residential care, it is still clear that a great many who do need it are not receiving such care.

There were 276 residential treatment institutions for emotionally disturbed children in this country in 1966. A number of states had no such institutions. These included: Alabama, Arkansas, Georgia, Hawaii, Idaho, Mississippi, Nevada, Puerto Rico, South Carolina, Utah, and the Virgin Islands. The states with the largest number of such institutions are: California (38), Illinois (12), Massachusetts (27), Michigan (17), New York (24), and Wisconsin (14). A number of states, primarily those in the far west and in the southeast, have only one such institution (Papenfort, et al., 1968).

Some of the existing residential centers have weaknesses or deficits in their programs. This is apt to be particularly true of a number of institutions which offer care for emotionally disturbed or mentally ill children but which do not come up to the standards set by such professional organizations as the American Association for Children's Residential Centers. Conspicuous inadequacies, in some of these institutions, as described by some specialists in the field, include the following:

In some institutional programs, well-trained staff members work with the children eight hours a day, five days a week, with the children cared for in the evenings and on weekends by personnel with the least training. Communication among the many professionals is often inadequate.

Many institutions for disturbed and retarded children provide diagnostic services only, with no place for children and their families to go to get help.

School is neglected or given secondary emphasis in many if not most residential treatment programs. Teachers are far down in the prestige hierarchy. They are often provided by public schools, are seldom the best teachers, and frequently remain on the fringe of the professional staff, and seldom are central to it.

Very few institutional programs have adequately conceptualized and staffed liaison programs to work with the child's family, school, and community, to speed his return and to follow-up to promote continuing progress and adjustment. Once children are admitted to institutional programs they tend to remain for long periods of time, which may often be more a matter of custom than of the child's condition. A lengthy institutional stay is often associated with an inadequate liaison service.

Fully staffed residential treatment programs involving the traditional psychiatric team (psychiatrist, clinical psychologist, psychiatric social worker, psychiatric nurse, sundry kinds of therapists, teachers, aides) are expensive, as already indicated. Moreover, highly trained personnel required for such programs are now and will remain in short supply. These facts mean that we cannot meet requirements for residential care for all children needing it by building exclusively on the psychiatric team model. Such programs are essential but must be used selectively, with clear goals in mind and costs carefully considered.

Few residential treatment programs evaluate the outcome of their work in rigorously designed, well-controlled, scientifically objective studies.

These are harsh criticisms but progress is not likely to be made until we take a hard look at current practice. This is not an indictment of any state or professional group. There are good residential treatment centers throughout the country, under varied auspices, inspired by psychiatrists, teachers, social workers, psychologists, at varying levels of cost. And there are many bad institutions that are underfinanced, under-staffed, and poorly housed, whose devoted and overworked professional staffs know better than anyone how inadequate the places are and how much needs to be done. On the whole, we are doing a very poor job in supplyng residential care for disturbed children.

There are times when a problem cannot be solved following accepted assumptions and procedures; such seems to be the case now in our efforts to extend tradiional treatment models for the residential care of all emotionally disturbed and nental ill children who need intensive specialized treatment. A not-too-sharp pencil can show what the problem is. Assume a most conservative estimate of the number of seriously disturbed children, say one-half of one percent of children inder 20. That means 450,000 seriously disturbed children in need of treatment. Assume that a psychiatric team is composed of one psychiatrist, one psychologist, wo social workers, and three nurses-not to mention teachers, aides, etc. Give hem a treatment load of 50 children in residence or intensive day care, a much heavier load than they can handle. This arrangement would require 9,000 child sychiatrists (more than one-half the psychiatrists in the country), 9,000 psyhologists (more than the entire number of clinical psychologists), 18,000 social workers, and 27,000 psychiatric nurses. Assume further a per-day treatment ost of $40 which is on the low side. The annual cost of the program would be

$6,570,000,000. Since traditional treatment programs tend to require about two years, this amount would need to be doubled to care for the children now estimated as being in need of help. Double the case load to reduce personnel requirements and the resulting figures are still staggering. The problem of residential and intensive day care for severely disturbed children simply cannot be solved the way we are trying to solve it.

