36
MENTAL WELFARE.
Mental Defectiveness. As defined in the Mental Deficiency Act 1927. By A. F. Tredgold, M.D. Since the beginning of this century, the interest of the general public and the medical profession in the subject of Mental Deficiency has been steadily increasing. The reason is clear. It is now known that the number of Mental Defectives in the community is very considerable, greater, in fact, than that of the Insane. It probably amounts to at least 8 per 1,000 of the total population of the country. It is also realized that defectives are a serious economic burden and, in many cases, a no less serious social menace; consequently, that their ascertainment, correct diagnosis, and proper administrative care, have become matters which the Nation can no longer afford to neglect. At the present day the subject is undoubtedly one concerning which every medical practitioner and social worker must have an adequate working knowledge. The term Mental Deficiency is comparatively new. Literally, it may be said to embrace all conditions of mind in which there is marked diminution of capacity. It may, for instance, be applied to the dement and the insane. For some years past, however, the term has gradually been acquiring a more restricted and specific meaning, and at the present day when we speak of mental deficiency we mean a condition of incomplete mental development, or, as it is technically " Amentia." termed, From at least as early as the fourteenth, to near the close of the nineteenth century, the only forms of such incomplete mental development which were generally recognized were the severe and obvious ones termed Idiocy and Imbecility. Towards the end of the last century, however, it was clearly demonstrated that less pronounced grades of defect existed, and these occurred amongst In the elementary school children as well as amongst the adult population. schools, at which attendance had then become compulsory, it was found that there was a class of children who, whilst not so defective in understanding as the imbeciles, nevertheless suffered from a degree of mental defect which seriously interfered with their education. Amongst the general population it was found that a class existed who, whilst similarly not so defective as imbeciles, nevertheless suffered from such a degree of defect that they were unable to compete on equal terms with their normal fellows, or to maintain an independent existence without some external care, supervision or control. In the course of time the recognition of these two groups resulted in the passing of two Acts of Parliament. The first of these was the Defective and Fpileptic Children (Education) Act, 1899, which was subsequently retraced by the consolidated Education Act, 1921. The second was the Mental Deficiency Act, 1913, which was subsequently amended in certain particulars by the Mental Deficiency Act, 1927. The Education Act, 1921, and the Mental Deficiency Acts, 1913 and 1927, are therefore the authoritative and legal pronouncements as to what constitutes Mental Deficiency. Unfortunately, the definitions in these respective Acts are not quite in agreement, and this has led to some confusion, and to two different types of individuals being designated mental defectives. This discrepancy in the definitions is in large measure attributable to the different purposes underlying the Education and Mental Deficiency Acts. The purpose of the Education Act is to provide suitable education for those who cannot profitably be taught in ordinary schools, hence the criterion adopted is that of educational incapacity. The main purpose of the Mental Deficiency Acts, on the other hand, is to provide suitable care and control, and hence the criterion is that of social incapacity. Although
MENTAL WELFARE.
37
test laid down by the definition in the Education Act is that of scholastic ineducability, I am of the opinion that the intention of the framers of the Act was not to legislate for children who were solely and simply defective in capacity for school learning, but for children who, whilst suffering from a defect of this kind, were also defective in general intelligence. That is to say, for children who, subsequently to leaving school, would be found to suffer from social incapacity identical with that which constitutes mental deficiency under the Mental Deficiency Acts. In many, perhaps even in the majority of children, who are certified as defective under the Education Act, this is actually the case, for the reason that defective scholastic educability and defective social capacity are often A large number of associated. But this association is by no means constant. children have a low capacity for school learning, but are by no means lacking in general intelligence, and there is no doubt that many such children are certified as mentally defective under the Education Act, and sent to special schools, who subsequently prove capable of fending for themselves. It is necessary to bear this class in mind, although in my opinion it is unfair to stigmatize such children as mentally deficient. I regard them as belonging to the lower stratum, the "dull and backward" group, of the normal population. It is with Mental Deficiency as defined in the Mental Deficiency Acts that I now propose to deal. The Mental Deficiency Act of 1913 did not define mental deficiency as such, but it defined four classes of defectives, namely:?Idiots, Imbeciles, Feebleminded, and Moral Imbeciles. With the purpose of making it clear that the Act only referred to conditions of incomplete mental development, and not to states of mental disorder or decay, it specified that the defect must have been present from birth or from an early age." Experience of the working of the Act showed that these words caused considerable administrative difficulties, and it the Mental Deficiency Act 1927 was passed was largely to remedy them that last year. In this Act, in addition to certain alterations in the definitions of the four classes, a new section was added defining mental deficiency. This Section, 1. (2), is as follows : Mental Defectiveness means a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury."
the only
"
"
It is at once apparent that this definition is based upon a much wider concept of the nature of mental deficiency than that which was held by the Law before 1913. Prior to that date mental defect was legally and commonly regarded as consisting of a pronounced want of understanding. The present definition says nothing about understanding or any particular mental attribute. It simply arrested or incomplete development of mind." It therefore becomes of says "
importance to consider what form and degree of arrest or incompletion are necessary to bring the individual within the various classes of defectives defined by the Act. In order make a short
rightly to understand this fundamental question, it is necessary to digression, and to refer very briefly to certain points regarding the constitution of mind. We may regard mind as divisible into three main groups of functions, namely:?(1) instinctive, (2) emotional, and (3) intellectual. The instinctive functions, or instincts, of man consist of certain inherited tendencies to particular modes of purposive behaviour which, in all probability have been gradually acquired by man's primitive human and pre-human ancestors in the course of their past evolution. They were vital to the survival of the individual and the perpetuation of his kind, and hence they became organically fixed. At the present day, human instincts constitute powerful urges to particular modes of conduct, such, for example, as those of sex, self-preservation, combat, ac-
quisition, self-display,
and many others.
