In this two-part series of articles, it is predicted that institutions will be phased out because of five trends: development of nonresidential community services; new conceptualizations of and attitudes toward residential services: increased usage of individual rather than group residential placements; provision of small, specialized group residences; and a decline in the incidence and prevalence of severe and profound retardation due to reduction in the birthrate of high risk groups, improvement of health services for the population generally and for high risk groups specifically, increased practice of abortion, general environmental betterment, and early childhood education. In this (second) part, the impact of the developing new service model upon the institution is discussed.
Residential alternatives to institutions can be divided into group and individual residences, both to be discussed below.
A major new model of group residential services involves small residential units which, in most cases, are of family size and employ live-in houseparents. These units would be highly specialized in terms of their mission, their clientele, and their manpower structure. They would be administratively, physically, and socially integrated into the community, and located in all the population centers of their states.
The group residences of this new model lack the features which I earlier defined as archetypal of institutions. Thus, the new model involves small groups, extensive autonomy on the part of residents, a high expectancy for normalized behavior, and a separation of functions such as sleeping, learning, working, treatment, and playing. Thus, the new model is highly individualized and individualizing. It has been described in enough detail elsewhere (e.g., Dunn 1969; Dybwad 1969; Governor's Citizens' Committee 1968; Menolascino, Clark, and Wolfensberger 1968, 1970; Wolfensberger 1969a) so as not to need extensive recapitulation here. However, certain other options for individual residence do.
In the past, removal of a retarded person from his home was almost automatically equated with group placement, and group placement was generally equated with and tantamount to life-long group residence. For instance, the state often imposed the life-long total service of the institution as a solution to a short-term situational family crisis. While it was difficult to gain admittance to an institution, it was often even more difficult to gain release from it. Rarely was an attempt made to arrange individual rather than group placement. Yet, at least three forms of individual placement suggest themselves: boarding, foster, and adoptive placement.
The term “boarding” can have multiple meanings, some of them equivalent to fostering. I propose to use the term to refer to (a) temporary individual (rather than group) placement of a child who has a home which continues to function as the primary and legal residence; and (b) any individual placement of an adult into a family setting where he receives room and board, regardless of the likely duration of the arrangement. In both cases, it is assumed that the family providing boarding receives remuneration, and it is obvious that boarding can be for adults what fostering is for children. The term “family care” is sometimes used to refer to both foster- and boarding-type arrangements.
Boarding placements, especially for adults, were common prior to the advent of institutions. During the alarmist period (ca. 1890–1925), boarding was ruled out by attitudes (Wolfensberger 1969c); between 1925 and the recent past, it was ruled out by ignorance and the lack of legal and fiscal frameworks. Today, it is ruled out only by rigidity of our service structures.
Yet, boarding placement is a creative and very normalizing alternative to the hospital placement of an adult who is in vocational training or in sheltered or competitive work. In rural areas, it is of particular promise regardless of the boarder's age. For instance, in sparsely populated areas, local services may not be feasible even in the service system of tomorrow. Special classes, workshops, etc., may have to be placed into regional population centers which are beyond commuting distance of much of the surrounding population. One solution, of course, is the establishment of hostels, including some that operate only for five days a week. Such hostels, for example, have been established in several population centers of rural Nebraska, and serve severely retarded children who live with houseparents and who attend special classes during the day.
However, even more creative than five-day hostels is the provision of five-day boarding arrangements. Again, such boarding situations with individual families have been set up in at least eleven Nebraska towns. This arrangement has several advantages: a one-to-one relationship; a more normalizing atmosphere; economy; reduction of the hostel staffing problem; and a solution to the problems of finding buildings that meet the stringent fire codes for group living.
I predict that once the advantages of boarding arrangements have been recognized, and once resistance to novel service options has been overcome, this provision will play a role in reducing demand not only for institutional but also for other types of group residences.
