THE INADEQUACY OF PRESENT-DAY CONCEPTS OF MENTAL DEFICIENCY AND MENTAL ILLNESS IN CHILD PSYCHIATRY

1. A survey of patients with severe disorders of mentation indicates that we are dealing with an "organic" brain syndrome in which the failure of mentation is due to factors that interfere with the proper function of the central nervous system. We are dealing with "symptomatic" mental conditions and behavior patterns that vary greatly in their psychiatric manifestations. The only essential difference between mental "deficiency" and mental "illness" lies in the time of onset. If one wishes to restrict the term mental illness to those conditions in which there existed a period of mental health before onset, all those disorders that are of a prenatal, developmental, or traumatic and vascular character, connected with the process of birth, could be classified as mental deficiency. As soon, however, as the posttraumatic, post-infectious, and metabolic syndromes of infancy and childhood are included, such distinction cannot be maintained. This would have important legal consequences as all such patients would have to be excluded from institutions for mental defectives until such a time as the laws should be changed.

If, however, the problem is approached from a dynamic and biological point of view, it makes little difference whether a child's nervous system is injured by an infection in the seventh month of gestation, at birth, or 5 years afterwards. From a clinical point, the terms mental deficiency, idiocy, imbecility are inadequate and should be discarded.

2. Knowledge of the severe forms of disorders of mentation has made much more progress than is reflected in present-day textbooks or articles on this matter; and the practical management of the "feebleminded" has not kept pace with the scientific understanding of this subject. The terms idiocy and imbecility have outlived their usefulness and should disappear from psychiatric nomenclature. These diagnoses are psychometric terms indicating mental ages from 1 month to 8 years in an adult, but the idea of expressing severe mental inadequacy in terms of mental ages carried, inherently, the misconcept of comparing morbid conditions of mental derangement with stages of normal development through which every child has to pass.

The different developmental disorders of mentation lead to intellectual inadequacies and personality disorders that should be classified according to etiological factors and the time of their occurrence.

3. These deliberations are of practical consequence for the building of institutions for all types of children affected with mental disorders. The so-called "state schools" should be transformed into psychiatric hospital-schools with the clear realization that their lot is to care for and train children, from infancy through adolescence, affected with conditions both psychologic and organic interfering with the normal process of mentation. While the age limit for patients in hospital-schools should be possibly 25 years, two facts have to be integrated into the management and legal regulations for persons needing institutionalization from childhood on. A large number of the severely handicapped are not able to leave an institution at 25 years of age. Under present conditions the custodial cases are lifetime residents, many of them reaching an age of 60-or-70-odd years, and such patients gradually fill an institution thus depriving children of the benefits of the educational facilities that are available and could be utilized to a much greater extent. The hospital-schools should, therefore, be relieved of such a case load at the age of 25 by other types of institutions where custodial cases of chronic mental defect could be placed and employed according to their limited capacities.

The other factor that has not been given sufficient consideration and should be included in future regulations and administrative measures is that the growing child needs long-term provision. The artificial distinctions between mental defect and mental illness and the definition of psychosis as legally used in adult psychiatry are not feasible in child psychiatric administration. Many children are not "psychotic" by legal definition, but they are in need of long-term care by social, educational, and medical standards. Is the brain-injured child with erratic behavior and emotional instability "psychotic" if he takes a knife and tries to attack another person? Such a person could not be helped in a 30-day observation period nor the problem of management even approached in any adequate way. This problem is even more pertinent with regard to sex offenders and other types of behavior disorders. It is true that the needs of the "psychotic" child are different from those of children suffering from prenatal or paranatal disorders, but among the whole group the differences are not as great as the common interest in having hospital and boarding school facilities for these patients whose psychosomatic needs cannot be sequestered. All the standards of management that have been derived from needs of adult psychiatry have been, in the past, transferred to childhood and adolescence without understanding that the field of child neuropsychiatry is a different one and that standards of diagnosis and management must grow out of the needs of the children and not out of regulations designed for a totally different group.

4. Under present conditions the care of the severely handicapped and the large group of intellectually inadequate persons is under one management and legal ruling. Although one may argue the wisdom of such arrangement, one may agree that this way of management has many advantages. Such institutions have possibilities for employment and training that otherwise would not be available and could not be achieved in the community for this intellectually inadequate group. The problem of indenture in penal institutions shows clearly how difficult it is to gradually integrate into the community those persons who still need supervision. The high-grade, intellectually inadequate "moron" is not only a psychiatric problem. Sociology, education, and anthropology are equally interested in his welfare and have to contribute greatly to better understanding; and yet, even the diagnosis "moron" is not a psychiatric diagnosis and it was demonstrated that the group consists of 4 separate categories that have very different needs. The whole planning and management can be successfully carried out only when a differential diagnosis is established.

5. Psychiatric responsibility for patients of this type is postulated by the observations that the blame for social misbehavior, criminality, and psychopathic reactions cannot be put on the diagnosis of mental defect. Observations on thousands of patients indicate that their behavior patterns are conditioned according to dynamics that are universal in each culture and that we have just recently started to understand through psychodynamic psychiatry. The behavior of 2 patients with the same diagnosis differs greatly, not so much according to their "personalities," but according to their emotional experiences as a part of a group. Since the number of mentally handicapped patients is a large one, psychiatry, mental hygiene, and education must develop programs for the mentally handicapped, not only by creating new and better institutions, but by better integration of these persons into the community life outside a hospital.

6. Present-day psychiatric concepts of the mentally retarded are totally inadequate. Nomenclature should be revised as suggested above and the term "Psychosis with Mental Deficiency" dropped completely.