An Analysis Of Factors In The Family'S Withdrawal Of A Patient From A Hospital For The Mentally Retarded

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Content AN ANALYSIS OF FACTORS IN THE FAMILY'S WITHDRAWAL
OF A PATIENT FROM A HOSPITAL
FOR THE MENTALLY RETARDED
by
Jane Ross Mercer
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Sociology)
January 1963
UNIVERSITY O F SO U TH ER N CALIFORNIA
GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES 7. CALIFORNIA
This dissertation, written by
Jane R os s M er cer
under the direction of h^.X...Dissertation C o m
mittee, and a p p ro ved by all its members, has
been presented to and accepted by the D ean of
the Graduate School, in partial fulfillment of
requirements for the degree of
D O C T O R O F P H I L O S O P H Y
Dean
Date January 1963
DISSERTATION
Chairman
/
PREFACE
The present study is one of a series which have been
made by the Population Movement Study at Pacific State
Hospital, Pomona, California in an effort to analyze
patient movements. The major purpose of the present study
was to determine some of the significant structural and
social-psychological characteristics which differentiate
families who withdraw patients from a hospital for the
mentally retarded from families who leave patients in the
hospital.
Specifically, this study focuses on the character
istics of families of patients who were discharged from
home leave into the care of their families during the fis
cal years 1957, 1958, and 1959 from Pacific State Hospital.
These families are compared with the families of patients
who were still in the hospital in June, 1961. The two
groups of patients were matched for age, sex, intelligence
quotient, ethnicity, and year of admission.
A study of this type requires the assistance of many
persons. Special thanks should go to Dr. Harvey F. Dingman,
ii
Director of the Population Movement Study, for making the
facilities of his research organization available, sup
porting the project with funds from the National Institute
of Mental Health, and giving continued supervision and
assistance in all aspects of the study, and to Dr. Georges
Sabagh of the University of Southern California and of
Pacific State Hospital who, with Dr. Dingman, first pro
posed the project to the investigator and gave considerable
time and thought to various problems which arose during its
execution.
Sincere appreciation goes to those who assisted with
the interviewing, driving over the four county areas
covered by the sample and following all possible leads in
an attempt to trace elusive cases, Mrs. Barbara Huemer,
Mrs. Valerie Ridgeway Huloc, Mrs. Wanda Baker, and
Mr. Juan X. Womble.
The author is also indebted to the other members of
the committee from the University of Southern California
who supervised this study as a dissertation project,
Dr. James Peterson, Chairman, Dr. Edward McDonagh,~
Dr. Melvin Vincent, and Dr. C. E. Meyers.
iii
Finally, appreciation should be expressed to those
on the staff of the Population Movement Study who helped in
many ways. Special thanks are due Mrs. Katherine Moticha,
Mr. Curtis R. Miller, Mr. John M. McQuiston, who helped
with problems in data processing, and Mrs. Gertrude Boylin,
Mrs. Constance Eckhardt, and Mrs. Eleanor Sullivan, who
assisted with the stenographic and clerical aspects of the
study.
iv
TABLE OF CONTENTS
Page
PREFACE............................................ ii
LIST OF TABLES.......................................viii
Chapter
I. THE PROBLEM AND DEFINITIONS OF TERMS ..... 1
The Problem
The Scope of the Study
Hypothetical Framework
Definitions of Terms
II. REVIEW OF THE LITERATURE..................... 23
Empirical Studies of Factors in Release
from Hospitals for the Mentally Retarded
Empirical Studies of Factors in Admission
to Hospitals for the Mentally Retarded
Clinical Observations and Theoretical
Considerations in Release and Admission
of the Mentally Retarded
III. THE DESIGN OF THE RESEARCH.................. 61
The Discharged Group
The Resident Group
Effectiveness of the Matching Procedure
Data Collection
Statistical Measures
v
Chapter Page
IV. COMPARISON OF PATIENTS IN DISCHARGED
AND RESIDENT GROUPS ON VARIABLES NOT
CONTROLLED IN THE RESEARCH DESIGN.......... 93
Age at Admission
Physical Handicap
Diagnosis
Summary
V. ANALYSIS OF SOCIOECONOMIC VARIABLES............ 108
Education Level
Occupational Level
Levels of Economic Consumption
Summary
VI. ANALYSIS OF VARIABLES IN FAMILY
STRUCTURE.................................... 121
Characteristics of Family Members
Stability of the Marital Relationship
Family Cycle
Summary
VII. ANALYSIS OF DIFFERENCES IN THE PERCEPTION
OF THE RETARDATE BY THE RESPONDENT.......... 152
Awareness of Retardation
Perception of Deviance Using Normal
Siblings as the Criterion
Problems Reported Caused by the Retarded
Child
Summary
VIII. ANALYSIS OF SOME SUBJECTIVE RESPONSES
TO RETARDATION........................... 185
Belief About Cause of Retardation
Analysis of Direction of Blame for
Retardation
Summary
vi
Chapter Page
DIFFERENTIAL PARTICIPATION IN THE LARGER
SOCIAL STRUCTURE .................. 195
X.
Religious Affiliation and Activity
Participation in Secular Community Roles
Participation in Occupational Roles
Index of Social Participation
Summary
ANALYSIS OF FACTORS RELATING TO ADMISSION
OF PATIENT TO HOSPITAL...................... 213
Uhanimity of Family Attitude For or
Against Placement
Important Person in Placement
Residence at the Time of Admission
Community Problems Compared to Family
Problems in Placement
Summary
SUMMARY AND CONCLUSIONS........................ 234
Summary
General Conclusions
Limitations of the Present, Study
Contributions to Sociological Knowledge
Need for Future Research
APPENDIXES 252
BIBLIOGRAPHY
332
vii
LIST OF TABLES
Table Page
1. Discharged Cases Excluded From the Sample .... 68
2. Reasons Resident Cases Were Replaced In
Drawing the Sample........* ................ 73
3. Relationship of Respondents to the Patient ... 81
4. The Outcome of Attempted Interviews......... 85
5. Interviewer Rating of the Cooperativeness
of the Respondent......................... 88
6. Persons Other Than the Respondent Present
at the Interview......................... 89
7. Comparison of Resident and Discharged Patients
by Age at Admission....................... 95
8. Resident and Discharged Patients Compared
by Physical Handicaps ........................ 97
9. Rating Scale on Multiple Handicaps Comparing
Resident with Discharged Patients ............ 100
10. Comparison of Resident and Discharged Patients
by Diagnostic Category ...................... 102
11. Discharged and Resident Patients Compared by
Dichotomization of Diagnostic Categories . . . 104
12. Diagnosis of Resident and Discharged Patients
Compared, Holding Social Status Constant . . . 106
viii
Table Page
13. Discharged and Resident Groups Compared by
Education of Mother and Education of Head
of the Household .................... 110
14. Discharged and Resident Groups Compared by
Occupational Level of the Family.............. 114
15. Interviewer Ratings of the Economic Status
of the Street of the Families of Discharged
and Resident Patients ........................ 116
16. Interviewer Ratings of the Housing Condition
of the Housing Uhits of Families of
Discharged and Resident Patients ............ 118
17. A Comparison of the Scores of Discharged and
Resident Group Families on a Household Goods
and Equipment Rating Scale .................. 119
18. Family Available to the Patient Outside the
Hospital Ranked According to Degree of
Consanguinity Holding Social Status
Constant...................................... 124
19. Discharged Patients Compared to Resident
Patients by Age of Mother and Age of
Father........................................ 128
20. Comparison of Discharged and Resident Groups
on Number of Siblings in the Family and
Holding Social Status Constant .............. 131
21. Discharged Patients Compared to Resident
Patients by Number of Divorces of Biological
Mother Controlling for Social Status ........ 139
22. Comparing the Length of Marriage of Biological
Parents of Discharged Patients with that of
Resident Patients Controlling for Social
Class.......................................... 143
ix
Table Page
23. Comparison o£ Families of Discharged and
Resident Patients on Stage in the Family
Cycle at Time of Admission and at Time
of Discharge.................................. 148
24. Relationship Between Stage in the Family Cycle
at the Time of Interview and the Year of
Birth of the Biological Mother................ 149
25. Level of Awareness of Retardation Comparing
Respondents in Discharged Group with
Respondents in Resident Group and Controlling
for Social Status.............................. 161
26. The Relationship Between Awareness of
Retardation and Physical Handicap in the
Patient........................................ 163
27. Social Status Differences in Awareness of
Retardation for Patients Having no Physical
Handicap...................................... 166
28. Discharged and Resident Patients Rated Above
and Below the Median on Seven Rating Scales
Comparing Retarded Child with Normal
Siblings...................................... 174
29. Number of Problems Reported Caused by the
Retarded Child Controlling for Education
of the Respondent.............................. 178
30. Respondent's Perception of Problems Caused by
the Retardate Controlling for the Degree
of Physical Handicap ........................ 180
31. Relationship Between Number of Problems
Reported by the Respondent and Patient
Diagnosis...................................... 182
32. Respondent's Belief About the Cause of
Retardation Comparing Discharged and
Resident Groups .............................. 189
x
Table Page
33. Direction of Blame for Retardation Comparing
Mothers in Discharged and Resident Groups . . . 192
34. Comparison of Intropunitive and Non-
intropunitive Reactions of Mothers of
Discharged and Resident Patients ............ 193
35. Religious Affiliation of the Families of
Discharged as Compared to the Families
of Resident Patients ........................ 197
36. Attendance at Religious Activities Reported
by Respondents of Resident as Compared to
Respondents of Discharged Group Controlling
for Social Status.............................. 199
37. Reported Activity in Secular Community
Organizations Comparing Respondents of
Resident with Respondents of Discharged
Group Controlling for Social Status .......... 201
38. Comparison of Resident and Discharged Group
Families on Basis of Dependency Status of
the Family at Time of Interview................ 203
39. Working Status of Mothers of Resident and
Discharged Patients at the Time of the
Interview Controlling for Social Status .... 205
40. Index of Social Participation Comparing
Discharged and Resident Groups Controlling
for Social Status.............................. 207
41. Family Consensual Level on Placement of the
Retardate in the Hospital...................... 218
42. Person Reported as Being Most Important in
the Placement of the Retardate in the
Hospital Controlling for Social Level ........ 221
43. Patient's Place of Residence Immediately
Prior to Hospitalization...................... 224
xi
Table Page
44. Patients Living with Biological Parents
Immediately Prior to Placement Controlling
for Social Status ...................... 226
45. Problems Leading to Placement Comparing
Resident and Discharged Groups . . . 229
46. Origin of Problems Leading to Placement
Controlling for Social Status . . . . 231
47. Chi Square Values When Interviewed and
Non-interviewed Groups are Compared on Sex
of Patient, Ethnic Status of Patient,
I.Q. of Patient, Age of Patient, Admission
Cohort of Patient, Age at Admission of
Patient, Education of Patient's Father,
and Occupation of Head of the Household in
the Patient's Family.......................... 249
48. Discharged Group Compared with Resident Group
by Patient Intelligence Quotient ............ 257
49. Discharged Group Compared with Resident Group
by Year of Birth.............................. 258
50. Discharged Group Compared with Resident Group
by Year of Admission.......................... 259
51. Families of Discharged and Resident Patients
Compared on Socioeconomic Rating Using a
Modification of the Hollingshead System .... 260
52. A Comparison of the Health Ratings Given
Mothers and Fathers of Discharged and
Resident Patients 261
53. A Comparison of the Health Ratings Given
Mothers and Fathers by Social Status 262
54. Health Ratings Given Mothers of Patients
as Related to Age of Mother ........ 263
xii
Table Page
55. Number of Divorces of the Biological Mothers
of Low Status Patients Related to Year
of Birth of Mother............................ 264
56. The Relationship Between Social Status and
Awareness of Retardation .................... 265
57. The Relationship Between Scores on the Social
Participation Index and Social Status ......... 266
58. Discharged Patients Compared to Resident
Patients on Physical Handicaps Controlling
for Social Status.............................. 267
59. The Relationship Between Physical Handicap and
the Person Important in Placement.............. 268
60. The Relationship Between Social Status and
Person Important in Placement.................. 269
61. Comparison of Interviewed and Non-Interviewed
Groups by Sex of Patient...................... 270
62. Comparison of Interviewed and Non-Interviewed
Groups by Ethnic Status ...................... 271
63. Comparison of Interviewed and Non-Interviewed
Groups by Intelligence Quotient of
the Patient.................................... 272
64. Comparison of Interviewed and Non-Interviewed
Groups by Age of Patient....................... 273
65. Comparison of Interviewed and Non-Interviewed
Groups by Year of Admission................... 274
66. Comparison of Interviewed and Non-Interviewed
Groups by Age of Patient at Admission.......... 275
67. Comparison of Interviewed and Non-Interviewed
Groups by Education of the Mother............. 276
xiii
Table Page
68. Comparison of Interviewed and Non-Interviewed
Groups by Education of Father ..............
69. Comparison of Occupation of Head of the
Household of Interviewed and Non-Interviewed
Groups Using Hollingshead's Categories . . .
70. Cross-Classification for Matching Discharged
and Resident Groups ...................... .
277
278
280
CHAPTER I
THE PROBLEM AND DEFINITIONS OF TERMS
The Problem
This study was focused on the problem of determining
how the families of retarded persons who have been institu
tionalized and who have been discharged back to the family
differ from the families of retarded persons who have been
institutionalized and have remained institutionalized.
This problem is growing in importance. With the
rapid growth in population, demand for institutional care
for mentally retarded persons has also grown and has tended
to increase more rapidly than growth in facilities for
their care. Most public institutions for the care of the
mentally retarded have long waiting lists and are over
crowded. There are two possible ways by which this problem
can be solved. One is to build more and more institutions
for the mentally retarded. The other is to attempt to dis
cover alternative solutions for the care of the mentally
1
2
retarded. One such alternative solution is that of return
ing mentally retarded persons to their families after they
have benefitted as much as possible from institutional
care, thus making room for others who are on the waiting
list.
Before it is possible to do definitive planning, it
is essential to ascertain what differentiates families who
take retarded persons back into the family after they have
once been institutionalized from families who institu
tionalize their retarded members permanently. Hopefully,
such an investigation may discover some of the factors
which influence the probability that a patient will be dis
charged to his family and so make future planning more
productive.
The Scope of the Study
This study was limited to an investigation of
retarded persons who were discharged from only one institu
tion, Pacific State Hospital, Pomona, California. Further
more, it studied only persons who had been discharged
during three fiscal years, 1957, 1958, and 1959. It com
pared them with a matched group of retardates who were
still hospitalized June 4, 1961.
3
Information about the retardates and their families
was secured from the patient file and from an interview
with a family member, usually the mother. The interview
secured information on family composition, problems pre
sented the family by the retardates, beliefs about the
nature and cause of retardation, perception of the retard
ate and other materials which could be learned in a struc
tured interview situation.
Because the interview was with only one family mem
ber and because the respondent was interviewed only once,
it was not possible to assess the emotional adjustment of
the mother, the possibility of mental illness in other
family members, the more subtle factors in marital adjust
ment, the social and emotional adjustment of the siblings
of the retardate, or other personality variables which are
undoubtedly important.
Given these limitations in scope, the study
attempted to investigate some of the variables which may
be significant in discharge. The investigation was organ
ized around a matrix of hypotheses which will be presented
formally in the next section of this chapter.
4
Hypothetical Framework
There was nothing reported in the literature which
dealt specifically with family variables related to the
probability of discharge from an institution for the men
tally retarded. There has beeu some work done on charac
teristics of the patient which are related to the proba
bility of discharge. There has also been some work on the
characteristics of the family which are associated with
a retarded person's being institutionalized. These sources
are cited in detail in Chapter II.
Using the findings in the above studies which bore
upon the present problem and the observations of staff
members of Pacific State Hospital who, through their
clinical experience, had developed impressions as to sig
nificant differences between the families of patients who
were discharged and the families of patients who were not
discharged, a matrix of hypotheses was developed and
methods for testing the hypotheses evolved. The major
experimental hypotheses have been grouped together with
their related minor experimental hypotheses.
Hypotheses Related to Socioeconomic Variables
5
Drawing primarily on the work done by Sabagh and
Miyake at Pacific State Hospital and Stein and Susser in
England, it was hypothesized that the families of resident
patients will have a significantly higher socioeconomic
status than the families of discharged patients.
1. The mothers or mother-substitutes of resident
patients will have significantly more education than the
mothers or mother-substitutes of discharged patients.
2. The heads of the household for resident patients
will have significantly more education than the heads of
the household in the families of discharged patients.
3. The occupational level of the heads of the
household of families of resident patients will be sig
nificantly higher than the occupational level of the heads
of the household of families of discharged patients.
4. When occupational level and education of the
head of the household are combined into a weighted score
following the Hollingshead system, the score for the head
of the household in resident patients' families will be
significantly higher than that for the head of the house
hold in the families of discharged patients.
6
5. The economic status of the streets on which the
families of resident patients live will be rated as sig
nificantly higher than the economic status of the streets
on which the families of discharged patients live at the
time of the interview.
6. The level of repair of the housing of the
families of resident patients will be rated as signifi
cantly better than the level of repair of the housing of
the families of discharged patients at the time of the
interview.
7. The household furnishings and equipment found in
the homes of the families of resident patients will be
greater than the household furnishings and equipment found
in the homes of the families of discharged patients at the
time of the interview.
Hypotheses Related to Variables in Family Structure
and Marital Stability
The hypotheses about family structure and marital
stability were generated primarily from the work of
Saenger, Farber, and the cohort studies done at Pacific
State Hospital which are discussed in Chapter II.
7
The family structure of families of resident
patients will differ significantly from the family struc
ture of families of discharged patients.
1. Patients in the discharged group will have a
greater degree of consanguinity with their families than
will the patients in the resident group.
2. The age of the parents of resident patients will
not differ significantly from the age of the parents of
discharged patients.
3. Patients in the discharged group will signifi
cantly more often come from homes with a larger number of
siblings than will the patients in the resident group, when
social class is controlled.
4. The families of resident patients will have sig
nificantly more persons living in the family who are not
nuclear family members than the families of discharged
patients.
5. The number of half-siblings in the family will
be significantly greater in the families of resident
patients than in the families of discharged patients.
6. The families of resident patients will have
significantly more often suffered the death of a parent
8
or parent substitute between admission and the time of the
interview than the families of discharged patients.
7. Significantly more families of resident patients
will have experienced the divorce or separation of the
parents or parent substitutes between the time of admission
and the time of the interview than the families of dis
charged patients.
8. The health of the parents or parent substitutes
in families of resident patients will be significantly
poorer than the health of the parents or parent substitutes
in the families of discharged patients.
9. The number of retarded siblings will be signifi
cantly greater in the families of discharged patients than
in the families of resident patients.
The families of discharged patients will have a sig
nificantly higher level of marital stability than the
families of resident patients, when social status is con
trolled.
1. The biological mothers of resident patients will
have had significantly more divorces than the biological
mothers of discharged patients, when social status and age
are controlled.
9
2. The length of marriage of the biological parents
of resident patients will be significantly shorter than the
length of marriage of the biological parents of discharged
patients, when age is controlled.
The families of resident patients will significantly
more often consist of adults only than the families of dis
charged patients.
Hypotheses Related to Variables in Perception
of the Retardate by the Respondent
Several studies contributed ideas which lead to the
formation of the following hypotheses. This study is espe
cially indebted to the work of Holt, Shonnell, Saenger,
Tizard and Grad, Frisch, and Stone.
The families of resident patients will have sig
nificantly different perceptions of the retardate from
those of the families of discharged patients.
1. Families of discharged patients will be sig
nificantly less aware that the patient is retarded than the
families of resident patients.
2. Families of resident patients will rate the
patient's behavior significantly lower when comparing it
to the behavior of normal siblings than will the families
10
of discharged patients.
3. The families of resident patients will report
the patient as having caused significantly more problems
than will the families of discharged patients.
Hypotheses Related to Subjective Reactions
to Retardation and Residence
Graliker, Parmalee, and Koch's study together with
that of Grebler were important sources for the following
hypotheses. The theoretical discussions of Kanner, Smith,
and Wardell were also influential.
Subjective reactions of the families of resident
patients to retardation and hospitalization will differ
significantly from the subjective reactions of the families
of discharged patients to retardation and hospitalization.
1. The belief about the cause of the retardation in
the patient will differ significantly when the beliefs of
respondents from the families of resident patients are com
pared with the beliefs of respondents from the families of
discharged patients.
2. The adoptive or biological mothers of discharged
patients will be more likely to blame themselves for the
retardation than will the adoptive or biological mothers
11
of resident patients.
Hypotheses Related to Differential Participation
in the Larger Social Structure
Saenger and Farber both reported religious affili
ation as a significant variable in their studies while Holt
and Shonnell were the primary sources drawn upon in the
formulation of the hypotheses on social participation in
non-religious activities.
Families of discharged patients will participate
in significantly fewer activities outside the home than
families of resident patients.
1. The religious affiliation of the families of
resident patients will differ from that of the families of
discharged patients.
2. Families of resident patients will participate
more in religious activities, when social status is con
trolled, than families of discharged patients.
3. Families of resident patients will participate
more actively in secular community roles than the families
of discharged patients.
4. The families of discharged patients will be more
dependent upon agency support than the families of
12
resident patients.
5. More mothers or mother substitutes o£ resident
patients will have full or part-time employment outside the
home than mothers or mother substitutes of discharged
patients, when social class is controlled.
6. Using an index of social participation, the
families of resident patients will score significantly
higher in social participation than the families of dis
charged patients, when social class is controlled.
Hypotheses Related to Factors in Admission of the
Patient to the Hospital
The route to the hospital for discharged patients
will differ significantly from the route to the hospital
for resident patients.
1. The members of the families of resident patients
will have been more favorable to placement than the members
of the families of discharged patients.
2. Patients in the discharged group will have been
placed in the hospital as a result of the influence of
persons employed by the government more frequently than
patients in the resident group.
13
3. Patients In the discharged group will have been
living with their biological parents Immediately prior to
admission more frequently than patients In the resident
group.
4. Patients In the discharged group will have been
placed In the hospital more frequently as the result of
problems which they created In the community while patients
In the resident group will have been placed In the hospital
more frequently as the result of problems which they
created within the family.
Definitions of Terms
Terms which are specific to only one section of the
analysis will be defined in the appropriate section. Terms
which are used throughout the study and are of importance
in more than one section of the analysis are defined here.
Parent
The term "parent" is used in the more generic sense
and includes not only the biological parents of the patient
but adoptive parents, step-parents, or other adult indi
vidual who is acting in the role of parent for a particular
patient. When biological parents are the referents,
14
the term "biological parent" will be used. When persons
other than biological parents are the referents, the term
"parent substitute" will be used.
Parent Substitute
For the discharged patients who had no biological or
adoptive parents, the "parent substitute" was identified as
the family member to whom the patient was discharged. For
resident patients, the "parent substitute," if there was
no biological parent, was the individual who was designated
as the legal guardian of the patient. In cases where there
was no legal guardian designated, the family member with
whom the hospital maintained contact and who had shown the
most consistent concern for the patient was considered the
"parent substitute" and was interviewed.
Family
The family of a patient refers to those individuals
related to the patient by blood, adoption, or marriage
who either have assumed responsibility for his welfare, as
in the case of the discharged patient, or who would be the
most likely to assume responsibility for his welfare in
the event he were to be discharged, as in the case of
15
the resident patient.
Nuclear Family
The social unit which consists of a man and woman
joined in marriage and their biological or adopted children.
Mental Retardate
For the purposes of this study, any individual who
has been coranitted to Pacific State Hospital as a mentally
retarded person is defined as a retardate, regardless of
whether he is so defined by his family or other social
agencies.
Five levels of retardation are now recognized by
Pacific State Hospital, which uses the definitions of the
Statistical Research Bureau of the California State Depart
ment of Mental Hygiene.
Level I— Borderline
Retardates which score between approximately one and
two standard deviations below the mean on an intelligence
test are classified as borderline. For the Wechsler Intel
ligence Scale for Children and the Wechsler Adult Intelli
gence Scale, the standard deviation is 15 points. For the
Revised Stanford-Binet (IM) published in 1961, the standard
16
deviation Is 16 points. Therefore, the Intelligence
quotient range for borderline level retardates is 68 to 84
on the Stanford-Binet (LM). The intelligence quotient
range will vary according to the standard deviation of the
test used. If tests other than those mentioned above are
used, the range of scores defined as borderline level will
vary.
Level II--Mildly Retarded
Retardates with an intelligence quotient between
approximately two and three standard deviations below the
mean are placed in this category. For the Revised Stanford-
Binet (Ul), this is a score of 52 to 67.
Level III--Moderately retarded
Retardates who have an intelligence quotient between
approximately three and four standard deviations below the
mean are classified as moderately retarded. On the
Stanford-Binet (LM), this is an intelligence quotient of
between 36 and 51.
Level IV— Severely Retarded
The severely retarded are defined as those having an
intelligence quotient of between approximately four and
five standard deviations below the mean. On the Revised
17
Stanford-Binet (121) > this is an intelligence quotient of
20 to 35.
Level V--Profoundly Retarded
The profoundly retarded person is one whose intelli
gence quotient is more than five standard deviations below
the mean. On the Revised Stanford-Binet (LM), this would
be a score of less than 20.
Social Status
Social status has been measured using a modification
of Hollingshead's system, as described in Chapter V.
Social status scores were computed for each family. All
families in the study were placed in a comnon frequency
distribution and the median computed. Families described
as having "high status" are those which had social status
scores above the median for the total group of families in
the study and those described as having "low status" are
those which had social status scores below the median.
The Discharged Group
The discharged group is composed of all the patients
who were discharged from home leave into the care of their
families during the fiscal years of 1957, 1958, and 1959
18
from Pacific State Hospital and who met the criteria for
inclusion in the study. A detailed description of the
selection and composition of the discharged group is given
in Chapter III.
The Resident Group
The resident group is composed of all the patients
who were chosen from residents of Pacific State Hospital in
June 1961, on the basis of random selection matching the
discharged group for age, sex, ethnicity, admission cohort,
and intelligence quotient. A detailed description of the
procedure used in the selection of the resident group is
given in Chapter III.
Diagnosis
Diagnostic labels applied to patients in this study
are those which have been assigned by the medical staff
of Pacific State Hospital. The meaning of each label as
defined below is derived from definitions used by the hos
pital. These definitions are those suggested for use of
institutions for mental defectives by the National Com
mittee for Mental Hygiene.^
^National Committee for Mental Hygiene, Statistical
Manual for the Use of Institutions for Mental Defectives
(New York: 1946).
19
Pacific State Hospital has currently adopted the
nomenclature of the American Association for Mental
Deficiency but, at the time when the sample for this study
was selected, the older nomenclature was being used. The
older classifications are, also, the only ones which are
available for discharged cases before 1960. Although the
older diagnostic system has many obvious deficiencies, it
was the only one available for use in this study.
Only definitions for categories which occurred in
this sample are listed. Although some patients have
characteristics of more than one clinical type, only the
one outstanding type is designated on the statistical card.
Familial
Included here are cases in which mental deficiency
in the family appears to have a direct relation to mental
deficiency in the patient. This is characterized by the
presence of proven mental deficiency in one or more blood
relatives and mental retardation is diagnosed as probably
due to heredity. Such cases are usually of the mildly or
moderately retarded levels, are sometimes severely retarded,
but are seldom profoundly retarded. Endocrine dysfunction
is frequently found in these cases. If a more specific
20
etiology is known which would place the patient in a more
definitive category, the category of "familial" is not
used.
Mongolism
This term is applied to persons suffering from marked
arrest in physical and mental development who possess cer
tain anthropological resemblances to the mongolian race.
These individuals seldom have an intelligence quotient
above the moderately retarded level. This is probably due
to defective fetal development.
With Developmental Cranial Anomaly
This classification includes cases in which mental
retardation is accompanied by cranial abnormalities which
are probably due to defective fetal development. This
diagnosis includes hydrocephaly, microcephaly, crani
ostenosis, and other forms of cranial malformation.
Due to Post-Natal Central Nervous System Infection
All cases in this group give evidence of cerebral
involvement due to infection by viral, bacterial, spiro
chetal, protozoal, mycotic, or other causative agent,
21
post natally. This includes cases In which mental de
ficiency was the result of epidemic encephalitis, measles,
scarlet fever, whooping cough, and meningococcus meningitis
which was accompanied by an encephalitic process.
Pre-Natal Infection
All cases in this group give evidence of having suf
fered from pre-natal infection by viral, bacterial, spiro
chetal, protozoal, mycotic, or other causative agent. This
includes German measles in the pregnant mother and con
genital syphilis.
Due to Trauma During or After Birth
Classified here are cases of mental retardation
which are probably due to injuries at time of birth or to
injuries to the head during infancy or childhood. Post-
traumatic cases are readily differentiated from the con
genital cases in that the distribution of neurological
signs and symptoms is less bilaterally symmetrical, signs
of general developmental inferiority are absent, and the
intelligence defect is dependent on faulty execution (motor
and speech handicaps) rather than on an inherent amentia.
Occasionally, skull fractures and severe concussions,
22
incurred in infancy and early childhood, may result in
arrested mental development.
Uhdifferentiated
There are many retardates who cannot be placed tinder
any of the clinical types because they are not differenti
ated either by symptomatology, cause, or pathological
manifestations. These cases are probably due to defective
fetal development. Uhdifferentiated is used as a residual
category for cases which cannot be placed with assurance
under any other label.
Epilepsy
This refers to a clinical syndrome the central
feature of which is the epileptiform attack. Epilepsy is
customarily divided into two major divisions: (1) idio
pathic epilepsy which, so far as is known, is not caused
by organic disease or anomaly and (2) symptomatic epilepsy
which has a well-defined organic background such as brain
tumor, general paresis, arteriosclerosis, and so forth.
This diagnosis is assigned to hospital patients only if
mental deficiency and epilepsy cannot be attributed to any
other diagnosis and are believed to be due to defective
fetal development.
CHAPTER II
REVIEW OF THE LITERATURE
The inclusion of a review of the literature as part
of a research study, has two primary purposes. First,
the review assists the investigator in determing which
variables have been found to be significant in past studies,
and thus enables him to determine which variables it will
be necessary to control in the current research. Second,
a review of the literature informs the investigator about
variables which previously have proved to be significant
and thus assists him in developing useful hypotheses for
further investigation.
Three types of articles were found to yield informa
tion that was useful in the current study. Some studies
were found which specifically analyzed factors related to
discharge of patients from an institution for the mentally
retarded. wever, the number of such studies was rela
tively small. A second type of study analyzed factors in
23
24
the initial institutionalization of the retarded child and
subjective reactions of parents to retardation. While such
studies did not specifically deal with factors in dis
charge , it was concluded that some of the factors predic
tive of initial Institutionalization of the child might
also be predictive of the reciprocal process of de
institutionalization. Consequently, these studies were
reviewed to find suggestive hypotheses. A third type of
article found in the literature consisted of reports based
on clinical observations of relationships between parents
and their retarded children. While these were not based on
systematic data collection techniques and were often
theoretical and speculative, some of these articles con
tained ideas which were used as hypotheses for the current
research.
The review of the literature which follows has been
organized into three sections. The first section reviews
empirical studies of factors in release from a hospital for
the mentally retarded. The second section reviews em
pirical studies of factors in the institutionalization of
the retarded child. The final section reviews articles
discussing clinical observations and theoretical consider
ations of factors in the institutionalization and release
of the mentally retarded person.
25
Empirical Studies of Factors in Release
from Hospitals for the
Mentally Retarded
Relatively little work has been done in the analysis
of factors which are related to the probability of release