Foster (exclusive of group foster placements, which are really more like hostels) and adoptive placements constitute additional types of individual residential placement. Again, such placements were often ruled out because of peculiar attitudes and practices that prevailed and largely still prevail in the relevant agencies. Such attitudes often demanded that prospective substitute parents be paragons of parenthood—better yet than the typical parent in the community—motivated only by idealism and unmoved by material incentives. Thus, it came about that foster homes were ridiculously underpaid, and that numerous children were placed into no-love high-cost institutions rather than into medium-love medium-cost foster homes, even though a workable legal-fiscal and even administrative structure existed.
In addition, there prevailed an attitude that retarded children should not be adopted. For instance, in Iowa, infant testing had its upswing primarily in order to prevent adoption of children who were retarded (Crissey 1970).
Finally, an almost universal agency dogma was that citizens would not accept a retarded child for foster or adoptive placement. Today, we can only wonder to what degree this agency dogma was an agency myth. What we do know is that prophecies can be self-fulfilling. Obviously, an agency worker who “knows” that retarded children cannot be placed is not going to seek such placements and support them with vigor and inspiration, if at all, and is therefore not likely to make many successful placements, if any.1
In Omaha (Nebraska), we wanted to find foster homes for eight mongoloid infants who had been transferred from the institution to a ward at the College of Medicine for a research project. With the agencies emitting the customary owl hoots, a young nurse and a social work student were told to go out and do the job. These two people employed unorthodox means such as a mobilization of the news media, and within two months, every child had a foster home (Kugel 1970). Three years later, seven children are still placed; had they been free for adoption, several would have been adopted by their foster parents. (The eighth child lives in a hostel.) Similar reports of the feasibility of foster placements are beginning to trickle in from other sources (e.g., Chambers 1970).
The realization is slowly growing that removing a retarded child from his home need not be tantamount to institutional or even group placement. Foster, adoptive, and boarding placements are virtually unmined resources of potentially major proportion. However, to actualize these resources, it may be necessary to provide more vigorous programmatic and more realistic financial backup than has been customary in the past. Thus, the fees for fostering a retarded child should be increased substantially—at the same time as certain standards for foster homes are raised and others lowered. Subsidized adoption (now enacted at least in Illinois and Nebraska) should be made permissible in all states. To both foster and adoptive parents, a continuum of services should be made available. Particularly, specific child development guidance and assistance should be offered in order to assist the parent surrogates in surmounting the crises of the family life cycle.
One day these things will be done, and institutions will be prevented from admitting any child that can be fostered or adopted. Such developments will not only reduce the demand for group residential places rather directly, but also indirectly: parents who now seek and obtain institutional placement inappropriately will refrain from seeking such placement if they know that another family, probably in the same town, will accept their child as their own.
I can see no reason why small, specialized living units (mostly hostels) connot accommodate all of the persons now in institutions.2 In turn, I believe that many persons who could be well served in hostels will be served even better in individual placements. Thus, we should experience not only a shift of places from institutions to other group residences, but also a decline in the demand for any type of group residence.
Furthermore, any feature of a residential service that is normalizing will increase the likelihood that the resident will either return to his family, move to a more advanced form of residence (e.g., from hostel to apartment or boarding), or be fully habilitated. Therefore, the more normalizing atmosphere and practices of small group residences, the use of community instead of segregated resources, the maintenance of family ties because of close physical proximity, the use of five-day instead of seven-day, and nine-month instead of twelve-month residences, will all combine so as to reduce the need for life-long residence, and increase the movement from group to individual residence.
In addition, the open-endedness of the flow into and out of the various types of residences, and the increased availability of residential services specifically geared to genuine short-term crisis relief for the family (e.g., “vacation homes,” “respite centers,” or “crisis assistance units” as proposed and described in Governor's Citizens' Committee 1968) are apt to further reduce the need for long-term or even life-long residences. Those individuals in group placements that are of a long-term nature are more apt to spend days, weekends, and holidays at home. This, in turn, will open space for the short-term admission of others for purposes of family relief, thus further reducing the need for long-term placements.
