RATIONAL COMMITTEE FOR MENTAL HYGIENE, INC, REPORT OF ME-NTaL HYGIENE SURVEY OF KENTUCKY WITH RECOMMENDATIONS Report of The Mental Hygiene Survey of Kentucky with Recommendations Conducted by The National Committee for Mental Hygiene, New York City Thomas H. Haines, M, D. Survey Requested by Joint Resolution of the General Assembly Commonwealth of Kentucky February 27, 1922 November, 1923 THE STATE JOURNAL COMPANY Printer to the Commonwealth Frankfort, Ky. CONTENTS Page ADVISORY COMMITTEE FOR KENTUCKY MENTAL HYGIENE SURVEY 5 HOUSE RESOLUTION, No. 4 (KENTUCKY) 1922 8 SURVEY STAFF IC REPORT OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE Il State Expense for Mental Illness and Defect 14 The State Hospital Service 18 Training the Feebleminded .... 37 Methods of the Survey 42 Explanation of Terms Used to Designate Mental Diagnoses 44 State Penitentiary and Reformatory 48 Recidivists in Reformatory 54 Disciplinary Cases in Reformatory 58 Suspected Mental Cases at Reformatory 58 Inmates in Eleven County Jails... 67 Inmates in Eight County Almshouses , , 73 The Houses of Reform 78 Pauper Idiots in Jefferson County 91 Family Studies 97 Dr. See's Choreic Family .. 97 The Sh. Group 98 The W. Family-(Chart p. 102) 102 The P. Family-(Chart p. 110) 116 The H. Family 115 The K. Family 118 The iS. Family-(Chart p. 123) 123 Conclusions from Family Studies 129 Public School Children (874 Rural) in Four Scattered Counties.. 133 General Discussion of Mental Health Conditions, State Hospitals, The State Institution for Feebleminded, Defective Delinquents, Criminal Insane, Epileptics, Houses of Reform, The Reforma- tory and Penitentiary, County Jails, County Almshouses, Pub- lic Schools, Mental Health in Kentucky, Board or Commissioner of Mental Health 154 RECOMMENDATIONS OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE 172 MEMBERS OF THE ADVISORY COMMITTEE FOR THE KEN- TUCKY MENTAL HYGIENE SURVEY OF 1922 John M. Tinsley Barbourville Dr. Arthur McCormack Louisville Prof. George Colvin Frankfort Mrs. Churchill Humphrey t Louisville Judge Harry E. Tincher : Louisville Bishop C. E. Woodcock Louisville Rev. G. W. Schuhmann Louisville Rabbi Joseph Rauch Louisville Mrs. Chas. B. Semple Louisville Robert W. Bingham Louisville Harry Giovannoli Lexington Brainard Platt Louisville Dr. Irvin Abell Louisville Dr. W. E. Gardner , Louisville Mrs. J. G. Reynolds Paducah Dr. Frank L. McVey Lexington E. S. Tachau Louisville Judge Alex. P. Humphrey Louisville Miss Lucy Blythe Simms Paris Henry P. Barret' Henderson Judge Robert H. Winn Mt. Sterling Mrs. Lafon Riker Lexington Dr. Samuel H. Halley Lexington Fred M. Sackett Louisville Lewis Humphrey '. Louisville Senator White Moss Pineville Senator Robt. C. Simmons Covington Mrs. W. T. Lafferty ....' Lexington Mrs. Jno. D. Grayot .Madisonville Mrs. Robt. Lee Johnson Clinton C. G. Gladfelter Louisville Mrs. L. L. Robertson Middlesboro Mrs. Fannibelle Sutherland Paris Mrs. Mary Elliott Flanery Catlettsburg Senator Wm. L. Wallace ...Richmond Senator J. D. Whiteaker Cannel City Desha Breckinridge Lexington John E. Brown v. Shelbyville Senator J. Will Stoll Lexington Senator Chas. J. Hubbard Hodgenville Senator Newton Bright Eminence Frank Rives Hopkinsville Leon Lewis Louisville Dr. J. P. Stewart Farmdale Dr. Geo. P. Sprague Lexington Mrs. Benjamin W. Bayless Louisville J. P. Byers Frankfort "The prevention of at least a large proportion of abnormal mental states through the timely application of the principles of metal hygiene is now recognized as a practically realizable ideal. Many important reforms are now in process throughout the United States, no small part of them directly attributable to the active efforts of our leading psychiatrists and to our National Committee's work. The old "asylums" are being changed into "hospitals." Psychiatric clinics are being at- tached to teaching hospitals and psychiatric instruction in the medical schools is being vastly improved. The mental symptoms of disease now receive attention in hospitals and in private prac- tice and at a much earlier stage than formerly. Even the courts, the prisons, and the reformatories are awakening to the im- portance of scientific psychiatry; before long penology may be brought more into accord with our newer and juster conceptions of the nature and origin of crime, dependency, and delinquency. That schools of hygiene and the public-health services must soon fall into line and consider mental hygiene seriously is obvious. The objection sometimes made that the practical problems are too vague, not sufficiently concrete, to justify attack by public- health officials is no longer valid. In no direction, probably, could money and energy be more profitably spent during the period just ahead than in the support of a widely organized campaign for mental hygiene." Dr. Lewellys F. Barker in The Importance of Psychiatry in General Medical Practice, an address delivered at the Bloom- ingdale Hospital Centenary Celebration at White Plains, N. Y., May 26, 1921, and published as a chapter in A Psychiatric Mile- stone, privately printed by the Society of the New York Hos- pital, 1921. 8 REPORT OF MENTAL HYGIENE SURVEY HOUSE RESOLUTION NO. 4 (Passed at the 1922 Session of the General Assembly, Com- monwealth of Kentucky.) Resolution inviting1 The National Committee for Mental Hygiene to make a survey of conditions in the State of Ken- tucky. Whereas, the State of Kentucky is incurring considerable expense on account of its care and treatment of the feeble- minded and epileptic; and Whereas, there are thousands of people afflicted this way to whom the State has not given any aid and over whom the State has not assumed control in any way; and Whereas, the State is not in possession of sufficiently def- inite information as to the needs of the future; and Whereas, the future welfare of the State will be best sub- served by a thorough investigation along this line; and Whereas, The National Committee for Mental Hygiene has offered to make a survey of the State concerning the status of the feebleminded and epileptics, which survey would be similar to those they have made and are making in other States and which would involve no expense to the State except the use of suitable rooms for office purposes; and Whereas, a study and survey of the conditions and needs would materially assist the future legislature in determining a practical policy to be pursued in this matter; Now, Therefore, Be It Resolved, By the House of Rep- resentatives of the State of Kentucky, The Senate Concurring Therein; That The National Committee for Mental Hygiene be and are hereby requested to make a thorough investigation of the number and needs of the feebleminded and epileptic living within this State, and to make a report of their investigation, together with their recommendations, to the Governor and the next Gen- eral Assembly; and that the State Board of Health of the State of Kentucky be requested to co-operate with said National STATE OF KENTUCKY 9 Committee for Mental Hygiene, furnishing to them any neces- sary information in its possession; Resolved, further, that the Custodian of Public Buildings shall furnish said National Committee for Mental Hygiene such suitable offices and furniture as may be necessary for the time required in their work. James H. Thompson, Speaker of the House of Representatives. Thruston Ballard, President of the Senate. Edwin P. Morrow, Governor of Kentucky, Feb. 27, 1922. 10 REPORT OF MENTAL HYGIENE SURVEY SURVEY STAFF Harley A. Haynes, M. D., Director of the Division on Mental Deficiency of The National Committee for Mental Hygiene, planned the survey and carried out the work in the Houses of Reform, the State reformatory at Frankfort, and the peniten- tiary at Eddyville. In this work he was assisted by Frank J. O'Brien, Ph. D. Dr. Samuel W. Hamilton visited each of the three State hospitals. He reported upon the character of State care for the mentally ill and made recommendations for its im- provement. The work in the public schools, the family studies, and the county jail and almshouse studies were planned by Thomas H. Haines, M. D., who succeeded Dr. H. A. Haynes as director of the Division on Mental Deficiency in October, 1922. The following persons also took part in the field work. Arabelle J. O'Brien, M. D., Psychiatrist. Wilson K. Dyer, M. D., Psychiatrist. C. M. Elliott, Ph. D., Psychologist. Miss Bertha M. Allen, Psychologist. Mr. Frank H. Church, Psychologist. Mr. Carl G. Beck, Psychologist. STATE OF KENTUCKY 11 REPORT OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE The National Committee for Mental Hygiene has made two studies of mental-health conditions in Kentucky prior to this survey. In 1916 Governor Stanley, by direction of the General As- sembly, appointed a commission on provision for the feeble- minded, consisting of Mr. E. S. Tachau, chairman; Mr. Fred Levy, secretary and treasurer; Mrs. Morris B. Belknap; Dr. Henry E. Tuley; and Mr. Stuart Chevalier. The National Committee for Mental Hygiene accepted the invitation of this commission to make a study of the conditions of care and training of feebleminded persons in the State. This study was limited, by the terms of the resolution that author- ized the governor to appoint the commission, to five months. The field work was done for the most part by the author of the present report and the report was written by him.* It was pub- lished by the commission. The chief factor that stimulated the appointment of this commission and the making of the study was the so-called "Pauper Idiot Act." Under the terms of this act,t $165,000 was paid out of the State treasury in 1916 to the committees of 2,200 feebleminded dependents. Feebleminded dependents, who were receiving $75 each per annum, were visited by the di- rector of that survey in four counties. In these four counties there were 92 persons on the "pauper idiot" lists. Eighty-two of these were personally visited. It was found that only a por- tion of the State allowance actually reached the committee of the feebleminded person for whom it was allowed. Some of these State-supported mental defectives were kept at county poor farms. Others were let out to persons who would bid for their support. Some were kept in specially built outhouses like domestic ♦ Report of the Commission on Provision for the Feebleminded in Ken- tucky, by Thomas H. Haines, M. D., New York : The National Committee for Mental Hygiene, 1917. 23 p. t Subsidized Mental Deficiency. The Pauper Idiot Act of Kentucky, by Thomas H. Haines, M. D., Mental Hygiene, Vol. 1, pp. 274-78, April, 1917. 12 REPORT OF MENTAL HYGIENE SURVEY animals. The act, as administered, was found to serve as a direct deterrent to the proper training of mental defectives. The possibility of the State pension encouraged keeping the mentally defective person as dependent as possible. Many able- bodied persons, each quite capable of earning enough for his own support, if trained, remained untrained in order that their families might secure the State stipend. The feebleminded person was considered an asset in some families. The survey of 1917 comprised individual studies of the chil- dren in the Louisville Industrial School, in the Kentucky Houses of Reform, in the Kentucky Institute for the Blind, in the Ken- tucky State School for the Deaf, and in the care of the Ken- tucky Children's Home Society in Louisville. Studies were also made in Kentucky State Reformatory at Frankfort and in 17 county poor farms. There were found, in three State hospitals for mental diseases, 381 non-insane persons afflicted with epilepsy and 171 non-insane mentally defective persons. The "Pauper Idiot Act" ceased to function finally on June 30, 1922. A colony farm at Frankfort was purchased in 1920 and was made a part of the Kentucky State School for Feebleminded. In 1922, Dr. Harley A. Haynes, assisted by Frank J. O'Brien, two other psychologists, another psychiatrist, a psy- chiatric social worker, and five volunteer social workers in Louis- ville, made a careful study of mental-health conditions in that city for The National Committee for Mental Hygiene. The National Committee undertook this study as the result of a general invitation from the Welfare League of Louisville, from State and local health officers and nursing associations, from judges of county and city courts, from relief agencies, and from the Mental Hygiene Committee of Louisville. A careful study was made of 3,000 children in the public schools, 116 juvenile-court cases, and 177 individuals in homes for dependent children. Home conditions and neighborhood situations as bearing upon personality difficulties were care- fully studied, as were also the facilities and the procedure of each institution concerned. STATE OF KENTUCKY 13 It is clear that provisions for the State care and training of children who are feebleminded, of children who are delinquent, and of children who are dependent are intimately related tc problems of this nature in Louisville. If the State were making adequate provision for training mentally defective children, the problems arising from mental defect in Louisville would be fewer and they would be more easily dealt with. The mental-hygiene clinic recommended in Dr. Haynes' re port for Louisville, and its suggested relations to the public schools, to courts, to health organizations, and to other social! agencies, would be similarly serviceable all over the State. In dealing with social problems, it is commonly recognized as of fundamental importance to discover the personality difficulties involved. A health clinic should be so broadly conceived and planned that mental-health studies would be considered as neces- sary as tests for infection of the blood stream. Such health clinics, by analyzing personality difficulties, will lead to more constructive solutions of the social problems that arise out of mental deficiencies and personal peculiarities in rural districts aa well as in the city. 14 REPORT OF MENTAL HYGIENE SURVEY State Expense For Mental Illness and Defect It seemed desirable in this survey to review in a general way the conditions that have to do with mental health in Kentucky. For the first view of the matter we have made a study of State expenses in Kentucky for the year ending June 30, 1921 (the last available report). There are more persons in the United States occupying beds designed for those mentally ill than there are in all other hospital beds combined. That Kentucky has her share of these mentally ill persons is indicated by the fact that the three State hospitals and the institute for the feebleminded had a combined average daily population for the year of 4,845 and that these institutions cost the State the net sum of $1,136,- 108 that year. Table 1. Current Expenditures of the Commonwealth of Kentucky for the Year Ending June 30, 1921 Expenditures Amount Per cent for education: University of Kentucky, Normal Schools,. School for Blind and Deaf and Common School Fund $ 5,384,861.62 36.0 State road department 3,910,099.36 26.1 For mental diseases and defects: Three State Hos- pitals, Institution for Feebleminded (not count- ing cost of farm) "pauper idiots", conveyance of lunatics and one-half expenses of Board of Charities and Corrections 1,257,909.87 8.4 Tor delinquents in State institutions: Houses of Reform, Penitentiary, Reformatory, and one- half expenses Board of Charities and Corrections 536.448.42 3.6 For dependents: Children ($70,000), Confed- erate Soldiers' Home and Confederate soldiers pensions 462,581.13 3.1 Miscellaneous other expenditures 3,407,394.42 22.8 Total warrants issued, less revenue from institu- tions, federal grants and fire insurance paid. . $14,959,294.82 100.0 Table 1 exhibits the total net expenditures of the common- wealth of Kentucky for the year ending June 30, 1921, as accurately as can be determined from statements on pages 74-82 of the biennial report of the auditor of public accounts for the two years ending June 30, 1921. We have deducted from the auditor's statement of warrants issued such items as revenue derived from institutions and federal grants for education. In arriving at the total current net expenditures for mental diseases STATE OF KENTUCKY 15 and defects, we have deducted, from total warrants issued on the State treasury on account of the three State hospitals and the institution for the feebleminded, the pauper idiots, and the transportation of the insane, all the revenue derived from these institutions and also the cost of the farm purchased at Frank- fort for the institution for the feebleminded. The purchase price of this farm is not properly chargeable to current ex- pense of maintenance. The net expense for mental disease and mental deficiency is next but one to the largest single item in the State's expense. Education stands first, with about 36 per cent of the total expenditure. The State road department comes second with 26 per cent. Mental disease and mental defect con- stitute 8.4 per cent of the commonwealth's total expenditures. Kentucky in her early history was a leader in this field of mental health. In 1822 the State took over as a State asylum the Fayette Hospital, the first of its kind erected west of the Appalachian Mountains. Virginia established the first State hospital for the insane at Williamsburg in 1773. Kentucky's at Lexington was the second State hospital in the country. The institution for the feebleminded was established in 1860 and opened in 1861. (It had a population of 443 in 1920). Ken- tucky was the sixth State to provide State-institution training for mentally defective children. The first institution of this kind in this country was opened in Massachusetts in 1848. New York, Pennsylvania, Ohio and Connecticut followed, in that order. Kentucky has in a large measure avoided county care of the insane in county almshouses. The State has not been con- fronted with such problems in this field as have been faced by such States as Iowa, Maryland, New Jersey, Pennsylvania and Wisconsin. It is also a significant factor in the efficiency of State ministration to the needs of the mentally ill that Ken- tucky has avoided the part county pay system as it is now in vogue in Missouri and Tennessee. Kentucky as a State has provided care for the most pressing cases of poor persons who are mentally ill. She has done this for a hundred years. We might note in passing, however, that Kentucky in 1920 stood thirty-first among the States in the rate per 100,000 of 16 REPORT OF MENTAL HYGIENE SURVEY the general population of patients with mental disease cared for in State and private institutions specially designed for their treatment in the State. In Kentucky 171.9 persons per 100,000 of the general population were in such institutions, whereas in New York 374.6 persons per 100,000 of the general population were in such institutions. The average rate for the United States was 220.1 persons per 100,000 of the general population.* Mental defectives in State and private institutions in Ken- fucky specially designed to train them, numbered in 1920, 26.5 for every 100,000 of the general population. This ranked Ken- tucky as the twenty-eighth State in this respect. In Massachusetts 82.9 persons per 100,000 population were in institutions for mental defectives. In the United States as a whole, 38.3 per cent persons per 100,000 of general population were in such special" training institutions for mentally defective persons.* These figures demonstrate that the commonwealth of Ken- tucky is somewhat behind the average of the country and very much behind some of the States in the extent of the provision made for institution care of the mentally ill and for institution training of mentally handicapped persons. In still another way we may emphasize the more extensive care and training offered by some other States. In Massachusetts, for the year ending in 1920, 13.4 per cent of all State expen- ditures were for the insane, feebleminded, and epileptic.! One- sixth of the total expenses of the State of Illinois are for the insane alone.J In New York, for the year that ended in 1920, 15 per cent of all State expenditures were for the insane, feeble- minded and epileptic, and this excluded the hospitals at Danne- mora and Mattewan, since these institutions are under the prison department.! In comparison with this it is seen from the table that Ken- tucky, for the year ending in 1921, has laid out only 8.4 per * Patients with Mental Disease, Mental Defect, Epilepsy, Alcholism and Drug Addiction in Institutions in the United States, January 1, 1920, by Horatio M. Pollock, Ph. D. and Edith M. Furbush. Mental Hygiene, Vol. 5, ?»p. 139-69. January, 1921. t Report of Maryland Mental Hygiene Survey, by Thomas H. Haines, M. T>., Baltimore, 1921. p. 90. t Mental Health Bulletin. Chicago: Illinois Society for Mental Hygiene, lune, 1923. cent of her total State expenditures for maintaining the insane and training the feebleminded. Instead of the one and one- quarter million, therefore, that Kentucky spent in that year upon her feebleminded and insane, had she been doing as well by these cases as Massachusetts, New York and Illinois, she would have spent about two and one-quarter millions. In order to urge properly a general and large increase of expenditures in this field, it is necessary to consider carefully the ways in which the existing service can be rendered more effective. This was, as we understand it, the first objective that the General Assembly had in view when they invited the National Committee to undertake this survey. To these ends our activities in the field have been directed. STATE OF KENTUCKY 17 18 REPORT OF MENTAL HYGIENE SURVEY The State Hospital Service In visiting the State hospitals of Kentucky one is struck with the spirit of progress and hopefulness. These institutions have until recently suffered much from lack of intelligent in- terest on the part of the citizenry, resulting in political control and its consequences-inefficient and ignorant personnel, low standards of care and deterioration of plant. Much has been done in the last two years to restore the buildings of the hospitals to a State of respectable repair. The medical staffs have been built up by securing a few men with good training and putting them in charge of instructing physicians who are inexperienced in the diagnosis and treatment of mental disease. Nursing staffs have been somewhat strengthened. Measures have been taken to put the bookkeeping of the institutions into better shape so that the operations of storeroom, kitchen, laundry and mechanical departments may be more easily understood and supervised. Those who have led in this work seem to have enjoyed their labors of restoration and improvement and are hopeful that the process may go on for years. Sometimes they venture to hope that the hospitals will never fall back into the former lamentable state of political control and fiscal neglect. With all these advances a visitor should and does heartily sympathize. Our purpose here is not, therefore, to disparage the work already done, but to point out to those who control the finances and policies of the State some directions in which further progress needs to be made if the hospitals of Kentucky are to be as good as those of any State. Physical Conditions: The Eastern State Hospital is located at Lexington, the center of the rich blue grass district. This institution was founded in 1815 as a private institution called the Fayette County Sanitarium. The city now surrounds the hospital on three sides. Only 260 acres are owned, an altogether inadequate tract; 165 acres of fertile land are under cultivation. A pleasant lawn in front is used by the patients not only in the day time, but also in the evenings when moving picture entertainments are held.. There is also a little additional recrea- tion space between one end of the block and two outlying build- STATE OF KENTUCKY 19 ings. On the lawn are trees of mature growth and younger ones set out during a later period of activity. Various shelters are provided for patients who are taking their ease or watching games of croquet. The arrangement of the buildings is irregular. The earliest section of the main block, comprising three stories and a base- ment, was opened in 1817. It has been extended at various times. In one of the additions is the administration section. There is a separate two-story infirmary, a tuberculosis shack, and two buildings for colored patients, one of which is the oldest building on the premises. The cornerstone of this was laid by Henry Clay in 1815. There are also residences, a male attendants' home, a laundry, and farm buildings. A few buildings are of frame construction, the rest of brick with wooden beams. It is painfully obvious that these buildings are a great fire risk. Fortunately fire protection is liberally provided. Standpipes are equipped with hose which is tested every six months; buckets, five-gallon extinguishers, and a hose cart are provided, and best of all the city fire department is near by. A combined chapel and amusement hall is on the third floor of the administrative building. Fortunately it could be emptied rapidly. A great amount of painting and repair work has been done in the last two years and general conditions are fair. Light has been let into certain dark corners and further reconstructive work will be carried on. The city supplies water and sewerage connections. Fly screening is almost complete. Every ward has a bathroom equipped with either tub or spray. Toilet seats number only 130 for 1,373 patients. The laundry is of good size, but will bear enlarging soon. The ice plant supplies the hospital and a nearby reformatory. The Central State Hospital is at Lakeland, a village twelve miles from Louisville, reached by trolley and by railroad. Across its one street is the hospital with an attractive campus decked with flower beds and fine old trees and used freely by the pa- tients. The hospital owns 562 acres. It cultivates 350. The 20 REPORT OF MENTAL HYGIENE SURVEY land is fairly productive, but there is too little of it. Nine miles away is a colony on a beautiful tract of 280 acres. This was formerly a school for delinquent girls. This colony has an inadequate water supply and is far from a railroad; hence it cannot be extensively developed in the near future. About the campus are scattered buildings of various periods and a few others are tucked to the rear of the main group. There is an irregular block resembling somewhat a Kirkbride building, and others of various sizes and shapes. By all odds the best structure is the "Pusey" building. The dormitories hold from 6 to 107 beds and there are many small rooms in- tended for one patient and now holding two, three or four. A great amount of repair work and painting has been done in the last two years. There are still some floors that swell in hot weather, and other remediable defects in construction. This plant is burdened with much wretched old plumbing, including many three-seat toilets over a common trough, without vent, flushed occasionally by a hand-operated valve. Foul odors are not infrequent in these sections. Spray baths have been installed in all wards and are regularly used. Most of these buildings are quite inflammable, but much attention has been paid to fire protection, standpipes and ex- tinguishers, three hose carts and two chemical carts being avail- able. A fire did occur last winter and was well handled; the Louisville apparatus came eleven miles in twenty minutes. The chapel and amusement hall occupy the first floor of a building connected with the main block and could be easily emptied. Water is supplied from the Louisville mains and sewage passes through a new Imhoff disposal system. The ice machine is adequate and the laundry large enough. Fly screening is complete for the patients' quarters. The Western State Hospital is located two miles out of Hopkinsville. It is the best of the three hospital plants. The main block was opened in 1854. Seven hundred and sixty acres are owned, only 45 of which are good soil. There is an attractive lawn enclosed by a long iron fence. STATE OF KENTUCKY 21 Where the ground slopes upward from one end of the main block other buildings have been placed and those for negroes are behind the main block. The grounds here give a greater impression of spaciousness than is the case with the other hospitals. The general state of repair is good, though one building for male negroes is not yet in a creditable condition. Dormi- tories hold from 4 to 39 patients. Fly screening is complete. Every ward has a water-closet and bathroom. Spray baths have been installed in half the wards but some are not used. The number of toilets, as in the other hospitals, is inadequate. Some buildings are of frame, others of brick with wooden beams. All are inflammable. There are standpipes at most of the important places, hose tested every two years, extinguish- ers and two chemical tanks, one of them in a basement some- what cluttered with benches and other obstacles. Patients go down the spiral chutes every week. The laundry looks to be somewhat small. All stockings and socks are washed, dried and hung in the wards. The negro women wash their own dresses. This hospital has eight residences and an unusually good dairy barn. Water is supplied from a stream on the premises and pumped to a settling tank. Medical Staffs: Anything that hospital patients receive beyond bed and board-in other words, all treatment-depends on the number and quality of the physicians. A well-balanced medical staff comprises physicians both young and old, the older ones well trained and with long experience in mental diseases, the younger ones with various special interests, but all studying problems in mental diseases under the instruction of their seniors. In recent years, especially since the war, the demand for physicians with good training in mental diseases has greatly 22 REPORT OF MENTAL HYGIENE SURVEY increased. Hospital managements that have any ambition to hold their ablest and best trained physicians have found it neces- sary to put salaries at figures comparable to the income from private practice or the emoluments of government service, pub- lic health activities, and various types of hospital practice. In the hospitals of some States there are several grades of medical salaries, depending on experience and knowledge of this specialty. The position of hospital physician in Kentucky has been held in light esteem. Until recently superintendents were appointed absolutely without training in mental diseases or institution management. Their salaries were small and the salaries of their assistants far from attractive. The State has now embarked on a policy of giving real treatment to its patients and has made some slight increases in the salary schedule for physicians. The salary of a physician who is just beginning his work is $1,200 a year and maintenance. The maximum received by an assistant superintendent is $2,200. Very few young men are entering the service and it is safe to predict that able super- intendents will not remain indefinitely at the sum set for them. All three superintendents now have comfortable quarters but no other members of the medical staffs are well housed. The medical activities of these hospitals were so meager in former times that the training given to an inexperienced physi- cian may be disregarded. Each superintendent under the present regime has secured an assistant from another State. One of these well-trained men has already left for a more attractive position and has been replaced. It is to be hoped that induce- ments will soon be offered sufficient to hold such men and bring in more until the time comes when Kentucky will be able to give adequate training in mental diseases to its own physicians. The number of patients to which a physician can give ade- quate personal attention in addition to his other duties is on STATE OF KENTUCKY 23 the average about 150 in mental hospitals. Where outside work, such as clinics, has not been developed an average number of not more than 200 patients to one physician should be established. The following figures show the situation in the three State hos- pitals in Kentucky: Physicians and Patients in Kentucky State Hospitals Physicians Patients Ratio to patients Eastern 5%* 1383 1 to 251 Central 7 1907 1 to 272 Western 6%* 1419 1 to 218 There is much to be praised in the attitude of the present medical staffs toward their work. Medical work appears to be best organized in the Central State Hospital. In all three in- stitutions staff conferences are regularly held for the examina- tion and discussion of the patients' cases. A laboratory is main- tained in each hospital. Post-mortem studies are infrequent. Medical libraries are poor. Little out-patient work is done, but the Eastern Hospital, in pursuance of its policy of establishing close relations with the community, assists in the diagnosis of various conditions at a regular time weekly. Nursing Services: In the effort to secure for mental patients the same high type of nursing that is demanded for those ill from other diseases, various types of training school have been devised during the last thirty years. Kentucky was reached by this movement and schools were maintained for a time in the State hospitals. These are no longer in existence. Where a number of graduates are still in the service-instance particu- larly the Central State Hospital-their effect in holding up nursing standards is evident. In this connection it must be remarked that the number of ♦ One physician gives half time to hospital. 24 REPORT OF MENTAL HYGIENE SURVEY ward employees is less than in the best institutions. The follow- ing table indicates how this matter stands at present: Table 2.-Ward Personnel and Patients, Kentucky State Hospitals Eastern Central Western State State State Total Hospital Hospital Hospital Male Service Supervisors 10 3 4 3 Charge attendants .... 25 9 10 6 Other attendants Total nurses and 107 27 44 36 attendants 142 39 58 45 Number of patients ... Patients to each nurse 2,535 787 1,034 ' 714 or attendant 17.9 20.2 17.8 15.9 Female Service Supervisors 10 4 3 3 Charge attendants .... 31 14 11 6 Other attendants 113 26 49 38 Total nurses and attendants 154 44 63 47 Number of patients . . . Patients to each nurse 2,174 596 873 705 or attendant 14.1 13.5 13.9 15.0 Total nurses and at- tendants 296 83 121 92 Total number of • patients 4,909 1,583 1,907 1,419 Patients to each nurse or attendant 16.6 19.1 15.8 15.4 Of this nursing staff only fourteen are graduate nurses. Of these, ten are at the Central State Hospital, three at the Western and one at the Eastern. The care of patients in these hospitals will not meet the best present-day standards until the ward personnel is organized with competent persons, specifically trained in general nursing and mental nursing, at the head of the ward personnel as executives and instructors, with courses arranged to meet the needs of the institutions, open to all ward employees and required to some degree of all, and with an at- mosphere in which sympathetic study of the patient will be a natural part of the work of the attendant. Unless we under- stand our patients we cannot give them proper care. It is to be hoped that excessive hours of duty will be de- creased. We cannot expect much activity on the part of at- STATE OF KENTUCKY 25 tendants who are continuously on duty for fourteen to sixteen hours; instead of working a great deal with her patients the attendant merely watches them. Better service can be required when hours of duty are not excessive, but hours cannot be re- duced until the number of attendants is increased. The Western Hospital seems to have least difficulty in se- curing desirable attendants. It possesses the only employees' home for women. The Central Hospital has no more quarters for employees, hence does not try to increase its ward personnel. The Eastern Hospital has a comfortable home for its men. Reception Service: In the best hospital for mental diseases it is customary to have the reception service at a little distance from the wards in which the protracted cases are quartered. This gives the new patient a better opportunity to adjust him self to the situation, saves him from some disagreeable sights, and protects him from having to listen to the fears and sus- picions of a certain type of patient always to be found among chronic cases. In all three Kentucky hospitals the reception service is in the main block, or in a building with other wards. New patients are surrounded by older ones and at mealtimes must sit with several hundred others. The reception services are not provided with many special facilities for treatment. No physicians are assigned specially to this service, but any working here is also responsible for other wards. No physician's office is located in the reception ward, an arrangement that aids the doctor to spend more time with new patients and watch more closely what they do, say, and think. Medical Wards: The physically sick are in each hospital assembled to a greater or less extent in certain wards. There are not enough of them to need a physician on duty in this service alone. In the Eastern and Central hospitals a graduate nurse is in charge of the physically sick men. Surgical Wards: There is not the best provision for sur- gical operations, though these are necessary every now and then in a mental hospital as elsewhere. There are operating rooms, however, which can be used for this purpose. 