38
MENTAL WELFARE.
The emotional functions are the affective or feeling processes of mind. Each instinct is accompanied by its corresponding emotion. The instinct of combat, for instance, is accompanied by the emotion of anger or rage. Emotions, however, are not restricted to the manifestation of instincts; they are associated with The ideas of behaviour, and they then constitute the sentiments or senses. emotion which attaches to percepts or concepts of harmony in form, colour, or sound, for instance, constitutes the aesthetic sentiment; that which attaches to ideas of right and wrong, and of moral duty, constitutes the moral sentiment. Since the emotions serve to reinforce and increase the driving power of the instinct or idea, they are exceedingly powerful incentives to behaviour. The intellectual functions consist of the perceiving, understanding, delib-
erating,
discriminating,
planning,
co-ordinating
and
controlling
processes of
Their development increases with man's gradual evolution from a state of The intellectual functions, together with the savagery to one of civilization. higher sentiments, may be regarded as the summation of the mental architecture, and their importance consists in the increased capacity they bestow upon man for acquiring knowledge, understanding relationships, making plans, learning from experience, and modifying and controlling primitive instincts and emotions so as to enable him to adapt himself to his surroundings and achieve an ideal.
mind.
Let us now consider the importance respectively of these instinctive, emotional and intellectual functions of mind in enabling the individual to maintain an independent existence in a civilized community. There is no doubt that in the various forms of life below that of man, adaptation to environment, individual survival, and perpetuation of the species, are secured in a very efficient It is otherwise with man. Even in the case of the manner mainly by instincts. most primitive human types living in communities of the most simple nature, some conscious understanding of the relationship between causes and effects, some capacity to make comparisons, to form simple judgments, to learn from experience, to look ahead and make plans, and to co-ordinate behaviour in accordance with the plans made, are necessary if the individual is to secure food, to keep alive and propagate his kind. Moreover, the maintenance of individual life and the safety of such a community must often necessitate an inhibition or modification of man's primitive instincts. It would clearly be impossible for any community to continue to exist if free and unfettered instinctive action were the order of the day. Hence, whilst instincts and emotions still continue to act as powerful incentives to conduct, the intellectual processes of mind have gradually become of more and more importance. We may say, in fact, that while in the case of the lower animals survival is largely, although perhaps not entirely, dependent upon instincts, in man it is dependent upon the intellectual functions of mind. It is necessary to point out, however, that what we term the intellectual functions consist of several groups of processes. The chief of these groups are as follows:?(1) That group of processes concerned in the acquirement of knowledge and the operations of thought. An individual with a high development of these will be a profound scholar, but he may be devoid of any practical ability and even lacking in the capacity for adaptation to the ordinary requirements of life. (2) That group of processes concerned in some specific motor or mental operation, such, for instance, as music, mechanics, art, or arithmetical calculation. An individual with a high development of these may not be learned, and may be lacking in adaptiveness, but he may be a genius in his own particular sphere. (3) That group of processes concerned in the co-ordination and general control of conduct, and its adaptation to present and future needs. An individual with a high development of these may have little learning and no special ability, " common sense." but he will be adaptive, and the possessor of
MENTAL WELFARE.
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Now, whilst there are, of course, certain basic processes, such as attention, perception, memory and ideation, common to all these groups, there is no doubt that the special processes which are characteristic of each group may be developed in very different degrees in different individuals. There is equally no doubt that these groups are not of equal value in enabling the individual to maintain an independent existence. Thus, there are persons with a high capacity for learning, or a degree of special ability amounting to genius, who are incapable of managing their affairs without supervision. There are others whose capacity for learning is so subnormal as to cause them to be certified as mental defectives and sent to special schools who are nevertheless capable of fending for themselves because they possess common sense. In fact, while learning and special aptitudes are undoubtedly advantageous to the individual, they are are not essential to survival. Independent survival, whether in a savage or a civilized community, demands the presence of that group of mental processes which determine adaptation, without this the individual will be in need of some care or supervision?in short, he will be a mental defective within the meaning of the Act. We may say, then, that the essential psychological basis of mental defect is a deficiency in that group of the intellectual functions of mind which determine adaptation to surroundings. But, just as there are variations in the development of the respective groups which compose intellect, so there are variations in the development of the various processes which determine adaptation. Hence, mental defectiveness may be of various grades, and, dependent upon the defect falling more particularly upon certain processes, it may be of various types.