In sum, there are many features associated with the envisioned new residential model which will tend to diminish the need for residential places of any kind.
Nonresidential Community Services
Nonresidential community provisions will serve those who have been placed into group and individual residences in the community, as well as those domiciled with their families or on their own. However, whether such services will reduce the demand for residential placement has been controversial.
On the surface, one would certainly think that many residential placements of the past would have been prevented by the provision of alternative services. Yet it is a fact that this assertion has not been very well documented to date. One reason for this failure is the shifting interrelationship among the following: amount and type of residential placement as reflected in applications and waiting lists; real demand; actual admissions when residential places are offered; the nature of a service area and its population; and changes in the conceptualization of and attitudes toward retardation and both residential and nonresidential services. Also, service areas with good or plentiful services tend to attract families who move there from elsewhere, thus creating a demand not inherent in the original population base. As in our conceptualization of the prevalence of retardation, we must give up our search for “the” service demand which, once satisfied, remains stable. The service demand must be conceptualized as differing between localities, and as changing over time.
It appears reasonable to think that some services will have greater impact upon residential demand than others. Thus, services that relieve a major share of those family stresses which are particularly burdensome should be most effective in reducing this demand. Yet it is exactly this type of service which we have not done very much about. For instance, very few young retarded children are receiving (or receiving adequate) developmental day care. In many states, the severely retarded of school age are still excluded from school. We have only begun to meet the need for vocational services for adults. And sustained, wise family guidance is almost impossible to obtain, although it is the key to adaptive and full use of all other services.
A striking example of what the introduction of even a modest service system can do are the recent events in Nebraska. Until about 1967, there were hardly any community service provisions in the entire state; the state institution had a population of over 2,300; and the need for additional “beds” seemed endless. Then, within a brief period of incredibly intense planning, campaigning, legislating, funding, and service development, community provisions expanded greatly. Perhaps of greatest impact was the passage of a mandatory education act for the severely retarded, and the establishment of county-funded service systems in the two largest population centers of the State. Almost immediately, the number of residents at the institution dropped. By early 1971, it was down 34% (by 700) and to its lowest level in over thirty years. The remarkable thing is that the new services alone probably do not account for this drop; instead, two other factors appear to be decisive: for the first time, parents could hold realistic hope for the future; and professionals and agencies now apply more stringent standards on what they consider appropriate reasons, sites, and facilities for placement. Thus, despite the once hopeless-appearing demand for institutional and other group residential places, there are now grounds for believing that the need for such places, at least among the younger age groups, can be cut drastically. And all this in less than three years!
At this point, I want to focus upon one particular type of service option which I believe will be of some impact upon residential demand in the future: family subsidy.
A foster placement is a form of family subsidy: a family is paid to raise somebody else's child who presents special problems. Only socio-political attitudes have prevented us from generalizing this option to include families who raise their own very special child.
These attitudes have cost us dearly. The cost of life-long institutional residence has been estimated to be between $100,000 and $300,000. A small fraction of this sum applied to family subsidy may often suffice to keep a child at home. In many cases, this sum may amount to no more than a few hundred dollars a year.
For instance, there are many cases where institutional placement is sought because of the stresses created by the fact that the mother is overworked. Here, a family subsidy might permit the purchase of a washer, a dryer, a dishwasher, and the hiring of a housekeeper for a half-day a week. In other cases, living quarters may be too cramped or inappropriate to accommodate a hyperactive child. Here, a subsidy might permit a move to more spacious quarters, the addition of a room, installation of a yard fence, and/or the purchase of some gross motor play equipment. In yet other instances, the direct or indirect cost of special treatment may threaten to impoverish a family. Subsidy here might pay for such treatment, for special gadgets, special clothing, cab fare to community services, etc.