26 REPORT OF MENTAL HYGIENE SURVEY Provision for Tuberculous Patients: A considerable num- ber of mental patients have tuberculosis. Insane women whose mental illness lasts several years are more liable to this disease than men, apparently because they lead a less active outdoor life than male patients who can be employed on the farm and grounds. Special provision has been made in each of the hos- pitals. In the Eastern State Hospital there is a fairly good frame structure for eleven patients of each sex. The Central State Hospital has a very attractive tuberculosis building, plan- ned on the lines of the best sanitarium construction at the time this was built. The Western State Hospital has a considerable unit with capacity for more than 45 men and 92 women; this is far more than is needed, and most of the beds are occupied by non-tuberculous patients. The situation is not satisfactory in any of the three hospitals in that there is no good provision for disturbed patients with tuberculosis-the ones who spit promis- cuously and menace the health of others. Furthermore, there is no active anti-tuberculosis regimen. The Disturbed: A striking fact is that there are fewer dis- turbed patients in the Kentucky institutions than would be ex- pected in hospitals of the same size whose population comes from the large cities of the northeastern and northern States. There are no wards specially designed for their care, but in each hospital they are grouped in certain convenient places. The Infirm: Aged and infirm are found in various wards. Epileptics: Epileptics are to a considerable extent cared for in special wards. Such an arrangement is desirable when the number is large enough so that they can be divided into sub-groups in accordance with their standards of conduct. Negroes: The number of negro patients is much smaller than that of the whites and largely on this account they are not very well classified into groups according to conduct and mental attitude. The Western Hospital is best equipped in this regard. Isolation: Contagious diseases occur now and then and some place for treatment is improvised. Only two years ago there was a considerable number of cases of smallpox, but the STATE OF KENTUCKY 27 vaccination done in that period and since gives a considerable degree of protection against another outbreak. Open Wards: The Central State Hospital has four open wards (wards left unlocked during the day time) beside its colony. The Western State Hospital has nine such wards. Dispensary Treatment of Early Cases-. This subject has been under consideration by the State Board. There are not many physicians on hospital stall's who have yet had ex- perience and training to fit them for this important work, but when the staffs are strong and stable great benefit can be brought to many communities by putting at the disposal of schools, courts and welfare agencies the services of psychiatrists from the State hospital staffs. Conveying Patients to the Hospital: Kentucky has a high- ly commendable law providing that a patient committed to a state hospital shall be conveyed thither by a competent at- tendant from the hospital. Some patients are brought to the hospital by their friends-an unobjectionable procedure-and some are brought in by sheriffs. This last arrangement is bad, for sheriffs as such have had no training in the care of the mentally sick. Kentucky is to be praised for providing skilled care during this very difficult transition period in the patient's career. It is probable that more patients are brought to the Eastern State Hospital by sheriffs than to both the Central and Western, since the district of the Eastern Hospital covers so many mountain counties. Restraint and Seclusion: Restraint and seclusion should be considered as types of treatment prescribed by a physician to meet certain definite indications and when so handled these measures may serve therapeutic purposes. Their general em- ployment, nevertheless, is a holdover from the standards of the almshouse and jail and, when much used, they indicate willing- ness on the part of physicians to allow the welfare of the patient to be settled on the basis of the convenience of a caretaker. These measures are not infrequently resorted to as an easy way out of a difficulty, rather with the definite purpose of helping a patient. The State Board of Charities and Corrections no 28 REPORT OF MENTAL HYGIENE SURVEY longer requires reports on this subject and the position they take in the matter is entirely correct; these are things that only the superintendent can decide, since the professional organization of the service does not extend into the office of the State Board. The matter is considered less seriously in some hospitals than in others. It is of course unfortunate that any patient may be kept for months at a time in a small room, nor can the observer take pleasure in seeing men walking about hospital grounds handcuffed, though this measure is preferable to keeping them indoors. "Seclusion" has been defined as confinement alone in a room during the day time; therefore not technically included in re- ports of seclusion are hundreds of cases of patients who are locked in their rooms overnight. Sometimes one patient is in a room alone, sometimes from 2 to 20 are locked in together. After making night rounds in each one of these hospitals one comes away somewhat depressed by the thought that so many patients must thus be shut away during sleeping hours. This is not good treatment. Further it is not possible to maintain the best sanitary standards under a system where the night vessel has such wide employment. Two things are necessary in order to change this: first, the assistant physicians in charge of the various services must be convinced that the present system is undesirable, and second, a nursing personnel competent in quality and numbers must be provided to care for and supervise these patients during the night hours. Care at Night-. Night supervision is apparently adequate on some services, but elsewhere such is not the case. That a male employee should be leaving the door of a women's ward at 11:45 P. M.; that a strap should be used by an attendant during a difficulty with a patient at midnight; that the only at- tendant in a building should be locked away from all the pa- tients; that a supply room with a poison bottle in plain sight should be open to any person in the ward; that a kindly but ignorant night attendant should have no thought even of straightening the sheet for patients whom he recognizes as dy- ing-such things indicate the need for better standards of night nursing. STATE OF KENTUCKY 29 Hydrotherapy: Hydrotherapy is almost totally in abey- ance in Kentucky. They are many bathtubs, but they are used only for cleansing purposes. The Western State Hospital has one douche apparatus, but it is little used. The importance of the prolonged bath in cases of excitement and anxiety, and the value of douches systematically administered in cases of mental inactivity, are too well known to justify the continuance of their neglect. At this point it might be noted that the number of disturbed patients in these hospitals, either by day or night, seems to be very small, a situation differing markedly from that in many institutions further north and east and quite resembling the ease in Colorado where the clearness and coolness of at- mosphere are thought to reduce the amount of disturbance. Even so, there are patients who would be benefited by the pro- longed bath and many whose sluggishness might be lessened by suitable douches. A certain amount of apparatus is necessary for these purposes, but the principal needs are physicians with convictions on this subject and attendants with a degree of special training. Occupation of Patients: In poorly managed asylums a great many patients are idle. Mental disease often tends to lessen a person's ambition and make him satisfied with brood- ing and daydreaming in place of healthy activity. It is of very great importance to encourage patients to useful activity. Every progressive hospital employs what is known as "occupa- tion therapy" or "diversional occupation", and it is of special importance in mental hospitals. All three hospitals have embarked upon a course of occupa- tion therapy. Perhaps the greatest vigor in the matter of pro- duction has been displayed at the Eastern Hospital. All three, however, need greater activity in order to reach more patients, and the Central and Western will need a larger salary allowance in order to obtain persons of good training to head this work. It may also be remarked that the greatest amount of produc- tion may not involve the employment of the largest number of patients. Every mental hospital should have an occupational center, and inevitably a considerable number of beautiful and useful articles will be produced. Then as soon as possible the 30 REPORT OF MENTAL HYGIENE SURVEY work should be extended to the wards where the untidy, the restless, and the indifferent patients are quartered. In over- coming bad habits occupational therapy has achieved its crown of results. Radiotherapy: The use of the X-ray in diagnosis and treat- ment has received attention in these hospitals and will un- doubtedly be carried further if the State assures such a degree of stability to the medical staff that a man who has familiarized himself with these special processes is not promptly lured away by the advantages of private practice or the larger salary of hospital service elsewhere. Libraries as Therapeutic Apparatus: The use of the library, not simply as a collection of books which a particularly interested patient may consult, but as a definite means of treatment of mental apathy, has been taken up of late years in several places to very good effect. The Veterans' Bureau hospitals have per- haps led in this matter, but equally important work has been done at Chicago, Illinois, and Worchester, Massachusetts. This work has not yet been attempted in Kentucky. More periodical literature might be used in the wards. A librarian would of course have this matter in purview. The Chaplain: Sunday services are commonly held in all three hospitals. A chaplain who combines the gift of brief and interesting speech with a willingness to study the mental state of his parishioners in a mental hospital is often a valuable adjunct to the therapeutic agencies. If the chaplaincy in these hospitals were to include some responsibility for ward visita- tion over the period of several weeks during which the chaplain serves, in addition to his delivering a stated number of dis- courses, the service would probably be more satisfactory both to the clergyman himself and to the officers of the hospital. Compensation should be in accordance with duties. Amusements'. The means of diversion have been consider- ably developed, but might be still further extended. Parole and Discharge: A considerable number of patients in each hospital have ground privileges. In the Central Hospital STATE OF KENTUCKY 31 they are required to carry identification cards. The degree of improvement which makes leaving the hospital desirable is passed upon in all these institutions by a staff conference, and a considerable number are paroled before final discharge. Medical Records: One way of securing better individual treatment is to have better medical records. The question is sometimes asked what advantage comes to a patient through a medical record; the answer is not far to seek. Only one of those rare persons possessed of a comprehensive memory for details can carry in his mind the histories of two or three hun- dred patients. The treatment of a patient in a hospital must be a matter of collaboration and only through a careful system of records is such a collaboration possible. Business houses, fac- tories and farmers have their own system of accounting; so does the practice of medicine. The profits of a mental hospital are the recoveries and improvements secured among the patients, and only by a good record of the progress of a patient under treatment can the best results be obtained. At present it is customary in these hospitals to record a mental examination not long after the patient's admission and to make a variable number of notes. These are of varying degrees of excellence. Physical examinations are recorded on a blank which is altogether too rigid. At the present time the records of the Central State Hospital surpass the others by a considerable margin, but all have improved vastly on the standards of a few years ago. Social Service: Social service for mental hospitals involves several functions: (a) The supervision of a patient at home on parole before his final discharge from hospital care; (b) the study and supervision of dispensary cases when a hospital is maintaining an out-patient department; (c) obtaining all in- formation about a new patient from home and community sources; (d) establishing friendly contacts with relatives, friends, and agencies so as to make the patient's return from the hospital easier and to increase the likelihood of his remain- ing at home. An especially interesting attempt to develop social service has been made in the Eastern State Hospital, which has gathered under the direction of an experienced field organizer a group 32 REPORT OF MENTAL HYGIENE SURVEY of young women in or just out of college. If the necessary in- struction and supervised experience can be obtained for these young women, they should become thoroughly competent social workers. The other two hospitals have one social worker each. Emphasis is laid on the different aspects of work in the dif- ferent hospitals. The Eastern specializes in establishing cordial relations with local officers and gathering concise information about its hundreds of patients on whom almost no records existed until two years ago. The Central Hospital, in view of its overcrowding, is concerned particularly about making con- tact with homes to which patients can go. The Western Hos- pital aims primarily to secure information about incoming patients. All these are important projects and no less atten- tion should be given to them in future than at present. It is of quite as much importance to develop skilled supervision of the patient who is out of the hospital on visit and assistance for him in the problems that he may have to face. This work should be expanded at as early a time as possible. Service of Food: The food was well prepared and abund- ant. Its service varied in different places. Most of the patients in this State now eat off good stoneware plates. Some have a side dish, so that it is not necessary to mix incongruous articles of diet. All who should be are supplied with cutlery. Dining Rooms : In some of the larger dining rooms music is provided at certain meals. The most attractive special build- ing for this purpose is the one at the Western State Hospital erected during a superintendency which seems to have been marked by progress in several directions. The Central State Hospital has recently developed some commodious basement din- ing rooms which will serve their purpose quite well for some time. The Eastern Hospital is using certain third-floor quarters for these purposes. It is desirable that in each hospital there should be a just balance between large and small dining rooms. Huge assemblages of patients are to be deprecated, but an un- limited number of small dining rooms cannot be properly super- vised. Dietitian's Duties: The preparing of diets, the checking STATE OF KENTUCKY 33 up of waste and its sanitary care before removal are not en- tirely well performed. The value of the trained dietitian has not been everywhere appreciated. The State provides a con- sulting dietitian, but insists that the local work-which is of course the most extensive and important part of dietary over- sight-be left for the most part to persons with an inferior type of training. The wisdom of loading such responsibilities onto a matron or cook is very questionable. Clothing and Bedding: Day clothing is generally adequate and good. Few of the patients sleep in nightgowns. Shoes seem sufficient and the barefooted are so by choice. Beds are comfortable. The straw tick, generally discarded a generation ago, has been rediscovered and is highly praised because it is easy to renew. No method has been found to secure uniformity of size. A row of beds with mattresses of varying heights does not make a tidy looking dormitory. A sufficiency of quilts and blankets is reported present or already ordered for each hos- pital. More rocking chairs would doubtless be welcomed by the patients. Building Program: To a large extent these hospitals have grown without a definite plan. The Commonwealth of Kentucky should now determine its policy and not build further on the hit-or-miss plan. There is no doubt that provision for many more mental cases will be demanded within the next two or three decades. As hospital methods of treatment improve, more patients are entrusted to mental care; as the drift to the cities continues, more persons whose abnormalities are not objection- able in the country must become patients in mental hospitals be- cause they will annoy denizens of closely settled neighborhoods; and with the increase in the span of life (it has arisen from an average of 48 to an average of 60 years during the present generation) mental diseases of middle life will occur in & greater number of persons and will require hospital treatment It would be unfortunate to allow the state hospitals of Ken- tucky to grow much larger. A hospital of 1,500 patients is large enough to secure economy7 in administration and further increase means duplication of many functions. It is time, therefore, for the State to consider whether land should not be secured for 34 REPORT OF MENTAL HYGIENE SURVEY another hospital. At the present time land is relatively cheap. The State would probably do a good piece of business by securing one or more sites now, leaving them to be developed a few years later when building costs may not be excessive. Another question should be considered at the present time, namely, the gradual abandonment of the plant at Lexington. If a site of 1,000 acres were now to be secured in the same district, perhaps near Winchester or some other convenient railroad center, building construction could proceed at a leisurely pace and by the time the State is ready to leave the present site its value for residence and manufacturing purposes would possi- bly equal the cost of the land for the new institution. The present institution is old and many parts of it are undesirable for hospital uses. Furthermore, the city is crowding it. As to the need of addition and reconstruction a few words may be said. The plant at Hopkinsville is altogether the best of the three; a good reception building at a little distance from the main group would improve its usefulness. The crying needs of the Eastern and Central hospitals are homes for women em- ployees. The Central Hospital also needs a considerable amount of plumbing. Neither the Central nor the Eastern Hospital has enough land. The Central Hospital to be sure has a colony which can be used to some extent for farming, but it is so far from a railroad that no great number of patients can be sup- ported on it in the near future without considerable expense for hauling coal and supplies. Future Changes in Organization: The present-day organiza- tion has done much for the mental patient and its achievements are viewed most sympathetically by The National Committee for Mental Hygiene. It is not suggested that hasty changes be made in the law. Certain matters, however, should be pointed out at this time in order that they may receive attention when any statutory revision is in prospect. With the growth of the work of the State hospitals, both within and without their walls, the State will need at the same time to provide a greater degree of expert supervision than has ®ver yet been attempted. It may be that in time a commissioner 35 STATE OF KENTUCKY of mental health will be needed to divide the work with the present commissioner of institutions. This matter should be under consideration as the work develops. It may be proper to emphasize further one point in relation to the work of these hospitals. There is one wide-open way te increase the efficiency of the present service of the State hos- pitals without adding to their expenses. Should the State in- augurate an effective social service and institute a parole and community-clinic program such as exists in some of our State hospitals, it would be possible to shorten the residence of many patients, thus decreasing State expense, accelerating the re- covery of patients, and increasing their happiness and efficiency. Dr. Steckel has shown that at the King's Park State Hospital (N. Y.) in the year ending June 30, 1921* with the social- service department costing $14,411, a net saving of $128,614 was effected to the hospital by the paroles arranged for and super- vised through this department. He further shows that 280 of the 669 patients paroled during this year earned $134,344. It is well recognized that the highest service of our hospitals for mentally ill persons, like that of hospitals for other sick people, consists in the restoration of the sick to health. It is equally well recognized that occupation is one of the best thera- peutic agencies for restoring mental health. It is a matter of the highest importance that the mental patient who is recovering should be taken out of the institution and restored to a vocation and to normal life in a family and that he should assume the direction of his own activities at the earliest possible moment. Such removal from institution life is an important part of the rehabilitation of his personality. The social service that is di- rected to the early parole of the patient through careful selec- tion of a home and an occupation for him, and through oversight of his life as he makes a fresh start outside the institution, is of *The Social-Service Department and its Delation to an Extensive Paroh System, by Harry A. Steckel, M. D. Mental Hygiene, Vol. 6 pp. 798-81< October, 1922. 36 REPORT OF MENTAL HYGIENE SURVEY much more vital significance than is indicated by the figures quoted above from the King's Park State Hospital. The thera- peutic value to the patients themselves, and therefore to the community, cannot be stated in terms of money values. There are transcendent spiritual and moral values. STATE OF KENTUCKY 37 Training the Feebleminded The State Institution for the Feebleminded at Frankfort has undergone considerable growth in the last decade. This growth is an expression of the State's meeting of the increased demand made upon the institution for the kind of service it is expected to render-the training of mentally defective children. The following summary gives the average daily number of pa- tients cared for in this institution from July 1, 1910, to June 30, 1921, and the per capita cost of maintenance during this period. Average daily Per capita cost Fiscal Year population of maintenance 1910 214 $166.27 1911 248 153.83 1912 285 140.79 1913 308 153.73 1914 315 162.38 1915 328 182.75 1916 351 161.51 1917 398 186.98 1918 369 235.58 1919 398 234.32 1921 417 306.23 A training school is now in operation. About half the pupils are attending school. The school facilities are very inadequate. There are no proper rooms for school purposes. The training work is carried on, therefore, under serious handicaps. That this training has been instituted reflects great credit upon the management. In order to do the constructive work in training these mentally handicapped children that the people of Kentucky have a right to expect of it, this school has imperative need of increased equipment in buildings and in personnel. The dining room and kitchens are good. Good food is well prepared and served attractively. The children are well nourished. But the dormitory facilities for both boys and girls are poor of their kind and poorly adapted to the use in- tended. Better facilities for medical and all examinational work are seriously needed. A larger hospital, another physician, and a psychologist are needed also. Housing facilities for teachers and attendants should be provided. The institution 38 REPORT OF MENTAL HYGIENE SURVEY should be equipped with social service to supplement its examina- tional and training facilities and to facilitate the parole of pupils and their establishment in community life. The purchase of the farm for the institution for the feeble- minded, the building that has already been effected and that is planned on this farm, and the final annulment of the ' ' Pauper Idiot Act" and its worse than useless drain upon the State treasury, are all to be most highly commended. Kentucky has taken a decided step forward in each of these procedures. Fa- cilities for the more extensive use of the institution farm and for establishing other colonies, some for girls and some for boys, in various parts of the State should now be developed. A colony offers a useful halfway station between the training school and the community.* It is an experimental proving ground for the adolescent mental defective with a personality equipment that may enable him to get along satisfactorily outside the in- stitution. The most important feature in connection w7ith the com- munity management of mentally defective persons in modern democratic society is that as nearly all the people as possible shall understand what mental defect is. It is important that the people generally shall realize that the feebleminded are children, that the rest of us must assume responsibility for them and must help them as we help children. After we have trained them so that they have developed the best personalities possible with their limited congenital equipment-wThich means after they have formed habits of cleanliness, industry, thrift, and self- respect-it is necessary for some person or persons in the com- munity to assume responsibility for each one of them much as a father assumes responsibility for his child. This means that mental hygiene must be taught in the public schools today, that we may have a community in which real understanding of the problem of feeblemindedness shall prevail twenty years hence. When the whole community does understand the mental hygiene of feeblemindedness and all are ready, therefore, to * Twenty-eighth Annual Report of the Board of Managers of the Rome State School at Rome, N. Y., for the year ending June 30, 1922. See also Social Control of the Feebleminded, by Stanley P. Davies, Ph. D. New York: The National Committee for Mental Hygiene, 1923. pp. 108-170. STATE OF KENTUCKY 39 recognize the lack of capacity for development of these "chil- dren" and to help them, the community will have much less difficulty and expense on account of the feebleminded persons residing therein. When such an understanding of community responsibility prevails, continued institutional life will be neces- sary only for those who have vicious habits that have not been corrected and for those who lack self-control to such an extent that the restraint of an institution constitutes the only means of preventing antisocial behavior. Such a logical conception of the management of mentally handicapped persons at once throws a greatly increased burden upon the State institution for the training of mentally defective children. It also expands the field for this training work beyond the possibility for its being completely covered by State board- ing and training institutions. The brunt of the burden of special education of mentally handicapped children falls directly upon the public schools. The State training institution or institutions can be- expected to assume the training work only for those whose cases present problems impossible of solution and manage- ment in the public schools and in their own homes. Such a con- ception, however, of the increased educational activity that is necessary in order to secure satisfactory control of mentally handicapped persons leads inevitably to the closest possible rela- tionship between public school officials, boards of education, superintendents and teachers, the State authorities in charge of State training schools, the State board of charities and cor- rection, and the superintendents and personnel of the institu- tions. Thq present budget of the institution for the feebleminded at Frankfort evidences an all too weak effort on the part of Kentucky to deal with the social problems involved in congenital mental defect. Plans should be laid for spending at least as much for the proper training of mentally defective children as is expended in the attempt to rehabilitate the mentally diseased. Kentucky spent, in 1920-21, more than one million dollars on the patients in the three State hospitals. The average daily population in these three institutions was 5,428. There are more than 5,000 children and young persons in Kentucky so hand- REPORT OF MENTAL HYGIENE SURVEY 40 icapped mentally that they need specially adapted training facilities to make them not only harmless to the community, but to varying extents contributors to community life. From the point of view of prevention, which is the great ob- jective in the field both of mental disease and of mental defi- ciency, it is necessary to consider how these mental factors op- erate and to what extent they operate in producing problems for the State, for counties, and for local health authorities and social agencies in the way both of dependency and delinquency. Re- ferring again to Table 1, we find that delinquents actually in institutions operated at State expense cost the State in 1920-21, above all the revenues derived therefrom, the net sum of $536,- 448. This amount constitutes 3.6 per cent of the total State expenditures for that year. Our survey results will demonstrate how much of this expense is due to mental-health problems and how far these problems are being intelligently met. We find also that the State expended for children and Con- federate soldiers that year the net sum of $462,581, or 3.1 per cent of the total State expenditures. The care of dependents is left largely to counties, cities, and the smaller political divisions. Much of the burden is borne by private philanthropic agencies and institutions. Notwithstanding this fact, however, the com- monwealth of Kentucky spent upon delinquents and dependents in 1920-21 nearly a million dollars, or four-fifths of the amount spent upon the mentally ill and the mentally defective as such. On account of the important role played by mental factors in dependency and delinquency, the field work of the survey was devoted largely to a study of the populations of State and county institutions. Studies were made in the penitentiary, the State reformatory, county jails and almshouses in various regions of the State, and the Houses of Reform at Greendale. Advantage has been taken of studies made of the pauper idiots in eJefferson County under the direction of eJoseph P. Byers, Commissioner of Public Institutions. In order to get a general view of the extent and kind of mental-hygiene problems existing in various communities, studies were made of public school children in four different counties in STATE OF KENTUCKY 41 the State. These public school studies were made also for the reason that the best expectation of substantial betterment of mental conditions in any community lies largely in ascertaining the conditions of disease and deficiency among the children of that community. In fact, we are seeing now the high im- portance of such corrective work even in the pre-school years. But the school affords the opportunity of getting at all chil- dren when they reach the age of six. There is no reason why the public school should wait until six to begin to exert its in- fluence on the developing personality. It is, however, far from doing the best now possible for the child even from six to four- teen years of age. Studies of school children may be expected to reveal certain facts necessary for planning a thoroughgoing state-wide pro- gram for the improvement of mental-health conditions. 42 REPORT OF MENTAL HYGIENE SURVEY Methods of the Survey In all institution studies, whenever it was possible, and in the studies of school children, the first procedure was to give a group intelligence test. The Pressey and National Intelligence tests were used in this survey. These tests enabled us to ascertain roughly the mental age and grade of intelligence of each per- son in the group. In using group intelligence tests, one must constantly bear in mind the possibility of any given individual's making a showing lower than that to which his native ability en- titles him. On the other hand, with a well-standardized test and conditions properly controlled while the test is being given, so that each paper represents only the work of the individual whose name it bears, no one can make a better showing than that to which his native ability entitles him. Another preliminary step in each group study consisted in securing a personal history of each individual in the group. An endeavor was made to secure information as to the nativity of the person himself and of his father and mother, his race, history of his family, a brief history of his physical development, and information as to his present physical condition, including his height in inches and his weight in pounds (in the case of a school child). We also gathered information as to school progress-what grades, if any, he had repeated, and his present advancement in school subjects. In the case of school children we secured the teacher's opinion of the native ability of each. We particularly requested information from teachers, superin- tendents, wardens, and other custodians in regard to the make- up of each personality. We asked for an underscoring of character traits, desirable and undesirable, on the record sheet for each individual. By means of these two lines of approach we were enabled to pick out in each group a smaller group comprising the problem personalities. In some cases these would be 70 per cent of the whole group, in others not more than 5 per cent, as in some good schools. These problem personalities we studied more minutely. Many of them were given individual psychological examinations. The test used was the Stanford-Binet. STATE OF KENTUCKY 43 We considered social, economic, and physical factors quite as important as an intelligence rating in assessing the person- ality. All these various lines of study were made to converge upon the diagnosis. The mental diagnosis represents our best attainable statement on personality make-up. With the evidence in hand from the nature of the conditions under which the work was done, it must be recognized that some of these diagnoses must be considered provisional. To arrive at fairly satisfactory conclusions in regard to many such persons, more time and more varied lines of observation and experimentation are required than wrere available in such field work. In some situations it is quite impossible to give any sort of formal test or make any satisfactory examination. In county jails one must frequently converse with prisoners through the iron bars that separate the cage from the rest of the inclosure, and several men may be standing in close proximity to the one with whom conversation is in progress. The cage is so small that it is impossible to secure anything approximating a private inter- view. Diagnoses made under such circumstances are even more provisional in character than those made in the public school or in a larger institution where better conditions are obtained for the studies desired. County-almshouse inmates are rarely studied under as favorable conditions as obtain in a penitentiary. The aim of the study of each person comprised in the survey is to ascertain the nature of his mental constitution, to find out what kind of a person he is, and, if he is abnormal, what is the nature of the abnormality and how it can be most successfully treated with a view to restoring him to mental health. 44 REPORT OF MENTAL HYGIENE SURVEY Explanation of Terms Used To Designate Mental Diagnoses When a child or other person has no apparent defect in learn- ing capacity or in character make-up, the mental diagnosis is normal. When the person under examination is evidently unusually endowed in his capacity both for pursuing educational and train- ing work and for becoming a socialized individual, he is diagnosed as of superior endowment. Such persons usually con- stitute about 3 per cent of any large unselected group. Persons who are so backward in development that there can be no reasonable question of their remaining permanently at a child level of mentality are diagnosed as mentally defective or feebleminded persons. Some children are very backward and at the same time have had poor school opportunities. They have questionable heredi- ties, or physical defects that can be corrected, or they have shown tendencies to delinquency. We are left in doubt whether they will develop the power for self-control and initiative necessary for citizenship or whether they will remain permanently at a child level. In such cases, our diagnosis is borderline mental defective, meaning that they are on the border line of mental defect. Future development may throw them into the defec- tive group or it may show them to be dullards or even normals. We also classified as in the borderline group some children con- cerning whom we could not obtain sufficient information for a diagnosis of mental defect, knowing that our research probably did not reveal all of the situation. This holds also of some adults. Children who are not mentally defective or in the borderline group and yet are not able to pursue the ordinary curriculum at the rate designed for normal children, even though they attend school regularly, are classed as dullards. Dullards are of many varieties. The dullard is lacking to some extent in imaginative power or rather in capacity to use imagery. He is unable to use symbols for ideas to the extent to which they are commonly used. When such a person is confronted, for instance, by num- ber work, he has difficulty in conceiving of numbers as abstrac- STATE OF KENTUCKY 45 tions. Arithmetic, therefore, presents serious difficulties to him. His difficulty is the same in kind as that of the feebleminded boy who could feed his horse the proper number of ears of corn, but could not count an equal number in any other terms. This same kind of difficulty, higher up in the scale, characterizes the dullard intelligence. We see the same lack of ability to use imagery in many of our poor spellers. Many children do not learn to spell for the simple reason that they do not learn to carry visual images of words. Frequently this kind of lack is shown in high-school students by their inability to carry the imagery necessary for under- standing algebra or geometry. The triangle, for example, they cannot conceive as a wholly general image or concept-as serv- ing for any and every three-sided rectilinear figure, no matter what the size or relations of the three angles. A triangle must needs be, for such a person, a perfectly definite individual triangle. It is of a certain size and its angles have definite re- lations one to another. Such a limited imagination must per- force follow along the course in geometry by verbally com- mitting to memory both the proposition and the demonstration. For such minds there is no logic in geometry; they cannot "learn" geometry. Children in the lower grades are prevented by similar lacks in the field of imagination from grasping essential steps in the instruction offered. If, however, these children have distinct ability in dealing with the concrete and have no obvious character defects, they will make useful citizens. They have obvious mental defects. These defects, however, are not such as to class them as mental defectives. We use the term mentally defective, as indicated above, to designate those whom we prog- nose as unlikely to be able to manage for themselves, because in intelligence and in character they will remain on a child level A careful analytic study of the dullard will often enable the psychologist and educator to correct his defect and to remove him from this group. Herein lies the most fruitful field for the clinical psychologist in his work with school children. Persons who have character twists or warps that make them decided problems in the home or in the school or both are called 46 REPORT OF MENTAL HYGIENE SURVEY psychopathic persons. An abnormal irritability may constitute the ground for such diagnosis. A child who is unusually seclu- sive and does not play as other children do would be so diagnosed. Any child given to unusual temper tantrums, one who is exces- sively low in self-esteem, a child who lacks energy to pursue the ordinary activities of children of his age-is abnormally lazy- or a child who is abnormally emotional, all would be diagnosed as psychopathic. In many of these conditions the experienced eye of the psychiatrist can see the faint beginnings of definite mental disorder, which is bound to develop if the environmental forces, notably those of the home and of the school, do not succeed in modifying the character of the child. These children offer another cardinal opening for the skillful clinician to effect great savings in human resources. Of course, personality building is the primary function of education. Personality develops during extra-uterine existence. We are not born with personalities; they develop after we are born. The school, therefore, as the supervisor of this develop- mental process, has a great opportunity for modifying unfor- tunate and psychopathic traits and trends. To do this effectively the school must have a clinician, who is able to analyze the mis- formed person and prescribe and administer the necessary cor- rective treatment. Some persons are definitely hysterical, hypochondriacal, neurasthenic, or psychasthenic. These persons have neuroses or psychoneuroses or both. They are on the borderline of mental disease. We do not consider that they have mental diseases, but there is pathology of the mind. In the more popular speech of the day, they are not insane, but they are approximating that condition. The service of mental medicine will be greatly im- proved to our people when we have come to view those who are suffering from mental diseases as we now view the psycho- neurotic. We should consider persons whom we call insane as like the rest of us in that their minds are working according to definite psychological principles. We should be able to trace the causes of their unfit and inappropriate ideas and actions back to their sources. This is what we try to do for psychoneurotics. If a person has definite epileptic seizures or if we find evi- dence of even petit mat attacks, we make a mental diagnosis of epilepsy. Epilepsy is not a mental disease. Severe and fre- quent attacks, however, are generally attended by more or less rapid deterioration of mental capacity and frequently by conduct that classes the person as insane or as having insane episodes. If a person manifests unmistakable mental disorder, such as unusual and continued activity, either in speech or otherwise, or a similarly unusual depression of motor processes, or if he has delusions or hallucinations, or if his memory is markedly af- fected, he is classed as suffering from a psychosis, the name of the mental disease characterized by the symptoms in question constitutes the mental diagnosis. STATE OF KENTUCKY 47 48 REPORT OF MENTAL HYGIENE SURVEY State Penitentiary and State Reformatory In order to secure a general view of the mental-health prob- lems in the State penitentiary and the State reformatory, a study was made of 100 men at Eddyville and of 86 men at Frankfort, taken in the order in which they were admitted to the institution, and of all of the 29 women at Frankfort. This group of 215 persons may be considered a mine-run sample of the com- bined populations of these two institutions. The State author- ities make no distinction between the classes of inmates in these two institutions and there is no striking mental difference be- tween the two institutions as shown by these studies of two groups of men. Of the 100 men at Eddyville, 6 were found to be of border- line intelligence, 14 mental defectives, and 19 psychopathic per- sons. Forty-six of these were colored men. Of the 86 at Frankfort, 4 were found to be of borderline intelligence, 13 mental defectives, and 13 psychopathic persons. Of these, 26 were colored men. Of the 29 women at Frankfort (13 white, 16 colored), 4 were found to be of borderline intelligence, 12 mental defectives, and 4 psychopathic persons. These were quite evenly distributed between the two racial groups. The most striking difference is that 7 of the 13 white women were defective, while only 5 of the 16 colored women were so diagnosed. Table 3.