Search

Since intelligence tests were designed originally to diagnose mental retardation (see Chapter 1), it is eminently appropriate that this group be discussed first. Mental retardation (MR) has been recognized by societies for some time-at least since the Roman Empire. It has been said that Roman parents often threw their children with mental retardation into the Tiber River in order to not have to care for them, and Spartans killed or abandoned mentally retarded individuals. It was not until the Middle Ages that some societies began to care for these individuals’ needs (Weiss & Weisz, 1986). Given such potential dire consequences, one cannot help but wonder about the accuracy of the diagnoses that were made in those days!

In the last two decades there has been a proliferation of research dealing with dynamic—interactive assessment (DA) as an alternative approach to the conventional psychometric measures. This proliferation has paralleled dissatisfaction with the static test approaches. The term static test refers to a test where the examiner presents items to the child and records his or her response without any attempt to intervene in order to change, guide, or improve the child’s performance. Many psychologists and educators have pointed out static tests’ inadequacy in revealing the learning potential of minority students or of students with varied types of learning disabilities (e.g., Budoff, 1987; Carlson & Wiedl, 1992; Feuerstein, Rand, & Hoffman, 1979; Guthke & Wingenfeld, 1992; Haywood, 1997; Lidz, 1991; Tzuriel & Haywood, 1992). This has been amplified by their inadequacy in indicating specific learning processes and in providing prescriptive teaching. DA, with all its limitations (i.e., time consuming, subjectivity of observation, and requirement of trained examiners), has been suggested as a more accurate procedure than the static testing approach in revealing individuals’ learning potential.

Cystathionine β-synthase (CBS) deficiency was first demonstrated in 1964 in an eight-year-old mentally retarded girl with bilaterally dislocated optic lenses who excreted abnormally elevated amounts of homocystine in her urine [1]. Patients with similar metabolic abnormalities and clinical findings had first been discovered 2 years earlier by Carson and her colleagues during a survey of mentally backward children in Northern Ireland [2]. CBS deficiency has proven to be the most frequently encountered of the human genetic diseases causing homocystinuria and severe hyperhomocyst(e)inemia. Worldwide, it is detected with a frequency of about 1:344,000 by screening programs of the newborn, but this is undoubtedly an underestimate because some individuals are being missed [3]. This chapter will briefly focus on the major clinical manifestations and metabolic aspects of CBS deficiency.

Historically, research efforts have been lacking in the investigation of age-related changes in the physical, psychosocial, and cognitive adaptation of mentally retarded adults. Much remains unknown about how the central nervous system (CNS) ages in this population (Wisniewski & Merz, 1985). While nearly 25 years of effort have been directed at elucidating aspects of cognitive development in mentally retarded children (Hodapp & Zigler, 1995), research on the effects of aging has been limited to the last 10 years.

Deinstitutionalization has been perhaps the most important development in the way services for people with intellectual disabilities have been organized in Western Europe and North America over the last 25 years. The book Changing patterns in Residential Services for the Mentally Retarded (Kugel and Wolfensberger, 1969) represented a turning point in thinking about services, summarizing the shift from traditional forms of institutional care of the 1950s and 1960s to new models based on the community, and elaborating new objectives and ideals for the change towards community services.

Alterations in the erythrocyte NAD(P) concentration have been reported in inherited defects of purine metabolism, such as PNP and HPRT deficiency, and phosphoribosylpyrophosphate synthetase (PRPS) superactivityl. The neurological disturbances associated with these disorders, as well as the utilization of nicotinate (NA) or nicotinamide (NAm) for the treatment of psychotic states, schizophrenia and depression2 and the findings on the role of NAD in the synaptic modulation3, suggested a correlations between neurological disorders and pyridine nucleotides.

Every year millions of people, particularly children, die of diseases for which a vaccine exists (Walsh, 1988; Warren, 1989). Countless others are left blinded, mentally retarded, or severely crippled. The problem is most significant in developing countries where access to health care is poor. In these countries, it is estimated that more than half of the children who receive primary vaccinations do not complete their required booster immunization schedule (Aguado, 1993; Bloom, 1989). These children are left unprotected, accounting for the enormous number of reported deaths.