Family subsidy is one of the most efficient service options. It already exists in some indirect forms as when certain treatment expenses of poor and dependent persons are paid by various public programs. The sociopolitical climate is now such as to permit expansion of this option, and the formulation of some direct forms of subsidy. These forms should be applied not merely to the poor, but also to those middle class families who are apt to seek residential placement for their child because of conditions which might be alleviated by modest, perhaps even short-term, expenditure of money. I predict that the family subsidy option will become an accepted provision that will contribute to the lowered demand for removal of a child from his home.
Conceptualization of Services
The demand for and use of services is profoundly affected by prevailing ideologies which are based on facts, attitudes, traditions, politics, and other factors. For instance, during the alarmist period arose the ideology that all the retarded should be institutionalized. I remember that even during my training as a clinical psychologist in the mid-1950s, it was common and appropriate to write in a psychological report: “This person is mentally deficient and therefore should be institutionalized.”
Today, we are more advanced in some respects, but we still adhere to objectionable and confused ideologies regarding residential placement. For instance, the literature extols the subjectivity of the placement decision, as if there were no principles that could be applied, or as if decision theory were not relevant to this problem. Thus, we can see extreme inconsistency: on the one hand, our residences are crowded and our waiting lists long: on the other hand, we keep admitting many persons inappropriately. Yet, it appears that specific principles for placement can be evolved (Wolfensberger 1967), and that decision theory can be utilized (Wolfensberger 1969b).
Failure to apply decision theory and systems management principles results in an almost universal failure to distinguish between the process and the mission of a service. For instance, we may say that a family needs counseling, that a child should be in a special class, that an adult should be in a hostel, etc., when we mean that the family should be prevented from making an inappropriate placement, that the child needs to be shaped, and that the adult needs to live away from home. Because we equate goal and process, we never stop to explore alternative processes and means, and therefore we fail both in the creative development of new service options, and in the application of cost-yield rationales. This issue is rather complex, and can only be mentioned here; it is elaborated at greater length elsewhere (Wolfensberger 1969a).
A corollary of our present ideological confusion is the strong but inappropriate ideology prevalent today that parents have a right to decide whether to keep a retarded child or whether to divest themselves of it. The literature is replete with this implication, or with explicit statements that “the placement decision is the parents'.”
In our society, it is assumed that when couples contract to procreate, they assume a heavy burden of personal responsibility for their offspring. Society makes very few exceptions from this expectation. One exception is the parent who, in effect, did not contract (i.e., the unwed mother). Here society sanctions her choice of keeping or discarding her offspring. Otherwise, such a choice is virtually never sanctioned, and only under extreme conditions—unless the child is retarded. Then, a child can be discarded even if it is only mildly retarded, or even if the parents have both the personal and financial resources for discharging customary parental responsibilities. For instance, when we permit (as we do) an upward mobile young couple to discard its mongoloid infant, we are saying in effect: “The mere fact that you find your responsibility distasteful and bothersome suffices for you to divest yourself thereof, and for us to spend $100,000 to $300,000 in assuming this burden for you.” Such an ideology is difficult to understand, unless one makes the assumption that it is based on the dehumanizing interpretations of retardation of the past (Wolfensberger 1969c). This then makes it clear: the retarded individual is not a human being, or human child, but a chattel and therefore discardable. That this is so is further underlined by the fact that parents can divest themselves of their retarded child not only physically, but also legally and emotionally. In most of our states, placement has transferred not only custodianship but even guardianship to the state. To this day, there are no measures for censure of parents for breaking all contact with the child, and even for moving out of the state and ceasing payments.
I have discussed this issue and its implications elsewhere (Wolfensberger 1969b; see also, Dybwad 1969). We need to reconceptualize the parental right as being one of seeking divestiture of the child but not necessarily of implementing it. At least where public funds are involved, society (through its representatives), and not the parents, must be conceptualized as making the ultimate decision on whether a parental demand for divestiture should be met.