-Mental Diagnoses of 215 Penitentiary and Reformatory Inmates by Color and Sex Mental diagnosis Mental M F Total White T M F T M F T Normal 50 3 53 31 1 32 19 2 21 Dullard 33 2 35 12 12 21 2 23 Subnormal 28 4 32 20 1 21 8 3 11 Borderline mental defect. 10 4 14 5 2 7 5 2 7 Mental defect .. . 27 12 39 17 7 24 10 5 15 Psychopathic personality. 32 4 36 24 2 26 8 2 10 Psychoneuroses .. 2 2 2 2 Endocrine disorder Mental disease or 1 1 1 1 deterioration .. 2 2 2 2 Unascertained .. .. 1 1 1 1 Total 186 29 215 114 13 127 72 16 88 STATE OF KENTUCKY 49 In Table 3 we present the distribution of these 215 mental diagnoses according to color and sex. There is to be noted a preponderance of dullards and of borderline mental defectives amongst the colored and of psychopathic persons amongst the white. The only two cases of mental disease were white men. Race and Nativity: An analysis of the 127 white persons con- sidered in this group shows that 126 of them were born in this country. One was born in Poland. Three fathers and one mother were born in other countries. We have then to do with a group of white persons almost exclusively native born and of native-born parents. It was impossible to ascertain the race in 96 instances. Of the remaining 31, 10 were Irish, 5 English, 4 German and 1 each of French, Polish, Scotch and Spanish descent. Seven were mixed Nordic races and 1 mixed American Indian and Nordic. The negroes were born in this country and for the most part in Kentucky. Age: Of the 127 white persons, 81, or 64 per cent, were less than thirty years of age. In the fourth decade there were 32, and in the fifth decade 10. Only 4 persons were over fifty years of age. This was essentially a young men's group, as is common in our penitentiaries. These men, however, were rather younger than the average. Fifty per cent under thirty years is the more general finding. Of the 88 negroes, 62 were under thirty years of age. Nine- teen were in the fourth decade of life, and 5 in the fifth, while only 2 were over fifty years old. The negro group was, there- fore, even more essentially a young men's group. Seventy per cent of these men were under thirty years of age. Training: Twenty-five whites and 18 negroes claimed that they had never been in school. Twenty-three other whites and 30 other negroes claimed no better than third-grade schooling. Seventy-two whites and 36 negroes claimed various degrees of grammar-school education. Six whites and 3 negroes said that they had been in high school. One negro claimed a normal school education and 1 white man a college education. Occupation: Data as to occupations were obtained from the statements of the prisoners themselves. The 127 white inmates 50 REPORT OF MENTAL HYGIENE SURVEY were for the most part common laborers. Fifty claimed to be farmers, 11 laborers, 15 miners, 9 domestic servants, 3 factory workers, 3 chauffeurs, 3 teamsters, and 6 barbers. Skilled work- men were rare. Three claimed to be machinists and 5 mechanics, 1 a telegraph operator, 1 an accountant, 1 a carpenter, 1 a black- smith, 2 electricians, 1 a'gas-engine operator, 2 painters, 1 a plumber and 1 a wagon maker. Physical Condition: Sixty-five whites and 34 negroes were found to be in good physical condition, 51 whites and 40 negroes in fair condition, and 11 whites and 15 negroes in poor condition. Among the somatic defects of these 11 white and 14 negro men in poor condition, we found 14 cases of the incidence of gonorrhea, 17 of syphilis (13 negroes), 3 of hernia, 4 of heart trouble, 11 of eye, nose, or throat trouble, 3 of speech defects, 1 of pleurisy and 2 amputations. Civil Condition: Of the whites, 55 claimed to be single and 52 of the colored made the same claim. Fifty-four whites and 23 colored claimed to be married; 4 white and 4 colored, widowed; 3 whites and 1 colored, divorced; and 11 white and 8 colored, separated. Table 4.-Mental Diagnoses of 215 Penitentiary and Reformatory Inmates, Classified by Number of Times Arrested Mental diagnosis Total Once arrested Twice arrested Three times arrested Four times arrested Normal ... 53 35 11 4 3 Dullard ... 35 19 12 2 2 Subnormal Borderline mental .. . 32 23 6 2 1 defect .. 14 6 2 4 2 Mental defect Psychopathic .. 39 17 11 5 6 personality , 36 10 8 9 9 Psychoneuroses .. .. 2 1 1 Endocrine disorder . Mental disease or 1 1 deterioration . ... 2 2 Unascertained 1 1 - - - - - Total .. 215 114 51 27 23 Recidivism: Table 4 distributes these 215 inmates of the STATE OF KENTUCKY 51 two institutions according to mental diagnoses and the number of times each acknowledged he had been arrested. Allowing for the inaccuracy of this information, owing to the fact that it is obtained from the prisoner himself and not by objective means, we have a certain expression of the relationship between mental condition and recidivism. Twenty-three acknowledged being arrested four or more times. Eleven of these were negroes and 12 white. It is notable that 6 of these (4 negroes) were mental defectives and 9 (7 white) were psychopathic persons. Six of them, however, were classed as normal, dullard, or subnormal. Of the 27 acknowledging 3 arrests, 5 (3 negroes) were mental defectives and 9 (7 whites) were psychopathic. Eight of these were normal, dullard, or subnormal. Notably large percentages of those claiming only one arrest were of normal intelligence and without psychopathic traits. The facts in this table concur with the generally accepted view that mental abnormality is a factor in repeated difficulties with law officers and courts. Offenses-. Table 5 presents the distribution of mental condition according to the nature of the offense for which the person was serving sentence. Of the 41 persons serving sentence for murder or manslaughter, it will be seen from the table that 26 (13 white and 13 colored) were either mentally defective (in- cluding borderline) persons or psychopathic. This emphasizes the fact that human life would be safer in Kentucky if proper care were taken of those who are mentally unbalanced and defective. Likewise, of the robberies and burglaries, compris- ing 99 of the total 186 offenses for which convictions were had in these cases, 34 were committed by persons mentally defective (including borderline) or psychopathic. Proper care, there- fore, of mental-health problems in the State would significantly increase the safety of property as well as of human life. Taken in the large, we see that 53 of these 215 persons were mental defectives, 36 of them psychopathic persons, 2 psy- 52 REPORT OF MENTAL HYGIENE SURVEY Mental diagnosis Total Murder and m a n- s laughter. Forgery and obtaining money under false pretenses. Robbery, larceny and burglary. Assault, malicious shooting and cutting. Sex crimes. Bigamy. Damaging property of another. Child abandonment. Confederating to kill jailer. False swearing. Receiving stolen goods. Moonshining. Embezzlement. Normal 53 6 5 32 4 2 1 2 1 Dullard 35 2 5 20 5 1 1 1 Subnormal 32 5 6 12 3 3 1 1 1 Borderline mental defect .. 14 5 2 3 1 2 1 Mental defect ., .. 39 10 3 17 5 3 1 - . Psychopathic personality .... 36 1] 2 14 5 1 1 1 1 Psychoneuroses ... 2 1 1 . • • • Endocrine disorder 1 1 . - Mental disease or deterioration 2 1 1 Unascertained .... 1 • • 1 • • • • - - - - - - - - - - - -- Total 215 41 25 99 24 12 4 1 3 1 2 1 1 1 Table 5-Mental Diagnoses of 215 Penitentiary and Reformatory Inmates, Classified by Offenses STATE OF KENTUCKY 53 choneurotics, 1 suffering from endocrine imbalance, and 2 from mental disease or deterioration. The question here is one of proper community management of these offenders. Are we dealing most effectively with them in considering them only as offenders? Is it a square deal to them or to the community to put them into the reformatory institution and expect them to mend their ways so that when they are paroled they will straight- way become productive citizens? Can we expect them to have learned not to commit again acts such as those of which they have now been convicted and for which they are made to feel that they are "doing time"? Would it not be more economical in the long run to recognize the short-mindedness and mental imbalance of these offenders and give to each the training ap- propriate to his shortcomings and deficiencies? The present community procedure with these defectives does not recognize the differences in mental equipment between those men who are normal and those who are defectives. If we continue to treat offenders of these two different groups by the same court procedure and the same institution manage- ment, it is important that the court and the institution should recognize these mental differences. Parole and discharge should be merited before they are granted. Parole should be given only to such offenders as have given reasonable ground for as- surance that they will go straight when granted such conditional discharge from the institution; and final discharge should come only as the result of satisfactory demonstration of ability to contribute to the welfare of the community while on parole. Recidivists in Reformatory In order to demonstrate the relation of mental condition to repetition of offenses a group of 100 cases at Frankfort, picked out as repeaters, were given careful study. Twenty-five of these had been arrested twice, according to their own statements, 54 REPORT OF MENTAL HYGIENE SURVEY 27 three times, 23 four times, 8 five times, 7 six times, and the remainder from 7 to 25 different times. Of the 10 who claimed to have been arrested 7 or more times, all were diagnosed as psychopathic persons. Of the 15 claiming arrest five or six times, 11 were mental defectives or psychopathic. Of the 23 claiming four arrests, 13 were mental defectives or psychophatic. Of those claiming 2 or 3 arrests, only 8 in each group were men- tal defectives or psychopathic. Of the whole group of 100 cases, just 50 cases had some form of mental abnormality. These facts are exhibited in Table 6. Ages: Forty-nine of these cases were under thirty years of age. Forty-eight were in the third decade of life, 30 were in the fourth decade and 17 in the fifth. Civil Condition: Fifty-four of them were single, 34 mar- ried, 2 widowed, 6 divorced, and 3 separated. Training: Three of them claimed college education, 5 high school, 45 fourth to eight grade schooling, 33 first to third grade, and 14 no schooling. Physical Condition: Thirty-nine were judged to be in good physical condition, 49 in fair, and 12 in poor. Race and Nativity: Fifty of them were white and fifty colored. Ninety-nine of them were born in the United States and 1 in England. In ninety-six cases, both father and mother were born in this country. Very little could be ascertained with respect to the racial origin of the whites. Four seemed to be English, 1 Irish and 1 Italian. The group is essentially, like the run-of-the-mine group, native-born whites of native- born ancestry. Offenses: Robbery, larceny, and burglary constitute the majority group of offenses, comprising 68 cases. Of the 68, STATE OF KENTUCKY 55 Table 6.-Mental Diagnoses of 100 Recidivists at Frankfort, Classified by Number of Times Arrested. Mental diagnosis Total Twice Three times Four times Five times Six times Seven times Eight times Ten times Fifteen times Twenty- five times Normal 27 9 11 6 1 Dullard 12 4 5 2 1 Subnormal 11 4 3 2 1 1 Borderline mental defect 4 1 3 Mental defect .. . 12 3 2 3 1 3 Psychopathic personality .... 33 3 3 10 5 2 3 1 4 1 1 Mental disease or deterioration 1 1 - - - - -- - - - - - Total 100 25 27 23 8 7 3 1 4 1 1 56 REPORT OF MENTAL HYGIENE SURVEY 38 presented mental-health problems. Only 11 of them were convicted of murder or manslaughter and 6 of these were defec- tive (or borderline) or psychopathic. Of the 9 convicted of forgeries, only 2 were psychopathic and none defective. Table 7 exhibits these distributions. Disciplinary Cases in Reformatory In order to exhibit further the influence of mental illness and deficiency as a factor in prison life, a study was made of 98 disciplinary cases. Race and Nativity. Forty-seven of these were white and 51 colored. Ninety-seven of them were born in the United States. Seven fathers and four mothers were born abroad, 2 in Italy, 3 in Ireland, 4 in Germany, and 1 each in France and England. Here again, therefore, we have to deal with a group essentially of American stock. Age: This group was even more youthful than either of the others. Seventy-one of the 98 were under thirty years of age; 57 were in the third decade of life, 19 in the fourth decade, 3 in the fifth, 4 in the sixth, and 1 over sixty years old. Training-. One claimed a college education, 8 high school, 44 fourth to eighth grade, 28 first to third grade, and 15 no education. In two cases the amount of training was unascer- tained. Physical Condition: In regard to physical condition, 57 were found to be in good condition, 36 in fair, and 5 in poor. This is a decidedly better showing than that made by either of the other groups reported above. STATE OF KENTUCKY 57 Mental diagnosis Total. Murder and m a n- slaughter. Forgery and obtaining money under false pretenses. Robbery, 1 ar c e n y, burglary. Assault, malicious shooting and cut- ting. Sex crimes. Perjury. Normal 27 4 4 15 1 2 1 Dullard 12 1 1 8 1 1 Subnormal 11 2 7 2 Borderline mental defect .. 4 1 3 Mental defect 12 11 1 Psychopathic personality . Mental disease or 33 5 2 23 2 1 deterioration 1 • • 1 Total 100 11 9 68 6 5 1 Table 7.- Mental Diagnoses of 100 Recidivists at Frankfort, Classified by Offenses 58 REPORT OF MENTAL HYGIENE SURVEY Table 8.-Mental Diagnoses of 98 Disciplinary Cases at Frankfort, Classified by Offenses Mental diagnosis Total Murder and m a n- slaughter. be o 1=1 'S .5 ci -Q « O rd TJ S a 3 aS - a) aS o sc 2 a o Assault, malicious •r cutting. Arson. Bigamy. Perjury. pretenses. Robbery, 1 a r burglary. shooting c Sex crimes. o a Normal 24 3 1 18 1 1 Dullard 18 2 2 12 1 1 Subnormal 12 2 2 7 1 Borderline mental defect .. . 10 1 1 5 2 1 Mental defect .... 15 2 10 2 1 Psychopathic personality .... 19 4 14 1 Total 98 14 6 66 5 4 1 1 1 Offenses-. Table 8 shows a distribution of these cases ac- cording to mental diagnosis and the offense for which each was convicted. Of the 14 convicted of murder or manslaughter, again we found 7 mentally defective (and borderline) or psy- chopathic. Of the 66 convicted of robbery, larceny, or burglary, 29 were found defective or psychopathic. A slight majority of the assaults and sex crimes were committed by defectives and psychopathies, while a decided majority of the forgeries were by this group. In this respect the disciplinary cases dif- fered in no essential manner from the unselected or mine-run group first considered. .Recidivism: A distribution of these cases according to mental diagnosis and number of times arrested brings out the predominance of psychopathic persons and mentally defective persons amongst those arrested more than twice. There were 21 of these cases. Eleven of them were psychopathic and 6 mem- tally defective persons. STATE OF KENTUCKY 59 Suspected Mental Cases at Reformatory A study was made of 22 persons (16 white and 6 colored) at Frankfort who were picked out by prison authorities as probably defective or psychopathic. The principal point in this study was to verify the judgment of the prison authorities. To be sure, it was a small group. Of the 22, only 6 were under thirty years of age. In this respect it was far from an average sampling. Of these, however, 10 were single, even though 16 of them were more than thirty years of age. Only 7 were in poor physical condition. Twenty of them were native born. Nineteen had parents born in this country. It is rather noteworthy that 9 of these 22 persons were con- victed of murder or manslaughter, and 8 of these 9 present mental problems. The distribution according to mental diag- noses and offenses of which each was convicted is shown in Table 9. Table 9.-Mental Diagnoses of 22 Suspected Mental Cases, Classified by Their Offenses Mental diagnosis Total Murder and m a n- slaughter. Forgery and obtaining money under false pretenses. Robbery, larceny, burglary. Assault, malicious shooting or cutting. Sex crimes. Subnormal 2 1 1 Mental defect 2 2 Psychopathic personality . 8 2 1 3 1 i Epilepsy Mental disease or 1 1 • • deterioration 9 5 3 1 - - - - -- - Total 22 9 5 5 2 1 REPORT OF MENTAL HYGIENE SURVEY 60 Conclusions The outstanding fact of the mine-run group, the recidivists, the disciplinary cases, and the suspected mental cases is that a very large proportion (nearly one-half) of all these persons were mentally defective or psychopathic or had some other sort of personality difficulty. Nearly half of these prisoners were "not right" mentally. These persons in the reformatory and the penitentiary are there because they have been found guilty of seriously offensive conduct. They are in these institutions for the purpose of correction. It seems to be the intention of the community that their confinement shall reform them. It seems to be expected that the treatment they receive in the institution will make them over so that they will not offend again when they have been discharged. In order to effect such correctional work in any given in- dividual, with the minimum of effort and in the surest fashion, it is necessary to understand the motives that originated his offensive conduct. These institutions need a diagnostician who can look into the minds and personalities of the prisoners when they come to the institution, who can find out how they got into the trouble that brought them there, and who can, therefore, intelligently plan their management and training so that it shall be as short and as effective as possible. Of course there are large numbers of mentally defective persons and of psychopathic persons in the community. Many of these go through life without becoming offenders. This fact does not run counter to the plan and proposition called for by the facts obtained from our studies in the penitentiary and the reformatory. The diagnoses made among these populations argue directly for mental diagnoses of all prisoners, and for STATE OF KENTUCKY 61 training and treatment determined and guided by the mental analyses. The kind of defect and the kind of psychopathic trend found in the offender constitutes the mental origin of his offense. Simply calling his mental condition by a name and designating him as a mental defective, a psychopathic person, or an insane person does not constitute the sort of diagnosis that will be required of the specialist who will undertake the management and training and rehabilitation of these men in prison. How he shall classify them matters little. His primary business will be to find out how the offensive line of response originated in each man's personality. Having made this discovery, he will plan to rebuild the personality so that this kind of behavior shall not be likely again to emerge. Each prison should have a mental-hygiene clinic, and a thor- ough-going analysis of personality should be made of each per- son who comes into the institution. This is the basal work of the institution. What is discovered in this clinic should guide all arrangements made for the individual throughout his life in the institution, should determine the time and the manner of his parole, his management during parole, and the time of his discharge. As a matter of fact, these things should be done for the in- dividual offender much earlier. We should be able to anticipate his difficulties when he is a school boy and take measures to prevent them. But the point is that we are not doing so. Of- fenders are coming in large numbers to these institutions. They are becoming offenders despite such preventive measures as we are taking in the home, the school, and the community. The business of their rehabilitation is, therefore, clearly thrown upon the reformatory institution. This institution should be equipped to proceed logically about its task. 62 REPORT OF MENTAL HYGIENE SURVEY First of all, upon his reception each one of these persons should be given the benefit of the best possible physical exami- nation. A thorough search should be made for disease and defect. Modern hospital facilities should be utilized to put him in good physical condition. The principles of sanitation and hygiene should be brought to bear to secure him good, nourish- ing food and decent, wholesome housing conditions. Provision should be made for such exercise and work as will provide for physical health. Training is the one idea upon which all the work of the institution for the offender should be based. If he has no school training, if he is an illiterate, he should be taught to read and write and figure, provided he has the mental ability requisite for acquiring such knowledge and facility. Fitting each prisoner for a career is really the first col cern of the prison. It is well recognized that occupation has a definite therapeutic value with mental patients. Activity of the muscles directed toward an achievement that is interesting to the subject is the best possible means of organizing a dis- organized personality as well as an unorganized personality, a child. Occupation, therefore, directed toward an interesting achievement is as good for the man who is so out of tune with his environment and community that he has become an offender and been sent to prison as it is for the nervous patient in a sanitarium or for the backward child in the public school. The prisoner is to be remade. His personality is to be rehabilitated by the w'ork that he does and the love of this work that he at- tains. This work is to be the primary means of reinstating him in the community, of socializing him. It is to be the means of turning the antisocial person into a contributing member of the group, of putting him in possession of his personal forces. In order to make the prisoner's work a therapeutic measure STATE OF KENTUCKY 63 toward establishing his personality upon the proper basis, the State should develop a variety of industries in these institutions suitable for the training of such men and women as are placed here. The State itself should have absolute control of the man and of his work. This means that the contract system will have to be abolished, and that marketing plans satisfactory to the rest of the community will have to be established. The product of the labor of men inside the prison must be sold. It should be sold well. The laborer himself should have the benefit of his labor, the State making reasonable deductions for his main- tenance and for the cost of his delinquency. It is important that the laborer should realize on his labor. Such an incentive is a valuable factor in producing the interest in his work that is necessary if it is to be a rebuilding factor in his personality. There should be no difficulty in devising a plan for selling that will be entirely satisfactory to labor outside the prison. The State needs the money just as the private producer does. The State should be able to sell in a competitive market and in fair competition and give the individual prisoner his net earn- ings above expenses incurred by and for him. The State institu- tion should sell its products on their merits and give the in- dividual producer that share of the income which he really de- serves. The main thing is to secure work for each man that will interest him and lead to his following up the same line of ac- tivity when he is paroled and discharged. One indispensable condition of securing such interest is that the work shall bring real satisfaction to him. He must feel that he is working for himself. There is, of course, among these prisoners, a considerable group of what are termed defective delinquents. We know that they are offenders because they have been found such by juries and have been committed to the prisons by the courts. We know that they are mentally defective because we found them so upon examination. Some of these defective delinquents are so defective that they cannot be "corrected" by the course of treatment (occupational therapy) here outlined. Some of them can be "corrected." but by a much longer process than is 64 REPORT OF MENTAL HYGIENE SURVEY necessary with the normal-minded offender. The mental defec- tive who cannot be trained for citizenship should be segregated and detained indefinitely. No man should be placed on parole until he has shown by his life in the institution that there is reasonable prospect of his making good outside the institution. More than half of these men (normal and dull) seem to have no apparent mental kink or twist or defect. They are offenders in whom we should expect rather rapid working of the rehabilitation process. They should be able to merit parole in relatively short periods. These men should be committed to the institution on indefinite or indeterminate sentences. They should be committed to the experts of the prison for rehabilita- tion. The law might well require the concurrence of the com- mitting court and of the prosecuting attorney with the prison authorities before parole and also before final discharge. The point is to have these determinations made on the known pre- paredness of the personality for such parole or discharge. De- terminate sentences belong to a justice of expiation. Society now asks of the offender a demonstration of his will and capacity to make good-to be a contributor. Fa- cilitation of such demonstration is provided by indeterminate sentences, personality studies, occupational training, and parole determined and watched over by those who know the man's personality and his progress in rehabilitation. If the institution is making such careful personality studies as outlined above and is supervising the training and rehabilitation of each man by the adaptation of his work to his needs, the institution is able to judge day by day of the progress the man is making. It is in possession of facts that could not have been known by the jury or the court when he was sent to prison. It is unfair to the man in prison and it is unfair to the community to sen- tence a man to spend a given term of years or a minimum of two years or ten years or any other definite time in the prison. It may require ten years or it may require three months to rehabilitate him, to straighten out the kinks and handicaps that he had when he committed the crime, and to put him in such a condition that it seems entirely right and proper to the prison authorities to try him out on parole. STATE OF KENTUCKY 65 Parole is the complement to occupation. It is a continued application of the institution therapeutics, occupation or "work" within the institution. The mental process of the offender's adjustment to life, of understanding his relations to the com- munity, and of feeling his responsibility to others-in fact, the attainment of a social sense-is greatly facilitated by trial on. parole when his own personal adjustment has reached a stage that warrants this procedure. The prison should be viewed as a great school. It should be organized as a training institution with clinical facilities that will enable it to adapt the training of each man to his individual needs. The prison needs, therefore, a clinic that will be able to use all the technique of psychological medicines In order to use this clinic to the best advantage, it must have a variety of occupational facilities at its disposal and com- pletely under its control. In order to use these facilities to the best advantage of each individual, the prisoner should be sent to the institution with- out definite term of sentence. He should be put into the hands of the prison as a boy puts himself into the hands of a university for'a given kind of training. If the prisoner is a defective and cannot be rehabilitated or trained to a point that warrants his parole, he should be detained indefinitely or for life in a group of his own kind. This will probably entail the development of a special institu- tion. One clinical examination should not be allowed to suffice in any ease. The best training that he is capable of receiving should be given to every man who comes to the institution. Only those responsible for the training can determine when and how parole should be tried. The moral effect of universal indeterminate sentences, in fa- cilitating rehabilitation, would be great. It would be marked, both upon the prisoner himself and upon the personnel of the prison. When the State puts a trained criminologist in charge of these institutions and gives him the personnel and the facili- ties for medical and mental examinations, for treatment and correction of defects, and for the thorough training (occupa- 66 REPORT OF MENTAL HYGIENE SURVEY tional therapy) of each man, there can arise no question as to the desirability of leaving in the hands of such a prison per- sonnel not only the management of the parole of each man but also the determination of the time when he shall be tried on parole and the time when his parole shall terminate in final discharge and the restoration of his rights and privileges as a citizen. In a word, these prisons need: 1. Indeterminate sentences (offenders sent in for rehabilita- tion). 2. Mental-hygiene clinics and hospital facilities. 3. Occupational training under the direction of the prison. 4. Determination of time and all conditions of parole and discharge as well as supervision of parole by prison authorities, who should be trained specialists. STATE OF KENTUCKY 67 Inmates In Eleven County Jails In order to study the offender closer to the community from which he comes, and also to study the petty offender as well as the so-called convict or person found guilty of a felony, we made examinations of 223 persons in 11 county jails. These counties were selected with the view of getting fairly typical populations in the eastern, central, and western parts of the State. The 223 persons were found, as the numbers indicate, in the counties named, as follows: Henderson 16, Muhlenberg 18, Daviess 23, Scott 5, Hardin 5, Bourbon 11, Knox 20, Bell 20, Harlan 53, Letcher 17, and Perry 35. Table 10.-Mental Diagnoses of 223 Inmates of Eleven County Jails, Classified by Sex and Color Mental diagnosis Total White Colored M F T M F T M F T Normal 11 . . 11 9 9 2 .. 2 Dullard 26 . . 26 16 16 10 .. 10 Borderline mental defect 43 . . 43 25 25 18 .. 18 Mental defect 31 . . 31 25 25 6 .. 6 Psychopathic personality Mental disease or 97 3 100 78 3 81 19 .. 19 deterioration 6 1 7 3 1 4 3 .. 3 Unascertained 5 . 5 3 3 2 .. 2 Total 219 4 223 159 4 163 60 .. 60 Race and Nativity: The mental diagnoses in the cases of 223 persons are distributed in Table 10 according to color and sex of the individuals. It will be seen that only 4 of these per- sons were female and these were all white. Of the 219 males, 159 were white and 60 were colored. Of the 57 persons found in the three western counties, Muhlenberg, Daviess, and Hen- derson, only 20 were colored. Of the 21 found in the jails of Hardin, Scott, and Bourbon counties, only 9 were colored. Of the 145 found in the five eastern counties, 31 were colored. Of these 223 persons, all but 4 were born in this country. These 4 were Austrians. Of the native born, all but 9 had 68 REPORT OF MENTAL HYGIENE SURVEY fathers and mothers born in this country. Of these foreign- born parents, 3 persons were Irish, 1 French, 1 Mexican, and 4 undetermined. Age: Several of these persons found in county jails were minors. Of the 159 white males, 26 were under twenty years of age. Two of the 4 white females and 4 of the 60 colored males were under twenty years of age. A total, therefore, of 32 of the 223 county jail inmates were minors. Ninety-nine others (68 white males and 31 colored males) were in the third decade of life. More than 58 per cent (131) of this aggregate population of eleven county jails were under thirty years of age. Forty-four were in the fourth decade of life, 24 in the fifth, 14 in the sixth and 7 in the seventh. Two colored males were more than seventy years of age. The age of one white female was unascertained. Physical Condition: Among these 223 persons the follow- ing physical defects were found: 2 cases of blindness, 3 of amputated arms or legs, 1 of deformity of hip, 1 of deformity of nose, 1 of hernia, 1 of Huntington's chorea, 2 of pulmonary tuberculosis, and 11 of scleroses. Training: The education claimed by these county-jail in- mates corresponds closely with that found among the various groups studied in the penitentiaries. Two claimed college ed- ucation and 7 (4 white) some high-school education. Twenty- seven claimed to have finished the eighth grade. Eighty-two others finished school in grades from the fourth to the seventh. Twenty-seven claimed schooling of grades from the first to the third. Sixty-one claimed to have had no schooling whatever (44 white males and 17 colored males). In the cases of 17 (10 white males, 3 white females, and 4 colored males), educa- tion was not ascertained. » Occupation: These individuals were unskilled workers, for the most part. Thirty-three white males and 36 colored claimed to be laborers; 47 white and 12 colored, coal miners; 43 white STATE OF KENTUCKY 69 and 7 colored, farmers. Eight whites claimed to have no oc- cupation, and the 4 white females all claimed to have been in domestic service. Two white men and 1 colored claimed to be mechanics and 2 white males, machinists; 3 white men painters; 3 white men, motormen; 2 white men, shoemakers. Of the white men, one each claimed the following occupations; barber, boiler- maker, carpenter, chauffeur, clerk, grocer, horse buyer, hotel manager, machinist helper, moving picture operator, printer, travelling salesman, teamster, and tobacco grader. The oc- cupation of one white man was unascertained. Of the colored men, one each claimed to be a clothes presser, cook, plasterer and real estate agent. Civil Condition: Of the 223, 104 claimed to be single, 93 married, 14 w'idowed, 5 divorced, and 7 separated. Recidivism: Many of these persons found in county jails, and for the most part awaiting trail, claimed to have been ar- rested more than once. Of the whole number, only 98 claimed to have been arrested only once. One other, a white female, was lodged in jail awaiting transportation to the State hospital for the insane. Sixty-eight (47 white and 21 colored) claimed to have been arrested only twice, 21 three times, and 32 four times or more. In 3 cases, the facts with regard to previous arrests were unascertained. Of the 74 mental defectives and borderline mental defectives, 17 acknowledged three or more arrests. Of the 100 psychopathic persons, 22 had been arrested three or more times. Of the 37 diagnosed as normal or dull normal, only 12 had been arrested three or more times. Of these 223 county-jail inmates, 149 were serving jail sentences, 69 were awaiting trial, 2 were held as witnesses, and the facts with regard to 3 were unascertained. 70 REPORT OF MENTAL HYGIENE SURVEY Table 11.-Mental Diagnoses of 223 Inmates of Eleven County Jails, Classified by Offenses S rt *= aj K ® | K « o © xs a> >i t> O cS « Mental diagnosis « h ~ £ 1 « © ■♦■J c^ S-X - b< S I .2 , i: : c 2 7 v rc a 5 x> © 5 " © S J 3 -2 H W <1 CZ2 > Normal 11 1 .. .. .. 2 Dullard 26 3 .. 3 4 1 Borderline mental defect. 43 2 1 7 4 1 Mental defect .. 31 3 2 5 3 1 Psychopathic personality . .. 100 7 4 19 5 3 Mental disease or deterioration 7 .. 1 * 1 Unascertained . . 5 2 .. .. 1 Total 223 18 8 35 17 8 1 1 «D £ ■? cn K o 8 11 .. 4 20 4 4 12 .. 5 53 .. 9 1 .. 4 1 .. 