for people to grow up in an environment which is not conducive to the developments of kinds of problems which we are faced with. Thank you, Mr. Chairman.

Mr. MCMILLAN. Thank you very much.

Mr. FOWLER. Mr. Chairman, Mr. John L. Johnson who is associate superintendent for special education in the D.C. schools would like to make just a brief statement.

Mr. JOHNSON. Thank you, Mr. Chairman, and members of the Committee.

I would emphasize the points already made in the testimony, that is, the part of the treatment of any child who is emotionally disturbed and mentally ill is that he has a right to public supported education suited to his needs.

The public schools in the District of Columbia, particularly in the public education department, as one of the newest departments has a gigantic responsibility to attempt to meet the needs of the more than 1500 children we know of and to build and develop a system of services which helps to prevent the kinds of problems we are here today speaking of.

My own particular field of expertise in special education began as a teacher in a psychiatric hospital and in working in child guidance clinics and having served as the Vice President of the Michigan Association for Emotionally Disturbed Children, I have a fairly intimate knowledge of the kinds of programs which are necessary, and the testimony that has been presented here today is a cooperative testimony and we're hopeful that the Committee and any other agencies and organizations of government officials will see to it that the needs of our children who are disturbed are met and that the services are provided.

Thank you.

Mr. MCMILLAN. Thank you.

I'm certain that every member of this Committee is very sympathetic to the fine work that you people are doing and we want to cooperate in sponsoring legislation to this effect.

Mr. FOWLER. Thank you, Mr. Chairman. We'd like to thank you once again for your attention and interest this morning. Mr. MCMILLAN. The Committee is adjourned.

(Whereupon, at 12 p.m., the hearing in the above-entitled matter was adjourned.)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

'Report of the Joint Commission on Mental Health of Children, Inc."-1969 0398-0475, Chapter VI, "Emotionally Disturbed and Mentally Ill Children 1 Youth" (Harper & Row, Inc., 49 East 33rd Street, New York, N. Y. 10016) 7.S. Bureau of the Census, Current Population Reports, Series P-60, No. 53, come in 1966 of Families and Persons in the United States," Washington, C.: U.S. Government Printing Office, 1967, p. 28.

3.S. Department of Health, Education, and Welfare, "America's Children and 11th in Institutions: 1950-1960-1964," Children's Bureau Publication, No. 435, 1.5.

J.S. Senate, Subcommittee on Employment, Manpower, and Poverty of the mmittee on Labor and Public Welfare, Hunger and Malnutrition in America th Congress, 1st session on Hunger and Malnutrition in America, July 11 and , Washington, D.C.: U.S. Government Printing Office, 1967.

Werkman, S., Shifman, L. and Skelly, T., "Psychosocial Correlates of Iron ficiency Anemia in Early Childhood," Psychosomatic Medicine, No. 26, 1964,

125-34.

Yamamoto, J., Quinton, C., Bloombaum, M. and Hattem, J., "Racial Factors Patient Selection," American Journal of Psychiatry, 124, 5, 1967, pp. 84-90.

APTER VI-EMOTIONALLY DISTURBED AND MENTALLY ILL CHILDREN AND YOUTH 1

This chapter is speci, cally concerned with problems of mental illness and ious emotional disturbance of children and youth. The earlier chapters of this port were focused primarily on the programs that are needed in this country to event emotional and mental disorders and to promote mental health in our ung population. Preventive programs have been emphasized along with proms that promote positive mental health, with positive mental health being fined as more than the absence of mental illness or severe emotional disabilities. These programs are not seen as being in place of, or necessarily completely parate from, the other more massive, preventive programs that have been cussed previously in this report. Rather, they are seen as being chiefly more ensive and more specific in their emphasis on the provisions of pychiatric and ated services for children and youth with severe problems of mental illness i emotional disturbance.

