ED 035 136

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PUB DATFNOTF,AVAILABLE FROM

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ABSTRACT

DOCUMENT RESUME

EC 004 788

Mental Health Services for Children; Focus: TheCommunity Mental Health Center.Oct 6824D.Superintendent of Documents, U.S. GovernmentPrinting Office, Washington, D.C. 20402 00.30)

EDRS Price MF-$0.25 HC Not Available from EDRS.*Community Health Services, Community Programs,Consultation Programs, Cooperative Programs, DayCare Programs, Educational programs, *EmotionallyDisturbed, *Exceptional Child Services, HealthPersonnel, Medical Services, *Mental Health, MentalHealth Programs, Physical Facilities, Prevention,Professional Training, *Psychiatric Services,Special Programs

The need to help the emotionally disturbed isdiscussed with a focus on community mental health centers.Psychiatric services described are diagnosis, inpatient care, daycare, outpatient care, emergency care, continuity of care andservices, and care adjusted to age groupings ranging from infancy toadolescence. Aspects of the community goal of prevention consideredare detection through consultation; the education of teachers,parents, and the general public; and special programs, such astutoring, designed to help poverty areas. Attention is also given toresearch and evaluation, the training of staff and professionalDersonnel, the facilities and physical plants of institutions, andplans for establishing a community mental health center. (JM)

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Mental Health Services for Children

Mental HealthServices for Children

Focus: The Community Mental Health Center

October 1968

U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE

OFFICE OF EDUCATION

THIS DOCUMENT HAS BEENREPRODUCED EXACTLY AS RECEIVED FROM THE

PERSON OR ORGANIZATIONORIGINATING It POINTS Of VIEW OR OPINIONS

STATED DO NOT NECESSARILYREPRESENT OFFICIAL OFFICE OF EDUCATION

POSITION OR POLICY.

National Institute of Mental HealthHealth Services and Mental Health Administration

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFAREChevy Chase, Maryland 20203

,it...11r,JI

111

Prepared byPublic Information Branch

andCenter for Studies of Child and Family Mental Health

National Institute of Mental Health

Public Health Service Publication No. 1844

For sale by the Superintendent of Documents, U.S. Government Printing LaceWashington, D.C. 20402 - Price 30 cents

Contents

Foreword 1

Help: Needed Now 3Help: How? 3Treatment: A Variety of Services 5

Diagnosis 5Inpatient Care 5Day Care 7Outpatient Care 7Emergency Care 8Continuity of Service 8Infants to Adolescents 9

Prevention: The Community's Goal 10Consultation 10Education 11

Other Special Programs 12Research and Evaluation 14Training 15Staff 16Facilities 17Establishing a Center 19

iii

4,- "V .311.4100

Felneword

The figures speak clearly for themselves: the number of children

suffering from mental or emotional disturbances today constitutes aproblem we cannot ignore, the number seeking treatment is risingsteadily, and adequate treatment facilities and personnel are sorely

lacking.The community mental health center can be the focus for a wide

variety of facilities and services needed to help children and their families.

Various groups and agencies can work together to provide the needed

services.The community mental health center is ideally suited to handle the

mental and emotional problems of young people within the context of

home and family life. During the early years in a child's development,

timely therapeutic intervention and social restoration in familiar sur-roundings can do much to prevent serious problems later in life.

The mental health center, in conjunction with other communityprograms, can also act as a preventive force in the community. Its con-sultation and education service can help protect and strengthen themental health of children and adolescents through work with schools,well-baby clinics, and other community agencies which serve youngpeople.

Examples of successful children's programs in a variety of settingsare presented here, not as exact models, but as suggestions of what canbe done in community programs to improve treatment and preventiveservices.

Total mental health care for the entire communitythe goal of thecommunity mental health centers programincludes services gearedto the mental health needs of children and their families. These needsdemand effective treatment and early intervention; but beyond this, theprimary prevention of illness and disability is our essential task. Thehealthful development of all childrenincluding the disadvantaged andthe most vulnerableis our imperative goal.

Stanley F. Yolles, M.D.Director

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Mental Health Services for ChildrenFocus: Community Mental Health Centers

NATIONAL INSTITUTE OF MENTAL HEALTH

Help: Needed NowIt is estimated that as many as 500,000 children in

this country suffer from psychoses and borderline psy-chotic conditions and that another million are afflictedwith personality and character disorders.

Of the 50 million school age youngsters, evidencesuggests that between 10 and 12 percent have mod-erate to severe emotional problems requiring somekind of mental health service.