1 106 4 27 Offenses and Diagnoses: Of the 74 mental defectives and borderline defectives, it is seen that 5 were charged with murder or manslaughter and 12 with robbery, larceny, or burglary. The offense of heaviest incidence is violation of the Volstead Act, with 106 cases. Of these 106 offenders, only 32 were diagnosed as mental defectives or borderline defectives. Of those diagnosed as psychopathic persons, 7 were charged with murder or manslaughter. A total of 18 were so charged. Nineteen psychopathic persons were charged with robbery, larceny, burglary, and so forth. Total charges for robbery, larceny or burglary were 35. Of the 106 persons charged with violating the Volstead Act, 53 were diagnosed as psychopathic persons. Of the 7 found suffering from mental diseases, one was charged with no offense. She was held for transfer to the State hospital. One was charged with robbery, larceny, or burglary, and 1 with violation of the Volstead Act. Of the 8 persons charged with sex crimes, 2 were mentally defective (or borderline) and 3 were psychopathic. STATE OF KENTUCKY 71 The delinquencies charged in the cases of these inmates in county jails were, in a great majority of cases, minor offenses. Felonies were naturally much rarer than among prisoners in the penitentiary. Of the whole 223 per- sons, only 18 were charged with murder or manslaughter and 35 with robbery, burglary, or larceny. Some few were serving jail sentences. A great majority were awaiting court action. These persons were predominantly young men. A sub- stantial majority were under thirty years of age. For the most part they were without school training and unskilled as to occupation. There were fewer normal and dull among them than there were in the penitentiary (only 11 and 26 respectively among the total 223). There were larger numbers of mentally defective and borderline defective persons (31 and 43 respectively of the total 223). Psychopathic persons abounded, 100 of the 223 being so classified. These persons were, for the most part, found to be in good physical condition. That nearly one-half of them were charged with violation of the Volstead Act is a significant fact. The problem of these county jail inmates is essentially a problem of the readjustment and training of young persons. With these persons the schools have failed. About a third of the whole number, being mentally defective, may be only slightly influenced by further training. With more than one- half of these latter, however, who are of borderline intelligence, there is reasonable expectation that careful training will pro- duce a fairly satisfactory sort of citizen. The psychopathic per- sons are eminently fit for training. These are the significant failures of the schools and very fruitful material for specialized habit and personality training in youth and young manhood. The first essential for training this sort of person is varied and graded opportunity for occupation. The first essential for Conclusions 72 REPORT OF MENTAL HYGIENE SURVEY putting the problems of these county jails upon a rational basis is provision for occupation. Far as it is from the ordinary conception of his duties, the jailer should be a social worker rather than a politician. Idleness and the common associations of small jails foster and breed breakdowns of character and personality. They do nothing for rehabilitation. Criminals are made in our county jails rather than rehabilitated. The first essential is to get these jail inmates out on farms and into shops. Medical and sanitary regulations should be provided that would make the living condi- tions thoroughly wholesome. Each inmate should be interested in and occupied with an industrial activity. This adjustment implies careful study of each personality. The court should require in each case before trial a mental analysis and the aid of a physician who knows mental medicine. The court should know the personality and should have reason- ably accurate information as to the mental origin of the of- fensive conduct, before deciding where to send the prisoner and what to make his sentence. When the penitentiary shall have organized such a clinic, when indeterminate sentences become the routine procedure in commitment, and when the penitentiary is as an institution given control of the parole of its inmates, then the court may distribute and commit offenders very much according to the seriousness of the offense and the apparent need for each of rehabilitation. When there is more of wisdom and reasonable- ness in the procedure of the prison, there will be less of stigma attaching to the person who is sent thither, and there will be practically no occasion for sentencing to the county jail. The day when such educational ideals shall prevail in a prison has not yet come. The county jail will continue to be used for detention. It should be recognized that it is an educa- tional and training institution. Whenever any person is sent to the county jail, and while he remains confined therein, his treatment and management should be directed continually with the single purpose of building up his personality and his capacity for living the life of a constructive, contributing mem- ber of the community. STATE OF KENTUCKY 73 Inmates In Eight County Almshouses In order to study the problems of adult dependency, the almshouses and infirmaries were visited in the llyounties where jail populations were studied, so far as these counties had such institutions, and in Mason county. A total of 129 persons (101 white, 28 colored) were found in the eight counties, as follows: Henderson 29, Muhlenberg 13, Daviess 15, Scott 13, Hardin 13, Bourbon 18, Bell 8, and Mason 20. Aye: One child of fourteen years was found in one of these county institutions. Two other persons were under thirty, but in the third decade of life. Eleven (8 white and 3 colored) were in the thirties, 14 white were in the fifth decade, 14 (11 white and 3 colored) in the sixth decade, 28 (22 white and 6 colored) in the seventh decade, 36 (32 white and 4 colored) in the eighth decade, and 19 (11 white and 8 colored) in the ninth decade. Two colored were over ninety years of age, and the ages of 2 other colored were unascertained. Table 12.-Mental Diagnoses of 129 Inmates of Eight County Almshouses, Poor Farms, and Infirmaries, Classified by Sex and Color Mental diagnosis Total White Colored M F T M F T M F T Normal . . . 5 5 2 2 3 3 Dullard 6 2 8 6 1 7 1 1 Mental defect . . . 20 14 34 14 14 28 6 6 Psychoneuroses 1 1 1 1 Epilepsy 1 1 1 1 Mental disease or deterioration .. . . .. 58 22 80 47 16 63 11 6 17 Total . . . 91 38 129 70 31 101 21 7 28 Sex, Race and Nativity: Table 12 shows the distribution of these 129 inmates according to mental diagnoses, sex and color. Ninety-eight of the 101 white persons and all of the colored were born in the United States. One was born in Germany, 1 in Ireland, and the birthplace of 1 was unascer- tained. Ten others had one or both parents foreign born or unascertained. Five fathers and 4 mothers were born in Ire- land. Here again, therefore, we have to do with a relatively 74 REPORT OF MENTAL HYGIENE SURVEY pure American stock, persons whose parents and more distant ancestors have for the most part lived in this country. Table 13.-Mehtal Diagnoses of 129 Inmates of Eight County Almshouses, Poor Farms and Infirmaries, Classified by Physical Condition Mental diagnosis Total Good Fair Poor Normal 5 4 1 Dullard 8 4 3 1 Mental defect . . 34 31 2 . 1 Psychoneuroses .. 1 1 Epilepsy 1 i Mental disease or deterioration 80 8 21 51 -- - - - Total 129 47 28 54 Physical Condition: Table 13 distributes the mental diagno- ses of these 129 persons according to physical condition. It is rather significant that of the 80 persons diagnosed as suffering from mental disease or deterioration, 51 (40 white persons and 11 colored) were in poor physical condition. There were only 3 other persons found in poor physical condition. These are all white, one a dullard, one a mental defective, and one a psy- choneurotic. Conversely a very small number of those suffering from mental disease or deterioration (8) were found to be in good physical condition. Twenty-one were judged to be in fair physical condition. The mental defectives in this group were nearly all in good physical condition (31 out of 34). Training-. We find a larger amount of illiteracy amongst these dependents than amongst the persons found in the pen- itentiaries and the county jails. Thirty-seven (34 white. 3 colored) were unascertained in respect to education. Fifty-two (28 white, 24 colored) claimed no schooling. Seven claimed second or third grade schooling. Five others were able to read and write. Twenty-seven claimed fourth to eight grade, and 1, college education. None of these persons claimed to have been skilled workers. Thirty-six were farmers, 22 common laborers, 27 houseworkers, 1 porter, 1 coal miner, 2 sewing women, 2 bartenders, 1 gardener, 1 paper hanger and painter, 1 stationary fireman, 1 steward, and 1 tobacco worker, and 33 had no occupation. STATE OF KENTUCKY 75 The irregularity of employment, taken in connection with mental diagnoses, brings out the fact that none of the mentally defective persons had ever been regularly employed. Of the 34 mental defectives, 18 had never done any work, 5 had worked at odd jobs, 5 had been irregularly employed, and 5 had done housework at home. In 1 case this information was unascer- tained. The one person diagnosed a psychoneurotic worked at odd jobs and the one epileptic did no work. Of the 80 suffering from mental disease or deterioration, 29 had been regularly employed, 15 had worked at housework, 4 had been irregularly employed, 14 had worked at odd jobs, 2 had done no work, and the occupations of 16 were not ascertained. Civil Conditions: Of the 129 persons, 59 claimed to be single, 10 married, 50 widowed, 3 divorced and 6 separated. The facts with regard to 1 were unascertained. Of the 34 mental defec- tives, 25 were single, 4 married, 4 widowed, and 1 divorced. We have no record of the children of these married defectives, either as to number or mental condition. Offenses: Some behavior anomalies and some arrests oc- curred amongst these dependents. Of the 34 mental defectives, 1 had untidy habits and two had uncontrolled sex proclivities. Of the 80 suffering from mental disease or deterioration, one each offended by stealing, cruelty, and sex perversion. A larger number of offenses would seem to be indicated by the fact that 24 persons out of 118 ascertained acknowledged having been arrested. Six had been arrested twice and 6 three or more times. Duration of Dependency: Mental diagnoses were distributed according to the length of dependency. We found 3 mental defectives who had been dependent over thirty years, another dependent over twenty-five years, another over twenty years, and another over sixteen years. Six had been dependent over eleven years and ten over six years. One person, classed as a dullard, had been dependent over thirty years, 1 other so classed over eleven years, and 2 others over six years. One epileptic had been dependent over thirty years. 76 REPORT OF MENTAL HYGIENE SURVEY Of the mentally ill and deteriorated, one had been dependent over thirty years, 4 others over eleven years, 11 others over six years. Of the five normal-minded dependents, only 1 had been dependent over eleven years so far as ascertained. The length of dependency was not ascertained in 17 cases. Conclusions The majority of these inmates were old people. Sixty- five per cent of them were physical and mental wrecks. The majority of the other third were mentally defective persons. They were definitely short on the mental side, but, for the most part, were in good physical condition. Mentally defective per- sons should not be detained in the county almshouse. Very few county almshouses are organized to give them the care necessary to protect society from their delinquencies. The county alms- houses of Kentucky have in the past directly contributed many feebleminded persons to the population of the State. Feeble- minded women kept in county poorhouses have repeatedly borne illegitimate children who in turn have become dependents on account of their own mental deficiencies and been supported through life by the taxpayers. Steps should be taken to make it unlawful for any feeble- minded person to be committed to or received in a county alms- house. Proper training, either in the special classes in public schools or in a State institution for feebleminded, should be provided for such persons while they are young. All feeble- minded persons who are not in custody in an institution should be under the supervision of a social-service or welfare agency, either local or general, preferably both, very much as are persons on parole from a State hospital. Some one who knows and appreciates the significance of the lack of responsibility and self-control in mentally defective persons should have the super- vision of every such person. It should be known by some one in authority that the conditions surrounding him in his work and his home are suitable. This knowledge of their suitableness should be confirmed at- intervals frequent enough to guarantee continuance of these conditions. Every feebleminded person found in unsuitable environment should be moved to better sur- roundings. Power to make such removals should reside in the supervising social agency. Those mentally defective persons STATE OF KENTUCKY 77 who are offenders should be kept in custody as long as tendencies to offend are manifest. ♦ The large majority of these inmates of the county almshouse, those who are old and sick in body and mind, deserve hospital care. All sick persons should be provided with hospital care. The few accidental dependents who are not mentally defec- tive and who do not need hospital care could be boarded in private homes quite as economically as they are in the county poorhouse. By such arrangements most of them receive better care as well as cheaper. Everyone who is in health and many who are not in health need, above everything else, to be helped to proper occupation. Many of these people need, above all else, aid in finding work suited to their capacities and tastes. The social-welfare de- partment of the State Board of Charities and Corrections, through cooperation with county and city welfare agencies, should be able to provide this sort of help. With the proper organization of a State welfare department which would supervise defectives in the community and help other social failures to connect up with community life, it should be possible to close up most of the county almshouses in Ken- tucky. These institutions are costly and they are not efficient. Some means should be adopted to do better the work that they now undertake and to abolish county-almshouse care. 78 REPORT OF MENTAL HYGIENE SURVEY The Houses of Reform Table 14 exhibits the distribution of mental diagnoses by sex and color of 407 children found at the time of this study in the Houses of Reform at Greendale. Table 14.-Mental Diagnoses of 407 Children at Kentucky Houses of Reform, Classified by Sex and Color Mental diagnosis Total White Colored M F T M F T M F T Normal 45 8 53 29 8 37 16 16 Dullard 69 10 79 41 6 47 28 4 32 Subnormal 44 16 60 32 13 45 12 3 15 Borderline mental defect. 23 8 31 18 7 25 5 1 6 Mental defect 74 35 109 59 30 89 15 5 20 Psychopathic personality. 48 20 68 37 17 54 11 3 14 Psychoneurosis 1 1 1 1 Question of epilepsy .... 1 1 2 1 1 2 Congenital syphilis 4 4 3 3 1 1 ■ - ■ ■ - ■ - - - - - - - ■ Total 308 99 407 220 83 303 88 16 104 Sex, Age, Race, and Nativity: Three hundred and three of these children were white (220 boys and 83 girls) and 104 were colored (88 boys, 16 girls). A distribution of these chil- dren by age will be found by reference to Table 15. The white boys ranged in age from ten to twenty-one. The mode was at seventeen years with 47 cases. There were 43 at sixteen years, 28 at eighteen years, 27 at fifteen, and 33 at fourteen. For colored boys the mode was also at seventeen years, there being 35 of this, age. There were 19 sixteen-year-olds, 9 at eighteen years, and 7 at fifteen and fourteen years each. For the white girls the mode was at seventeen years with 24 cases. There were 22 eighteen-year-olds, 14 sixteen-year-olds, and 9 fifteen-year-olds. There were only two white girls under fourteen. STATE OF KENTUCKY 79 Of the colored girls none were under fifteen and only one was above eighteen. The mode of the whole group was seventeen years, with 111 cases. There were 80 at sixteen years and 62 at eighteen years. There were 46 at fourteen and fifteen years each. Four hundred and six of these children were born in this country. One was born in Russia. Only 5 others had foreign- born parents. As to race, 104 were Africans and 255 unclassified Americans. Eleven were of Irish stock, 8 of German, 8 of English, 12 of mixed Nordic, 3 of Italian, 3 of French, 1 of Hebrew, and 1 of Welsh. One was a mixed European and American Indian. Of the 140 mental defectives (and border- line), shown in Table 14, 26 were negroes and 106 native-born whites of native-born ancestry, 2 were French and 1 each English, German, Hebrew, Italian, mixed Nordic, and mixed Indian. Of the 68 psychopathic persons, 14 were negroes, 38 un- classified white Americans, 6 mixed Nordic, 4 German, 3 Irish, 2 English, and 1 French. Of the 192 normal, dull normal, or subnormal, 63 were negroes, 105 unclassified white Americans, 5 English, 3 German, 8 Irish, 2 Italian, 1 Welsh and 5 mixed Nordic. Physical Condition: Of the 407 children, 167 were judged to be in good physical condition, 189 in fair, and 51 in poor. Of these 51 in poor physical condition, 15 were white boys, 24 white girls, 9 colored boys, and 3 colored girls. We would expect to find very few of these children married, widowed, divorced or separated. Among the boys there were 2 white and 2 colored who claimed to have been married. Among the girls, however, 8 white girls claimed to have been married, 1 widowed, 2 divorced, and 10 separated. 80 REPORT OF MENTAL HYGIENE SURVEY Table 15.-Mental Ages of 407 Children at the Kentucky Houses of Reform, Classified by Chronological Age Mental Age Total 10 11 12 13 14 15 16 17 18 19 20 21 III years .. 1 .. 1 IV years .... 1 .. 1 V years 1 .. 1 VI years . .. 9 .. 1 1 3 1 3 VII years .. . .. 31 .. 1 5 5 4 9 2 4 1 VIII years . .. 69 .. 3 2 2 9 9 15 18 9 2 EX years .... .. 100 2 6 5 6 6 12 9 33 17 2 2 X years .... .. 63 .. 1 6 1 8 5 16 13 9 2 1 1 XI years .... . . 49 .. 1 2 6 5 10 18 5 2 XII years . . . .. 28 .. 1 3 6 7 9 2 XIII years .. .. 27 .. 4 5 8 8 2 XIV years . . 8 .. 2 1 4 1 XV years . .. 6 .. 1 1 2 1 1 XVI years . . 3 .. 3 XVII years . 1 .. 1 Adult 5 .. 2 1 1 1 Not tested . . 5 .. 1 1 1 2 Total .. . .. 407 2 10 15 18 46 46 80 111 62 12 3 2 Mental Age: Table 15 shows the relation of mental ages (by test) to chronological ages among these children. It is note- worthy that only a very small number of these 407 children tested above age. Those who did were all white. Of the chil- dren under sixteen years of age, none tested at age, and only 1 was above age, while the remaining children whose mental ages were ascertained, were all below age mentally, in degrees vary- ing from one to twelve years. Eleven children were one year retarded mentally. One fourteen-year-old white boy was advanced mentally one year. All the other white boys under sixteen years of age were retarded. One fifteen-year-old white boy tested three years mentally. Ten were one year retarded, 15 two years, 16 three years, 15 four years, 7 five years, 14 six years, 9 seven years, 2 eight years, 1 nine years, and 1 ten years. Of the white girls under sixteen whose test ages were as- certained, 1 was one year retarded mentally, 1 three years, 4 four years, 3 five years, 5 six years, and 3 seven years. Of the colored boys under sixteen, 1 thirteen-year-old tested four years, 1 fourteen-year-old tested six mentally and 2 fifteen- STATE OF KENTUCKY 81 year-olds tested seven. Two more were two years retarded mentally, 4 three years, 2 four years, 4 five years, 4 six years and 2 seven years. The colored girls were all fifteen years old or over. Three of the fifteen-year-old girls tested nine mentally. Of the sixteen- year-old girls, 2 tested seven years and 2 eleven years. Two seventeen-year-old colored girls tested eight, 2 nine, and 1 eleven years mentally. One eighteen-year-old colored girl tested seven, and 2 nine years mentally. There was 1 colored girl twenty years old who tested ten. We realize that intelligence tests fall far short of measuring the capacity of a person for constructive social endeavor. These facts, however, and the general presentation of Table 14, when compared with results of similar tests with school children, ex- hibit clearly the extreme backwardness of these children at Greendale. School Advancement: The fact that these children had not, as a class, done well in school is indicated by the classification by school grade, which we present in Table 16. We found the white boys, for example, whose modal chronological age was seventeen, presenting their modal school grade as third, and, though these boys ranged up to twenty-one in age, we found only 4 in high school. The colored boys whose modal chronological age was seven- teen years, with 35 cases, presented the modal school grade of fourth with 27 cases. The white girls with a modal chronological age of seventeen years (24 cases) presented a modal school grade of the seventh, with 21 cases. This was the best age-color group showing, but even at that presented a retardation of three years by ordinary standards of school progress. The modal chronological age for the whole group of 407 was seventeen years, with 111 cases, while the modal grade was third with 87 cases. A seventeen-year-old child in the third grade was nine years retarded. 82 REPORT OF MENTAL HYGIENE SURVEY Table 16.-Mental Ages of 407 Children at the Kentucky Houses of Reform, Classified by Grade in School Mental age Total None 1st 2nd 3rd 4th 5th 6th 7th 8th In high school Un- ascer- tained II! years .. 1 1 I'V years .. 1 1 V years .. .. 1 1 .. .. VI years ... 9 2 5 2 .. .. VII years .. 31 1 12 12 3 3 .. VIII years . 69 1 6 21 28 8 3 1 .. 1 IX years .. 100 .. 1 13 30 24 19 3 9 1 X years .. .. 63 .. 1 4 14 17 7 8 6 6 XI years ... 49 1 5 9 12 7 5 10 XII years .. 28 114 5 4 10 3 XIII years . 27 .. .. 24 2 11 8 XIV years . 8 1 .. .. 3 2 2 XV years .. 6 1 1 3 1 XVI years . 3 1 1 • . 1 XVII years. 1 1 Adult 5 1 3 1 Not tested . 5 1 1 2 .. 1 Total .. 407 2 25 58 87 67 51 27 47 37 5 1 Recidivism: Even amongst these minors we found con- siderable evidence of repetition of offenses. Among the 407 children we found only 202 who claimed to have been ar- rested only once. One hundred and six claimed to have been arrested twice, 58 three times, and 41 four or more times. By the testimony of the subject himself, therefore, we have about as much evidence of repetition of offensive conduct in this group of children as amongst the adults in the penitentiary and re- formatory and in the county-jail populations. The children who had given repeated occasion for treat- ment at the hands of law officers were, by an analysis of our findings, somewhat more dominant amongst the mentally de- fective and psychopathic persons than amongst those of normal personality make-up. This emphasis, however, was not so de- cided as amongst the adult offenders. STATE OF KENTUCKY 83 g W Op o P g ® a, Ba c r- © H p ft 00 cc CD CD 3 ft. &- sr 5- 2. s cd I o' I £ CD [ opath oneui ion o nital g* CD 2 X so B ft 2. Q ? B p T3 T3 co ►© 3 crq B* c B r: <d . • £ p O . B ■ □2 . P CD H.--. CD . i : <5 CD o cd 4^ bO h- X O 00 XJ >-• □a o -J ^1 •c Total. .... Murder and man- tO .... slaughter. Forgery and obtaining 5 -• • to 3D money under false pretenses. o • • • ►- to -• o House breaking and O • • • Bl jo co => 35 burglary. Robbery, larceny and 2 • to to >- . H- tO to cd - X to 01 35 stealing. .... Malicious shooting and CD . . . . 4^ >- cutting. 4- . ce . H- . Cl X) DO □1 Sex crimes. 8 bD W • H- h- DO co 4^ b© L>D 3D Incorrigibility and delinquency. Truancy. to : : : w Vagrancy. Trainwrecking. • • • ►-* . . . Arson. . . . - : : : : to: Injuring property. to • • I pu Carrying deadly weapons. .... Running car without to .... h-» owner's consent. w bO Improper guardian- ship. ►-J : : : : Disorderly conduct. Table 17.-Offenses of 407 Children at the Kentucky Houses of Reform, Classified by Mental Diagnoses 84 REPORT OF MENTAL HYGIENE SURVEY Offenses-. In the consideration of juvenile offenses against the social order, we must always bear in mind the laudable tendency of courts to avoid stigmatizing the child as an offender. Therefore, the nature of the offense as stated in the record is often quite misleading. For instance, amongst the 49 instances of "sex crimes" in Table 17, 6 were attributed to white boys, 2 to colored boys, 4 to colored girls, and 37 to white girls, while the 120 instances of "incorrigibility and delinquency" were dis- tributed 54 to the 220 white boys, 15 to the 88 colored boys, 7 to 16 colored girls, and 44 to the 83 white girls; of the 201 instances of "house breaking, robbery, larceny and stealing", 140 cases were attributed to white boys, 56 to colored boys, 4 to colored girls and 1 to a white girl. It is highly probable that much of the "incorrigibility and delinquency" could be much more definitely specified. However, as matters stand, with these rather indefinite state- ments as to the nature of the offensive conduct of these minor persons, it is evident from the table that we have an undue proportion of the graver offenses among those whom we have diagnosed as mentally defective or psychopathic. Only two cases of murder or manslaughter were found. One of these, a white boy, was diagnosed as a mentally defective person. The other, a white girl, was normal as to personality make-up. But when we look at the sex crimes and the other crimes against property and the person, we find an undue percentage of these charges falling to persons diagnosed as defective or psychopathic. Discussion The importance of this exhibit of the types of offen- sive conduct does not consist in the kinds of offenses so much as in the fact that there are 407 children from whom have emanated anomalous and troublesome behavior. These children have failed in the public schools. They have failed with the probation officers of children's courts. Some of them are not yet adolescent. Most of them, however, are in the storm- and-stress period of youth, and this fact has much to do with their antisocial activities. Some of them are so young that the school can shoulder very little of the responsibility for their lack of socialization. The school has not had a fair op- portunity with them. They have been preordained to fail in STATE OF KENTUCKY 85 school because of the pre-school situation in the home and in the*neighborhood. School failures are shown by retardation in school work as well as by the antisocial behavior that has brought each to this institution. All conduct arises in the mind. The origins of activity are in the mental life. Of course, much activity is not clearly voli- tional. We do not deliberate and decide intelligently upon any large part of our activities. There are, however, various and numerous mental processes which are not distinctly rational and consciously guided and controlled. Nevertheless, there is a psychic factor in every bit of action. It may be mere feeling and emotion. It is involved in the liking of one person for oysters, and the dislike of another for navy beans. Because of the same sort of mental factor, one person dislikes navy beans and another person steals a bicycle. There is a mental cause in every case of truancy. One boy dislikes school; another boy dis- likes his father. These likes and dislikes are mental and they determine action. The abnormal types of behavior, represented in these 407 boys and girls, have originated, therefore, in their minds. The causes of these offensive acts are mental. They lie in the person- ality make-up of the individual. The mind and the personality make-up of the child are exactly what we are attempting to educate and adapt. The aim of the school is to develop, to draw out the mental forces and to organize the psycho-physical mechanism which we call a person. It aims to organize the whole of the person for efficiency and for happiness. These children have failed to organize under the kindly guidance of the public school, supplemented by probation officers of the chil- dren's courts. They are sent to the Houses of Reform as to a sort of over-school, where their difficulties will receive the attention of experts. The Houses of Reform are designed to deal with the especially knotty problems of youth, the difficult personalities. This institution is organized to take these difficult problems and fit them to take their places in productive in- dustry and in community life. Its purpose is to convert these community liabilities into community assets. 86 REPORT OF MENTAL HYGIENE SURVEY Mental Clinic Needed-. The matter of first concern to the Houses of Reform when the boy or girl comes to this institution should be to ascertain the particular nature of the problem that has made him an offender and that has prevented him from de- veloping a normal personality and progressing in his develop- ment along normal social lines. For this purpose, the institution needs a clinic wherein the child can be thoroughly examined and studied. The educational problems that have been missed by the home, the school, and the juvenile court should be set out clearly by such a clinic. Its personnel should make a complete physical examination, including neurological and serological studies of every entrant. It should study the home, developing the relationship of each parent, of the other children and of other persons in the family and in the neighborhood, as to the per- sonality difficulties of the particular child under study. It should study his educational attainments as well as the difficul- ties he encounters in learning. It should make a thorough- going study of his personality make-up, including a test of his intelligence, alertness, and learning capacity. Only by such a thorough sifting of the factors that have entered into the dif- ficulties of his present situation can the educational and re- habilitation agencies of the Houses of Reform be properly prepared to set about their task of making a new boy or girl of the young offender sent thither by the court. Only such a thorough examination, physical, mental, and social, can enable them to see the job to be done and to lay plans to tackle it in- telligently. Analyses that the survey made of the boys and girls found in the school at the time of this study afford a general view of the various kinds of educational problems that are presented to the staff of the institution for education and rehabilitation. Defective Delinquents: The fact that there are 109 of these children (more than 25 per cent) judged to be mentally de- fective does not necessarily mean that all of these children ought of necessity to be in the institution for the feebleminded in Frankfort. They are delinquents. The institution for the feebleminded is not provided with facilities for caring for de- linquents. We have seen that it is greatly overcrowded and STATE OF KENTUCKY 87 that it is handicapped both in personnel and material facilities, in both its medical and its educational work. Since, however, it is definitely designed for the training of the mentally hand- icapped, it would seem logical for the State to develop facilities at this training school for the training of all mentally handi- capped children of school age who cannot be successfully trained in the local public schools and in their homes. Defective delinquents, whether children or adults, constitute a special problem. Special facilities must be developed for con- trolling them during training if they are to be trained with the other mentally defective children at the institution for feeble- minded. They must be restrained from escape by special facil- ities. They should be separated from the non-delinquent in order to avoid contamination of the latter with their anomalous and offensive forms of behavior. On the other hand, if these defective delinquents are to be trained and rehabilitated at the Houses of Reform, special education facilities should de developed for them at this school. For the same reasons that we require special educational facilities (special classes) for mentally handicapped children in public schools, we should have special facilities for the feebleminded in the Houses of Reform. Children who are seriously mentally handicapped do not progress under ordinary instruction. They do not receive educational development from the curriculum as arranged for the average child. They demand and consume an inordinate share of the teacher's time and energy and act as a positive hindrance to the progress of the other pupils. Special facilities for the training of the mentally handicapped are a necessity in the Houses of Reform if these feebleminded chil- dren are to continue in this institution and are not to prej- udice and impair the proper training of the other children. The 31 borderline mental defectives found amongst these 407 boys and girls would probably be included in the special facilities for training defective and delinquent children, whether these are provided for at the institution for the feebleminded at Frankfort, or at the Houses of Reform at Greendale. Psychopathic Children: The 68 psychopathic persons found 88 REPORT OF MENTAL HYGIENE SURVEY amongst these children constitute a group of personality difficul- ties most of which have arisen by virtue of unfortunate situations in the home or in the neighborhood as a result of which the person has developed kinks and twists. Such persons have failed to develop normal, useful, and average social responses. Many of these developments are to be attributed to environ- mental forces working upon the child. These forces work through what has been termed social hered.ty. In other words, psychopathic persons are for the most part not born with these defects, as are the feebleminded. The mental defects of the psychopath are acquired by untoward forces and situations in the home, before and during school life, and in the school and the community. We should be able to prevent the development of many of these psychopathic persons. We should be able to prevent their becoming psychopathic. There are undoubtedly hereditary tendencies which favor the development of such kinks and twists. These tendencies should be observed, recognized, and dealt with by an intelligently or- ganized educational system. Psychopathic personality, in other words, should be diagnosed in the incipient stage of its develop- ment and special precautionary measures taken to prevent its further development. Until such preventive measures are generally adopted by our schools, these psychopaths will pro- vide the most difficult sort of problem for the industrial train- ing school. It is for handling problems of this sort that such schools have been organized. We may consider the normal, dull normal, and subnormal, which comprise about half the population of this school, as accidental delinquents and children for whom the public school and their homes have proved inadequate. The defects are in the homes and the schools. The State is called upon to main- tain, rear, and train these normal-minded boys and girls be- cause of the failure of the public school and the home in matters clearly within the respective provinces of these institutions. Comparison with 1917 Survey Findings: *In 1917, 463 * Report of the Commission on Provision for the Feebleminded in Kerk- tucky, by Thomas II. Haines, M. D. New York : The National Committee for Mental Hygiene. 1917, p. 23. STATE OF KENTUCKY 89 inmates (208 white boys, 50 white girls, 192 colored boys, and 13 colored girls) were found in the Houses of Reform by Dr. Haines and Dr. Young. Comparing this distribution by sex and race with Table 13 (p. 74) one finds now (1922) larger numbers both of white boys and girls and about half the number of colored boys (of 1917) making a total of 407. The institution is, there- fore, reduced 56 in population and very markedly reduced in its colored population. In 1917 we found 110 children whom we classed as mentally defective. Of these it was stated that two were epileptic and there was a question of epilepsy in another case. Two were probably suffering from mental disease (dementia praecox). One was classed as a psychopathic person, one as a sex pervert, and one as a spastic paraplegic. In 1922 an entirely different staff, without knowledge of the 1917 findings, classified 109 as mentally defective, 31 as borderline defective, 68 as psychopathic persons, 2 as epileptic, 1 as psychoneurotic, and 4 as congenital syphilitics. These results clearly bear out the similarity of the problems in this institution in 1917 and 1922. They certainly indicate that the conditions prevailing now are not new. They indicate that this Kentucky institution has been dealing with the same diverse problems of mental health through this five-year period. In this one institution such steps as shall now be taken to deal more rationally with its problems will be steps in the direction that has long been indicated by its problems. In the arrangements and organizations of the Houses of Reform, a mental-hygiene clinic, for the analysis of the personality problems of these children as they come to the in- stitution, is of fundamental importance. It is necessary to come to an understanding as to the nature of each personality problem before the rehabilitation of that person can be undertaken with any reasonable expectation of success. When the school has made arrangements for such personality studies, all training work for each should be adapted to his specific needs, as shown by clinical analysis. Conclusions 90 REPORT OF MENTAL HYGIENE SURVEY The mental defective presents quite a different problem from that of the normal child and also from that of the psychopathic child. The mentally defective child lacks capacity for social adaptation. Such is our social definition of feeblemindedness. This inherent lack of capacity for development and adaptation shows that the defective delinquent child should be dealt with by methods different from those adopted with other children. The defective delinquent group should be dealt with separately either at Greendale or in an institution for mentally defective children. Quite as important as the training in the school and its adaptations to the needs of each individual child is the parole or trial visit in the community of each child. His success in get- ting along in a small home and in his work outside the institu- tion marks the progress he has made in development. It sets the seal of success upon the training of the institution. It gives the child himself confidence and assurance. It really puts him into the position in the community that he should have occupied before he went to the training school. Nothing about the whole work of the institution is as important, therefore, as the selection of home and work for each paroled child and the supervision of the child during the time that his release is considered temporary and in the nature of a trial visit. STATE OF KENTUCKY 91 Pauper Idiots of Jefferson County A study of some of the "pauper idiots" of Jefferson County was made by Miss H. T. Reeves under the direction of Mr. Joseph P. Byers, Commissioner of State Institutions, in February, 1921. Mr. Byers put the results of this study at our disposi- tion. It seems desirable to review these results since they af- ford an important picture of mental deficiency as it exists in the community. Miss Reeves visited in all 96 persons in Jefferson County who were at the time on the payroll of the state as "pauper idiots." They had been declared dependent on account of mental deficiency and each had been awarded $75 per year from the State treasury by the circuit court. Of these, 80 w'ere white and 16 colored, 54 were males and 42 females. Age and Duration of Pension: In Table 18 we pre- sent the distribution of seventy-four of these dependents in re- gard to chronological age and length of time each had been re- ceiving his pension from the state. One person in the third decade of life had not received any payment of the allowed pension. In the cases of 21 others, the length of time each had been pensioned was not ascertained. Of these 21, 1 was in the second decade of life, 3 in the third, 4 in the fourth, 7 in the fifth, 3 in the sixth, 1 in the seventh and 2 in the eighth. The table shows the age distribution of the others. For the whole group of 96, the third decade of life is the modal period, with a total of 28. There is a total of 19 in the fifth decade and of 18 in the fourth. These 74 persons, whose years of pension in Jefferson County were ascertained in this study, had a total to their debit of 777 years. At the rate of $75 per person per year these 74 mentally defective dependents of Jefferson County have drawn from the 92 REPORT OF MENTAL HYGIENE SURVEY Table 18.-Ages of 74 Pauper Idiots in Jefferson County, Classified by Number of Years on State Support Age. Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 30 11-19 years ..12 1 1 1 3 1 1 2 2 20-29 years .. 24 1 2 2 1 2 1 4 4 1 1 1 1 2 1 30-39 years . .14 .. 1 2 1 1 1 .. 1 1 1 1 1 1 1 1 40-49 years . .12 .. 1 1 1 1 3 1 1 2 1 50-59 years . .3 .. 1 1 1 .. 60-69 years . .. 8 .. 1 2 1 1 1 1 1 70-79 years . . 1 .. 1 Total . . 