It is very probable that most, if not all, of these disabilities are an extreme nifestation of the universal difficulties that human beings encounter in the rse of their growth and adaptation to the complex process of becoming effective, tended, contributing members of society. Thus, programs aimed at promoting sitive mental health may, in part, serve more seriously handicapped youngsters, t general mental health and related services, by themselves, are usually inquate to meet all the needs of the seriously afflicted. Thus, specialized programs st be added to those more general ones that have been espoused earlier in s report.

DEFINITIONS OF MENTAL ILLNESS AND EMOTIONAL DISTURBANCES

There is considerable confusion at present regarding the definition of mental ess and serious emotional disturbances. Many different diagnostic categories ways of viewing the problem exist. This is related to the fact that child chiatry and clinical psychology are rather new fields, and that the major phases have been on treatment rather than research. Moreover, the search for ar, definitive understanding of emotional and mental disorders has proven to exceptionally baffling and complex. A full discussion of these matters is out The subject of mental health manpower is not discussed in this Chapter. See Chapter XI.

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of place here--the American Psychiatric Association and other professional organizations are currently working towards more generally accepted and widely used systems of definition and diagnostic categories. A few of the current formulations will be presented in the pages that follow.

For example, some authorities suggest that there are five major categories of emotional and mental disorders when they are viewed in terms of their origins. These categories are as follows: 1) faulty training and faulty life experiences, 2) surface conflicts between children and parents in reference to such adjustment tasks as relations between siblings, school, social, and sexual development, 3) deeper conflicts which become internalized within the self and create emotions! conflicts within the child (these are so-called neuroses), 4) difficulties associated with physical handicaps and disorders, 5) difficulties associated with mental disorders (the psychoses). It is proposed that 80 percent of emotional problems are related to the first two categories; 10 percent to the third category; and 10 percent to the fourth and fifth. In reference to the first large group, highly trained mental health specialists are not required for handling these kinds of problems; rather such children can generally receive sufficient help from a variety of people who work with them, such as parents, teachers, public health and school nurses, etc. Dr. Dane Prugh has worked out a system for diagnosing, classifying, and treating emotional and mental disorders. He ties this system primarily to the developmental stage of the child and the degree to which he is handicapped or suffering from dysfunction. Prugh sees mental health as being largely on a continuum, ranging from excellent to very poor psychosocial-physical functioning. His charts will be found in the Appendix of this chapter. This approach appears to be particularly promising.

The Committee on Child Psychiatry of the Group for the Advancement of Psychiatry proposes a classification system divided into the following main categories: healthy responses, reaction disorders, developmental deviations. psychoneurotic disorders, personality disorders, psychotic disorders, psychophysiologic disorders, brain syndromes, mental retardation, and other disorders. This Committee also adlopted three basic propositions to the effect that a) there is a unity of mind and body and psychological and physical processes are tlosely inter-related, b) diagnosis must be related to the developmental stage of the child, and c) the child's behavior is deeply affected by his experiences in his family and the larger society. The Committee further stresses that a child's behavior is a product of multiple factors: physiological, psychological, and social, but concludes that, at the present, a classification system cannot take into account all of these factors in their great complexity and interaction.

Another approach, which might be termed social-psychological-educational, emphasizes that a child's behavioral difficulties are closely associated with gaps or deficits in his learning of social, behavioral, and academic skills as a result of failures and problems in his environment: family, school, and neighborhood.

Yet another approach to the definition and description of emotional disturbance, not fully developed at present, may be called the ecological or systems analysis of the problem. The child is seen as defining a small social system of which he is an integral part and which includes his home, school, neighborhood, and larger community. The behavior patterns of the child in the context of requirements and expectations of a particular social system may lead to acceptance and support of the child or to his rejection, to his being defined as "disturbed" or "delinquent" or perhaps "mentally retarded." A child is identified as emotionally distrubed when there is too much discord in the system, when there is an intolerable discrepancy between the behavior of the child and the expectations of the normal socializing institutions. This concept is increasingly a part of most classification systems. When taken seriously it leads to intervention that may include conventional psychotherapeutic procedures but would involve other strategies as well (Hobbs, 1966).