from a hospital for the mentally retarded. What work has
been done has focused primarily on the characteristics of
the patient himself and how these are related to the proba
bility of his being discharged. No work has been done in
the area explored by the current study, that is, the ex
ploration of characteristics of the families of patients
which may be predictive of release from a hospital for the
mentally retarded.
Frankel, studying 1,400 patients who entered New
Jersey institutions for the mentally deficient, found that
patients who were between the ages of ten and twenty at
admission had a higher probability of being in the com
munity six to eight years later than those who were either
older or younger at admission. However, Frankel did not
control for the fact that younger patients have a higher
death rate than those admitted at an older age, nor did he
26
consider that persons admitted at less than ten years of
age would still have been under eighteen years of age at
the time of his follow-up study.^
A study by Kramer, Person, Tarjan, Morgan, and
Wright which was done at Pacific State Hospital studied a
cohort of patients from the period 1948 to 1952 and con
firmed Frankelfs findings regarding age at admission and
probability of release. They found that the greatest
likelihood of release was for patients admitted between the
ages of fourteen and eighteen and was especially low for
those admitted between the ages of twenty-five and thirty-
four. The highest release rates were for those who were
fourteen to fifteen years old at admission. This rate was
65 per cent within a four-year period. The rate was
69 per cent for those aged sixteen to seventeen at admis
sion and 49 per cent for those aged eighteen to twenty-four
at admission. Chances of release were found to be directly
related to the level of the intelligence quotient. They
were highest for those with intelligence quotients of fifty
to sixty-nine and those with intelligence quotients of
"hs. Frankel, "The 1,400 Who Entered New Jersey Insti
tutions for the Mentally Deficient," American Journal of
Mental Deficiency. XLIII (September, 1938), 186-200.
*!
27
over seventy. Through cross-tabulation, the relationship
between intelligence quotient, age, and retention was ex
plored. Patients with high age at admission and high
intelligence showed a very high proportion released as
compared to those with low age and low intelligence. They
also examined the probabilities of separation from the
hospital specific for the number of years of hospitaliza
tion and found that for those over sixteen years of age
with an intelligence quotient between thirty and forty-
nine, the probability of release declines with increasing
o
length of hospitalization.
Windle summarized the findings of various studies on
the relationship between age at admission and discharge.
He reports that Shafter, using data from Elwyn Training
School, found that age is a significant factor for both
males and females in adjustment on discharge, and that it
is the practice of a high proportion of institutions to
assume that emotional maturity comes with advancing age.
Slorton Kramer, et al., "A Method for Determination
of Probabilities of Stay-Release and Death for Patients
Admitted to a Hospital for the Mentally Deficient; the
Experience at Pacific State Hospital for the Period 1948-
1952," American Journal of Mental Deficiency, LXXI (Novem
ber, 1957), 481-495.
28
Windle reports that Whitney found it to be the policy of
Elwyn Training School to prefer to discharge older patients
and concludes that there is a definite age bias in selec
tion for discharge. He concludes that there seems to be a
curvilinear relationship between admission age and likeli
hood of release. The youngest patients and those over
twenty years of age at admission have the least likelihood
of release while patients ten to twenty years old at admis-
3
sion have the most likelihood of release.
Tarjan, Dingman, Eyman, and Brown made one of the
most extensive studies of variables in patient character
istics which are predictive of discharge. Studying
releases from Pacific State Hospital, they concluded that
males were over-represented on home leaves and that the
probability of release increases as the degree of defi
ciency decreases. Patients diagnosed as familial or as
undifferentiated had the highest probability of any diag
nostic category of being released from the hospital.
Patients over eighteen years of age had the best chance
3
Charles Windle, Prognosis of Mental Subnormals,
Monograph Supplement to the American Journal of Mental
Deficiency, LXVI (March, 1962), 46.
29
for release and represented 76 per cent of the home leave
population. Younger age groups had a higher probability of
remaining out continuously on home leaves.
Miyake made a cross-sectional study of the home
leave population from Pacific State Hospital and, unlike
Tarjan, Dingman, Eyman, and Brown, found no significant
differences by sex, but did find that Mexican-Americans
were over-represented in the home leave group at the time
of his study. He found that the home leave population was
made up of a disproportionate number of persons with higher
intelligence quotients. Although the mean intelligence
quotient for the hospital was thirty-four, the mean for the
home leave population was fifty-one. He found no signifi
cant difference by age when the home leave group was com
pared with the hospital population. However, he did find
that younger persons on home leave tended to be severely
retarded and to have been kept on home leave for a long
period of time.'*
^George Tarjan et al.. "Effectiveness of Hospital
Release Programs," American Journal of Mental Deficiency,
LXIV (January, 1959), 611.
^Frances M. Miyake, "Social Characteristics of
Patients on Home Leave from Pacific State Hospital; A Popu
lation Study" (unpublished Master’s thesis, School of Social
Work, The University of Southern California, 1956), p. 6.
30
Robinson made a study of a small sample of six cases
in which interviews were held with the parents of children
following the discharge of the child from the hospital.
The purpose of the study was to determine reasons for dis
charge. The investigator found that regression of the
child following admission to the hospital was a factor in
discharge even though parents had been warned at the time
of admission that regression might occur. Having the
patient become ill was also a factor in some of the dis
charges. The author noted that in all six cases previous
placements had failed. On the basis of qualitative evalu
ation of data from the interviews, the author concluded
that there was in all of the families studied an underlying
sense of guilt which was a basic dynamic in the unreadiness
of the parents to place the child in the hospital. "It may
be that living with this child and his excessive disagree
able needs has given the mother or father a way of holding
their guilt in abeyance."*’
£
Helen B. Robinson, "Families Unable to Adjust to
Hospitalization of Their Mentally Deficient Children"
(unpublished Master's thesis, School of Social Work, The
University of Southern California, 1954), p. 61.
31
This review of the literature on factors related to
discharge from a hospital for the mentally retarded shows
that there are broad areas which have not been researched.
Most of the studies included characteristics of the patient
himself, but did not include analysis of the family of the
patient or the type of environment from which he came and
to which he would have to return if discharged. Except for
the very limited study by Robinson, the perceptions and
emotions of the family members were not studied. It is
this broad deficiency in the literature which the current
study hopes to help remedy.
Empirical Studies of Factors in Admission
to Hospitals for the Mentally Retarded
The literature reviewed in this section is that
which deals with differences between retardates and the
families of retardates who have been institutionalized as
compared to retardates and the families of retardates who
have not been institutionalized. While such studies are
only indirectly related to the problem posed in the current
research, they are included here because some of the
factors which have been predictive of institutionalization
also may be predictive of discharge from an institution.
32
One of the best studies of this type was that done
by Gerhart Saenger in the late 1950’s. This was a follow-
up study of former pupils in low intelligence classes in
the city of New York between the years 1929-1956. Clinical
psychologists and psychiatric social workers interviewed
the families of a sample of 500 cases selected randomly
from the 1,725 cases comprising the universe. There was a
10 per cent refusal rate.
Saenger found that the families of retarded children
were larger than the average for the city. Two-thirds of
the occupations of the heads of household of retardates
were skilled or unskilled. He found that the families of
retardates had a lower educational status than the general
population.
Of the retardates in Saenger's sample, 25 per cent
were in institutions. Of those in institutions, 89 per
cent were in state schools and 8 per cent were in mental
hospitals. Most of those in institutions had entered
during school years. Forty-one per cent had been admitted
by their seventeenth year, and an additional 27 per cent
before their twenty-first year. Of those who had been in
an institution and then had returned to the home,
33
80 per cent had been admitted during childhood and released
during the same period. Those who were institutionalized
a£ter school years, in other words after eighteen to twenty
years of age, had a high probability of remaining in the
institution. The highest probability of institutionaliza
tion appeared to come during the school years and immedi
ately following maximum schooling. He concluded that the
crisis years are seventeen to twenty.
Saenger investigated family factors related to the
institutionalization of a child and found that rates of
institutionalization were higher in broken families than in
intact families. Rates were higher in families where the
mother worked full time. They were higher in Jewish fami
lies than in Catholic or Protestant families. Institu
tionalization was lowest among Italians and highest among
Jews. It was second highest among families with Anglo-
Saxon names, and more frequent if both parents had been
native bora.
Using data based on rating scales filled out by the
interviewers following each interview, Saenger concluded
that parents whose retarded child was at home tended to
have a better marital adjustment than the parents of
34
children in the institution. There appeared to be no
relationship between degree o£ handicap and parental
acceptance of the child. An exception to this rule was
found in the case of the mongoloid child who, in contrast
to other types of retarded children, had the highest rates
of acceptance. Embarrassment over having a retarded child
appeared most frequently among the better educated. Guilt
feelings were suspected in 43 per cent of the cases and
were detected three times more frequently among those who
blamed heredity than among those who did not blame heredity
for the retardation.^
A second study done by Saenger was quite produc
tive of hypotheses for the present study. He compared
a representative sample of institutionalized and non
institutionalized mentally retarded. He found that the
retarded who were committed to hospitals had significantly
different characteristics from the non-institutionalized
group. Institutionalization was highly related to the
degree of retardation, but secondary handicaps played
^Gerhart Saenger, The Adjustment of Severely
Retarded Adults in the Community, Report to New York State
Interdepartmental Health Resources Board (New York: New
York University, 1957).
35
little role in commitment unless they were very severe.
In that case, there were slightly higher rates o£ commit
ment. Saenger found that low family income was positively
correlated with the incidence of retardation of the high
grade type and that Negroes and Puerto Ricans made up a
disproportionately large share of the mildly retarded.
Ethnic background was related to institutionalization. One
of every two Puerto Ricans known to be retarded had been
committed to an institution. One of every four known
Negroes, one of every ten known Catholic and Protestant
whites, but only one of every twenty known Jewish retard
ates was in an institution.
Behavior problems were the single biggest factor
determining institutionalization. Passive behavior prob
lems did not seem to be related to institutionalization but
hyperactivity and aggression were related. Community
maladjustment, especially sexual misconduct, was related to
institutionalization and was most common in lower social
groups. The number discharged from schools for unmanage
able behavior was three times larger in the institutional
ized group.
Some family characteristics were also found to be
significantly related to institutionalization. The dis
solution of the family was a major corollary of placement
in a hospital. Of all recently committed high grade re
tardates, 77 per cent had not been living with both natural
parents as compared to 44 per cent of the retardates in the
community. This was especially true of Negro and Puerto
Rican retardates. Parental attitudes toward the retardate
rated on the basis of observation by the interviewers were
found to be only of minor significance but family cohesion
as rated by the interviewer was found to discriminate the
two groups. A highly cohesive family tended to keep the
child at home, if he was a high grade retardate. However,
there was no relationship between cohesiveness and institu
tionalization if the child was severely retarded. Those
who were institutionalized came more often from socially
deprived families who had had more contact with welfare
agencies and the courts, who had low income and who lived
O
in sub-standard housing. High grade retardates who
8
Gerhart Saenger, Factors Influencing the Institu
tionalization of Mentally Retarded Individuals in the City
of New York. A Report to the New York State Interdepart
mental Health Resources Board (New York: New York Univer
sity, January, 1960).
37
were known to social agencies were institutionalized at
a higher rate than those not known to agencies.
Bernard Farber has also done one of the better
studies in this area. Using a volunteer sample of 233
families contacted through associations of parents of men
tally retarded children, he conducted a separate face-to-
face interview with the father and then with the mother,
keeping a verbatim report. In addition, a questionnaire
containing multiple choice items was filled out by each
respondent. The sample was limited to parents who were
living together and whose retarded children had an intelli
gence quotient of fifty or lower.
Family integration was considered the primary depen
dent variable and was measured by degree of consensus
between husband and wife in ranking ten domestic values,
and on the basis of a role tension score composed of
ratings given to other family members on ten negative
traits. The ratings used were the husband's and wife's
ratings of each other and the mother's ratings of her
normal child.
Some of the more significant findings of this study
will be briefly summarized. Having a severely mentally
38
retarded boy appeared to affect the marital integration of
the parents more adversely than having a severely retarded
girl. This difference was more pronounced in the middle
class than in the lower class family. The marital inte
gration of the parents with an institutionalized girl was
not significantly different from that of parents with the
girl at home, but those with the boy at home had signifi
cantly lower scores than those with a boy in an institu
tion. Farber found that, as the retarded boy grows older,
he tends to exert an increasingly disruptive effect on the
relationship of his parents.
Farber, in examining the effects on the siblings of
the retardate, found that institutionalizing the retarded
child decreases the role tension in a normal girl sibling,
but tends to increase role tension in the normal boy
sibling. Having a younger retarded child at home had a
more adverse effect on the normal siblings than having an
older retarded child at home. Turning to extra-family
relationships, he found that non-Catholic families bene
fited more than Catholic families by the institutionaliza
tion of a boy retardate. There was no significant rela
tionship, however, between church attendance, marital
integration, and having a retarded child at home. When
Farber investigated family relationships with the larger
kinship group, he found that families with retarded chil
dren showed significantly higher marital integration when
the wife's mother was seen frequently but significantly
lower marital integration when the husband's mother was
seen frequently. He concluded that the interaction of the
mother of a retarded child with her mother-in-law was more
apt to generate hostility while her interaction with her
Q
own mother was more likely to be supportive.
There have been many smaller studies in this area.
Caldwell and Guze studied mothers and key siblings in a
sample of sixteen retardates living at home and sixteen
living in an institution who had been matched for age, sex,
level of retardation, position in family with respect to
key sibling, number of children in the family, and socio
economic status. Key siblings were defined as the sibling
between ten and sixteen years of age who was immediately
older or younger than the retarded child. Using the
^Bernard Farber, Effects of a Severely Mentally
Retarded Child on Family Integration, Monograph of the
Society for Research in Child Development, Child Develop
ment Publications, Vol. XXIV, No. 2, Serial No. 71, 1959.
40
Cornell Medical Index, the authors found no significant
difference in the health of the mothers of the two samples.
They found no significant difference in the reaction of the
mother to the handicapped child as compared to her reaction
to other family members when they administered a family
attitude scale devised by the authors. Similarly, they
found no significant differences between the two groups on
any of the twenty-three scales on the Parental Attitudes
Research Instrument developed by the National Institute
of Health. In interviewing the key siblings, they found no
significant differences in manifest anxiety nor in re
sponses to the series of questions asked in the interview
which were expected to tap attitudes toward the retarded
child. Using psychiatric ratings, they found no differ
ences in ratings of rejection or of guilt given the mothers
in the two groups. In view of the small sample studied,
the finding that none of their variables significantly dif
ferentiated the two groups is far from conclusive.^
Florence Frisch made a small, intensive study of
^Betty Caldwell and Samuel B. Guze, "A Study of the
Adjustment of Parents and Siblings of Institutionalized and
Non-Institutionalized Retarded Children," American Journal
of Mental Deficiency. LXIV (March, I960), 845-861.
41
six families. She concluded that awareness of the child's
defect was not the same as acceptance of the defect and was
not sufficient reason alone for parents to consider insti
tutionalization. The parents in this small sample appeared
to wait for some traumatic event before signing the appli
cation form. Community pressure was quite influential in
getting them to apply. In three of the six cases, the
application was filed only when the mother realized that
she was pregnant again.^
In a study with a much larger sample than Frisch's,
Stone also examined the dimension of awareness of retarda
tion on the part of the parent. Parental attitudes toward
retardation in forty-four cases coming to the Child Center
at the Catholic University of America were rated according
to the degree of awareness of the child’s deficiency.
Three categories were used. "Considerable awareness" was
the category used to describe parents who state that the
child is retarded, recognize the limits of treatment,
Florence Frish, "Factors in the Decision of
Parents to Apply for Commitment of Mentally Deficient
Children to Pacific Colony" (unpublished Master's thesis,
School of Social Work, The University of Southern Cali
fornia, 1952).
42
and request information about care and training. "Partial
awareness" is used to describe parents who recognize and
talk about the symptom but continue to hope for improve
ment. "Minimal awareness" was defined as the category for
parents who refuse to recognize the child's behavior as
abnormal and blame other causes than retardation for the
symptoms. They believe that treatment will produce a
normal child.
The author noted that marital difficulties seem to
occur when parents blame each other for the retardation of
the child and use the child as a symbol of punishment.
Difficulties also arise when the child is not accepted in
the circle of the family's intimates. She also reported
that parents who are caught up in the competitive norms of
our culture are more likely to reject and institutionalize
their retarded child than those who were less aspiring.
Mothers who get obvious pleasure from mothering activities
seemed more likely to accept retardation in the child than
12
those who did not.
Retardation," American Journal of Mental Deficiency. LIII
(October, 1948), 363-372.
Stone, "Parental Attitudes Toward
43
Other investigators have also attempted to study
the subjective reactions of parents of retarded children.
Graliker, Pannelee, and Koch studied sixty-seven cases of
retardation coining to the clinic at the Los Angeles Chil
dren's Hospital during 1954. The authors were concerned
with parental reactions to the diagnosis of mental defi
ciency and noted two main types of reactions, subjective
reactions and objective reactions. Subjective reactions
were of three kinds. First, some wondered about the cause
of retardation. Second, about 48 per cent rejected the
child with feelings of shame and guilt. Third, some showed
concern about what to tell the relatives about the baby.
Objective reactions were those concerned with reality
factors, such as concern for the health problems of the
retarded child and fear for the child's future. They
found that one-third of the parents initially rejected the
13
diagnosis of retardation.
Grebler was interested in a similar problem but
studied a smaller sample. Using data gained from
13
Betty V. Graliker, Arthur H. Parmelee, and Richard
Koch, "Attitude Study of Parents of Mentally Retarded
Children," Pediatrics. XXIV (May, 1959), 819-821.
44
investigation of eleven cases at the City College of New
York Clinic, the reactions of parents to the frustration of
retardation was studied. The intelligence quotient of all
cases was below seventy-five. She noted three reactions to
frustration on the part of the mothers. The first group
responded with anger and tended to condemn the outside
world, an extra-punitive reaction. The second group of
mothers responded with emotions of guilt and remorse and
showed a tendency to condemn themselves, an intra-punitive
reaction. The third group reacted with embarrassment and
shame. These mothers tended not to blame anyone but to
concentrate on conciliation of self and others to the situ
ation. This was essentially an impunitive reaction. In
her small sample, she found that three mothers were extra-
punitive, seven were intra-punitive, and one was impuni
tive.14
Rosen was also concerned with subjective reactions
to retardation. He interviewed a selected group of thirty-
six mothers of retarded children and attempted to trace
14
Anne Grebler, "Parental Attitudes Toward Mentally
Retarded Children," American Journal of Mental Deficiency,
LVI (January, 1952), 475-483.
45
the development of the mother's understanding of her men
tally retarded child. He came to the conclusion that there
are five stages through which the parent seems to progress.
First, there was awareness that the child might be re
tarded. Second, came the recognition and definite ack
nowledgment that mental retardation existed. Third was the
search for a cause. The author believes that this occurs
almost simultaneously with the recognition of retardation.
The fourth phase is that of seeking a solution for the
retardation through contacts with the schools, medical
doctors, and other service agencies. The final stage he
calls the stage of acceptance. This occurs when the mother
finally accepts the fact that the child is mentally re
tarded. This was the most difficult step and appeared to
be precipitated primarily by comparison with normal
siblings.^
Peck conducted a study using a small sample of ten
families, primarily from the lower middle class, which
investigated the impact of a retarded child on family
Leonard Rosen, "Selected Aspects of the Mother's
Understanding of the Retarded Child," American Journal of
Mental Deficiency. LIX (January, 1955), 522-528.
interaction. He used as his instrument the Fels Parent
Behavior Rating Scale and the Fels Child Behavior Rating
Scales. Comparing his families with the norms for the
scale, he found that the parents of retarded children
tended to be less sociable than the norm. Homes with re
tarded children tended to be organized around interests
other than those of the mentally defective child. Inten
sity of contact with the retarded child was below the
median for the norm group and scores in understanding were
also below the median. On the other hand, readiness to
criticize and emotionality were traits which tended to be
higher in families with mentally retarded children than in
the families on which the scale was normed. He found six
of his ten families had serious marital difficulties. With
such a small sample, the findings, at best, are only sug
gestive. ^
Another approach to the study of factors in institu
tionalization of the retardate is that used by Pacific
State Hospital, Pomona, California. In this approach,
^John R. Peck and Will Beth Stephens, "The Study
of the Relationship Between the Attitudes and Behavior
of Parents and That of Their Mentally Defective Child,"
American Journal of Mental Deficiency, LXIV (March, 1960),
839-844.
47
a cohort of admissions to the hospital is studied inten
sively. Sabagh, Dingman, Tarjan, and Wright investigated
the social class and ethnic status of patients admitted to
Pacific State Hospital between 1948 and 1952. Using data
gathered from clinical records on the social backgrounds,
intelligence quotients, and diagnosis of the 709 patients
in that cohort, they found that there were no significant
differences between ethnic distribution of the general
population and of patients with intelligence quotients
under fifty or those with diagnoses of mongolism, develop
mental cranial anomaly, trauma, or infection. However,
among patients with intelligence quotients higher than
fifty, or with a diagnosis of undifferentiated or familial,
there was a significantly greater proportion of Mexicans
and Negroes than was found in the general population.
They found that patients with intelligence quotients
of thirty and over or with a diagnosis of undifferentiated
and familial, had fathers who were less well educated than
the general population. This trend was even more marked
for patients having intelligence quotients of over fifty.
Using occupation as a measure of social class, the investi
gators found that the more severely retarded patients
48
had a social class background comparable to the general
population while the mildly retarded tended to have sig
nificantly lower social class backgrounds. When social
class was controlled in the analysis of ethnic status, the
proportion of ethnic minorities among patients with intel
ligence quotients over fifty was significantly greater than
the proportion of ethnic minorities in metropolitan Los
Angeles. This was not true for patients with intelligence
quotients under fifty. Among severely retarded patients
with a lower social class background, there is an over
representation of Mexicans and non-whites, while for those
with a higher social class background there is no such
ethnic over-representation. This study indicates that
intelligence, diagnosis, social status, and ethnic status
are all variables operating in the process of admission to
a hospital for the mentally retarded.^
Another study of the same cohort of admissions at
Pacific State Hospital done by Tarjan, Wright, Dingman, and
Eyman found that patients admitted at a younger age are
^Georges Sabagh et al., "Social Class and Ethnic
Status of Patients Admitted to a State Hospital for the
Retarded," Pacific Sociological Review, II (Fall, 1959),
76-80.
49
likely to show more severe degrees of mental deficiency.
They also found that the type of mental deficiency also
varies with admission age. Only 21 per cent of the
youngest patients are diagnosed as familial or undiffer-
entiated while 43 per cent of those in early adolescence
and 74 per cent in late adolescence, and 55 per cent in the
adult groups are diagnosed as familial or undifferentiated.
The relationship between age at admission and sex was very
striking. In the age group ten to thirteen, two-thirds of
the admissions were males and only one-third were females,
while for admissions over eighteen years of age, 54 per
cent were females and 46 per cent were males. They found
that age at admission and socioeconomic status were
strongly related. Only 14 per cent of the children ad
mitted between zero and nine years of age were from fami
lies of unskilled workers, while 37 per cent of those
admitted between the ages of fourteen and seventeen came
from such backgrounds. Age at admission and ethnic origin
were strongly related. Mexican-American and Negro groups
form the largest component of the ten to thirteen group
and the fourteen to seventeen group.
50
In general, they found that newly admitted patients
appeared divisible into two groups. One group enters the
hospital at an early age, has a severe degree of defi
ciency, and comes from socioeconomic and cultural back
grounds similar to the general population. The second
group is represented by those who are admitted during their
adolescent years with a mild degree of deficiency, few
physical handicaps, and come from minority groups and
parents who represent the lower occupational and educa
tional strata.^
In a third report of their study of the same admis
sion cohort, the investigators found that patients admitted
before their sixth birthday were more likely to be boys and
to have a mental defect which was associated with observa
ble physical signs. Nineteen out of twenty had an intelli
gence quotient of less than fifty, had superimposed handi
caps of a visual, auditory, neuro-muscular, or convulsive
nature, rarely had significant speech development, and
18
George Tarjan et al., ’ ’Natural History of Mental
Deficiency in a State Hospital; III. Selected Character
istics of First Admissions and Their Environment,” American
Medical Association Journal of Diseases of Children. Cl
(August, 1961), 195-205.
51
were not toilet trained. They were more likely to come
from the major racial group and to resemble, in family back
ground, the adult general population of the community in
19
educational, occupational, and social status.
Several studies of retardates and their families
have been done in countries other than the United States.
A study by Stein and Susser, which attempted to evolve a
typology of families, came to conclusions not unlike those
reached in the cohort study just described. The families
of dull children who were bom in Lancashire, England
between 1920 and 1924 made up a universe of 106 families.
Of these, 102 were interviewed. Patients were classified
as clinically normal, if they tested below fifty-five but
had no neurological symptoms, and as clinically abnormal,
if they tested below fifty-five and had neurological
symptoms. The two major dimensions of the family typology
which the investigators developed were occupation of the
father and education of the siblings. Four family types
19
George Tarjan et al., "Natural History of Mental
Deficiency in a State Hospital; II. Mentally Deficient
Children Admitted to a State Hospital Prior to Their Sixth
Birthday," American Medical Association Journal of Diseases
of Children. XCVIII (September, 1959), 370-378.
52
were described. The "aspirant family" was one in which the
father had a non-manual occupation and at least one child
who had completed a grammar school education. The "artisan
family" was one in which no child had a grammar school edu
cation and the father had a skilled occupation. The "rough
family" was one in which no child had a grammar school
education and the father was semi-skilled or unskilled in
occupation. The fourth type was the "dull family" in which
there were other mentally retarded siblings in addition to
the individual being studied. There were nine families
classified as aspirant and these families had only clini
cally abnormal retardates. The families in the other three
categories had both clinically abnormal and clinically
20
normal retardates.
Holt, using a list of the local mental deficiency
authorities to locate cases of retardation in the community
of Sheffield, England was able to contact 201 out of a
possible 272 cases. He interviewed the families, using a
memorized questionnaire, and inquired into the types of
20
Mervyn Stein and G. L. Susser, "Families of Dull
Children," Journal of Mental Science. CVI (October, 1960),
631-635.
53
problems created for the family by having a retarded child.
He found that when the child had been normal and had become
retarded after an Illness or accident, the parents appeared
to be better adjusted to their problems than when the child
had been retarded since birth. He noted what he called
"excessive quarreling" in twelve of the families, but since
he had no control group of normal families with which to
make comparisons, the significance of this cannot be
tested. Rejection of the normal children in favor of the
retarded one was quite marked in some cases. He also noted
that, in 126 of the families, the parents tended to
restrict their social interaction to a small group and to
isolate themselves socially. The major source of help for
most families came from relatives, but 53 per cent reported
finding their neighbors helpful. This condition was found
more frequently on higher than lower social levels. The
author concluded that the families most successful in
adjusting to having a retarded child usually were not in
the upper classes because upper class people tend to be
ambitious for their children and have difficulty overcoming
their frustration and disappointment at having had a re
tarded child. The best parents were those who were
54
intelligent enough to appreciate the needs of the child,
but who did not have great ambitions for the child and did
not constantly display their disappointment. They were
better adjusted if they had not concentrated all their
hopes and desires on one child and had other things to
think about. Unfortunately, the findings of this study
must remain purely descriptive because Holt did not have a
21
control group of families without retarded children.
Shonnell conducted a study of fifty families in
Brisbane, Australia who were registered with the Sub-Normal
Children's Welfare Association of Queensland. This study
attempted to determine what effect a sub-normal child has
on the family unit. The investigator found that most fami
lies felt a pressing worry about what would happen to the
retarded child if the parents were to die. Host respon
dents reported that fathers, siblings, relatives, and
others had a favorable attitude toward the child, but some
reported unfavorable attitudes. Over half reported that
the presence of the retarded child curtailed visits in
other people's homes, made shopping difficult, and made it
21
K. S. Holt, "The Home Care of Severely Retarded
Children," Pediatrics, XXII (May, 1958), 746-755.
55
impossible to have daily social activities outside the
home. ^
A second survey of the same families was made by
Shonnell, after the retarded child had begun attending a
day care center. Parents reported that meeting other
parents who also had sub-normal children had helped to
reduce tension and that the mothers, being relieved of the
constant care of the child, had more time for social
activities. Parents also noted marked improvement in the
23
social behavior of the retarded child.
One recent study made in England should be mentioned
because its findings are also suggestive for the present
project. Tizard and Grad studied a representative, strati
fied, random sample of 150 families known to the government
of London to have a retarded child at home. They compared
these families with a group of 100 families of institu
tionalized retardates, matching for sex and age of the
22
F. J. Shonnell and B. H. Watts, "First Survey of
the Effects of a Subnormal Child on the Family Unit,"
American Journal of Mental Deficiency, LXI (October, 1956),
210-219.
23
Frederick J. Shonnell and Meg Rorke, "A Second
Survey of the Effects of a Subnormal Child on the Family
Unit," American Journal of Mental Deficiency. LXII (March,
1958), 862-868.
56
retardate. There were thirty-six refusals. Forty-one
cases were lost because of moving from the area or the
death of the retardate. The investigators found that the
institutionalized group had significantly lower social
quotients on the Vineland Scale, had significantly more
physical handicaps, had presented more problems to their
families, and were more likely to come from families with
other retarded children. They did not find any significant
difference, however, in the number of broken homes, the
health of the parents, the neuroticism of the mother, or
the size of the household. The number of social contacts
of the non-institutionalized retardates' mothers was sig
nificantly lower than for those whose child was in an
institution.^
Each of the studies reviewed in this section con
tributed to the present project in some way. Some were
useful in suggesting variables in the family or in the
patient which should be studied, some suggested hypotheses,
and some suggested categories and conceptual schemes
24
J. Tizard and Jacqueline C. Grad, "The Mentally
Handicapped and Their Families" (Institute of Psychiatry,
Maudsley Monographs, No. 7, Oxford University Press,
1961).
57
which were found to provide useful ways of looking at the
data. However, none of these studies dealt specifically
with the problem at hand.
Except for Saenger, Farber, and Tizard and Grad,
none of the investigators used any type of a control group.
The cohort studies done at Pacific State Hospital might be
one exception in that they used comparisons with the
general population for tests of significance.
Another shortcoming of many of the studies was their
very small samples. Even those which had samples of
acceptable size often had samples that were clearly biased.
Farber used a volunteer sample of parents who belonged to
a specific group of organizations. Stone and Graliker,
Parmalee and Koch, and Grebler made studies of patients
coming to a particular clinic during a given period of
time. Holt and Tizard and Grad had excessive rates of
non-interview which were not carefully analyzed. These
deficiencies in their samples make generalization about
a larger universe hazardous.
58
Clinical Observations and Theoretical Considerations
in Release and Admission of the Mentally Retarded
A small group of articles, written on the basis of