74 2 4 3 6 4 2 4 5 6 10 1 3 2 2 2 4 2 3 2 3 1 1 1 1 STATE OF KENTUCKY 93 state treasury $58,275. In 1917 we found 2,200 such persons in Kentucky drawing $75 each, making a total annual draw of $165,000. The wastefulness of this mode of support has been seen and the statute has been annulled. Self-Support: Of these persons visited in Jefferson County (February, 1921) one was found working in a bakery and earning $16 a week; another had charge of the farm work at the Home for the Aged, and still another did the housework in the quarters of the superintendent of the Home for the Aged, without supervision. In another case the person who kept the beneficiary did not receive the pension. It went to the brother of the beneficiary, who lived elsewhere. Miss Reeves found 28 of these persons able to help with housework or farm work. Some of these she judged to be quite low in mental endowment. Two were adjudged as of four-year mental ability, 7 of five-year mental ability, 9 of six-year mental ability, and 6 of seven-year mental ability. Of the 68 whom she found unable to help with the housework or farm work, the majority were idiots in the accepted meaning of this term. She judged 27 of them to be of two-year mental ability or less. Eight were of three-year mentality. Several, however, of good mental ability were quite unable to take part in the simple duties of the farm home. One high-grade moron and 2 of eight- year mentality were described as unable to do any work. Such persons have been purposely kept without training in order to demonstrate their dependency to the court. Mental Equipment: Table 19 shows a distribution of these 96 persons according to estimated mental age and personal traits. A considerable number (17) were of low mentality and helpless. On the other hand, a number (8) who were of low- grade mentality were not helpless and were quite amiable and tractable. REPORT OF MENTAL HYGIENE SURVEY 94 Table 19.-Approximate Mental Age of 96 Pauper Idiots in Jefferson County, Classified by Personality Traits VII] IX Higl Not III £ II s B > A o E L t-grade moron. stated ears and under pproximate tai age «= o to h w h w to to X K) X -4 Total. Amiable, tractable, w to • • ►-< . co cn JI I-* b0 b0 C5 good-natured. Slow, particular. -1 • • • to • o to ►-। • Shy, diffident. "Paranoid." w 1 w 1 to 1 O1 1 1 . • • • >-• >-< H H • H-' H-i . • • • to • h-» • ►-1 • b0 Negativistic. Depressed. Talkative. Restless, irritable. Excitable. w 1 - H-< . • i . b0 • • ►- »-• b0 Outbursts of temper. Surly. oo I . . to to Ol o< to ►- ci Unascertained. Helpless custodial cases. STATE OF KENTUCKY 95 Information as to personal traits was not secured in 18 cases. Of the remainder, about one-fifth were helpless and one-third tractable and good-natured. The undesirable and less easily managed traits were scattered about in small numbers and about as many presented themselves among the higher-grade de- fectives as in the low grades. Of these 96 defectives, 16 were epileptic as well as mentally defective. Twelve others were paralyzed. Four were of the cretinoid type, and 2 were mongolians. Sixty-two were men- tally defective without other complications. Of these 96 persons, 12 were living in institutions, 10 in the Home for the Aged and Infirm, 1 in the Convent of the Good Shepherd, and 1 in St. Anthony's Hospital. Sixty-two others were living with their parents, 19 with relatives other than parents, and 4 were living in private homes with persons un- related to them. Miss Reeves estimated that 25 of these persons (17 white and 8 colored) were in need of institutional care. Behavior: The study of behavior anomalies among these persons shows that 2 exhibited uncontrolled sex impulses, 1 was a beggar, 8 were wanderers. The remaining 85 exhibited no conduct disorders and presented no problems to the community other than those of dependency. There is no relation between these few behavior anomalies and the stated mental ages of the subjects. Conclusions The state has done well, in view of our present knowledge of the mentally defective-how they originate and how they are best managed-to annul the "Pauper Idiot Act." The most important procedure in the management of such persons is to train them when young, so that they shall be rendered self-supporting or as nearly so as possible. This statute operated to place a premium upon dependency; the 96 REPORT OF MENTAL HYGIENE SURVEY less training, the more dependent. Therefore, it operated to keep feebleminded children away from the state institution for feebleminded, away from the public school and from the train- ing that many receive in farm homes. Now that this obstruction to the best ministration to the needs of defectives has been removed, provision for the proper training of all mentally handicapped children in special classes in the public schools and in state institutions should be effected speedily. Provision should also be made for state supervision of all older defectives in the community. Many of them remain child- ren and have no proper relatives or friends to lean upon as children do upon their parents. Adequate supervision organ- ized from the State Board of Charities and Correction would prevent most delinquencies of the feebleminded in the com- munity. STATE OF KENTUCKY 97 FAMILY STUDIES It seemed worth while to make some family studies of de- pendents and delinquents in neighborhoods where these prob- lems seemed to be connected with mental deficiency. Such pic- tures as we are able to present by chart and description bring home very clearly the complicated social problems involved in defective human stock. We have been so under the spell, in recent years, of the influence of heredity that there has been a tendency to neglect the development of facilities for the train- ing of mentally handicapped children. These people have been cared for in institutions, and in many cases it is a question whether the institutions-state, county, and private-are giving them the kind of service that is best calculated to develop them into real community assets. Left without training, they cer- tainly do develop into liabilities of a very expensive sort. Our public schools and our other institutions, no matter how apt we are to forget it, are service stations. The service each one of these institutions is designed to perform is that of building or rebuilding personalities. These family studies re- veal numerous cases in which such service has been attempted, but not rendered. They also reveal numerous cases in which no service has been attempted, and some instances of service at- tempted along quite improperly conceived lines. Service that is directed toward giving temporary relief only is no real ser- vice. It tends to break down the personality rather than to build it up. 1. Dr. See's Choreic Family. Among the rural dependents and ne'er-do-wells of Kentucky, a family now numbering about 900 persons and living in the sand belt between the blue-grass region and the mountains has been studied by Dr. Sherman See of Mount Sterling* and W. S. Anderson of the University of Kentucky, t The family traces back to a pioneer who came into this region * Huntington's chorea in Montgomery County, by Sherman See, M. D_ Kentucky Medical Journal, Vol. 21. No. 5, pp. 226-228, May, 1923. t The Effect on the Germ Plasm of Isolation in a Mountain Section, by W. S. Anderson. Eugenics, Genetics, and the Family. Vol. 1, Proceeding Second International Congress of Eugenics, pp. 297-302. Baltimore: Williams and Wilkins Company, 1923. 98 REPORT OF MENTAL HYGIENE SURVEY about one hundred and fifty years ago. This man had, according to Dr. See, well-defined symptoms of Huntington's chorea. A son of his married into a low-grade feebleminded family. The descendants of this son have closely intermarried and his pro- geny now afford numerous instances of Huntington's chorea, and the whole group are very low in mental endowment. They do not go to school. They marry early. They have large families. The incidence of infant mortality is great. The onset of the symptoms of Huntington's chorea comes in earlier years in the succeeding generations. These people are peculiar. They have outbursts of temper as well as the involuntary move- ments incident to Huntington's chorea. The petty crimes of the feebleminded are frequent amongst them. Their own short- comings have isolated them from surrounding communities. They are on very poor land which can hardly support them. If they were upon an island and lived entirely by themselves, they might become extinct. Situated as they are, close to one of the best agricultural regions in the country, they are likely to present heavy bills of expense to the community in the near future. . 2. The Sh. Group. A family of dependents in whom a social worker sees no improvement after many years of assist- ance rendered shows how help may be extended without profit. The help that has been given this family should have been given after a thorough understanding of mental conditions had been reached. One must know the kind of personality with which one is dealing and the personality difficulties from which the individual suffers before one. can extend help in such a way that the individual may develop the ability to> help himself. Many of the children of this family are now in the public schools. A mental and social study of them would bring to light the causes of the dependency and the shiftlessness that have characterized the family. Our studies have not been ex- haustive. We do find syphilis and mental deficiency in the fam- ily. We find this mental deficiency in mother and three child- ren in one instance and in mother and two children in another instance. STATE OF KENTUCKY 99 Three fraternities (family groups) of school children were studied. A syphilitic father and a feebleminded mother have three feebleminded children. A nephew of this man and his feebleminded wife have six children, one of whom is a borderline defective and another definitely feebleminded. Another nephew of the father of the first group has four children, one of whom is a borderline defective. The paternal stock is poor in these cases. These men, however, seem to have been particularly un- happy, so far as their children are concerned, in selecting feeble- minded wives. It is as important that parenthood be denied to persons infected with syphilis as to feebleminded persons. The head of one of these family groups was J. R. Born in 1863, he was an illiterate of the dull, plodding type. He always worked hard as a miner and farmer, but was never able to get anything ahead. When forty-five years old, he married a girl of fifteen. He was infected with syphilis at the time. He died in 1916, at fifty-three years, of kidney trouble, leaving his wife and three children in very poor circumstances. His wife soon married a man seventy years old for her second husband, blit- he has not been able to provide adequately for the family be- cause of old age and poor health. This woman is now twenty-nine years old, illiterate, and very slow in all her reactions. She cannot sew, can cook only the simp^st foods and these very poorly, and keeps a very dirty house. She is a mentally defective person. She and her first husband had three children. a. A girl, fifteen years and three months old, is in the third grade in school. She has repeated both the second and third grades. On the Stanford-Binet scale, she had a mental age of 7 years and 9 months. She has a speech defect. There is a question of anomalous sex behavior here. She is a mentally defective person. b. A boy, fourteen years old, is in the second grade in school. He has repeated both the first and second grades and is at present doing very poor work. He is poorly de- veloped physically. On the Stanford-Binet scale he made a mental age of 5 years and 9 months. He is a mentally de- fective person of low grade. 100 REPORT OF MENTAL HYGIENE SURVEY c. A girl, seven years and three months old, is repeat* ing the first grade in school. She has a speech defect. She is somewhat deaf, and has Hutchison teeth. On the Stan- ford-Binet scale she has a mental age of 4 years and 3 months. She is a mentally defective person. The head of the second family group, K. R., is a nephew of J. R. whose family has been described above. K. R. is thirty years old. He did not get beyond the second grade in school. He now works irregularly in the mines. He is a shiftless fellow who moves often from place to place to avoid paying his bills. He married into a family in which there are several cases of low-grade mental defect. His wTife is twenty-nine years old and so much undersized that she might almost be called a dwarf. She left school at eighteen years when in the fifth grade. She keeps a very dirty house and does not know how to care prop- erly for her children. The nurse who has visited in her family says that she cannot be depended upon to carry out the simplest instructions in regard to the care of her babies. She is a mentally defective person. They have had six children: v a. A boy, ten years and five months old, is in the third grade in school. On the Stanford-Binet, he made a test age of 7 years and 9 months. His mother says that he is very helpful about the house. He is a borderline mental defective. b. A girl, seven years and eleven months old, is not yet in school. On the Stanford-Binet scale she has a test age of 4 years and 6 months. She is a mentally defective child. c. A boy, five years and three months old, has a test age of 3 years and 6 months. He is a borderline mental defective. d. A girl, three years and ten months old, has a test age of 2 years. She is retarded in her mental development. e. A girl, fifteen months old, cannot walk or talk. f. A boy, one month old. J. B., whose intelligence is below the average, a second STATE OF KENTUCKY 101 nephew of J. R., heads the third family group. He is a first cousin of K. R. He is thirty-five. He works as a digger in the coal mine about two months out of each year. We have no description of his wife. They have four children. a. A boy, fifteen years old, is doing average work in the eighth grade. He made a mental age of 11 years. He is a dullard. b. A boy, thirteen years old, does fair work in the sixth grade. He made a mental age of 9 years and 7 months. He is a dullard. c. A girl, eleven years and eleven months old, is doing fair work in the third grade. She has repeated both the first and second grades. Physically she is in good condi- tion. On the abbreviated Stanford-Binet scale she made a mental age of 7 years. She is an extremely timid and shy child. She seems to be best classified as a borderline mental defective. d. A girl, nine years and nine months old, is doing good work in the fourth grade in school. She made a men- tal age of 7 years and 6 months on the Stanford-Binet and was diagnosed as a dullard. The families of four other nephews of J. R., all the four being of one fraternity, have received aid from the same social worker for a period of several years. They have also been visited by the county nurse. We visited none of these- families, and have, therefore, no examinations of the children. All were living in dirty, poorly managed homes. Two family heads worked irregu- larly. Both lacked ambition. The other fathers had died. The mothers were in poor condition physically. The children of one of these families subsisted mostly upon scraps thrown away from a nearby dormitory. 3. The W. Family. A partial studj yj here mad? of the family of J. W. These family groups, each showing some person mentally defective, all trace back directly to "Old Jim," THE W FAMILY STATE OF KENTUCKY 103 who married successively two of his cousins. The parts of the family here studied present three instances of "pauper idiots," several years of residence in the county poorhouse, one child at the institution for the feebleminded and two at the Houses of Reform. Syphilis, chorea, trachoma, mental deficiency, and heavy child mortality characterize the family. These people frequently marry mental defectives. They of- ten have large families born and reared out of wedlock. Mar- riage means little to them. They live more like savages of the jungle. They have little appreciation of the purpose of schools. The public school, so far as it has influenced them, has done no more than scratch the surface in the way of training these child- ren. The other institutions to which they have been presented have performed no real reconstructive work upon them. Noth- ing in the way of prevention of such conditions has been brought about. Reference to the chart (p. 102) shows that only three of the 13 children of "Old Jim" have been studied here. One of these had seven children, only one of whom has been studied. Num- erous other family groups have been omitted for want of time for fuller study. It has been stated that every one of these lines would have proved as rich in cacogenics and social prob- lems, if we could have followed them out, as those presented here. "Old Jim" is remembered by some of the older residents of the neighborhood as being much below the normal order of intelligence and also as having possessed a very low standard of morals. We have no description of either of his wives, both of whom were cousins to him. 1. One of the children by his first marriage was Bill. He is still living, is about eighty years old, blind as a result of trachoma, and crippled by a badly set broken leg. He is a mentally defective person. His wife, seventy-six years 104 REPORT OF MENTAL HYGIENE SURVEY old, is also mentally defective, though of a somewhat higher grade than her husband. Bill and his wife have had twelve children, eight of whom died in infancy. Of the four living, descriptions follow: a. M. W., fifty-five years old, a female, has been a pauper idiot for fifteen years, and has the intelligence of a three-year old child. She shows few physical stig- mata, attends to her personal wants, but says only a few words and is contented to stay in her chair most of the time. She is subject to attacks of violent temper. She lives at home with her parents. b. W. W., a male, is about thirty-eight years old, with an intelligence of about 6 years. He has been a pauper idiot for fifteen years. He is cheerful and will- ing, but is of little help to his father on the farm. This group of four mental defectives, M. W. and W. W. and their parents, live in a lopsided cabin with scarcely any furniture. The father owns the cabin and seven acres of very good land, but, when visited, he and his wife were in such poor physical condition that they could get about very little. This leaves the responsibility of carrying on the place to the two mentally defective children. Consequently there are times when they do not even have wood for the fire or food to eat. And the matter of planting and caring for crops is entirely outside of the range of their abilities. c. L. W., a female, fifty-two years old, went to school three years, but cannot read or write. She is emaciated. She is probably a mentally defective person. She was very much upset at the situation in the home of her parents, but did not know what to do about it. She married her first cousin, J. W., who is fifty-two years old, and has had three children. (1) A. W., male, w7as born in 1893 and died in 1915, at twenty-two years of age, of pneumonia. He was un- able to talk or attend to his personal wants. (2) A female was born in 1894 and died in infancy. (3) C. W., a female, twenty-seven years old, never went to school and cannot read or write On the Stan- ford-Binet scale she had a mental age of 9 years. She is a mentally defective person. She says that she could STATE OF KENTUCKY 105 not go to school because she had to stay home and take care of her idiot brother. She keeps a fairly clean house and met the visitor in a friendly way. She is married and has one child, three years old. This child, a boy, is restless and excitable and hard to manage, but seems to have developed normally up to the present time. d. B. W., a female, thirty-six years old, never went to school and cannot read or write. She has a speech de- fect and is probably a high-grade feebleminded person. She married a man who seems fairly intelligent and who owns the forty acres of land on which they live. They have one child, a boy of four and a half years. On the Stanford-Binet scale he made a mental age of 2 and one-half years. He is a stubborn, self-willed child. 2. By his second marriage to another cousin, "Old Jim" W. had a son, Pete. Pete was born about 1846 and died an old man. He was remembered as of low-grade in- telligence. He managed to keep his family by working as a farm hand. His widow, L. F. W., is now about seventy- five years old. She does not know her age. She has been in the county poorhouse for ten years. She has defective hearing and vision and suffers from Bright's disease. Peo- ple who knew her when she was younger say that she has always been dull and slovenly. At the present time she cannot do any work and does not keep herself clean. She and her husband had seven children. This family, when the children were small, lived in a dirty little cabin. When it burned down they moved into a square pen built of split rails where they lived for some time with no furniture of any kind, not even beds or dishes. The story is that they lived on corn meal and soap grease and that their relations were like those of animals. Descriptions of their seven -children follow: a. F. E. W., a female, forty-four years old, was an inmate of the same county poorhouse in which her mother is now living for four or five years and is re- ported to have been a low-grade mental defective. She had nine illegitimate children, the fathers of whom are unknown. Six of them died in infancy. Two of the three now living are reported to be somewhere in In- diana. Nothing is known about the order of their in- telligence. 106 REPORT OF MENTAL HYGIENE SURVEY b. M. W. K., a female, forty-two years old, went to school very little and says that she could not learn. She was unable to give facts about the members of her fam- ily-didn't know her own age or the ages of her child- ren. The two-room cabin in which she lives was dirty and almost devoid of furniture. She is reported as suf- fering from choreic symptoms (Huntington's chorea) and syphilis. She is almost blind. Her husband is de- scribed as a worthless fellow, but of better intelligence than his wife. They have had twelve children, of whom seven died in infancy. Descriptions of the five living follow: (1) A girl, twenty years old, reached the fourth grade in school and married a man who is a tenant farmer and is getting along fairly well. (2) A girl, eighteen years old, is spoken of even in her low-grade family as "not right" mentally. She has a decided speech defect, defective hearing, a strab- ismus, and is undernourished. She could not answer questions about her history. She cannot read or write, although she went to school several years. She keeps a dirty cabin and feeds her family on corn meal prac- tically all the time. She is a mental defective of the imbecile grade. She is married to a tenant farmer, thirty-five years old, who seems unintelligent and slov- enly. She also has a child two years and one-half old who is a hunchback and unable to walk of talk. This child is probably a mental defective. (3) A girl, seventeen years old, is unmarried and is living with her oldest sister. She reached the third grade at school. Sometimes she works out, but most of the time she stays with her sister. She is reported to have a poor order of intelligence. (4) A male, fourteen years old, is in the third grade in school and on the Stanford-Binet made a mental age of 8. He is very small for his age and is a mental de- fective. (5) A girl, eleven years and eight months old, is in the third grade at school. She is described as the the brightest one of the family. On the Stanford-Binet she made a mental age of 8 years and 3 months. She is a borderline defective. STATE OF KENTUCKY 107 c. R. W., a female, died in 1916, of tuberculosis, when about thirty-three years old. She had been in the county poorhouse for a short period and was said to have, been a low-grade mental defective. She has six illegitimate children who she claimed were all the child- ren of her sister's husband. Three of these children died in infancy. Descriptions of the other three follow: (1) A male, twenty-six years old, has been a pau- per idiot for about ten years. He has a mental age of about 7 years, is deaf, has a speech defect, and is able to do work only of a very simple sort. He cannot drive a horse or take care of stock. He was brought up in the home of the man reputed to be his father. (2) A female, twenty-five years old, went to school for a while, but says she cannot learn. She did not know her own age or that of her children. She could not tell the month of the year. Her cabin and her children were dirty. She has a speech defect, and is a mental defective. She married a tenant farmer and has two children, five and three years old. The youngest child is just beginning to pronounce words and the older child is much retarded in development. (3) A male, nineteen years old, cannot read or write, has a bad speech defect, and is almost blind. He was not seen, but from description probably is a mental defective. d. E. W., male, forty years old, has never married and spends his time tramping from place to place. He is reported to have a low order of intelligence. e. C. W., a male, born in 1834, was murdered sev- eral years ago while walking along a railroad track. He never married and was reported to have been men- tally defective. f. J. W., female, thirty-seven years old, has never been to school and cannot read or write. She has been an inmate of the county poorhouse for the last ten years. On the Stanford-Binet she has a mental age of 5 years and 3 months. She is an imbecile. She is very fat. She complains of "smothering spells," and has a history of syphilitic infection. She has a speech defect and a strabismus. She has had seven illegitimate children, three of whom were born at the county poorhouse. Three of her children died in infancy. Accounts of the four remaining follow: 108 REPORT OF MENTAL HYGIENE SURVEY (1) A male, twenty-one years old. cannot count, read, or write and drifts about the country working here and there as a farm hand. No employer will keep him very long. He is reported to be as low grade in intelligence as his mother. (2) A boy, eighteen years old, was described as like his older brother and with him wanders about the coun- try. (3) A boy, fourteen years old, is an inmate in the institution for feebleminded, where he is classed as a low-grade imbecile. He is able to dress himself, but can- not do any work. (4) A girl, seven years old, according to her mother was sent to the Kentucky Children's Home about five years ago, but the records of the Home do not show that she was ever received by them. g. G. W., a male, thirty-five years old, is reported to be of the same low order of intelligence as the other members of the family, and to spend his time wandering from place to place. He has been married and has one child. His wife is at present living with his nephew. 3. Maria (see chart) died several years ago. We have no description of her. She was married to her second cousin, a man who is now living at the age of eighty years. He is reported to have a somewhat higher order of intelli- gence than the other members of the family. He and his wife had seven children of whom we have description of one only: a. D. W., fifty-two years old, cannot read or write and is unable to do any work of a higher order than bringing in wood. Once in a while he is employed for short periods at road work. He and his family spent one winter in the county poorhouse «and at the present time his family is being supported by the county. He is a men- tal defective of the imbecile class. He has a speech defect and paralysis of the right side. He is almost blind, probably from trachoma, and gives a history of syphilis. He married his first cousin, who is now forty years old and whose intelligence is about on a par with that of her husband. They live in a two-room cabin in which one chair and one bed seem to be the only articles of furniture. When interviewed, she was sitting in front of a fire smoking a pipe. She had a vacant expression and was very slow in her reactions. She also gives a STATE OF KENTUCKY 109 history of syphilis. The social worker who visited the family observed a baby, two years old, lying on the bed, with three blankets pulled over her face. When asked why she covered the baby's face, the mother replied it was because the baby was so fat that she caught cold easily. D. W. and his wife have had six children, of whom two died in infancy. The four living are as follows: (1) A girl, nineteen years old, has left home and is working in a factory in a nearby town. (2) A boy, seventeen years old, left school at fifteen years when in the third grade. He was sent to the House of Reform at Greendale for house breaking and when seen by the social worker was out on parole. He was spending a good deal of time riding freight trains and was bragging a good deal about his delinquencies. He has no insight into his situation. He seems to be a mental defective. He was said by former teachers to be of lower grade intelligence than his younger brother, twelve years old. (3) A boy, twelve years and nine months old, is in the third grade at school, where he is doing poor work. He is at the House of Reform, where he was sent for stealing chickens and for truancy. On the Stanford- Binet he had a test age of 7 years and 9 months and was diagnosed as a feebleminded boy. (4) A girl, two years old. A doctor who saw her, when she was a year old, reported that she was suffering from congenital syphilis. 4. The P. Family. The P. family is presented by chart and description as an exhibit of the delicacy of some mental-defi- ciency problems and of some of the intricacies with which any effective eugenic control would have to deal. We find here un- mistakable evidence of an inbred mental deficiency, a congenital deafness, and speech defects as well as "peculiar" personality traits amounting to psychopathic trends. The grandmother, E. S. P., of five fraternities of school THE P FAMILY STATE OF KENTUCKY 111 children is a peculiar person. She is of unknown age, apparently about seventy. Those who have known her a long time say that she has always been considered "peculiar." She is irritable and self-centered. She is said to have attended school but she can- not read or write. She is probably mentally defective. Her husband, grandfather of these school children, was killed more than thirty years ago by accident. We know noth- ing about him. After his death his widow placed her seven children in homes and had nothing to do with them until they grew up. Two of these seven children are mentally defective. One of them married his first cousin, who is psychopathic. They had eleven children, three of whom are mentally defective, two deaf, and one a psychopathic person. Three died in infancy. The two mentally defective daughters (of the progenitor's seven children) married men who are incompetent, but seemingly not mentally defective in the ordinary sense of that term. One of these has three children, one a psychopathic person and one a borderline defective. The other has six children, four of whom are mentally defective. Two other sons of the progenitors, not defective themselves, have married. One has five children, the oldest of whom is a delinquent. The other has two children, the oldest of whom is a mentally defective child. The other two sons of the progenitors have remained single so far as known. They live in distant parts and were not visited. Description of the seven children of E. S. P. and of her grand- children follow: 1. F. P., a female, fifty-one years old, born in Ken- tucky, left school at fourteen years, when she had finished third-grade work. She can barely read and write. In giving her family history, she said that her sister had five children and then named six. When asked if she had named five or six, she insisted that there were five. Again, she was not clear as to dates of birth and death of her own child- ren. Her physical condition is not good. She is very much 112 REPORT OF MENTAL HYGIENE SURVEY underweight and has what she calls chronic bronchitis. She is loud and noisy and a very poor housekeeper. She is a mentally defective person. She married D. P., a saw- mill hand. He has not always been able to make a living for his family. They have moved seven or eight times in the last two years and have received assistance from the district nursing association. They have had three children: a. M. P., a girl, twenty-six years old, was born in Kentucky. She reached the fifth grade at sixteen years, and married immediately after she left school. She im- pressed the worker as a quarrelsome, irritable, com plaining person of the dullard type. Her husband is a painter and she has two children. (1) A boy, six years and eight months old, just started to school, where he does fair work. On the Stan- ford revision of the Binet scale he made a mental age of 5 years and 6 months. He was diagnosed as a dullard. (2) A girl, four years old, seems to be normally developed. b. K. P., a girl, twelve years and six months old, is in the fifth grade in school where she does poor work. She tries hard, but cannot learn. On the Stanford-Binet she has a mental age of 9 years. She was diagnosed as a borderline mental defective. She has a normal type of personality. c. A child wds born in 1914 and died in 1918 of in- fluenza. 2. T. P., a male, forty-nine years old, was born in Ken- tucky. He can write his name and read a little. He has been a tenant farmer, but his last landlord complained that he had lost $2,000 in two years through T's stupidity and unreliability. His family have had to be helped many times by individuals. There are no relief agencies in the section in which they live. He is certainly of the dullard type if not lower in the scale. He married his first cousin, J. D. She is forty-six years old and reached the fourth grade at fourteen years. She is very fat, and keeps a dirty house with almost no furniture. She is so irritable and suspicious that the children in her community are afraid STATE OF KENTUCKY 113 of her. She is of the dullard type. She and her husband have had eleven children. a. A boy, twenty-eight years old, completed the sixth grade at fifteen years of age. He works in a blacksmith's shop and has the reputation of being a hard-working man. He was eight months in the army during the war. He is reported to have a violent temper, to be sullen, suspicious, irritable, and ' ' grouchy. ' ' He was diag- nosed as a psychopathic person. He married I. R., an ignorant woman, but a neat housekeeper. They have one small baby. b. S. P., a girl, twenty-six years old, is married and living in a distant city. A former teacher reports that she had normal intelligence. c. H. P., a boy, twenty-three years old, is congeni- tally deaf. He attended the State School for the Deaf and is now at home helping his father with farm work. He has learned to talk a little. d. L. P., a girl, seventeen years old, left school at sixteen years when she was in the fourth grade. She repeated the first, second, and third grades. She has a speech defect. On the Stanford revision of the Binet she made a mental age of 7 years and 9 months. She is a mental defective with an inadequate type of per- sonality. e. J. P., a boy, thirteen years old, is in the fourth grade at school. On the Stanford-Binet he made a test age of 9 years. He is a mental defective. He has a slight speech defect and a rather emotional make-up. f. M. P., a girl, eleven years old, is deaf and at- tended the State School for the Deaf. g. and h. Two girls died in infancy. i. K. P. a girl, eight years old, is in the first grade at school. She made a test age of 4 years and 9 months and is a mental defective. She has a marked speech defect and is very timid. j. W. P., a boy, five years and two months old, is a very timid child and cries easily. On the Stanford- Binet, he had a mental age of 4 years and 3 months. k. A girl died in infancy. 114 REPORT OF MENTAL HYGIENE SURVEY 3. B. P., forty-six years old, has no children. 4. C. P., forty-four years old, is unmarried. B. P. and C. P. were living in the same distant locality. No de- scriptions were obtained. 5. J. P., a male, was born in 1884 and died in 1916, at thirty-two, of typhoid fever. He had been a heavy drinker. He married M. C., who is now forty years old. She never went to school. She is a very talkative, emotional person. After the death of her husband, she placed her children in homes and took a position as saleswoman in a clothing store. She was diagnosed as a dullard. She had five children: a. A. P., a boy, twenty years old, was considered "incorrigible" and finally joined the navy. b. S. P., a boy, seventeen years old, left school at fifteen when in the sixth grade. He is now working on the farm of the people who brought him up, for his board and clothes. He is said to be good help, but lacks ambition. c. J. C. P., a boy, thirteen years old, is in the sixth grade in school. He is considered a normal child. d. H. P., a boy, eleven years old, is in the seventh grade. He has normal intelligence. e. A. P., a boy, eight years and eleven months old, is in the second grade at school. He made a mental age of 7 years and 9 months on the Stanford-Binet. He is a normal child. 6. B. P., a female, thirty-six years old, went to school about three years, but cannot read or write. She suffers from "chronic appendicitis." She has very badly abscessed teeth. She is lazy and keeps a dirty house with almost no furniture. Her children are ragged and dirty. She has the appearance of a mental defective. She married J. J., a tenant farmer, who is ignorant, shiftless, and unable to make an adequate living. They have had six children. a. A girl, twenty years old, left school at sixteen when in the fourth grade. On the Stanford-Binet she had a mental age of 8 years and 9 months and was diagnosed as a mental defective. Her husband is about thirty years old and has been arrested for bootlegging. She has two children, two and one years old, respectively. STATE OF KENTUCKY 115 b. A boy, eighteen years old, left school at sixteen years when he was in the fourth grade. He lives at home and helps his father on the farm. Nothing was ascertained about his intelligence equipment. c. A boy, sixteen years old, left school at fifteen when in the third grade, after having repeated all three grades. His mother refused to allow him to be given an intelligence test, saying that he was weak-minded and never could learn. He is very bashful and stays at home helping his father. d. A boy of twelve, testing 7 years, 3 months, and in grade 3, has repeated two grades and is mentally defective. e. A girl, ten years and ten months old, is in the fourth grade at school, where she does poor work. On the Stanford-Binet she makes a mental age of 6 years and 9 months and was diagnosed as mentally defective. She is a boisterous, egotistical child. f. A girl, two years old, is able to walk and talk. 7. L. P., a male, thirty-four years old, formerly worked on a section gang. He gave that up and became a tenant farmer. He is at present barely making enough to get along. He married a woman who has the reputation of being sexually immoral. They have had two children. a. A girl, fifteen years and six months old, is in the seventh grade at school, where she does poor work. She repeated the sixth grade. On the Stanford-Binet she made a mental age of 9 years and 6 months. She is a mental defective. b. A girl, fourteen years and one month old, is doing good work in the eighth grade. She is very much overweight. On the Stanford-Binet she made a mental age of 10 years and 6 months. She is a dullard. 5. The II. Family. We find this family group of sixteen children mostly of school age and in school. Their three mothers are sisters. The situation can be set out so clearly by description that a chart seems unnecessary to exhibit the public-health and educational problems, and the possible field for eugenic control that this family presents. Of the sixteen children, eight are mentally defective, two are borderline defectives, one is a psychopathic person and one other has a court record. 