It is these variations in degree and type of defect which give rise to the different classes of defectives defined by Law. There is no hard and sharp line of demarcation, either between the different grades of defect, or between mental defectives and the normal. The one passes into the other by insensible gradations. It thus results that the separation of defectives into different classes is largely arbitrary and artificial, and that, whilst the diagnosis of the lower grades is a matter of comparative ease, that of the highest grades may be attended with the greatest difficulty. However, apart from individuals on the borderland, either of the different grades of defect or of the normal, the bulk of those in the four classes of defectives do present certain tolerably well defined characteristics which will be briefly described. Idiots are the lowest grade of defectives. They are characterized by such a profound defect of adaptiveness that they are unable to understand the relationship between simple causes and their effects. Imbeciles are less defective and have sufficient understanding to protect themselves from ordinary physical dangers. They are defined by the Act as incapable of managing themselves or their affairs." This is true, but it is a misleading definition which does not at all adequately describe the marked deficiency of imbeciles. "
The Feeble-viinded
are the mildest grade of defectives and are by far the important class for several reasons. They are the most numerous; for every idiot there are approximately 3 imbeciles and 15 feeble-minded. The fact that they suffer from a comparatively mild degree of defect causes them to have considerably greater potentialities both for good and for evil, and this entails important social consequences. As a class they are markedly superior to the imbeciles in scholastic educability and capacity for work. Many of them acquire a fair range of school and general knowledge, and, if provided with a suitable occupation and afforded a little supervision, can earn wages which will pay for, or contribute materially to, their keep. In spite of this superiority, a careful mental investigation will usually reveal such a definite defect of general adaptiveness
most
40
MENTAL WELFARE.
doubt regarding them. Cut in some of them the degree of defect diagnosis may be a matter of considerable difficulty, and it is necessary to describe these in greater detail. Many of these high grade feeble-minded have been educated in ordinary schools, and although enquiry will show that the majority of them have been behind the average standard for their years, when they are seen as adolescents or young adults they present no very obvious educational failing. Their range of general information is not markedly inferior to that of their social compeers. They have a good appreciation of their surroundings and they converse intelligently upon ordinary topics. In fact they look, and talk, and apparently behave, like normal persons. They are consequently far removed from the concept of mental deficiency which formerly obtained, and which still exists in many quarters. And yet, when the life history of these persons is investigated, it is found to be one long record of inefficiency and failure. Some of them may have been provided with a suitable form of occupation in which they can earn enough money for their keep; but they cannot lay out the money they earn so as to provide for themselves without outside help. Should they lose their situation, they are rarely able of themselves to get another. If any change takes place in their circumstances they are unequal to the adaptation necessary to meet it. Those whose parents are well to do are tried at occupation after occupation, but they cannot make good. Eventually they are usually shipped off to a farm in one of the Colonies, or some rural clergyman is found who, for a consideration, allows them to assist with his poultry or garden. In short, it is quite clear that they cannot fend for themselves, and that they are in need of some special environment and some amount of care and supervision, if they are not to come to grief. as
to leave
is
so
slight
no
that
The class I have just described, apart from their inefficiency, give no trouble. They are well-behaved and good tempered; and although there is clearly some defect, their mental equilibrium is stable. There is another class, however, which I have termed the unstable type, who are markedly different, and in whom the outstanding characteristic is excessive emotional reaction. Anger, contrition, jealousy, revenge, elation, depression, overwhelm their minds in succession, with the rapidity of the turn of a kaleidoscope, and their whole conduct is so fickle and undependable that no one will employ them. The term temperamental defective has been applied to this type, and it has been suggested that their condition is purely one of excessive emotionality. But I cannot subscribe to this view, for I cannot see how the excess of a function can constitute mental defect. It appears to me that the excessive display of emotion is in reality due to a defect of general control, and that in most, if not all, of these persons this defect of control is merely an additional complication which is superadded to defects similar " to those which exist in the stable type. I therefore prefer to call them the un" "
"
stable type of feeble-minded. Now whilst the life history of these high grade feeble-minded persons, of either the stable or unstable type, clearly shows that they are in some way defective and in need of care and supervision either for their own protection or for the protection of others, it is nevertheless equally clear that the step which separates them from the lowest stratum of the normal community, from the hewers of wood and the drawers of water, is a very slight one. Of what then does the difference consist ? What is the nature of their defect ? It is this. The lowest stratum of the normal, illiterate though they may be, have enough common sense to manage themselves and their affairs without outside help. They make mistakes, but they profit by the experience and do not repeat them. Their ability is limited, but they have some ability to adapt themselves to conditions outside their previous experience. They may not be able to look a long way ahead, but they can look far enough for their needs. They can make plans
MENTAL WELFARE.
