PATTERNS OF CHILD PSYCHIATRY-

PROMISE OR FULFILLMENT?

Meyer Sonis) M.D.

If we were to examine the current problems of maintammg themental health of children and the problems of prevention and treat­ment of the emotional disorders of children, we would discover aperplexing paradox. On the one hand, the interest in, concern for,and the acceptance of responsibility by our nation in achieving anenvironment conducive toward mental health for children hasbrought about changes in our society that should have led to thepositive goal of a healthy child in a healthy community. On the otherhand, the increased number of emotionally disturbed children in ourcountry and the lack of available services seemingly belie the progressthat presumably has been made. It is the intent of this presentationto explore this paradox with you, not for the purpose of suggestinga pat formula, but for the purpose of posing the questions raised bythis paradox and its implications for those of us in child psychiatry.

The steps we have taken as a nation during the last fifty years haveindicated our positive belief: that the welfare of our children mustbe heeded; that a child is not simply a miniature or junior citizen,but a citizen in need of protection, care, and nurturance; that a childis a dependent individual who needs an environment of emotionalsecurity in order eventually to arrive at independence and citizenresponsibility; that we must have services and supports available to

Dr. Sonis is DirectoT of PittsbuTgh Child Guidance CenteT, and Chief of Child Psy­chiatTy, UniveTsity of PittsbuTgh School of Medicine, PittsbuTgh, Pa.

This papeT was pTesented at the scientific meeting of the AmeTican Association ofPsychiatTic Clinics faT Children, March 6,1963.

9

10 Meyer Sonis

aid the child in his constructive growth toward assuming citizenresponsibility; that we must have means available to intercede whenand where the environment is not conducive to the healthy growth ofthe child.

It would not be within the scope of this presentation exhaustivelyto list the steps that we have taken during these past fifty years, buta few examples will suffice: the establishment of child labor lawsto prevent the abuse of children maturationally unable to cope withthe realities of work; the development of the juvenile court systemto protect the dependent nature of the child; the compulsory educa­tion laws to maintain the child in a dependent position for a longerperiod of time while allowing him to learn and to master learningas a step toward independence and judgment; the general welfareprograms for families to minimize the threat of reality insecurity toa family which would only increase emotional insecurity; the aid-to­dependent-children laws to maintain the child-mother unit neededfor emotional growth; the public and private child care protectiveservices of a community, which through intercession and responsiblecustody of a child in a dependent and neglected state supported thedependent nature of the child and the need of the child for construc­tive adult relationships; the establishment of day care centers forchildren of working mothers, which again became a step aimed towardmaintaining the intact family unit so necessary for childhood growth.

And yet, an examination of the current hue and cry in our com­munities could raise question as to whether we have made progressfor the welfare of children. For the moment, let us listen to the hueand cry. The increased interest, concern, and anger of the communityat the rise of juvenile delinquency has raised the question in theminds of many as to the wisdom of our juvenile court system. Theincreased number of children in the families on ADC who show bothphysical and mental deviations has raised question in the minds ofmany as to the soundness of such a law; in fact, in some circles, it isbelieved that such a law only aids in the propagation of this problemsince these mothers are only interested in the financial gain.

The dilemma of our public school systems, caught between thetask of teaching and/or character molding, caught between the es­tablishment of a milieu for living, and caught between the task ofaiding families to assume increased parental responsibilities and/or

Patterns of Child Psychiatry 11

picking up the slack of family deficiencies, has allIed to the question­ing of our educational system. The increased number of children andtheir families, in child care services, who have not been able to utilizesuch services constructively, and the increased number of these chil­dren changed from one foster home to another repeatedly with in­creasing signs of emotional disturbances manifesting themselves, haseventually raised questions as to the value of such services. In brief,if the cry continues, if the problems continue to mount, we may beled in the direction of both throwing out the baby and the crib, whenall that might be needed is a larger bed.