116 REPORT OF MENTAL HYGIENE SURVEY One mother of eight (four mentally defective, one psycho- pathic, and one with a court record) is herself a mental de- fective. Her husband, and the father of her children, is a psychopathic person and is afflicted with pellagra and asthma. Her sister, the mother of five children, (three mentally de- fective and one borderline) is herself a mentally defective per- son afflicted with pellagra. The other sister, mother of three children, (one mentally defective) appears to have been mentally defective, but her husband seems to have had average intelligence. This mother, however, died some years ago of tuberculosis. These women had three brothers. No study has been made of them or of their families. One brother, about forty-seven years old, is reported to be a mentally defective person. He has eight children, all said to be dull, but about whom no definite facts were obtained. The other two brothers married. They are said to be doing very well. The grandfather, J. H., father of the three sisters described below with their children, died several years ago of tuberculosis. He is reported to have been ignorant, dull, and of a "mean disposition." His wife is now' living and is dependent upon her children for support. We have no gauge of her intelligence. 1. M. H., the mother of eight children (four mentally defective and one psychopathic), is fifty years old and suffers from asthma and pellagra. She cannot read or write. She appeared very dull when interviewed. She keeps a dirty house and allow's her children to go uncared for. The family doctor says that she is unable to carry out the simplest orders in case of sickness. The father of these eight children is a man fifty-four years old who works as a drayman and farmer. He is an irritable, complaining person, illiterate, but honest and hard-working. He suffers from rheumatism and asthma. He is dull. Descriptions of their children follow: a. A girl, twenty-three ' years old, left school at sixteen when she was in the fourth grade, has since married, and now has two children. According to their family physician, she is a mental defective. STATE OF KENTUCKY 117 b. A boy, twenty years old, left school at sixteen when in the fourth grade. He now spends most of his time at home, but works occasionally in the coal mines. He has been in court twice for "disturbing the peace." He is at best a dullard. He may be lower in the scale of intelligence endowment. c. A boy, seventeen years old, left school at six- teen when he had finished the third grade. His former teacher says that he was not able to learn at all. He is at the present time working irregularly in the coal mines. He is probably a mentally defective person. d. A girl, fourteen years and two months old. She is doing good work in the fifth grade in school. On the Stanford-Binet she made a mental age of 8 years, but was emotionally upset while being examined, so per- haps would have rated higher under other conditions. She is an excitable child, rather self-centered and lack- ing in ambition. She is a psychopathic person. e. A boy, twelve years and eleven months old. does poor work in the second grade. He has repeated several grades and has been a great trial to his teacher. He laughs all the time, becomes excited easily, and cannot concentrate his attention on anything. On the Stanford- Binet he made a mental age of 6 years and 9 months. He is a mentally defective person. He has recently been expelled from school on account of his trouble- some behavior. f. A male, ten years and eight months old, is in the first grade in school which he has repeated three times. He has a speech defect and on the Stanford- Binet made a mental age of 6 years and 6 months. He is a mentally defective person. g. A female, eight years and seven months old, is in the first grade, which she has repeated once. On the Stanford-Binet she made a mental age of 6 years and 6 months and was diagnosed as a dullard. h. A male, six years old, has not yet entered school. He made a test age of 4 years and 3 months. 2. A. H., a sister of M. H., about forty years old, is unable to read or write. She appeared very unintelligent in conversation. She suffers from pellagra and asthma. She lives in a very dirty house, of two rooms, with almost 118 REPORT OF MENTAL HYGIENE SURVEY no furniture. Her husband is dead. When visited, she and her five children were in need of relief. Descriptions of her children follow: a. A girl, sixteen years old, is in the fifth grade at school. On the Stanford-Binet she made a mental age of 8 years and 6 months. She is a mentally defective person. She does most of the work about the house. She chops the wood and does what housekeeping is done. b. A girl, twelve years old, started school at seven years and is still in the first grade. On the Stanford- Binet she rtiade a mental age of 6 years and 9 months. She is a mentally defective person. She was living with a cousin who has a clean and orderly home. c. A male, eleven years old, is in the first grade at school. He is unmanageable at home, refuses to help with the work, and has outbursts of. temper. He is probably a mentally defective person. d A girl, five years and seven months old, is under- nourished and sick a great deal with gastro-intestinal disorders. On the Stanford-Binet she made a mental age of 3 years and 9 months. She is a borderline mental defective. e. A boy, one year and ten months old, seems co be in good physical condition and can walk and talk. 3. F. H., another sister of M. H. died at thirty-one of tuberculosis. < We have no information concerning her intelligence. Her husband is foreman of a section gang on the railroad and earning a good living. They had three children. a. A boy, fourteen years and six months old. is in the second grade in school. He causes trouble both at home and at school. On the Stanford-Binet he made a mental age of 7 years and 3 months. He is a mentally defective person. b. A boy, twelve years old, is doing good work in the fifth grade. He has a mental age of 10 years and 6 months. c. A girl, six years old, has a mental age of 5 years. 6. The K. Family. In this family group we have for consideration eighteen children of two mentally defective STATE OF KENTUCKY" 119 brothers. Most of the children were found in the public school. One fraternity of twelve (five mentally defective, two border- line defectives, and two who died in infancy) were mothered by a mentally defective woman. The other lot of six (three mentally defective) were mothered by a woman who was a men- tal defective and a sex delinquent. These two family groups were living in two tumbledown cabins set back three-quarters of a mile from the highway. The larger group of eight children at home (twelve births) lived with their father and mother in three rooms. These were fairly clean and well-kept. The widow of the other brother and her six children were living in two cold rooms. There were large holes in the floor. They had almost no furniture. Their house was nothing more than a very poor shelter. 1. J. K. is a man fifty years old. He is a hard worker, but his employer considers him very dull. This man said of him that he had no foresight in money matters and that, although he and his wife and the older children all worked hard on the farm, they were barely able to make a living. They had been helped at various times by neighbors. J. K. 's wife is forty-five years old, left school at sixteen years when in the fourth grade, and now does a man's work in the fields. In conversation she appeared very7 dull. She was reported to be "mean and spiteful." She and her husband have had twelve children, of whom ten are now living. Two are married. a. A girl, twenty-nine years old, left school at fif- teen when in the fifth grade. She was considered very dull by her teachers. She is now married. She has five children and lives in Ohio. b. and c. Two boys died in infancy. d. A girl, twenty-four years old, left school at six- teen years when in the second grade. Her health is not good and she is of such low grade mentally that she does not work in the fields as do the other members of the family. She is a mentally defective person. 120 REPORT OF MENTAL HYGIENE SURVEY e. A girl, twenty-two years old, left school at six- teen years when she was in the sixth grade. She is now married, has one child, and is living in a three-room house which is well kept. She would probably be classi- fied as a dullard. f. A girl, sixteen years old, is in the third grade in school, where she has repeated grades several times. She has had trachoma. On the Stanford-Binet she made a mental age of 7 and a half years. She is a mentally defective person. g. A girl, fourteen years and two months, is in the third grade at school, where she has repeated grades four times. On the Stanford-Binet, she made a mental age of 8 years. She is a mentally defective person. h. A girl, twelve years and one month old, is in the third grade at school, where she has repeated grades four times. On the Stanford-Binet she made a mental age of 7 years and 9 months. She is a mentally defective person. i. A boy, ten years and eight months old, is in the first grade in school, repeating that grade for the third time. On the Stanford-Binet he made a mental age of 6 years and 9 months. He is a mentally defective per- son. j. A boy of seven years and three months is in the first grade at school. He has a speech defect, is shy and easily frightened. On the Stanford-Binet he made a mental age of 5 years. He is of borderline intelligence. k. A girl, five years old, has a mental age between 2 and 3 years. She is a borderline defective. 1. A girl, one year old, is poorly nourished and seems dull. 2. K. K., brother of J. K., died in May, 1922, when about forty-eight years old, of "kidney trouble." He was illiterate, spoken of as "not right" by the neighbors, and generally considered the dullest of the five children of his STATE OF KENTUCKY 121 parents. He was probably a mentally defective person. His wife left school at twelve years, when she was in the second grade. She cannot read or write, and has a reputa- tion of being sexually immoral. Complaint has been made in court because she does not know how to care properly for her children. She does not know how to cook ordinary foods properly and does not keep her children or her cabin clean enough to insure ordinary health. She is a mentally defective person. When the cabin was visited, the family were found to be absolutely destitute. The mother was eight months pregnant. Her children follow: a. A boy of eleven years was in the first grade in school. On the Stanford-Binet test he made a mental age of 6 years and 9 months. He is a mentally defective child. b. A girl of eight years and four months was not in school. On the Stanford-Binet she made a mental age of 4 years and 9 months. She is diagnosed as a mentally defective child. c. A girl of six years and nine months was not in school. On the Stanford-Binet she made a mental age of 3 years. She is a mentally defective child. d. A boy, four years old, on the Stanford-Binet made a mental age of 3 years and 3 months. He is a dullard. e. A girl, three years old, made a mental age of 2 years and a half. She is a dullard. f. A boy, twenty months old, was retarded in de- velopment. J. K. and K. K. are of a fraternity of five. Two sisters mar- ried and moved to other states so that little was learned about them. A brother who has never married was described as a poor, ' ' weasened-up ' ' old man, who works on farms and is considered very dull. He has trachoma. The father of this fraternity of five, D. K. was described as a dull, plodding, hard-working ten- ant farmer. He always succeeded in keeping his family from child. 122 REPORT OF MENTAL HYGIENE SURVEY want. His wife, the mother of the fraternity of five, was described as one of the notoriously "bad women" of the county. She was illiterate, and was considered a mentally defective per- son. Neither she nor her husband is now living. 7. The S. Family. We present in this family group, by chart and description, the twenty-nine children, mostly of school age, of three brothers and two sisters. There are seven frater- nities, as one sister and one brother have each married twice. These children were found in one of the mining camps in the Western Kentucky coal district. It seems worth while to present the study with its relatively small incidence of mental defect as it is typical of much that is found among our school children to- day. The mental deficiency is real, although there are amongst these twenty-nine children only six cases and these occur in only two of the seven fraternities. Of the older generation, we find one sister a mental defective and one brother a borderline case. The other brothers and sister seem to be normal. The defective and the borderline defective married psychopathic persons. From these two matings have originated most of' the inadequacies and mental-health problems found amongst these school children. One brother married a drug addict. This wife has had three pregnancies. Two children died in infancy and the third is a psychopathic person. It would -seem that better advised matings might have obviated for the school and for other social agencies most of the mental-health problems that we now see amongst these school children. The paternal grandfather of these children, T. S., was born THE S. FAMILY 124 REPORT OF MENTAL HYGIENE SURVEY in 1856 and died in 1907, at fifty-one years of age, of typhoid fever. He worked on a section gang practically all of his life and was also a preacher of the "Holy Roller" church. Nothing was learned about the order of his intelligence. His wife, M. S., was born in 1859 and died in 1880 when thirty years old. The cause of death was given as a stroke of paralysis. She was described as a woman who was always sickly, very ignorant and illiterate. Descriptions of five children and of their children follow: 1. H. S., a male, forty-six years old, was born in Ken- tucky. He holds a good position in the mines, building cars. His wife is an intelligent, industrious woman whose home is neater and more attractive than the average in their mining camp. They would both be considered as meeting adequately the demands of their environment. They have five children. a. A boy, twenty years old, born in Kentucky, graduated from high school and is now working in the mines. He is considered to have a normal personality make-up. b. A boy, eighteen years old, born in Kentucky, is now in the second year of high school and so far as known is considered to be of normal personality make-up. c. A girl, fifteen years old, born in Kentucky, is doing poor work in the seventh grade. On the Stanford- Binet she made a mental age of 10 years and 5 months. She was diagnosed as a borderline mental defective. She has been treated for trachoma. d. A boy, eleven years old, born in Kentucky, is doing good work in the sixth grade in school. He made a mental age of 10 years and 6 months. He is considered of normal personality make-up by his teacher. He has been treated for trachoma. STATE OF KENTUCKY 125 e. A girl, seven years old, born in Kentucky, is do> ing good work in the second grade in school. She made a mental rating of 7 and one-half years. She is of nor- mal personality make-up. She also has been treated for trachoma. 2. F. S., male, forty-four years old, was born in Ken- tucky. He left school at twelve years, when in the second grade. For ten years he worked as foreman of a section gang, but lost this job because, through his carelessness, an express train ran into a hand car. He is said to have been earning $175 a month at the time he lost his job . He saved none of his salary. At the time he was visited, he was work- ing on an average of one day a week, loading in the mines, and his family was living on credit at the company store. He is an ardent "Holy Roller." He is lazy, slow in his movements, with a speech defect, and has the appearance of being very dull. He is a borderline mental defective. His wife, N. S., thirty-five years old, was also born in Kentucky. She left school at twelve years, when in the second grade. She is a good housekeeper, a hard worker, and keeps her house and children neat. However, she does not get along with any of her neighbors, and beats and mistreats her children until the neighbors become aroused She has attacks of bad temper when she curses and becomes very excited. She also has the reputation of loose standards of sex morality. She is a psychopathic person. These two have had six children : a. A girl, fifteen years old, was born in Kentucky. She is now doing fair work in the fourth grade in school. She has repeated each of the four grades. On the Stan- ford-Binet she made a mental age of 8 years. She is a mentally defective person. She is very slow in her movements and very suggestible. b. A boy, thirteen years old, born in Kentucky, is in the third grade in school. He has repeated each of 126 REPORT OF MENTAL HYGIENE SURVEY three grades. He is doing poor work. On the Stan- ford-Binet he made a mental age of 7 years and 9 months. He is a mentally defective person.' He has recently been stealing at school. c. A boy, eleven years and five months old, was born in Kentucky. He is in the third grade in school and has repeated both the first and second. His work at present is very poor. On the Stanford-Binet he made a mental age of 7 years. He is a mentally defective person. He is sluggish and suggestible. d. A boy, nine years and seven months old, was born in Kentucky. He is in the second grade in school, where he is doing fair work. He has not repeated any grades. On the Stanford-Binet scale he made a mental age of 7 years and 3 months. He was diagnosed as a dullard. He is slow and rather inadequate. He has perpetrated some petty stealing. e. A girl, six years and eight months old. was born in Kentucky. She has not yet entered school. On the Stanford-Binet she made a mental age of 3 years and 3 months. She has a vacant expression. She is a men- tally defective person. f. A girl, three years and ten months old, was born in Kentucky. On the Stanford-Binet she made a mental age of 2 years and 6 months. She was described as having little energy. 3. L. P. S., a male thirty-nine years old, was born in Kentucky. He works as a weighman in the coal mines. He is a preacher of the "Holy Roller" church. He has been treated for trachoma and scrofula. We have no information as to his personality. His first wife, M. C. S., was born in 1887 and died in 1909, cause not stated. She is said to have been an habit- ual user of laudanum. By her there were three children, two of whom died in infancy. Description of the third follows: STATE OF KENTUCKY 127 a. A girl, fifteen years and nine months old, is doing poor work in the seventh grade in school. She is known as a peculiar, eccentric girl, lacking in common sense. She is an ardent "Holy Roller." She has poor motor control and difficulty in concentrating her atten- tion. She is twelve pounds underweight. There is a story that her mother gave her laudanum as a child to keep her quiet. On the Stanford-Binet she made a mental age of 10 years and 6 months. She is a psycho- pathic person. L. P. S. married for his second wife F. B., now thirty- five years old. She is described as a fairly intelligent and well-meaning woman, and a neat housekeeper. She has had four children. a. A boy, ten years old, born in Kentucky, is doing good work in the third grade in school. On a psycho- logical test he made a mental age of 9 years and 4 months. He is a rather neurotic person. b. A girl, eight years and 6 months old, born in Kentucky, is doing very good work in the second grade at school. On a group psychological test she made a mental age of 7.8 years. She seems a normal child ex- cept for seclusive tendencies. c. A boy, six years and ten months old, is doing fair work in the first grade. On the Stanford-Binet he made a mental age of 6 years and 3 months. He is an unusually timid child. d. A boy, three years and five months old, made a mental age of 3 years. 4. G. S., a female, thirty-two years old, was born in Kentucky. She left school at sixteen years when in the fourth grade. A former schoolmate who is now a teacher reports that G. could never do anything expected of her in school except draw. When interviewed, she became much 128 REPORT OF MENTAL HYGIENE SURVEY confused in giving her children's ages. Her house was very dirty and her children unkempt. She is a feebleminded person She married for her first husband M. M., who is now serving a nine-year sentence in the reformatory for bigamy. He had left her and married another woman under an as- sumed name. He had had no particular trouble with his wife before leaving her. He had never gone to school be- fore his commitment, but is now in the fourth grade at the reformatory. He is of the dullard type and very easily in- fluenced. He is hyper-suggestible to such a degree that he was diagnosed as a psychopathic person. He is also mark- edly excitable. He and G. S. had three children. a. A boy, twelve years old, is a patient at the In- stitution for Feebleminded at Frankfort. He is an im- becile and is in the kindergarten class at the institution. b. A girl, six years and ten months old, is living in a foster home under very good conditions with an in- telligent foster mother. She has not yet entered school. On the Stanford-Binet she made a mental age of 6 years and 6 months. She seems to have normal intelligence with an emotional personality make-up. c. A girl, five years and eight months old, is living with her mother. She is described as stubborn, irritable, and hard to manage. On the Stanford-Binet she made a mental age of 3 years and 6 fnonths. She is probably a mentally defective person. When her first husband was sent to the reformatory, G. S. secured a divorce and married again. Tn the interval she worked as a cook at the county poor farm, where she also lived. Her second husband, T. M., is described as lazy and worth- less. He is thirty-five years old, and has three children by a previous marriage. She has had two pregnancies since her second marriage. 1. A boy, eighteen months old, seems to have devel- oped normally up to the present time. 2. A miscarriage. 5. M. S., a female, thirty-one years old, was born in Kentucky. She finished the eighth grade at fifteen years. She is described as a negligent, good-natured type of person. STATE OF KENTUCKY 129 She married J. L. a man fifty-six years old, the father of her sister-in-law. He works as a taxi driver. He has always provided satisfactorily for his family. They have had six children. a. A girl, fourteen years and three months old, is doing good work in the fifth grade in school. She and all of her brothers and sisters have been absent a great deal as a result of their mother's carelessness about sending them to school. On the Stanford-Binet she made a mental age of 12 years and 3 months. She is of a ner- vous, hypersensitive, excitable make-up. b. A girl, eleven years and eleven months old, was born in Kentucky. She is doing fair work in the third grade in school. He retardation is thought to be largely due to irregular attendance. On the Stanford-Binet she made a mental age of 10 years. Her personality make-up is normal. c. A girl, nine years and eleven months old, is do- ing fair work in the third grade. On the Stanford-Binet she made a mental age of 8 years and 9 months. She has normal intelligence and a normal personality make-up d. A girl, eight years old, is doing poor work in the first grade, which she is repeating. She is a mouth- breather. She is awkward in her movements, and has a decided speech defect. On the Stanford-Binet she made a mental age of 6 years and 3 months. She is a dullard with a personality of the slow, indolent type. e. A boy, five years old, appears to be normal. f. A girl, two years old, appears to be normal. Conclusions from Family Studies These charts and descriptions exhibit examples of the social work that lies ready to hand in rural regions in Kentucky for various welfare agencies. 1. The public school, in which many of the children were found, needs: a. Special classes for mentally handicapped children and other specially adapted facilities for developing the per- sonalities of exceptionally difficult and problematic children. By properly meeting the needs of mentally handicapped 130 REPORT OF MENTAL HYGIENE SURVEY children, whether feebleminded in the ordinary sense of the word or psychopathic, the public school may not only avert and prevent future delinquency, but also convert these rapidly developing community expenses into real assets. Large numbers of these peculiar and defective children can be taught to do useful things and can be made to enjoy being serviceable. b. The public school should have a mental clinic. The educator and the teacher are administrators. They are taught and trained to administer education and training They are not trained as physicians, as psychiatrists, as psychologists, or as psychiatric social workers. In order that the school and the teachers may be put in a position to administer most effectively the special training that pe- culiar and exceptional children require, it is necessary that such experts should study the peculiarities and deficiencies of such children. It is necessary that they examine these children as a physician examines his patients. It is necessary that they understand the previous development in each case. These experts should, as a result of their examinations, make diagnoses and prescribe treatment. After a visiting clinic has thus examined and prescribed for each problem child, it is the work of the educator to administer the educational facilities in such a way as best to meet the needs of the peculiar personalities of the problem children. c. The school needs to cultvate much closer contact with the homes from which its children come. Parent- teacher associations have been very serviceable in culti- vating understandings between parent and teacher. A visiting teacher, a teacher whose business it is to be liaison officer between the home and the school, seems an exceed- ingly useful adjunct to our educational facilities. Such a visitor has it in her power to do more than any other single person in making the public school the social agency of first importance in each community. d. The school, and through the school the community, should develop points of contact between child-guiding agencies and children under six. Our schools seem to have more than they can do to handle properly the children from six to fourteen, the period of compulsory school attendance. As we begin to understand, however, the tremendous po- tency of environmental factors upon the child's life through infancy and early childhood, we realize that this is the most important period educationally in the life of each child. Public education must ultimately concern itself with the STATE OF KENTUCKY 131 influences that surround children in their homes before they reach the present school age of six years. It must find an opportunity for consultation in the home and in the nur- sery. 2. Public-health agencies, such as the International Health Board, the State board of health, county health officers, and county nurses, are needed everywhere. Public-health work comes upon these problems of mental health and the production of an efficient and happy citizenry at every point of the developmental period. Agencies such as mentioned above have done significant work on trachoma in Kentucky. They have made tremendous progress in checking the devastating inroads of tuberculosis everywhere. Likewise malaria and hookworm have felt the onslaught of their attack. We are, however, in the midst of this campaign to se- cure better health for our people and especially for our children. Notable fields for renewed and greatly increased efforts are those of child mortality and the venereal diseases. Many child- ren come into the world seriously handicapped by the inheri- tance of syphilis. Many are allowed to live in cabins unfit for human habitation. Many are born to mothers who know little of sanitation and nutrition. Public health has much to do in providing good physical conditions for the rural child in Ken- tucky. 3. The State institution for the feebleminded confronts a great task. After the public schools have been effectively or- ganized for the training of mentally handicapped children all over the State, there will yet remain cases of unmanageable of- fensive conduct in handicapped children, cases of homes unsuit- able for the detention of mentally handicapped children, and handicapped children so isolated that the school will find it im- possible to develop the training facilities required. Such cases, now scattered over the State, outnumber the present capacity of the institution many times. We must bear in mind that this institution is a service sta- tion, just as the public school is a service station. Each has to render social service-service to the community. They are both training institutions. The mentally handicapped child, in some 132 REPORT OF MENTAL HYGIENE SURVEY eases, cannot be so effectively trained that he will need no fur- ther care and surveillance after childhood is past. But the in- stitution for the feebleminded is designed to render him and the community the service of training him for community life so far as the limitations of his handicaps permit. This institution, or some other, must assume the custody of the delinquent who is at the same time defective, so defective in mental endowment that he cannot or will not learn to live in- offensively out in the community. Such persons must be kept in custody either until suitable homes can be found or until they have so developed that custody is no longer required to prevent repetition of their offenses. 4. After the best possible training has been given to each mentally handicapped child either in the public school or in the State institution, he -will go into industry. He will live in a home, either his own or one selected for him as better adapted to his needs, and he will work. He will be so placed that he will be as happy and productive as possible. Some sort of social service in addition to the ordinary facili- ties of the public school and the ordinary facilities of the State institution for training mentally defective children must needs assume responsibility for placing the child in industry and in a home, and must recognize that it stands in the relation of parent to each feebleminded person so placed out in the community. Such welfare service should properly be represented in each com- munity in order to secure efficiency. It will probably be de- sirable to have some State agency, such as the State board of charities and correction, head up the county welfare services, each of which in turn would head up smaller community or- ganizations. Each community should realize and exercise the responsibility for the least well endowed members of the group. Each child should be taught elementary mental hygiene and social practice in the home and in the school. STATE OF KENTUCKY 133 Table 20 presents the mental diagnoses of 874 white children studied by the survey staff in the public schools. It shows the distribution of these children by counties and by schools. The schools were selected for study as typical samplings of various kinds of rural populations. In the northeastern part of the State two schools are in a region where the land is rather poor and one in the blue-grass section. In the southeast, six rural schools are located in a coal-producing county. In the western part of the State, we have two schools among farmers and two among coal miners. Everywhere we find unusually large percentages of native-born children with native-born parents. Of these 874 children, 151 (17.3 per cent) were either men- tal defectives or borderline defectives. These children consti- tute very special problems for the schools they attend. Seventy-seven others of the 874 children (8.8 per cent) were diagnosed as psychopathic persons. These constitute another very special problem, each one for the school in which he is found. These two groups, together with the group with psychoneu- roses, epilepsy and endocrine imbalance, aggregate 245 children out of the 874 (28.0 per cent) who are mental problems. The school that conceives its mission and service, with developing children, to be the guidance of their developmental processes so that as many of them as possible shall become happy, coopera- tive, and useful members of the community has, therefore, its most seriously problematical tasks with this quarter of its child- ren who are mentally abnormal. The service for these children is primarily and fundamentally that of so controlling the en- vironment as to bring out the capacities of each child. The schools are really dealing with pathology and abnormality in these cases. They must make very special efforts for these child- ren if they are to be developed into useful citizens. Public School Children 134 REPORT OF MENTAL HYGIENE SURVEY Knox County Mason County Muhlenberg County Scott County Mental Diagnosis ti •y (Sile $ 0) O 44 ki fl Ps o Q 1 T3 a o ti | 0Q 1 fl a> £ .fl '55 oo O O Total <D > 53 o Harps fl s o £ 44 O a fl & fl fl o s Washi 0) N £ o Ph o fl 55 Great Normal 369 17 4 25 6 6 9 32 89 34 39 12 19 77 Dullard 260 22 6 23 6 3 16 18 57 14 43 7 10 35 Borderline mental defect 61 4 2 6 3 2 3 1 10 5 13 4 1 7 Mental defect Psychopathic 90 9 1 3 4 3 3 11 9 11 14 5 4 13 personality 77 10 1 2 5 2 3 11 12 7 3 5 16 Psychoneuroses 3 1 1 1 Epilepsy 1 1 Endocrine disorder .... 13 2 5 2 1 1 2 Total 874 62 14 59 19 19 33 68 183 79 117 32 39 150 Table 20.-Mental Diagnoses of 874 'White Public-School Children, Distributed by Schools and Counties STATE OF KENTUCKY 135 Tabic 21.-Numbers and Percentages of Mental Problems among 874 School Children Distributed by Counties County Total Children Total mental health problems Mental defectives and borderline mental defectives Psychopathic personalities Other mental health problems Number Per cent Number Per cent Number Per cent Number Per cent Knox County .. .. 206 63 30.6 43 20.9 20 9.7 0 0.0 Mason County .... . , 251 55 21.9 31 12.4 14 5.6 10 4.0 Muhlenberg County . . . .. 267 89 33.3 57 21.3 27 10.1 5 1.9 Scott County .... 150 38 25.3 20 13.3 16 10.7 2 1.3 ■ • -- ■■ - ■ - ■ - -- - - -- - - Total .... 874 245 28.0 151 17.3 77 8.8 17 1.9 136 REPORT OF MENTAL HYGIENE SURVEY Table 21 summarizes the distribution of these mental abnor- malities amongst the 874 school children by counties, giving both numbers and percentages of total mental-health problems, total mentally defective and borderline defective cases, and total psychopathic cases. One may observe that the children studied in Mason County, for instance, showed lower percentages of psychopathic and de- fective children than any other county group. The Knox County group showed percentages of psychopathic and defective child- ren slightly higher than the average of the total group studied. The Muhlenberg County group was a little higher still in both these respects. When we inspect single schools, we find in Providence School (Knox County) that 7 of 19 children were mentally defective (or borderline) and in Smoky School (Knox County) that 5 of 19 children were psychopathic. In the Sharon School (Muh- lenberg County) 13 of 32 children were mentally abnormal. These facts and figures by counties and schools must not be taken as typical of the county or of the community. No attempt was made to secure an average sample of the county in any case. It may be possible that we had the best school in one county and the poorest school in another. Our data are presented for the purpose of showing the differences in the nature and extent of mental-health problems between school and school and com- munity and community. These differences emphasize the im- portance of mental clinics in connection with public schools. Education is really a ministration to the needs of the indi- vidual. Each child is a developing personality. His individual needs must be diagnosed and understood before the school can properly minister to them. Finding out wThat these needs are in each individual case is the business of a physician rather than of a teacher. It is impossible to know the educational problems of any given school until we know how many children are psychopathic and how many are mentally defective. One may go further. It is impossible to know the educational problems of any school until we know the nature of the mental defect or the nature of STATE OF KENTUCKY 137 the personality difficulties of each problem child in the school. These are medical problems that must be worked out in each school by a medical staff. One cannot take the facts from Muh- lenberg County, where we find 27 psychopathic children amongst 267, over to Mason County, where we find only 14 psychopathic amongst 251. Neither can one take the facts from Knox County, where we find 43 mentally defective children amongst 206, over to Mason County, where we find only 31 mentally defective amongst 251. The facts have no meaning if they are carried over. They do not apply to the situation. It is necessary for the schools to have clinics that shall be able to study the personality of each child. The needs of child- ren cannot be sufficiently defined by administering intelligence tests and making educational measurements. Each problem child must be studied as a problem in psychological medicine. Nativity and Race: These 874 children were all native born, 864 having been born in Kentucky. All but 4 of the fathers of these children were native born and 757 of them were bom in Kentucky. All but 10 of the mothers of these children were native born, 770 of them having been born in Kentucky. One father and 5 mothers were born in England, 3 fathers and 3 mothers in Germany, and 2 mothers in Ireland. The racial stock was not ascertained in 488 cases. Of the remaining, 248 were reported as English. 58 Irish, 13 Scotch, 21 mixed British, 17 German, 11 French, and 18 mixed Nordic. In Muhlenberg County, the 71 children in the two agricul- tural-district schools were all found to be of mixed native-born stock. Of the 196 children in the two schools in the mining settlements, 173 were mixed native born, 8 English, 7 German, 3 Irish, 1 Irish Indian, 2 Indians, and 2 French. In the six rural schools in Knox County, all of the 206 child- ren and all their fathers were native born. Three mothers were foreign born. Of these children, 187 were reported English, 4 Scotch, 3 English and Indian, and 12 unascertained. It appears, therefore, that very little foreign stock has come into these regions in recent years and that there are very slight 138 REPORT OF MENTAL HYGIENE SURVEY and quite insignificant differences in this respect between the farming and the coal-mining populations. Ages: By referring to Table 27, (p. 147), one sees that these children ranged in age from five to seventeen years. There were only 7 five-year olds and only 9 seventeen-year olds. Age groups ranged from 70 at six years to 102 at ten years, falling off decidedly from fourteen years, with 91 children, and fifteen years, with 56, to sixteen years, with 24. Sex: Of these 874,460 were boys and 414 girls. It is quite noticeable that the boys afforded the larger numbers of defec- tives and psychopaths (mentally defective, 54 boys, 36 girls; psychopathic personalities, 52 boys, 25 girls). Under the diag- noses normal, dullard, and borderline mental defective, for each sex, the numbers were almost equal. Another noticeable dis- parity, in which the girls fared more poorly, is in endocrine im- balance. There were 13 cases, 9 of girls and 4 of boys. School Grade: By reference to Table 26, (p. 145), it will be observed that these children were distributed in 10 school grades, ranging from 105 in the first up to 161 in the fourth and then down to 10 in the tenth. Nearly three-quarters of the children were in the first five grades. Table 22. Physical Condition of 874 Public-School Children Distributed by Counties County Total children Good Fair Poor Unascertained Muhlenberg County Two schools in farming dis- trict 71 19 40 10 2 Two schools in coal-mining district 196 69 101 25 1 Knox County Six rural schools 206 102 88 16 Mason County Moransburg School 68 28 26 14 Washington School ... . x. 183 46 97 40 Scott County Great Crossing School 150 55 76 19 Total 874 319 428 124 3 Physical Condition: Of these 874 children, 319 were found to be in good physical condition, 42§ in fair, and 124 in poor. In three cases physical condition was not ascertained. STATE OF KENTUCKY 139 72 g - CD O p 02 2 ° S' s' 0 X 3 H 3 p Total .. . at Crossing O o c S 5 S o os 2 o^S so'^ 72 72 2 Pi a Q c B 3 r-*~ 5' 5' 33 r O p, 02 ig district 0 0 02 ?nberg Cor County CTO p- o 5' S3 a o c o o cZ- 3 5 O o Pi B 00 4^ Cl o 00 co Ci oo to Ci ►- Ci Total Children 1,086 00 Ci tO Ci o 00 o to Ci OO Total defects Ci Ci H-< tO c< c< £ Cl 0 Ci to Total children without defects to Ci Ci to CO co co © 2; r 5 Defective teeth co o CD X 0 co Defective tonsils and adenoids h-< Cl tO to J, cc 4^ co Defects of the eyes co Cl tO GO co Ct ♦ ♦ Cl O to to Underweight 10 per cent or more co co to * ♦ to Cl Overweight 10 per cent or more CO o co co to co 4* Other defects Table 23. Somatic Defects Found in 874 Publie-School Children, Distributed by Counties *No weights or heights taken. 