41
for their future, and they can co-ordinate and direct their conduct so as to achieve these plans. The feeble-minded are lacking in these aptitudes. In one person it may be discrimination or judgment that is chiefly at fault, in another provision or planning, in another co-ordination or general control, and so on. All of them, however, are defective in some way or other in that group of mental factors which are essential for efficient adaptation to the exigencies of life, and which is conven" " common sense." wisdom or The lack of this, which can iently termed usually be demonstrated by appropriate tests and careful investigation, renders them in need of care, supervision or control, and brings them within the meaning of the Act. The fourth and last class of defectives specified by the Act are the Moral persons in whose case there exists mental Defectives. They are defined as defectiveness coupled with strongly vicious or criminal propensities, and who require care, supervision and control for the protection of others." I do not propose to give any detailed account of these persons for the reason that, although they are a very important class, they are an exceedingly small one. It will be enough to say that moral defectives, from the psychological aspect, These are (1) a defect of wisdom are characterized by three main conditions. similar to that which marks all high grade aments. (2) A defect of moral and social sentiment which results in them being devoid of any of those altruistic feelings which play such an important part in the inhibition of primitive instincts and the regulation of conduct. (3) The presence of strongly pronounced The net result of this instinctive tendencies of the purely self seeking order. combination is to give rise to an individual whose whole life is one of senseless misdoing, and who is as devoid of shame as he is of sense. Having now attempted to describe the nature of Mental Deficiency from the psychological aspect, it remains to consider two other terms of the statutory definition; namely, that the arrested or incomplete development of mind must have been in existence before the age of 18 years, and that it must either arise from inherent causes or be induced by disease or injury. The development of mind is dependent upon two factors :?(1) a potentiality for development inherent in the germ cell, and (2) external factors of the environment which operate to favour or thwart the realization of this potentiality. If the inherent potentiality is normal, and if there are no unfavourable external factors, then the development of mind proceeds stage by stage until it is complete. In the early months and years of life behaviour is almost entirely the result of emotions and instinctive impulses. The gradual acquirement of knowledge, the new experiences of each day, the necessity for checking instinctive tendencies in order that some project may be attained or some unpleasant consequence averted, all combine to favour the development of the intellectual processes, and to render the individual more and more capable of adapting his conduct to the demands of his surroundings. The highest and latest development of all is that of the sentiments, such as those of right and wrong, of honour, honesty, and of social and moral obligation. With the acquirement of these, mental development becomes complete, and the individual is fully equipped to maintain an independent existence in a well ordered and law abiding community. It is not possible to say precisely at what age this development of mind reaches completion, and undoubtedly there are individual differences. It is now generally agreed, however, that in the great majority of individuals development is complete between the 16th and 18th years of life. In saying this I do not suggest that no further improvement takes place in mind after this age, or that the mental capacity of the youth of 18 years is equal to that of the mature individual of 45. Clearly this is not the case. What is meant is that by the age of IS or thereabouts, the normal individual is in possession of all the processes of mind, and that they are sufficiently developed to admit of independent social "
"
42
MENTAL WELFARE.
adaptation. With further years he undoubtedly acquires more knowledge and experience. He is capable of a wider outlook, his judgment becomes more sound, and his general mental capacity greater. But no new mental processes are acquired; the achitecture of mind is complete by about the 18th year. To descend to a very materialistic metaphor, we may say that by this age the normal individual is equipped with a full set of mental tools, and that further years merely add to his skill in using them. It is for this reason that the words "from birth or from an early age have been deleted and that the new definition specifies that the defect of mind must have existed before the age of 18 years. Any mental disability sufficient to necessitate supervision or control which supervenes after this age is not arrested These are not or incomplete development, but some form of disorder or decay. Amentia, and they are not intended to be included within the Mental Deficiency Act. There is no doubt, however, that under the old definitions many defectives who were urgently in need of protection, were debarred from the provisions of the Act. It will now be possible to include them. It has been said that mental growth is the resultant of two sets of factors, intrinsic and extrinsic. There are some points regarding these to which it is The factor of chief importance is the intrinsic one; that is, necessary to refer. the developmental potentiality inherent in the germ cell. The amount of this varies considerably in different individuals, and the great majority of mental defectives, probably as many as 4 / 5ths of the total number, owe their condition to an impaired developmental potentiality. They are consequently termed Primary Aments." This impetus to development may be so inadequate as to cause defects in the development of the body as well as of the mind, and such defects are known as stigmata of degeneracy." A marked inadequacy of developmental potentiality results in Idiocy and Imbecility; if less severe it results in the various grades of feeble-mindedness. In idiocy and imbecility even the foundations of mind are not well and truly laid, and the condition is apparent in the early months of life. At the other extreme, that is, in the high grade feeble-minded, the developmental impetus has been sufficient for the growth of all but the highest controlling processes of mind; and then it may not be until adolescence, that is, until the age at which these processes are normally evolved, that the deficiency "
"
"
becomes manifest. In such a case the individual may not show any serious abnormality until he is required to take the responsibilities of life upon his own shoulders. His defect then stands revealed. But even if the developmental potentiality of the germ cell be perfectly normal, arrest of mental growth may be brought about by factors of the environment causing injury or disease to the growing brain. Although these will produce the greatest effect during the period of most rapid brain growth, that is, from the time of fertilization to the third year of life, it is clearly possible for them to arrest development, and produce mental deficiency, at any age before development is complete. In the Act of 1913 no specific reference was made to these causes, and hence it was often assumed that mental defect arising in this way, especially after early childhood, did not come within the scope of the Act. The new definition makes it quite clear that they are included. The number of cases so arising is undoubtedly very considerable ; but as most of the children so affected die in the early years of life, their relative proportion becomes greatly reduced. If defectives of all ages be considered, cases of this kind, which are termed Secondary Amentia, probably amount to about one fourth of the total. I do not propose to discuss these factors in detail. It will be enough to say that they may be conveniently divided into three groups : ?namely, those incident before, during, and after birth. During birth, the chief factor is some form of injury. Before and after birth, toxic processes of some kind or other predominate, causing the various forms of meningitis and encephalitis.
MENTAL WELFARE.
43
In conclusion, the essential concept to keep clearly in mind is this:?That the legal criterion of Mental Deficiency is social incapacity of such degree and kind as to necessitate care, supervision and control. If this incapacity is due to any imperfection of mental development, of no matter what kind, so long as it has existed before the age of 18 years, then the individual is a mental defective within the meaning of the Act.