clinical observation and experience, should be recognized
as having contributed to the present project. Leo Katmer,
using illustrative case studies, developed a descriptive
scheme for types of parental reaction to deficiency. He
described how some families were able to acknowledge the
actuality of retardation and to assign a place in the
family to the retarded child concordant with his specific
peculiarities. Without using either the term "role” or
"norm," he described the process by which a family re-
O C
defines its norms to include the retarded child. J
Smith described in detail the emotional conflict
observed in parents of retarded children at the time of
placement in Willowbrook State School, New York. Self
accusation, guilt, remorse, and the narrowing of the
parent's world were discussed. He observed that feelings
of guilt may be resolved through excessive concern and
2■ ’Leo Kaimer, "Parents' Feelings About Retarded
Children," American Journal of Mental Deficiency, LVII
(January, 1953), 375-383.
59
over indulgence of the retarded child. This lead to the
hypothesis that parents who had guilt feelings about the
26
retardate would tend to keep them at home.
Mendelsohn, in a sociological discussion of mental
deficiency, suggested that the climate of community opinion
as perceived by the parent, will have an important impact
on attitudes toward the retarded child. Parents who feel
their status in their peer groups is threatened by having
27
a retarded child will be more likely to reject the child.
Wardell, also, feels that the way a family defines
the situation of having a retarded child will be important
in determining their behavior. Those who perceive the
child as a disgrace will reject him and may displace family
tensions on the retardate. They may withdraw from social
activities, refuse to receive visitors in the home, and
direct their feelings of anger and frustration either at
themselves or at others. However, some families are able
26
M. Smith, "Emotional Factors as Revealed in the
Intake Process with Parents of Defective Children,"
American Journal of Mental Deficiency, LVII (April, 1952),
806-812.
27
Harold Mendelsohn, "A Sociological Approach to
Certain Aspects of Mental Deficiency," American Journal of
Mental Deficiency. LVIII (April, 1954), 506-510.
60
to overcome feelings of unacceptability in the community
and to see the problem as primarily one of special plan
ning, training, and supervision.
The chief defect of this type of report is that it
is based on observations that have not been systematized in
a way that can be verified by careful checks of validity
and significance. Such articles are useful in suggesting
areas which need more careful investigation. That has been
their chief function in the present research.
This review of the literature shows clearly that
almost no research has been done on the problem studied in
the present project. This deficiency constitutes the
primary justification for undertaking the research reported
in subsequent chapters of this dissertation.
28
Winifred Wardell, "Mentally Retarded in Family and
Community," American Journal of Mental Deficiency, LVII
(October, 1952), 229-242.
CHAPTER III
THE DESIGN OF THE RESEARCH
The basic method of this research project was to
compare the families of two groups of patients, the fami
lies of a discharged group with the families of a group of
patients who were still resident in the hospital.
The Discharged Group
In Pacific State Hospital, there are four routes by
which a patient may be discharged.*- If a patient has shown
sufficient response to treatment so that the hospital staff
believes he will be able to function on a job outside the
walls of the hospital, he is placed on "vocational leave."
The hospital arranges to have him placed on a job under the
supervision of his employer and he is regularly visited
^Sheldon Brown, Supervising Psychiatric Social
Worker at Pacific State Hospital, provided the information
on leave programs and procedures.
61
62
by a social worker. However, he is still retained on the
rolls of the hospital. If his adjustment continues good
and he appears capable of self-support and independent
responsibility for his own behavior, he may be discharged
officially from the hospital. In this case, he is listed
as having been "Discharged from Work Leave." In a study of
patients discharged from work leave which was done by
Sabagh and Edgerton, it was found that these persons were
all over twenty years of age and 54 per cent of them were
between thirty and thirty-nine years old. They were mainly
mildly retarded persons. Ninety-two per cent of them had
intelligent quotients of fifty and over as compared to the
general hospital population in which only 20 per cent had
o
intelligence quotients over fifty.
In this type of discharge, it is the response of the
patient to hospitalization which is significant. He may be
discharged from work leave without the necessity that his
family take any responsibility for his future welfare. In
essence, he has earned his own discharge. Undoubtedly,
2
Georges Sabagh and Robert B. Edgerton, "Sterilized
Mental Defectives Look at Eugenic Sterilization," Eugenics
Quarterly (in press).
63
there are significant family variables involved in pro
ducing the kind of patient who can benefit from hospital
training and achieve an independent status, but the study
of these was beyond the scope of the present study.
A second category of discharge is "discharge from
family care." Patients who appear to be well adjusted and
capable of finding jobs for themselves in the community are
placed on the "family care" program. They live in "halfway
houses" in the community and begin to pay board and become
financially independent as soon as they have located em
ployment for themselves. When sufficient time has elapsed
to determine if a patient is capable of self-support and
self-direction, he moves out of the "halfway house" into a
commercial boarding facility and may eventually be dis
charged. As with discharge from work leave, the family
assumes no responsibility for the discharged patient.
A third type of discharge, which involves less than
a dozen cases in the past ten years, is "discharge from
escape." A small number of patients who have escaped from
the hospital and have not been apprehended have eventually
been formally discharged from the hospital.
The final type of discharge is that analyzed in the
present study, discharge from home leave. Home leave
64
is usually granted at the request of the family. If the
home leave is for a specified period of time, such as a
Christmas or summer vacation, it is called a "definite home
leave" and the patient must be returned to the hospital on
a particular date. Although a few cases are known of
patients discharged from definite home leave, such a leave
is not usually regarded by the hospital as preliminary to
discharge.
If the family asks to take the patient home for an
"indefinite home leave," there is no specified date for his
return to the hospital and such a leave is often prelimi
nary to permanent discharge. Whether the patient will be
discharged depends upon his adjustment while living at
home, the wishes of his family, and the attitude of hos
pital personnel. Most persons who have adjusted well at
home over a period of time are usually discharged to their
families.
There are two types of "discharge from home leave."
Ordinarily, when a patient is discharged to his family
during a home leave, the family must be willing to assume
responsibility for his future welfare. There are a few
cases, however, when patients are discharged "From Home
65
Leave to Self." These are usually situations in which the
patient has married or has held a job and lived indepen
dently from his family while on home leave, thus proving
he is capable of self-direction. In these instances, the
family assumes no obligation for the patient and his dis
charged status is similar to having been discharged from
work leave. However, in the majority of cases, a patient
discharged from home leave must have somebody, usually his
family, who is willing to take responsibility for him.
Since the focus of the present study is to determine
significant differences between families who reassume
responsibility for the patient by taking him from an insti
tution and families who leave the patient in the hospital
and who do not reassume responsibility for him, only those
families are included in the discharged group which
actually did assume responsibility for the patient follow
ing discharge. Families of persons discharged "From Home
Leave to Self" were not included.
Tracing procedures are time consuming and expensive.
Also the probability of successfully tracing families of
discharged persons decreases with the passage of time
between discharge and follow-up attempts. Therefore,
66
it was decided to limit the study group to families of
patients discharged during the three most recent fiscal
years from Pacific State Hospital. Thus, the families of
all patients discharged to their families during the fiscal
years 1957, 1958, and 1959, whose last hospital movement
was a home leave, were included.
Family was defined to include any of the following
relatives: biological parents, step-parents, adoptive-
parents, grandparents, siblings (full or half), aunts,
uncles, or cousins.
In addition, it was necessary to limit the study to
those families which were within a reasonable driving dis
tance of Pacific State Hospital. Therefore, only those
families whose address at the time of discharge was in Los
Angeles County, Orange County, Riverside County, or San
Bernardino County, were included. Only a small number of
families were eliminated because of this criterion since
the hospital draws its cases primarily from these four
counties. Families whose addresses were not known to the
hospital at the time of discharge were also eliminated.
One additional ciLualification imHp. Since the
study was interested in the characteristics of the family
67
which assumes responsibility for a retarded person, fami
lies of patients who were subsequently readmitted to
Pacific State Hospital or some other state institution for
the mentally retarded or who were admitted to some other
type of state institution were not included.
Table 1 gives the numbers of cases eliminated as a
result of the application of each of the above criteria.
Of a total of ninety-nine cases discharged to their fami
lies in 1957, 1958, and 1959, whose last hospital movement
was a home leave, eight were eliminated because the family
lived outside the sampling area, three because the address
of the family was unknown at the time of discharge, and
twelve because the patient had been admitted to a state
institution subsequent to discharge. This left a total of
seventy-six cases in the group to be studied. This group
will be designated as the "Discharged Group" throughout the
rest of this report.
The Resident Group
The families selected as families having resident
retarded children with wM rh the families of discharged
patients would be compared were chosen with one primary aim.
68
TABLE 1
DISCHARGED CASES EXCLUDED FROM THE SAMPLE
Number of Cases
Reason for Exclusion Excluded
Total Discharged
Cases
Total discharged from
home leave to family in
fiscal years 1957, 1958,
1959 99
Address of family outside
sample area 8
Address of family unknown
at discharge 3
Readmitted to
Pacific State Hospital,
Fairview Hospital,
Porterville Hospital,
Atascadero Hospital, or
Chino Institution for Men
subsequent to discharge 12
Total cases excluded 23
Total in Discharged Group
studied 76
69
The objective was to control the characteristics of the
individual patient known to be related to the probability
of discharge so as better to identify variables in the
family related to probable discharge.
Some research has been done on characteristics of
patients which are significant in discharge. On the basis
of these findings, the decision was made to control for the
effect of five patient characteristics--age, sex, intelli
gence quotient, ethnic status, and length of hospitaliza
tion. Information for each patient was available on IBM
cards, making frequency matching feasible.
All patients on the hospital rolls June 5, 1961,
with the exception of two groups, were included in the uni
verse from \rtiich the resident group was drawn. The two
groups on the hospital rolls but not included in the pool
from which the resident group was selected were persons
currently on "indefinite home leave" and those on "voca
tional placement."
As explained earlier, "indefinite home leave" is
usually preliminary to discharge and, except for the fact
3
This has been reviewed in Chapter II.
70
that the patient's name is still on the rolls of Pacific
State Hospital, the family has reassumed responsibility for
the patient. Such patients are in a halfway state between
being in the hospital and being discharged to the family.
It was reasoned that this group would have more character
istics in common with the discharged population than with
the hospital population and should not be included in the
hospital population.
Similarly, patients who are on "vocational leave"
are also in a halfway state between being in the hospital
and being discharged. As described earlier, these are
patients who have responded well to hospital training and
are on the road to self-sufficiency. They are living out
side the walls of the hospital and are holding a job.
Because they are on a leave program unlike the one being
studied in this analysis and have a high probability of
being discharged from vocational leave, none of these cases
were included in the resident group.
All other patients on the hospital rolls were sorted
into 162 groups according to the following categories:
1. Sex: Male, Female
2. Ethnic Status: Caucasian, Mexican, Negro
71
3. Intelligence Quotient: below 40, 40 to 60,
over 60
4. Age: 14 years and below, 15 to 19 years,
over 20 years
5. Admission Cohort: Admitted 1940 through 1949,
1950 through 1954, and 1955 through 1960
All hospital cases and all discharged cases were
assigned to the appropriate cell. All hospital cases
within each cell were numbered and, by use of a table of
random numbers, enough hospital cases were selected from
each cell to match the number of discharged cases falling
in that cell. The files for each of these cases were then
analyzed to see if the case met the same criteria for in
clusion in the study which had been applied to the dis
charged group. There had to be a living family, as defined
earlier, and the family had to have a currently known
address in one of the four counties included in the geo
graphic area of the sample. If a case did not meet these
criteria, another case was drawn randomly, from the appro
priate cell, to replace it until there was an equal number
of discharged and resident cases in each cell. Table 70
in Appendix C shows the final distribution of cases as
72
matched on the five control variables.
As indicated in Table 2, it was necessary to draw
103 resident cases before seventy-six cases were found that
met the criteria. Seventeen patients had families living
outside the geographic area of the sample, five had no
living family, and five had families whose addresses were
unknown to the hospital and who could not be traced by the
hospital.
The Effectiveness of Matching Procedure
Matching on sex and ethnicity was on a one-to-one
basis with an equal number of each sex and ethnic category
in each group. Matching for the other three variables was
done on a frequency basis. The Rolomogorov-Smirnov Two-
Sample Test to determine if the groups had been success
fully matched on the three variables of age, intelligence
quotient, and length of hospitalization was used to compare
the two groups. The test for age was done by comparing
year of birth for the two groups. The test for length of
hospitalization compared admission year for the two groups.
No significant differences were found. The Chi Square for
intelligence quotient was .33, which, with two degrees
73
TABLE 2
REASONS RESIDENT CASES WERE REPLACED
IN DRAWING THE SAMPLE
Number of Cases Total
Reason for Replacement Replaced Resident Cases
Total drawn at random from
cells in which discharged
cases fell 103
Families living outside
geographic area of the
sample 17
No living family 5
Address of family unknown
to Hospital 5
Total cases replaced 27
Total in Resident Group
studied 76
74
of freedom, is not significant. Chi Squares of .045 for
year of birth and 3.38 for year of admission were likewise
insignificant.^ Thus, it may be concluded that matching on
the five variables was adequate and any observed differ
ences between the two groups on these variables could be
due to chance variations.
Data Collection
Design of the Interview Schedule
Two similar forms of the interview schedule were
used. The schedule used in interviewing the families of
discharged patients had four additional pages to gather
follow-up information on the patient's work history and
social history and information on reasons for discharge.
The resident schedule had one additional page inquiring
about plans for taking the patient out of the hospital.
Pre-Test of Interview Schedule
Ten families of discharged persons who had been too
recently discharged to appear in the study group were re
commended by the Social Welfare office of the hospital
^See Appendix B, Tables 48, 49, and 50, for data.
75
for purposes of pre-testing the interview schedule. Using
a preliminary form of the schedule, each interviewer did
a minimum of two interviews. On the basis of this experi
ence, some questions were reworded and the arrangement of
items in the schedule was modified so that the interview
flowed more smoothly.
Final Interview Schedule
A composite copy of the final interview schedule,
including additional pages from both forms, is in Appen
dix C. Since each question will be given in detail at the
time the findings are reported, only a summary view of the
schedule will be given at this point.
Information essential to the locating of the respon
dent and recording the completion or non-completion of the
interview was followed by inquiry about the work history,
social history, and caretaker problems for the discharged
group only. Next came an inquiry into attitudes toward
Pacific State Hospital and its services, the respondent's
stereotype of the hospital, and his perception of the
reaction of the child to hospitalization. Report of the
findings in this section of the schedule are not included
in the present paper.
76
The next major section of the interview included the
composition of the household at the time of admission and
at the time of interview. Also covered were attitudes of
various household members, relatives, and other significant
persons toward the original placement of the child at
Pacific State Hospital and inquiry into problems which the
patient presented to the family at the time of admission.
Following this, for the discharged group, was an
inquiry into reasons for taking the patient out of the hos
pital. For the resident group, inquiry was made into
whether they had ever considered taking the patient out of
the hospital and under what circumstances, if any, they
would consider doing so.
A section including a series of questions aimed at
assessment of the respondent's awareness of the nature of
the patient's defect, understanding of the causal factors,
and the direction of blame for the retardation was included
for both groups of respondents. Next was an inquiry into
the marital history of the patient's biological parents,
the geographic mobility of the family, and the marital
stability of the marriage of the parents of the patient.
77
After being asked about the social participation of
the respondent, and the educational and occupational
achievements of the head of the household and of the oldest
sibling of the same sex as the patient, female respondents
were asked to sort a series of cards indicating their role
preferences. A familism scale was followed by a Fels
rating scale on which the respondent rated the retarded
child and the normal siblings in the family on seven be
havior traits.
Following the interview, evaluations were completed
by the interviewer which assessed the type and value of the
housing, the kind and condition of household equipment, the
cooperation of the respondent, and perceived attitudes of
the respondent toward the patient and toward the spouse.
The Interviewers
There were four interviewers, in addition to the
author, who conducted all of the interviews. All of the
four interviewers were graduate students either in the
behavioral sciences or in education. Three of them were
female and one male. The male interviewer was of Spanish-
American extraction and spoke Spanish fluently. He con
ducted all the interviews with respondents who spoke
78
only Spanish as well as doing several of the English Inter
views. The interviewing load was distributed approximately
evenly with each individual completing between twenty-five
and thirty interviews each. Assignment of interviews was
made on the basis of geographic proximity. Since the
interviewers lived at widely separate locations within the
four counties to be covered, each interviewer took those
interviews located closest to his home.
Training of the interviewers had four aspects.
First, each interviewer participated in the preliminary
work of reading patient files and transferring pertinent
information from those files to the coding sheets which had
been prepared for this purpose. Thus, they became thor
oughly familiar with the background information on the
patients in the sample, the types of families they would
be interviewing, and the purposes of the study.
Secondly, they participated in two training sessions
in which interviewing techniques were explained, the pur
pose for the inclusion of each question was elucidated, and
in which they had an opportunity to "role play" an inter
view.
^See Appendix C for File Coding Form.
79
Third, each interviewer conducted a minimum of two
interviews in the pre-test which were followed by discus
sions leading to minor changes in the form of the schedule.
In these discussions, questions about how to code particu
lar responses were raised and clarified and problems met in
the initial interviewing were aired and solutions suggested.
Fourth, throughout the two-month period in which
interviewing activity was most intense, the interviewers
met one day a week to turn in completed interview schedules,
receive new schedules, and hold prolonged discussions on
any difficulties that had been encountered during the week.
These meetings served three primary purposes. They allowed
for close control over the ongoing interviewing procedure,
they permitted continuing reenforcement as to the type and
quality of interviewing desired, and they made a signifi
cant contribution toward maintaining the morale and en
thusiasm of the interviewers for the project.
Interviewing Procedure
The preferred respondent in all cases was the bio
logical, adopted, or stepmother of the patient. If she
was unavailable, the patient's biological, adopted,
80
or stepfather was interviewed. If neither of the above was
available, the female relative acting as a parent substi
tute or the female relative who would, in the case of the
resident group, serve as a parent substitute if the patient
were discharged, was interviewed.^ The actual respondents
contacted, according to their relationship to the patient,
are reported in Table 3. There was no significant differ
ence between the groups.
After the name and address of the anticipated re
spondent had been ascertained from the patient file, a form
letter, using the hospital letterhead, was mailed to the
respondent explaining the nature of the study, assuring
confidentiality, and asking for cooperation when the inter
viewer contacted her. Copies of the different letters sent
to the discharged and resident groups appear in Appendix A.
After allowing for the passage of a minimum of three days
to assure that the letter would have been received, the
respondent was contacted by telephone and a definite time
arranged for the interview. Since 68 per cent of the dis
charged group who were ever contacted, and 78 per cent
£
See Chapter I for an explanation of the manner in
which the "parent substitute" was determined.
TABLE 3
RELATIONSHIP OF RESPONDENTS TO THE PATIENT
Relationship to Patient Discharged Resident
Biological Mother 51 49
Biological Father 4 6
Stepmother 1 2
Adopted or Foster Mother 0 3
Grandparent 3 1
Other Relative 4 9
Total 63 70
X2 = 2.41, 3 df, p > .05
82
of the resident group who were ever contacted, had tele
phones, this was the procedure in the majority of cases.
In those cases in which the respondent had no tele
phone, approximately seven days were allowed to elapse
before a contact at the home was attempted. This gave suf
ficient time for the letter to be returned by the post
office if the person no longer lived at that address. The
home was then contacted directly by an interviewer without
a preliminary appointment.
All of the interviews, except two, were held in the
home of the respondent. The two exceptions were parents
who were planning to come to the hospital to visit their
child and asked to be interviewed while making the visit.
The interviews took from a minimum of one hour and
fifteen minutes to a maximum of approximately three hours,
depending primarily upon the garrulousness of the respon
dent.
For respondents whose introductory letters were
returned by the post office, several tracing procedures
were employed. First, registered letters were sent to the
old address with a "Please Forward" notice on them, and
a request for the address to which it was delivered.
83
In this way, if the post office had a forwarding address,
the letter was received by the respondent and the new
address reported. Second, the old address was visited by
one of the interviewers and the new residents and close
neighbors were questioned to see if they knew the new
address of the patient. This proved a fruitful source of
information. Third, the Bureau of Public Assistance in the
territory in which the family had formerly resided was con
tacted and in several cases, when the family was a depen
dent family, they were able to give a current address.
Fourth, the hospital used its standard tracing procedures
on some difficult cases sending the names to the appro
priate county agency for tracing. Fifth, the patient file
was reexamined and the names and addresses of any relatives
which appeared in the visitors' register or the correspon
dence were recorded and these relatives were sent a special
letter with addressed return postcard asking the where
abouts of the respondent. This was successful in several
cases. Sixth, on several occasions persons on the hospital
staff, especially the social workers or patients who had
been friends with the former patient, were able to provide
clues as to the whereabouts of the family. In one case,
84
the name of a physician appeared in the patient file and,
when he was contacted, he was able to inform the inter
viewer as to the current address of the family. In another
case, a vocational rehabilitation center had corresponded
with the hospital and, when they were contacted, they were
able to provide a current address for the family.
Response Rate
Table 4 shows the results of attempted interviews.
Of the seventy-six cases in the original discharged group,
sixty-three were contacted and an interview completed. Two
of the non-interviewed families had moved from the sampling
area subsequent to discharge and five of the families
proved impossible to locate. There were six refusals. In
three of the refusals, the primary reason for the refusal
was that the respondent did not wish to reopen old wounds
and to discuss unpleasant memories. In one case the re
spondent was bitter toward the hospital and did not wish to
cooperate. In another case the respondent had just suf
fered a mental breakdown following the death of her mother
and was under medical care in her home and the family did
not wish her disturbed. The final refusal was because the
respondent feared the interview might in some way reveal
85
TABLE 4
THE OUTCOME OF ATTEMPTED INTERVIEWS
Outcome Discharged Resident
Attempted interviews 76 76
Interviews not completed:
, Refusal 6 2
Moved from sampling area 2 0
Impossible_to locate 5 3
All relatives deceased 0 1
Total not completed
13 6
Total interviews completed 63 70
86
the patient's past hospitalization and, since he was making
a good adjustment to the community and no one knew of his
background, she did not want to run any risk of exposure.
Of the seventy-six cases in the original resident
group, seventy were contacted and an interview completed.
In one non-interviewed family, all the relatives had died
in the interim since the last contact with the hospital
except for a second cousin who was located through the
family doctor. She was not even aware the patient existed
and so was not interviewed. In three of the non-interviewed
cases, the family was impossible to locate. There were two
refusals. One refusal was from a mother who had great fear
that her friends and relatives would find out that her son
was in the hospital, did not want mail sent to her home or
to be telephoned, and was extremely suspicious about the
use which would be made of the interview material. The
second refusal was from a woman who also seemed to fear the
interview. Five visits were made to her home and on each
occasion she would disappear immediately, turn off all the
lights, pull down the blinds, and refuse to answer the
door. According to her neighbors, she never talks to any
one. In addition to the patient at Pacific State Hospital,
87
she has a daughter who is in a mental hospital and a son in
a juvenile detention home.
The non-interview rate for the study was 12.5 per
cent. The refusal rate for the study was 5.2 per cent.
Evaluation of the Interview
Each interviewer rated the cooperativeness of the
respondent on a four point scale immediately following the
interview. Table 5 shows the ratings given, according to
discharged and resident groups. There was a tendency for
the resident group to be rated as more cooperative. How
ever, using the Kolomogorov-Smirnov Two-Sample Test, the
Chi Square of 5.21 did not reach a statistically signifi
cant level.
Since the interviews were, for the most part, held
in the respondent's home, it was not uncommon for persons
other than the respondent to be present during all or part
of the interview. Table 6 gives both the frequency and the
percentage of interviews in which persons other than the
respondent were present. Respondents in the discharged
group more often had someone else present at the interview.
This difference was significant at the .01 level.
88
TABLE 5
INTERVIEWER RATING OF THE COOPERATIVENESS
OF THE RESPONDENT
Cooperation Discharged Resident
Very Good 36 52
Good 13 18
Fair 8 0
Poor 4 0
Total 61 70
X2 = 5.21, 2 df, p > .05
89
TABLE 6
PERSONS OTHER THAN THE RESPONDENT PRESENT
AT THE INTERVIEW
Discharged Resident
Group Group
Person Present f % f %
Level of
Significance
2 df
Patient
Respondent’s
Spouse
Persons Other
Than Patient
or Spouse
25 .41
12 .20 13
16
No Person Except
Respondent 21
.26 12
.34 39
.03
.18
.17
.56
28.9
.004
1.11
7.3
.01
N.S.
N.S.
.01
90
Also, respondents in the discharged group more often
had the patient present for all or part of the interview.
This difference is significant at well beyond the .01 level.
There is no significant difference between the two groups
in the presence of persons other than the patient at the
interview.
It is difficult to assess what effect the presence
of the patient may have had on the responses of the respon
dent. The biasing effect of this factor was minimized by
the fact that the patient stayed throughout the entire
interview in only a few cases. Respondents seemed to
assume that the interviewer wanted to see the patient. He
would come in immediately upon the interviewer's arrival,
so that the interviewer could see and talk with him.
Shortly thereafter the patient would disappear into another
part of the house. While the patient was present, respon
dents tended to talk about him as if he were not present,
commenting freely on his appearance, health, behavior, and
idiosyncrasies.
Statistical Measures
The data collected from the patient file and from
the interview were analyzed using the following statistical
91
tests. The choice of model In each Instance depended upon
the nature of the data and the model whose assumptions the
data most nearly met.
Chi Square Test for Two Independent Samples
The Chi Square test for two independent samples was
used when the data consisted of frequencies in discrete
categories and the purpose of the test was to determine the
significance of differences between two independent groups.
The hypothesis under test was that the two groups differ
with respect to some characteristic which is measured in
a nominal scale.^
Median Test
The median test was used to test whether two inde
pendent groups have been drawn from populations with the
same median. It was used when data could be placed in an
ordinal scale and could be dichotomized at the combined
median.8
Sidney Siegel, Nonparametric Statistics for the
Behavioral Sciences (New York: McGraw-Hill Book Company,
Inc., 1956), pp. 104-111.
8Ibid.. pp. 111-116.
Kolomogorov-Smirnov Two-Sample Test
92
The Kolomogorov-Smirnov Two-Sample Test was used to
test hypotheses o£ whether two independent samples had been
drawn from populations with the same distribution. It is
sensitive to any kind of differences in the cumulative
percentage frequency distribution of two groups, in the two
tailed test. In the one tailed test it is sensitive to
whether the values in one population are stochastically
larger than the values of the population from which the
other sample was drawn. It was used when data could be
o
placed in an ordinal scale.
Student’s "t" Test of the Significance of Difference
Between Two Population Means
Student's "t" test of the significance of difference
between two population means was used in instances where
variables were measured in at least an interval scale and
where it appeared, by inspection, that the two populations
were normally distributed and had the same unknown
variance.^
9Ibid., pp. 127-136.
Helen M. Walker and Joseph Lev, Statistical Infer
ence (New York: Holt, Rinehart and Winston, 1943), pp. 143-
178.
CHAPTER IV
COMPARISON OF PATIENTS IN DISCHARGED AND RESIDENT
GROUPS ON VARIABLES NOT CONTROLLED
IN THE RESEARCH DESIGN
In the selection of the cases to be used for the
resident group, five variables were controlled by a system
of frequency matching within cells on a random basis.
These variables were age, sex, ethnic group, length of
hospitalization, and intelligence quotient. Controlling
for these variables was satisfactory and what variation
occurred could be explained by chance factors.
However, there are other variables which were not
controlled in the original matching because it was not
feasible to match on more than five variables. Even using
only five variables, some of the cells in the Negro ethnic
group had such small frequencies that all cases in the cell
had to be used in order to secure enough hospitalized cases.
Consequently, it is important to compare the two groups
93
94
on variables other than those controlled in the matching.
Three variables which have been shown to be related to the
probability of release are age at admission, physical
handicap, and diagnosis.^
Age at Admission
Age at admission was indirectly controlled by the
fact that the two groups were matched for date of birth and
for admission year. As a result, it would be anticipated
that age at admission would also be controlled.
Table 7 shows the comparison of the two groups by age
at admission. Using the Kolomogorov-Smirnov Two**Sample
Test, the null hypothesis of no difference in the two
groups was tested and was upheld. A "t" test of the same
data was likewise insignificant, yielding a "t" of .49 with
132 degrees of freedom.
Physical Handicap
Age at admission, intelligence quotient, and physi
cal handicap are all correlated. Persons with low intel
ligence tend to have more physical handicaps and to be
■^See Chapter II.
95
TABLE 7
COMPARISON OF RESIDENT AND DISCHARGED PATIENTS
BY AGE AT ADMISSION
Age at Admission
1 J 1 '*-■ 1 --L " —
Discharged Resident
2-4 2 0
5-9
8 8
10-14 18 22
15-19 19 25
20-24 7 5
25-29 6 3
30-34 1 4
35-39 2 2
40-44 0 1
Total 63 70
X2 = .33, 2 df, p >.05
t = .49, 131 df, p >.05
96
younger at admission than are persons who have higher
intelligence quotients. It was hypothesized that, by con
trolling for intelligence quotient, physical handicaps
would also be controlled and there would be no significant
differences between resident and discharged groups on
physical handicap.
Each patient was rated on eight characteristics:
ambulation, hearing, vision, speech, arm-hand use in self
care, toilet training, feeding problems, and seizures.
Table 8 presents the results of these ratings. The
ratings for each physical handicap were tested using the
Kolomogorov-Smirnov Two-Sample Test to determine if there
were significant differences between resident and dis
charged patients. While there was a slight tendency for
resident patients to have more difficulty in ambulation,
speech, arm-hand use in self care, and history of seizures
than the discharged patients, none of these tendencies
approached the .05 level of significance, which, with two
degrees of freedom, is a Chi Square of 5.99.
However, before it is safe to conclude that there is
no significance between the two groups in physical handi
cap, it is necessary to examine the occurrence of multiple
97
TABLE 8
RESIDENT AND DISCHARGED PATIENTS COMPARED
BY PHYSICAL HANDICAPS
Physical Handicap Discharged Resident
Ambulation
No difficulty walking 58 54
Limps or walks unsteadily 4 8
Walks only when assisted 0 3
Unable to walk 1 5
X2 = 2.98, 2 df, p > .05
Hearing (with or without aid)
No difficulty 59 67
Some difficulty 1 0
Great difficulty 0 0
No usable hearing 3 3
X2 = .05, 2 df, p > .05
Vision (with or without glasses)
No difficulty 59 64
Some difficulty 1 5
Great difficulty 2 0
No usable vision 1 1
X2 = .33, 2 df, p > .05
Speech
Understandable by stranger 46 44
Somewhat difficult to understand 7 12
Hard to understand, small vocabulary 4 5
No speech 6 9
X2 = 1.33, 2 df, p >.05
TABLE 8--Continued
98
Physical Handicap Discharged Resident
Arm-hand use in self care
Full use 59 56
Requires some help 1 7
Requires much help 3 3
No use 0 4
X2 = 2.65, 2 df, p > .05
Toilet training
Bowel and bladder trained 59 64
Partially trained 3 2
Not trained at all 1 4
X2 = .33, 2 df, p > .05
Feeding problem
Feeds himself/herself 59 66
Is fed by other patients only 3 2
Must be fed by an employee
because of feeding problems 1 2
X2 = .01, 2 df, p > .05
History of seizures
No seizures ever observed
or reported 55 53
Seizures observed or reported 8 17
X2 = 1.66, 2 df, p > .05
99
handicap. The ratings on Table 8 are given for each In*
stance of handicap. The same person, If he has several
handicaps, may be rated several times. Thus, the cluster
ing of handicaps Is not adequately represented In the above
scheme.
Therefore, the data were organized so that each
Individual was given a score which would more adequately
represent his total handicap. For each of the eight handi
caps rated, an individual was given a score of "0" if he
was rated as having no handicap and a score of "1" if he
was rated as having any degree of the handicap. A physical
handicap score of "0" through "8" was possible when scores