140 REPORT OF MENTAL HYGIENE SURVEY Somatic Defects: Table 23 presents by counties and schools the distribution of the more prominent types of somatic defects, and the numbers of children found defective physically. Six hundred and seventy-five children had no no- ticeable defects. Among the remaining 199 children, 1,086 phy- sical defects and diseases were noted. One very striking feature of this exhibition was that rela- tively small numbers of children were found to be in good phy- sical condition. The fact that we found 1,086 physical defects amongst 874 white children in the public schools certainly emphasizes the need for more public health work among our rural school children. Nurses and phy- sicians should be discovering and correcting these physical de- fects among these young children. They are at an age when such correction can be most readily effected and when it will re- sult in the greatest permanent benefit to the individual. Outstanding features of these physical anomalies were the 95 cases of underweight in the Washington School and the un- usual incidence of abnormal adenoids or tonsils in the Scott, Knox, and Muhlenberg county schools. Defective teeth were most numerous in Mason and Knox counties. The problems vary as much in incidence and nature as do the mental prob- lems. Similar clinical studies will be necessary in each school if the good health of all the children is to be secured and main- tained. Each child must be individually examined and treated for each and every defect found. Behavior Anomalies: Notable in the exhibition of the kinds of behavior anomalies distributed according to the mental diagnoses of the children in whom they were found, in Table 24, was the prevalence of these anomalies amongst the children diagnosed as psychopathic. The psychopathic children had the behavior anomalies. Only 26 of the 77 children so diagnosed STATE OF KENTUCKY 141 Mental diagnosis Total children No outstanding difficulties Lying Stealing Cruelty Pugnacity Sex perversion Sex prosmiscuity Truancy Running away from home Others Normal 369 351 4 2 6 2 6 Dullard 260 246 5 1 5 6 1 Borderline mental defect .. 61 53 2 7 1 Mental defect 90 • 71 6 2 5 2 9 1 Psychopathic personality .. 77 26 29 5 10 34 1 4 14 6 3 Psychoneuroses 3 3 Epilepsy 1 1 Endocrine disorder 13 13 Total 874 764 46 9 11 57 5 4 36 8 3 Table 24.-Menial Diagnoses of 874 Public School Children, Classified by Behavior Anomalies 142 REPORT OF MENTAL HYGIENE SURVEY had no outstanding behavior difficulties. Among the 51 other psychopathic children 106 behavior anomalies were noted. Among the 90 children diagnosed as mentally defective, only 19 had behavior difficulties. These 19 exhibited 25 anomalies. Only 8 of the 61 diagnosed as borderline mental defectives had behavior difficulties. These 8 exhibited 10 instances of anomalous behavior. It is evident that the psychopathic child presents himself as a problem by his behavior. His personality difficulties ex- press themselves as conduct disorders. It is highly probable that, if he could be understood and managed with intelligence illuminated by knowledge of his difficulties, his behavior diffi- culties would disappear. If the school could have personality studies made of all children and could have the benefit of the advice of careful students of developing childhood (genetic psychology), they would be able to make special arrangements for meeting the needs of these children. This would save fric- tion and fretting in the school. It would save the energy of the teacher and of the child and would greatly facilitate the normal development of the child. Table 25.-Mental Diagnoses of 874 Public School Children, Classified by Numbers of Grades Repeated Mental diagnosis Total Grades repeated Four or More None One Two Three Normal 369 293 72 4 Dullard Borderline 260 148 100 12 mental defect . 61 10 37 11 3 Mental defect . . Psychopathic 90 4 33 32 12 9 personality . . . 77 26 42 6 1 2 Psychoneuroses . 3 1 2 Epilepsy Endocrine 1 1 disorder 13 8 3 2 - - - - Total 874 491 289 67 16 11 STATE OF KENTUCKY 143 Repetition of Grades: The records as to the repetition of grades by these children, distributed according to the mental diagnoses of the children, shows that 172 children diagnosed as normal or dull had repeated one grade and 16 of those so diagnosed had repeated two grades. Of the 369 normal child- ren 76 had repeated grades. Of the 260 dullard children, 112 had repeated grades. If we have judged these children properly, it would seem that the school should have been able to make better adaptations to their needs. It should be possible for a normal child to go through his school career without doing over again work that he has once attempted. One should be able to anticipate his failure early in the year, and take measures to prevent its occurrence. Some arrangement should be made by which he would complete his work as he goes. If the work is not done, he should not go on. This involves dropping out of the lock- step system. It presents difficulties of administration. But administration is a mechanism intended to serve a purpose. Psychology presents the problems this mechanism is intended to meet. Education ought to be for each child a presentation of suitable opportunities for the development of his powers. When education presents such a series of opportunities, normal children will not repeat work. A striking contrast, however, is presented by the table as between these normal and dullard children, on the one hand, and the defective and psychopathic, on the other. All the in- stances of three or more repetitions were found amongst defec- tive and psychopathic children. Much larger percentages of one and two repetitions were also found amongst them than among normal and dull children. Of the 61 borderline mental defectives, 51 had repeated grades one or more times. Of the 90 mental defectives, 86 had repeated grades one or more times. Of the 77 psychopaths, 51 had repeated grades one or more times. It is evident, therefore, that there is much more serious failure on the part of the school to adapt its work to these mentally handicapped children than to those whom we find normal or dull normal. Here we have striking evidence of 144 REPORT OF MENTAL HYGIENE SURVEY the need of special adaptation of the school to the mental condi- tions of the individual child. It is important that such rural schools, all over Kentucky, shall make special provision for training mentally handicapped children. Such special training adapted to the developmental capacities of each defective or psychopathic child constitutes the only means by which the community may make him as useful and as happy as is permitted by his mental handicaps. Such special facilities in the public schools will pay rich returns in the decreased crime and in- creased production of these handicapped persons. Test Ages by School Grades: Table 26 presents the distribution of children by school grade and by test age. Assuming that the child of 6 years mental age should be in the first grade and that when he attains a mental age of 7, he should be in the second grade and so on, we find that 224 of the 874 white children studied in these public schools were at grade, according to mental age as shown by test. A total of 101 of these children were in grades lower than were merited by mental ages ascertained by test. One child in the fourth grade had a mental age of 15 years or more. All the other children (549 of 874) were placed higher in school than their mental ages as ascertained by test would seem to warrant We must bear in mind, in considering this table and the relation of mental age to school grade, that many of these men- tal ages were assigned by the results obtained from group in- telligence tests alone. We must remember the shortcomings of the group intelligence tests as compared with the individual measurement of mental ability. We have already spoken of the likelihood of many children's falling lower in the scale, by their performance in the group tests, than is really merited by STATE OF KENTUCKY 145 Test Age Total First grade Second grade Third grade Fourth grade Fifth grade Sixth grade Seventh grade Eighth grade Ninth grade Tenth grade III years . 2 2 IV years . 10 9 1 • • V years .. 53 31 18 3 1 VI years . 151 49 44 43 14 1 VII years 139 14 38 48 37 2 VIII years 137 13 33 61 21 7 2 IX years . 138 1 12 29 61 24 11 X years .. 88 6 14 23 15 21 8 1 XI years . 63 2 6 17 20 15 3 XII years 40 2 4 5 14 12 1 2 XIII years 30 1 7 14 3 5 XIV years 14 1 4 1 6 2 XV years and over . 9 - - 1 2 3 2 1 - ■■■ - - ■■-- - - - - - - Total .. 874 105 115 145 161 118 70 81 53 16 10 Table 26.-Test Ages of 874 Public-School Children, Classified by School Grade Attained 146 REPORT OF MENTAL HYGIENE SURVEY their native ability. Any indifference, stubbornness, embarass- ment, or other factor that prevents a free outgo of responses during the test constitutes just so much failure to put forth the best effort. For this reason, any child may rate himself, in a group test, on a lower level than is warranted by his normal capacity to respond. In other words, such a child has a mental ability that is not measured by the test because he does not deliver the goods. The group test examiner has no means of assessing this individual hindrance under which each examinee works during the test. When a mental examiner is making an individual test, he ascertains whether or not there is any such hindrance to free response and is able to make a truer estimate of the mental ability of the individual. It is probable, therefore, that careful mental-age ratings by individual mental examinations would have raised the mental ages of a considerable number of these 874 children. Mental ages obtained by individual mental ex- aminations and distributed as in Table 26 would in all likelihood have appeared somewhat less critical of the school-grade rank- ing of these same children. We present the results for what they are worth. Our purpose in using group tests was simply as an initial means of sorting out the mental problems of the school. More general use of alertness tests and of educational or attainment tests would result in great advantage to the children in these rural schools. Each child would be saved much repeti- tion and the teacher's work with each would be applied more successfully at points of weakness. Intelligence tests and educational tests will help to check up educational progress and personality development. They will aid in conserving the energy of teacher and of children. Age and Test Age: The 874 public school children are distributed in Table 27 by test age and by chronological age. STATE OF KENTUCKY 147 Test Age Total 5 6 7 8 9 10 11 12 13 14 15 16 17 111 years .... 2 1 1 IV years .... 10 1 3 4 2 V years ... 53 3 29 11 3 4 2 1 VI years .... ... 151 3 28 46 34 26 9 1 2 2 VII years .... ... 139 9 21 21 37 26 7 5 5 4 1 3 VIII years ... ... 137 2 10 21 33 22 17 13 13 4 1 1 IX years ... 138 3 9 23 37 30 15 13 4 4 X years ... 88 1 6 12 18 13 23 12 3 XI years .. .. ... 63 2 7 13 12 12 5 6 6 X [I years .... 40 5 5 7 10 12 1 XIII years ... • • • 30 1 1 1 5 7 9 5 1 XI\ years ... 14 1 6 1 1 XV years .... over 9 1 2 2 4 - - - - - -- - - - - - Total . . . . .. 874 7 70 85 73 98 102 92 93 74 91 56 24 9 Table 27.-Test Ages of 874 Public School Children, Classified by Chronological Ages 148 REPORT OF MENTAL HYGIENE SURVEY We find that only 104 of the children tested at age and only 34 above age. The remaining 736 tested below age from one to nine years. There is, therefore, evident here much greater discoordination than between mental age and school grade as shown in Table 26. We must recognize here, however, that children three years or more retarded have practically all been carefully measured by an individual mental test-mostly the Stanford-Binet. We cannot, therefore, lay the large amount of discoordination evident in the large number of children who are more than three years retarded in mental age to the inaccuracy of the group intelligence test. Of the children under sixteen years of age, 314 (37.3 per cent of that group) were three years or more under age according to the best mental measurements that can be made at the present time. Of those children over fifteen years of age, 3 sixteen-year olds tested seven years, 1 eight years, and 4 nine years, and 1 seventeen-year-old tested eight years mentally. This amount of retardation should not be regarded as parti- cularly critical of the methods pursued by the particular schools attended by these particular children. It holds of public schools generally. The mental diagnoses that we have already presented show the necessity for a radical change in the whole method of approach used by the school when it undertakes to meet the problems of the individual child. Many of these children are quite ill prepared to profit by the curriculum and the methods of instruction that are employed in the schools they attend. The lack of coordination between the opportunities offered by the school and the needs of the individual child is so complete that remedy cannot be found in any given general modification of instructional methods. It is necessary to dig into the roots of the individual child's problems. It is necessary to make over completely the process that we have called education in order really to educate mentally handicapped children. It is necessary to use the clinical method of approach and to make a mental analysis of each problem STATE OF KENTUCKY 149 child. It will be necessary for the school to be ready after such analyses are completed, to arrange programs to minister to the limited facilities and "peculiar" needs of each exceptional child. Referring again to Table 20, we find that 245 of these 874 children were mental problems. Sixty-one of them were border- line defectives, 90 were cases of outspoken mental defect, 77 were psychopathic, 3 were cases of psychoneurosis, 1 was an epileptic, and 13 were cases of endocrine imbalance. It is likely, therefore, that somewhat over 100 of the children who were three years or more under age by mental measurement would have been classed as dullard as a result of careful in- dividual studies. Three hundred and fourteen under sixteen years of age were three years or more retarded, while 245 of the whole group were definite mental problems. This indicates that our diagnoses were along very conserva- tive lines. We have recognized that many children who are retarded in school and retarded also in mental development have, nevertheless, enough mental ability to enable them to get along satisfactorily. They are retarded in school because the school does not happen to understand them and does not draw out their energies effectively. Our diagnoses were made care- fully. Various lines of study were converged upon the diagnosis of each case. Each child that has been diagnosed as a mental defective lacks the ability to become capable of self-guidance and adapta- tion to community life. But there are as many degrees of such capacity for self-guidance as there are defective children, and capacity for self-guidance, in each case, can be improved by properly adapted educational opportunities. It is plainly a part of the business of the public school to facilitate in every possible way the development of mind and of personality in every child, no matter what his handicaps may be. Health of School Children: It is evident from these pre- sentations of our findings among the 874 white children in rural schools that the children labor under many physical and mental handicaps. It is most important for each one of these handicapped children that he have the benefit of examination 150 REPORT OF MENTAL HYGIENE SURVEY and treatment of his defects. It is important that school children should be examined periodically by competent nurses and doctors, and that they should have each and every form of treatment that will contribute to soundness of body and mind. The treatment indicated for enlarged and diseased tonsils, for astigmatism, for congenital syphilis, or for infantile paralysis is in each case medical or surgical. No adaptation on the part of the school is called for. The part of the school in such cases is to secure examination, to discover the difficulty, and to secure the cooperation of the parents in affording the child proper treatment. When mental abnormality is found, whether this be a mental deficiency or a kink or twist in the development of personality, the treatment is largely a matter of management. It is largely a matter of school administration. The failures of the school go to the children's courts, to the training school, and to the reformatory. The home and neighborhood have afforded such poor surroundings for the child that it has been impossible for him to develop a normal personality. The school is already seriously handicapped when it takes hold of such a child at six years. Finding such children of six with serious personality handicaps argues for earlier school control of children. If parents are willing to neglect their children and bring them up in disease and with handicaps, allowing defects of vision to go uncorrected, diseased tonsils unattended, and de- fective morals like their own to pass without concern, these are all matters of intimate community interest. The community will have to bear the expense of such neglect later on. The disease and crime incident to such neglect by parents, in the pre-school period, make the individual a liability to the com- munity. The community is, therefore, justified in taking pre- cautionary steps to correct these diseased conditions of mind and body in early childhood. The public school isf the first line of defense. It is the first social-service agency and it deals with all the children. The extension of the activities of the school health clinic to the con- STATE OF KENTUCKY 151 servation of the pre-school child is the most natural expansion of public-school activities. The school will thus be able to abort and prevent many problems of both physical and mental health before the age when the school life of the child now starts. It would simplify many of its own educational tasks later and would enable many boys and girls to develop more effectively. With school attendance compulsory from six to fourteen years, it is especially important to develop in rural schools: 1. Medical and nursing service for the diagnosis and correction of physical defects. 2. Mental clinics with psychiatrists, psychologists and psychiatric social workers for the study and diagnosis of children presenting problems either by their lack of pro- gress in school or by their behavior difficulties. 3. Special classes for mental defectives and other facilities specially designed to further the training of the mentally handicapped. The mental clinic must be a mobile or traveling clinic. A visit once a year, with such a clinical group, to each rural school, (vould provide reasonably well for the adjustment of each problem child in such school. The relations between the clinic and the school should be such that the school would invite the clinic. It should be made the privilege of the school to call in this group of consultants on its own most difficult problems. The cooperation of the State board of education and the board of charities and correction, in securing the functioning of such clinical groups in the rural schools, is suggested by the success of a similar plan in Massachusetts. In that State the public schools are districted to the State institutions (State hospitals and schools for the feebleminded). The superintendent of each institution is responsible for the organization and functioning of a school clinic group, or clinical team, which visits annually each school in the district. This clinical team consists of a psychiatrist, a psychologist, and a psychiatric social worker. For each problem child brought be- fore the visiting clinic, they secure a physical examination, a family history, a personal and developmental history, a his- 152 REPORT OF'MENTAL HYGIENE SURVEY tory of school progress, an examination in school work, an ex- amination in practical knowledge, a history of economic effi- ciency, a history of social and moral reactions, and a psycholo- gical examination. As a result of these various findings, which present a quite complete picture of the child as a person, the psychiatrist makes a diagnosis. His recommendations are made to the principal of the school. The management of the case continues with the school. The consultants have simply given the school the bene- fit of their various lines of special knowledge. By proper use of such information and advice the training of the problem child may be more skillfully administered, so that he shall be- come the best person and the best citizen compatible with his limitations. The Massachusetts law requires Special classes for mental defectives. Other forms of handicap are met by other special adaptations of the school. The problems of these Kentucky children who are themselves mental problems, children who are defective or who have kinks or twists in their personality structures, constitute a most vital interest of the people of Kentucky. That these children shall develop into assets instead of liabilities is of fundamental im- portance to all the people. No more vitally important invest- ment of public funds can be made than that which shall secure clinical service and special educational facilities for training mentally handicapped children in the public schools. STATE OF KENTUCKY 153 GENERAL DISCUSSION OF MENTAL HEALTH CONDITIONS State Hospitals- We find three general classes of persons concerned in this study: first, those who are mentally ill; second, those who are mentally defective; and third, those whose minds and personalities are twisted, warped, or kinked. The important implications for social progress in connection with the last men- tioned class we find mental-health agencies in Kentucky espec- ially slow to recognize. It is particularly among children that we can deal effectively with these personality difficulties. The aims of a mental-health campaign are distinctly different in dealing with each of these three classes. With the mentally ill, as with other sick persons, the first aim is to recover as many of them as may be as quickly and effectively as possible. Like all other publie-health activities, those dealing with mental illnesses seek also to prevent the onset of all illnesses that take persons out of productive industry and make them an expense to the community. With the mentally defective or feebleminded, the first aim is the training and development of their mental powers. If this training makes the mentally defective individual capable of community life, he should be carefully placed and watched over. Some individuals of this type must be kept in custody. The aim is to make each one as useful and as happy as possible. With those who have personality difficulties, whether they be children or adults, and whatever the difficulty into which they may have come, the first object is to unravel the difficulty and promote the natural and normal development of the person- ality. Education, guided by careful analysis of the mental difficulties, is the keynote of all our activities with such persons, whether they are children in the public schools, children or adults in court on account of behavior difficulties, or persons in training schools or penitentiaries. Training and rehabilita- tion constitute the means of re-establishing the individual in community life and making his life return to him and to others the richest possible income. The mental life of the human being is the most complex 154 REPORT OF MENTAL HYGIENE SURVEY organism in the world of organic nature. It is a developing, unfolding organism. There are definite principles of develop- ment by which this unfolding occurs. By understanding the normal processes in development, and by seeing, therefore, how the twists and kinks and other perversions of this organism are departures from the normal, it is possible to exercise control over the developmental processes, to abolish incipient mental disease, and to secure healthy growth. The recommendations that we shall make for the improve- ment of the services of institutions and agencies in Kentucky will have in view all the objects above enumerated. They will be directed to the single point of improving the mental health of the people of Kentucky. The one object in view will be to help to bring about a state of affairs in which in the wrords of Dr. Lewellys F. Barker, ' ' all the people shall think better, feel better, and act better than they do now." In no one of the three State hospitals has the transformation mentioned by Dr. Barker in his Bloomingdale Centenary ad- dress been completed. There is some of the "asylum" yet in each of them. No one of these institutions is as yet wholly a hospital for the mentally ill. No one is adequately emphasizing the prevention of mental illness. We do not forget the early start that the State made for hospital care of the mentally ill, and we do not forget the notable steps in progress in very recent years, but there are many goals ahead upon which it is important for us to fix our vision. One handicap to the advanced and up-to-date care of mental cases in the State lies in the commitment procedure. The con- stitution of Kentucky secures a jury trial to any and every person before he can be committed to a State hospital. This wras conceived of as a protection. It was devised as a means of preventing hasty deprivation of one's rights as a citizen. It is, however, productive of much undesirable publicity and exposure of the mentally ill to require them to appear in court and to be adjudged "insane" before they can have the medical attention that is indicated by their mental condition. It is important to preserve to each citizen the right to demand a jury trial before he be sent to any institution. From the point of view STATE OF KENTUCKY 155 of his mental condition, however, it is much more important that the mental patient have medical attention. It should be possi- ble to send the mental patient to a mental hospital with as little formality as is required for any sick person to be admitted to a general hospital. It should be possible for any health officer to send any person to a State hospital for temporary care. It should be made illegal to confine a person who is mentally ill in a county jail. The police should have nothing to do with those who are mentally ill except to get them into the hands of physicians and nurses who understand the mental conditions involved. Provisions should be made by which the hospital should send nurses to accompany patients who are to go thither. They should not be cared for by sheriffs and other officers of the law who have no special training in the care of the mentally ill. As further aids to reforming our conception of and use of the State hospital, facilities should be developed for out-patient clinics at each institution, and for community clinics held by members of the staff of each hospital at stated times and places in the district of each hospital. The hospital is a service station for the treatment of those who have mental difficulties. The efficiency of the hospital should be rated by the number of recoveries and by the speed of these recoveries. But its first rating should be by the effectiveness of measures adopted for preventing the development of mental difficulties. Both the out-patient clinics at the institutions and the community clinics held in the districts of the institutions will prove to be important means of increasing the efficiency of the hospital as rated by recoveries and preventive service. A very important means of making the State hospital a more genuine service station consists in the free use of a plan for voluntary admission. As it is important to put in the hands of health officers the power to send patients to these mental hospitals-a power that now resides in courts-so also it is important to put it into the hands of prospective patients them- selves to apply to the superintendent and to be admitted for treatment. It is in the early stages of mental disorder, when the patient himself knows that he needs treatment and when he will 156 REPORT OF MENTAL HYGIENE SURVEY thus voluntarily apply for admission, that the greatest oppor- tunity for service exists. Incipient disorders of every sort can be treated much more effectively than disorders that have become chronic. Facilities for early discharge under supervision, paroling to a home and to employment that have been carefully selected by a well-trained psychiatric social worker who is thoroughly familiar with the patient, constitute one of our most important means of restoration to normal mental health. Patients who are to be under the supervision of such a worker in their homes and in their work can be discharged much earlier than would be the case were no such supervision provided. The effect of the prospect of such provisional discharge and resumption of independent life in the community is very important as a therapeutic agent. Properly organized parole work greatly facilitates the recovery of the patient both before and after parole. It also greatly diminishes the expense of the community in caring for the patient. The social service that supervises the paroled patients can be paid for by a mere modicum of the cost of continued support of these same patients in the State hospital. In addition to this, the patient, in many cases, enters upon employment by which he supports himself. The hospital that is animated by such a spirit of community service, which seeks to prevent mental disorders by providing for easy consultation in clinics; which makes it easy for patients to come for treatment, admitting them upon their own request or when sent by health officers and sending nurses to bring them in rather than having sheriffs transport them; which studies the patient as an individual having mental abnormality; which brings to bear all that medicine can afford in the way of light and understanding of his case; which endeavors to reorganize his mind and personality by providing the best possible hygienic conditions for him and helping him to direct his energy into an occupation by which he will achieve ends and objectives planned and desired by himself; which plans to parole the patient at the earliest possible moment and to watch over his home life until he is ready for discharge from community supervision as recovered-this institution can be directed only by a STATE OF KENTUCKY 157 psychiatrist, a person thoroughly trained in general medicine and, in addition, familiar with all that we know as mental medicine. There are many questions of detail that come to the superintendent, with which it hardly seems necessary to occupy the mind of such a highly trained expert. But we must bear in mind that the one object of the institution is medical practice. Psychiatry is the art of healing the mentally ill; it is preventive medicine applied to disorganized and lame personalities. Every detail of the food and shelter and daily regimen of these patients bears directly upon this ultimate aim of the institution. The institution exists for the patients. The superintendent must be a business manager. He must be the head of the institution. He should be able to delegate much detail to others, but he is the general manager of the business. In order to make thorough medical studies of the patients m these hospitals, to facilitate recovery, and to organize the oc- cupational-therapy work and the mechanism of parole for the same end, the medical staff of each institution should be in- creased so that in general there will be one physician to each two hundred patients. The medical work of each institution, when pursued intensively with a view to rapid and effectiye recovery, will necessarily require more attention than can be given by the superintendent. The plan pursued in some hos- pitals of making the first assistant or assistant superintendent a clinical director would prove serviceable. The conducting of frequent meetings of the staff for the study of cases, the train- ing of efficient assistants, the proper recording of examinations and of results of treatment, as well as of the details of the treatment itself, constitute a large sphere of activity that is of the first importance. Meetings of the staff should be made occasions for intensive study and for thoroughgoing discussions of underlying personality difficulties in the patients considered. It is a matter of small importance to arrive at a name or a label or category that will characterize the difficulty of the patient. The important thing is to find out how the patient came into his difficulty and to devise means of ridding him of it and restoring his mind to normal functioning. All the resources of medicine and of social service should be brought to bear in these staff meetings to effect such changes in the mental conditions of 158 REPORT OF MENTAL HYGIENE SURVEY the patients considered. To manage these staff meetings and the medical work that heads up in them is a whole-time job for a competent psychiatrist. Of fundamental importance in most cases of mental dis- order is the physical condition of the patient. Laboratory facilities of every sort should be available. The State hospital should have facilities for performing dental and surgical serv- ice whenever indicated. Special facilities for treating tuber- culous patients should be provided. Hydrotherapy and occupa- tional therapy, together with all the refinements of mental nursing, should be so applied as to make such hospital care unnecessary to the patient at the earliest possible moment. Much of the success of treatment depends upon the nursing personnel. The mental attitudes of these nurses have great in- fluence upon the patients. Some women nurses should be placed in male wards generally since women are better nurses than men. The general use of parole, at the earliest moment feasible in each case, will have great influence in spreading hope and cheer among the patients of the hospital. Parole has a thera- peutic value not only for the patients actually paroled, but for all who see others going away from the institution. It leads each to expect an early opportunity to return home and resume direction of his affairs with his own family and in his own field or shop. Social service and community clinics are most intimately related. The social workers perform valuable service in secur- ing facts of the home life of the new patient-facts that may have an important psychogenic significance and that may lead to an understanding of the origin of his difficulties and so point out the way to recovery. When the patient comes through the clinic to the hospital, the social worker will obtain these facts at the clinic. It falls upon the social worker to select the home and the work for the patient when he is paroled, and to visit the paroled patient as frequently as is necessary in order to exercise the necessary supervision and to be assured that his recoven' is proceeding normally until such time as he shall be deemed sufficiently recovered to be discharged. In cases where community clinics are held sufficiently near to the STATE OF KENTUCKY 159 residence of the paroled patient, supervision can be exercised by the physician and the social worker who can see the patient by appointment at such clinic. When a clinical staff for com- munity service has been organized at each State hospital, it will be most natural for such service to hold itself subject to invitation by superintendents and principals of public schools. A psychiatrist, a social worker, and a psychologist, constituting such a clinical staff, could render invaluable service to schools by examining problem children and by advising the school au- thorities how best to manage them and to facilitate their training so as to obviate the difficulties and handicaps under which these children are found laboring. The State Institution for the Feebleminded: We have found that the State institution for feebleminded at Frankfort, with its farm, constitutes a pitifully small equip- ment on the part of the State for training Kentucky's mentally defective children. The effort that the State is making is inade- quate even for the 400 children now in attendance. The build- ings are poor and small. They were ill adapted to their intended uses. They are much too small even for the present population. The staff is not large enough. There is need of another doctor, of a psychologist, and of social workers. This institution should be developed along the lines indicated for the State hospitals, though there is a distinct difference in the end to be obtained. While the State hospitals are dealing with the mentally ill and should aim at taking them as early as possible and curing them as quickly as possible by applying every device of socialized medicine, the institution for the feeble- minded is concerned with the training of mentally handicapped children. Its clinical devices for ascertaining the nature and extent of the mental handicap of each child should be developed and refined to the highest point of efficiency. Mental defect, as we now conceive it, is much more of a problem than can be expressed by a mental-age figure resulting from any one intelli- gence test or any combination of such tests. Personality difficulties or imbalances in the development of the personality are of importance among defective children and 160 REPORT OF MENTAL HYGIENE SURVEY adults. Training, both in schoolroom subjects and in vocational lines, should be directed for each child by the results obtained in thoroughgoing mental examinations, including personality studies. Examinations should be repeated at frequent intervals as a means of checking up on the efficiency of the training processes, and in order to institute indicated changes in pro- cedure. Physical health should receive constant attention. When training processes are thus carefully guided by an intelligent understanding of what the training is accomplishing from month to month for each individual, large numbers of the children who come to this school will attain to a degree of socialization and of capacity for service