Therefore, it is important to experiment with other approaches to care for disturbed children who, for one reason or another, cannot remain in their own homes. These approaches include other kinds of group care, such as those pioneered by Project Re-ed (see last section of this Chapter), day care or night care programs, use of specialized foster homes, therapeutic nursery schools, and the like. In these programs, very careful consideration should be given to expert diagnosis of the nature of the child's problems. Differentiation should be made between those youngsters with such severe disorders that highly intensive psychiatric and other forms of medical care are essential and those children who are likely to respond well to a more generalized approach. These various forms of treatment and care should be tried on an experimental basis and carefully evaluated with welldesigned program research. (See Chapter XII.)

Included in such experimental approaches should be a more flexible use of mental health specialists who serve as consultants to other professionals, such as teachers and nurses, who are working directly with seriously disturbed children. Then, too, expanded use should be made of para-professionals: people without formal training in the field but who may do an excellent job in some aspects of group care for disturbed children, providing that such personnel receive appropriate in-service training, consultation, and supervision (Chapters XI, XIÐ. (See, also, section in this Chapter on services for adolescents and specialized programs in state hospitals.)

Mental health services for children, in general

In reference to the provision of mental health services for children, in general, a number of problems are apparent. In discussing those related to very young children, the Clinical Issues Committee Report (1968) identifies three major difficulties, as follows:

1. There has been a tendency for many years to regard pre-schoolers as the primary psychological property of their parents; thus, treatment has been aimed at the parents, although clinical experience indicates that the child himself also often needs treatment before his problems become too rigidly imbedded in his personality.

2. There is a widespread lack of training and special professional skill developed for dealing with pre-school children. The average child psychiatrist does not have specialized preparation for working with younsters of this age.

3. There is a strongly held belief that pre-school children should never be removed from their own homes, However, recent studies are indicating that children of this age may benefit from care in specialized foster homes, day care centers, or residential centers if there are assurances that the child will receive a high quality of continuous care from parent substitutes.

While changes in the child's environment and the provision of supporting serviices such as day care and counselling to his parents may be extremely useful for many children, some youngsters need direct individualized psychotherapeutic help (Neubauer, 1967).

Services for adolescents

Much of the treatment of the troubled teenager has fallen to clinics and private practitioners, but the major unmet need in this area is that of vastly improved institutional care. An enormous number of teenagers pass into and out of state institutions each year and instead of being helped, the vast majority are the worse for the experience. This is true for the average state training school or state industrial or state farm for boys or girls; it is true, also, of the state hospital in many areas.

The admission of teenagers to the state hospitals has risen something like 150 percent in the last 10 years. The number of youngsters in correctional institutions is also increasing. And few if any of these situations provide anything approaching adequate treatment or rehabilitation.

The usual picture is one of untrained people working without facilities attempting to deal with a wide variety of complex and seriously sick youngsters and and producing results that are most easily measured by a recommitment rate that is often 30 to 50 percent and occasionally higher.

The need for intensive skilled clinical and educational work with these many troubled youngsters and their parents is crying and urgent and it is imperative

that public attention be turned toward this shameful and correctible condition. State hospital programs for teenagers are still seldom geared to the special needs of the adolescent population. Many youngsters are placed on adult wards, usually to their serious detriment, without benefits of the special recreation activities, education, supervision, and group experiences that teenagers need. The result is at best a partial treatment program with many gaps left in what could be a major assist toward recovering from their illnesses.

Although this is the most glaring lack in programs for teenagers, mental health facilities in general are seriously lacking for this age group. Many child guidance clinics take youngsters only up to age 11 or 14. For the older adolescent, even the relatively commonplace clinic service is lacking and out-patient care is only one of a whole series of necessary services. For example, the nature of adolescence is such that to meet the needs of this period of life there must be a facility that will offer emergency service for the upset teenager at any time. Backing this up there must be a whole array of services beginning with a group living half-way house. This might be a professionally run youth hostel, with provisions for long-time residents who would live there for an extended period in a protected and supervised state until they were ready for full community adjustment. At the same time, such a hostel would include facilities for transients, for youngsters under pressure who would leave home for a night or two or a week or two if they felt they must. It could provide a haven under socially approved auspices where they could also look for relief from home pressures and outside help.

Protected work situations are necessary for many youngsters where remedial education and on-the-job training can give them a sense of career and direction. For the more disturbed boys and girls, a day care set-up is recommended where work-training, school, recreational activities, therapy, group work, and in short, a total treatment program are all provided under one roof. To put it briefly, insofar as mental health care is concerned, as a society we fail our teenagers at almost every level (Clinical Issues Committee Report, 1968).