on individual handicaps were summed. Table 9 gives the
frequency distribution for physical handicap scores calcu
lated in this fashion.
Using the "t" test of the significance of the dif
ference between two means, the differences proved sig
nificant at the .05 level. Resident patients had a higher
degree of physical handicap than discharged patients.
Diagnosis
Since diagnosis and intellectual level are closely
related, it was hypothesized that, by controlling for
100
TABLE 9
RATING SCALE ON MULTIPLE HANDICAPS COMPARING
RESIDENT WITH DISCHARGED PATIENTS
Number of Handicaps Discharged Resident
0 40 30
1 12 14
2 6 12
3 1 8
4 0 2
5 3 1
6 0 2
7 1 1
8 0 0
Total 63 70
t = 2.15, 131 df, p < .05
101
Intelligence quotient, differences in diagnostic categories
would also be partially controlled. Persons diagnosed as
"undifferentiated" or "familial" tend to have higher in
telligence quotients than persons diagnosed into the more
definitive diagnostic categories.
Although Pacific State Hospital is currently re
classifying all patients according to the American Associ
ation of Mental Deficiency nomenclature, at the time the
sample for this study was drawn the traditional diagnostic
categories were being used. It was beyond the scope of
this study to attempt to evaluate the accuracy of diag
nostic labels applied to individual patients. Therefore,
patients are classified according to the hospital diagnosis
2
which appeared in the patient file.
Table 10 gives the frequency distributions for the
various diagnostic categories. In the Chi Square analysis,
in order to meet the requirement that each cell have an
expected frequency of not less than five, it was necessary
to combine categories which had frequencies which were too
small for analysis. Consequently, "trauma during or after
2
See Chapter I for hospital definitions of diag
nostic categories.
102
TABLE 10
COMPARISON OF RESIDENT AND DISCHARGED PATIENTS
BY DIAGNOSTIC CATEGORY
Diagnostic Category
Assigned by
Pacific State Hospital Discharged Resident
Familial 38 32
Undifferentiated 11 6
Epilepsy 3 9
Trauma during or after birth
and developmental cranial
anomaly 6 8
Other 5 15
Total 63 70
X2 = 9.85, 4 df, p < .05
103
birth" was combined with "developmental cranial anomaly."
All other diagnoses were combined into the "other" category.
The calculation of the Chi Square for independent
samples produced a Chi Square of 9.71, which is significant
at the .05 level for four degrees of freedom.
It was concluded that there were significant dif
ferences in the diagnostic categories to which resident
patients were assigned as compared to discharged patients.
To test directly whether the discharged patients were more
likely to be diagnosed as "familial" and "undifferentiated"
than the resident patients, the data were collapsed into
a 2 x 2 table and the Chi Square test applied.
Table 11 shows the result of this dichotomization.
The Chi Square of 7.08 is significant at the .01 level for
one degree of freedom. This indicates that patients in the
discharged group are more likely to have other family mem
bers who are diagnosed as mentally retarded or to be
patients who cannot be assigned with assurance to a more
specific category because they do not show a definitive
symptomotology.
Since social status proved to be such a powerful
104
TABLE 11
DISCHARGED AND RESIDENT PATIENTS COMPARED BY
DICHOTOMIZATION OF DIAGNOSTIC CATEGORIES
Diagnosis Discharged Resident
Familial and Undifferentiated 49 38
Diagnoses other than
Familial or Undifferentiated 14 32
Total 63 70
X2 = 7.08, 1 df, p < .01
105
predictive variable, diagnostic category was analyzed in
relationship to social status. Table 12 presents the
results from this analysis. None of the differences was
statistically significant. Using the Chi Square test which
incorporates the correction for continuity,^ the relation
ship between diagnosis and social status produced a Chi
Square of 1.79, between discharged and resident groups
within high social status a Chi Square of 2.98, and between
discharged and resident groups within low social status a
Chi Square of 1.98. These findings indicate that the dif
ferences between discharged and resident patients in diag
nosis are not the function of the operation of social
status factors.
Summary
Three main conclusions may be summarized from this
chapter.
Patients in the discharged group did not differ
significantly from those in the resident group in age at
admission.
^See Chapter V, "Analysis of Socioeconomic Varia
bles."
^Sidney Siegel, Nonparametric Statistics for the
Behavioral Sciences (New York: McGraw-Hill Book Company,
Inc., 1956), p. 107.
TABLE 12
DIAGNOSIS OF RESIDENT AND DISCHARGED PATIENTS COMPARED,
HOLDING SOCIAL STATUS CONSTANT
Diagnostic Social Statusa High Status*5 Low Statusc
Category High Low Discharged Resident Discharged Resident
Undifferentiated
or Familial 39 48 18 21 31 17
Diagnoses Other
Than Undifferenti
ated or Familial 27 19 6 21 8 11
Total 66 67 24 42 39 28
107
Resident patients had more multiple handicaps than
discharged patients.
Discharged patients were more frequently diagnosed
as "familial" or "undifferentiated" than were resident
patients, even though they had been matched for intelli
gence.
CHAPTER V
ANALYSIS OF SOCIOECONOMIC VARIABLES
In the present study, discharged and resident groups
were successfully matched on intelligence quotient, and so
no difference in socioeconomic level of the two groups
would be hypothesized on this basis.* However, diagnosis
was not controlled and, as shown in Chapter IV, the dis
charged group contained significantly more patients diag
nosed as familial and undifferentiated. Inasmuch as the
study by Sabagh, Dingman, Tarjan, and Wright found patients
with these diagnoses to have fathers with significantly
less education and lower social class background, it would
be hypothesized that the discharged group would have a
o
lower socioeconomic status than the resident group.
■^Chapter III, "Design of the Research."
O
Georges Sabagh et al., "Social Class and Ethnic
Status of Patients Admitted to a State Hospital for the
Retarded," Pacific Sociological Review, II (Fall, 1959),
78.
108
109
Three Indices o£ socioeconomic status were used:
the education of the head of the household, the occupation
of the head of the household, and the level of consumption
of the family as rated by the interviewer immediately fol
lowing the interview.
Educational Level
Using the classifications developed by Hollingshead
for rating educational level, the education of the mother
or mother substitute for each group and the education of
3
the head of the household for each group was tabulated.
Table 13 shows the frequency distribution and Chi Square
values for the comparisons. Using the Kolomogorov-Smirnov
Two-Sample Test, differences were significant beyond the
.05 level for education of the mother or mother substitute
and beyond the .01 level for education of the heads of the
households.
Thus, the hypothesis that the families of discharged
patients will have a lower educational level is upheld
3
August B. Hollingshead and Fredrick C. Redlich,
Social Class and Mental Illness: A Community Study (New
York: John Wiley and Sons, Inc., 1958), Appendix Two.
TABLE 13
DISCHARGED AND RESIDENT GROUPS COMPARED BY EDUCATION OF MOTHER
AND EDUCATION OF HEAD OF THE HOUSEHOLD
Mother or Mother Substitute3 Head of the Household^
Education
Discharged Resident Discharged Resident
Standard Professional Training 1 1 1 2
Standard College Graduate 0 4 0 7
Partial College 3 7 3 10
High School Graduate 8 18 6 16
Partial High School 10 9 5 5
Junior High School 13 15 21 17
Less than Seven Years
of Schooling 25 13 26 12
Unknown 3 3 1 1
Total 63 70 63 70
®X2 = 7.29, 2 df, p < .05
V = 14.37, 2 df, p < .01
110
Ill
regardless of whether the education of the mother or the
head of the household is used as the measure.
Occupational Level
The measure of occupational level used in this study
was a modification of the system used by Hollingshead and
4
Redlich. In the system developed by Hollingshead, per
sons on "relief" and "unemployed persons having no occupa
tion" were categorized with "unskilled employees." In a
sample having only a small proportion of such persons, this
combining of the two lower categories may have only a
slight influence upon the findings and result in only minor
obscuring of relationships. However, in the present study,
17 per cent of the total households studied fell into the
category of "relief, unemployed, no occupation" for the
head of the household and another 16 per cent were classi
fied as "unskilled employees." To group these two occupa
tional levels together appeared to be obscuring an important
distinction, therefore, Hollingshead's lowest level occupa
tional category was divided into two categories, one for
4Ibid.
112
"unskilled employees/' which was rated higher than the
second which was for "relief (public or private), unem
ployed, no occupation."
A second modification was also made. Hollingshead
has no method by which a household that has a "housewife"
as its head can be rated by occupational level. Since
9.7 per cent of the households in this study had a "house
wife" as head of the household, to discard these households
as unratable would have represented considerable loss to
the study. This was especially true since socioeconomic
status proved to be such a powerful predictive variable
and, as will be seen in later chapters, had to be con
trolled in the analysis of other family variables. It is
assumed that households with "housewives" as their heads
have a socioeconomic status and this status is determined
by the occupational level of whomever in the family is
providing the major portion of the family income. There
fore, in those cases in which the head of the household was
a housewife, the occupational level of that household was
rated according to the occupation of the individual in the
household who was providing the major share of the family's
economic support. By this means, it was possible to give
113
all households In the study an occupational rating and,
also, a socioeconomic score.
Table 14 shows the results of classifying the fami
lies in the discharged and resident groups by the methods
described above.
The data were tested by using the Rolomogorov-
Smimov Two-Sample Test, resulting in a Chi Square of 9.67,
which, at two degrees of freedom, is significant beyond the
.01 level. To determine if modifying Hollingshead's system
had influenced findings, the data were also tested leaving
out households in which housewives were the heads, and an
even higher value of Chi Square was found, 10.69.
In order to get one socioeconomic score by which
a family could be rated, educational and occupational
rating scores were combined and weighted, using Hollings-
head's weights. The educational score was multiplied by
five and the occupational score by nine. A statistical
test of these weighted scores produced an even more marked
difference between groups. The Chi Square of the differ
ence is 11.94, significant well beyond the .01 level.^
^See Appendix B, Table 51.
114
TABLE 14
DISCHARGED AND RESIDENT GROUPS COMPARED BY
OCCUPATIONAL LEVEL OF THE FAMILY®
Occupational Level Discharged Resident
Higher executives, proprietors of
large concerns, major professlonals- 1 4
Business managers, proprietors of
medium sized businesses, lesser
professionals 3 6
Administrative personnel, small
Independent business, minor
professionals 2 9
Clerical and sales workers,
technicians, owners of small
business 5 12
Skilled manual employees 12 8
Machine operators and semi-skilled
employees 14 13
Unskilled employees 13 8
Relief (public or private)
unemployed, no occupation 13 10
Total 63 70
X2 = 9.67, 2 df, p < .01
hollingshead* s classificatory system was used with two
modifications. The lowest occupational level in Hollings
head* s system was subdivided into "Unskilled employees" and
"Relief (public and private), unemployed, no occupation"
Households in which housewives are the heads not rated by
Hollingshead. In this study, they were given the occupa
tional rating appropriate to the occupation of the indi
vidual in the household who was providing the major share
of the family’s economic support.
Levels of Economic Consumption
115
In order to get other types of measures to substan
tiate the more conventional measures of socioeconomic
status, interviewers rated the level of economic consump
tion of each family. Following the interview, the inter
viewer completed two ratings on family housing and one
rating on household furnishings and equipment. These were
observed by the interviewer and did not involve direct
questioning.
Housing Level
The economic status of the street of the patient's
fsmily was rated by the interviewer following the inter
view. In two cases it was not possible to make these
ratings because the respondent was not interviewed at home.
Table 15 shows the frequency distribution of the ratings.
Using the Kolomogorov-Smirnov Two-Sample Test, a
Chi Square of 8.82 was obtained which, at two degrees of
freedom, is significant beyond the .05 level.
Each dwelling was also rated on three levels as to
its state of repair: rundown, average, and above average.
The level of repair of the housing of discharged patients'
116
TABLE 15
INTERVIEWER RATINGS OF THE ECONOMIC STATUS OF THE STREET
OF THE FAMILIES OF DISCHARGED AND RESIDENT PATIENTS
Economic Status of Street Discharged Resident
Luxury apartments or private homes
worth $25,000 or more 2 3
Expensive apartments, homes worth
$15,000 to $25,000 1 13
Nice apartments, homes worth
$10,000 to $15,000 15 22
Working class apartments, homes
worth less than $10,000 27 18
Low income housing, deterioration
present 17 13
Unknown 1 1
Total 63 70
= 8.82, 2 df, p < .05
117
families was significantly lower than that of the resident
patients' families. The differences shown in Table 16 are
significant at well beyond the .05 level, when tested using
the Kolomogorov-Smirnov Two-Sample Test.
Household Furnishings and Equipment
A check list of eleven items comprising household
goods and equipment was developed ranging from equipment
which would be expected to be found in many homes, such as
an end table, to equipment which would be found as part of
relatively few homes, such as a swimming pool. A listing
of the items included on the check list can be found in
Appendix C. Interviewers were instructed to make observa
tions during the interview, which would make it possible
for them to code the check list "yes" or "no" immediately
following the interview. Each family was given a Household
Goods and Equipment Score which consisted of the number of
items checked "yes" by the interviewer.
Table 17 gives a frequency distribution of the
scores of the families on this rating scale. The "unknown"
scores are for the eight families which were either inter
viewed at some other place than their home and could not be
rated, or, although interviewed at home, were interviewed
118
TABLE 16
INTERVIEWER RATINGS OF THE HOUSING CONDITION OF THE
HOUSING UNITS OF FAMILIES OF DISCHARGED
AND RESIDENT PATIENTS
Housing Condition
Rundown 30 16
Average 29 AO
Above Average 3 13
Unknown 1 1
Total 63 70
X2 = 8.16, 2 df, p < .05
Discharged Resident
119
TABLE 17
A COMPARISON OF THE SCORES OF DISCHARGED AND RESIDENT
GROUP FAMILIES ON A HOUSEHOLD GOODS AND
EQUIPMENT RATING SCALE
Score Discharged Resident
0 2 1
1 2 3
2 7 4
3 4 5
4 11 4
5 1 5
6 4 3
7 8 9
8 13 16
9 or more 6 17
Unknown 5 3
Total 63 70
t = 2.11, 123 df, p < .05
120
in the yard or other location which made it impossible for
the interviewer to make the necessary observations.
Since the data on this scale were in a ratio scale
having an absolute zero, a "t" test for the significance
of difference to the two means was used as the statistical
test. With 123 degrees of freedom, a "t" of 2.25 is sig
nificant beyond the .05 level.
Summary
In summary, on all the measures of socioeconomic
status, the families of discharged patients had lower
status. They had lower educational levels, lower occupa
tional levels, less expensive housing, housing in a poorer
state of repair, and a lower level of consumption of house
hold equipment and furnishings.
These findings lend support to the hypothesis that
patients from lower socioeconomic backgrounds have a higher
probability of discharge from a hospital for the mentally
retarded than patients from higher socioeconomic back
grounds .
CHAPTER VI
ANALYSIS OF VARIABLES IN FAMILY STRUCTURE
Studies reported by Farber, Holt, Saenger, Tizard
and Grad, and the Population Movement Study at Pacific
State Hospital all indicated that the mentally retarded
child has an impact on family integration.^ However, none
of these studies investigated the relationship between
family structure and discharge from a hospital for mentally
defective persons.
Family structure of the patient's family is examined
under three main headings: characteristics of the family
members, stability of the marital relationship, and stage
in the family life cycle.
Characteristics of Family Members
Type of Parent or Parent Substitute in Current Family
Making the necessary adjustments and redefinition of
roles which is demanded by the presence of a retarded child
^See Chapter II, "Review of the Literature."
121
122
In the family is a difficult task. Since biological par
ents have closer genetic ties to the retarded child than
other persons, they would be more willing to make the
necessary sacrifices and role readjustment involved in
having a retarded child at home than persons not so closely
related to the child. Therefore, it was hypothesized that
the current family available to take care of the patient
outside the hospital would more often include one or both
biological parents for the discharged patient than for the
resident patient. Resident patients were hypothesized to
have a lesser degree of consanguinity with the current
family than discharged patients.
There are at least two confounding factors which
must be taken into consideration in analyzing this variable.
First, in the selection of the resident group, all resident
cases who had no families were replaced in the sample be-
2
cause an interview would be impossible. However, the type
of current family is the variable which is now being in
vestigated and the findings would be seriously biased by
the elimination of patients without families. Conse
quently, all non-interviewed cases were studied and,
2
See Chapter III.
on the basis of the patient file, the current family com
position of the patient was determined. All cases were
included in the analysis. This made a total of 103 resi
dent cases and ninety-nine discharged cases. In that way,
any bias introduced in current family status as a result of
the case selection process was eliminated.
A second confounding factor is that higher rates of
death and family dissolution in lower social classes may
increase the number of broken families in the discharged
group, which is drawn heavily from lower social classes,
and thus obscure a possible relationship. Therefore,
social status was controlled as a part of the analysis.
A rough ordering was made of parental composition of
the family on the basis of the degree of consanguinity.
Both biological parents married and living together was
ranked first, one biological parent living alone was ranked
second, biological parent and step-parent was ranked third,
a grandparent or sibling family was ranked fourth, blood
relative other than grandparent, sibling, or parent was
ranked fifth, an adoptive family or one containing only
step-parents was ranked sixth, and a family of a non-
relative was ranked seventh. Table 18 shows the distribu
tion of all cases, both interviewed and non-interviewed,
TABLE 18
FAMILY AVAILABLE TO THE PATIENT OUTSIDE THE HOSPITAL RANKED ACCORDING
TO DEGREE OF CONSANGUINITY HOLDING SOCIAL STATUS CONSTANT
Parental
All Cases, both Interviewed and Non-Interviewed
All Discharged Casesa All Resident Casesa
Composition Inter
viewed
Non-
Interviewed Total
Inter-,
viewed
Non-
Interviewed Total
Both biological parents 22 18 40 15 6 21
One biological parent only 24 9 33 27 6 33
Biological parent and
step-parent 10 6 16 15 6 21
Grandparent or sibling
family 3 1 4 5 2 7
Family of relative other
than parent, grandparent,
or sibling 2 1 3 4 3 7
Adoptive or step-parent
family or relative by
marriage 2 1 3 4 1 5
Family of friend, no family 0 0 0 0 9 9
Total 63 36 99 70 33 102
TABLE 18— Continued
Parental
Interviewed High Status0 Interviewed Low Status**
Composition Discharged Resident Discharged Resident
Both biological parents 9 11 13 4
One biological parent only 8 13 16 14
Biological parent and step-parent 5 9 5 6
Grandparent or sibling family 0 5 3 0
Family of relative other than
parent, grandparent, or sibling 1 2 1 2
Adoptive or step-parent family
or relative by marriage 1 2 1 2
Family of friend, no family 0 0 0 0
Total 24 42 39 28
q - - - - - - - - _ - _ . . " ' ’ ..... ... — 1 — ‘ n--------- -■ ........................................
All discharged cases drawn compared to all resident cases, = 9.59, 2 df, p < .01
^Discharged interviewed cases compared to resident interviewed cases,
X2 = 2.65, 2 df, p > .05
cHigh status interviewed discharged compared to high status interviewed resident
cases, X = 1.22, 2 df, p > .05
^Low status interviewed discharged compared to low status interviewed resident cases,
X2 = 2.28, 2 df, p > .05 125
126
and the distributions for the interviewed families.
Using the social class scores based on the modifica
tion of Hollingshead's system discussed in Chapter V, the
total sample was dichotomized at the median score. Those
above the median are designated as "high status" and those
below the median are designated as "low status." This same
dichotomization is used throughout the dissertation when
ever social status is controlled in any analysis.
As shown in Table 18, using the Kolomogorov-Smirnov
Two-Sample Test, the differences between discharged
patients' families and the families of resident patients
are significant in the hypothesized direction at the .01
level when both interviewed and non-interviewed families
are included in the analysis. When only interviewed fami
lies are included, Chi Square values drop well below the
required level of significance. This is true whether all
discharged interviewed cases are compared with all resident
interviewed cases or whether interviewed cases are analyzed
within social status levels.
Since the total of all families, interviewed and
non-interviewed, represents the group which is not biased
by the criterion for selection in the sample, it may be
127
concluded that the presence of a family with a high degree
of consanguinity to the patient Increases the probability
that he will be discharged from home leave. Resident
patients have a lesser degree of consanguinity with their
current families than do discharged patients.
Parental Age
Inasmuch as the patients in the two groups had been
matched for age, it was anticipated that the biological or
adoptive parents would also have approximately the same
ages. Since age of parents would be an important factor in
interpreting the meaning of possible differences in other
variables, such as number of divorces and length of mar
riage, mothers and fathers in the two groups were compared
by year of birth. Table 19 shows the resulting frequen
cies.
By inspection, the distributions appeared to be
normally distributed with approximately equal variances.
Since measurement was in an interval scale, the "t" test
for the significance of difference between two means was
used. The "t" for the fathers was 1.30, indicating that
observed differences could be accounted for by chance. It
was concluded that there was no significant difference
TABLE 19
DISCHARGED PATIENTS COMPARED TO RESIDENT PATIENTS BY AGE OF MOTHER
AND AGE OF FATHER
Birth Year
Biological or
Mother
Adoptive3 Biological or Adoptive^
Father
Discharged Resident Discharged Resident
Before 1880 0 5 1 3
1881-1890 4 13 12 13
1891-1900 9 13 20 17
1901-1910 23 26 13 8
1911-1920 23 2 11 19
1921-1930 2 9 1 5
1931-1940 0 1 0 1
Unknown 2 1 5 4
Total 63 70 63 70
at = 2.77, 128 df,
P < .05
bt = 1.30, 122 df, p > .05
128
129
in age for fathers. However, the "t" for the mothers was
2.77, which, with 122 degrees of freedom, is significant
beyond the .05 level. Inspection of the frequency dis
tribution shows that the mothers of resident patients are
significantly older than the mothers of discharged
patients, even though there is no significant difference
in the ages of the fathers. It appears that having a
younger mother is a factor increasing the probability that
a patient will be discharged.
Number of Siblings
Few studies have investigated the relationship
between number of siblings and the probability of institu
tionalization and none has investigated its relationship to
the probability of discharge.
In a large family in which the various stages of the
family life cycle overlap so that the mother has children
on all age levels in the home simultaneously, the mother's
role is relatively unchanging. She has young, dependent
children to care for and her interests remain home centered.
She does not have much opportunity to develop a more com
plex status set. However, if there are no other children
130
at home, the retarded child does force her to keep a home-
centered status set when she might otherwise become in
volved in more activities outside the home. Therefore, it
was hypothesized that retardates coming from families with
more siblings would more frequently be discharged than
those coming from small families.
Size of family is correlated with social status.
Lower social strata tend to have larger families. Conse
quently, it is necessary to analyze the data as a whole and
also within social strata. Table 20 shows the frequencies
for number of siblings. Since the data form an interval
scale, the parametric "t" test was used. When discharged
group is compared to resident group without regard to
social status, discharged families have more children.
When social status is controlled, the differences disappear
completely. For lower status families, "t” is only .79
and, for higher status families, "t" is 1.50. The sig
nificant difference in family size found when comparing
resident and discharged groups was apparently the function
of the significant social class differences between the two
groups, and not an independent variable operating to in
fluence the probability of discharge.
TABLE 20
COMPARISON OF DISCHARGED AND RESIDENT GROUPS ON NUMBER OF SIBLINGS
IN THE FAMILY AND HOLDING SOCIAL STATUS CONSTANT
Number of
Total Groupa High Statusb Low Status0
Siblings Discharged Resident Discharged Resident Discharged Resident
0 13 21 5 13 8 8
1 18 19 10 16 8 3
2 6 13 3 7 3 6
3 8 8 3 5 5 3
4 9 5 1 1 8 4
5 4 2 1 0 3 2
6 1 1 0 0 1 1
7 1 0 1 0 0 0
8 1 0 0 0 1 0
9 2 1 0 0 2 1
Total 63 70 24 42 39 28
at = 2.17, 131 df, p < .05
bt = 1.50, 64 df, p > .05
ct = .79, 65 df, p > .05
131
132
Other Variables in the Characteristics of
Family Members
With the exception o£ degree of consanguinity and
birth year of the biological mother, none of the other
variables in characteristics of family members which were
investigated differentiated between discharged and resident
groups.
The number of persons living with the family who
were not nuclear family members was not significantly dif
ferent. The number of half siblings in the household was
not significant. Death of a biological or adoptive parent
between admission and the present was not significant.
Divorce or separation of the parents or parent substitutes
between admission and the present did not differentiate the
groups.
On all these variables the trend was for the resi
dent patients' families to show a pattern that was more
deviant. That is, they had more deceased parents, more
divorces and separations while institutionalized, more per
sons not members of the nuclear family living in the house
hold, and more half-siblings than the discharged group, but
none of the differences were of themselves significant.
133
Inquiry about the health of parents or parent
substitutes was made by the Interviewer and health was
rated on a five-point scale to determine if poor health on
the part of either male or female parent or parent substi
tute might differentiate the groups. A rating of "0" was
given if the parent was deceased and there was no parent
substitute of that sex in the family. A rating of "1" was
given for a person who was an invalid, in bed or wheel
chair, primarily helpless, confined to home or hospital.
A ”2" rating was given for partially invalided persons who
were ambulatory with difficulty, able to do little work,
had severe arthritis or cardiac problems, feared leaving
the house because of weakness, and had curtailed activity
because of health. The "3" rating was made for persons
voicing mild complaints about chronic backaches or head
aches, or slight arthritic, cardiac or asthmatic conditions
but who were still able to do the usual amount of work,
were ambulatory and moved about the house and neighborhood
readily. The rating of "4" was reserved for those who made
no complaints except for mild, passing conditions such as
flu, colds, indigestion or occasional headache and who
experienced no interference with their usual work activities
134
by reason of health.
It was hypothesized that parents of resident
patients would have poorer health than parents of dis
charged patients. The findings on this variable were sta-
3
tistically Insignificant. Using the Kolomogorov-Smirnov
Two-Sample Test, the Chi Square of the difference was .33
for health of the mother or mother substitute and .15 for
health of the father or father substitute.
Since social classes have different levels of
health, the data were analyzed to see if, for this sample,
there was a relationship between social status and health.
Again the findings were insignificant. The Chi Square for
differences between the health of high status mothers and
the health of low status mothers was .66 and that for the
„ A
fathers was 2.98.
Finally, since the mothers of the discharged group
were significantly younger than those of the resident
group, the relationship between age of mother and health
was investigated. The relationship was insignificant.'*
■*See Appendix B, Table 52.
4
See Appendix B, Table 53.
■*See Appendix B, Table 54.
135
These findings parallel those of Tlzard and Grad who found
no significant differences In health when parents of insti
tutionalized and non-institutionalized retardates were
compared.^
The number of retarded siblings in the family was
also investigated. There were fifteen of the families in
the discharged group and five of the families in the resi
dent group which had one or more retarded children other
than the patient. This difference produced a Chi Square
of 3.97 using the Kolomogorov-Smirnov Two-Sample Test, but,
at two degrees of freedom, it was not significant at the
.05 level.
Stability of the Marital Relationship
It was hypothesized that the families of discharged
patients will show a higher level of marital stability than
the families of resident patients. This is hypothesized
for two reasons. First, the behavioral and physical care
problems which are likely to be presented by the retarded
child can be more readily coped with by a united family
*\ j . Tizard and Jacqueline C. Grad, "The Mentally
Handicapped and Their Families" (Institute of Psychiatry,
Maudsley Monographs. No. 7, Oxford University Press, 1961),
pp. 72 ff.
136
than by one which has suffered from disintegration in the
marital relationship. Secondly, redefinition of the role
of the retardate in the family and modification of other
familial roles which is made necessary by this redefinition
is a difficult process requiring high consensus in the
family so that norms contrary to the norms of the larger
society can be evolved. A family suffering from conflict
between parents would be in a less favorable position to
accomplish this task and thus more likely to hospitalize
the child permanently. Saenger concluded that warm rela
tions among all family members correlated with keeping the
high grade retardate at home, although he did not find this
relationship for low-grade retardates.^
Two measures were used to ascertain the extent to
which the stability of the relationship between the marital
pair was a significant variable differentiating families
of discharged from families of resident patients. The
measures were (1) the total number of divorces of the
^Gerhart Saenger, "Factors Influencing in the Insti
tutionalization of Mentally Retarded Individuals in New
York City: A Study of the Effect of Services, Personal
Characteristics and Family Background on the Decision to
Institutionalize," A Report to the New York Interdepart
mental Health Resources Board. Research Center (New York:
New York University, January, 1960), pp. 78-80.
137
biological mother as learned from her marital history taken
during the interview, and (2) the number of years the mar
riage of the biological parents lasted.
Marital stability is known to vary inversely with
social class. In view of the significant social class dif
ferences in the two groups being studied, it was necessary
to examine each of these measures of marital stability not
only between discharged and resident groups but within
social class.
Divorce
As one measure of marital stability, it was decided
to take the total number of times which the biological
mother of the retarded child had been divorced at the time
of the interview. It was recognized that, especially in
lower class families, separation and desertion frequently
occur without divorce and are symptomatic of marital
instability. However, there are problems inherent in using
separation as a measure of stability in that it is diffi
cult to define what constitutes a separation that shall be
viewed as a sign of disintegration in the relations of the
marital pair as opposed to a separation that is required by
occupational or other obligations and may not be indicative
138
of disintegration in marital relations. On the other hand,
divorce, however crude a measure, is an unequivocable sign
of marital instability that is readily recalled and re
ported.
Table 21 presents the data on number of divorces of
biological mother comparing all discharged with all resi
dent cases and also comparing discharged and resident cases
within social class levels.
The data constitute an ordered scale ranging from
mothers who have had no divorces to mothers who have never
been married at all, which is taken to be the extreme of
instability in the relationship of parents. Since the
distributions are highly skewed, the Kolomogorov-Smirnov
Two-Sample Test was considered more appropriate than the
parametric "t" test. When social class is not controlled,
the trend is strongly in the hypothesized direction but
does not reach the level of significance. When social
class is controlled, the trend is in the hypothesized
direction but does not reach the level of significance for
"high social status” families. However, differences become
highly significant for "low social status" families, dif
ferentiating discharged from resident group families
TABLE 21
DISCHARGED PATIENTS COMPARED TO RESIDENT PATIENTS BY NUMBER OF DIVORCES
OF BIOLOGICAL MOTHER CONTROLLING FOR SOCIAL STATUS
Number of
Divorces
Total Sample® High Status^ Low Status0
Discharged Resident Discharged Resident Discharged Resident
No divorce 46 39 17 27 29 12
One divorce 14 19 7 8 7 11
Two divorces 1 5 0 2 1 3
Three divorces 0 3 0 2 0 1
Four divorces 0 1 0 1 0 0
Never married 1 3 0 2 1 1
Unknown 1 0 0 0 1 0
Total 63 70 24 42 39 28
®X2 = 4.27, 2 df, p > .05
bX2 = 3.65, 2 df, p > .05
CX2 = 13.63, 2 df, p < .01
139
140
at beyond the .01 level.
A possible confounding factor In the analysis of
number of divorces Is the age of the parents. The analysis
of age of parents reported earlier, showed that there was
no difference in the age of fathers of the two groups but
that mothers of discharged patients were significantly
Q
younger than mothers of resident patients. The older the
mother, the greater exposure there is to risk of divorce.
Consequently, the higher number of divorces for mothers of
resident patients in lower status families may be a spuri
ous finding resulting from the fact that mothers in that
group are older. In order to test this possibility, the
mothers of low status patients were dichotomized into those
born in 1910 and before and those born after 1910. The
year of birth for two of the mothers was unknown, making
the total number in the analysis sixty-four. A "t" test of
the difference between means of the two groups showed that
there was no relationship between age and number of
Q
divorces among low status mothers.
8
Supra, pp. 127 ff.
Q
See Appendix B, Table 55.
141
It can be concluded that the higher number of
divorces for lower status mothers of resident patients is
not an artifact of greater exposure to risk but is a sig
nificant finding. The retarded child in a lower status
home where there is marital instability is more vulnerable
to permanent hospitalization but this factor makes no dif
ference in high status homes. A possible explanation of
this finding is that low status homes have fewer resources
to call upon when the family unit disintegrates and the
retarded child is more likely to be institutionalized in
such an emergency. Higher status families, having more
resources, are better able to cope with the problems pre
sented by a retarded child even in the face of marital
instability, and are less likely to institutionalize the
child permanently as a result of family disintegration.
Length of Marriage of Biological Parents
Another measure of marital stability used was the
length of marriage of the biological parents of the patient.
This measure is somewhat different from number of divorces
as an index of marital stability because it measures dis
solution of the parental marriage both by divorce and by
death.
142
Table 22 shows the frequency distribution of cases,
both for the total group and for high and low status groups
separately. Since measurement was in years, an interval
scale, the "t" test for significance of difference of the
two means was used. Because there was a decided skew in
the distribution, the scale was transformed by taking the
square root of the value.
The experimental hypothesis was that the biological
parents of the resident patients would have shorter mar
riages than the parents of discharged patients. This calls
for a one-tailed test. When resident and discharged groups
were compared without regard to social status, a "t" of
2.18 was found. With 131 degrees of freedom, this is sig
nificant at the .025 level with a one-tailed hypothesis.
When social status was held constant, both "t's” dropped
slightly below the level of significance. For a one-tailed
test, with sixty degrees of freedom a "t" must be 1.67 to
be significant at the .05 level. The "t" for high status
^Helen M. Walker and Joseph Lev, Statistical Infer
ence (New York: Holt, Rinehart and Winston, 1953), p. 424.
In cases of a poisson distribution, to make tests of
significance concerning the means of such distributions,
the variable should be replaced by its square root.
TABLE 22
COMPARING THE LENGTH OF MARRIAGE OF BIOLOGICAL PARENTS OF THE DISCHARGED PATIENTS
WITH THAT OF RESIDENT PATIENTS CONTROLLING FOR SOCIAL CLASS
Length of
Marriage
Total Sample® High Status^ Low Status0
Discharged Resident Discharged Resident Discharged Resident
0-4 3 16 0 8 3 8
5-9 8 4 3 3 5 1
10-14 5 7 2 5 3 2
15-19 7 5 4 2 3 3
20-24 11 12 3 8 8 4
25 or over 29 26 12 16 17 10
Total 63 70 24 42 39 28
at = 2.18, 131 df, p < .05
bt = 1.64, 64 df, p > .05
Ct = 1.58, 65 df, p > .05