that will make it possi- ble to parole them. Further development of the farm colony for boys, of other similiar colonies, and of colonies for girls, such as we see in other States, especially at Rome, New York, will prove a means of facilitating the return of trained mental defectives to community life. When they are paroled, it should be under the very careful supervision of a competent psychiatric social service. This supervision should continue indefinitely or until assurance can be had that such supervision is no longer necessary for the safety or well-being either of the person him- self or of the community. Some low-grade mental defectives who have no suitable home surroundings will have to be permanently cared for by the State institution. Some who constitute a menace to the community, but have not been delinquent, will have to continue in custody. Delinquents who are defective should have special custodial facilities. But the great majority of mentally handicapped children who come to the State institution for feebleminded for training can be trained, by the intensive application of laboratory methods and training processes, by the intensive use of parole through colonies, and by supervision while on parole, to live in private homes and on farms and to work for their own support, thus relieving the State of much expense for the main- tenance of older mentally defective persons. Community life and self-support will also make them feel much happier than they could in the less natural surroundings of a large institution. Defective Delinquents-. Mentally handicapped persons who STATE OF KENTUCKY 161 have proved delinquent we find in the Houses of Reform, in county jails, in penitentiaries, and at the institution for feeble- minded. Such persons, while young and trainable, clearly need the intensive study suggested above for the feebleminded and they need training directed along lines calculated to make them innocuous in community life. Teaching such persons to do something useful is the most promising way of preventing the recurrence of the delinquency, the offensive conduct. Such persons should be trained in groups separate from non-delin- quent mental defectives. They should also be trained in groups separate from mentally competent delinquents. Separation from the non-delinquent defectives is indicated as a means of avoiding contamination of the non-delinquent with delinquent tendencies. The separation from the delinquents who are not defective is indicated because of the very special training that is needed by the defectives. This latter is also indicated by the fact that the defectives require longer training. Some of them may not reach such a stage of development as will give reason- able assurance of good behavior while on parole. When any defective is paroled, it should be with the clear and definite recognition of his mental handicap. The criminal insane constitute a similar group which are not properly provided for in any State hospital or penitentiary. The fact that a mentally ill person has committed a crime con-^ stitutes no reason for denying to him the hospital care indicated by his mental condition. The hospital, however, in which he is cared for must be able to detain him. Defective delinquents and the criminal insane might well be cared for in a special new institution in Kentucky. New York has two hospitals for the criminal insane and one institu- tion for defective delinquents. With the smaller population of Kentucky, one institution to care for these two classes would suffice at the present time. The two classes are alike in that they are mental cases and both need to have more or less precaution- ary measures taken for their detention. Both need vocational or occupational training. The mentally ill need occupational training; its therapeutic value to most mental patients is great. The defective delinquents need training and supervision of their activities first, last, and all the time. 162 REPORT OF MENTAL HYGIENE SURVEY । Epileptics: We find in all institutions and in general school populations everywhere some neglected epileptics, both children and adults, who suffer from more or less frequent and severe seizures that leave in their wake more or less severe mental deterioration. Most of these are pitiful cases. As children, they do not find suitable opportunity for education in the public schools. As adults, they are handicapped socially. Many vocations are closed to them even though they retain good mental capacity. Medical science has revealed little as to the causes of epileptic seizures. Very little can be done to improve the condition of an epileptic, but something can be done by regulating the regimen. Hospital care and training for the young should be provided. Providing care in a hospi- tal and studying numbers of epileptics is most likely to bring to light information in regard to the causes of epileptic seizures and thus lead to means of alleviating their suffering. Houses of Reform : The institution at Greendale, when re- lieved of feebleminded children, will constitute in a still more real sense than at present a super-training school. When the feebleminded have been properly provided for in an institution for defective delinquents, the juvenile delinquents sent to this institution will be boys and girls with personality difficulties with which the public schools haveffieen unable to deal effectively. The business of the Greendale institution will then be to analyze these difficulties and find means of correcting them. The first problem will be one of mental analysis, the discovery of the nature and the origin of the personality difficulty. This means a psychiatric clinic and an educational labora- tory. It means the closest possible collaboration between scien- tific analysis, on the one hand, and the training arts commonly designated educational on the other. Parole in the hands of highly trained social workers will constitute the third part of the training activities of the institution. Clinic, training, and parole are the triad of activities for the industrial school, and their aim is personality construction. The problems of re-education or the further education of these boys and girls who come to industrial training schools have been found considerably simplified when boys and girls are at dif- STATE OF KENTUCKY 163 ferent places. It would greatly facilitate the work of the in stitution if the girls, who constitute the smaller part of the in- stitution's work, could be removed to another place. Especially important would be the bearing of such removal upon the education of the girls themselves. Much more natural lives could be lived by these girls were they not subject to tbe terri- torial restrictions at present imposed upon them. They need out-door activity in the garden and poultry yard and even in the hay field and the cow barn. Institution life could be made to lead up much more naturally and effectively to the period of parole for these girls if they had the freedom of farm life in which to find themselves. Since Kentucky has another industrial school, the Louisville Industrial School, and since fhis school now has a site in the country to which it will soon move according to present plans, one questions whether a satisfactory arrangement could not be made with this institution by which it would agree to take delinquent girls from all sections of the State and allow all delinquent boys to be sent to Greendale. When the Louisville Industrial School has substituted for its walls understanding and cooperation, when it has more land for gardens and for horticultural work, then all the girls could have facilities for training in these lines of activity on the farm and in the garden and in the shop as wre!l as in the house. * The essential goal to keep in view in all this work with problem boys and girls is the reconstruction of personality. Training through industry and actual production is the means for attaining this. Occupational training is socialization. The Reformatory and Penitentiary: If these institutions could be relieved of their mentally ill and mentally defective and could be given a free hand with the men and women sent to them, (all on indeterminate sentences), they could then apply medicine and education to the rehabilitation of every person in their custody. The clinic would be the beginning of the treatment of every one coming to either of these institutions It would provide for a thorough examination, physical and mental. 164 REPORT OF MENTAL HYGIENE SURVEY Physical defects would be corrected and the personality would be taken in hand by the school and by the occupation-training department. When personality reconstruction had proceeded to a point that seemed to warrant it, the prison authorities would authorize parole. The prison superintendent should be a criminologist. His clinician (a psychiatrist) and his parole officers would be expert engineers in human nature. These men should be worthy to be entrusted with the power to determine when and how any person should be paroled. It would be wrel! to provide for consulting the interests of the community from which each offender has been sent before he is paroled. The law might provide for the consent of the court from which the person was sent, and of the prosecuting attorney of the county from which he was sentenced, before such person could be paroled again to the community from which he came. < Reconstruction of the personality through wisely directed training and carefully supervised parole of the individual, so that he can resume a place in the community, should be the one aim of these institutions. Theirs is high-class educational work. County J ails: The more or less temporary nature of the detention of all inmates of county jails, together with the small- ness of the institutions, makes the organization of training in them a much more difficult matter than in the case of the peni- tentiary. Jail inmates are much more largely petty offenders. Nevertheless, it holds true that the idleness in which these persons are kept has a degenerating and deteriorating effect upon their personalities. The conditions under which persons are kept in county jails desocialize, whereas the sole object of detention should be socialization and rehabilitation of the per- sonality. A few State farms, organized for shop work as well as for farm labor, to which all minor offenders could be sentenced, would meet the situation of the sentenced offender. This would obviate all detention in the county jail after court procedure. Provision for prompt court action after arrest and grand-jury findings would shorten the period of detention prior to trial. In the larger county jails some vocational training might well be instituted. STATE OF KENTUCKY 165 County Almshouses-. The county poorhouse, in so far as it attempts to care for mental defectives and persons who are mentally ill, is taking on functions for which it was never in- tended. The feebleminded need school training and personality development. The mentally ill require hospital care. Even dotards deserve far better care than the ordinary county poor- house affords them. Those who are sick should be cared for in hospitals. When any county has disposed of its feebleminded, men- tally ill, and sick according to these indications, there will be very few, if any, inmates left in the county almshouse. These could be more cheaply boarded and better cared for in private homes. There is, therefore, little use in maintaining a county almshouse. Public Schools-. The mental health of children is the most important concern of society. The children constitute the best investment of this generation. Theirs will be the inheritance of all we have to leave in a few years. We are, therefore, con- cerned with the conditions of health of body and mind that they will bring to that heritage. The mental health of the child of pre-school age has an im- portance in its bearing upon the child's later life that has been too little appreciated. Trends are established, traits of character are ingrained in life, and the personality is in considerable measure formed by the home and neighborhood surroundings in these years of infancy and early childhood. A scolding mother, a mother who threatens with no serious intention of making good her threats, a. mother who is so inconsequential as to promise punishment from the father when he returns and then to interfere with the punishment by the father, a father who beats the child's mother and kicks the child around like a dog, a selfish father w7ho sees nothing in the home but his own in- terests and comforts-these are all offenders whose offenses are of tremendous importance in constructing the psychopathic per- sonality that we see later in the child and the youth and the man. Mental medicine can do much in the way of preventing these psychopathic trends and traits. Clinics for pre-school 166 REPORT OF MENTAL HYGIENE SURVEY children can do much in the way of enlightening parents, ex- plaining to them the nature of the problems presented by their children. It can offer to the children untold benefits by pro- viding for more natural, normal personality development. The physical health of the school child is receiving thought- ful consideration. Teachers generally are aware that infected tonsils, carious teeth, astigmatic vision, and defective hearing are handicaps, and that children should be relieved of them. They know that large numbers of children have these and similar defects. Nurses and health officers and school physicians are at work in the field inspecting and examining children, ad- vising parents, and having the defects corrected. The work has been well started in many places. The needs, however, of the rural school child in Kentucky are far from being adequately met in these respects. The mental condition of the child when he enters school, his personality traits, what he knows, his capacity to learn, and his ability to get along with other children are most important items to be assessed in planning his educational career. Children are all different. No two are alike. It is hardly to be expected that forty six-year-old children can be put through the same course of training for a year and brought out every one equally prepared to start upon the work of the next grade. It would seem very desirable to assess the personality of the child on entering school and to attempt to fit the training opportunities to his needs. The tests that will adequately assess the mental capacities of children are not mere intelligence tests. One must make a broad survey of the whole personality. As these schools are now organized, we find difficult and problem children scattered all along through the grades. These difficulties and problems indicate, for the most part, misfits. The school opportunities have not been made to fit the child. Thoroughgoing psychiatric examinations are the means of dis- covering the nature of the misfit in any such case and the method of adapting the school to meet the developmental needs of the child. Such studies can be best made by a clinical team sent out from a State institution wherein it should be the business of trained persons to be constantly making such examinations. STATE OF KENTUCKY 167 These institutions in Kentucky are the three State hospitals and the institution for the feebleminded. Each clinical team should consist, at the minimum, of a psychiatrist, a psychologist, and a psychiatric social worker. Such a visiting team would best come to the school by the invitation of the school. It would come as a group of consultants. The results of its work would be diagnoses and recommendations for treatment and training. The work of administering this training, which is educational, would be in the hands of the school. The purpose of such clinical examinations of problem children in the public school would be threefold. They would, in some instances, be the means of warding off mental disease likely to appear in later years. In other cases, such examinations would serve to minimize the effects of mental deficiency by securing proper training for the mentally defective child, so that upon the completion of his school training he would be prepared te live in the community, earning his own living or the greater part of it and looking out for himself under the kindly supervision of a competent welfare worker. The third and most important service, however, of such a clinical team in the public school would lie in the correction of the warpings, twisting, and kinks of the child's personality. This is the function that has been little realized. It is a field that has hardly been touched. The most important psychiatric service among children awaits the psychiatrist in the straightening out of apparently normally endowed or even superior children in whom environmental in- fluences have caused personality difficulties. In connection with these services of a clinical team in the public schools and the contemplated special training of mentally defective children (special classes) to prepare them for living in the community, it is apparent that some social service must needs be responsible for the continued supervision of these mentally defective persons. Many of them will need to be watched over and advised by some wiser head for many years. This supervision of feebleminded persons in the community calls for a local supervisor in each such community. It might well ba connected with the supervision of paroled patients from State hospitals and of paroled pupils from the State training school for 168 REPORT OF MENTAL HYGIENE SURVEY mental defectives. The whole service of supervision of such cases should be organized under a State board or commission. There is need for close contact between the community and the State institution, both when the patient goes in for service (restoration of health or training) and when he comes out on parole. Social service of the community and social service of the State institution would seem to be the liaison agency. To make such liaison effective, institution work and community care should be headed up in one management. Mental Health in Kentucky: The problems of mental health, considering the State as a whole, concern the work of the State board of charities and corrections, that of the commis- sioner of institutions, and the institutions under this board of commissioner, the State hospitals for the insane, the institution for the feebleminded, the Houses of Reform, the penitentiary and the reformatory. Mental health also is intimately connected with the work of the State board of health, of county health officers, and of public health nurses, particularly in their work with the public-school child. Physical health is essential to a wholesomely organized personality. Mental health, therefore, logically falls in the field of public health. It is, however, a newer field and one in which the ordinary public-health physician and nurse have, so far, little training. All these boards, institutions, and agencies, including the public school, constitute the most vitally important welfare work of the State and its minor divisions down to the separate com- munity or neighborhood. There is no matter of more intimate or vital interest to any neighborhood, school district, township, county, or city, or to the whole State, than that of the integrity of the personality of the individual members of the community. Mental health is of paramount importance to the people. That we should all think better, feel better, and act better is a matter of the first importance to each of us. That the mentally ill shall be restored quickly to health, that mental illnesses shall be prevented when possible, that the mentally defective shall be trained to be as useful as possible, and that personality diffi- culties shall be discovered early and obviated, are matters of STATE OF KENTUCKY 169 interest to every member of the community, whether mental disease, mental deficiency, or character difficulties inhere in his case or not. It makes life more fruitful and enjoyable to each of us if other members of the community are in good mental health. Board or Commissioner of Mental Health: Mental health, already so deeply intrenched in State activities, is evidently in need of unification and organization with an eye to the great ends to be achieved. The interests of the people of Kentucky in improved conditions of mental health necessitate a fruitful plan for bringing together all these interests under a single head or director. The communities and the schools over the State need expert advise in mental-health matters. This can best be organ- ized in the State institutions now in existence. The organization of extramural clinics in these institutions will have a wholesome and stimulating effect upon the institutions themselves. They need more professional service within their walls for their strictly intramural work, and organization for community ser- vice will necessitate increased professional staffs. A psychiatrist at the head of this work both inside the in- stitution and out in the district of the institution can exercise a wholesome and stimulating effect upon the work of the in- stitution. Many lines of work within each institution will develop more easily and effectively under the urge of such stim- ulating, unified direction based upon community needs. With increased staffs and the organization of each staff under a clini- cal director, more careful analytic work will be done for each patient. An increased use of occupational therapy and of parole, managed and supervised by competent social workers, will prob- ably ensue. Through such unifications of the State work lies the most serviceable avenue for organizing cooperation between the public school and the psychiatric talent now in the service of the State. Such unification of the State service and its preparation for community service constitutes the best plan for the management and supervision of mentally defective persons in the community after training has been completed, whether in the public school or in a State institution and its colonies. 170 REPORT OF MENTAL HYGIENE SURVEY RECOMMENDATIONS OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE First Recommendation ■ We recommend that steps be taken to unify and systematize, under the management and direction of a competent psychia- trist, all the mental health interests of the people of Kentucky. The four mental hospitals are in need of expert guidance. They have made progress in recent years. Better medical service, better nursing service, better social service, and more effective attacks upon the problems of mental disease and mental de- ficiency throughout the State are to be expected of these institu- tions. The service needs unifying and improving for a deter- mined attack upon mental disease and mental deficiency. There is need in the State of further constructive measures to im- prove the mental health of the people. This is a large field of community betterment work. It requires for its management one skilled in the field of psychiatry and mental hygiene. A commissioner of mental health should be placed in charge of all the institutions and agencies treating patients who are men- tally ill, training mentally defective persons and in any way aiming to conserve mental health. Second Recommendation We recommend that the commissioner of mental health should be selected on account of his special ability and training in the field of psychiatry and his success as an administrator. The law should provide that political affiliation and former place of residence should not enter into consideration in the selection of this executive. We conceive the State activity of which he is to be head of as much value to the people of Ken- tucky as is the State university. This commissioner will be in charge of organizing plans and sen-ice to improve the mental health of all the people of this State. In order to secure the services of one competent to tak° charge of such organization, he must be paid a good salary, probably as much as the president of the State university, and he must be assured of continuance in service during such time as he continues to give satisfaction. His tenure of office should STATE OF KENTUCKY 171 be far removed from the realm of partisan politics. His ap- pointment, therefore, should be by a board whose members are neither elected nor appointed at one time or by any single group of persons. His board should appoint superintendents of institutions from nominations made by the commissioner. The superintendent of each institution should employ physi- cians, nurses, psychiatric social workers, steward, farmer, ma- trons and all other employees. The board and commissioner should hold the superintendent responsible for results in his institution. Third Recommendation We recommend that statutory provision be made for the voluntary admission of patients to hospitals for mental diseases and to training schools for mentally defective children. These institutions are for service. The best service can be rendered when patients and pupils come voluntarily The law should also provide for emergency commitment and temporary care of patients in mental hospitals. Statute and practice would well provide that all patients, pending commitment to State hospitals, should be in charge of health officers, and that the police, the sheriff and the jailer should have nothing officially to do with such persons. These persons are ill. They need to be advised and managed by physicians rather than by law officers. While the constitution of Kentucky requires jury trial for commitment, the law might well provide for voluntary ad- mission, emergency commitment, temporary care and commit- ment for observation. These institutions should aim to re- cover the mentally ill and to train for community life the mentally defective. The legal formality for -entering upon the enjoyment of these services should be reduced to the min- imum which is consistent with the preservation of individual liberty and freedom of action. Voluntary admission, emergency commitment and temporary care, the last two mentioned on request of a health officer or some other practicing physician, or upon presentation of a certificate from a practicing physi- cian that the patient needs the service of such a mental hospi- 172 REPORT OF MENTAL HYGIENE SURVEY tai are working well in some States. We commend for adap- tion to Kentucky conditions, Laws of Massachusetts: 1. Section 45, Chapter 504, Acts of 1909 (voluntary ad- mission) 2. Section 42, Chapter 504, Acts of 1909 (emergency com- mitment) 3. Chapter 174, Acts of 1915 (temporary care, 10 days) 4. Chapter 145, Acts of 1919 (observation, 35 days) Fourth Recommendation We recommend that more adequate salaries be provided fox physicians, nurses, supervisors of occupational therapy, and psychiatric social workers; that provision be made for more service in all of these lines and that better quarters be provided for such workers. The physicians should be organized in each institution under a clinical director who should have charge of all clinical work and records and the training of the younger members of the staff. A distinct service can be contributed could the chaplain be enabled to conceive of his work as in part personal with the patients, and not confined to the hour specifically set apart for religious exercises. Fifth Recommendation We recommend that more land be provided for each of the present mental hospitals. It is also important that a new site be selected soon for the increasing hospital population. More land and buildings are urgently needed by the school for the feebleminded for the training of the children now in attend- ance. Those on the waiting list and those who should be pre- paring through colony life for parole in the community demand further additions to land, buildings and equipment. Sixth Recommendation We recommend the inauguration of a colony plan for insti- tution-trained boys and girls, farm colonies for boys, household work colonies for girls and industrial colonies for each sex. These colonies should serve as stepping stones from institution life to community life. The school should not be allowed to STATE OF KENTUCKY 173 become a reservoir or asylum for any large number of mentally defective persons. In other States where the colony system is in use, repeated failures in various colonies have preceded the successful placing out of many a feebleminded child. The judi- cious use of the colony plan should ultimately prepare a ma- jority of the trained mentally defective children for com- munity life. Seventh Recommendation We recommend that provision be made for the supervision of all patients, paroled from the mental hospitals, (for the men- tally ill and the mentally defective) by experienced psychiatric social tvorkers. Provision for such supervision of mental pa- tients by competent persons is one important ground for re- commending a commissioner of mental health. This State-wide organization, while it can never replace community interest in the patient who has been ill and in the person who is mentally defective, seems to be a very necessary means of securing the development of this community interest in such problems. Eighth Recommendation We recommend that defective children who are also per- sistently delinquent in the Houses of Reform, persistently de- linquent children found in schools for the feebleminded, men- tally defective adults found in prisons and jails, and other youths and adults who are persistently delinquent and mentally defective shall be provided for in a separate institution for defective delinquents. These persons ought to be considered primarily defective. The delinquency is incidental to the men- tal condition. They should be trained. This institution would have to provide for forcible deten- tion, and patients committed here would not be considered sub- ject to discharge until improvement in the mental condition warranted reasonable expectation that offenses would not be repeated. Parole from this institution should, of course, fol- low whenever the mental condition warranted such trial visit. Legal provision should be made for consultation with and ap- proval by the court that originally committed the delinquent before any such trial visit or final discharge could be made' 174 REPORT OF MENTAL HYGIENE SURVEY Ninth Recommendation We recommend the establishment of a separate mental hos- pital for the care and treatment of epileptics. The large num- bers of epileptics, both minor and adult, found in the institution for the feebleminded, in the State hospitals, in other institu- tions, and in the community, indicates the high desirability of a separate hospital wherein persons subject to such seizures and the mental consequences thereof might be trained and treated. Tenth Recommendation We recommend that all sentences to institutions for the correction, training, or detention of persons on account of their delinquencies shall be indeterminate in character. The work of rehabilitating the offender would thus be handed over directly and entirely to the institution to which he is sent. Such insti- tutions should be organized to take in hand the analysis of character or personality and the treatment of mental as well as physical conditions. When so organized, the staff of the institution would be able to determine, better than any other body of citizens, when the individual has been prepared for a trial visit back in the community. The law providing for indeterminate sentence might also provide for consultation with both the committing court and the county or State attor- ney in the case, before parole and before the final discharge of each individual who has been committed to an institution as a delinquent for either correction or custody. Eleventh Recommendation We recommend that the prisons and the industrial training school (Houses of Reform) be organized for making thorough medical studies of persons who come into their care. The men- tal constitution of each person should also be thoroughly ana- lysed in order to discover if possible the mental causes of his delinquencies. Correction and training should consist of work and other activities that will rehabilitate the individual. This is the social service for which these institutions are designed- rehabilitation and return to the community of persons who have proved delinquent. Such rehabilitation is best effected by STATE OF KENTUCKY 175 careful guidance of the person's activities. In order to do this, the superintendent should be an expert criminologist. The clinical work of the institution should be organized under a psychiatrist, the training work under an expert educator, and parole work under experts in the field of social service. Twelfth Recommendation We recommend that there be established one or more State farms, with facilities for training in agriculture and other industrial lines, to provide for the training of misdemeanants. Facilities for such training should be made by the larger coun- ties either by moving the county and city jails out of cities or by providing commodious well equipped shops within the pre- sent institutions. When sufficient facilities exist, the law should provide that misdemeanants may be sent only to such institu- tions as are prepared to make serious effort to analyze person- ality, discover the mental causes of offensive conduct, and adopt intensive training for the purpose of rehabilitating the of- fenders. Thirteenth Recommendation We recommend the establishment of mental clinics for the public schools. In cities, such clinics may serve constantly the schools of the one community. In rural districts, some provi- sion must be made for visiting travelling clinics. The present widely felt need in the public schools of the State for analysis of the mental problems of children who do not progress normally in school merits careful thought and plan- ning. In the cases of problem children, whether the problem be one of school progress or of behavior, the first need is evidently mental analysis. The organization of special classes for mentally handicapped children is most important. These classes, how- ever, cannot be organized for effective work until clinical facili- ties are at hand for discovering the nature of each child's problem. If it could be provided by law that the office of the com- missioner of mental health should be so organized that the in- stitutions under his direction would hold themselves open to accept invitations to send clinic teams to schools and to make 176 REPORT OF MENTAL HYGIENE SURVEY thorough mental studies of children referred to them, we be- lieve that this would prove to be the best method of providing such service for the public schools. It would secure the best available service. It would secure this service economically. It would prove a wholesome stimulus to enlarged interest in each mental hospital in the community mental health problems of its district. We recommend statutory provision for the organization of a clinical team of psychiatrist, psychologist, and psychiatric social worker at each mental hospital of the State. Invitations should come to the commissioner or to the superintendent of the hospital from local boards of education or from superintend- ents of schools to have this clinical team visit the schools in the district of the hospital at least once a year The team would visit the school as a body of consultants. By their analyses of problems and by their advice and recommendations for individual child- ren, they would help the teachers to meet and solve the diffi- culties in the way of training these problem children. Statutes should require report of every mentally defective child found by any school clinic to the commissioner of mental health. These records should be confidential. They will prove invaluable for the social service - department of the com- missioner's office in its care of mental defectives in the com- munity after they have been trained. Fourteenth Tiecommendation We recommend that the public schools be required by law to organize special classes or other special training facilities for children so handicapped mentally that they cannot profit by ordinary school instruction and cannot proceed normally through the grades, in every school where such children are found in sufficient numbers to warrant the organization of special facilities for their training. Appropriations should be made from the State school fund to provide at least half of the salary of each teacher for such special classes for mentally handicapped children. Consulta- tion with experts (a visiting clinic) being procurable upon in- vitation extended by the superintendent of schools or by the STATE OF KENTUCKY 177 local boards of education to the commissioner of mental health, the law should require a thorough mental and physical exami- nation to be made once each year of every child who is not progressing satisfactorily in his training. The State department of education could greatly help men- tally defective children in rural schools by providing teachers of such schools with a handbook. Fifteenth Recommendation We recommend that provision be made for the supervision of the feebleminded in the community after they have been trained, either in a public school or in a State training school, and in the colonies which should be organized under the com- missioner of mental health and the State training schools. This supervision should be provided by the training school under the commissioner of mental health and by local welfare organi- zations or agencies in the community. To be effective, this supervision must be in the hands of experienced psychiatric social workers. The most important factor in determining the success of such placing out on trial visit from an institution is the care with which a competent social worker has arranged for the home and employment of the feebleminded person. After he is placed it should be the duty of the social worker to be as- sured, as frequently as is found necessary by actual exper- ience in each case, that the visit or placement is continuing to be successful. The same kind of care seems desirable in the case of each ex-pupil of a special class in a public school. These persons re- main children and they need supervision, counsel and visiting just as do the feebleminded from State training institutions. More of the former are in their own homes and have parents competent to guide and help them. Some, however, do not have these advantages and the most fortunate may lose parents and home. The organization of a social-service department under the commissioner of mental health should be legally provided for. 178 REPORT OF MENTAL HYGIENE SURVEY It should be empowered to assume the oversight of the manage- ment of feebleminded persons in every community in the State. The law should provide for the commitment of mentally defective persons to the care of the commissioner of mental health. It is important, however, that each community be placed and held, both by law and practice, under the full burden of its own mental defectives. The State institution and the public, school are only service stations to aid the community in this work. For feebleminded persons, the community needs yet another sort of service. It needs welfare agents who would act as advisers to the feebleminded in the community. Persons who do not grow up in their minds and are not able to assume the full responsibilities of citizenship need councilors. Such wel- fare agents, as part of their community service, should act as "big brothers" and "big sisters" to these "grown-up child- ren." They are an indispensable factor in the successful or- ganization of any community to stand in loco parentis to each feebleminded person after his training is over and when he is, as it were, let loose again in the community. These communi- ty welfare agents should also be well trained psychiatric social workers.