If we now examine the field of child health, we will also discoverthe remarkable progress made by us as a nation in insuring the pro­duction of an environment conducive toward sound health in chil­dren. The establishment of hospitals for children confirmed the beliefthat a child is not a miniature adult, and therefore services wereneeded specific to the dependent state of children. The developmentof a specialized branch of medicine, namely pediatrics, indicated ac­ceptance of the concept that specialized knowledge, skill, and equip­ment were required to diagnose and treat the sick child. The increas­ing knowledge gained in the diagnosis, treatment, and eventuallyprevention of the many infectious diseases of children decreased themortality and the morbidity rate of children. The advent of theantibiotic age not only made possible the increase of the life spanof children but also allowed for the emergence of the tremendouschange in pediatric practice with its current emphasis on the wellbaby, the well child and his family. The increased knowledge gainedin psychiatry through psychoanalysis has led to the recognition thatchildhood is a breeding place for later emotional disorders, and withthis step there has been an increased interest in, and knowledge of,the emotional development of the child himself. The developmentof the child guidance clinic recognized the need for community sup­port of service for the diagnosis and treatment of emotionally disturbedchildren and their parents. The emerging knowledge of child psychia­try supported the view that parent-child interaction can positively ornegatively influence the emotional development of the child. Thechanges in pediatric hospitals, such as increased parent participationand involvement in procedures, increased parent visitation, all becamea step toward maintaining the intact family for the child through the

12 Meyer Sonis

emotional turmoil of separation. The development of the professionalplay programs and school programs in pediatric hospitals became astep aimed at the constructive emotional involvement of the child dur­ing the period of increased anxiety and fear. The refinement of psychi­atric hospitals for children differentiated the nature of services neededfor a child as compared to an adult suffering from mental illness. Theincreased knowledge gained through our recent investigations intoneurochemistry and neuropharmacology became a further step toward .understanding the mind, the body, and environment, and the relation­ship of each to the other.

And yet, the hue and cry of our current problems in coping withthe emotional disorders of children may seemingly belie our progress.As before, let us listen for a moment to the hue and cry. The increas­ing number of seriously disturbed children of younger age broughtto the attention of physicians and existing psychiatric facilities mayraise questions about the effectiveness of our increased knowledgeand services for children. The increased number of children withcongenital physical defects, who in addition to these defects andhandicaps now manifest signs of emotional disturbance, may posethe question in the minds of many as to the value of the advancesmade in pediatrics which have enabled these children to live. Theincreasing number of children with psychosomatic problems, formerlybelieved not possible, referred to existing child psychiatric facilitieswhen the prognosis is poor may raise questions in the minds of manypediatricians as to whether child psychiatric help can be effective.The increasing number of children in need of psychiatric hospitaliza­tion, added to the existing burden of psychiatric hospitals for chil­dren that at the same time are finding it difficult to avoid a staticpopulation of disturbed children in their hospitals, and the increaseddissatisfaction of child agencies and community psychiatric clinicsfor children with each other may pose the question in the minds ofmany as to whether either is effective in this service or both of no value.The increasing pressure of the community for relief from the destruc­tive acts of delinquent adolescents, added to by the pressures andanger of the courts for expedient action of one kind or another, canonly lead to expedient steps on the part of existing child psychiatricfacilities, and thus again the question may be raised in the minds ofmany as to the effectiveness of such service.

Patterns of Child Psychiatry 13

If to this list of problems are added the questions of the child psy­chiatric field itself, the difficulties are compounded. Questions andconcerns of the child psychiatric field are multiple. There are thewaiting lists of child guidance clinics, in which treatable cases areeither getting well or becoming untreatable on their own. There arethe service pressures by which existing child psychiatric facilities areunable to treat the more hopeful child because time has been pre­empted for those cases of poor prognosis, but cases that cause greaterconcern to the community. There are the children who are broughtto our attention for help only after a long series of foster home changes,and who, by the time of psychiatric intervention, anticipate the worstand therefore are prepared to hurt rather than be hurt. There are thefamilies that have literally disintegrated into an armed camp, as aresult of chronic parental disturbance, who are referred to existingchild psychiatric facilities for help but come only wanting relief fromthe disturbed child rather than wanting to become involved in find­ing more constructive methods of living together.

If we examine the problems outlined so far, we may arrive at theconclusion that progress in behalf of children has not been made orthat the price for such progress is exorbitant. In fact, if we examinethese same issues and problems, we may arrive at the pivotal questionasked by the Joint Commission on Mental Health in their reportentitled, Action for Mental Health) namely: "Why have our efforts toprovide effective treatment for the mentally ill lagged (1) behindour own professional objectives; (2) behind the public demand formental health services; and (3) behind programs staged against othermajor health problems?" It is to this question, but in the context ofchildren, that I will devote the remainder of this paper.

Do we need more services for children than we currently haveavailable, and if so, do we need more services to do more of what wehave already been doing without too much success? Do we need newservices, and if so, should they be primarily based on the gaps orproblems of existing services? Or do we need new services based onan understanding of why existing services have not been effective?Do we need more personnel trained as minor psychotherapists, be­cause we will never have enough major psychotherapists, and if so,are we really ready to offer our citizens a so-called second best? Dowe need the equivalent of a psychotherapist for every family to achieve

14 Meyer Sonis

our goal, or do we need a greater appreciation of the therapeuticpossibilities residing within the existing function and role of thechild caretaking professions, as they meet the family in life situa­tions? Do we still have insufficient knowledge in the behavioralsciences to clarify our problem and indicate future directions, or isit more a question of applying the knowledge that we do have?

It would seem to me that the literature of our field in the past fewyears has indicated that the latter question is more appropriate,namely, that we do have the knowledge but have not applied it. Asjust one example, a quote from the program notes of the AmericanAssociation of Psychiatric Clinics for Children for its scientific meet­ing of March 22, 1961 on the theme of "Appropriateness in the Useof Team Work Skills," would indicate that the organization had thebelief that we do have knowledge and now need to apply it, and Iquote, "Is our traditional treatment approach adequate and appropri­ate to meet the needs of these problem situations, or do we not needto look to the development of alternative methods of management?We would also hope that in considering various suggested alternativeapproaches, the question can be raised and seriously considered as towhether these are most appropriately carried on by the communitychild guidance clinic or by some other psychiatric or nonpsychiatricagency."

With the idea of applying our existing knowledge, though perhapsin hindsight, let us re-examine the previously outlined problems ofthe field of child health, education, and welfare to determine whetherwe have made progress or what has impeded progress.

For the first example, let us turn to the field of child welfare. Whenour knowledge indicated that separation of a child from its mothermay result in all of the horrible consequences of the institutionalizedchild, positive steps were taken to avoid this happening. The estab­lishment of ADC thus enabled the child to remain with his motherfor nurturance of his emotional needs. In other words, ADC was avehicle for support of the dependent side of the child, and thus couldresult in the constructive development of the child. However, whatwe knew but did not apply was the knowledge that many of thesemothers needed as much mothering as the child. Since we did nottake adequate steps to provide the services and personnel to enablethese mothers to develop their capacities, or the services needed to

Patterns of Child Psychiatry 15

identify the first signs of emotional decompensation in the family, wefinally arrived at the point where the incapacity of these mothers tosupply emotional nurturance to the child was overt and blatant. Thechild, with physical and emotional deviancies overtly manifested, wasthen brought to the attention of the child welfare organizations. Again,what we knew but did not apply was the knowledge that these childrenwere emotionally disturbed and manifested the signs and symptomsindicative of early problems in object relationship. They were chil­dren who were now defended against further hurt by a defense pat­tern of hurting first rather than be hurt. Instead of early identificationand diagnosis of the problem with recognition of a treatment planbased on that diagnosis, the services of the child welfare organizationswere applied as if these children were "dependent and neglected."In other words, these children were accepted for placement for pur­poses of containing their emotional disturbance and for purposes ofrelieving the parent and community of the disturbed child. As thiscontainment plan did not succeed, despite numerous foster homeplacements, child psychiatric help was sought. However, we mustnow keep in mind that psychiatric services were being sought forchronically disturbed children, with histories of emotional disturb­ance antedating the placement experience. As it became even moreapparent that many of these children in foster homes were disturbedchildren, and as existing child psychiatric facilities were not helpful,child welfare agencies sought the help of psychiatric consultants asa means of establishing treatment plans for disturbed children whilein placement. Again, what we knew we did not apply, namely thata social agency, though therapeutic in purpose and intent, is notestablished as a psychiatric setting and therefore consultation of apsychiatrist is not one and the same as psychiatric treatment. If, asstated in A ction for Mental Health) 64 per cent of children in fosterhome placement are emotionally disturbed and in need of psychiatrictreatment, do we need more psychotherapists in social agency settingsor do we need increased attention to early diagnosis of the difficultyand a treatment plan based on the diagnosis rather than arriving ata diagnosis through repetitive experiences of failure?

For our second example, let us review the previously outlined prob­lems of child health, but in the context of whether we applied theknowledge we had. As noted previously, the tremendous advances

16 Meyer Sonis

made in pediatrics enabled pediatricians to turn their attention tothe well child and his family, to problems of normal child develop­ment, and the care, management, and rehabilitation of children withchronic disabilities, such as nephrosis, cystic fibrosis, brain damage,neurological disorders, and surgical correction of congenital anom­alies. In short, pediatrics was now brought to the point of shifting itsmodel of care from the acute illness of children, with which thepediatrician had been successful, to that of a model of care whichwould include the psychosocial responsibility of pediatric practice.Though knowledge of the behavioral sciences was made available topediatrics, a tendency existed to inculcate pediatrics with the proce­dures and practice of psychiatry rather than the principles. What weknew but did not apply was the knowledge that the pediatricianneeded to develop a model of competence in a pediatric setting ratherthan in the confines of the psychiatric office. In other words, what weknew best in psychiatry is what we taught, namely, psychotherapy andthe diagnosis and treatment of the gross disorders of children, ratherthan a model of competence which would have aided the pediatricianin recognizing the various factors which negatively influence childdevelopment.

For example, our pediatricians needed to comprehend: that theinfant born with a congenital anomaly or some evidence of defectwill produce feelings in the parent as if the parents were defective,and that these feelings engendered in the parent may interfere withthe continued constructive medical management of the child, andmay interfere with the constructive development of the child per se.Pediatricians needed to recognize that a child with rheumatic fever,ostensibly needing a regime of modified rest, may break out in arash of behavioral symptoms as reflective of fears of abandonmentor fears of mutilation and incapacity. They needed to be aware thatan infant in need of transfusion for Rh incompatibility may producefeelings in the mother that this is not her child since "somebody else'sblood was used," and that this attitude in the mother may affect herchild-rearing practice and permeate the ongoing development of thechild despite the fact that no obvious neurological problems are evi­dent. They needed to be aware that a child on a restricting diet ora depriving diet may be unable to follow such a diet because of over­whelming feelings of deprivation brought about by earlier life experi-

Patterns of Child Psychiatry 17

ences. They needed to learn that the developmental history appliedwith interviewing skill by the pediatrician can be a most positiveentree into the past quality of parent-child interaction as this interac­tion has influenced child development. They needed to comprehendthat a child hospitalized with a diagnosis of uncomplicated pneumoniamay reflect parent incapacities to manage the child at home and thatcomprehensive medical care of the child would require involvementof the parent during the hospitalization, and not simply treatmentof the pneumonic process by antibiotic drugs. In short, what we knewbut did not apply was the knowledge that behavioral symptoms in achild were reflections of disturbed homeostasis (physical and psy­chological) within the child, as well as a barometer to the natureof parent-child relationship. Furthermore, recognition of these earlysigns by the pediatrician could help him avoid a practice of support­ing chronicity through temporization and containment of the seedsof future emotional disturbance.

One can go further in this model by stating that our medicalstudents and physicians needed to be taught psychiatric insight usefulto them as physicians. As a result of such teaching the various com­plaints of the pregnant woman would be seen not simply as an idio­syncrasy of pregnancy but as a possible reflection of anxieties or fearsand doubts in this woman, which may lay the seeds for a futureneonatal crisis. Physicians would know that the previous miscarriagesor stillbirths of a woman may express themselves as questions of heradequacy in the female role, which in turn may have implicationsfor the future development of a neonatal crisis. They would be awarethat the comprehension of a neonatal crisis is to be found in the suc­cessful or unsuccessful experiences of the mother in her previous rolesof girl, woman, wife, and expectant mother, and the father in hisprevious roles of boy, man, husband, and prospective father.

As with child welfare and health, let us examine the field of childeducation within the same context, namely, did we apply the knowl­edge we had? With the population explosion, and with the progressand problems of child welfare and health, we produced: more chil­dren in need of education; more children, now surviving with defectsand chronic illness but with limited abilities, in need of training andeducation; more children from socially and emotionally deprivedfamilies in need of education; and more children whose emotional

18 Meyer Sonis

disturbances were now treated through containment and temporiza­tion, but still in need of education. Having done so, we did not supplythe services or personnel required to aid the school in its task, andincreasingly we placed the schools in the untenable position of meet­ing all these varied pressures for education of children. The schoolincreasingly found itself attempting to pick up the slack whichfamilies could not provide in dependent support for their child. Theschools were asked to continue the plan of containment of the dis­turbance in a child and increasingly were pressured into the develop­ment of educational programs which would attempt to treat the dis­turbance in the child. In short, the school was pressured into becom­ing a milieu for character molding of children or a milieu for livinginstead of a milieu for learning, through which refined methods couldbe developed for the earlier identification of those children withemotional difficulties whose difficulties were manifesting themselvesin the learning process.

The point to be made in this re-examination of the problems inthe fields of child health, education, and welfare is that each of thefields was supporting the need for child psychiatric service for theovertly disturbed child, while at the same time each field was support­ing the development of covert chronically disturbed children througha practice of containment and temporization of the early signs ofemotional decompensation in child and family. With this progressionof vicious cycles, let us turn to the final link of our chain, namely,child psychiatry, to explain further the paradox of progress in behalfof disturbed children and problems which seemingly belie this prog­ress.

To illustrate, let us examine the evolution of child psychiatricservice patterns during the same period of time in which progress wasbeing made in the related fields of child health, education, and wel­fare.

(1) As child guidance clinics were increasingly involved with dis­turbed children and their parents, whose mutual disturbance posedproblems of inaccessibility to existing services, a variation of servicemodels was proposed by the child guidance clinic to meet the dilemma,such as individual treatment of the child, collaborative treatment ofparents, "triangular" therapy, individual and group treatment of thechild, individual and group treatment of the parent, group case work

Patterns of Child Psychiatry 19

for child, group case work for parent, parent groups for fathers, par­ent groups for mothers, drug therapy, drug and psychotherapy, familytreatment, and any combination of these models.

(2) As the child guidance clinics accepted the increasing numberof severely disturbed children, referred for treatment after a longhistory of chronicity, the clinics found themselves involved with child­hood disturbances in which the cyclical nature of action and reactionbetween child and parent had become a way of life for them, and away of life which mitigated against effective intervention into thisvicious cycle as long as the child and parent remained together. Thisled to the development of a new service such as the psychiatric in­patient hospital for children.

(3) As the child guidance clinics accepted the increasing numberof referrals of preschool-age children, with severe emotional disturb­ances, the clinics found themselves in a dilemma or a similar cyclicalnature of disturbance but not able to utilize an inpatient setting forchildren of this age. This led to the development of new services suchas the day care and nursery school programs for disturbed children.

(4) As the child guidance clinics were increasingly involved withchildren, whose histories indicated that more effective and less costlyintervention could have been achieved if the earlier signs and symp­toms of emotional disturbance had been recognized, the clinics foundthemselves again beset with the problems of increased time invest­ment on chronically disturbed children. This led to a closer involve­ment of pediatrics and child psychiatry.

(5) As the child guidance clinics accepted referrals of childrenincreasing in number, whose families were known to multiple agen­cies, whose problems were multiple in etiology and management,whose behavioral symptoms were bringing them to the attention ofthe school, the court, the pediatric hospitals, the child guidance clinicsagain were in the position of offering and attempting psychiatric treat­ment with resultant increased frustration and ineffectiveness. Thisled to the development of new services such as the diagnostic andevaluation services.

A review of this evolution of child psychiatric services into itscurrent pattern of a community outpatient child guidance clinic, apsychiatric hospital for children, a day care center or nursery fordisturbed children, a psychiatric coordinated diagnostic and evalua-

20 Meyer Sonis

tion center, and a pediatric center would suggest that the trend ofthe child psychiatric field has been in the direction of developingservices to fit the child rather than squeezing the child into the serv­ices available. Such a review would lend support to the idea that wehave been moving away from the traditional model to the develop­ment of newer models. It is to be remembered, however, that thehistory of this evolution has been a costly one to child, parent, com­munity, and the profession. A closer scrutiny of this evolution, butin juxtaposition to what was happening in the related fields of childhealth, education, and welfare, would lead one to the following con­clusions:

(1) Progress has been made in behalf of children in our com­munities.

(2) This progress brought with it changes in family structure andidentity, changes in the spectrum of health and illness in children,changes in the structure and function of child caretaking services;and in turn, all of these changes brought with them changes in thespectrum of emotional disorders in children.

(3) These changes in the spectrum of emotional disorders in chil­dren were not anticipated by the various fields of child health, educa­tion, welfare, and psychiatry, who continued to offer services basedon previous beliefs and not on existing or emerging knowledge.

(4) When it became clear that the existing patterns of serviceswere not effective, the fields of child health, education, welfare, andpsychiatry attempted to develop new services, but these services werenot yet based on the new knowledge of the changing spectrum ofemotional disorders in children, and thus led to an increasing mis­match of the service to the needs of the child and family.

(5) This state of affairs of an increasing mismatch of service ledto the point wherein the same child might be viewed by the courtas a juvenile offender, by the child care agency as a problem of depen­dency and neglect, by the family agency as a problem in family dis­unity, by the pediatric center as a physical problem, by the child psy­chiatric center as a personality problem, and by the school as a learn­ing problem.

(6) The many issues and problems which then emerged andwhich seemingly belied the progress made, resulted from the un­anticipated changes in the spectrum of emotional disorders in chil-

Patterns of Child Psychiatry 21

dren and the development of new services which increasingly mis­matched the type of service to the nature of the problem.

(7) Finally, each field responsible for the health, welfare, andeducation of children was caught in a double bind of unwittinglysupporting the development of an ever-increasing amount of chroni­cally disturbed children while at the same time consciously and pri­marily developing services to treat only those children overtly dis­turbed.

If these conclusions are valid, it becomes apparent that though ouremphasis on the need for more services, more personnel, and morefacilities for disturbed children may be correct, we run the risk ofagain repeating our costly and painful history unless we take activesteps to correct our existing errors. It would seem to me that ourpast history is a tale of too little, too late, and that our future historymay repeat the story unless we can be bold to apply what we do knownow. We must bear in mind:

(1) That current statistics of the number, frequency, or incidenceof emotional disorders in children in our country, at best, are con­servative estimates, and will continue to show an increase as progressand the current patterns of child health, welfare, and education con­tinue.

(2) That valid epidemiological studies of emotional disorders inchildren cannot be done as long as "hidden" reservoirs for emotionaldisorders exist and are not tabulated.

(3) That the impression of behavioral clinicians, engaged in workwith children, attests to the belief that a state of emergency has existedand continues to exist with regard to emotional disorders in children.

(4) That studies on the effectiveness of child psychiatric servicecan only show negative results as long as they are based on our emerg­ing knowledge of etiology of emotional disorders in children, ourpast and current patterns of service and operation, our lack of agree­ment on definition of terms, the complex nature of clinical materialin our child guidance clinics, the issues existing between researchmethodology and clinical practice.

(5) That the pressure for and establishment of an increased num­ber of child psychiatric services will not appreciably make a dent inour current emergency unless these services are enabled at one andthe same time to:

22 Meyer Sonis

(a) develop a model of service for the emotionally disturbed childand family, with a history of chronicity evident;

(b) develop a model of service for the emotionally disturbed childand family, whose covert disturbance is precipitated overtly by anacute crisis;

(c) take medical responsibility for aiding the fields of child health,education, and welfare in developing criteria for the early identifica­tion of emotional disorders in children, and a plan of interventionbased on the nature of the problem;

(d) participate in conjoint effort with all child caretaking servicesand professions in the task of primary prevention.

(6) That community duplication and fragmentation of efforts,in behalf of emotionally disturbed children, does exist. That sucha state of affairs will continue to exist as long as: the child caretakingprofessions vie with each other for the distinction of the primaryrole; mental health practice or studies are approached as if separatefrom physical health; a lack of clarity of their function, role, respon­sibility, and setting pervades the child caretaking professions.

For those of us engaged in the field of child psychiatry, the im­portance of these conclusions and this painful history is in its sig­nificance for the future of the community child guidance clinic, andthe question of whether the community child guidance clinic canpositively and soundly accept the challenge of change.

In summary, it would seem to me that the enviable past recordof this organization, in supporting the development of child psy­chiatry in this country, holds out a promise of fulfillment of our goalif we can now accept the bold challenge of change. We must re-exam­ine our clinics and organize the already-existing rudimentary struc­ture of our future direction into:

(1) Patterns of child psychiatric services which could match thespectrum of emotional disorders in children through the coordina­tion and integration of our existing services such as the outpatientcommunity child guidance clinic, the psychiatric hospital for chil­dren, the day care and nursery center for disturbed children, thediagnostic and evaluation centers, and the pediatric centers.

(2) Programs of child psychiatry, whose organization of servicescould be related and available to the various community child care­taking services, as these nonpsychiatric services may tend to become"reservoirs" of hidden emotional disturbances in children.

Patterns of Child Psychiatry 23

(3) Patterns of child psychiatric programs which could present amore valid epidemiological picture of emotional disorders in chil­dren through the capacity of these programs to reflect the currentspectrum of emotional disorders in children, the type of service neededto match this spectrum, the earliest signs of mismatch, and the futuretrends in spectrum and type of service needed.

(4) Programs of child psychiatry which could then participate withlocal, state, and national bodies in planning for the future needs ofemotionally disturbed children, but on the basis of fact rather thanpressure.

(5) Programs of child psychiatry which could join with all otherchild caretaking services in fostering community plans for coordina­tion of child services, in order to minimize the practice of containmentof emotional disturbances in children or run the risk of losing the emo­tionally disturbed child between the various services. In such plans forcoordination, support must be given to methods of early identificationof emotional disorders in children, and the designation of the serviceor combination of services necessary to match the nature of the prob­lem.

(6) Programs of training in child psychiatry, based on patternsof service as outlined above, which could thus prepare each residentfor his current and future responsibilities as these relate to: the cur­rent spectrum and changing pattern of emotional disturbances inchildren; the current and changing spectrum of child health, educa­tion, and welfare services; the changing pattern of education of thephysician, social worker, psychologist, teacher, nurse.

(7) Finally, we must re-examine our clinics and organize the al­ready-existing rudimentary structure of our future direction into pro­grams of child psychiatry which could offer a maximum opportunityfor clinical, developmental, and operational research based on co­ordination and integration of efforts rather than on diffusion, frag­mentation, duplication, and mismatching.