We have every reason to believe that one other ideology will change: societal tolerance of dehumanizing practices. Perhaps not since the days of the American Revolution has concern over individual rights been as strong and widespread in the United States as today. In all areas of our society, practices once considered normative are now rejected as objectionable on constitutional and moral grounds. We have witnessed the manifestation of this trend in retardation, where the retarded share a new acceptance with other deviant groups. Increasingly, the man on the street perceives the retarded as humans, as citizens, and as capable of change and growth. Increasingly, therefore, he will reject not only the more grossly dehumanizing features of our current institutions, but even the more subtle ones. Consumers, in the new spirit of the consumer rights revolution, will file suit against such practices where they continue, and will win these suits. As in mental health, suits for appropriate services, if filed, will also win, and even a vastly improved institution is apt to fail the future standards for appropriate services. Citizens will demand, and get, the new service system of which the group residential component will consist of small, community-integrated units.
Finally, society's tolerance for deviance appears to be increasing considerably, and because of the high interrelationship between societal tolerance for different types of deviance (Wolfensberger 1969c), community tolerance for the retarded should increase. This, in turn, is apt to lower residential demand, both by resulting in greater community acceptance of retarded persons' deviant behavior, and by making such behavior more tolerable to the family.
In conclusion, I predict that we shall adopt new ideologies as well as systems management and decision theory principles into our service system of the future, that this will result in the evolution and/or implementation of new service options, and that these developments will reduce not only institutional placements, but also the need for other group residence places.
Our Institutional Investment
The dogma that we cannot afford to scrap our institutional system because of financial reasons is almost universally accepted. I submit that this dogma is a myth.
According to the President's Committee (1968), the average age of institutional buildings is 44 years; some are 100 years old; many are in a state of decay; at least 50% are functionally inadequate; and renovation is often economically unjustifiable because it would be cheaper or little more expensive to tear down and rebuild.
In Nebraska, an architectural-engineering survey of the Beatrice State Home (Henningson, Durham, & Richardson, Inc., with Davis & Wilson, Inc., 1968) disclosed that five buildings housing 460 residents were condemnable, and some had been condemned years ago; buildings housing another 325 residents could be renovated as service buildings only; and nine buildings housing 1,528 residents could be renovated to accommodate 684 occupants. Only one building, just erected, was usable “as is.” Applying contemporary group residence standards, the entire institution, then housing 2,313 residents, was judged fit for only 822 after extensive renovation estimated to cost an average of $5,800 per bed.
A similar architectural-engineering survey was conducted in Colorado (Division of Mental Retardation 1968). Even though many buildings and even entire institutional modules were relatively new, much of the same situation prevailed, or even worse: of 32 residential buildings in three institutions housing 3,918 retarded persons, 16 structures with 2,360 occupants were either condemned, condemnable, or programmatically unsuitable as well as unprofitable to renovate as residences. Another six buildings (including some very new ones) with 878 residents required considerable renovations in order to accommodate a maximum of 574 beds. Yet another eight buildings with 640 residents were judged renovatable for short-term occupancy only, and only for 480 persons. Only two buildings with 40 residents were usable “as is,” and for their current number of occupants. In other words, in their present conditions, the three institutions with their combined 3,918 occupants were judged fit for 40 occupants; after renovation, they were to be fit for 1,054 residents for 10 years at most; and after that, for only 574 persons at the most, at a renovation cost of almost $4,800 per space.
Undoubtedly, the situation in Nebraska and Colorado is repeated in many, probably most, states, and the implications are clear: if we apply prevailing community health, welfare, fire, hospital, child residence, nursing home, and other group living standards to our state institutions, and if we adopted a rule that no building requiring renovation should be renovated if such renovation costs more than 60% of replacement cost, then perhaps 75% of our entire state institution system would be out of business.
Confronted with such a reality, and the need to create living space for those that would be displaced by the application of needed, common, and basic group living standards, one can choose from a number of options to be discussed below.
New Construction on the Grounds of Old Institutions
Given the chance for new construction, it would be foolish to construct at inappropriate locations, to enlarge already large congregations of deviant individuals, or to perpetuate such large congregations which violate all aspects of the principle of normalization. Therefore, new residential construction on the sites of old institutions is not defensible on rational and programmatic grounds.