A few years ago a student in our university wrote about the life of a Japanese movie star for her Psychology of Women class. She believed the actress, Miyagi Mariko, personified the “essential mother nature,” even though she was not married and had no children. Miyagi Mariko spent much of her personal wealth building a school for mentally retarded children, and she took pleasure in giving time and attention to the children. The American professor who taught the class wanted to explore the ironies of this case and develop a more structural analysis—had the actress really become a “mother,” her movie career would most likely have been curtailed. Or perhaps philanthropy and good works are different from the daily commitments of motherhood. But the student held fast to her psychodynamic theory, convinced that the actress, a highly successful, resolutely single woman, was still the embodiment of an essential mother nature. On the day for individual conferences, the student came to school wearing a T-shirt that said “MILK” in large pink letters across the front.

Andrei Chikatilo of Russia, serial killer extraordinaire, was arguably more power hungry and control minded than Ted Bundy and John Wayne Gacy put together. Between 1978 and 1990, Chikatilo killed, dismembered, and occasionally devoured 21 boys, 14 girls, and 18 women in and around Rostov while he worked as an office clerk and part-time teacher. The 54-year-old father of two didn’t particularly care about the age or gender of his prey, as long as they were naive and willing to follow him from a bus or rail station, cafe, or other public meeting place. Some of his victims were too young to know better, and others were mentally retarded or homeless drifters, but many of those whom Chikatilo destroyed were bright youngsters from middle-class families.

Any defect or physical handicap whatsoever challenges an organism to overcome that defect, to make up for the deficiency and to compensate for the loss which it represents. Thus, the result of a defect is invariably twofold and contradictory. On one hand, it weakens the organism, undermines its activity, and acts as a negative force. On the other, precisely because it makes the organism’s activity difficult and disturbs it, the defect acts as an incentive to heightened development in the organism’s other functions; it nudges, awakens the organism to redoubled activity, activity which might compensate for the deficit and overcome the difficulty. This is a general law, equally applicable to the biology and to the psychology of an organism: The negative character of a defect acts as a stimulus to heightened development and activity. Two basic types of compensation can be distinguished: direct and organic, and indirect or psychological. The first usually takes place when one of a pair of organs is impaired or destroyed. For example, when a kidney or lung fails, the remaining organ in the pair develops compensatorily, taking over the function of the ailing organ. Whenever direct compensation is not possible, then the central nervous system and psychological apparatus bear the burden of creating a protective superstructure over the ailing or deficit organ. This superstructure is composed of higher functions which fulfill the tasks of the defective organ. According to A. Adler, awareness of an organ defect serves as a perpetual stimulus to psychological development.

We are indebted to medical clinics for their diagnostic descriptions of mentally retarded children, yet such clinics took little interest in the development of the child afflicted by retardation. Because of the character of the practical problems facing a medical clinic, such institutions could not probe deeply into the problem of child development inasmuch as child retardation relates to a number of clinical forms which are readily ameliorated and in general are not responsive to therapeutic treatment. These forms of underdevelopment did not become the topic of serious investigation in clinics because there has never been any practical incentive toward this end nor have efforts been made in any other direction of clinical thought. Clinics were mainly interested in the possibility of determining those symptoms which can facilitate our recognition of mental retardation and distinguish this form from other similar handicaps—but it could do no more. With these goals in mind, clinics raised the problem of the development of the oligophrenic child. They established that an oligophrenic child does develop—not regress—just as the mentally ill child does. This fact is reiterated by a series of other indicators. With the help of these indicators, a child’s mental debilitation is discerned and distinguished from other forms externally resembling it.

The Revolution, which redesigned our schools from top to bottom, barely affected the special schools for handicapped children. In schools for blind, deaf-mute and mentally retarded children, everything stands now precisely as it did before the Revolution, if one does not take into account a few unessential mechanical changes. Thus, work remains even now unrelated in theory and in practice to general principles of social education and to our Republic’s system of public education. The problem is that in order to connect abnormal child education (education for the deaf, the blind, the mentally retarded, and so forth) with the general principles and methods of social education, we must find a system which would successfully coordinate special education with normal education. Before us stands the enormous creative task of rebuilding our schools on new principles. We must project basic policies for such an undertaking, in other words, start from the beginning.