RECOMMENDED MENTAL HEALTH PROGRAMS !

Programs attuned to development stages

Mental health programs should start before pregnancy with provisions for genetic counseling and family planning services. With increasing information becoming available regarding some of the genetic factors that are related to mental retardation and physical handicaps, it is important that parents have access to skilled, sensitive counseling on this subject. Family planning should be available to all parents or prospective parents regardless of age or marital status, since an unwanted pregnancy presents a threat to the mental health of both the mother and her unborn child. Moreover, abortion services should be available at the request of the mother for the same reason.

As emphasized earlier in this chapter and in Chapter VII, much more emphasis should be placed on providing a wide range of mental health and related services to expectant mothers and infants and their parents. Current research into early learning in infant life suggests that the kind of learning that goes on in the early months and years is probably more significant than anything that the child is going to learn during the rest of his life. The evidence is fairly weighty that if severe deficits occur in early infant experiences, later therapy is likely to have only a partial effect. We do not yet know to what extent early deprivations can be undone later by therapy. Critical points in human life such as pregnancy, child birth, infancy, toddlerhood, pre-school and school entry can present opportunities to work with families and help parents rear their children more appropriately, This approach to families with very young children requires a large commitment on the part of the whole society to seriously regard the human development of infants and children as a very serious business (Gioscia, et al., 1968).

In general, services to children or affecting children must be organized along the lines of the child's developmental stages and his needs at these different stages this will be also true for the training of specialized personnel to deal with the characteristic problems of each period. It also applies to the nature of agencies,... their types and locations... and to the practices and community relations of each individual involved with children. The range of childhood includes

1 In reference to most of the recommendations that follow, there is a lack of firm, research-based evidence as to the effectiveness of the various kinds of programs that are recommended. However, the need is so acute that it is not possible to delay action until all the needed research is completed. Basic and applied research must take place concomitantly with the launching and operation of a wide range of services. (See Chapter

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the prenatal care of the pregnant mother on one end of the spectrum and the transition of the college-age youth into young adulthood at the other.

A wide range of coordinated preventive and treatment services

Establishment of services and training programs should include these goals: the treatment of every child as well as the family around the child wherever demonstrable emotional and mental disorders are found; an attempt to prevent these disorders by large-scale planning; and the reorganization of services in a way that will encourage the maximum flowering of each person's individual potential for self-realization and social contribution. In this planning, it is imperative that services be individualized and adapted to the needs of specific individuals (Clinical Issues Committee Report, 1968).

A broad range of coordinated remedial mental health services must be provided for the seriously disturbed, juvenile delinquent, mentally retarded, and otherwise handicapped children and their families. It is strongly urged that future services to the child be given according to the child's level of functioning rather than on the basis of diagnostic labeling. This will mean that children with many different diagnostic labels will be treated jointly under the same service program. Further, it is recommended that community-based facilities be developed so that children and youth can be kept as closely as possible within their normal, routine setting. For the more severe cases who must be removed from the normal setting, it is recommended that there be further development of residential treatment centers, special units in general and psychiatric hospitals, and separate care-taking provisions for children and adolescents in state hospitals.

Plans for care of the emotionally disturbed or mentally ill child should be based on: a) the behavior stability of the child, b) the strength and capacity of the family to support him, c) the resources of the community. The disturbed child is likely to need a wide variety of services and it is essential that arrangements be made so that he may move easily from one service to another. Many emotionally and mentally disturbed children are excluded from services that they need either because a general service has made no provision for such children or because the cost of specialized services for these youngsters is beyond the means of the families involved.

The following are the services that are necessary for a comprehensive mental health program for troubled youngsters: 1. information referral services easily accessible and equipped to direct families to available services, resources, and facilities; 2. comprehensive developmental and psycho-educational assessment of each child's special treatment and educational needs should be made as early as possible by a team that may include a pediatrician, psychiatrist, social worker, neurologist, psychologist, speech and language specialist, ophthalmologist, audiologist, educational specialist, and/or any other professional disciplines available and considered essential for the proper treatment of the disturbed child. Highest priority should be given to the coordination of these services so that a comprehensive diagnosis is possible.

This assessment service should assume responsibility for following up recommendations and referrals and for on-going, periodic re-evaluations to make certain that the appropriate and adequate community treatment, training, and educational facilities are available.