MENTAL WELFARE.
Mental Defectiveness. As defined in the Mental Deficiency Act 1927. By A. F. Tredgold, M.D. Since the beginning of this century, the interest of the general public and the medical profession in the subject of Mental Deficiency has been steadily increasing. The reason is clear. It is now known that the number of Mental Defectives in the community is very considerable, greater, in fact, than that of the Insane. It probably amounts to at least 8 per 1,000 of the total population of the country. It is also realized that defectives are a serious economic burden and, in many cases, a no less serious social menace; consequently, that their ascertainment, correct diagnosis, and proper administrative care, have become matters which the Nation can no longer afford to neglect. At the present day the subject is undoubtedly one concerning which every medical practitioner and social worker must have an adequate working knowledge. The term Mental Deficiency is comparatively new. Literally, it may be said to embrace all conditions of mind in which there is marked diminution of capacity. It may, for instance, be applied to the dement and the insane. For some years past, however, the term has gradually been acquiring a more restricted and specific meaning, and at the present day when we speak of mental deficiency we mean a condition of incomplete mental development, or, as it is technically " Amentia." termed, From at least as early as the fourteenth, to near the close of the nineteenth century, the only forms of such incomplete mental development which were generally recognized were the severe and obvious ones termed Idiocy and Imbecility. Towards the end of the last century, however, it was clearly demonstrated that less pronounced grades of defect existed, and these occurred amongst In the elementary school children as well as amongst the adult population. schools, at which attendance had then become compulsory, it was found that there was a class of children who, whilst not so defective in understanding as the imbeciles, nevertheless suffered from a degree of mental defect which seriously interfered with their education. Amongst the general population it was found that a class existed who, whilst similarly not so defective as imbeciles, nevertheless suffered from such a degree of defect that they were unable to compete on equal terms with their normal fellows, or to maintain an independent existence without some external care, supervision or control. In the course of time the recognition of these two groups resulted in the passing of two Acts of Parliament. The first of these was the Defective and Fpileptic Children (Education) Act, 1899, which was subsequently retraced by the consolidated Education Act, 1921. The second was the Mental Deficiency Act, 1913, which was subsequently amended in certain particulars by the Mental Deficiency Act, 1927. The Education Act, 1921, and the Mental Deficiency Acts, 1913 and 1927, are therefore the authoritative and legal pronouncements as to what constitutes Mental Deficiency. Unfortunately, the definitions in these respective Acts are not quite in agreement, and this has led to some confusion, and to two different types of individuals being designated mental defectives. This discrepancy in the definitions is in large measure attributable to the different purposes underlying the Education and Mental Deficiency Acts. The purpose of the Education Act is to provide suitable education for those who cannot profitably be taught in ordinary schools, hence the criterion adopted is that of educational incapacity. The main purpose of the Mental Deficiency Acts, on the other hand, is to provide suitable care and control, and hence the criterion is that of social incapacity. Although
MENTAL WELFARE.
37
test laid down by the definition in the Education Act is that of scholastic ineducability, I am of the opinion that the intention of the framers of the Act was not to legislate for children who were solely and simply defective in capacity for school learning, but for children who, whilst suffering from a defect of this kind, were also defective in general intelligence. That is to say, for children who, subsequently to leaving school, would be found to suffer from social incapacity identical with that which constitutes mental deficiency under the Mental Deficiency Acts. In many, perhaps even in the majority of children, who are certified as defective under the Education Act, this is actually the case, for the reason that defective scholastic educability and defective social capacity are often A large number of associated. But this association is by no means constant. children have a low capacity for school learning, but are by no means lacking in general intelligence, and there is no doubt that many such children are certified as mentally defective under the Education Act, and sent to special schools, who subsequently prove capable of fending for themselves. It is necessary to bear this class in mind, although in my opinion it is unfair to stigmatize such children as mentally deficient. I regard them as belonging to the lower stratum, the "dull and backward" group, of the normal population. It is with Mental Deficiency as defined in the Mental Deficiency Acts that I now propose to deal. The Mental Deficiency Act of 1913 did not define mental deficiency as such, but it defined four classes of defectives, namely:?Idiots, Imbeciles, Feebleminded, and Moral Imbeciles. With the purpose of making it clear that the Act only referred to conditions of incomplete mental development, and not to states of mental disorder or decay, it specified that the defect must have been present from birth or from an early age." Experience of the working of the Act showed that these words caused considerable administrative difficulties, and it the Mental Deficiency Act 1927 was passed was largely to remedy them that last year. In this Act, in addition to certain alterations in the definitions of the four classes, a new section was added defining mental deficiency. This Section, 1. (2), is as follows : Mental Defectiveness means a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury."
the only
"
"
It is at once apparent that this definition is based upon a much wider concept of the nature of mental deficiency than that which was held by the Law before 1913. Prior to that date mental defect was legally and commonly regarded as consisting of a pronounced want of understanding. The present definition says nothing about understanding or any particular mental attribute. It simply arrested or incomplete development of mind." It therefore becomes of says "
importance to consider what form and degree of arrest or incompletion are necessary to bring the individual within the various classes of defectives defined by the Act. In order make a short
rightly to understand this fundamental question, it is necessary to digression, and to refer very briefly to certain points regarding the constitution of mind. We may regard mind as divisible into three main groups of functions, namely:?(1) instinctive, (2) emotional, and (3) intellectual. The instinctive functions, or instincts, of man consist of certain inherited tendencies to particular modes of purposive behaviour which, in all probability have been gradually acquired by man's primitive human and pre-human ancestors in the course of their past evolution. They were vital to the survival of the individual and the perpetuation of his kind, and hence they became organically fixed. At the present day, human instincts constitute powerful urges to particular modes of conduct, such, for example, as those of sex, self-preservation, combat, ac-
quisition, self-display,
and many others.