The group of children whose behavior deviates from the norm and who therefore stand out from the general mass of children with respect to education,—that is, problem children in the broad sense of the word—must be divided into two basic types: (a) the type of child whose behavior deviates from the norm as a result of some organic defect (physically handicapped children including blind, deaf, blind-deaf, and crippled children along with mentally retarded or feebleminded children who suffer from some organic defect); and (b) the type of child whose behavior deviates from the norm as a result of some functional disorder (difficult children in the narrow and strict sense of the word, such as delinquents, children with character disorders, and psychopaths).

Until recently, within the problem of mental retardation it has been the intellectual deficiency of a child, his feeble-mindedness, that has occupied the foreground as the basic feature. This is locked into the very definition of such children, who are habitually called mentally retarded or mentally deficient. All other sides of such a child’s personality are regarded as arising secondarily and as depending upon that basic intellectual defect. Many are inclined not even to see real distinctions between the affective and volitional spheres of these children and of normal children.

Systematic attempts to teach and habilitate mentally retarded children and adolescents began in the early nineteenth century, when Jean-Marc-Gaspard Itard (1775–1838), a French physician, attempted to educate Victor, the “wild” 11-year-old boy who was discovered by hunters in the forest of Aveyron. Using techniques similar in theory to current behavior modification methods, Itard aided Victor in developing adequate self-care, social skills, and receptive language ability over a 5-year period. Although Itard considered his approach a failure because Victor did not develop speech, his methods suggested that mentally retarded individuals could acquire and refine a variety of adaptive behaviors through systematic training. Edouard Seguin (1812–1880), who as a medical student had worked with Itard, continued developing his mentor’s techniques, and by the mid-nineteenth century, had established educational programs for mentally retarded individuals throughout Europe (cf. Tylenda, Hooper, & Barrett, 1987).

Several supportive techniques can be mobilized to effectuate and intensify the mutual change process. In assuming responsibility for this change, caregivers need to have the skills to enable the establishment of feelings of companionship. This is much easier said than done since each marginalized individual brings unique emotional challenges to the situation. Some might fear the caregiver and rebel against any interactions. Others might be consumed by an overwhelming sadness and withdraw from any contact. Some individuals will be mentally ill, others, mentally retarded, and still others, aged. Some will have strong supportive networks while others will be alone and abandoned. Some will be destitute, unemployed, and homeless while others will have material goods and yet still be burdened by feelings of apartness.

Mental retardation is one of the most prevalent types of handicapping conditions among the human populace. Although reports of the incidence of mental retardation vary, estimates generally indicate that 3% of the population of the United States is mentally retarded (Beck, 1983). The disability of mental retardation affects afflicted individuals throughout their lifespan, including adulthood—which is the chronological period of concern of this chapter. However, despite the widespread prevalence of mental retardation, mentally retarded adults have historically received relatively little attention from an outpatient treatment perspective. Reasons for the lack of attention as well as recent events that have caused increased professional interest in this area of service provision will be discussed later.

Professionals who work with exceptional children, whether they are of high or low intelligence need to meet the challenge of enabling them to communicate. Communication with retarded children is particularly challenging because these children have not reached age-appropriate development in many areas and therefore often cannot communicate adquately in either behavioral or cognitive situations.

Self-help skills, or daily living skills, may be defined as those behaviors that allow individuals to care independently for their own bodily needs. The mentally retarded person needs to be able to eat, use the toilet, dress, and perform personal hygiene to meet basic requirements for independence and normalcy. Once these skills are acquired, caregivers could redirect time and effort previously devoted to basic care to education and training of residents, thus facilitating a more productive environment.