Construction of New Institutions
If we truly believe in the normalization principle, and if we wish to give the model of dispersed small group residences a chance, we must oppose the building of further institutions until the demand and need for small residences has been met. New institutions—even regional centers which are normally only small institutions—will be major obstacles in the development of the new residential model.
Utilization of Institutions Discarded by Others
We are all familiar with the mental hospital, the VA hospital, the general hospital, the tuberculosis sanatorium, the prison, the orphanage, and now even the monastery or convent that is discarded by its former users, and converted for the retarded. Often, such arrangements merely create “instant old” institutions. Only occasionally should such facilities be used, and even then they should be labeled as compromises, rather than glorified. Temporary compromises may be defensible if the facility is small, located in a population center, and does not require extensive remodeling. Too often, we spend more money putting these monstrosities to use than it would cost us to develop hostels—but the rigidity of tradition is so terribly hard to overcome!
New Construction of Noninstitutional Group Residences in the Community
Extensive construction of community group residences will undoubtedly be needed. However, it is almost impossible under existing codes to construct such buildings without making them institutional in appearance. The moment retarded persons are mentioned to an architect or building inspector, a mental shutter clicks shut. Even architects who are not bound by fiscal restraints, and who pride themselves on their skill to design a building on the basis of its function described to them by others, will design institutional features that go even beyond those required by the building codes.
I was deeply impressed to observe this phenomenon even in the almost incredibly normalizing hostels of the Swedish service system. Most homes used as hostels were indistinguishable from ordinary homes, but purpose-built hostels often had a slight institutional flavor. Even in an apartment that was designed for the retarded in the construction of a new apartment house for ordinary citizens, “heavy duty” features were added by the architect—and quite unnecessarily so, as the personnel acknowledged.
I have a phrase for this, and maybe it says more than volumes of technical discussion: “You mention retardation, and they just can't let things be.”
Another remarkable fact is that data are now coming in from all over the country, indicating that construction of a new institutional place costs up to $40,000 each. Even at that level of costs, we still end up with large, dehumanizing buildings which are part of an inappropriately large congregation of deviant persons, usually at an inappropriate location. In contrast, residential space even in the upper-middle and lower-upper class neighborhoods of our cities may cost no more than $3,500–5,000 per person, if we think in terms of groups of large family size. This contrast between the high cost of dehumanization and the low cost of normalization is almost beyond belief.
Utilization of Existing Community Buildings
New construction not only devours massive blocks of capital funds, but does so all at once and in a highly visible fashion. This explains in part why legislatures do not appropriate adequate operating costs once they have approved capital costs. In our Douglas County (population 400,000) plan in Nebraska, we therefore adopted a cardinal principle: money for services, not for buildings. Accordingly, we rent or lease if we can, buy on occasion, and build only if we must, after all alternatives are exhausted.
Obviously, one major advantage of leasing or renting is that capital costs can be both “hidden” as operating costs, and spread out over time, in both cases in the form of lease or rent expenses. This appeals to many powers-that-be, such as county commissioners and state legislators. It also opens the way to get residences going on establishment-type grants when no capital funds are available.
Utilization of existing buildings has three other advantages. First, existing buildings can be selected so as to be normalizing in terms of design and location. The codes may permit the use of an existing building that does not have the institutional features that would be required in new buildings. Also, existing buildings in normalizing surroundings are common, while available building sites are less commonly found in areas which are clearly normalizing. Second, existing buildings can be acquired and put into use relatively quickly; the delay between initially plannning and finally utilizing a new building may be as much as five years. Third, a building that is rented, leased, or even bought can be abandoned or sold within a reasonable period, and the service can move as our ideology demands, or as the neighborhood or the population changes. In contrast, a new building erected with public funds and owned by a public agency is quasi-permanent. It is an obstacle to change of any kind.