38
MENTAL WELFARE.
The emotional functions are the affective or feeling processes of mind. Each instinct is accompanied by its corresponding emotion. The instinct of combat, for instance, is accompanied by the emotion of anger or rage. Emotions, however, are not restricted to the manifestation of instincts; they are associated with The ideas of behaviour, and they then constitute the sentiments or senses. emotion which attaches to percepts or concepts of harmony in form, colour, or sound, for instance, constitutes the aesthetic sentiment; that which attaches to ideas of right and wrong, and of moral duty, constitutes the moral sentiment. Since the emotions serve to reinforce and increase the driving power of the instinct or idea, they are exceedingly powerful incentives to behaviour. The intellectual functions consist of the perceiving, understanding, delib-
erating,
discriminating,
planning,
co-ordinating
and
controlling
processes of
Their development increases with man's gradual evolution from a state of The intellectual functions, together with the savagery to one of civilization. higher sentiments, may be regarded as the summation of the mental architecture, and their importance consists in the increased capacity they bestow upon man for acquiring knowledge, understanding relationships, making plans, learning from experience, and modifying and controlling primitive instincts and emotions so as to enable him to adapt himself to his surroundings and achieve an ideal.
mind.
Let us now consider the importance respectively of these instinctive, emotional and intellectual functions of mind in enabling the individual to maintain an independent existence in a civilized community. There is no doubt that in the various forms of life below that of man, adaptation to environment, individual survival, and perpetuation of the species, are secured in a very efficient It is otherwise with man. Even in the case of the manner mainly by instincts. most primitive human types living in communities of the most simple nature, some conscious understanding of the relationship between causes and effects, some capacity to make comparisons, to form simple judgments, to learn from experience, to look ahead and make plans, and to co-ordinate behaviour in accordance with the plans made, are necessary if the individual is to secure food, to keep alive and propagate his kind. Moreover, the maintenance of individual life and the safety of such a community must often necessitate an inhibition or modification of man's primitive instincts. It would clearly be impossible for any community to continue to exist if free and unfettered instinctive action were the order of the day. Hence, whilst instincts and emotions still continue to act as powerful incentives to conduct, the intellectual processes of mind have gradually become of more and more importance. We may say, in fact, that while in the case of the lower animals survival is largely, although perhaps not entirely, dependent upon instincts, in man it is dependent upon the intellectual functions of mind. It is necessary to point out, however, that what we term the intellectual functions consist of several groups of processes. The chief of these groups are as follows:?(1) That group of processes concerned in the acquirement of knowledge and the operations of thought. An individual with a high development of these will be a profound scholar, but he may be devoid of any practical ability and even lacking in the capacity for adaptation to the ordinary requirements of life. (2) That group of processes concerned in some specific motor or mental operation, such, for instance, as music, mechanics, art, or arithmetical calculation. An individual with a high development of these may not be learned, and may be lacking in adaptiveness, but he may be a genius in his own particular sphere. (3) That group of processes concerned in the co-ordination and general control of conduct, and its adaptation to present and future needs. An individual with a high development of these may have little learning and no special ability, " common sense." but he will be adaptive, and the possessor of
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Now, whilst there are, of course, certain basic processes, such as attention, perception, memory and ideation, common to all these groups, there is no doubt that the special processes which are characteristic of each group may be developed in very different degrees in different individuals. There is equally no doubt that these groups are not of equal value in enabling the individual to maintain an independent existence. Thus, there are persons with a high capacity for learning, or a degree of special ability amounting to genius, who are incapable of managing their affairs without supervision. There are others whose capacity for learning is so subnormal as to cause them to be certified as mental defectives and sent to special schools who are nevertheless capable of fending for themselves because they possess common sense. In fact, while learning and special aptitudes are undoubtedly advantageous to the individual, they are are not essential to survival. Independent survival, whether in a savage or a civilized community, demands the presence of that group of mental processes which determine adaptation, without this the individual will be in need of some care or supervision?in short, he will be a mental defective within the meaning of the Act. We may say, then, that the essential psychological basis of mental defect is a deficiency in that group of the intellectual functions of mind which determine adaptation to surroundings. But, just as there are variations in the development of the respective groups which compose intellect, so there are variations in the development of the various processes which determine adaptation. Hence, mental defectiveness may be of various grades, and, dependent upon the defect falling more particularly upon certain processes, it may be of various types.