The treatment and education of mentally retarded individuals has changed considerably over the years, alternating between compassionate concern and neglect and ridicule (Gearhart & Litton, 1975). Although residential institutions for mentally retarded persons in the United States were initially conceived for the purpose of treatment and education, a custodial-care orientation emerged early in the twentieth century, and, as a consequence, treatment and educational programs virtually disappeared. It was not until the 1950s that a growing concern for mentally retarded persons led to social change. In 1952, the National Association for Retarded Children (NARC, now called the Association for Retarded Citizens) was formed through the efforts of parents of mentally retarded children. Subsequently, the NARC and its state and local member units catalyzed community agencies into developing services for mentally retarded persons and provided, when necessary, direct services. Concurrent with this type of development, public enlightenment and awareness about mental retardation increased. The 1960s and 1970s were times of moral indignation, during which man’s inhumanity to man was exposed in such books as Christmas in Purgatory (Blatt & Kaplan, 1966). During the Kennedy and Johnson administrations, a national effort began to address the needs of mentally retarded persons and the problems associated with mental retardation. As a consequence of these social and political concerns, an educational movement occurred, as movements to normalize, educate, and treat, and secure civil rights for mentally retarded persons gained impetus.

The various degrees of mental retardation bring unique challenges relative to the risk of development of clusters of maladaptive behaviors. In general, persons with mental retardation are nearly twice as likely to have severe behavioral problems or mental illness as are the nonmentally retarded (Balthazar & Stevens, 1975; Beier, 1964; Eaton & Menolascino, 1982; May & May, 1979; Menolascino, 1975; Penrose, 1966; Pollock, 1958). This risk may result in part from the person’s difficulty in processing information, allied medical, physical, or sensorial difficulties; actual organic problems; cultural-familial factors; and society’s nonacceptance of retarded persons and elements of raw prejudice toward them.

Anxiety disorders and depression in mentally retarded persons have received less attention than other behavior disorders. The inattention is not because anxiety and depression are rare among mentally retarded individuals; survey data indicate that these problems are relatively common. Rather, anxiety disorders and depression may be overlooked because individuals experiencing these problems are less difficult for caretakers to deal with than individuals who are aggressive or noncompliant. Thus, mentally retarded persons with anxiety disorders or depression may be less readily identified and referred for treatment.

Every year new service models are demonstrated by energetic professionals who are seeking better ways to serve mentally retarded people (e.g., Menolascino & Stark, 1984). The new models are constantly challenging behavior modifiers to broaden their horizons or risk the possibility of becoming outdated (Reiss, 1987). In this chapter, we will consider three new models for serving people with mental retardation and discuss some of the ways in which behavior modifiers might relate to these models. The models are outpatient mental health services, inpatient mental health services, and foster care. Two of the models, outpatient and inpatient mental health services, relate to the critical need for services to people who are dually diagnosed (i.e., mentally retarded and emotionally disturbed). The third model, foster care for persons with mental retardation, provides a desirable alternative to residential placement in state institutions and other restrictive environments. Although the three models discussed here are from Illinois, similar programs have been created in many places across the United States. Thus, the models are relevant to important national trends in the field of developmental disabilities. Because two thirds of this chapter is concerned with behavior modification and service models for the dually diagnosed, our discussion begins with a consideration of general information on the importance of increasing the supply of mental health services for mentally retarded people.

This chapter consists of two parts, a general discussion of the postindustrial society and potential impacts on the mentally retarded (Part I) and a description of a structural modeling effort undertaken to illuminate certain cross-impacts (Part II).

Beginning with the preface to this volume and continuing throughout the majority of its chapters, a heavy emphasis has been placed on the concept of empiricism and its role in the determination of treatment effectiveness. Simply put, the empirical model involves a quantifiable or data-based approach to clinical decision making that is heavily weighted by objective observation and yields information that is verifiable through replication. It is unfortunate that within many of the professional disciplines that serve mentally retarded clients, such as psychology, psychiatry, and special education, the empirical model is equated strictly with research and, all too often, is dismissed from its potentially valuable contribution to clinical practice, in general.

The historical relationship between the symptoms of mental retardation and mental illness will initially be reviewed. The interrelationships between the symptoms will then be illustrated by presenting one of our recent studies in a community-based sample of retarded citizens. Specific focus on the clinical diagnosis of schizophrenia in the retarded, and its differential response to treatment modalities, are reviewed through the author’s recent study on the efficacy of psychopharmacological agents. Lastly, the current and future challenges which this “dual diagnosis” presents will be underscored.