143
144
parents was 1.64 and for low status parents 1.58.
Since the mothers of resident patients were sig
nificantly older than the mothers of discharged patients,
they would, on the basis of age alone, be expected to have
had longer marriages. Thus the age factor would be oper
ating contrary to the experimental hypothesis. In spite of
this contrary trend, the resident group parents had shorter
marriages than those of the discharged group. Considering
this factor, together with the fact that levels of sig
nificance when social status was held constant were only
slightly greater than .05, makes it highly probable that
the shorter length of marriage of the resident group
parents when compared to the parents of discharged patients
is a real difference, and not the result of chance factors.
Family Cycle
Farber has theorized that each family goes through
a typical life cycle that progresses according to the age-
grading pattern which evolves as the child matures. The
family is seen as a system of individual life careers that
are so interrelated that a change in one pattern affects
all others. The retarded child causes an arrest in the
normal career development of other family members, pri
marily the parents, which may cause disunity over values
within the family.
On the basis of this theory, it may be hypothesized
that the advent of a retarded child would cause more arrest
in the normal career development of the parents, especially
the mother, if that child is the only one at home demanding
constant care and attention. If there are other siblings
who are still dependent, the mother will be required to
meet their dependency needs and having a dependent retarded
child would not of itself be the sole factor keeping her at
the stage of the family cycle in which her major interest
is in the home.
To test whether there is any relationship between
stage in the family cycle and the probability of discharge
from home leave, the family cycle was conceptualized as
having three stages.
Stage I: The family which has children under six
years of age at home. Such children are
" * ■ ' ^Bernard Farber, Effects of a Severely Mentally
Retarded Child on Family Integration (Child Development
Publications of the Society for Research in Child Develop
ment, Vol. XXIV, No. 2, Serial No. 71, 1959), pp. 6-11.
pre-school level and require almost constant
attention, especially from the mother.
Stage II: The family which has children in the home
over six years of age. This covers the school
age years until the children leave home. During
this time the mother and father do not need to
give the children their constant attention but
still have considerable responsibility for their
welfare.
Stage III: The family in which all the children
have grown and the parents are left alone with
no responsibility for persons other than them
selves.
It is hypothesized that the time when the presence
of the retarded child will produce the most arrest in the
career patterns of the parents will be when the other
children have grown and gone and only the retarded child
remains at home. Specifically, it is hypothesized that a
significantly larger number of the families of resident
patients will be in Stage III of the family cycle.
Families in the study were coded according to
the stage of the family cycle they were in at the time
147
of admission and at the time of interview. As can be seen
in Table 23, when the Chi Square test for k independent
samples is used, there is no significant difference between
the two groups in stage in the family cycle either at
admission or at time of the interview. The Chi Square is
2.76 at admission and 1.92 at interview. With two degrees
of freedom, this is not significant.
Since the mothers of resident patients were found
to be significantly older than the mothers of discharged
patients, and older persons are more likely to live in
families in Stage III of the family cycle, it is possible
that the lack of relationship between hospitalization and
stage in the family cycle may be the result of the sig
nificant differences in age of the mothers. Therefore,
stage in the family cycle was analyzed in relation to age
of the mother.
In Table 24 this relationship was examined. Using
the Chi Square test for k independent samples, it was found
that stage in the family cycle does differ significantly
for those mothers bom after 1910 as compared with mothers
bom in 1910 or before. The Chi Square is 11.82, which is
significant at the .01 level with two degrees of freedom.
TABLE 23
COMPARISON OF FAMILIES OF DISCHARGED AND RESIDENT PATIENTS ON STAGE
IN THE FAMILY CYCLE AT TIME OF ADMISSION AND AT TIME OF DISCHARGE
Stage in
At Admission® At Interview*5
Family Cycle Discharged Resident Discharged Resident
Stage I
Children Under 6 12 18 9 9
Stage II
Children Over 6 33 28 31 29
Stage III
Adults Only 11 18 16 26
Not Applicable0 7 6 7 6
Total 63 70 63 70
flX2 = 2.76, 2 df, p > .05
V = 1.92, 2 df, p > .05
These were cases in which the family situation was so irregular as to make these
categories not applicable.
148
TABLE 24
RELATIONSHIP BETWEEN STAGE IN THE FAMILY CYCLE AT THE TIME OF INTERVIEW
AND THE YEAR OF BIRTH OF THE BIOLOGICAL MOTHER®
All Mothers** Born 1910 or Beforec Born After 1910^
Stage in 1910 and After
Family Cycle Before 1910 Discharged Resident Discharged Resident
Stage I
Children Under 6 4 14 2 2 7 7
Stage II
Children Over 6 33 27 21 12 10 17
Stage III
Adults Only 28 14 10 18 6 8
Unknown or
Does Not Apply 8 3 3 5 2 1
Total 73 58 36 37 25 33
£
Age of mother unknown in two cases.
bX2 = 11.82, 2 df, p <.01
CX2 = 4.73, 2 df, p > .05
^ 2 = .65, 2 df, p > .05
149
150
Mothers bom in 1910 or before live in families having
adults only more frequently than would be expected under
the null hypothesis and in families with children under six
years of age less frequently than would be expected. The
opposite is true for mothers who were bom after 1910.
However, when discharged and resident groups were
analyzed within age categories in order to hold the age of
the mother constant, there are still no significant differ
ences between the two groups. For mothers bom in 1910 or
before, the Chi Square is 4.73. For those bom after
1910, the Chi Square is .65. With two degrees of freedom,
neither of these values approaches the level of signifi
cance. It must be concluded that stage in the family cycle
is not a variable which is related to the discharge of the
patient from a hospital for the mentally retarded.
Summary
To summarize the findings of this study on the
relationship between the probability of discharge from home
leave and variables in family structure, it was found that
patients who have a high degree of consanguinity with their
families are more likely to be discharged than those having
more distant kinship ties.
151
Patients who have younger mothers are more likely to
be discharged than patients with older mothers. The age of
the father Is not significant.
Patients with a large number of siblings are more
likely to be discharged than those with a small number of
siblings. However, this finding is the result of the
operation of social class and disappears when social class
is held constant.
In low status families, resident patients have
mothers who have had more divorces than have the mothers
of low status discharged patients. This was not true of
the mothers of high status patients.
The number of years which the marriage of the bio
logical parents lasted for resident patients was less than
that for discharged patients.
Stage in the family cycle was related to the age of
the mother but did not differentiate families of resident
patients from families of discharged patients either at
time of admission or at time of interview.
CHAPTER VII
ANALYSIS OF DIFFERENCES IN PERCEPTION
OF THE RETARDATE BY THE RESPONDENT
Following the suggestive lead of Stone,* who had
found there were differences in parents' level of awareness
that the child was retarded, the present study attempted to
explore some of the ways in which the retardate was per
ceived by the respondent.
It was hypothesized that the families of discharged
patients would have significantly different perceptions of
the retardate from those of -families of patients still
remaining in the hospital. There were three dimensions
along which this hypothesis was explored.
First, it was hypothesized that families of dis
charged patients would have significantly less awareness
Hlargaret M. Stone, "Parental Attitudes Toward
Retardation," American Journal of Mental Deficiency. LIII
(October, 1948), 363-372.
152
153
that the patient was retarded than families of resident
patients.
Secondly, it was hypothesized that, using the re
spondent's evaluation of the behavior of the normal
siblings as a criterion, resident group respondents would
perceive the retarded child's behavior more negatively than
would the respondents of the discharged group.
Third, it was hypothesized that families of dis
charged patients would report having had fewer problems
with the patient than would the families of resident
patients.
Awareness of the Retardation
Three open-ended questions were asked in the course
of the interview, which made possible an appraisal of the
extent to which the respondent was aware of and accepted
the reality of the diagnosis of retardation for the
patient. Responses were recorded verbatim.
1. "We know that there have been a lot of people
who have told you that ________ is retarded, but
we would like to know how you feel about this.
Do you think ________ is retarded?"
154
2. "Do you believe there is anything which can be
done to change this condition?"
3. "What do you see in the future for ________?"
Responses to these three questions were evaluated
and the response coded into one of three categories.
Coding was done by the individual who did the interview.
A reliability check of coding was made nine months later
when a senior sociology student was trained in coding the
procedure and recoded each case. There was complete agree
ment in coding in 78 per cent of the cases and no more than
a one-step difference in any of the remaining cases. Dif
ferences were resolved in conference with the author and,
in doubtful cases, the decisions were made conservatively,
that is, in a direction favoring the null hypothesis.
The categories into which responses were coded were:
0--No awareness that the child is either physically
or mentally deviant.
1--Partial Awareness. Any one of the following
types of responses:
a. Answers "I don't know" or is "uncertain" in
response.
b. Is confused about meaning of retardation
and indicates only partial comprehension
155
of nature of condition.
c. Recognized there Is a physical handicap
(seizures, blindness, deafness, etc.) but
denies there Is mental deviance.
d. Recognizes there Is mental deviance but Indi
cates some expectation that the child will
become normal If given training, medical
treatment, special care, or if the child
makes more strenuous efforts himself.
2--Full Awareness
Recognizes that the child is retarded and men
tally deviant and does not expect training or
medical treatment or care or strenuous efforts on
the part of the child to make him normal, and has
realistic expectations of the child’s potential.
Expressions such as "only a miracle will heal
him" or "some great unknown medical discovery may
be made which will heal him" do not obviate full
awareness.
Samples of typical types of responses coded into
each of the three categories are given below.
156
0— No awareness
Nobody'8 told me he is retarded. He's very
attentive with his elders, a good boy. He's been
pretty well--only his nerves. He got nervous
when Manuel went to the army. He would see army
movies and come home crying. ... I wish he
would get a good job so he could dress himself.
I wish he would stay with me for my companion
ship.
The doctor said she had the mind of a eight year
old but she ain't no eight year old kid— only
time she gets off is when she loses her temper.
As long as she gets them temper pills she's okay.
No, I don't think she's retarded.
No, it's just that she didn't have much educa
tion— that's why she didn't learn too well how to
read or write. We were moving from job to job,
and were not steady in any place, so she moved
from one school to another . . . maybe she'll
think of getting married.
No, the judge sent him to the hospital but he
didn't belong over there with all those crazy
people else he'd turn crazy himself. You could
see those people in that bad condition and could
see that was not the place for him . . . well,
there's nothing wrong with him. He just got into
trouble that one time. He can work and get a
job.
The first time anyone told us something was wrong
with ________ was in court when the doctor from
the state hospital said he was crazy. I stood up
and said he wasn't crazy, he's not an idiot.
He'll get worse if you call him an idiot. It was
just that he was drunk and he won't do a thing
like that again. He's going to work in a big
factory and make good money and put it in the
bank. He likes expensive clothes.
157
1— Partial Awareness
She doesn't have lower mental ability, she has
seizures and fluid in the brain. They told me
I shouldn't see her often. She says "I don't
belong here, I want to come home." I said
"you can't, because. ..." She's paralyzed and
passes out and I couldn't keep her. If there
would be a future for my daughter, I'd do any
thing in the world. She's the only thing I've
got. If I would only know, you would be a god
to me.
I don't know, sometimes I just wonder. There's
something there but I don't know if you'd say
retarded. ________ had diphtheria and the doctor
gave her anti-toxin and said it would take seven
years for that to work out.
No, it's because she lost her hearing she's that
way. She was in very cold water when her
menstrual periods first began. The shock of it
at this time was what caused the deafness.
Well, to a certain extent but I can't say he's
retarded. When he started to school he didn't
learn, that was the only thing wrong with him.
He just can't learn, it's just a handicap.
As far as ________ intelligence is concerned, he
is intelligent. He remembers things eighteen
years ago. He did all right in school until he
started to get spells and it frightened the other
children and the school asked us to take him out.
One reason we put him in the hospital was to
learn to read and write and they never tried to
do this. When they took him over there we under
stood they would try and correct the stuttering
and teach him to read and write. If he could
learn this he could come out and live a normal
life.
158
2— Pull Awareness
Very definitely. I was suspicious that something
was wrong and took him to see some doctors.
Dr. _______, a brain specialist, said he was
completely retarded. He didn't talk. There was
a lump on his head when he was bom. As the
fluid drained, it went down into his brain and
maybe caused the damage. . . . I don't know about
the future. He watched TV and puttered with TV
and radio repairs. I think that if someone were
patient and loving he could be trained to run a
service station or something.
Yes, I knew it all the time. He couldn't concen-
trate, couldn't remember. He had a half sister
with epilepsy, maybe he inherited it, but I don't
believe that. . . .
________ has been retarded since before ten years
old. It was caused by an accident, he got run
over, got his head caught in the wheel of a
buggy. . . . No, nothing can be done--just keep
him happy, well fed, and clean and that's all
that can be done . . . and I think that's being
done.
Yes, he was injured at birth as far as I know.
He had a great big hole in his head. When he
started growing up he couldn’t play with other
children and I knew then that something was
wrong. I know what my child is and what he is
not. They did tell me he's never gotten any
worse or any better— I don't know what to do for
him. . . . The boy isn't able to do anything.
I'm not able to take care of him. I'm not
twenty-five any more and we've had our ups and
downs.
Yes, the first day that we took him to school,
during recess his teacher or principal came to
me and said the boy would have to go to another
school because he was sub-normal. He had some
159
peculiarities but we had not given it much
thought. He set £ire to a garage one day, but
it didn't amount to much. He had a habit of
running away and hiding in somebody's garage, but
it was nothing serious. One day he went into the
back yard and gathered sticks and leaves and lit
a fire and somebody complained to the police and
they came and took him downtown. He went to
school on Washington street and then after that
on West Pico street. He got along all right—
he'll stay in the hospital now. He can't come
home. We can't afford to kill ourselves on
account of the boy. He came home and almost
killed us last time he was here. He wandered
around. We just couldn't take it if he came home
on leave. He put the TV and radio out of com
mission. He was gone all day. We had to call
the supervisor to come and take him back.
Yes, he was about three years old before he
walked. He had seizures from birth. He was hard
headed about staying home. If he had been right,
he would have knew better than to go downtown
. . . the doctor says there's no cure. ______ is
still on medication. It can be arrested, but not
cured. ______ is not able to take care of him
self on the outside. When he was home this last
time, my husband took him where they give jobs
for handicapped. He couldn't get a job.
Yes, his I.Q. is 64, I think it might be a little
better now. His first seizure was at twelve
years of age. He was hard to handle earlier but
I didn't suspect there was anything wrong. In
school he was not doing quite average work. He
is much better now, it may be his age.
Yes, she didn't react like a little normal girl—
she's deaf and dumb all her life. I sent her to
a school for the deaf and dumb children but she
never learned or caught up like the other chil
dren. Then I sent her to a psychiatrist and
found out she was retarded as well as deaf and
dumb. The psychiatrists told me— not just one
160
but two or three. They had to take a lot of
tests and they wouldn't lie. What can be done?
It's impossible . . . kids like that, what
future do they have? I couldn't say.
I'm definitely certain. We knew something was
wrong. He wouldn't socialize with other chil
dren, wouldn't talk, just wouldn't fit. . . .
Well, we all have hope in something— a new dis
covery, some new medicine. If there was, I
would do all in my power to get this type of
prescription. . . . The future? This is ray big
worry, I don't know.
When the data were cast into Table 25, and analyzed
by use of the Kolomogorov-Smirnov Two-Sample Test, it was
found that awareness of retardation was not significant
when the entire discharged group was compared with the en
tire resident group but approached a significant level.
Two degrees of freedom requires a Chi Square of 5.99 for
significance and the data yielded a Chi Square of 5.26.
When the results were cross classified and analyzed within
social status levels, the Chi Square values dropped well
below any significant level to 1.19 for high status and
2.09 for low status persons.
These results made it appear that the relationship
between awareness of retardation and probability of dis
charge might be tied to social status differences. Higher
status persons, having higher educational achievement
TABLE 25
LEVEL OF AWARENESS OF RETARDATION COMPARING RESPONDENTS IN DISCHARGED GROUP
WITH RESPONDENTS IN RESIDENT GROUP AND CONTROLLING FOR SOCIAL STATUS
, _ Total Group® High Status*5 Low Status0
Level of -------------------- -------------------- --------------------
Awareness Discharged Resident Discharged Resident Discharged Resident
No Awareness 10 2 2 0 8 2
Partial Awareness 19 17 6 9 13 8
Full Awareness 33 51 15 33 18 18
Unknown 1 0 1 0 0 0
Total 63 70 24 42 39 28
®X2 = 5.26, 2 df, p > .05
bX2 = 1.19, 2 df, p > .05
CX2 = 2.09, 2 df, p > .05
161
162
themselves and higher aspirations for their children, would
be expected to be more aware of deviance. When awareness
of retardation and social status were analyzed using the
Kolomogorov-Smirnov Two-Sample Test, a Chi Square of 5.29
2
resulted. Again it was just below a significant level.
However, the fact that it was this high made it appear that
the trend for discharged group respondents to be less aware
of retardation might be due to differences in social status
and this variable should be further explored.
Another variable related to awareness of retardation
is physical handicap. Resident retardates had more
3
physical handicaps than discharged retardates. Since
physical handicap may make deviance more visible, this
variable was examined. The data were cross-classified by
dichotomizing the physically handicapped group into those
who had no physical handicaps and those who had one or more
physical handicaps, and the relationship to awareness of
retardation was tested. Table 26 shows the result of this
analysis.
2
See Appendix B, Table 56.
3
See Chapter IV.
TABLE 26
THE RELATIONSHIP BETWEEN AWARENESS OF RETARDATION AND
PHYSICAL HANDICAP IN THE PATIENT
Total Group8 No Handicap^ One or More Handicaps0
Level of No One or More
Awareness Handicap Handicaps Discharged Resident Discharged Resident
No Awareness 11 1 10 1 0 1
Partial
Awareness 20 17 13 7 6 11
Full Awareness 39 44 17 22 16 28
Unknown 0 1 0 0 1 0
Total 70 63 40 30 23 40
aX2 = 2.96, 2 df, p > .05
b 2
X = 6.51, 2 df, p < .05
CX2 = .13, 2 df, p > .05
163
164
The amount of physical handicap, per se, does not
significantly increase the likelihood that the family will
recognize that the patient is mentally retarded. The Chi
Square of 2.96 is not significant at two degrees of free
dom. However, looking within the cells containing patients
with no handicap and comparing the discharged and resident
groups, the Chi Square is 6.51. This is well beyond the
.05 level of significance at two degrees of freedom. It
indicates that resident patients who have no physical handi
caps have families who are significantly more aware they
are retarded than are the families of discharged patients.
For those who have one or more handicaps, the level of
awareness is essentially equal in both discharged and resi
dent groups with the majority of both families of dis
charged and families of resident patients having full
awareness that the patient is retarded.
The interrelationships of the variables relating to
awareness of retardation, thus, appear to be quite complex.
If a retarded child has no physical handicap, the recogni
tion by his parents that he is retarded becomes an impor
tant variable in determining whether he is or i$ not in the
hospital for a long time. If he is physically handicapped,
165
his parents' recognition, that in addition to the physical
handicap he is also retarded, is not significant in deter**
mining whether he will be permanently hospitalized.
Physical handicap, per se, is not a significant factor in
awareness of retardation.
The fact that social status differences in awareness
of retardation approached the level of significance pro
vides a hint that social status may also be a factor which
is involved. Therefore, the patients who had no handicap
were analyzed separately, by social class level.
After being grouped into high and low social status,
the discharged and hospitalized groups were compared as to
their level of awareness. Since this cross-classification
had reduced the number of cases drastically, the data were
collapsed into 2 x 2 tables by combining the categories of
"no awareness" and "partial awareness." Table 27 shows
the resulting frequencies. Since all expected frequencies
would be at least five, the Chi Square test was used.
Within the high status group of patients who had no
physical handicap, having a family which is aware that the
child is retarded occurs significantly more often in the
resident group than in the discharged group. The Chi
Square is 4.78 which, at one degree of freedom, is
TABLE 27
SOCIAL STATUS DIFFERENCES IN AWARENESS OF RETARDATION FOR PATIENTS
HAVING NO PHYSICAL HANDICAP
Total Groupa No Handicap1 5 No Handicap0
Level of No One or More High Status Low Status
Awareness Handicap Handicaps Discharged Resident Discharged Resident
No Awareness 11 1
16 3 7 5
Partial Awareness 20 17
Full Awareness 39 44 8 10 9 12
Unknown 1
Total 70 63 24 13 16 12
aX2 = 2.96, 2 df, p > .05
bX2 = 4.78, 1 df, p < .05
°X2 = .24, 1 df, p > .05
166
167
significant at the .05 level. Within the low status group
which has no physical handicap, awareness of retardation on
the part of the family does not vary significantly between
discharged and resident groups. The Chi Square is just .24.
It would thus appear that awareness of mental
retardation when there are no accompanying handicaps is
a factor which operates in higher social status groups to
keep the child in the hospital once he has been placed
while it does not operate in lower social status groups in
the same fashion.
In summary, awareness of retardation proved to be a
complex phenomenon related not only to whether the patient
was discharged or resident but also influenced by social
status and degree of physical handicap. If a patient has
no physical handicap, awareness of retardation becomes a
significant variable differentiating the discharged group
from the resident group. In this circumstance, families of
resident patients are significantly more likely to be aware
that the patient is mentally retarded than the families of
discharged patients. If the patient has one or more
physical handicaps, then there is no difference in aware
ness of retardation when discharged and resident groups
168
are compared. Having a physical handicap In addition to
being retarded apparently makes the retardation equally
visible to both the families of resident and discharged
groups and the awareness that a patient is mentally re
tarded in addition to being physically handicapped does
not influence the probability that a patient will be dis
charged. It is only when retardation occurs alone, without
physical complications, that awareness of mental deviance
becomes a significant factor in whether a patient remains
in the hospital or is discharged to his family.
When the tendency described above was investigated
within social status levels, it became clear that it is in
the high status groups that awareness of retardation, when
there is no physical handicap, is a significant variable
differentiating those still in the hospital from those dis
charged. In the low status group, awareness that a non-
physically handicapped patient is mentally retarded does
not increase the probability that he will be in the hos
pital.
Therefore, it can be concluded that the non-
physically handicapped retardate of high social status
whose family is aware that he is mentally retarded has
a higher probability of being in the hospital than those
whose families are not aware they are retarded. For the
non-handicapped lower status patient, the awareness on the
part of his family that he is mentally retarded does not
influence the probability of his being permanently hos
pitalized. Awareness of mental retardation operates as a
significant variable only on higher status levels.
Perception of Deviance Using Normal Siblings
as the Criterion
If it can be assumed that the behavior of the non
retarded siblings is a criterion of what constitutes normal
behavior in any particular family, then the degree to which
the behavior of the retarded child is perceived to deviate
from this norm would constitute a subjective measure of
perceived deviance.
In order to get a measure of this perceived deviance
between normal and retarded child, the respondent, at the
close of the interview when it was believed that rapport
would be highest, was asked to complete a Fels-type rating
scale.
Respondents were asked to rate the retarded child on
seven different variables by placing a mark on a five-inch
170
line at the point where they believed the retarded child
belonged. The lines were arranged vertically across one
page of paper. The extremes of the seven dimensions were
written at either end of the line with the positive end
toward the top. The seven dimensions were, in this order,
Good-bad; Pretty-ugly; Gentle-rough; Friendly-unfriendly;
Loving-unloving; Unselfish-selfish; Obeys-does not obey.^
An eighth line, Strong-weak, was placed first and
was used as a practice line, to be certain that the re
spondent tinderstood what was expected of her. This line
was not used in the analysis. Instructions were as fol
lows:
On this paper are some lines. You notice that at
the bottom of the line is a word, for example, weak.
At the top of the line is the exact opposite of that
word, like strong. Now we want you to think of this
line as if it were a thermometer and you are going to
place (child's name) where you believe he belongs on
this line. For example, if _______ is very strong,
you would place him near the top of the line and make
a mark. Or, if he is weak, you would place him near
the weak end. If he is neither very weak or strong,
you would place him near the middle. Do you under
stand? Here is a pencil so you can make the mark on
each of these lines where you think _______ belongs.
( j L
See Appendix C.
171
When the respondent completed the page for the re
tarded child, that page was taken away and she was given
another page identical to it, and instructed:
Now, on this paper are lines exactly like the ones
on the paper you just finished. But, this time, we
would like you to think about the "other children" in
your family. We want you to make a mark on each line
where you believe the other children fit.
After it was clear the respondent understood the
instructions, she was allowed to complete the page without
further comment. In the case of those who could not read
English, the interviewer had to read the words at the
extreme dimensions of each line as the respondent pro
ceeded. In the case of those few who understood only
Spanish, the Spanish speaking interviewer translated the
terms into Spanish equivalents.
In the analysis, only those scales which met these
criteria were used.
First, scales which had been filled out by a natural,
adopted, or step-parent were used but not those in which
grandparents, aunts, cousins, and "other" relatives had
served as respondents because of the death of both parents
or for other reasons. Seldom had these other respondents
had responsibility for rearing the child and it did not
172
seem that their perception of the retardate's behavior as
compared to that of his normal siblings would be directly
comparable to the perception of the child's parents.
Second, since it was a comparison between normal
siblings and the retarded child, families in which the
patient was an only child could not be included.
Third, scales had to be scorable. In one case a
mother was not able to fill out the scale because she was
paralyzed and was not able to make the mark. In another
case, the mother was practically blind with cataracts and
the scales were so confused they were impossible to score.
The scales were scored by measuring the distance in
centimeters between the bottom of each line and the mark
made by the mother. This was the raw score for each scale.
The raw score for the retarded child was then subtracted
from the raw score for the normal child and the difference
was divided by the raw score for the normal child. This
resulted in a ratio score for each parent on each of the
seven scales. A negative ratio indicated that a parent
rated his retarded child higher than the normal siblings,
while a positive ratio indicated the retarded child was
rated lower than the normal siblings.
173
The ratio scores for all cases for each scale were
arranged In array and the median computed. Dichotomizing
at the median, frequencies were tabulated for discharged
and resident patients above and below the median. These
were cast into a 2 x 2 table and a Chi Square test for the
significance of difference calculated. Table 28 gives the
frequencies above and below the median for discharged and
resident groups on each scale.
As can be seen from Table 28, the Fels type rating
scales failed completely to differentiate the evaluations
of parents of discharged patients from the evaluations of
resident patients. Although the scores had a wide range,
from minus 244.00 to a plus 9.51, scores for resident and
discharged group respondents were distributed approximately
equally along the entire range.
There are several possible reasons for this failure
to differentiate. It may be that the scale itself is too
obvious a comparison between retarded child and normal
children and many parents are reluctant to rate the handi
capped child as lower. The scale may be actually measuring
willingness to compare one's children and this character**
istic distributed at random in the two groups.
TABLE 28
DISCHARGED AND RESIDENT PATIENTS RATED ABOVE AND BELOW THE MEDIAN ON
SEVEN RATING SCALES COMPARING RETARDED CHILD WITH NORMAL SIBLINGS
Level of
Scale Discharged Resident Chi Square Significance
Good-Bad Above Median 26 26
Below Median 26 26
o
o
•
p > .05
Pretty-Ugly Above Median 25 27
Below Median 27 25 .03
P >-05
Gentle-rough Above Median 25 27
Below Median 27 25 .03 P > .05
Friendly- Above Median 23 29
Unfriendly Below Median 29 23 .96
P > .05
Loving- Above Median 26 26
Unloving Below Median 26 26 .00 p > .05
Unselfish- Above Median 26 26
Selfish Below Median 26 26 .00 P > .05
Obeys- Above Median 30 21
Does Not Obey Below Median 21 30 2.51 p > .05
"Above the Median" indicates that the normal child is rated above the median, which
is indicative of a negative perception of the retarded child.
175
It may be that the parents In both groups do, In
fact, have approximately the same evaluations of their
retarded child's behavior as compared to his normal sib*
lings and that there is indeed no difference in the way in
which the retarded child is perceived by the two groups,
at least along the dimensions measured by the Fels scale.
Problems Reported Caused
by Retarded Child
It was hypothesized that the families of discharged
patients would report a significantly smaller number of
problems produced by the child than families of resident
patients.
To measure the extent to which each respondent per
ceived the retarded child as having caused problems in the
family, each was asked the following questions:
As you think back to the time when _______ was first
admitted to the hospital and the time since, what are
some of the problems which you have had with him/her?
Were there any problems with you or your husband?
With his brothers and sisters? With other children?
With physical care? At school? In the neighborhood?
Responses were recorded verbatim. Respondents also
throughout the interview would bring up various problems
which they had had with the retardate. Interviewers were
176
instructed to record any such information. A check list of
fifty-six problems mentioned by one or more respondents was
developed and the entire interview coded as a unit. Any
problem mentioned by the respondent at any time in the
interview was checked.
Obviously, some problems are more serious than
others. Stealing and setting fires probably constitute
more serious problems than having meals disturbed by the
child or bed wetting. However, a system of weighting
responses creates problems. Given wide social class dif
ferences in what is considered problem behavior, it would
be difficult to select a group of judges to weight the
responses according to severity with any assurance that
their weighting reflected how the family would rate the
seriousness of the behavior. Consequently, it was decided
not to weight responses but to give each problem mentioned
by the respondent a value of "1." It was assumed that more
serious behavior would involve related problems which would
also be checked. Less serious problems would probably not
involve so many related problems. While simple counting of
problems is admittedly a crude measure, it appears to in
volve fewer difficulties than an attempt to weight answers.
177
Another difficulty with this type of measure is that
some respondents are more articulate than others. If we
could assume that "articulateness" is a random variable
distributed equally in both resident and discharged group
respondents, we could assume this problem solved by chance
factors. However, given the fact that respondents in the
resident group have significantly higher educational
attainment than those in the discharged group and that edu
cation and articulateness could reasonably be expected to
vary together, it was deemed advisable to analyze the data
in two ways. First it was analyzed without a control for
education of respondent and then with a control for re
spondent's education.
Table 29 gives the frequency distribution for prob
lems reported by respondents within the various classifica
tions. The "t" test of the significance of the difference
between two means was used since inspection of the dis
tributions indicated that they met the assumptions of
normality and of homogeneity of variance. Measurement was
in an interval scale. Significantly more problems were
reported by respondents in the resident group than were
reported by those for the discharged group. The "t"
TABLE 29
Number of
Problems
Reported
NUMBER OF PROBLEMS REPORTED CAUSED BY THE RETARDED CHILD
CONTROLLING FOR EDUCATION OF THE RESPONDENT
Total Group
Discharged Resident
Above 9th Grade
Education”
Discharged Resident
Below 9th Grade
Education0
Discharged Resident
0 2 1 1 1 1 0
1 4 0 1 0 3 0
2 8 5 2 1 6 4
3 11 4 3 3 8 1
4 8 11 1 9 7 2
5 9 12 5 6 4 6
6 5 8 4 4 1 4
7 5 7 2 5 3 2
8 2 2 1 1 1 1
9 or over 9 20 2 12 7 8
al 63 70 21 41 41 28
*t = 3.11, 129 df, p < .005
bt = 1.53, 58 df, p > .05
2.32, 67 df, p < .05
178
179
o£ 3.11 is significant at the .005 level, with 129 degrees
of freedom. When education was controlled, those with
below a ninth grade education still showed a significant
difference. The "t" of 2.32, at sixty-seven degrees of
freedom indicates that the higher number of problems re
ported by the resident group is significant at the .05
level. However, the level of significance for respondents
with above the ninth grade education dropped to 1.53,
which, at fifty-eight degrees of freedom, is not signifi
cant at the .05 level. However, the trend is still
strongly in the hypothesized direction.
Two additional variables which might influence the
perceptions of problems caused by the retardate are the
amount of physical handicap and the diagnosis. Since there
is a significant difference between discharged and resident
groups in number of handicaps and in diagnosis, analysis of
the data was made holding handicap constant and holding
diagnosis constant. Table 30 presents the results from
this analysis. Since it is a one-tailed hypothesis, the
number of problems reported by the respondent as caused by
the retarded child continues to differentiate the two
groups when handicap is held constant. The "t" of the
TABLE 30
RESPONDENT’S PERCEPTION OF PROBLEMS CAUSED BY THE RETARDATE
CONTROLLING FOR THE DEGREE OF PHYSICAL HANDICAP
Total Group®
No Handicap^ One or More Handicaps0
Number of
Problems
No
Handicap
One or More
Handicaps
Discharged Resident Discharged Resident
0 1 2 1 0 1 1
1 2 2 2 0 2 0
2 7 6 5 2 3 3
3 8 7 7 1 4 3
4 12 7 7 5 1 6
5 9 12 4 5 5 7
6 7 6 2 5 3 3
7 7 5 4 3 1 4
8 2 2 1 1 1 1
9 15 14 7 8 2 12
Total 70 63 40 30 23 40
«t = .08, 131 df, p >.05
bt = 2.13, 68 df, p <.05
ct = 1.72, 61 df, p < .05, one-tailed test.
181
difference Is 2.13 for patients with no handicap, and 1.72
for those with one or more handicaps. There is no rela