3. Treatment for the child and his family when indicated. Psychiatric, psychological, social work, educational and other support services should be vailable as needed.

4. Special education programs must be an integral part of the range of services to be provided:

a. Pre-school home training program should be established for the special training and education of disturbed children and for the guidance and counseling of their parents.

b. Regular nursery schools can help children who show inadequacies of learning and adjustment skills. There are, however, children who are too disturbed or disruptive to be contained in a regular nursery school. These children should have special nursery schools offering a variety of techniques and approaches to correct or reduce maladaptive behavior. Special classes within regular schools offer advantages for those children who need a somewhat more intensive program. These classes are usually close to the child's home and can be partially integrated with regular classes.

c. Special schools should be established under public school auspices or by voluntary agencies with government and public support for children who, because of the severity of their disturbances, cannot be accommodated in special classes within a regular school.

5. Rehabilitation is needed to provide a plan and purposeful process of restoration, remediation, and psycho-social adjustment.

6. Residential care which may be provided by specialized foster homes, group residences, residential treatment centers, sheltered villages, or hospital settings. It is essential that these facilities offer comprehensive treatment and have adequate resources for medical care, psychological and psychiatric consultation, special education, and other support services.

7. Transitional services must provide the resources to meet the inability of the family to care appropriately for the child, the inability of the school to provide adjusted educational services, the infrequent availability in the community of intensive out-patient treatment or other services for the child and his family or or some combination of these. Transitional services may include partial hospital care as in day or night hospitals; half-way houses and hostels; and social habilitation programs. In offering transitional services to children and adolescents it is necessary to recognize that hospitalization is usually deemed necessary when the child's disturbed behavior is acute and over-taxes the supports offered either in the home or in the community, especially the school. The child's inability to assume independence of functioning is often the chief block to early release from hospital care. This highlights the need generally for more adequate community-based services and most particularly the need for transitional services. Every effort should be made to not place children in hospitals except during the acute stages of physical and/or emotional illnesses when intensive medical care is needed.

8. Relief services for the families of severely disturbed children should be provided. In any plan to provide partial hospitalization and transitional services, the goal should be to use supportive services to keep the family intact. Examples of the above services are foster grandparents, baby sitting, homemaking services, day care, public health nursing, and home-bound services.

9. Within the systems of services there should be periodic assessment, evaluation, and follow-up to ascertain that the child is receiving maximum benefits from the system (National Association for Mental Health, 1968).

Comprehensive continuous programs such as those outlined above might well be tied in with the functions and activities of the Child Development Councils recommended by this Commission and carried out in relation to community mental health programs.

Further recommendations are available from the American Association of Psychiatric Clinics for children. They are as follows: 1) services which reach larger numbers of children at earlier ages or at earlier stages of disturbances are generally less expensive, more short-term, and achieve a more favorable effect than those services which reach children later on when the children are more deeply disturbed; 2) the soundest progress in community organization for emotionally disturbed children and their families is achieved by developing services in "developmental succession"; Preventive before diagnostic, diagnostic before outpatient treatment, out-patient treatment before hospital care, and so forth; 3) communities with inadequate educational, preventive, diagnostic, and treatment resources are compelled to move children out of the community into institutions instead of reaching younger or less disturbed children more quickly and treating them with shorter, less expensive community and out-patient services. 4) In practice, it may be soundest to begin by making better use or refocused use of existing services than to establish and promote new services immediately. If a small community, for example, has a family service agency but no out-patient clinic, the addition of psychiatric services to the agency may be more economical than establishing a clinic itself.

5. No program can be soundly based which does not include careful diagnostic evaluation as a basis for any service or treatment planning. Such diagnostic evaluation means evaluation not only of the child and his problems but of the parent-child relationship, the parents, and the relationship of the family unit to the community and its resources. 6) When more specialized services are required, the transition for the child and his family should be as simple and direct as good community organization and intra-agency cooperation can make it. 7) The multiple roles of the psychiatric clinicians and psychiatric services today have come not only from the many demands of various community services but have also come from the contributious made by the many new directions in the filed of medicine. For example, the contributions of psychopharmacology and genetics are having special present significance. Psychiatry is involved in the general present movement of medicine toward health preservation and the prevention of illness. 8) The child psychiatric clinician and the child psychiatric services today need to be aware of important class differences, ethnic differences, value