A decade ago, a major milestone marking the reform of the human service delivery system for mentally retarded and other developmentally disabled persons was introduced—normalization (Nirje, 1969; Wolfensberger, 1972). The normalization principles has as its most rudimentary tenet the delivery of services in environs and under circumstances (contingencies) that are as culturally normal as possible. Today, interpretation of normalization includes enlarging the scope of programming for mentally retarded individuals to encompass the broad array of services, activities, and events that most nonhandicapped individuals have access to and benefit from.

Persons of normal intelligence who experience psychiatric problems can avail themselves of clinical services from a variety of resources within the mental-health delivery system. Mentally retarded persons, on the other hand, who experience similar psychiatric problems do not have easy access to mental health services either within the mental-health delivery system or within the mental retardation system. These persons, although in need of multiple services because of their double handicap, are frequently without the necessary support systems. Historically, neither the mental health nor the mental retardation systems have adequately addressed the mental health needs of this population. Because these individuals are not appropriately categorized and directed into one or the other delivery-care system, their unique mental-health problems have largely been neglected. Persons in this population who are typically unidentified as doubly handicapped either “fall through the cracks” or are programmed into a system in which their needs are only partially addressed.

This chapter reviews the establishment, function, and results of a special needs assessment and plan to develop services for persons who have been identified and diagnosed as both mentally retarded and emotionally disturbed. Because the findings and the plan of services developed by the project have been applied in other areas of the country, a community may wish to establish a similar approach to meet the needs of this special dual-diagnosis population.

The application of event related potential (ERP) techniques to the mentally retarded presents a somewhat different challenge to the electrophysiologist than does the application of ERPs to other clinical populations. In particular, while differential diagnosis is of major interest in the investigation of such problems as minimal brain damage (MBD), schizophrenia and dementia, diagnosis is of less importance in mental retardation. What is important is to differentiate among the different types of information processing deficits occurring in the retarded so that educational remediation may be designed on an individual basis to compensate for sensory and intellectual inadequacies.

The previous chapter detailed programs with psychiatric patients, the mentally retarded, and individuals in classroom settings. While that research illustrates the extensive literature on token economies, it does not convey the breadth of applications. This chapter reviews a number of other populations that have been exposed to token-reinforcement procedures including delinquents, adult offenders, drug addicts, and problem drinkers. In addition, diverse uses of token programs in outpatient treatment both with children and adults are reviewed. Finally, applications with select populations who have been infrequently treated with token programs and in select research areas are briefly cited.

In recent years there has been an increasing realization that not all of the dysfunctional behavior of the developmentally disabled can be attributed solely to biomedicai factors. Although primary sensory or motor deficits have a biomedicai etiology, many of the cognitive-social-emotional problems of the developmentally disabled, as described in Chapter 1, may have an environmental as well as a biological basis (Green & Durocher, 1965). The relevance of psychosocial environmental factors1 to cognitive, social, or emotional development has been noted for the hearing impaired (Altshuler, 1974; Cheskin, 1981; Galenson, Miller, Kaplan & Rothstein, 1979; Sanders, 1980), the visually impaired (Willis, 1979), the mentally retarded (Poznanski, 1973), and the motorically impaired (Battle, 1977; Cruickshank, Hallahan & Bice, 1976; Lewandowski & Cruickshank, 1980; Shere & Kastenbaum, 1966; also see review in Chapter 1 by Wachs & Sheehan). Particularly for the hearing-impaired and the motorically impaired, most theorists hypothesize an interactive process, in which an initially less responsive handicapped child does not elicit the types of parental interactions necessary for optimal cognitive- social-emotional development (Greenberg & Marvin, 1979; Henggler & Cooper, 1983; Kogan, 1980; Richardson, 1969; Wedell-Monnig & Lumley, 1980).

This chapter offers a discussion of issues in training teachers and other school personnel to work with severely behaviorally disordered/mentally retarded students. School personnel may include classroom teachers, par-aprofessionals, preservice or student teachers, school psychologists, and a host of other staff members (e. g., principals, counselors, speech and language specialists). This discussion, however, will be limited to the former group of professionals. The school may refer to a regular public school in which a few self-contained classes for the severely handicapped operate, or a special public, private, or parochial school devoted entirely to the education of the handicapped. A group of classrooms may also be located on the grounds of a public or private residential institution.

The recognition that mental illness can strike mentally retarded persons, as well as those of normal intelligence, is not new. During the nineteenth century many psychiatrists were actively involved in the field of mental retardation. They provided enlightened clinical care, pursued research, filled important administrative posts, and were effective advocates for the mentally retarded. However, during the period referred to by Menolascino1 as the tragic interlude (1900–1920), psychiatric interest in mental retardation waned. In fact, it was replaced largely by an attitude of despair and helplessness—a change that led to the relative withdrawal of psychiatry from the field. During the last two decades (since the early 1960s), psychiatrists have begun to return to the treatment of mentally retarded persons—especially those with allied symptoms of mental illness—with modern treatment tools and techniques that promise to improve the lives of these individuals.

The recent national movement removing the mentally retarded from institutional settings into the community has literally changed the definitions of normal and abnormal behavior in these individuals. Specifically, the impact of deinstitutionalization not only has changed the physical site of service delivery but has also dramatically altered the need for mental health services for the mentally retarded. Behaviors that were traditionally viewed as “expected” in institutionalized retarded citizens are often viewed as abnormal within the mainstream of society.1 For example, the clinical phenomena of rocking, rumination, and head banging are frequent in the institutionalized retarded; within the institutional setting, they are traditionally viewed as “expected” behaviors, and their abnormalities are tolerated. Such behaviors are rarely seen in retarded citizens raised at home. That certain behaviors occur more frequently in certain settings can be explained either by a difference in the individuals in the two settings or by an environment that promotes, allows, or expects such behavior.

The systematic application of learning principles to modify the behavior of humans has perhaps one of its most basic and important functions in the training of toileting skills in mentally retarded persons. Many of these persons have no language and lack the ability to dress, feed, and groom themselves. However, in many instances the most degrading aspect of their behavior, both to the client and to his or her parents or caretakers, is the absence of toileting skills (Baumeister & Klosowski, 1965; Bettison, Davison, Taylor, & Fox, 1976; Ellis, 1963; Osarchuk, 1973).

Our society is in a state of massive transition. For the first half of this century, resources were substantially unlimited and manpower was in short supply, as were consumer goods and services. In such a situation, the simple free-enterprise system of Adam Smith and the Puritan ethic were functional. The more effectively the total manpower pool of the nation could be coupled to productive acitivity, the better off the whole nation would be.

Diagnosticians are aware of the fact that disturbances of social contact occur in children with specific sensory disorders in infantile autism, in infantile psychosis and in mental deficiency.

The field of mental retardation has perhaps the oldest tradition of any area of psychology. For example, the work of Binet attempted to distinguish the mentally retarded from those without handicaps. The development of the Binet, and, later, the Stanford-Binet IQ tests were among the beginnings of psychometry as we know it today. Furthermore, the IQ test played an important part in the separation of children’s performance in school and thus the creation of special education was closely linked to this movement. Categorization into regular and special classes was largely associated with the IQ test.

To discuss the pharmacological treatment of learning disabilities and mental retardation simultaneously is a difficult task. Even though both have in common learning difficulties, these two conditions are quite different, having distinct diagnostic characteristics, treatment approaches, and outcomes. Whereas the mentally retarded child functions below his or her chronological age in many areas of development because of impaired ability, the learning-disabled child underachieves in school despite normal or above-normal intelligence. On the other hand, in both conditions, pharmacological intervention, when used, is aimed at treating the underlying or associated psychiatric, emotional, or behavioral problems. In other words, medications may be used either to suppress undesired behaviors or to facilitate and enhance desired behaviors and, incidently, to facilitate learning.