tionship between degree of handicap and number of problems
reported by respondent. The "t" for these variables is .08.
Findings were similar when perception of patient
problems was analyzed in relationship to diagnosis.
Table 31 presents the results from this analysis. There
was no significant difference between the number of patient
problems reported for patients diagnosed as familial or
undifferentiated when these diagnostic categories were com
pared with all other diagnostic categories. The "t" of .82
is insignificant at 131 degrees of freedom. When diagnosis
was held constant, the number of reported problems with the
patient was significantly larger for the hospitalized group
than it was for the discharged group. For patients diag
nosed as either familial or undifferentiated, the "t" was
2.11, significant at beyond the .05 level with eighty-five
degrees of freedom. For patients diagnosed in categories
other than familial or undifferentiated, the "tM of the
difference was 2.18, also significant at beyond the .05
level with forty-four degrees of freedom.
TABLE 31
RELATIONSHIP BETWEEN NUMBER OF PROBLEMS REPORTED
BY THE RESPONDENT AND PATIENT DIAGNOSIS
Number of
Problems
Total Group3
Familial
Undifferentiated Other
Familial or
Undifferentiated
Diagnoses Other Than
Familial or
Undifferentiated0
Discharged Resident Discharged Resident
0 2 1 1 1 1 0
1 4 0 4 0 0 0
2 9 4 6 3 2 2
3 9 6 7 2 4 2
4 13 6 8 5 0 6
5 13 8 6 7 3 5
6 11 2 4 7 1 1
7 5 7 4 1 1 6
8 2 2 2 0 0 2
9 19 10 7 12 2 8
Total 87 46 49 38 14 32
*t = .82, 131 df, p > .05
bt = 2.11, 85 df, p < .05
ct = 2.18, 44 df, p < .05
182
183
It must be concluded that families of resident
patients report more problems with the patient than do
families of discharged patients. This finding remains at
a significant level both when degree of physical handicap
and diagnosis are held constant. It is also significant
for respondents with less than nine years of education but
drops slightly below the level of significance for those
above nine years of education. This may indicate that edu
cational achievement has some minor influence on the number
of problems reported by a respondent but is not the most
important variable operating in the situation.
Summary
To summarize the major conclusions of this chapter,
families of discharged patients have different perceptions
of the patient from those of the families of resident
patients.
When there is no physical handicap, higher status
families are more likely to leave their child in an insti
tution if they are aware he is retarded. This is not true
of lower status families. For the physically handicapped
child, having a family that is aware that he is retarded
in addition to his being physically handicapped does not
184
Increase the probability of his being permanently institu-
tionallzed on either high or low status levels.
The Fels type rating scale by which the behavior of
the retardate was compared with that of his normal siblings
failed to differentiate the discharged from the resident
patient.
Respondents describing the behavior of resident
patients reported more problems with them than did respon
dents describing the behavior of discharged patients. This
finding remained significant even when degree of handicap
and diagnostic category of the patient were held constant.
This variable differentiated the groups best when the
respondent had had less than nine years of formal educa
tion.
CHAPTER VIII
ANALYSIS OF SOME SUBJECTIVE RESPONSES TO RETARDATION
There has been little research on subjective re
sponses to retardation by family members. Most of the
literature on the subject is based on clinical observations
which have not been systematized or quantified.1
In the present study, an attempt was made to study
reactions of parents which might be indicative of guilt.
For our purposes, following the suggestive lead of Anne
Grebler, guilt is defined as the tendency to blame oneself
for the defective child. Therefore, questions were asked
which aimed at determining what the respondent believed was
the cause of the retardation in the child and whether the
respondent expressed attitudes indicating that she believed
herself to be in some way responsible.
See Chapter II. Note especially the studies by
Robinson, Grebler, Holt, Stone and Graliker, and Parmalee
and Koch.
185
186
The following open ended questions were asked and
the responses recorded verbatim.
What was it about ________ that made you/them think
he/she was retarded?
What do you believe caused this?
Have you ever thought that something you did while
you were pregnant (carrying) with_________may
have caused his/her problem?
(Probe) I imagine you wonder why this happened to
you?
Belief About Cause of Retardation
The data gained from the above questions were coded
in two ways. First, beliefs about the cause of retardation
were analyzed for all respondents and were categorized into
eleven categories.
1. No idea what caused it. Responses such as
"I don't know," "I wish I knew," and "It was
God's will."
2. Birth injury
3. Premature birth
4. Stress during pregnancy. This category included
toxemia of pregnancy, German measles In preg
nancy, any illness or operation during pregnancy
which the respondent believed caused the retar
dation, and any fall or accident during preg
nancy which the respondent believed caused the
defect.
5. Medical doctor performed some act or prescribed
some medicine which the respondent believed was
responsible for retardation.
6. Father believed to have caused it because he was
an alcoholic, had syphilis, or was "no good."
7. Physical trauma after birth. This category
included responses such as, "He fell out of a
window on his head," "He was hit in the head
with a ball bat," and "Her brothers and sisters
used to hit her in the head."
8. Mental retardation in the family cited as the
cause. Respondent sees it as an inherited
weakness.
9. The patient lacked love and affection as a child
and this is blamed for the retardation. His
home was "insecure" or he came from a "broken
home." No physical mistreatment is implied.
188
10. Disease in childhood. Diseases specifically
mentioned were encephalitis, meningitis, and
scarlet fever.
11. Sees no deficiency in the child.
Because the sample was too small to produce ade-
quated expected frequencies in every cell for use of the
Chi Square test, related categories were combined so that
expected frequencies were 4.73 in the smallest cell.
Stress in pregnancy and premature birth were combined, in
herited weakness and father believed to have caused it were
combined, and physical trauma, acts of a medical doctor,
and lack of love and affection were combined and labelled
as "physical or emotional trauma in childhood." Table 32
shows the frequency distribution for this analysis. At six
degrees of freedom, the differences are significant at
beyond the .02 level of significance. The two categories
in which expected frequencies deviate most markedly from
observed frequencies are "birth injury" and "sees no de
ficiency in the child." The discharged group is under
represented in birth injury and over-represented in seeing
no deficiency in the child.
TABLE 32
RESPONDENT’S BELIEF ABOUT THE CAUSE OF RETARDATION
COMPARING DISCHARGED AND RESIDENT GROUPS
Belief
Discharged Resident Total
fo fe fo fe
No idea what caused it 12 9.94 9 11.05 21
Birth injury 5 11.37 19 12.63 24
Stress in pregnancy or
premature birth 13 11.84 12 13.16 25
Physical or emotional trauma
in childhood 13 11.84 12 13.15 25
Inherited weakness or
father caused it 3 4.73 7 5.26 10
Disease 8 8.52 10 9.47 18
Sees no deficiency in child 9 4.73 1 5.26 10
Total 63 70 133
X2 = 16.54, 6 df, p < .02
189
190
Analysis of Direction of Blame
for Retardation
The second way in which responses to the question
covering guilt were coded was to assess the direction of
blame. If the respondent was the adoptive or biological
mother of the child, her response was evaluated to deter
mine whom she blamed for the child's defect. If she, in
her answer, reveals that she believes something she did or
did not do herself was to blame for the retardation, this
was coded as "intropunitive" and defined as a guilt re
action. If she blames some other person, such as the
father, a midwife, a medical doctor, a teacher, or someone
who was negligent in the care of the child, or if she
blamed God, this was categorized as "extropunitive." If,
however, she made a response in which there is no blame
directed at any source, this was categorized as a "non-
punitive" response. Some typical responses in this cate
gory are, "I don't know what caused it. We can't think of
anything we did." "I wish I knew why it happened," and
"We've thought and thought but cannot imagine why it
happened."
191
Because It was felt that guilt reactions would be
comparable only If the relationship of the child to the
respondent was held constant, only the responses of adop
tive or biological mothers were used for the assessment of
the direction of blame. Biological or adoptive mothers who
saw no deficiency in the child were not included since they
had no blame to direct either toward self or others. The
responses from forty-one discharged and fifty-eight resi
dent group interviews were analyzed.
Table 33 shows the results of this analysis. The
Chi Square of 6.38 is significant at the .05 level with two
degrees of freedom.
To test Robinson's hypothesis that feelings of guilt
are a basic dynamic in the inability of families to adjust
to the hospitalization of the retarded child, the data were
collapsed into a 2 x 2 table. It was hypothesized that
mothers with resident retardates would be less likely to
direct blame toward themselves while mothers of discharged
retardates would be more likely to blame themselves for the
retardation. As shown in Table 34, the null hypothesis of
no difference is rejected at one degree of freedom at the
.01 level of significance with a Chi Square of 6.31.
TABLE 33
DIRECTION OF BLAME FOR RETARDATION COMPARING MOTHERS
Direction of Blame
Discharged Resident Total
fo fe fo fe
Int ropuni t ive
9 4.98 3 7.03 12
Ext rapunitive 13 15.32 24 21.68 37
Non-punitive 19 20.70 31 29.29 50
Total 41 58
99
Respondent not biological
or adoptive mother or saw
no deficiency in child 22 12 34
Total 63 70 133
X2 = 6.38, 2 df, p < .05
192
TABLE 34
COMPARISON OF INTROPUNITIVE AND NON-INTROPUNITIVE REACTIONS OF MOTHERS
OF DISCHARGED AND RESIDENT PATIENTS
Direction of Blame
Discharged Resident Total
fo fe fo fe
Intropunitive 9 4.98 3 7.03 12
Non-intropunitive 32 36.03 55 50.97 87
Total 41 58 99
X2 = 6.31, 1 df, p < .01
193
194
Summary
The data from this study would seem to indicate that
families of patients who have been discharged from the
hospital to the family have different subjective responses
to the mental retardation of the patient than have families
of resident patients. Resident group respondents more
frequently believe that birth injury produced the retarda
tion, and discharged group respondents more frequently see
no deviation for which an explanatory cause is needed.
When direction of blame is analyzed, using only
responses made by biological or adoptive mothers who recog-
< *
nize that the patient is deviant, the mothers of discharged
patients significantly more often blame themselves than do
the mothers of resident patients.
CHAPTER IX
DIFFERENTIAL PARTICIPATION IN THE
LARGER SOCIAL STRUCTURE
Various investigators have noted that parents who
have a retarded child at home tend to isolate themselves
from the activities of the larger community.^
The hypothesis of this study is that there would be
a significant difference between the participation of the
families of hospitalized patients in the larger social
structure and the participation of the families of dis
charged patients. Questions were asked each respondent
about his or her religious affiliation, religious activity,
activity in non-religious community organizations, and
participation of the mother or mother substitute of the
patient in occupational roles.
See Chapter II. Note especially studies by Holt,
Schonell and Watts, Schonell and Rorke, Peck and Stephens,
and Wardell.
195
196
Religious Affiliation and Activity
Each respondent was asked the church to which he or
she belonged. Table 35 gives the frequency distribution of
the responses. The category "Protestant (Denominational)"
includes the established Protestant denominations of
Methodist, Baptist, Presbyterian, Episcopalian, and Con
gregational. The category "Protestant (Pentecostal Sects)"
includes sect groups which are less well established and
tend to be evangelical and emotional in their appeal and
also the "cultist" beliefs. The "other" category includes
those groups which did not fit into the above categories
and whose frequencies were too small for separate sta
tistical analysis.
The Chi Square test of k independent samples was
used resulting in a Chi Square of 7.12 which, at four
degrees of freedom, is not significant.
The respondents were asked to rate their attendance
at religious functions into one of five categories: none,
a few times a year, once a month, once every two weeks,
once a week or more. While the trend was for resident
group respondents to report more activity, when the data
were tested using the Kolomogorov Smirnov Two-Sample Test,
197
TABLE 35
RELIGIOUS AFFILIATION OF THE FAMILIES OF DISCHARGED
AS COMPARED TO THE FAMILIES OF RESIDENT PATIENTS
Church Affiliation Discharged Resident Total
No Church 16 9 25
Roman Catholic 19 20 39
Protestant
(Denominat ional) 17 22 39
Protestant
(Pentecostal-sect) 4 13 17
Other 6 5 11
Unknown 1 1 2
Total 63 70 133
XZ = 7.12, 4 df, p > .05
198
the Chi Square of 3.21 was not significant at two degrees
of freedom.
Because social participation is highly contaminated
by social class, an analysis was also made for this cate
gory within high and low social status classifications.
As shown in Table 36, the Chi Square for the high social
level was 4.73 but was not significant, while the one for
low social level was a very insignificant .97. It must be
concluded that, on the basis of this sample, no significant
difference in religious affiliation exists between the dis
charged and resident groups. While there is a tendency for
higher status families of resident patients to be more
active in church functions, this does not reach the neces
sary level of statistical significance.
Participation in Secular Community Roles
When respondents were asked about their participa
tion in non-religious community organizations, the most
usual response was to say that they did not belong to any
organizations of any kind. Of the 131 respondents who
answered the question, 103 reported either that they
belonged to no organizations other than church or that
TABLE 36
ATTENDANCE AT RELIGIOUS ACTIVITIES REPORTED BY RESPONDENTS OF RESIDENT
AS COMPARED TO RESPONDENTS OF DISCHARGED GROUP
CONTROLLING FOR SOCIAL STATUS
Total Groupa High Status** Low Status0
Activity Level Discharged Resident Discharged Resident Discharged Resident
None 25 17 11 10 13 7
Few times a year 12 16 5 11 8 5
Once a month 6 2 3 0 2 2
Once every two weeks 3 6 0 4 3 2
Once a week or more 17 28 5 16 12 12
Unknown 0 1 0 1 1 0
Total 63 70 24 42 39 28
°X2 = 3.21, 2 df, p > .05
V = 4.73, 2 df, p > .05
CX2 = .97, 2 df, p >.05
199
200
they were inactive in organizations to which they did
belong. As shown by Table 37, the twenty-eight respondents
who did report some activity were relatively evenly dis
tributed between groups.
Since none of the Chi Square values approached sig
nificant levels, it must be concluded that no significant
difference exists between these two groups on the basis of
participation in community activities of a non-religious
nature.
Participation in Occupational Roles
The most vital links between the individual family
and the larger social structure are the occupational roles
of family members. A family which has no member who is
filling an active occupational role is isolated from an
important point of contact with the wider community, while
a family that has one or more members filling an occupa
tional role is inevitably involved in activities outside
the family.
The purpose of this section is to look specifically
at the probability of discharge and its relationship to
(1) the dependency status of the family, and (2) whether
TABLE 37
REPORTED ACTIVITY IN SECULAR COMMUNITY ORGANIZATIONS COMPARING RESPONDENTS
OF RESIDENT WITH RESPONDENTS OF DISCHARGED GROUP
CONTROLLING FOR SOCIAL STATUS
Total Group3 High Status** Low Status3
Activity Level Discharged Resident Discharged Resident Discharged Resident
No organizations
or inactive 51 52 19 27 32 25
Moderately active 5 9 3 8 2 1
Very active 6 8 2 6 4 2
Unknown 1 1 0 1 1 0
Total 63 70 24 42 39 28
®X2 = .65, 2 df, p >.05
bX2 = 1.53, 2 df, p >.05
CX2 = .16, 2 df, p > .05
201
202
the family has a mother or mother substitute working.
Dependency Status
Three categories of dependency status were used In
the analysis: (1) financially Independent, (2) retired but
living on earned pension, savings, rentals, or Insurance,
and (3) dependent, living on agency support. Table 38
shows the frequency distribution for this variable. In
spite of the fact that discharged families have a signifi
cantly lower occupational level than the resident group,
they are not significantly more dependent on agency support
than families of resident patients. The Chi Square of A.11
is below the level of significance at two degrees of free
dom.
Working Status of Mother or Mother Substitute
Another link which a family may have to the larger
community is that of the mother's full or part time occupa
tional role. It was hypothesized that more mothers of
resident patients would be filling either full or part time
occupational roles outside the family and thus have a more
complex status set than the mothers of discharged patients.
203
TABLE 38
COMPARISON OF RESIDENT AND DISCHARGED GROUP FAMILIES
ON BASIS OF DEPENDENCY STATUS OF THE FAMILY
AT TIME OF INTERVIEW
Dependency Status Discharged Resident
Financially independent 38 53
Retired but living on earned
pension, savings, rentals,
insurance 13 7
Dependent, living on agency
support 12 10
Total 63 70
X2 = 4.11, 2 df, p > .05
204
However, the working status of mothers is strongly
linked to social class with lower status women having a
higher proportion in the labor force. For this reason, it
is necessary to look at working status both between dis
charged and resident groups and within social levels.
Table 39 shows the responses to inquiry about the working
status of mothers or mother substitutes at the time of the
interview.
Differences between discharged and resident patients'
mothers or mother substitutes working is negligible. The
Chi Square is only .33. Within the high status group,
there is a tendency for mothers of resident patients more
often to have full time or part time positions, but the
difference is not statistically significant. Among low
status mothers discharged patients' mothers tend to be
employed more often, but again the difference is not sta
tistically significant.
Index of Social Participation
In order to get a summary view of social participa
tion, an index was computed including activity in religious
organizations, activity in secular organizations, and
working status of the mother or mother substitute.
TABLE 39
WORKING STATUS OF MOTHERS OF RESIDENT AND DISCHARGED PATIENTS AT THE TIME
OF THE INTERVIEW CONTROLLING FOR SOCIAL STATUS
Total Group® High Status^ Low Statusc
Working Status Discharged Resident Discharged Resident Discharged Resident
Not working outside
home 46 51 21 27 25 24
Working less than
40 hours a week 7 4 0 3 7 1
Working 40 or more
hours a week 9 15 2 12 7 3
Unknown 1 0 1 0 0 0
Total 63 70 24 42 39 28
®X2 = .33, 2 df, p >.05
bX2 = 4.88, 2 df, p > .05
CX2 = 3.15, 2 df, p > .05
205
206
For religious activity, if the respondent reported that he
belonged to no church or, belonging to a church, never
attended, he was given a "0." A response of "a few times
a year" or "once a month" was scored "1." A response of
"once a week" or "once every two weeks" was scored as "2."
For activity in secular organizations, a response of
"no organizations" or "inactive" was scored as "0." A re
sponse of "somewhat active" was scored as "1." A response
of "very active" was scored as "2."
For working status of the mother or mother substi
tute, a response of "no job" was scored as "0." A response
of "part time employment— less than forty hours a week" was
scored as "1." A response of "full time employment— forty
or more hours per week" was scored as "2."
These scores were summed for each interviewed family
making a possible range in scores for the index of "0" to
"6." The results of this handling of the data are shown
in Table 40, which compares discharged and resident groups
both for the entire group studied and within social status
levels.
The most interesting outcome is that, although
there was a tendency in the analysis of each of the
TABLE 40
INDEX OF SOCIAL PARTICIPATION COMPARING DISCHARGED AND RESIDENT GROUPS
CONTROLLING FOR SOCIAL STATUS
Social
Participation
Score
Total Groupa High Status*5 Low Status0
Discharged Resident Discharged Resident Discharged Resident
0 17 10 9 4 8 6
1 13 12 6 5 7 7
2 18 25 4 15 14 10
3 7 9 4 8 3 1
4 4 10 1 6 3 4
5 2 3 0 3 2 0
6 1 0 0 0 1 0
Unknown 1 1 0 1 1 0
Total 63 70 24 42 39 28
®X2 = 3.8, 2 df, p > .05
V = 10.29, 2 df, p < .01
°X2 = .42, 2 df, p >.05
207
208
individual items for them to differentiate in high social
status category between discharged and resident groups with
resident respondents reporting more activities outside the
home, this tendency did not reach a significant level for
any of the individual items. However, when the items are
combined in the scale, thus pooling the tendencies in each
individual item, they reach a level of significance
beyond .01 for high status families.
It would appear that participation in activities
outside the home does differentiate respondents with resi
dent retardates from respondents with discharged retardates,
in the higher status levels, but does not differentiate in
low status levels. At least three possible explanations
may be found for this. Since persons with higher social
status who have retardates are more likely to have severely
retarded and physically handicapped children, families on
this social level who have their retardates at home may be
more confined because of the need to give physical care
to the retarded child than families on lower social levels
2
See Chapter II. Note especially studies by
Saenger, by Sabagh, Dingman, Tarjan, and Wright, and by
Stein and Susser.
209
who are more likely to have only mildly retarded children.
This would serve to differentiate the group with retardates
at home more sharply from the group with the child in the
hospital in higher social status levels, but would not be
a factor operating on the lower level.
Another explanation could be that families on higher
social levels typically participate more in the life of the
community than do persons on the lower levels, thus the
family on the higher social level must make a choice which
involves keeping the retarded child at home and being
relatively isolated from the conmunity or hospitalizing the
child and being able to participate. The lower class
family, which typically participates less in the community,
is not faced with this choice since, in either case, they
are not likely to participate very actively in community
affairs.
A third possible explanation may be that social
participation differentiates higher status discharged and
resident groups because persons of higher status who prefer
active occupational and community roles are less likely to
want to modify their own career patterns sufficiently to
keep the retarded child at home. They enjoy a complex
210
status set and are unwilling or unable to make the re
adjustments in their own style of life which would be re
quired if the child were not in an institution.
In an attempt to explore which of these explanations
may be more valid, the relationship between handicap and
social status and the relationship between social par
ticipation and social status were studied independently.
When social status and social participation were studied,
there was found to be no significant difference between
high status and low status persons* social participation.
Thus, the hypothesis that higher social levels must make
a choice between having the retarded child at home and
social participation which is not likely to be faced by
3
lower social status families does not seem to be tenable.
When the relationship between handicap and social
status was examined, no significant relationship was found.
High status patients did not have significantly more handi
caps than low status persons. The Chi Square of 3.99 was
not significant with two degrees of freedom. Within the
higher social status, degree of handicap did not differ
entiate the resident from the discharged group, although
3
See Appendix B, Table 57.
211
a Chi Square of 4.42 showed a tendency for resident
patients to have more handicaps. The Chi Square of 2.87
for low status groups indicated no differences between
resident and discharged persons on this social level in
number of handicaps.^
The third explanation remains a possibility. It may
be that among higher status individuals, persons who desire
active occupational and community roles prefer to institu
tionalize the retarded child permanently rather than making
the modifications in their own career patterns which would
be necessitated by keeping him at home. This motivation
may not operate at lower status levels.
Summary
In summary, examination of religious affiliation and
activity, activity in secular organizations, dependency
status, and working status of the mother did not yield
significant differences between families of discharged
and families of resident patients when each variable was
analyzed individually. When combined into a social par
ticipation index, however, the families of resident, higher
4
See Appendix B, Table 58.
212
status patients were found to have significantly higher
social participation scores. Three possible explanations
of this finding were explored and only one proved to be
tenable. This explanation suggested that the preference
for active community roles may be a significant character
istic of higher status persons who permanently institu
tionalize their children but is not significant on lower
social levels.
CHAPTER X
ANALYSIS OF FACTORS RELATING TO ADMISSION
OF PATIENT TO HOSPITAL
There has been nothing discovered in the literature
which directly bears upon the problem of how factors sur
rounding the admission of a mentally retarded person to a
state institution may be related to the probability of his
subsequent discharge. Tarjan, Wright, Dingman, and Eyman,
in studying the characteristics of 724 first admissions to
Pacific State Hospital did investigate complaints of the
parents and community which commonly precipitated admis
sion.^ They found that aggressiveness and rejection by the
neighborhood accounted for a larger percentage of complaints
against older retardates than younger and that some in
fraction of the law had occurred in up to 50 per cent
George Tarjan et al., "Natural History of Mental
Deficiency in a State Hospital," American Journal of
Diseases of Children. Cl (February, 1961), 204.
213
214
of these patients. However, they did not study the Im
plications of these findings on probability of discharge.
It was the hypothesis of this study that the route
to the hospital would differ significantly for patients who
were subsequently discharged to their families than for
patients who remained In the hospital. It was hypothesized
that the patients who remained hospitalized would have
followed a route to the hospital which Involved social pro
cesses within the family by which the family came to per
ceive them as deviant, and, rather than modifying family
norms to accommodate their deviant behavior, the family
gradually excluded them from the family social system.
Thus, hospitalization would be preceded by pressures within
the family to place the child and by the development of
consensus within the family on the desirability of place
ment. Persons reported as important in placement would be
family members or persons approached voluntarily by family
members, such as medical doctors.
For patients subsequently discharged to the family,
it was hypothesized that the route to the hospital would
have involved pressures from outside the family such as
from welfare agencies, law enforcement agencies, rather
215
than pressures generated from changes occurring within the
family or In the family's perception of the retarded child.
Further, It was hypothesized that there would not have been
the development within the family of the same degree of
consensus on the desirability of placement and that persons
reported as Important In placement would more often be
non-family members and persons whose advice had not been
solicited, such as welfare persons, law enforcement agen-
cies, and court officials.
To explore these possibilities, the analysis has
been divided Into four sub-categories: (1) unanimity of
family attitude for or against placement, (2) important
persons in placement, (3) residence at the time of admis
sion, and (4) community problems as compared to family
problems in placement.
Unanimity of Family Attitude for
or Against Placement
In order to ascertain the attitudes of various
family members toward placement of the patient in the hos
pital, the respondent was asked, ’ ’How did you feel about
putting ______ in the hospital? Were you for it or against
it?" Then he was asked the same question for other
216
relatives. This made it possible to code the attitude o£
the mother or mother substitute, the father or father
substitute, the grandparents, sibling, aunts, and uncles.
So that a composite score could be derived that
would represent, at least crudely, the amount of consensus
of the family on the placement of the child in the hos
pital, a scoring scheme was developed by which an attitude
favorable to placement on the part of the mother or mother
substitute was scored as "1," and an attitude favorable to
placement on the part of the father or father substitute
was scored as "1," and all relatives reported as favorable
to placement was scored as "1." If the mother or mother
substitute was deceased at the time of placement, had
deserted the family, or was reported as "didn't care," this
was scored as "0," since it was assumed that she had little
influence on the decision to place. The same procedure was
used in the case of the father or father substitute. If
relatives were reported as divided so that some were for
and some were against placement, this was also scored
as "0." In cases where the mother or mother substitute was
opposed, the score was -1. Where the father or father
substitute was opposed, it was also scored -1. In the
217
cases In which all relatives were reported as opposed, a
score of -1 was also given.
This procedure produced a possible range in total
scores from "plus 3" in which all relatives, mother or
mother substitute, and father or father substitute were
favorable to placement to a "minus 3" in which they were
all opposed to placement. Using this system, the table of
frequencies found in Table 41 was procured.
The finding that there was more unanimity of opinion
favorable to placement in the families of resident patients
than in the families of discharged patients is significant
beyond the .01 level. No family in the resident group had
more than one member opposed to placement.
Important Person in Placement
Each respondent was asked the question, "Who would
you say was the most important person getting you to place
_______ in the hospital?" Responses were grouped into four
categories: (1) a relative or friend, (2) a medical person,
(3) a governmental agency, which included police, juvenile
authority, or welfare persons, (4) the schools and other
persons not included in the first three categories.
218
TABLE 41
FAMILY CONSENSUAL LEVEL ON PLACEMENT OF THE
RETARDATE IN THE HOSPITAL
Score Discharged Resident
Plus 3 19 19
Plus 2 16 32
Plus 1 4 9
0 5 8
Minus 1 6 2
Minus 2 9 0
Minus 3 4 0
Total 63 70
X2 = 9.28, 2 df, p < .01
219
There were four cases In the "other” category distributed
equally between groups.
It was hypothesized that the person who would be
important in the placing of the retarded child would vary
according to two variables which would confound any rela
tionship found by a direct comparison of discharged and
resident groups. These variables were social status and
degree of physical handicap.
To study the influence of physical handicap, the
groups were dichotomized by placing all patients with no
physical handicap in one group and patients with one or
more handicaps in the other group. The relationship
between these two groups and important person in placement
was then tested by means of the Chi Square test of k inde
pendent samples. A Chi Square of 6.85 was not significant
at four degrees of freedom and it was concluded that there
was no significant relationship between physical handicap
and the person reported as most important in placement.
The relationship between social level and person
important in placement was then tested by means of the
2
See Appendix 8, Table 59.
220
Chi Square test for k independent samples, and the rela
tionship was found to be highly significant. A Chi Square
of 22.59 at four degrees of freedom was significant well
beyond the .01 level. The cells in which observed fre
quencies deviated most markedly from the frequencies which
would be expected under the null hypothesis were government
persons and medical persons. The low social status had
more government persons than expected and high status
fewer. High status persons had more medical persons than
expected and low status persons had fewer.
Consequent to these findings, the data were studied
both comparing the groups regardless of social level and
within social level.
Differences significant at beyond the .01 level were
found in persons reported to have been important in place
ment. Table 42 shows both observed and expected frequen
cies for the Chi Square analysis of the differences. The
cells which deviate most markedly from the null hypothesis
of no difference are the cell for governmental agencies,
which has more cases in the discharged than expected,
3
See Appendix 8, Table 60.
TABLE 42
PERSON REPORTED AS BEING MOST IMPORTANT IN THE PLACEMENT OF THE RETARDATE
IN THE HOSPITAL CONTROLLING FOR SOCIAL LEVEL
Person Important
In Placement
Total Group
a
High Status
b
Low Status0
Discharged Resident Discharged Resident Discharged Resident
fo fe fo fe fo fe fo fe fo fe fo fe
Relative or
Friend 20 21.78 26 24.21 10 7.27 10 12.73 9 13.39 14 9.61
Government 30 19.42 11 21.57 5 4.00 6 7.00 25 17.46 5 12.54
Schools-Other 5 9.00 14 10.00 2 4.36 10 7.64
5 8.15 9 5.85
Medical 8 12.78 19 14.21 7 8.36 16 14.64
Total 63 70 24 42 39 28
®X2 = 19.70, 3 df, p < .01
V = 4.36, 3 df, p >.05
CX2 = 14.16, 2 df, p <.01
221
222
and the cells for school persons and medical persons, rtiich
each has more resident cases than would be expected under
the null hypothesis.
When the data are analyzed within social levels, It
appears that the person Important In placement Is not a
significant variable In differentiating high status dis
charged from high status resident patients but is very
significant in differentiating low status patients. The
Chi Square for the low social status group is 14.16, which
is significant at beyond the .01 level with two degrees of
freedom. For these low status patients, it is the cell for
governmental persons that deviates most markedly from the
expected frequencies. The discharged group has more cases
than expected under the null hypothesis and the resident
group has less than expected.
On the basis of these findings, it may be concluded
that the person reported as most important in placement
significantly differentiates discharged and resident groups
on low status levels and it is the significant differences
found here which account for the differences found when
discharged and resident patients are studied without regard
to social status.
223
Residence at the Time of Admission
In fifty-five of the 133 cases interviewed, the
patient had not been living in the home of his biological
parents prior to admission. This means that for approxi
mately half of the interviewed group, hospitalization had
not been a direct procedure but had been accomplished with
an intermediate stage during which the patient lived out
side the home of his biological parents but was not in the
hospital. It was hypothesized that the type of residence
which the patient had before hospitalization might be an
important variable in the route to the hospital which would
differentiate those who would later be discharged from
those who would remain in the hospital.
Place of residence immediately prior to hospitaliza
tion was coded into five categories: (1) the home of the
biological parents, (2) home of adoptive parents or home
of relatives, (3) foster home, boarding home, or school,
(4) hospital (medical, psychiatric facility or home for
mentally retarded), (5) juvenile facility. Table 43 shows
both observed and expected frequencies for discharged and
resident groups. Using the Chi Square test for k indepen
dent samples, the Chi Square of 6.13 was not significant
TABLE 43
PATIENT'S PLACE OF RESIDENCE IMMEDIATELY PRIOR TO HOSPITALIZATION
Place of Residence Discharged Resident Totals
fo fe fo fe
Home of biological parents 40 36.34 35 38.65 75
Home of relative or
adoptive parents 5 5.33 6 5.66 11
Foster home, boarding home
or school 5 7.26 10 7.73 15
Hospital-medical, mental,
retarded 6 9.20 13 9.79 19
Juvenile facility 7 4.84 3 5.15 10
Unknown 3 3
Total 63 70 133
X2 = 6.13, 4 df, p >.05
224
225
at the .05 level of significance.
It seemed probable that placement outside the home
of biological parents prior to commitment might be a
variable significantly influenced by social class, there
fore, it was studied within social levels. Since the
frequencies were not large enough to allow for analysis in
a 5 x 2 table, the table was collapsed to a 2 x 2 table
in which all persons living with biological parents prior
to placement were grouped together and all those living
with other than biological parents were grouped together.
Table 44 shows the results of this dichotomization. Again,
results show no significant differences.
Community Problems Compared to Family Problems
in Placement
It had been hypothesized that patients in the resi
dent group would significantly more often have been placed
because of some felt need on the part of the family, some
social process generated within the family which made the
family define the child out of the family social system.
On the other hand, it was hypothesized that patients in the
discharged groups would more frequently have been institu
tionalized as the result of influences from outside the
TABLE 44
PATIENTS LIVING WITH BIOLOGICAL PARENTS IMMEDIATELY PRIOR TO PLACEMENT
CONTROLLING FOR SOCIAL STATUS
Place of Residence
High Status® Low Statusb
Discharged Resident Discharged Resident
With biological parents 16 18 24 17
Not with biological
parents 8 21 15 11
Unknown 0 3 0 0
Total 24 42 39 28
V = 1.76, 1 df, p >.05
bX2 = .24, 1 df, p >.05
226
227
family, such as action of governmental agencies or schools.
Respondents were each asked the question, "As you
think back to the time when_______ was first admitted to
the hospital, what are some of the problems which you had
with him/her? (Probe: Were there any problems with you or
your husband/wife? With his brothers and sisters? With