According to the Clinical Issues Committee Report, the emotional and mental illness problems of pre-school children may include:

1) Childhood psychoses which are the most serious forms of mental illness and which include such diagnostic categories as infantile autism and childhood schizophrenia;

2) Childhood neuroses which are characterized by such symptoms as extreme and unreasoning fears; continuing rituals carried out in a driven way; deep emotional depression; severe shyness and withdrawal from people and the environment; compulsive manipulation of parts of the self such as pulling of one's own hair, head rubbing, unceasing masturbation, and the like;

3) Children with minimal brain dysfunction who demonstrate such problems as physical awkwardness, hyperactivity, and learning disorders;

4) A large group of disturbances which lie in the area of behavioral problems. The latter category includes the dangerous child, the child whose tantrums, ing, and destructiveness set him apart from other children from a very early e" (Clinical Issues Committee Report, 1969).

5) Children with sexual deviations which lead to confusion over their sex entity and various forms of perversion and unusual sex interest. "Some boys, example, show marked feminine interests from age two or even younger, along th compulsive patterns of sexual activity."

5) The failure-to-thrive syndrome is an important and serious condition rticularly found in some infants and young children. It reveals itself in the lure of some youngsters to grow and develop normally in the areas of physical, ellectual, and emotional development. This is becoming an increasingly wideead problem and its origins are incompletely understood, although at least ne of these children appear to be products or neglecting or unusually cruel rents (Task Force II, 1969; see, also, Chapter V, Section I).

7) Children with physical or mental handicaps which are generally made more abling because of the associated emotional reactions of both parents and idren.

NATURE AND SCOPE OF PROBLEM

The Joint Commission has made the following definition of emotionally disbed children: "An emotionally disturbed child is one whose progressive perality development is interfered with or arrested by a variety of factors so that shows impairment in the capacity expected of him for his age and endowment: for reasonably accurate perception of the world around him; 2) for impulse trol; 3) for satisfying and satisfactory relations with others; 4) for learning; 5) any combination of these. This definition would seem to cover, in a general v, the major features of the various definitions which have been sketched here. reviewing various treatment approaches, Gioscia and associates (1968) conde that regardless of varying diagnostic and theoretical systems, the basic thods of treatment tend to be fairly similar in actual work with disturbed Idren and youth (see, also Chapter XII, Research). The goals of such treatment generally tied to the criteria of mental health presented above.

cidence of Mental and Emotional Disorders

Estimates vary as to the number of mentally ill (psychotic) children and ing people in this country. It is estimated that about .6 percent are psychotic I another two to three percent are severely disturbed. It is further estimated t another eight to ten percent of our young people are afflicted with such serious otional problems (neuroses and the like) that they are in need of specialized vices. However, it appears that only about five to seven percent of the children this country who need professional mental health care are getting it (Gioscia, al., 1968; Task Force V, 1968). According to the best available figures, only out 500,000 children are currently being served by mental health facilities nies, hospitals, private therapists) but over 7,000,000 young people under age need professional help.

As a nation, we do far better for our physically handicapped children than we for those with emotional and mental handicaps. For example, it is estimate t 7.6 million children are in need of services for the physically handicapped and t 5.6 million receive such services (Task Force V, 1968). It is clear that the sent dearth of mental health services will become more acute in the immediate ure. The child and youth population is growing and there are indications that a er proportion of this population will be in need of such services; for instance, e 1950, the number of boys under age 15 in the population has doubled but ir number in mental institutions has quadrupled (NIMH, 1968). lthough mental health services for the population have been greatly expanded r the past 15 years or so, we are falling far short of our frequently announced ional goals regarding a commitment to the youth of this nation. For instance, Rexford of the Boston University School of Medicine writes "Our national es and intentions to care adequately for emotionally disturbed children have articulated repeatedly and with eloquence." For example, groups of citizens government officials drew up the following statement at the 1930 White Ise Conference:

The emotionally disturbed child has a right:

1) to grow up in a world which does not set him apart, which looks at him not scorn or pity or ridicule-but which welcomes him, exactly as it welcomes y child, which offers him identical privileges and identical responsibilities. 2) to a life on which his handicap casts no shadow, but which is full day by day those things which make it worthwhile, with comradeship, love, work, play,

laughter, and tears a life in which these things bring continually increasing growth, richness, release of energies, joy in achievement.