On programmatic, ideological, and fiscal grounds, the present institutional system is essentially unsalvagable. Indeed, I believe that it is the duty of every institution's superintendent to do all he can to phase out his institution, and to encourage the new residential and service model. Among the residential alternatives, the use of existing community housing is optimal, although new construction in the community is often necessary. Provisional use of institutions discarded by others is to be viewed as a temporary desperation compromise at best. Construction of new institutions, and of new buildings at old institutions, should be categorically prohibited, and Federal agencies and even law should prevent the use of Federal funds for such purposes.
The argument is sometimes raised that increased provision of nonresidential services will not necessarily reduce residential demand, and high residential rates from nations with extensive community provisions are occasionally cited in support. In rebuttal, I submit that such data are the results of cultural differences, and of different strategies which we should not and/or need not emulate. For instance, one of the major reasons why Denmark and Sweden have a relatively high rate of residential provision can be a lesson to us: residential placement for children is not strongly discouraged, and residential placement for adults is actually encouraged (e.g., Nirje 1969). While community provisions are steadily increasing, I cannot see where Danish—and to some degree Swedish—service ideology places high emphasis on a vigorous policy of attempting to maintain the retarded person with his family.
In contrast, in the United States, maintenance of the retarded person in the home has not merely been advocated because of scarcity of alternatives, but also because of a different set of historical and socio-cultural attitudes and values. Such values can be expected to endure even when our service provisions are greatly improved. Thus, it appears safe to predict that the demand for residential places in this country should decline if the prevalence of severe retardation can be reduced, if needed community services are provided, and if these services are provided in conjunction with vigorous and sustained family guidance which emphasizes home maintenance of retarded children.
At the 1969 National Conference on Residential Care in Houston (National Association for Retarded Children 1969), a sentiment of state program coordinators was summarized as follows: “I hope that we can recognize the fact that institutions are with us, they are going to continue to be with us and we had better accept the fact that this is one facet in a total program for the retarded” (p. 19).
Obviously, my conclusion differs sharply: institutions will not always be with us. Some of the newer ones will take a long time dying, and will be visited by our students as historical curiosities. In some states, there will be regional centers with built-in residential components, but these will be transitory (and inappropriate) in the rapid move toward small, specialized, dispersed, homelike units which are physically and socially intimately integrated into the community.
Not only will the institution fade away, but the need for any type of group residence will decline, except perhaps for the aged retarded who, however, can be served in regular community homes for the aged. We may find that the need for places in group residences specifically for the retarded will be less than half what it is now, i.e., perhaps .3 to .5 instead of about 1 per thousand population.
Some nations, such as Denmark and Sweden,3 have a much lower prevalence of mental retardation than the United States, and yet have a residential rate which is as high and higher, and still considered inadequate. While this fact should make us cautious in relating the need for residential places to the prevalence of mental retardation, as long as we take into account other factors which determine residential needs, at a given point in time and location, there is bound to be a causal relationship between the prevalence of retardation on the one hand, and the need for residential places on the other.
Franklin's (1969a, 1969b, 1969c) documentation of successful adoptive placements of children with even severe medical conditions is highly relevant. Also, today, we should move toward subsidized adoption (e.g., Wheeler 1969) as another powerful option, especially with handicapped children whose upbringing may be very expensive.
The references cited earlier explain how even the more severely impaired can be served in small units.
For Swedish prevalence and residential data, see Grunewald (1969). A rate of 2 per 1000 population is projected for 1974. Prevalence data on Denmark are available from various Danish sources; of special interest is an apparently unpublished translation of a paper by E. Berg, entitled “The Frequency of Mental Retardation in Denmark,” and furnished to the author by the Danish National Service for the Mentally Retarded. Residential rates for Denmark are quoted by Bank-Mikkelsen (1968) as about 9000 per 4.8 million, or roughly 1.9 per 1,000 population. Both figures correspond to about double our own rates (Public Health Service 1969).
Originally published in 1971: Mental Retardation, 9, 31–38.