It is these variations in degree and type of defect which give rise to the different classes of defectives defined by Law. There is no hard and sharp line of demarcation, either between the different grades of defect, or between mental defectives and the normal. The one passes into the other by insensible gradations. It thus results that the separation of defectives into different classes is largely arbitrary and artificial, and that, whilst the diagnosis of the lower grades is a matter of comparative ease, that of the highest grades may be attended with the greatest difficulty. However, apart from individuals on the borderland, either of the different grades of defect or of the normal, the bulk of those in the four classes of defectives do present certain tolerably well defined characteristics which will be briefly described. Idiots are the lowest grade of defectives. They are characterized by such a profound defect of adaptiveness that they are unable to understand the relationship between simple causes and their effects. Imbeciles are less defective and have sufficient understanding to protect themselves from ordinary physical dangers. They are defined by the Act as incapable of managing themselves or their affairs." This is true, but it is a misleading definition which does not at all adequately describe the marked deficiency of imbeciles. "
The Feeble-viinded
are the mildest grade of defectives and are by far the important class for several reasons. They are the most numerous; for every idiot there are approximately 3 imbeciles and 15 feeble-minded. The fact that they suffer from a comparatively mild degree of defect causes them to have considerably greater potentialities both for good and for evil, and this entails important social consequences. As a class they are markedly superior to the imbeciles in scholastic educability and capacity for work. Many of them acquire a fair range of school and general knowledge, and, if provided with a suitable occupation and afforded a little supervision, can earn wages which will pay for, or contribute materially to, their keep. In spite of this superiority, a careful mental investigation will usually reveal such a definite defect of general adaptiveness
most
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doubt regarding them. Cut in some of them the degree of defect diagnosis may be a matter of considerable difficulty, and it is necessary to describe these in greater detail. Many of these high grade feeble-minded have been educated in ordinary schools, and although enquiry will show that the majority of them have been behind the average standard for their years, when they are seen as adolescents or young adults they present no very obvious educational failing. Their range of general information is not markedly inferior to that of their social compeers. They have a good appreciation of their surroundings and they converse intelligently upon ordinary topics. In fact they look, and talk, and apparently behave, like normal persons. They are consequently far removed from the concept of mental deficiency which formerly obtained, and which still exists in many quarters. And yet, when the life history of these persons is investigated, it is found to be one long record of inefficiency and failure. Some of them may have been provided with a suitable form of occupation in which they can earn enough money for their keep; but they cannot lay out the money they earn so as to provide for themselves without outside help. Should they lose their situation, they are rarely able of themselves to get another. If any change takes place in their circumstances they are unequal to the adaptation necessary to meet it. Those whose parents are well to do are tried at occupation after occupation, but they cannot make good. Eventually they are usually shipped off to a farm in one of the Colonies, or some rural clergyman is found who, for a consideration, allows them to assist with his poultry or garden. In short, it is quite clear that they cannot fend for themselves, and that they are in need of some special environment and some amount of care and supervision, if they are not to come to grief. as
to leave
is
so
slight
no
that
The class I have just described, apart from their inefficiency, give no trouble. They are well-behaved and good tempered; and although there is clearly some defect, their mental equilibrium is stable. There is another class, however, which I have termed the unstable type, who are markedly different, and in whom the outstanding characteristic is excessive emotional reaction. Anger, contrition, jealousy, revenge, elation, depression, overwhelm their minds in succession, with the rapidity of the turn of a kaleidoscope, and their whole conduct is so fickle and undependable that no one will employ them. The term temperamental defective has been applied to this type, and it has been suggested that their condition is purely one of excessive emotionality. But I cannot subscribe to this view, for I cannot see how the excess of a function can constitute mental defect. It appears to me that the excessive display of emotion is in reality due to a defect of general control, and that in most, if not all, of these persons this defect of control is merely an additional complication which is superadded to defects similar " to those which exist in the stable type. I therefore prefer to call them the un" "
"
stable type of feeble-minded. Now whilst the life history of these high grade feeble-minded persons, of either the stable or unstable type, clearly shows that they are in some way defective and in need of care and supervision either for their own protection or for the protection of others, it is nevertheless equally clear that the step which separates them from the lowest stratum of the normal community, from the hewers of wood and the drawers of water, is a very slight one. Of what then does the difference consist ? What is the nature of their defect ? It is this. The lowest stratum of the normal, illiterate though they may be, have enough common sense to manage themselves and their affairs without outside help. They make mistakes, but they profit by the experience and do not repeat them. Their ability is limited, but they have some ability to adapt themselves to conditions outside their previous experience. They may not be able to look a long way ahead, but they can look far enough for their needs. They can make plans
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for their future, and they can co-ordinate and direct their conduct so as to achieve these plans. The feeble-minded are lacking in these aptitudes. In one person it may be discrimination or judgment that is chiefly at fault, in another provision or planning, in another co-ordination or general control, and so on. All of them, however, are defective in some way or other in that group of mental factors which are essential for efficient adaptation to the exigencies of life, and which is conven" " common sense." wisdom or The lack of this, which can iently termed usually be demonstrated by appropriate tests and careful investigation, renders them in need of care, supervision or control, and brings them within the meaning of the Act. The fourth and last class of defectives specified by the Act are the Moral persons in whose case there exists mental Defectives. They are defined as defectiveness coupled with strongly vicious or criminal propensities, and who require care, supervision and control for the protection of others." I do not propose to give any detailed account of these persons for the reason that, although they are a very important class, they are an exceedingly small one. It will be enough to say that moral defectives, from the psychological aspect, These are (1) a defect of wisdom are characterized by three main conditions. similar to that which marks all high grade aments. (2) A defect of moral and social sentiment which results in them being devoid of any of those altruistic feelings which play such an important part in the inhibition of primitive instincts and the regulation of conduct. (3) The presence of strongly pronounced The net result of this instinctive tendencies of the purely self seeking order. combination is to give rise to an individual whose whole life is one of senseless misdoing, and who is as devoid of shame as he is of sense. Having now attempted to describe the nature of Mental Deficiency from the psychological aspect, it remains to consider two other terms of the statutory definition; namely, that the arrested or incomplete development of mind must have been in existence before the age of 18 years, and that it must either arise from inherent causes or be induced by disease or injury. The development of mind is dependent upon two factors :?