As federal and state courts throughout the nation developed the constitutional right of handicapped children to equal treatment in the public school system, Congress considered a uniform national procedure for funding and implementing these educational rights. In the spirit of court decisions in the area, as well as in recognition that vast differences existed among the states in providing services to handicapped children, P.L. 94-142 was passed. It was a critical statutory recognition that, in the famous words of the PARC court, … all mentally retarded persons are capable of benefitting from a program of education and training; that the greatest number of retarded persons, given such education and training, are capable of achieving self-sufficiency … that the earlier such education and training begins, the more thoroughly and the more efficiently a mentally retarded person will benefit from it; and, whether begun early or not, that a mentally retarded person can benefit at any point in his life and development from a program of education and training.1

For years mentally retarded people have been shut in harsh, dehumanizing institutions. There is an increasing realization, however, that people may only achieve their full potential if they are exposed to the patterns and expectations of everyday life. This realization prompted the renovations at a large state institution which were evaluated in the previous case. A number of critics have argued, however, that any living situation where people are housed in large institutions is inherently destructive of personal growth. The present evaluation examines a sheltered village where a small number of mentally retarded people live and work in a supportive setting.

This chapter discusses medical issues related to behavior disorders of the mentally retarded child or adult. Psychopharmacology (i. e., the use of behavior-altering drugs, such as neuroleptics, stimulants, axiolytics, etc.) is not discussed here because this represents a whole area of study in itself. The present discussion is confined to those issues of medical diagnosis and treatment that have potential relationships to behavior and behavior disorders.

Self-injury and stereotypies are behavioral problems that have caused considerable concern and have received a good deal of attention in the child psychopathology literature. Similar etiologies have been proposed for both problems, and many of the overt manifestations of the conditions are similar. In this chapter, a review of these two conditions is undertaken, with a discussion of their similarities and differences, their prevalence, and their etiology, as well as some discussion regarding the evaluation of the conditions. Self-injury and stereotypies are found most frequently in particular subpopulations of handicapped children: visually impaired, autistic, and mentally retarded persons. For the visually impaired, the stereotyped responses in particular are evident. Also, there is an overlap of the autistic and mentally retarded groups. It is estimated that 70% of autistic persons also evince mental retardation. The mentally retarded group is subdivided into four groups: mild, moderate, severe, and profound. And the rate of these disorders increases as the severity of the mental retardation increases. Several proposals about this relationship have been made from an etiological standpoint. At present, these relationships are correlational only. Considerable future research will be needed to pinpoint precisely what causes and maintains self-injury in a given child. However, we do know that these problems are often idiosyncratic, so that explanations are difficult. Self-injury is the first area to be discussed.

Before World War II mental health services to the mentally retarded were virtually non-existent in Hong Kong and the task of caring for them remained the sole responsibility and burden of family members, (1). The latter tended to conceal their problems to avoid stigma and shame and confined the retarded at home segregating them from the rest of society.

The present project, entitled the Home Intervention Program (HIP), is an attempt to help fill the gap in services offered to individuals with mental retardation and emotional disturbance. The program model represents the unique combination of several distinct components: (1) services provided in the natural environment; (2) a husband-wife therapist team; (3) an eclectic approach to treatment; and (4) flexible time scheduling (i.e., time of day and amount of time).

The transition from institution-based services to community-based services has probably generated more controversy and opinion than any other single concept in the long history of public services for the mentally ill and mentally retarded.

In 1798, a young man who had apparently grown to physical maturity in the wild, without human companionship, suddenly appeared in a French town. Jean Jacques Rousseau’s concept of the “noble savage” was popular at the time, and the young man caused great interest. Adjudged retarded, he was given the name Victor and at first placed under the care of the physician, Phillipe Pinel, who specialized in mental disorders. Pinel, however, held the view that “idiocy” was incurable, and the French government subsequently allowed Jean Marc Itard to try to educate Victor. This effort was the first documented attempt at the education of a mentally retarded individual. Itard, who was aware of John Locke’s ideas concerning the intellect as a storehouse, went on to develop the first self-help activities for the retarded. He made skillful use of a system of rewards for performance—a form of positive reinforcement, as it would be called today. Although he had some success with Victor, the young man’s lack of speech development hampered Itard’s work with him. It is unfortunately impossible to judge whether, in today’s terminology, Victor would be called culturally deprived, emotionally disturbed, or just mentally retarded.