which we are all too familiar.
I visited the schools and the manual centre. Everywhere one finds the spirit of Dr Fernald ; the devotion to his memory was very touching and an eloquent tribute to the man himself.
The Schools are on the lines of Special Schools generally and there is still the interesting historical Seguin Sense training room. The material he used, and his principles, have generally been introduced into the various classes in all countries and it hardly seems as if sense training could be so successfully con- ducted as a thing apart.
All the manual work for children and adults is taken in one large central building, the children go there as well as the older patients. The rooms were large and spacious but the staff seemed very small for our ideas.
I had unfortunately no time to visit the Wrentham State Schools. My visit to Vineland raised so many interesting points connected with their psychological work, and the Training of Teachers, that I fear I must pass over.
In the Institutions I visited I made careful enquiries about the Parole system that is, letting defectives out on Parole but keeping them in touch with the In- stitution. Each Institution has its own social worker who is responsible for finding work for cases and for visiting them, but owing to the enormous distances very few cases comparatively speaking could be visited and even those not very frequently. The advantage of having a social worker attached to the Institution carrying on this work is that they have an opportunity of getting to know the defectives in the Institution and discussing their capabilities, temperament, etc., with the staff. Its weakness is the want of economy in time and the im- possibility of one or more workers knowing the conditions over a large area. On the whole, I think our system of visits by the Local Authorities or Mental Welfare Associations of the area in which the defective lives, and also the guardianship system are capable of more systematic development and should conduce to more thorough work. At the Fernald Schools I was given the following figures for five years, that is, since the Parole Law came into operation, which the social worker has just got out for girls.
35 on Parole have been discharged. 39 still on Parole. 9 returned to the School. 2 have been lost sight of.
I feel great hesitation in putting forward these sketchy notes, as I am very conscious of the very short time I gave to this branch of Mental Welfare work, and the impossibility of giving an adequate idea of the volume of work carried on in the States. I must again express my gratitude for all the courtesy and kind- ness shown to me.
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