other children? With physical care? At school? In the
neighborhood?)" Responses to this question were recorded
verbatim and were later coded into six categories, accord
ing to the primary problem configuration. These categories
were then grouped into two main divisions: (1) problems
originating outside the family, and (2) problems origi
nating within the family. The categories were defined in
the following manner.
A. Problems originating outside the family.
1. Presence of the patient had proved in
tolerable to police, neighbors, or welfare
agencies.
2. The schools had excluded the child and
school personnel exerted pressure for place
ment.
228
B. Problems originating within the family.
1. Behavior of child in the home proves in
tolerable to family members.
2. Medical problems produced by child being
severely ill and demanding more medical care
than the home can give.
3. Changes in the family such as divorce,
death, or aging of parents make care of
patient no longer possible.
4. Patient is unhappy or in danger at home and
family feels the need to protect him from
exploitation, accident, or injury or make
him more contented through institutionaliza
tion.
Table 45 gives the frequencies with which the re
sponses were coded into the categories defined above. When
the data were collapsed into a 2 x 2 table using the total
frequency for each major subdivision under discharged and
resident groups, there was a Chi Square value of 17.7
which, at one degree of freedom, is significant well beyond
the .01 level.
However, the types of problems which lead to the
institutionalization of the retarded child could vary by
TABLE 45
PROBLEMS LEADING TO PLACEMENT COMPARING RESIDENT AND DISCHARGED GROUPS
Problems Discharged Resident Total
Problems originating outside family;
Pressures from police, neighbors,
or welfare agency 25 10
School pressures: Child excluded
by school, pressures from school
personnel 9 3
Total 34 13 47
Problems originating within family:
Behavior of child proves intolerable
to family 14 31
Medical problems 4 6
Changes in family 9 15
Patient unhappy or in danger at home 2 4
Total 29 56 85
No pressures or problems cited
Total 63
(1)
69 132
X2 = 17.7, 1 df, p < .01
229
230
social class and the above relationship be spurious. To
investigate this possibility, the relationship between
origin of problems leading to placement and social status
was studied. Table 46 presents the findings. Social
status and origin of problems leading to institutionaliza
tions are strongly related. High status persons are sig
nificantly more likely to institutionalize for problems
originating inside the home. The Chi Square of the dif
ference is 6.48, which, at one degree of freedom, is
significant at the .02 level.
Within the high status group and within the low
status group there is not a significant difference between
discharged and resident groups on origin of problems. The
Chi Squares of 1.2 and 2.55 are not significant with one
degree of freedom.
On the basis of these data, it is possible to con
clude that discharged patients were more often placed as a
result of problems with the police, neighbors, welfare
agencies or schools while resident patients were more often
placed following problems originating within the home.
However, this difference is produced primarily because
of the effects of social status differences between the
TABLE 46
ORIGIN OF PROBLEMS LEADING TO PLACEMENT CONTROLLING FOR SOCIAL STATUS
Origin of Social Status3 High Status^ Low Status0
Problems High Low Discharged Resident Discharged Resident
Problems originating
inside home 50 35 12 37 17 19
Problems originating
outside home 16 31 12 4 22 9
Total 66 66d 24 41 39 28
*X2 = 6.48, 1 df, p < .02
hx2 = 1.20, 1 df, p > .05
V = 2.55, 1 df, p >.05
d
One resident, low status case mentioned no problems leading to placement.
231
232
two groups and origin of problem leading to institutional
ization is not a variable which operates independently of
social status.
Summary
In summary, four conclusions may be drawn from the
analysis contained in this chapter.
The families of resident patients were more favor
able to institutionalization at the time when the retarded
child was placed than were the families of discharged
patients.
Persons reported as important in influencing the
family to place the retarded child in an institution varied
significantly between discharged and resident groups. This
relationship was primarily due to the influence of social
status. When social status was held constant, the person
reported as important in placement did not differentiate
the groups for high status families but was highly sig
nificant in differentiating low status families. Patients
placed as the result of the influence of governmental per
sons were more likely to be discharged while those placed
as the result of the influence of medical or school persons
233
were less likely to be discharged. Degree of physical
handicap was not related to person reported as Important In
placement.
Discharged and resident patients were equally likely
to have lived In the home of biological parents Immediately
prior to Institutionalization.
Discharged patients were more likely to have been
placed in the institution as a result of problems origi-
nating in the community with the police, neighbors, welfare
officers, or schools. Resident patients were more likely
to have been placed following problems originating within
the home. This difference was the result of the operation
of social class differences and disappeared when social
class was controlled.
CHAPTER XI
SUMMARY AND CONCLUSIONS
Summary
The Problem and its Importance
The demand for institutional care of mentally re
tarded persons has tended to increase more rapidly than the
facilities available to meet this demand. Thus, it is of
increasing importance to explore alternative solutions for
the care of the mentally retarded. One means by which this
may be done is to study factors which are related to the
institutionalization and the discharge of persons who have
been in institutions for the mentally retarded.
This study focused specifically on the families of
retarded persons. It proposed to discover some of the
important variables which characterize a family which takes
a retarded person from an institution and assumes responsi
bility for his welfare. It seeks to determine what kind
of a family is able and willing to have a retarded person
234
235
live at home.
Methodology
The method by which this study attempted to answer
the preceding problem was to compare the characteristics of
the families of a group of retardates who had been dis
charged to their families from an institution for the men
tally retarded with the families of a group of persons who
were still institutionalized. The retardates were matched
for age, sex, ethnic group, year of admission, and intel
ligence quotient.
Two sources of information were used. The hospital
file for each retardate was analyzed to gain information
about the patient and family which was known to the hos
pital. The second source of information was through an
interview with a member of the family of the retardate,
usually the mother. Of the seventy-six retardates in each
group, interviews were completed with a family member of
sixty-three of the discharged cases and seventy of the
resident cases.
Responses to questions asked in the interview were
coded and analyzed statistically. When the data were
236
qualitative in nature, the Chi Square test of two inde
pendent samples was used. If the data formed an ordinal
scale, the Kolomogorov-Smirnov Two-Sample Test was used.
In those cases where the answers to the questions could be
arranged in an interval scale, the "t" test for the differ
ence between two means was used.
Specific Findings of This Study
Specific hypotheses about the major variables to be
investigated were formulated before the study was under
taken. The findings in terms of these hypotheses are given
in summary fashion here.
Socioeconomic variables:
1. The mothers or mother substitutes of resident
patients had more education than those of discharged
patients.
2. The heads of the households of resident patients
had more education and a higher occupational level than the
heads of the households of discharged patients.
3. The economic status of the streets on which the
families of resident retardates lived was higher than that
of discharged retardates' families.
237
4. The level of repair of the housing of the fami
lies of resident retardates was better than that of the
housing of discharged retardates' families.
5. The kind and quality of furnishings and equip
ment found In the homes of resident retardates' families
were better than those found In the homes of discharged
retardates' families.
Variables In family structure and marital stability:
1. Discharged patients have a greater degree of
consanguinity with their families than do resident patients.
2. The mothers of discharged patients are younger
v
than the mothers of resident patients.
3. Discharged patients have more siblings than
resident patients but this difference is due to social
status differences between the two groups.
4. There is no difference between the two groups of
patients in number of persons who are not members of the
nuclear family living in the home, the number of half
siblings, the incidence of death of a parent or parent
substitute between admission and discharge, the incidence
of divorce or separation of parents or parent substitutes
between admission and discharge, or the health of parents
238
or parent substitutes.
5. The biological mothers of resident retardates
from low status homes had a greater number of divorces than
those of discharged retardates from low status homes.
There was no difference in number of divorces of the
biological mothers in high status families. Age of the
mother was not related to number of divorces.
6. The biological parents of discharged retardates
had marriages which lasted a longer length of time than did
the marriages of the biological parents of resident re
tardates.
7. There was no difference in the stage of the
family cycle in which the families of the two groups were
in either at time of admission or at the time of the inter
view.
Variables in perception of the retardate:
1. The level of awareness proved to be a variable
related in a complex way to degree of handicap of the
patient and status level of the family.
a. If the patient has no physical handicap, the
families of resident patients are more
aware that the patient is retarded than
the families of discharged patients. If the
patient has one or more handicaps, the fami
lies in both groups are equally aware of his
retardation,
b. If a non-physically handicapped retardate
comes from a high status family which is
aware that he is retarded, he probably will
be permanently hospitalized. If a non-
physically handicapped retardate comes from
a low status family which is aware that he
is retarded, he has about equal probability
of being hospitalized or discharged.
2. Families of resident retardates did not rate the
behavior of the retardate lower them that of the normal
siblings.
3. Families of resident retardates reported more
problems with them than did the families of discharged
retardates. This was true regardless of the degree of
handicap or the diagnostic category of the patient.
Variables in subjective reactions to retardation
and hospitalization:
1. Families of resident retardates attribute the
retardation to different causes than do the families of
240
discharged retardates. Families of resident retardates
attribute retardation to birth injury more frequently,
while families of discharged retardates are more likely to
see no deficiency in the patient.
2. Biological or adoptive mothers of discharged
retardates are more likely to blame themselves for the
patient's retardation than are mothers of resident retar
dates.
Variables in participation in the larger social
structure:
1. There is no difference in the religious affili
ation of resident and discharged patients.
2. Families of resident patients do not participate
more in religious activities than families of discharged
patients nor do they participate more in secular community
roles nor do they have more working mothers than discharged
patients.
3. Families of discharged patients are no more
dependent upon agency support than the families of resident
patients.
4. When participation in religious activities,
secular community roles, and having a working mother
241
were combined Into a social participation Index, resident
retardates' families of high social status were more likely
to have high levels of social participation than discharged
retardates' families of high status.
Variables related to factors in admission to the
hospital:
1. Families of resident patients had achieved a
higher level of consensus favorable to placement before the
retardate was placed in the hospital than had the families
of discharged patients.
2. Discharged retardates from low status levels
were more likely to have been placed in the hospital as a
result of the influence of the police, governmental
authority, or welfare persons than were resident retardates
from low status levels. On high status levels, there was
no difference between discharged and resident groups in the
person influential in placement.
3. Resident patients were just as likely as dis
charged patients to have been living with their biological
parents immediately prior to institutionalization.
4. Discharged patients are more likely to have been
placed in the hospital as a result of problems which they
242
created in the community, while resident patients are more
likely to have been placed as a result of problems created
within the family. However, this difference is due pri
marily to social class differences between the two groups.
Variables related to characteristics of the patient:
Although the research design attempted to hold
constant the characteristics of the patient which would be
significant in probability of discharge, two patient
characteristics still remained uncontrolled.
1. Resident patients had multiple physical handi
caps more frequently than did discharged patients.
2. Discharged patients were more frequently diag
nosed as familial or undifferentiated while resident
patients were more frequently diagnosed into categories
having a recognizable, clinical symptomotology.
General Conclusions
This study has resulted in four general conclusions:
1. The social status of the family of the retarded
person is a critical variable in determining whether he
will be discharged from a hospital for the mentally re
tarded. Any future studies of discharge or of institu
tionalization should consider this variable systematically.
243
The results of past studies which did not control for the
effects of social status need to be accepted with extreme
caution. Size of family, marital instability, problems
with governmental agencies, participation in community
roles, and the effects of physical handicap on the process
of discharge are all variables which have differential
influence by social status.
2. Family structure needs to be analyzed carefully
in any study of factors in the process of discharge from
the hospital. Making the redefinitions of norms which is
necessary in order to cope with the behavior of the re
tarded child within the family and making the necessary
accommodations to the arrest in the normal career develop
ment of the parents which is occasioned by the presence of
the retarded child is more readily accomplished by a young
mother and by a family which is closely related to the
retardate genetically. The retardate who has only the
family of distant relatives or only an older mother to whom
he may be discharged has a high probability of remaining
in the hospital. He is also in a more favorable position
for being discharged if the marriage of his biological
parents has lasted a long time.
244
3. Sociopsychological variables were also £ound to
have a bearing on the probability of a retardate being dis
charged. Direction of blame for the retardation, percep
tion of problem behavior, and awareness of retardation are
all variables which proved worthy of consideration.
4. Finally, the importance of the characteristics
of the patient himself was reemphasized by the findings of
this study. The retardate who requires greater physical
care will probably be in the hospital, regardless of social
status.
Limitations of the Present Study
The present study suffered from several limitations
which need to be taken into consideration in any attempt
to generalize from its findings.
1. This study covered only retardates who had been
institutionalized in one institution for the mentally re
tarded. Policies and leave programs vary greatly from one
institution to another and from one political jurisdiction
to another. Therefore, the findings presented here can be
taken as characteristic only of Pacific State Hospital and
cannot be generalized beyond this hospital without in
curring great risk of error.
245
2. The group studied in this project was not a
representative sample of all persons discharged from home
leave throughout the history of the hospital but was rather
the complete universe of cases for three fiscal years.
Consequently, it is not possible to generalize the findings
to the total population of discharged persons since factors
influencing discharge may have changed over the years.
The method of selecting cases for this study does not make
it possible to gain an historical perspective of factors in
discharge over a period of time.
3. Two characteristics of the patients themselves
were not controlled by the research design. Although an
attempt was made to control for these variables when
examining factors in discharge which they might influence,
a more adequate research design would have controlled for
diagnosis and degree of handicap.
4. A longitudinal-panel type research design would
be a more fitting one for the examination of several of the
variables studied in this project. Recall of problems and
family structure at the time of admission by the respondent
meant remembering events which, for some respondents,
occurred as much as twenty years before the interview.
246
This necessity undoubtedly reduced the accuracy of re
sponses. Investigation of variables at admission would
better be made shortly following admission. Also, this
ex post facto type questioning made it impossible to deter
mine the time sequence of event and attitude.
5. Having only one interview with the respondent
made it impossible to investigate with any thoroughness the
intra-psychic processes of the respondents. The finding
that direction of blame did differentiate the mothers of
discharged patients from the mothers of resident patients
is indicative that further explorations in this area might
prove valuable.
6. There were sixty-nine cases which fell within
the definitions of the discharged and resident groups but
which were not interviewed. If these families had been
interviewed, it is possible that the results of this study
may have been modified.
There were twenty-three discharged cases and twenty-
seven resident cases which were not included in the groups
to be interviewed because the family lived outside the
geographic area within which the interviews were to take
place, the patient had been readmitted to a state
247
institution, the address of the family was unknown, or all
the family was deceased. There were thirteen discharged
cases and six resident cases with whom interviews were
attempted but who were not interviewed because of refusals,
because the family had moved from the geographic area in
which interviews were to take place, because all relatives
knowing the patient had died, or because the family proved
impossible to locate.
An attempt was made to assess the extent to which
not interviewing these sixty-nine cases may have biased the
results of this study by comparing the interviewed group
with the non-interviewed group on variables from the
patient files which were known for all or for most cases.
Since age of patient, intelligence quotient of patient, sex
of patient, ethnic status of patient, and admission year
of patient were variables controlled in matching resident
and discharged groups, these variables were also investi
gated in relation to interviewed and non-interviewed
groups. In addition, the age of the patient at admission
was analyzed together with the education of the mother, the
education of the father, and occupational level of the
head of the household. The three socioeconomic measures
248
were selected because these variables proved to be so sig
nificant In differentiating the discharged and resident
groups, as Is discussed In Chapter VI.
Table 47 presents the results of these comparisons.
As can be seen, all differences on these variables can be
accounted for by chance. To the extent that other
variables investigated in this study are related to the
above, it may be concluded that the results of this study
were probably not significantly biased by the cases not
interviewed.
Contributions to Sociological Knowledge
Probably the most significant contribution which
this research makes to sociological knowledge is the find
ing that there are clear and significant differences by
social class in the way in which the retarded person is
perceived, in the way in which he is treated, in his route
to the hospital, and in his probability of being dis
charged. These findings lend support to the broad area of
social theory which holds that behavioral norms vary by
social class and that social classes have different life
styles. They reemphasize the necessity of taking into
TABLE 47
CHI SQUARE VALUES WHEN INTERVIEWED AND NON-INTERVIEWED GROUPS ARE COMPARED
ON SEX OF PATIENT, ETHNIC STATUS OF PATIENT, I.Q. OF PATIENT, AGE OF
PATIENT, ADMISSION COHORT OF PATIENT, AGE AT ADMISSION OF PATIENT
EDUCATION OF PATIENT* S FATHER, AND OCCUPATION OF
HEAD OF THE HOUSEHOLD IN THE PATIENT'S FAMILY®
Chi Square Degrees of Level of
Variable Value Freedom Significance
Sex of patient .4 1 Not significant
Ethnic status of patient .02 2 Not significant
I.Q. of patient .65 2 Not significant
Age of patient 3.09 2 Not significant
Admission cohort .89 2 Not significant
Age at admission of patient .65 2 Not significant
Education of patient's mother 1.45 2 Not significant
Education of patient's father 1.35 2 Not significant
Occupation of head of household 2.38 2 Not significant
aA regular Chi Square model using a 2 x 2 table was used to calculate the Chi Square
value of differences in sex of the patient. The Kolomogorov-Smirnov Two-Sample test
was used for all other variables. Data on which the values reported in this table
are based are in Appendix B, Tables 61, 62, 63, 64, 65, 66, 67, 68, and 69.
249
250
account social status variables whenever a study is made
of human behavior.
In addition, this study contributes to sociological
knowledge of methods by which intrapsychic phenomena may
be studied empirically. Coding of the direction of blame
for retardation as an operational method for the study of
guilt proved feasible and productive. Although the find
ings from the Fels Scale ratings did not show significant
differences between the groups studied in this project, the
technique itself was shown to be a useful way to secure
behavioral ratings when comparisons between members of the
same family are desired.
The study made significant contributions to the
sociology of the family in that it showed that consan
guinity is a significant factor in the ability of the
family to adjust to deviant behavior in a family member
and that instability of the marital relationship is more
disorganizing on lower status levels than higher levels.
Need for Future Research
The type of study done in the current project for
patients discharged from Pacific State Hospital needs
251
to be done for patients discharged from other hospitals.
This would make It possible to determine If the social
status differences, the attltudlnal differences, and dif
ferences in family structure found in this study are also
characteristic of patients discharged from other hospitals.
A more thorough analysis is needed of variables
within social status levels. The findings of this study
seem to indicate that the processes leading to institu
tionalization and to discharge are quite different for the
high status retardate as compared to the low status re
tardate. Realizing the importance of social status, future
studies could be designed to allow for adequate samples on
all status levels. This would make it possible to deter
mine how factors influencing discharge vary by status level
and within status level.
Longitudinal studies are needed so that the complex
interrelationship of behavior and attitudes can be un
raveled. The various strategies which the family uses when
it faces the problem of having a retarded child need to be
studied, and the consequences to the family resulting from
the use of these strategies need to be evaluated.
APPENDIX A
253
(Letter sent to families of Resident Group)
STATE OF CALIFORNIA
DEPARTMENT OF MENTAL HYGIENE
PACIFIC STATE HOSPITAL
POMONA, CALIFORNIA
The hospital is continually striving to improve its
services. One of the ways this is being done is through
its Research Program.
At this time, an effort is being made to learn more about
how families and relatives of patients feel about the hos
pital. We need your help in this project. We are planning
to interview families and relatives of a carefully selected
group of patients who are representative of the total
hospital population. That is how you came to be chosen.
All information gained in the study will be kept completely
confidential. No names will be used in any report. You
need not worry that any information will make a difference
in a patient's hospital status.
A research assistant will be calling you within the next
few days to make an appointment to see you at your con
venience. We need your help. Your feelings and reactions
to the hospital can assist in making its program more
effective.
Sincerely yours,
Harvey F. Dingman, Ph.D.
Project Director
254
(Letter sent to families of Discharged Group)
STATE OF CALIFORNIA
DEPARTMENT OF MENTAL HYGIENE
PACIFIC STATE HOSPITAL
POMONA, CALIFORNIA
The hospital is continually striving to improve its
services. One of the ways this is being done is through
its Research Program.
At this time, an effort is being made to learn more about
how families and relatives of former patients feel about
the hospital. We are also interested in knowing how these
patients are doing now.
We need your help in this project. We are planning to
interview families and relatives of all patients who were
discharged during a three-year period. That is how you
came to be selected.
All information gained in the study will be kept completely
confidential. No names will be used in any report. You
need not worry that any information will make a difference
in a former patient's discharge status.
A research assistant will be calling you within the next
few days to make an appointment to see you at your con
venience. We need your help. Your feelings and reactions
to the hospital can assist in making its program more
effective.
Sincerely yours,
Harvey F. Dingman, Ph.D.
Project Director
255
(Letter thanking all respondents)
STATE OF CALIFORNIA
DEPARTMENT OF MENTAL HYGIENE
PACIFIC STATE HOSPITAL
POMONA, CALIFORNIA
We wish to thank you for receiving our Research Assistant
so cordially when she called on you recently, and for being
so generous with your time and assistance. It is only
through your help that we are able to find out how families
feel about the hospital and what we can do to improve our
services.
We also appreciate your taking the time to fill out the
Inventory of Attitudes on Family Life and Children. We
know that this required effort and thought. With your
help we hope to gain a greater understanding of American
families.
Thank you again for the help you have given us.
Sincerely yours,
H. F. Dingman, Ph.D.
Project Director
APPENDIX B
257
TABLE 48
DISCHARGED GROUP COMPARED WITH RESIDENT GROUP
BY PATIENT INTELLIGENCE QUOTIENT
Intelligence Quotient Discharged Resident
0-9 2 4
10-19 2 1
20-29 4 3
30-39 6 4
40-49 13 15
50-59 14 18
60-69 19 19
70-79 3 4
80-89 1
90 and over 1
Total 63 70
X2 = .33, 2 df, p > .05
258
TABLE 49
DISCHARGED GROUP COMPARED WITH RESIDENT GROUP
BY YEAR OF BIRTH
Year of Birth Discharged Resident
Before 1920 4 5
1920 - 25 6 6
1926 - 30 7 6
1931 - 35 10 14
1936 - 40 23 20
1941 - 45 7 13
1946 - 50 5 4
1951 - 55 1 1
1956 - 60 0 0
1960 + 0 1
Total 63 70
X2 = .045, 2 df, p > .05
259
TABLE 50,
DISCHARGED GROUP COMPARED WITH RESIDENT GROUP
BY YEAR OF ADMISSION
Year of Admission Discharged Resident
Before 1943 2 5
1943 - 44 3 4
1945 - 46 8 5
1947 - 48 3 5
1949 - 50 9 4
1951 - 52 6 10
1953 - 54 10 11
1955 - 56 17 10
1957 - 58 3 7
1959 - 60 2 9
Total 63 70
X2 = 3.39, 2 df, p > .05
260
TABLE 51
FAMILIES OF DISCHARGED AND RESIDENT PATIENTS COMPARED
ON SOCIOECONOMIC RATINGS USING A MODIFICATION
OF THE HOLLINGSHEAD SYSTEM®
Socioeconomic Scores Discharged Resident
14-24 1 6
25-34' 1 3
35-44 1 6
45-54 2 7
55-64 3 8
65-74 12 10
75-84 16 11
85-94 7 11
95-104 12 3
105-114 8 5
Total 63 70
X2 = 11.94, 2 df, p < .01
aLow Scores indicate high status.
TABLE 52
A COMPARISON OF THE HEALTH RATINGS GIVEN MOTHERS AND FATHERS
OF DISCHARGED AND RESIDENT PATIENTS
Health Rating
Mother or Mother Substitute® Father or Father
J--' 1 1 ■J' l
Substitute
Discharged Resident Discharged Resident
0 - Deceased— None 1 1 4 7
1 - Invalid 0 2 2 1
2 - Partially Invalid 7 5 3 4
3 - Mild Complaints 24 24 6 7
4 - Good Health 31 38 27 31
Unknown 0 0 21 20
Total 63 70 63 70
SX2 = .33, 2 df, p > .05
bX2 = .15, 2 df, p > .05
261
TABLE 53
A COMPARISON OF THE HEALTH RATINGS GIVEN MOTHERS AND FATHERS
BY SOCIAL STATUS
Health Rating
Mother or Mother Substitute8 Father or Father Substitute^
High Status Low Status High Status Low Status
0 - Deceased— None 0 2 5 6
1 - Invalid 1 1 0 3
2 - Partial Invalid 8 4 2 5
3 - Mild Complaints 20 28 9 4
4 - Good Health 37 32 33 25
Unknown 0 0 17 24
Total 66 67 66 67
ax2 = .66, 2 df, p > .05
bX2 = 2.98, 2 df, p >.05
262
263
TABLE 54
HEALTH RATINGS GIVEN MOTHERS OF PATIENTS
AS RELATED TO AGE OF MOTHER®
Health Rating Born 1910 or Before Born After 1910
0 - Deceased--None 2 0
1 - Invalid 2 0
2 - Partial Invalid 8 4
3 - Mild Complaints 27 20
4 - Good Health 34 34
Unknown 0 0
Total 73 58
X2 = 2.25, 2 df, p > .05
aYear of birth was unknown for two cases.
264
TABLE 55
NUMBER OF DIVORCES OF THE BIOLOGICAL MOTHERS
OF LOW STATUS PATIENTS RELATED
TO YEAR OF BIRTH OF MOTHER®
Number of Divorces Born 1910 or Before Born After 1910
None 27 13
One 9 9
Two 2 2
Three 1 0
Four 0 0
Never Married 0 2
Total 39 26
X2 = 2.18, 2 df, p > .05
^ear of birth was unknown for two cases.
265
TABLE 56
THE RELATIONSHIP BETWEEN SOCIAL STATUS AND
AWARENESS OF RETARDATION
Awareness High Status Low Status
No Awareness 2 10
Partial Awareness 15 21
Full Awareness 48 36
Unknown 1 0
Total 66 67
X2 = 5.29, 2 df, p > .05
266
TABLE 57
THE RELATIONSHIP BETWEEN SCORES ON THE SOCIAL
PARTICIPATION INDEX AND SOCIAL STATUS
Social Participation
Score High Status Low Status
0 13 15
1 11 14
2 19 24
3 12 4
4 7 7
5 3 2
6 0 1
Unknown 1 0
Total 66 67
X2 = 2.66, 2 df, p > .05
TABLE 58
DISCHARGED PATIENTS COMPARED TO RESIDENT PATIENTS ON PHYSICAL HANDICAPS
CONTROLLING FOR SOCIAL STATUS
Number of
Physical
Handicaps
Total Group Compared
by Social Status® High Social Status^ Low Social Status0
High Low
Discharged Resident Discharged Resident
0 33 37 16 17 24 13
1 12 14 3 9 9 5
2 6 12 2 4 4 8
3 7 2 1 6 0 2
4 2 0 0 2 0 0
5 2 2 1 1 2 0
6 3 0 1 2 0 0
7 1 0 1 0 0
Total 66 67 24 42 39 28
®X2 = 3.99, 2 df, p > .05
bX2 = 4.42, 2 df, p > .05
CX2 = 2.87, 2 df, p > .05
267
TABLE 59
THE RELATIONSHIP BETWEEN PHYSICAL HANDICAP AND THE PERSON
IMPORTANT IN PLACEMENT
Person Important
in Placement
No Physical Handicap
fo fe
Some Physical Handicap
fo fe
Total
Relative 18 22.63 25 20.37 43
Government 27 21.58 14 19.42 41
Schools 10 7.89 5 7.11 15
Medical 11 14.21 16 12.79 27
Other 4 3.68 3 3.32 7
Total 70 63 133
X2 = 6.85, 4 df, p >.05
268
TABLE 60
THE RELATIONSHIP BETWEEN SOCIAL STATUS AND PERSON
IMPORTANT IN PLACEMENT
Person Important
in Placement
High Social Status Low Social Status
Total
fo fe fo fe
Relative 20 21.34 23 21.66 43
Government 11 20.35 30 20.65 41
Schools 8 7.44 7 7.56 15
Medical 23 13.40 4 13.60 27
Other 4 3.47 3 3.53 7
Total 66 67 133
X2 = 22.59, 4 df, p < .01
269
270
TABLE 61
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY SEX OF PATIENT
Sex Interviewed Non-Interviewed
Male 93 45
Female 40 24
Total 133 69
X2 = .4, 1 df, p > .05
271
TABLE 62
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY ETHNIC STATUS
Ethnic Status Interviewed Non-Interviewed
Caucasian 80 42
Negro 17 9
Mexican 36 18
Total 133 69
X2 = .02, 2 df, p > .05
272
TABLE 63
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY INTELLIGENCE QUOTIENT OF THE PATIENT
Intelligence Quotient Interviewed Non-Interviewed
0-9 6 0
10-19 3 5
20-29 7 4
30-39 10 8
40-49 28 14
50-59 32 17
60-69 38 14
70-79 7 6
80-89 1 0
90 and over 1 1
Total 133 69
X2 = .65, 2 df, p > .05
273
TABLE 64
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY AGE OF PATIENT
Year of Patient’s
Birth
Interviewed Non-Interviewed
Before 1920 9 6
1920 - 25 12 7
1926 - 30 13 13
1931 - 35 24 13
1936 - 40 43 19
1.941 - 45 20 6
1946 - 50 9 5
1951 - 55 2 0
1956 - 60 0 0
1960 + 1 0
Total 133 69
X2 = 3.09, 2 df, p > .05
274
TABLE 65
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY YEAR OF ADMISSION
Year Interviewed Non-Interviewed
Before 1943 7 8
1943 - 44 7 2
1945 - 46 13 4
1947 - 48 8 8
1949 - 50 13 7
1951 - 52 16 7
1953 - 54 21 8
1955 - 56 27 17
1957 - 58 10 5
1959 - 60 11 3
Total 133 69
X2 = .89, 2 df, p >.05
275
TABLE 66
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY AGE OF PATIENT AT ADMISSION
Age at Admission Interviewed Non-Interviewed
2-4 2 1
5-9 16 8
10-14 40 22
15-19 44 18
20-24 12 8
25-29 9 3
30-34 5 5
35-39 4 1
40-44 1 2
44 + 0 1
Total 133 69
X2 = .65, 2 df, p > .05
276
TABLE 67
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY EDUCATION OF THE MOTHER
Education of Mother Interviewed Non-Interviewed
None 7 2
Grammar School
(through 8th grade) 52 29
High School
(not graduated) 23 5
High School Graduate 23 8
College (not graduated) 7 4
College Graduate 6 4
Graduate School 1 0
Unknown 14 17
Total 133 69
X2 = 1.45, 2 df, p > .05
277
TABLE 68
COMPARISON OF INTERVIEWED AND NON-INTERVIEWED GROUPS
BY EDUCATION OF THE FATHER
Education of Father Interviewed Non-Interviewed
None 8 4
Granxnar School
(through 8th grade) 42 25
High School
(not graduated) 19 5
High School Graduate 16 7
College (not graduated) 11 4
College Graduate 8 4
Graduate School 2 1
Unknown 28 19
Total 133 69
X2 = 1.35, 2 df, p >.05
278
TABLE 69
COMPARISON OF OCCUPATION OF HEAD OF THE HOUSEHOLD
OF INTERVIEWED AND NON-INTERVIEWED GROUPS
USING HOLLINGSHEAD'S CATEGORIES®
Occupation Interviewed Non-Interviewed
Higher Executives, Proprietors
of Large Concerns, Major
Professionals 5 1
Business Managers, etc. 9 3
Administrative Personnel, etc. 11 3
Clerical and Sales, etc. 17 5
Skilled Manual Employees 20 13
Machine Operators, etc. 27 11
Unskilled Employees 21 13
Relief, Unemployed, etc. 23 11
Unknown 0 9
Total 133 69
X2 = 2.38, 2 df, p > .05
August B. Hollingshead and Frederick C. Redlich, Social
Class and Mental Illness: A Community Study (New York:
John Wiley and Sons, Inc., 1958), Appendix II, pp. 387-397.
APPENDIX C
TABLE 70
CROSS-CLASSIFICATION FOR MATCHING DISCHARGED AND RESIDENT GROUPS
Caucasian (94) Mexican (40) Negro (18)
14 & 20 & 14 & 20 & 14 & 20 &
Below 15-19 Over Below 15-19 Over Below 15-19 Over
(8)
(10) (76) (0) (8) (32) (0) (2) (16)
Male
Below 40 IQ (14)
40-49
50-54 E E
C C
55-60 3E E E
3C C C
40-60 IQ (52)
40-49 3E 3E 2E
3C 3C 2C
50-54 5E 2E 3E
5C 2C 3C
55-60 E 2E E 3E E
C 2C C 3C C
Over 60 IQ (40)
40-49 5E
5C
50-54 7E E
7C C
55-60 5E E E
5C C C 280
TABLE 70”-Continued
Caucasian (94) Mexican (40) Negro (18)
14 & 20 & 14 & 20 & 14 & 20 &
Below 15-19 Over Below 15-19 Over Below 15-19 Over
(8) (10) (76) (0) (8) (32) (0) (2) (16)
Female
Below 40 IQ (18)
40-49 E E
C C
50-54 E E
C C
55-60 E 2E E E
C 2C C C
40-60 IQ (18)
40-49 2E E 2E
2C C 2C
50-54 E 2E
C 2C
55-60 E
C
Over 60 IQ (10)
40-49 2E
2C
50-54 2E
2C
i
55-60 E
1
C
(N = 152; E = 76; C = 76)
281
282
Coder___________________ Date of Coding^
Experimental Control_____
(1) Current Case Number__________________
(2) Name_________________________________
Last First Middle
(3) Date of Patient's Birth:
________month________ day year
(4) Date of Admission:
________month ________ day year
(5) Race:
1. _______Caucasoid
2._________Negroid
3. _______Mexican
4. _______U.S. Indian
5._________Chinese, Japanese, Filipino
6._________Other (Specify)____________
(6) Sex:
1. ______male
2._________female
(7) Age at admission
_______year months days
(8) Religion: (Specify)
1. _________________
2. unknown
(9) I.Q.
(10) Diagnosis:
1._________Undifferentiated
2. _______Familial
3. _______Trauma
4. _______Epilepsy
5. _______Mongolism
6. _______Other (Specify)_____
7._________Unknown
(11) Birth year of Biological Mother:
1. _______
2. unknown
(12) (If parent is Step-Mother, answer)
Birth year of Step-Mother:
1. ____
2. unknown
(13) Mother's age at admission:
1. _______
2. unknown
(14) Mother's age at discharge:
1. _______
2. unknown
(15) Birth year of Biological Father:
1. _______
2. unknown
(16) (If parent is Step-Father, answer)
Birth year of Step-Father
1. _______
2. ______ unknown
(17) Father's age at admission:
1. _______
2. unknown
(18) Father's age at discharge:
1.
2. unknown
284
(19) Date of Discharge:
______month _______ day_______year
(20) Condition at Discharge:
1. _______Age tinder 15
2._________Over 15, capable self-support
3._________Over 15, partially capable
4. _______Over 15, incapable
(21) Time on visit, indefinite leave, directly preceding
discharge:
_______days
(22) Time in PSH under this case number, excluding time
on visit, indefinite leave, etc.
_______years ______ months _______days
(23) Relative to whom discharged: Specify relationship:
(24) Name and most recent address of relative to whom
discharged:
Name____________________________
Last First Middle
Number Street
City County
(25) Children in patient's home--list from oldest to
youngest with patient in his proper birth order on
the list:
Full Age Age
At Birth or Re- Ad- Dis-
Name Home Sex Year Half tarded mitted charged
285
(26) What is the social worker's perception of the chief
reasons for hospitalization?
1.
2.
3.
4.
Place a check before any problem mentioned on the blue
pages by the social worker as having been involved in the
case, including those listed above.
(27) Interaction with Parents
1. Conflict or tension with father
2. ___Conflict or tension with mother
3. Physical attack on parent
4. Mother hasn't time for rest of family because
of care of child
5. ___Child hard to control and discipline
6. Mother exhausted by care of child
7. Mother in poor health
8. Father in poor health
9. Other (specify)
(28) Interaction with Siblings
1. Overt conflict with siblings, attack
2. Tension, hostility to sibs, more covert
3. __Vague disturbance with sibs, not specified
4. Sibs exhibit shame at having retarded child
in family
5. Sibs resent toother's attention to retarded
child
6. Sibs resent having to care for retarded child
7. Other (specify)
(29) Interaction Outside Family
1. ___Conflict or physical attack on neighborhood
children
2. Public masturbation
286
3._____Sexual activity with outsiders
4. Neighbors complain about child
5._____Police been called because of child
6._____Child does not get along with other children