(1) a potentiality for development inherent in the germ cell, and (2) external factors of the environment which operate to favour or thwart the realization of this potentiality. If the inherent potentiality is normal, and if there are no unfavourable external factors, then the development of mind proceeds stage by stage until it is complete. In the early months and years of life behaviour is almost entirely the result of emotions and instinctive impulses. The gradual acquirement of knowledge, the new experiences of each day, the necessity for checking instinctive tendencies in order that some project may be attained or some unpleasant consequence averted, all combine to favour the development of the intellectual processes, and to render the individual more and more capable of adapting his conduct to the demands of his surroundings. The highest and latest development of all is that of the sentiments, such as those of right and wrong, of honour, honesty, and of social and moral obligation. With the acquirement of these, mental development becomes complete, and the individual is fully equipped to maintain an independent existence in a well ordered and law abiding community. It is not possible to say precisely at what age this development of mind reaches completion, and undoubtedly there are individual differences. It is now generally agreed, however, that in the great majority of individuals development is complete between the 16th and 18th years of life. In saying this I do not suggest that no further improvement takes place in mind after this age, or that the mental capacity of the youth of 18 years is equal to that of the mature individual of 45. Clearly this is not the case. What is meant is that by the age of IS or thereabouts, the normal individual is in possession of all the processes of mind, and that they are sufficiently developed to admit of independent social "
"
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adaptation. With further years he undoubtedly acquires more knowledge and experience. He is capable of a wider outlook, his judgment becomes more sound, and his general mental capacity greater. But no new mental processes are acquired; the achitecture of mind is complete by about the 18th year. To descend to a very materialistic metaphor, we may say that by this age the normal individual is equipped with a full set of mental tools, and that further years merely add to his skill in using them. It is for this reason that the words "from birth or from an early age have been deleted and that the new definition specifies that the defect of mind must have existed before the age of 18 years. Any mental disability sufficient to necessitate supervision or control which supervenes after this age is not arrested These are not or incomplete development, but some form of disorder or decay. Amentia, and they are not intended to be included within the Mental Deficiency Act. There is no doubt, however, that under the old definitions many defectives who were urgently in need of protection, were debarred from the provisions of the Act. It will now be possible to include them. It has been said that mental growth is the resultant of two sets of factors, intrinsic and extrinsic. There are some points regarding these to which it is The factor of chief importance is the intrinsic one; that is, necessary to refer. the developmental potentiality inherent in the germ cell. The amount of this varies considerably in different individuals, and the great majority of mental defectives, probably as many as 4 / 5ths of the total number, owe their condition to an impaired developmental potentiality. They are consequently termed Primary Aments." This impetus to development may be so inadequate as to cause defects in the development of the body as well as of the mind, and such defects are known as stigmata of degeneracy." A marked inadequacy of developmental potentiality results in Idiocy and Imbecility; if less severe it results in the various grades of feeble-mindedness. In idiocy and imbecility even the foundations of mind are not well and truly laid, and the condition is apparent in the early months of life. At the other extreme, that is, in the high grade feeble-minded, the developmental impetus has been sufficient for the growth of all but the highest controlling processes of mind; and then it may not be until adolescence, that is, until the age at which these processes are normally evolved, that the deficiency "
"
"
becomes manifest. In such a case the individual may not show any serious abnormality until he is required to take the responsibilities of life upon his own shoulders. His defect then stands revealed. But even if the developmental potentiality of the germ cell be perfectly normal, arrest of mental growth may be brought about by factors of the environment causing injury or disease to the growing brain. Although these will produce the greatest effect during the period of most rapid brain growth, that is, from the time of fertilization to the third year of life, it is clearly possible for them to arrest development, and produce mental deficiency, at any age before development is complete. In the Act of 1913 no specific reference was made to these causes, and hence it was often assumed that mental defect arising in this way, especially after early childhood, did not come within the scope of the Act. The new definition makes it quite clear that they are included. The number of cases so arising is undoubtedly very considerable ; but as most of the children so affected die in the early years of life, their relative proportion becomes greatly reduced. If defectives of all ages be considered, cases of this kind, which are termed Secondary Amentia, probably amount to about one fourth of the total. I do not propose to discuss these factors in detail. It will be enough to say that they may be conveniently divided into three groups : ?namely, those incident before, during, and after birth. During birth, the chief factor is some form of injury. Before and after birth, toxic processes of some kind or other predominate, causing the various forms of meningitis and encephalitis.
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In conclusion, the essential concept to keep clearly in mind is this:?That the legal criterion of Mental Deficiency is social incapacity of such degree and kind as to necessitate care, supervision and control. If this incapacity is due to any imperfection of mental development, of no matter what kind, so long as it has existed before the age of 18 years, then the individual is a mental defective within the meaning of the Act.