There are in the United States: 2,500,000 children with well-marked behavior difficulties including the more serious mental and nervous disorders.

Even as early as four years of age, it has been shown that more than 35 percent of the apparently normal children of self-sustaining families, average intelligence, have detectable behavior difficulties.

A comprehensive program to prepare the emotionally handicapped child for life's work must include: early discovery and diagnosis which will determine the nature and extent of the handicap while it is in the incipient stages and when the greatest possible benefit may be secured from care and treatment.

Protective legislation which will make a comprehensive program for the handicapped fully effective, safeguarding the interests of the handicapped as well as the employer.

Research which will determine the fundamental causes of mental and physical disabilities and discover the most effective methods of prevention and control of all handicaps.

National and central state agencies which will provide for the integration of national, state, and local educational, vocational, industrial, health, and welfare activities in a comprehensive plan on behalf of the handicapped child.

"Have we really made headway during these 30 years, years during which we have attained the highest per capita income the United States and indeed the world has ever seen? We can note lamentably limited progress. What has been the cost to individual lives, what the waste to our nation of ignoring these recommendations? During 1967, the federal government appropriated $1.11 billion for cotton price support and one-twentieth that amount for child mental health services conceived in the broadest possible terms. What are our priorities? Do we indeed lavish care upon our children? What happens between the rousing statement of the child's bill of rights and the feeble, inadequate implementation of these goals?” Dr. Rexford also comments: "A curious factor has emerged about the basis for this support. Certain public figures have given such an endeavor (mental health programs) their interest in 'cutting down crime in the streets'. . . The extent and seriousness of youthful anti-social behavior are cogent reasons for wishing to plan more effectively and to ameliorate mental disturbances in the young; the possibility that the youthful delinquent becomes a serious adult criminal is often borne out. It takes one aback, however, to be told that protection of society from its children in this direct sense is the compelling motivation of many influential citizens for programming for emotionally sick children and youth and those at high risks" (Rexford, 1969).

Our national failure to provide even minimally adequate services for the emotionally disturbed and psychotic children and youth in this country is related to many factors. One of them is the greater emphasis that is generally placed on providing programs for adults. For instance, special services required for children have not been included in many Community Mental Health Center programs. "The failure of the great majority of states to include any plans for children in mental health programs presented to the U.S. Public Health Service in 1963 led to the convening of a national conference that year on planning child psychiatric services within community mental health programs. However, the recent visit of a survey team to eight Comprehensive Mental Health Centers planned with and funded by the U.S. Public Health Service brought forth the distressing observation that only two had any kind of specific children's services and of these two instances, only one offered a satisfactory program. There were no plans in the other Centers to move ahead in providing appropriate children's services although these had been included in the original blueprints. "Moreover, "Many child guidance clinics are currently the nuclei for mental health center programs, their staff serving adult patients, their activities for children steadily declining.

Supposedly, this diversion from the children's program is temporary, but given staffing realities in many communities embarking upon a Center program, it may not be unlikely that less service for children will be available within so-called comprehensive programs than was provided for children previously. It appears that whenever in-patient beds must be allocated to adult or child services, the latter rarely receive precedence. You may say that it is clearly more important to have the bed for the adult patient, but is that true? Is the adult's depressive and suicidal status so obviously more significant than that of a 10 year old boy that no questions are raised about the decision? What of the suffering in the present? What of the important for the future?

'Who speaks for the sick children?' is a question which might echo across the country these days as the planners, citizens, and government agents sit down