in school
7._____Child failing in school work
8._____No schooling available for child
9._____Other (specify)_________________
(30) Physical Care Problems
1._____Cost of maintaining child too great
2. Parents fear child will have no one to care
for him
3._____Child wanders from home
4._____Child destructive of property and possessions
5._____Parents never able to get out together because
of child
6. ___Parents unable to take vacation because of
child
7._____Child needs attention at night
8._____Shopping made difficult by child
9._____Family meals disturbed by child
10. ___Toileting problems--enuresis
11. ___Other (specify)_____________
(31) Does Patient Have Police Record?
1._____yes
2._____none mentioned
If ’ ’ yes," specify:
1. Crime against property________________________
2. Crime against persons_
(32) Was patient committed to PSH by the Juvenile Hall
or the Juvenile Courts?
1. ___yes
2. no
(33) Patient's School Achievement:
1. ___No formal schooling
2. ___Attended regular classes in public school
(a) until what age or grade:
3. Attended special classes in public school
(a) until what age or grade:
4. Attended private school
(a) until what age or grade:
5. Schooling unknown
(34) Was patient attending school at time of admission?
1. ___yes
2._____no
3. unknown
(35) Age at which retardation was first noted:
1.
2. _______unknown
(36) By whom was retardation first noted?
1. _______________________________
2. _______unknown
(37) Level of self-help of patient:
(check "yes" or "no" for each statement)
yes no
1._____ ___ Can patient walk unaided?
2. ___ ___ Is patient toilet trained?
3. ___ ___ Is patient free of seizures?
4. ___ ___ Can patient feed self?
5. ___ ___ Can patient dress self?
6._____ ___ Can patient talk distinctly?
288
(38) Does patient have any major physical handicap?
1. ___no
2. ___yes (specify)______________
(39) Previous placement:
1. No previous institutionalization
2. ___Private hospital for mental deficients
3. Public hospital for mental deficients
4. Youth Authority or County Institutions for
Delinquents
5. ___Other (specify)_________
(40) Nature of Legal Relationship to Parents
1. ___illegitimate birth
2. ___legitimate birth
3. ___adoptive
4. unknown
(41) Who is the principal caretaker of the child at time
of admission by relationship?
1. mother (biological)
2. ___biological father
3._____step-mother
4. ___step-father
5._____other (specify)____________
(42) Marital status of parents at time of application
1. Parents married and living together
2. Parents separated
3. Parents divorced— neither remarried
4. Parents divorced— mother remarried
5. Parents divorced— father remarried
6. ___Both parents deceased
7. Father deceased— mother remarried
8. Father deceased— mother not remarried
9. Mother deceased— father remarried
10. Mother deceased— father not remarried
11. ___Other (specify)______________________
(43) With whom was patient living prior to admission?
1. ___both biological parents
2._____biological mother only
3. ___biological father only
4. ___biological mother and step-father
5. ___biological father and step-mother
6. ___other (specify)__________________
(44) Education of Mother
1. None
2. __Grammar School
3. High School, not graduated
4. __High School graduate
5. College, not graduated
6. College graduate
7. Graduate School
8. Unknown
(45) Education of Father
1. None
2. __Grammar School
3. High School, not graduated
4. High School graduate
5. College, not graduated
6. College graduate
7. __Graduate School
8. Unknown
Dependency Status of Parents
1. financially independent
2. supported by relatives
3. agency supported
4. unknown
(47) Principal breadwinner at admission time
1._____Father
2. ___Mother
3. ___Other (specify)_________________
290
(48) Occupation of Father
(49) Employment of Mother at time of admission
1. Employed 40 hours or more per week
2. Employed 20-39 hours per week
3. Employed less than 20 hours
4. Not employed outside home
5. Unknown
(50) Amount of Family Income
1. per month
2. unknown
Health of Principal Caretaker
1. Normal
2. Poor physical health
3. Evidence mental deficiency
4. Evidence mental illness
5. ___Mother pregnant
6. Unknown
291
INTERVIEW SCHEDULE
COMPOSITE SCHEDULE FOR DISCHARGED AND RESIDENT GROUPS
(Study- of Discharges from Home Leave to Relatives)
1. Case Number ________________________
2. Patient's Name __________________________
First M. Last
Anticipated Respondent:
3. Name ____________________________________
First Last
4. Relationship to Patient:
1. natural mother
2. step-mother
3. adopted or foster mother
4. grandmother
5. aunt
6. female cousin
7. natural father
8. step-father
9. other (specify)
5. Address of Anticipated Respondent:
Number Street
City County
Nearest Cross-Street
6. Telephone:_________________
Alternative Addresses or leads from the Patient File:
292
First Letter________Phone Call________PARI Returned________
7. Record of Appointments and Calls at Household
Appt. 1 Call Completed? 3 Call Completed?
Date Yes No Yes No
Time
Appt. 2 Call Completed? 4 Call Completed?
Date Yes No Yes No
Time
Reason for Non-Interview
1. Refusal
2. Moved— Unable to Locate
3. In sample by mistake
4. Respondent not available
Specify:
5. Other: Specify:
Comment on Non-Interview:
293
NOTE TO RESPONDENT: "Good morning (afternoon)! I’m from
the Sociology Department of the University of Southern
California. (Show identification letter attached.) We
are conducting a study, with the help of Pacific State
Hospital. We want to find out how the people of California
who have had relatives in a state hospital feel about the
hospital and whether they think the hospital is doing a
good job. We, of course, cannot interview everyone who has
ever had a child in the hospital, but we will be talking
to all those who have discharged a patient in a three-year
period about their experiences with their children. We
would appreciate it greatly if you would assist us by
telling us of your opinions. The answers you give to the
questions will be confidential and will be used only for
the purpose of tabulation. This will not affect the
patient's discharge in any way."
INFORMATION ABOUT PATIENT
(For Discharged Group Only)
1. I understand that you have a son/daughter, etc. who
was once a patient at Pacific State Hospital.
After______ left the hospital, where did he/she live?
(Residential Movement of Patient after Discharge)
Where did With whom?
he/she live? (name) (relation) How long?
2. (If "No," ask:) Where is he/she living now?
0 no response
1 relative (specify)
2 by self
3 ___spouse
4 mental hospital
5 Atascadero
6 ___private hospital for retarded
7 returned to PSH or other public hospital for
retarded
8 other (specify)
PATIENT'S WORK HISTORY
(For Discharged Group Only)
Did he/she attempt to find work outside home?
0 no response
1 yes
2 no
Does he/she have a job now? (Probe: What kind of
work is he/she doing? Sheltered workshop, part-
time , newspapers ?)
0 no response
1 yes
2 no
Work history since discharge: (Start with first job
following discharge)
Type How Long?
work? From To Wages? How found job? Why quit?
How many hours a week is he/she currently working?
0 no response
1 20 or less
2 ___21 to 39 hours
3 ___40 or more hours
4 don't know
5 unemployed
Current Income: __________Hourly
__________Weekly
.Monthly
295
PATIENT’S SOCIAL HISTORY
(For Discharged Group Only)
8. Who are his/her best friends?
Name Sex Former Patient?
9. Has he/she gotten married since he/she left hospital?
Probe: To whom? Former patient?
0 no response
1 no
2 yes
3 don't know
10. Is he/she married now?
0 no response
1 married
2 single
3 divorced
4 separated
5 mate deceased
6 don’t know
11. Does he/she have any children since discharge?
How many?
0 no response
1 no
2 yes (Number)______
12. Does he/she belong to any clubs or organizations?
List names? Patient organization? (Yes-No)
0 no response
1 yes
2 no
296
13. How Is patient's health since discharge? Seizures?
Other Illness? (Verbatim)
14. Is patient happy since discharge? (Verbatim)
0 no response
1 yes
2 no
3 don't know
15. Does patient want to return to hospital?
0 no response
1 yes
2 no
3 sometimes
4 don't know
CARETAKER PROBLEMS
16. Is _______ a financial burden?
17. Has _______ presented behavior problems?
18. Is _______ emotional burden?
19. Caretaker's health?
a. Mother's (female caretaker's health)--note
especially mental illness, alcohol, drugs, cardiac
problems, overweight)
b. Father's health?
20. What use are you making of community resources?
a. Special classes in schools?
b. Parent clubs for exceptional children?
c. Aid from handicapped children's organizations,
Kiwanis, etc.
21. What do you see in the future for ________?
297
HOSPITAL IMAGE
Well, to start with, we know that you have had some experi
ence with Pacific State Hospital, since _______ was there
for a while, and we would like to know what you think of
the hospital.
22. What do you think of the state hospital? (verbatim)
23. How did the hospital take care of _______when he/she
was sick? Was it very good, rather good, rather poor,
or very poor?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
24. How do the people on the wards treat the patients?
Is it very good, rather good, rather poor, or very
poor?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don’t know
25. How is the food that patients get?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
26. How does the hospital treat parents of patients?
0 No response
1 Very good
2 Rather good
298
3 Rather poor
4 Very poor
5 Don’t know
27. What do you think of the way the hospital grants home
leaves for patients?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
28. How is the schooling which the patients get at the
hospital?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
29. What do you think of the ward _______ was on in the
hospital?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
30. What do you think of the way the hospital handles the
money sent to patients by their parents?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
299
31. How is the clothing provided by the hospital for
patients?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don't know
32. What do you think about the way the hospital gives
work duties to patients around the hospital?
0 No response
1 Very good
2 Rather good
3 Rather poor
4 Very poor
5 Don*t know
33. While ________ was in the hospital you probably got
to know some of the people who work there. Who do
you remember best?
34. Probe: Do you remember his/her name?
Name:______________________
0 No response
1 Yes
2 No
35. What did he/she do at the hospital?
0 No response
1 Don*t know
2 Specify job:
300
36. Do you remember him/her as being friendly, unfriendly,
or in-between?
0 No response
1 Friendly
2 In-between
3 Unfriendly
37. (If respondent answered above question in "friendly"
end of continuum, word following question "unfriendly"
and vice versa.) Who do you remember as the most
friendly/unfriendly person you got to know at the
hospital?
0 No response
1 Nobody was friendly /unfriendly
2 Specify ___________
38. What was his job with the hospital?
0 No response
1 Don't know
2 Specify____________
39. After ________ was in the hospital, what changes did
you notice in the way he/she acted?
0 No response
1 No change
2 Specify____________
40. Was he/she worse than before, better than before, or
about the same?
0 No response
1 Worse
2 About the same
3 Better
4 No change
41. What changes, if any, did you notice in his/her
general health?
0 No response
1 No change
301
42. Was his/her general health better than before, worse
than before, or about the same?
0 No response
1 Worse
2 About the same
3 Better
4 No change
43. (HOSPITAL IMAGE CARDS)
People see Pacific State in different ways. On these
cards are written different ways people see it.
Read them through and tell me which way you see
Pacific State most. Now, which is next most like
you see Pacific State? Next?
(Read following with respondent if he/she has diffi
culty reading: This is the order of the cards.)
Rank 1
Rank 2
Rank 3
Rank 4
Rank 5
1. A place to keep child until the
family is able to take him back.
2. A reform institution to teach child
to keep out of trouble.
3. A permanent home for the child.
4. A school to educate child.
5. A hospital to give child medical
care.
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49. How much does his/her
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44. Now, I’d like you t o think back to the time when was first admitted to
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51. Did your _____ know
______ was/is in the hos
pital?
0. No response
1. Yes
2. No
3. Don't know
4. Deceased
5. No such relative
52. If answer ’ ’ no," ask:
How often do you see or
write him/her?
0. No response
1. Every day
2. Couple times a week
3. Couple times a month
4. Few times a year
5. Less once a year
6. Never
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53. How did/Joes he/she
feel about _ being
in the hospital? Was he/
she favorable, opposed,
or uncertain?
0. No response
1. Favorable
2. Opposed
3. Uncertain
4. Don't know
5. Didn't care
54. How much does his/her
opinion matter to you?
Is it very important,
somewhat important, or
unimportant?
0. No response
1. Very important
2. Somewhat important
3. Unimportant
4. Don't know
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(Relationship
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51. Did your know
was/is in the hos-
plt'aT?
0. No response
1. Yes
2. No
3. Don't know
4. Deceased
5. No such relative
52. If answer "no,” ask:
How often do you see or
write him/her?
0. No response
1. Every day
2. Couple times a week
3. Couple times a month
4. Few times a year
5. Less once a year
6. Never
53. How did/does he/she
feel about being
in the hospital? Was he/
she favorable, opposed,
or uncertain?
0. No response
1. Favorable
2. Opposed
3. Uncertain
4. Don't know
5. Didn't care
54. How much does his/her
opinion matter to you?
Is it very important,
somewhat important, or
unimportant?
0. No response
1. Very important
2. Somewhat important
3. Unimportant
4. Don't know
305
55. Were there any other people, besides the ones men
tioned, whose opinions about ' s being in the
hospital mattered to you? (Use "Other” category and
code as before.)
56. How did you feel about putting _______ in the hos
pital? Were you for it, or against it?
0 no response
1 for it
2 against it
3 uncertain
4 didn't care
57. Who was the most important person getting you to
decide to place ______ in the hospital? (Probe:
Relationship or position)
0 no response
1 no one— decided myself
2 specify_______________
58. Was there anybody among your family and friends whom
you did not tell about ______ being in the hospital?
(Prove if "yes”) Who? Why was that?
0 no response
1 yes
2 no
59. As you think back to the time when _______was first
admitted to the hospital and the time since, what are
some of the problems which you have had with him/her?
Probe: Were there any problems with you or your
husband? With his brothers and sisters? With other
children? With physical care? At school?
In neighborhood?
CHECK LIST
Parents
1 Conflict or tension with father
2 Conflict or tension with mother
3 Physical attack on parent
306
4 Mother hasn't time for rest of family because
of care of child
5 Child hard to control and discipline
6 Mother exhausted by care of child
7 Mother in poor health
8 Father in poor health
9 Mother working, can't watch child
Siblings
1 Overt conflict with siblings, attack
2 Tension, hostility to sibs, more covert
3 Vague disturbance with sibs, not specific
4 Sibs exhibit shame at having retarded child
5 Sibs resent mother's attention to retarded child
6 Sibs resent having to care for retarded child
7 Sex play with sibs
8 Bad influence on sibs
Child's General Behavior
1 Stealing
2 Setting fires
3 Runs away
4 Child molesting
5 Illegitimate pregnancy
6 Cruel to animals
7 Bed wetting
8 Toilet problems
9 Broke curfew
10 Destroys possessions and property
11 Sex activity with those outside family
12 Masturbation
Other: (verbatim)
Physical Care
1 Needs medicine hospital has
2 Needed medical care (specify)__________
3 Severe epileptic seizures
4 Cost maintaining child too great
5 No one to take care of child
6 Fear child will have no one to care for him
later on
7 Shopping made difficult by child
307
8 Parents can't take vacation because of child
9 Child needs attention at night
10 Meals disturbed by child
School
1 Truancy, won't go to school
2 Failed school work
3 No special classes available
4 School excluded him
5 Conflict with other children at school
Neighborhood
1 Neighbors complained about child
2 Conflict with neighborhood children
3 Child teased by neighborhood children
60. Was there any especially important event which
occurred just before ______ went to the hospital which
made you decide that he/she should go there?
(Verbatim)
(For Discharged Group Only)
61. What were the main reasons you decided to have ______
discharged from the hospital? Probe: Were there any
changes in the family that made a difference? Any
changes in _______ that made a difference? Anything
that happened in the hospital that made a difference?
Any changes in the care of ______ that made a differ
ence?
Family
1 Mother lonely without patient
2 Father lonely without patient
3 Didn't feel it was right to have him/her in
hospital
4 Mother remarried and can take care of him/her
now
5 Need patient to help support family
6 Parent understands him/her now
7 Relatives think he/she should be home
8 Father remarried and can take care of him/her
now
308
9 Parents able to watch him/her more closely now
10 Never wanted patient in hospital in first place
11 Parents separated, now patient can come home
12 Brothers and sisters grown up and gone
Patient
1 Patient acts better now at home
2 Found school for patient
3 Patient's health got worse in hospital
4 Patient found job
5 Patient acted worse in hospital
6 Patient wanted to come home
7 Patient's health is better now
8 Want patient to help at home, e.g., baby sit,
iron, garden, etc.
Other: Give verbatim report where necessary
Hospital
1 Social worker felt he/she should be out
2 Patient treated badly in hospital
3 Found another hospital for patient
Physical Care Factors
1 Moved too far from hospital to visit
2 Get veteran benefits if patient at home
3 Found somebody to take care of patient at home
4 Moved into larger house and have more space
5 Moved to new neighborhood
6 No way to get to hospital to visit
7 Get more money from state aid with patient at
home
8 Have more money now and can keep patient at home
62. Who was the most important getting you to take ______
back out of the hospital? Probe: Relationship or
position.
0 no response
1 no one, decided myself
2 specify_______________
309
63. Was there any especially important event which
occurred just before you took out of the hos
pital which made you decide to have him discharged?
(verbatim)
(For Resident Group Only)
64. Have you ever considered the possibility of taking
______ out of the hospital in the near future, say,
in the next year or so? (Probe: Yes or No Response)
Why? (Verbatim)
0 no response
1 yes
2 no
65. (If answer "no" to 64, ask:) Do you ever plan to
take ______ out of the hospital, say, sometime in the
more distant future? (Probe: Yes or No Response)
Why? (Verbatim)
0 no response
1 yes
2 no
66. Is there anyone in your family or among your friends
who thinks you should take ______ out of the hospital?
(If "yes": probe for relationship or position)
0 no response
1 no one
2 yes
67. Is there any especially important event which might
occur in your family--such as a death, a move out of
state, someone's leaving your household--which might
make you decide to have ______ discharged? (If answer
"yes": probe) What would that be? (Verbatim)
0 no response
1 none
2 yes
310
68. We know that there have been a lot of people who have
told you that _______ is retarded, but we would like
to know how you feel about this. Do you think ______
is retarded?
0 no response
1 yes (unequivocal)
2 yes (ambivalent)
3 uncertain— don’t know
4 no
69. Who was it who first noticed or told you that ____
was retarded?
0 no response
1 respondent noticed
2 father or step-father
3 medical doctor
4 relative (specify)_______
5 school (specify who in school)_______
6 police
7 other (specify)_______
70. How old was _______ then?
0 no response
1 don't know
2 age in years_______
71. What was it about that made you/them think
he/she was retarded? (verbatim)
0 no response
1 don11 know
2 age in years_______
72. What do you believe caused this? (verbatim)
311
Ask following four questions only if respondent replied
"yes" or "uncertain" to question 68.
73. Have you ever thought that something you did while
you were pregnant (carrying) with _______ may have
caused his/her problem? (Probe: If "yes")
What was that? (verbatim)
0 no response
1 yes
2 no
3 don't know
74. Have you ever thought that something you did while
_______ was still small may have caused this?
(Probe: If "yes") What was that? (verbatim)
0 no response
1 yes
2 no
3 don't know
75. (Probe:) I imagine you wonder why this happened to
you? (verbatim)
76. Do you believe there is anything which can be done
to change this condition? Probe: What? (verbatim)
FAMILY INTERACTION
Ask following questions only if respondent is not a parent
of patient.
77. What has happened to _______'s mother once he/she was
admitted to the hospital?
0 no response
1 deceased, when?_______
2 still living
312
Type
(legitimate-
Marriages Prom To common law)
1
2
3
Health: (note alcoholism, drugs, cardiac problems
especially)
Mobility:
78. What has happened to _______'s father since he/she was
admitted to the hospital?
0 no response
1 deceased, when?_______
2 still living
How ended?
Type (1-divorce
(legitimate- 2-separation
Marriages From To coranon law) 3-death)
1
2
3
Health: (note alcoholism, drugs, cardiac problems
especially)
How ended?
(1-divorce
2-separation
3-death)
Mobility:
313
79. How did you happen to be the one to arrange for
' s discharge? (verbatim)
FAMILY INTERACTION
Ask following questions only if respondent is a parent
of patient.
80. Present marital condition of biological parents.
0 no response
1 parents married and living together
2 parents separated
3 parents divorced— neither remarried
4 parents divorced— mother remarried
5 parents divorced— father remarried
6 both parents deceased
7 father deceased— mother remarried
8 father deceased— mother not remarried
9 mother deceased— father remarried
10 mother deceased--father not remarried
11 other Specify:______________________
81. How long have you been married to present spouse?
0 no response
1 length in years
82. Have you been married more than once?
0 no response
1 yes
2 no
If married more than once get marital history.
How ended?
Marriage From To 1-divorce; 2-separation; 3-death
1
2
3
314
83. Did _______ have anything to do with breaking up any
of your marriages? (verbatim)
84. Did _______ have anything to do with your deciding
to get married any of these times? (verbatim)
85. Now, I would like to ask you some questions about the
place where _______ lived when________was first
admitted. What kind of place was it: a single family
house, a duplex or apartment, a trailer, or what?
0 no response
1 single family house
2 duplex
3 apartment
4 rooming house
5 trailer
6 other (describe)__________
86. How many rooms were in that house/apartment?
(Count a kitchen as a room, but do not count bath
rooms, garages, or halls.)
0 no response
1 one room
2 two rooms
3 three rooms
4 four rooms
5 five rooms
6 six rooms
7 seven rooms
8 eight rooms
9 nine or more rooms
87. Was that place owned, being bought, rented, or
what?
0 no response
1 owned
2 buying
3 rented house
4 rented apartment
5 other (specify)_______
315
88. Have you moved since _______was admitted to the
hospital?
0 no response
1 yes
2 no
If answer is "yes," ask:
89. What is/was the place like you were living at time
of discharge? Was it a single family house, a duplex
or apartment, a trailer, or what?
0 no response
1 single family house
2 duplex
3 apartment
4 rooming house
5 trailer
6 other (describe)_______
90. How many rooms do you have? (Count kitchen but do
not count baths, garages, or halls.)
0 no response
1 one room
2 two rooms
3 three rooms
4 four rooms
5 five rooms
6 six rooms
7 seven rooms
8 eight rooms
9 nine or more rooms
91. Is this place owned, being bought, rented, or what?
0 no response
1 owned
2 buying
3 rented house
4 rented duplex or apartment
5 other (specify)___________
316
92. What relationship did your moving have on your
decision to have ______ discharged from the hospital?
Did it help you decide to have him/her home because
you had more room, because you were too far from the
hospital, or what? (verbatim)
0 no response
1 no effect on discharge
93. How many times has the patient's mother been pregnant
since _______ was admitted to the hospital? What
years?
0 no response
1 year_______
2 year_______
3 year_______
4 year_______
Do not ask following questions if respondent is separated
or divorced.
We are interested in knowing how often husbands and wives
in families like yours think and talk about the possi
bility of a separation or divorce.
94. Have you ever day-dreamed about what your life would
be like if you were not married?
0 no response
1 yes
2 no
95. Have you ever thought about plans for what you would
do if you were to get a divorce or separate from
your husband?
0 no response
1 yes
2 no
317
96. Have you and your husband ever talked about
separating?
0 no response
1 yes
2 no
97. Have you ever wished that you had married someone
else Instead of your husband?
0 no response
1 yes
2 no
98. Have you ever talked with your friends or relatives
about the advantages you would enjoy if you were
to separate from your husband?
0 no response
1 yes
2 no
99. Have you and your husband ever talked about how your
property would be divided in case of a separation
or divorce?
0 no response
1 yes
2 no
100. At the present time, who is the principal breadwinner
in your family?
0 no response
1 husband
2 wife
3 none, public assistance
4 none, retired
5 other (specify)
318
101. As you think about your marriage, would you rate it
as very happy, happy, average, unhappy, or very
unhappy?
0 no response
1 very happy
2 happy
3 average
4 unhappy
5 very unhappy
102. How many times since your marriage have you lived
apart from your husband/wife as a result of bad
feelings between you?
0 no response
1 one or more
Spec i fy_______
2 never
103. As you think about the future of your marriage, how
certain are you that it will last until one of you
dies? Are you absolutely certain it will last,
rather certain it will last, rather certain it will
not last, or absolutely certain it will not last?
0 no response
1 absolutely certain it will last
2 rather certain it will last
3 rather certain it will not last
4 absolutely certain it will not last
104. Now, we would like to know something about some of
your interests. Do you belong to a church?
0 no response
1 no church
2 Protestant (specify)
3 Catholic
4 Jewish
5 other (specify)
319
105. During the past year, about how often have you gone
to church?
0 no response
1 no church
2 once a week
3 once every two weeks
4 once a month
5 a few times a year
6 not at all
106. Do you belong to any clubs or organizations? Which
ones? Are you very active, somewhat active, or
inactive in each of them?
Name of Organization Activity
0 no response
1 none
2 total number
Rate Activity:
1 very active
2 somewhat active
3 inactive
107. When_______ first went to the hospital, were you
working? About how many hours a week did you
work?
0 no response
1 don't know
2 no job
3 ___20 or less hours per week
4 ___21-39 hours a week
5 ___40 or more hours a week
320
108. When _______ was discharged, were you working?
About how many hours a week did you work?
0 no response
1 don't know
2 no job
3 ___20 or less hours per week
4 ___21-39 hours a week
5 ___40 hours or more a week
(Ask questions 109 and 110 if not the biological mother
of patient.)
109. In what year were you born? _______
110. How many years of school were you able to complete?
111. At the present time, who is the principal breadwinner
in your family?
0 no response
1 husband
2 wife
3 none--public assistance
4 none--retired
5 other (specify)________
112. What is the principal breadwinner's occupation?
Probe: What exactly does he/she do on his/her job?
0 no response
1 _______
(Ask question 113 only if Hollingshead Classification
not clear.)
113. What kind of business or industry does he work in
usually? (If necessary: "For example, a garage,
a store, a school. . . .")
321
114. (Probe) Does the principal breadwinner work for
someone else or does he have his own business or
practice?
0 no response
1 work for someone else
2 work for self
115. (Probe) What is the name of the company or employer
of the principal breadwinner?
0 no response
1 _____________________________________________________________
116. During the past 6 months, about how many hours a week
has he/she been employed?
0 no response
1 none (unemployed)
2 less than 10 hours a week
3 ___11-39 hours a week
4 ___40 or more hours
5 none (retired)
6 other___________
117. (If unemployed) what is the source of your income?
118. What was the occupation of the principal bread
winner's father? Probe: What exactly did he do
on his job?
0 no response
1 don't know
2 ______________________________________
119. How many years of school did the principal bread
winner's father complete? (Don’t count kinder
garten. )
0 no response
1 don't know
2
322
(Ask questions 120-124 only if principal breadwinner
is not a biological parent.)
120. How many years of schooling has the principal bread
winner completed? (Don't count kindergarten.)
0 no response
1 don't know
2 ____________
121. What year was the principal breadwinner born in?
0 no response
1 don't know
2 __________
122. (Note the oldest sibling of same age and sex as the
patient. If no "same sex sibling/' use opposite sex
sibling but make note.)
0 no response
1 no siblings
2 opposite sex sib (reply)
3 ___________________
123. How many years of regular schooling has your
son/daughter_______ completed? (Give in years not
counting kindergarten.) (If below 20 years of age
change wording to: How many years of schooling would
you like your son/daughter to complete?)
0 no response
1 don't know
2 __________
124. What kind of work is he/she doing now? Probe: What
exactly does he/she do on his/her job? (If unem
ployed: What kind of work did he/she do when he/she
was working?”) (If tinder 20 years of age: What kind
of work would you like to see _______ do?)
0 no response
1 don’t know
2
323
FEMALE ROLE CARDS
(Skip if interviewing male)
125. We would like to know what you most enjoy doing.
On these cards are written different activities that
most women like to do. I'm going to give you the
cards two at a time. Pick out the activity you
would most enjoy doing of the two and put that card
here. The card you would least enjoy, put here.
Sometimes you will like both activities and it will
be hard to choose, but try to make a choice anyway.
(Present paired comparison cards, two at a time
until all have been separated.) Put rubber band
around chosen ones and place in folder. Place "not
chosen" ones loose in folder. Record choices
following interview on following scale.
These are the proper pairs: Score:
Pair 1 1-2 Pair 6 3-5 Role 1
Pair 2 3-4 Pair 7 2-3 Role 2
Pair 3 3-5 Pair 8 1-4 Role 3
Pair 4 1-3 Pair 9 4-5 Role 4
Pair 5 4-2 Pair 10 1-5 Role 5
People have different ideas about how family members should
act toward each other. Please tell me the extent to which
you agree or disagree with the following statements.
126. It is best that a man and wife confide in each other
regarding all things.
0 no response
1 completely agree
2 agree somewhat
3 disagree somewhat
4 disagree completely
127. People should always get together with relatives on
holidays and other important special occasions.
0 no response
1 completely agree
324
2 agree somewhat
3 disagree somewhat
4 disagree completely
128. Children should be included in all activities of
a family.
0 no response
1 completely agree
2 agree somewhat
3 disagree somewhat
4 disagree completely
129. A family should eat together at least twice a day.
0 no response
1 completely agree
2 agree somewhat
3 disagree somewhat
4 disagree completely
130. A husband and wife should often go out together
without the children.
0 no response
1 completely agree
2 agree somewhat
3 disagree somewhat
4 disagree completely
131. A father should take care of the children when the
mother wants some time to herself.
0 no response
1 completely agree
2 agree somewhat
3 disagree somewhat
4 disagree completely
132. Having children is the most important thing that
can be done by a married woman.
0 no response
1 completely agree
325
2 agree somewhat
3 disagree somewhat
4 disagree completely
133. How often does _______ go shopping with you?
0 no response
1 frequently
2 occasionally
3 seldom
134. When you go on a family trip that will keep you
overnight, how often do you take ________with you?
0 no response
1 frequently
2 occasionally
3 seldom
135. When you go to visit relatives, how often does
_______ go with you?
0 no response
1 frequently
2 occasionally
3 seldom
136. How often does _______ go with you to church or
other community activities?
0 no response
1 frequently
2 occasionally
3 seldom
137. When you go to visit friends, how often does ____
go with you?
0 no response
1 frequently
2 occasionally
3 seldom
326
FELS SCALE--RETARDED CHILD
138. On the next page are some lines. You notice that at
the bottom of the line is a word, for example, weak.
At the top of the line is the exact opposite of that
word like, strong. Now we want you to think of this
line as if it were a thermometer and you are going
to place _______where you believe he belongs on this
line. For example, if _______ is very strong, you
would place him near the top of the line and make a
mark. Or if he is weak, you would place him near the
weak end. If he is neither very weak nor strong,
you would place him near the middle. Do you under
stand? Here is a pencil so you can make the mark on
each of these lines where you think _______ belongs.
FELS SCALE— OTHER CHILDREN
139. Now, here is a paper with lines exactly like the ones
on the paper you just finished. But this time, we
would like you to think about the "other children"
in your family. We want you to make a mark on each
line where you believe the other children fit.
(Be sure to mark which scale is for patient with a "P" and
the other children scale with "0"--put case number on
each.)
Now, just one more thing before we finish. As you think
about _______ and his/her experience at Pacific State
Hospital,
140. If you had it to do over again, would you send
him/her to the hospital?
0 no response
1 yes (absolutely)
2 yes (ambivalent)
3 no
4 uncertain— don’t know
Strong
Weak
(Scale used for retarded child or for other children in the family)
Handsome
Good or Pretty Gentle Friendly Loving Unselfish Obeys
Bad Ugly Rough Unfriendly Unloving Selfish Doesn't
obey
327
328
141. If you had a friend with a child who needed to go
to the hospital, would you advise them to send the
child to Pacific State?
0 no response
1 yes (absolutely)
2 yes (ambivalent)
3 no
4 uncertain— don't know
142. Do you ever plan to return _______ to Pacific State
Hospital sometime in the future? (verbatim)
0 no response
143. (HOSPITAL RATING) On the next page is a line like
the ones you used before except this time we want
you to rate the hospital on how good it is. If you
think it is very good, put a mark near the top; if
you think it is very bad, put a mark near the bottom.
If you think it is somewhere in the middle, put a
mark there.
144. PARI
HOUSING UNIT EVALUATION
145. Housing unit type:
0 single detached
1 single attached
2 duplex
3 triplex
4 apartment (4 or more)
5 trailer
6 rooming house
7 other (describe_______
329
High
Low
330
146. Housing unit condition:
0 rundown
1 average
2 above average
147. Is the street on which the respondent lives:
0 mainly single family detached houses
1 mainly single attached houses
2 mainly duplexes or triplexes
3 mainly apartment houses
4 mainly rooming and boarding houses
5 mainly trailers
6 other (describe) _________________
148. Is the street on which the respondent lives:
0 mainly residential
1 mainly residential and commercial
2 mixed residential and industrial
3 mixed commercial and industrial
149. Does the street on which the respondent lives have:
0 heavy through traffic, including commercial
vehicles
1 light through traffic, mainly private cars
going to and from houses
2 mainly local residential traffic
150. Describe the economic status of the respondent's
street:
0 luxury apartments or private homes worth
$25,000 or more
1 expensive apartments, homes $15-25,000
2 nice apartments, homes from $10-15,000
3 working class apartments, homes less than
$10,000
4 low income housing, deterioration present
331
INTERVIEW EVALUATION
List of household goods and equipment which were on the
check list for rating level of consumption of discharged
and resident families:
Draperies
Overstuffed chair in good condition*
Overstuffed couch in good condition*
Major portion of floor covered by carpet
End table
Floor or table lamps In good condition*
Television set
Fireplace
Telephone
Patio or outdoor barbecue
Swimming pool
Present at interview:
0 respondent only
1 children under six (number)_____
2 older children (number)_____
3 spouse
4 parents
5 other relatives (number)_____
6 other adults (describe)______
Cooperation was:
0 very good
1 good
2 fair
3 poor
If there was anything unusual about the interview situation
which you think affected the respondent's answers, tell us
about it here.
*Good Condition was defined as having unbroken, un
spotted upholstery and no noticeable broken springs in the
case of the overstuffed furniture. Good Condition for
lamps was defined as having an unbroken lamp shade and
stand.
BIBLIOGRAPHY
BIBLIOGRAPHY
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Caldwell, Betty, and Guze, Samuel B. "A Study of the
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Farber, Bernard. Effects of a Severely Mentally Retarded
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Publications of the Society for Research in Child
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Flory, Mary C. "Helping Parents Train Their Retarded
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Frankel, E. "The 1400 Who Entered New Jersey Institutions
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Freeman, Howard, and Simmons, Ozzie. "The Use of the
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Frisch, Florence. "Factors in the Decision of Parents to
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Grebler, Anne. "Parental Attitudes Toward Mentally
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Asset Metadata

Creator Mercer, Jane Ross (author)

Core Title An Analysis Of Factors In The Family'S Withdrawal Of A Patient From A Hospital For The Mentally Retarded

Contributor Digitized by ProQuest (provenance)

Degree Doctor of Philosophy

Degree Program Sociology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,sociology, individual and family studies

Language English

Advisor Peterson, James A. (committee chair), Meyers, Charles Edward (committee member), Sabagh, Georges (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-281896

Unique identifier UC11358810

Identifier 6304236.pdf (filename),usctheses-c18-281896 (legacy record id)

Legacy Identifier 6304236.pdf

Dmrecord 281896

Document Type Dissertation

Rights Mercer, Jane Ross

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA