How Shall We Treat the Children in the 21st Century?

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How Shall We Treat the Children in the 21st Century? CLARICE J. KESTENBAUM, M.D. INTRODUCTION:HOW IT WAS

My father was graduated from the University of Colorado Medical School in 1910. He was 24 years old, the youngest in his class of 50 (there were no female graduates). In 1960, the same year I was graduated from UCLA Medical School, he attended his 50th-year ciass reunion in Denver. Adding his 56 years in medical school and practice to my 44 years of training and practice, I can present a personal history of medicine in the 20th century. My father‘s internship and residency was simple. He apprenticed himself to a senior physician for 3 years and, following him from patient to patient, delivered babies, performed surgery, and counseled the dying. There were few instruments. Clysis was the standard treatment for ascitesdiabetes was fatal. Intravenous needles were not yet in use. Medications were few-morphine, aspirin, phenobarbital. Physical diagnosiswas an art-listening to the chest wall to diagnose a tubercular lung or examining earlobes, conjunctiva, and nail beds for anemia provided the answers. Surgical gloves were just beginning to be used for operations and obstetrical deliveries. There were no rules to govern many decisions, such as whether to inform patients of an anencephalic newborn. Such ethical decisions had to be made on the spot, without consultation. My father’s hero was William Osler, who was convinced that he who knows syphilis knows medicine. Thomas Eakins’ paintings depicted the bedside scenes and anatomy lessons “the way it was,” with beauty and sensitivity. Patients at the beginning of the century had one thing we rarely have today-a family doctor whom they revered and trusted, who made house calls day or night, and who listened to their troubles. Accepted September 2, 1999. Dr. Kestenbaum is Profissor of Clinical Pycbiatry, Columbia Univenity, College of Physicians and Surgeons, New %k, and Director o f Training, Division of Child and Adolescent Pycbiatry, Columbia University, College of Physicians and Surgeons, New York. Reprint requests to Dr. Kestenbaum, 15 West 81 Street, 14B, New Erk, NY 10024. 0890-856710013901-0001 02000 by the American Academy of Child and Adolescent Psychiatry.

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My father moved to Los Angeles in 1926 and began a practice in South Central Los Angeles, Boyle Heights, and later, Watts. He never left. An attending physician at Los Angeles County Hospital, he became a “specialist” in the treatment of venereal disease-syphilis and gonorrheatreating such patients with urethral soundings, arsenical, and bismuth lavage. He devoted his time to the poor and disadvantaged and never moved his practice to more f l u e n t neighborhoods. I remember the joy he experienced when penicillin was first used. “This is a miracle,” he said, and the miracle drugs indeed changed the face of medicine. As a child I used to visit my father in his office. I would peek through the crack in the doorway while he administered his treatments, or I would enter his private “museum” to gaze at a 100-pound ovarian cyst in formaldehyde, a 2-headed fetus, and other manifestations of nature’s mistakes. During the depression years he often did not get the usual $2 and $3 fees but instead came home with an apple pie, a live chicken, a watch chain, or a radio, until the patients could retrieve them for cash. Our attic was 111. “It‘s not good for a man’s self-respect if he can’t give you something, and the treatment won’t be as effective,” he told me, a true freudian concept. He had little respect for psychiatry and did not tell anyone that I was becoming a psychiatrist, not a “real doctor,” for 2 years. Nevertheless I observed that he had his own version of the DSMat the top of some of his charts. I noted the letters NAT and AUS. “Oh, that‘s my note to myself that this patient is Not All There or Absent Upstairs,” he answered. In 1960 he received the award for Los Angeles humanitarian of the year. When he died in 1970, there were hundreds of people-former patients-at his funeral. Medical School Experience

My own medical journey was special in its own way. Before I decided on a medical career I had planned to become a pianist like my mother. I had majored in music and English literature at UCLA, but a course of psychoanalytic therapy with Dr. Leo Rangell (who had been a psychiatric resident at Columbia in the 1940s) convinced me that I should become a physician. I spent the first years of medical school in Israel before transferring back to 1

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UCLA to complete my training. Israel, after the war of independence, was an enormously exciting place. My teachers were refugees from Nazi Germany or Poland, world-famous researcher-physicians such as the immunologist Herman Zondek (pregnancy test), Saul Adler (tickborne fever), and other world leaders in medicine. The professors spoke a dozen languages, but few spoke Hebrew. The textbooks were British and American. My class counted 25 women out of 50 students. All had served in the army and were treated as equals with the men. As a medical student I observed insulin coma therapy, which was widely used for psychotic depression and schizophrenia,without much success, and I delivered Arab babies “in the field.” When I returned to UCLA, as 1 of only 4 women in a class of 50, I experienced a great deal of hostility from some of my male professors, who lost no time in letting me know in no uncertain terms that women belonged at home. Nevertheless I persevered, and after an internship (the only female intern at the VA Hospital in Los Angeles), I came East to Columbia and never looked back. Psychiatric Training

Psychoanalysis in the 1960s was at the height of its popularity. Most of the residents in my class entered a psychoanalytic institute or at least engaged in a course of psychoanalytically oriented therapy I was trained in both adult and subsequently child analysis and found the experience the most valuable part of my training. That conviction remains, although I have not practiced so-called classical analysis for years. At the same time, great advances were being made in psychopharmacology.My first manic patients were restrained in ice baths to keep them calm. Lithium therapy was in its infancy. Because of the new neuroleptics, the state hospitals began to empty out. Unfortunately, the community mental health centers and residential facilities could not meet the patients‘ needs. Thus began the homeless mentally ill population, still so prominently with us. I decided to become a child psychiatrist during my general residency training at Columbia. The field of child psychiatry has developed from many diverse paths and directions. A relatively new subspeciality, board certification, was instituted in 1959. Many of the early pediatrician-psychiatrists, such as Benjamin Spock and David Levy, set the tone of clinical practice and clinical research for decades to come. I remember David Levy’s approach to psychiatric measurement in the days before questionnaires and structured 2

interviews existed. His personal scale to determinewhether a mother was showing an appropriate response to her infant at the initial well-baby visit was to say to the mother who was holding her child, “Oh Mrs. Smith, what a lovely little girl you have there.” If the mother looked at her baby and smiled while he offered the compliment he knew that bonding attachment would occur; if she did not look down or looked depressed or upset, he knew that something was wrong. He would make a little note on the chart that the mother may need mental health services by the next visit. My own professor of child psychiatry, Wiiam Langford, was trained as a pediatrician and general psychiatrist. Our training was relatively informal, and those of us who decided to follow his footsteps had nonetheless to ‘play it by ear.” There were no formal standards for residency training, each program specializing in whatever the professor knew best. Trainees at Bellevue had the good fortune to learn about childhood schizophrenia on site from Loretta Bender and Barbara Fish. I probably learned more about the Riley-Day-Langford syndrome (dysautonomiaor crying without tears) than anything else, since it originated with us. Training was catch-as-catch-can. The 2 or 3 child psychiatry fellows had dozens of fascinating cases to discuss with a half-dozen supervisors and attending physicians. We had the luxury of keeping a case as long as we wanted; we had no managed care, Medicaid forms, or DRGs to contend with; our notes read like novels--full of speculation, fantasy, hyperbole, and sometimes a thoughtful, analytic discussion of all the facts that led to Johnny’s inability to control his cursing or cure his inordinate fear of dogs. Many of us met in small groups in the evening to read and review important child psychiatric papers. We taught ourselves and we taught each other, and we learned how one case could be treated in a variety of wayspharmacologically, behaviorally, or psychoanalyticallydepending on the favorite approach of a particular supervisor. We even participated in a rabbinical exorcism of a schizophrenic girl who was convinced that the dybbuk of her dead twin possessed her. My colleagues developed the ability to work in teams as well as “do it all yourself,” including initial psychological testing, social service intake, and home visits. At the same time, 30 years ago, while child fellows were learning how to treat children with emotional problems by the trial-and-error method, many of us were beginning to demonstrate our expertise to those even less experienced than we were. It was the year of paraphrasing the

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surgical intern’s motto, “see one, do one, teach one.” The child psychiatry fellows were called upon to teach the general residents, medical students, and pediatricians and to consult with schools and agencies after a few months of training (Kestenbaum, 1987). The Real World

The day I was graduated I accepted a job at the Hudson Guild as consultant to the therapeutic nursery, a position formerly held by none other than Margaret Mahler. That was an impossible act to follow, but I read everything I could about symbiotic psychosis and separation disorders and soon developed my own consultation style. I was supposed to conduct a weekly child development didactic seminar as well as to discuss any clinical problem that a teacher presented. Parent groups met from time to time as well. After a year I became reasonably comfortable with lecturing to small groups. My experience with the preschool children and their teachers convinced me of the necessity of early intervention in order to prevent psychopathology in later childhood. One of my first papers was titled, “By Three It‘s Two Years Too Late,” a view I never forsook (Kestenbaum, 1973). Because my practice was small, I took a job, first as Director of the Consultation Service at St. Luke’s Hospital and later as a Director of the Division. In those days most hospitals would not permit parents to stay overnight with preschool children or to remain with them during the better part of the day Bowlby’s work on the sequelae of in-hospital separation from parents had not yet been accepted by the pediatric community in the United States.There were no child-life programs that prepared children for tonsillectomies and herniorrhaphies. Many of us did presurgical play therapy with the pediatric patients. We lectured to general practitioners on the emotional care of hospitalized children and to mental health workers from our consortium of community agencies on “the best time to refer to a child psychiatrist,” or “how long do you wait for a child to outgrow it?” During those early postgraduate years I did a fair amount of medical student teaching. A group of general residents made a film in which they interviewed hospitalized children. The natural style of the residents coupled with the open responsiveness of the young patients served to make the film a unique way to teach the adaptive and maladaptive coping mechanisms of children in stressful situations. The videotape was the first in a series of a dozen or so child development tapes made at the New York State Psychiatric Institute. These tapes on early and middle childhood, ado-

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lescence, parenting, and assessment became superior training tools (Kestenbaum, 1991). Psychosocial research in psychiatry, especially child psychiatry, was in its infancy. Systematic research in the 1930s and 1940s had attempted to investigate Freud’s theories of particular personality constellations: Is breastfeeding better than bottle-feeding?Is self-demand feeding more likely to produce a nonneurotic personality than rigid scheduling? Are there links between toilet training and anal character?Mothers were blamed for everything, including autism. In fact, there is no evidence to show that specific infant care practices have an unvarying psychological effect in later years; rather, parental style covering many aspects of child rearing, not a single event (i.e., primal scene), was implicated. A second wave of research activity was devoted to the study of mothering as a set of attitudes. During the 1950s and early 1960s parental attitudes were identified, measured, and related to characteristics of child behavior. The greatest upset in children resulting from severe toilet training was found when the training was combined with a cold, undemonstrative attitude on the part of the mother. These results, however, were not replicable. Thus, neither signal events nor parents’ attitudes were enough to explain personality attributes. What was left out of the equation was the role of the child, his particular constitutional makeup, and his specific effects on his caretaker. Many physicians of that era had difficulty identifying their roles according to their view of medicine as either “art” or “science.” The attempt to integrate the 2 domains of psychology and neurology was unsuccessful. The attempt at a marriage of mind and brain was, at best, a shotgun wedding, polarized by opposing, even feuding factions. In 1973 my colleague Hector Bird and I were invited by L. Erlenmeyer-Kimling, the principal investigator, to participate in a follow-up study of children at high risk for schizophrenia. We were asked to develop a childhood assessment instrument (the Mental Health Assessment Form) for the project (Bird and Kestenbaum, 1988).One of the initial goals of the high-risk study was to identify endophenotypic “markers” that flag the genetic liability to schizophrenia. There has been considerable progress, both in these studies and in research on other relatives and population groups, toward establishing several such markers. In the New York High Risk Project, for example, we focused on childhood attentional dysfunctions and their association with certain psychiatric and psychological outcomes in adolescence and young adulthood in

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the different risk groups (Erlenmeyer-Kimling et al., 1995; Kestenbaum et al., 1989). Through my interest in high-risk research, I engaged in a study of children vulnerable to affective illness. It seemed clear that certain precursors of manic-depressive disorder could be identified in childhood or adolescencebefore the onset of the first full-blown episode. Such individuals, I believed, demonstrate the lack of a central inhibiting regulatory mechanism that may become manifest under stress. Later research proved this to be the case (Kestenbaum, 1992, 1994). In 1984 David Shaffer invited me to become theTraining Director of the Division of Child and Adolescent Psychiatry at Columbia. I honed my teaching skills and broadened my interest in program development. At the same time, together with my colleague Ian Canino, whose chief interest was cultural diversity, I founded CARING at Columbia, a creative arts community program for children at risk. As a clinician I continued to treat patients and their families. The combination of clinical practice, research, and community outreach gave me the breadth and depth of experience I needed to train others. In that capacity I became actively involved with the Academy, my professional home for the past 25 years. The Academy

The American Academy of Child Psychiatry was “born” in 1953 (“Adolescent”was not added to the name until 1987 during the presidency of Jerry Wiener). We are celebrating our 46th Annual Meeting this year. From 100 child psychiatrists looking for a professional forum, the membership has grown to nearly 7,000, with links to many other organizations and disciplines. The Academy’s primary goal was to serve its members and by doing so, to serve society. During the years, as the members’ interests broadened and current societal issues presented themselves, special committees were formed. Today there are 64 components, including work groups and task forces that deal with our professional and societal problems: Community Systems of Care, Cultural Diversity, Health Care Reform and Financing,Training and Education, to name but a fm. We have an Assembly consisting of 56 regional councils, currently in the process of consolidation and standardization of their administrative structure. We have a leading peer-reviewed scientific journal, a newsletter, and a publication for trainees, The Developmentor. From an office staff of one 46 years ago, the Academy has a 28-member staff that provides information and mate-

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rials to the membership and the public. We have an active public relations department and a government liaison that helps inform our legislators about child and adolescent concerns and advocates for children’s mental health needs. We provide our members with state-of-the-art Practice Parameters, Facts for Families, and the recently published set of books, Your Cbikdand YourAdolescent, which have received well-deserved praise. The Academy provides assistance to young career investigators and offers numerous awards to medical students, general residents, and child and adolescent residents. The greatest change in the AACAP has been the advent of the Internet-ur Web page, currently 1,000 pages, is our greatest communication tool, with 2 million hits in 1998. The jewel in our crown, I believe, is our Annual Meeting, so rich in state-of-the-art institutes, symposia, and workshops. HOW IT IS

The field of medicine has changed so dramatically during the past century, my father would barely recognize this Brave New World. Communication is instantaneous. Who would imagine the technology allowing us to perform cardiac bypass, heart and liver transplants, whole hand grafts, in vitro fertilization? We have eradicated diphtheria, polio, tuberculosis, and smallpox (that is, until new resistant strains appeared defying traditional drugs). Modern genetics has developed so rapidly that soon we will have the map of the human genome. Brain imaging and molecular biology have made brain research into a hard science so that we can study the factors that predispose to stress and depression. Gene-environment interaction can now be studied with far greater precision. New developmental theories can be tested, notably the study of attention and memory. ‘X key contribution that biology can now m&e-with its ability to image mental processes and its ability to study patients with lesions in different components of procedural memory-is to change the basis of the study of unconscious mental processes from indirect inference to direct observation”(Kandel, 1999, p. 5 11). As I noted earlier, there is ever-increasing evidence that many disorders are genetically determined, such as bipolar disorder, major depression, and panic disorder. Recently Siever has written that personality traits may have their origin in innate predispositions, as well as from early learning and ongoing developmental influences (Siever et al., 1990; Siever and Davis, 1991). The past decade has brought about new developmental models for melding

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mind and brain. Steven Hyman, Director of the NIMH, recently stated that the fundamental insight of the last decade in neuroscience and molecular biology is an understanding of the way genes and the environment interact in complex and inseparable ways (Hyman, 1998). The work of Hyman and others revolutionizes the understanding of normal and pathological development and links molecular biology and behavior so as to render the mind-brain dichotomy moot. The salient point in the emerging understanding of the brain is plasticity, that the ability to learn and change is brain-based, so that at any given moment there is a complex mix of one’s genome and environmental interventions. We know now that psychotherapy and medication both act on the brain to change behavior, brain neurophysiology, and neurochemistry. There is evidence from human and animal studies that early experience affects psychophysiological and neurobiological regulation. Using Bowlby’s theoretical framework (1969), theoreticians such as Stern (1985) and Fonagy and Target (199 1) have concluded that interpersonal experiences with early caregiver-child relationships can facilitate or impair the development of the capacity for reflection, the substrate for self-awareness, and the ability to process information about oneself and others. Scientific revolution is not the only one; we have had a social revolution as well. The prejudice against women in medicine, while subtly still present, is far less than it was during my medical school days.The same can be said for minorities (soon to become the majority) and individuals with alternate lifestyles, namely gay and lesbian families. More fathers are sharing childbearing duties with their wives than ever before. Our country is affluent, despite the growing disparity between haves and have-nots. So why do we still have so many problems--violence, child abuse and neglect, alcohol and drug abuse, homelessness, increasing divorce rates-and what can we, in the Academy, do about them? The Facts: A Brief Overview of Health Care

At the first White House Conference on Mental Health last June, the following facts were distributed: Status. There are currently 12 million children and adolescents who suffer from a mental disorder out of a total of 70 million individuals below age 18. Only 20% of those in need of psychiatric services receive treatment. Despite radical changes in the delivery of health care, 19 million children and adolescents are uninsured. Whrkj%rce.There are approximately 8,000 child and adolescent psychiatrists practicing in the United States.

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Federal medical specialty advisory boards recommended the need for 22,000 additional child and adolescent psychiatrists a decade ago. The shortage is accentuated for rural youths and those who are at the greatest risk for mental disorders (Thomas and Holzer, 1999). Financing. There are serious limitations in funding for medical education, and support is decreasing, further threatening training programs. Service. Children and adolescentswith serious emotional disorders need many kinds of services from a variety of sources; many managed care systems are not coordinating or paying for these services, which include a continuum of treatment modalities. Parity. At the present time most managed care companies practice discriminatory coverage, limiting the number of inpatient and outpatient visits. Research. Despite major breakthroughs in neuroscience and behavioral medicine, the number of researchers in child and adolescent psychiatry remains incredibly small: 55 at the present time. Violence Violence takes precedence over love. It took (and takes) the immigrants to tell us that we live in a violent land; that the violence is not caused by “the other,” but is in us all; and that there may be both a remedy and consolation, but that we cannot recognize, let alone enjoy, either, until we correctly understand and frankly admit the nature of our day-today lives (Mamer, Make Believe Town, 1996, p. 91).

Facts. There are 192 million privately owned firearms in the United States, 1 for each adult American. Two million are military style weapons. We are the most violent industrialized nation, with more guns per capita than any other country. Youth violence has become a public health hazard. Almost one half of violent crimes are committed by young males, who make up only 8% of the population (Steiner and Stone, 1999). Shootings such as the ones at Moses Lake, Washington; Pearl, Mississippi; Paducah, Kentucky; Jonesboro, Arkansas; Springfield, Oregon; and Littleton, Colorado, are nearly unknown in other countries. Adolescence is the time of the greatest risk for victimization as well as violence. Some studies report that 20% of inner-city males reported a family member being beaten or robbed in the past year. Three million children were reported as having been maltreated or abused; 33% of violent crime victims are children under the age of 19. Hundreds of recent publications have attempted to deal with the multiple causes of violence, individual and societal. “Violence,juvenile delinquenq, and related psychopa5

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thology are problems in which research, clinical practice, public policy, and activism intersect” (Steiner and Stone, 1999, p. 233). There is no need for pessimism, however, according to the report of the GAP committee on preventive psychiatry: The complex problems of youth violence and its origins must be approached from an epidemiological perspective, considering both risk and protective factors. This model stands in strong contrast to the single event hypotheses often used by clinicians. Risk factors for violent behavior include the following: the presence of violence in the home or neighborhood, alcohol abuse, involvement in drug trade, gun possession, criminal activities, and association with older delinquent adolescents and/or adults (Group for the Advancement of Psychiatry, 1999, p. 237).

WHAT IT WILL BE On-Site School Mental Health Programs

Is there one solution to the myriad problems facing us in the future? Of course not, but if we conceptualizea system of care that provides service to millions of people in an environmentally stable setting, namely, the school, we can, in large part, achieve our goal. “The idea of developing health and medical programs through schools has historical precedents dating to 1892 with the inception of a public health program delivered to schools in New York City” (Adelson, 1999). During the past 2 decades mental health services have been added to primary health care in schools. These school-based health centers are intended to improve access to care. “By virtue of their comprehensiveness, and integration with school based community and social services, such health centers are intended to improve problem finding, treatment, and health and social outcomes among underserved youth” (Earls et al., 1989, p. 1001). Since 80% of children with mental and emotion problems are not treated by traditional techniques, we need new models of service delivery for primary and secondary prevention of mental illness. I first learned about the value of school-based services in my consortium days at St. Luke’s Hospital in 1975. Paul Levine, at that time a social worker from the Children’s Aid Society, directed a clinic in an urban public housing project and noticed that the children referred to the clinic failed to keep their appointments, preferring after-school recreation to the therapy sessions. “I decided to adopt what I have come to refer to as the Willie Sutton Theory of Children’s Mental Health,” he said. “When reporters asked Willie Sutton, the notorious bank robber of the 1930s, why he robbed banks, he answered, ‘that’s where the money is.’ If you wanted to provide mental health services 6

to children, I reasoned, you had to go where the children were: in the schools!” Of our 80,000 schools attended by 53 million students, there are approximately only 1,000 school-based health centers. Only half include mental health services. Current treatment interventions in those programs have focused on improving life slulls, problem-solving, and social networks for high-risk children and teenagers. Several mental health school intervention models have been studied. James Comer (1980) has described in detail his comprehensive school-based mental health program for New Haven inner-city children. Columbia College of Physicians and Surgeons is currently studying the effects of such intervention in school settings. There are also model programs in Dallas, Albuquerque, and Baltimore, among others, that illustrate that success is achieved because child and adolescent psychiatrists are working together with pediatricians, family physicians, psychologists, teachers, counselors, social workers, and others in multidisciplinary teams to help students. This success has been measured in the reduction in discipline problems, truancy, and absenteeism. With the Dallas model, in I year absences decreased by 25Yo and course failures by 31Yo, and in 2 years disciplinereferrals decreased by 95% (G. Pearson, personal communication, 1399). School administrators are pleased because their students are having academic success, which is one of their key goals. Parents are also pleased because their children have access to services at school that they might not otherwise have received. Equally important is that students feel good about themselves. The negative side to this success is that there are too few programs. The model I wish to describe in detail is the Community School of the Children’s Aid Society in New York City. Phil Coltof& the Executive Director, writes: The Children’s Aid Society was founded in 1853 to care for New York‘s poor and abandoned children. Today, we serve 100,000 children and families each year, with adoption and foster care services, health care, recreation, camping, preventive services, job placement and emergency food and shelter. We concentrate our work in New York City, but many CAS programs have become national models, including free school lunches, free day schools, PTAs and kindergartens. We have been involved in education since our beginning. In 1992, Children’sAid formed a n unprecedented partnership with the New York City Board of Education to establish a new model of public school in northern Manhattan-”community schools” that combine academics with full child and family services and are open 16 hours a day, six days a week, all year. Medical dental, mental health, recreation, supplemental education, teen programs, parent education, and camp programs all emanate from the school sites. Children line up at their doors at 7 in the morning, and have to be ushered out at night (Coltoff, 1997, p.4).

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In such a model there is a unique dovetailing of class work with after-school activities, creating a “seamless” learning day. There is a high level of parent involvement; mental health services are integrated, not fragmented. Stigma is practically nonexistent in such a setting. The program is not expensive. The society’s full-service fullyear program costs about $850 per child per year (about $400 for health programs and $450 for extended-day, evening, weekend, and summer). This compares to New York City public schools spending $6,600 per middle school student for 9 months, 6 hours a day, Monday through Friday. By locating all child and family services in the school facility, schools and agencies also have the opportunity to save, or to direct more of their spending to services. The cost of failure-welfare, incarceration, or chronic ill health-is far greater than the cost of these preventive services. The country would be far better served if, instead of spending millions on school safety measures and SWAT teams, we instituted mental health programs in every school. The comprehensive full-service program I have described needs to begin in the preschool years. Three-yearold children learn the concept of “sharing” and respecting children different from themselves. Anti-bullying programs should start early. Researchers such as those in Norway and Finland who have studied bullying, “an act of physical aggression by a person against someone who is weaker, smaller, less popular or less secure,” agree that it is rarely a problem children can work out on their own (Kaltiala-Heino et al., 1999, p. 348). Bullies and victims need help from parents, teachers, and therapists. In school programs that deal specifically with the aggression toward others, bullying markedly declined (Olweus, 1994). In terms of emotionally ill students, underdiagnosed and undertreated, Coltoff notes: School based mental health services can be a line of defense against the emotional disorders that impede children’s learning. They can catch problems that potentially lead to violence and suicide, maybe even avert the devastating tragedy that occurred in Colorado this spring. But nationally our “state of readiness” is weak-with only one guidance counselor for every 1,000 schoolchildren, one social worker or school psychologist for every 2,500 (p. 4).

This summer, with a grant from the American Academy of Child and Adolescent Psychiatry, the Children’s Aid Society produced a film that focuses on a Depression Screening and Treatment Project (Shaffer et al., 1996). Thus far 1,500 of the student body totaling 1,800 have been screened.

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Juvenile Justice Reform

While I believe that primary and secondary preventive measures can nip in the bud incipient problems, there is a vast population of juvenile offenders who need our help. Available data indicate that the prevalence of mental disorders among juvenile offenders is high. Sixty percent of young people in the juvenile justice system have behavioral, mental, or emotional disorders, including many disabilities, and are in need of treatment. More than 2.7 million individuals under the age of 18 are arrested each year, and more than a million have formal contact with the juvenile justice system. Fifty percent to 75% of them have serious substance abuse problems (Cocozza, 1997). Along with several colleagues involved in juvenile justice reform, I visited several correctional health services. Horizon House, a new facility, was particularly impressive; it could serve as a model program for those children and adolescents who are awaiting adjudication. The program offers academic, psychological, and psychiatric evaluation, as well as school and recreational activities. An aftercare program involving 600 adolescents who were placed on probation was highly successful: recidivism after 1 year was only 2% compared with 40% to 50% at other centers. (Such follow-up programs are in short supply, and thus many adolescents given probationary status fall through the cracks.) Psychiatry in a Managed Care World

I would now like to address problems concerning the majority of our members, the child and adolescent psychiatrists in the real world. Despite major improvements in the delivery of psychiatric care within many HMOs, we still are faced with numerous problems, the parity issue being only one of them. Until recently, child and adolescent therapists did not have a body of research data from controlled studies with which to demonstrate the long-term results of treatment. The choice of therapeutic modality often reflected the therapists’ particular training and bias and was not related to the patient‘s diagnosis or cognitive developmental level. The last 2 decades, however, have brought a change in research methodology examining the effect of therapeutic interventions in adults. We have a growing body of data concerning the effectiveness of child and adolescent therapies as well as a deepening knowledge base concerning the biological foundations of many psychiatric disorders. Barnett has formulated the question concerning the effectiveness of psychotherapy: “Which set of proce7

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dures is effective when applied to what kind of patients with what kind of problems as practiced by what sort of therapist?” (Barnett et al., 1991, p.2). The recent developments in the areas of individual, non-behavioral, and non-cognitive psychotherapy represent a modest but positive turn in the development of the field of child and adolescent treatment. Researchers in child and adolescent psychotherapy are benefiting from following the adult model and asking similar or related questions regarding children and adolescentswho are participating in treatment. The field requires a systematic effort to develop an empirical base to further inform clinicians about their treatment and to inform society as a whole about expectations for treatment and the need for supportive financial resources for treatment. Previously, it was concluded that there had been multiple decades of anecdotal evidence of the usefulness of child psychotherapy and several decades of developing attempts to establish scientific legitimacy (Barnett, 1994, p. 474).

As Barnett implies, knowledge of each disorder should be based on scientific research. Several general principles apply to the practice of child and adolescent psychotherapy. It is not a genetic modality of treatment. Rather, it is diagnosis-specific. Diagnosis involves careful assessment of cognitive, familial, biological, and psychological factors. Child and adolescent psychotherapy is also essentially integrative, combining many modalities of treatment. Of the various disciplines of professionals who treat children, I feel that it is the child psychiatrist who can uniquely integrate these various approaches, particularly where diagnosis is concerned. The identity of the profession is influenced by the loss of the primary psychotherapeutic role for the psychiatrist over and above his or her role in prescribing medications. This is a profound loss for the field. Psychiatrist residents need training and experience in providing psychotherapy if they are going to be expected to refer to, supervise, and consult with many of the mental health professionals, especially social workers and nurses, who will be providing most, but not all, psychotherapy. Psychotherapy is not monolithic, and expertise in short-term and long-term dynamic, cognitive-behavioral, and supportive group and individual therapy is needed for the future of patient care. (Sharfstein, 1994, p. 448).

Three vignettes are representative of children with behavioral and academic problems at school. Each child needed a careful evaluation with specific treatment recommendations: although some of the symptoms seem to be identical, the underlying psychopathology is markedly different for each child. Roger, Jeff,and Armond were each 7 years old when they came for consultation. All 3 were referred by their schools for similar behaviors: distractibility, difficulty following through on instructions from teachers, failing to pay close attention to schoolwork, leaving their seats to wander around the classroom, difficulty waiting their 8

turn, blurting out answers to questions asked of other children, interrupting others, incessant talking, and restlessness. All the children were extremely bright and imaginative but had few friends, especially a close friend. The first 2 had warm and nurturing families, but Armond was in foster care, having had an extremely traumatic early life. A careful diagnostic evaluation in each case revealed that Roger suffered from an anxiety disorder following the accidental near-death of his father. Jeff exhibited all the features of classic attention-deficidhyperactivity disorder. Armond, having experienced multiple separations, child abuse, and depression, demonstrated symptoms of an attachment disorder, posttraumatic stress disorder, as well as a learning disability. All 3 needed specific treatments, tailor-made for them. A body of literature is developing on empirically validated psychosocial treatments (or evidence-based treatments), in which the findings demonstrated that there is not one single “best” psychotherapy modality, but different psychotherapeutic techniques that can be efficiently demonstrated. Whether the treatment of choice is cognitive, behavioral, dynamic, or a combined psychopharmacological intervention, more evidence-based research is needed. Managed care, if utilized well, can be effective. If we as physicians take charge there is, I believe, room for optimism. We do need an overhaul in our health care system. Forty-one million people are without any coverage whatsoever, and emergency room Band-Aid treatmentinstead of scheduled office or clinic visits-serves as a last resort for many. For the seriously mentally ill, managed care has thus far contributed to better continuity of care, with shorter hospital stays, day treatment including group and family sessions, followed by outpatient treatment frequently coordinated by the same mental health team. The role of the psychiatrist, however, needs to be redefined so that we will not be merely dispensers of medication but the primary leaders of active interdisciplinary teams that provide the initial diagnosis, formulate a tailormade treatment plan, and treat specifically selected patients with psychotherapy. Psychiatry is rich in new research findings, particularly with the advent of clinical trials, and psychiatrists have the database to make the most informed decisions. I am concerned, however, about the physician’s loss of authority to make informed decisions, the weakening of the foundation of optimal clinical care, particularly by not teaching young physicians the necessary skills to practice and teach psychotherapy. The American Psychiatric Association has expressed concern

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that psychotherapy skills will continue to atrophy under managed care. Sharfstein notes: The devaluing of psychotherapy is reinforced by market forces by limiting demand through high deductibles and co-payments and with an ever-expanding supply of Master’s- and Bachelor‘s-level psychotherapists. The de-skilling of psychotherapy is the inevitable consequence of these changes, as more and more “treatment” is provided by practitioners with no more than two years of experience (Sharfstein, 1994, p. 449).

Of course, nonmedical therapists (who far outnumber physicians) . . . will . . . continue to conduct much of the psychotherapy, often in consultation with psychiatrists: my message is not that these nonmedical therapists . . . do b55, but that we do more than merely prescribe and consult. We are in the unique position to conduct medical . . . psychotherapy because we are members of the most informed discipline in the biopsychosocial sphere. If we are not permitted to practice dynamic psychiatry we will have lost a major part of our professional identity, and the public at large will be the worse for it (Kestenbaurn, 1995, p. 513).

Back to the Future

I would now like to return to my original thesis, namely, that we have a lot to learn from “the good old days.” We have not had the family doctor who makes house calls since the 1940s. In the days before family disruption and the migration of the young to distant cities for job security, the older doctor was a good listener. The family doctor knew every member of a family as well as the family genes: who was vulnerable to which condition. He knew firsthand the family history. The young doctor of today knows the patient from disjointed test results and the briefest of histories. Except for the psychiatrist, there is no time to know the meaning of symptoms in the context of a patient‘s entire life experience. Despite our exciting new advances in medicine, the doctor-patient relationship has suffered. Split treatments, so commonly recommended in the managed care setting, are effective for many but by no means for all patients. Moreover, it is not true that split therapy is cheaper: It is more cost effective for psychiatrists to provide medication and psychotherapy to depressed patients than it is to split treatment between medical doctors and other mental health providers, according to a study began in 1995 (Goldman et al., 1998, p. 479).

Burton and Marshall (1999), for example, describe a case of a 39-year-old woman who had experienced severe psychological trauma. She had had multiple hospitalizations for suicide attempts, depression, and anxiety and had had many therapists. Her initial diagnosis, adjustment disorder, was changed over time from major depressive disorder to bipolar disorder. Her medications during this time

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included amitriptyline, buspirone, thioridazinr, lithium, bupropion, valproate, and trazodone. Her life was extremely chaotic. She had been in a split treatment with a nonmedical psychotherapist and a psychopharmacologist. Because of the complexity of her case, The patient was reevaluated and assigned to one psychiatrist for psychotherapy and medication management. The new psychiatrist used the Dissociative Evaluation Scale, and the patient’s diagnosis was reformulated to posttraumatic stress disorder. She had been repeatedly raped from age 6 by her alcoholic father and had chosen abusive men as lovers and husbands. The resident psychiatrist listened carefully to her as she described the traumatic events of her life and helped her to reconstruct a life narrative. Eventually she was able to stop taking all medication except for a small amount of fluoxetine. This patient’s condition improved when she finally found a physician who “listened,” so that she could be correctly diagnosed and treated with individual multimodal therapy. CONCLUSION

As we enter the 21st century, the Academy is faced with a challenging task: to improve the mental health care and

the well-being of wery child and adolescent. We are well equipped to try. With our solid infrastructure, we can chip away at the enormity of the problems-violence, prejudice, and inequality. We have made inroads in changing health care through advocacy. The Work Group on Schools and the Task Force on Juvenile Prison Reform are already working to achieve some of the plans I have outlined. The Work Groups on Health Care Reform and Community Based Systems of Care and the Task Forces on Ethics and Outcomes, as well as all our other components, are working hard to achieve their goals. Child and adolescent psychiatrists of the future, I believe, will combine the best of both worlds, the old and the new. They will demonstrate the passion for the wonderful changes in the years to come and compassion for their patients and their families. I thank you for electing me to serve as the Academy President as we enter the new century. REFERENCES Adelson SL (1999), Psychiatric public health opportunities in school-based health centers. In: Adohscent Pychiuty, Vol 24, Esrnan A, ed. Hillsdale, NJ: Analytic Press, pp 75-89 Barnett RJ (1994), Research updare in psychotherapy with children and adolescents. In: Review of Pqchiuty, Vol 13, Oldham M, Riba M, eds. Washington, DC: American Psychiatric Press, pp 473-492

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