Among some 300,000 children seen in outpatientpsychiatric clinics each year, only one in three re-ceives more than a diagnosis.

Among the 15 million youngsters in the UnitedStates who are being reared in povertyone out ofthree has serious emotional problems that needattention.

More than 500,000 youngsters are brought beforethe courts each year for antisocial acts. If presenttrends continue, one in every nine youngsters will ap-pear before a juvenile court before the age of 18.

Suicide is believed to be the fourth ranking causeof death among 15- to 19-year olds. Adolescents ofcollege age present the highest potential suicide riskgroup within the population.

The number of children and adolescents being ad-mitted to and resident in mental hospitals is increasingmore rapidly than their increase in the population.For example, since 1950 the number of boys widerthe age of 15 has doubled but their number in mentalinstitutions has quadrupled.

Projections for the decade 1965-1975 predict a 10percent population increase of children under the ageof 18. If current patterns persist, the number of thesechildren in mental hospitals will more than triple.

The number of children in the 15- to 24-year-oldage group is expected to increase by 36 percent in thepopulation as a whole, but by 70 percent in wardsof mental hospitals.

It is estimated that approximately 5 percent of thechildren in the United States who need psychiatrichelp are getting it; and of those who are treated, lessthan one-half receive help that is of the kind, quality,and duration needed.

These figures and others compiled by the NationalInstitute of Mental Health indicate the acute and im-mediate need for a wide range of effective communitymental health services for children and adolescents.

Adequate facilities for children which provide con-tinuity and variety of services, are lacking in mostareas of the country.

Help: How?Under a national mental health program providing

Federal support for the construction and staffing ofcommunity mental health centers, comprehensivemental health services are being made availablethroughout the country, in many areas for the firsttime.

Since the enactment of the Community MentalHealth Centers Act in 1963 more than 260 centershave been established, bringing services within reachof 41 million Americans, including 15 million chil-dren. These centers are serving their communitiesin cooperation with many agencies and communitygroups.-It is anticipated that by 1970, 500 centers willbe in operation.

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Services for children can be organized in the com-munity in a number of ways. A variety of facilitiesand types of programs are neededfrom special schoolor residential treatment centers, for example, to teen-age clubs and recreation areas. These may be incor-porated within the total program itself, or in affilia-tion with a center, or in liaison with a center pro-gram. For example, a child guidance clinic or resi-dential institution may choose to affiliate with otheragencies to form a comprehensive program. An ex-ample of such a cooperative effort is the Grand ValleyCommunity Mental Health Centers Compact in GrandRapids, Michigan. A child guidance clinic, a generalhospital, and a county mental health center are theprincipal affiliates in a coordinated community men-tal health program. In addition, several local child-caring agencies and the Board of Education are col-laborating to provide comprehensive and coordinatedservices for children.

Whatever the arrangement, Federal assistance forconstruction or staffing requires that the overall cen-ter program include five essential elements of care;inpatient and outpatient services, partial hospitaliza-tion, emergency services, and consultation and edu-cation.

Such a program can help children and adolescentsthrough its direct services which focus on the treat-ment and rehabilitation of those who are ill, andthrough its more indirect services which emphasize pre-vention through work with schools, physicians, andother professionals in the community.

The preventive services of the center are especiallyimportant for the mental health care of the com-munity's youth. These services can create a store ofmental health competence among the many adultsteachers, doctors, clergymen, police, and parentswho

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work with the young. New programs for preventiveintervention in schools, prenatal clinics, and well-babyclinics are being reported, as well as therapeutic nurs-ery school programs. Mental health research projectspoint the way to early child care programs to enrichthe rearing of deprived youngsters.

The availability of active treatment services in thecommunitywhether inpatient, outpatient, or emer-gency caremeans that the disturbed child or adoles-cent can receive the type of care he needs near hishome and family. Institutionalization is frequently un-necessary, or may be kept very brief, provided alterna-tive services are at hand.

Community programs for the disadvantaged childand his familysuch as day care centers, neighbor-hood health centers, maternal and child care facili-ties, and youth activity groupscan work togetherwith their local mental health center to form a compre-hensive network of care and prevention services.

Cooperation among agencies is essential. Possibili-ties for pooling resources and for joint funding shouldbe explored. A variety of solutions are possible and mustbe sought for the variety of problems and needs inchild and family mental health.

Rural and sparsely populated areas where resourcesare limited may be served by satellite units of a regionalmental health center program. Or they may be servedby "teams on wheels," with staff setting up servicesin a church basement, for example, or in a school, orother town building.

Facilities for services may range from store-frontneighborhood service centers'in urban areas to regionalor community treatment centers equipped with cot-tages for residential care. Whatever the arrangement,a mental health center can coordinate the youth serv-ices in its area, or itself undertake to meet the needs.

Treatment: A Variety of Psychiatric Services

Diagnosis

Differential diagnosis is the essential forerunner ofgood treatment. When a child exhibits symptoms ofbehavioral or emotional disturbance, the professionalstaff of a children's service can determine whetherthese symptoms are transient problems of maturationor evidence of more serious developmental disorders.The diagnosis, including whatever physical or psy-chological tests are needed, sets the stage for planningappropriate treatment. Guidance to parents and briefprofe'ssional attention to the child's problem at theright time may be all that is required.

In the adolescent service of the Maimonides Com-prehensive Mental Health Center in Brooklyn, NewYork, a professional team uses family therapy as acentral diagnostic and treatment tool. Therapy beginswith the initial family interview. Joining in the firstsession is a team composed of a psychiatrist (teamleader), two psychiatric social workers, and a psychi-atric nurse. Individual members of the team may thenfunction as solo-therapists in subsequent meetings.After the first session, in which the family of the dis-turbed adolescent is interviewed both as a family unitand as individuals, the team determines the nextstage in treatment.

Since schools, family physicians, courts, and socialwelfare agencies refer children to the center, the diag-nostic service affords a unique opportunity for com-munity collaboration. Effective communication acrossdisciplinary and agency lines is essential in carryingout treatment plans for children. Combined and co-ordinated sharing of information and treatment plan-ning can avoid wasteful duplication of effort.

For example, the Child Guidance Clinic of theGrand Valley (Michigan) Community Mental HealthCenters Compact, provides diagnostic service to theBoard of Education to assist in the screening of po-tential candidates for classes for emotionally disturbedchildren. Through this collaborative relationship theclinic staff identify the kinds of children who might

812-117 0-08-2

profit from a more specialized education experience,such as a day treatment program within the clinicalsetting.

An NIMH-sponsored project at the Virginia Treat-ment Center in Richmond, Virginia, demonstratesanother approach involving community cooperation.This is the Children's Psychiatric Hospital Field Unit,a program designed to improve continuity of carefor children. Staff teams go out into the communityto provide diagnostic screening, as well as referral, con-sultation, and followup services for agencies workingwith children.

Inpatient CareAlthough many children can be treated without full

hospitalization when other services are at hand, in-patient facilities for both acute and long-term careare needed and are still in severe shortage in manyareas. Beds are needed for psychiatric emergencies, forobservation to clarify diagnosis, for treatment whilelong-term plans are made, and for short-term careduring an acute crisis. The major need in communityinpatient services is for short-term bedsthat is, ac-commodations for children who need the service; for afew weeks to a few months.

Because of the limited number of patients who re-quire inpatient care, the mental health center mayutilize beds in a pediatric or psychiatric ward in a gen-eral hospital. General hospitals in numerous commu-nities are providing this service as partners in aprogram of comprehensive care for children. Servicesclose to home are particularly important for children,permitting family involvement in treatments For somechildren, specialized temporary foster homes may beuseful.

The inpatient service provides intensive care aimedat returning the child to his family as soon as pos-sible. Among the numerous treatment methods, suchas group, family and individual therapy, educational

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and vocational programs are of the utmost importancein treating children and adolescents. Education pro-grams prepare the child for his return to a regularschool; vocational programs prepare young peoplefor employment.

Among new programs and facilities being devel-oped for disturbed children are special residentialschools. If such a school is available in an area servedby one or more centers, it may arrange to affiliate orcooperate with the centers' programs. The centerscan provide diagnostic, referral, and followup serv-ices, home-visiting, and family therapy or consulta-tion. These and other services, added to the residentialservice, can round out and provide continuity for thechild's mental health care.

Programs for the "re-education" of moderately dis-turbed children can operate effectively even in areasof scarce psychiatric manpower. National attentionhas been attracted to Project Re-Ed, an NIMTIported demonstration program, directed by 31. NiCao-las Hobbs. A cooperative effort of the Departn .-ms ofMental Health in Tennessee and North Cat.-Lni.. andthe George Peabody College for Teachers in Nash-ville, the project is based on the theory that an edu-cational setting with its emphasis on health ratherthan illness encourages the development of healthyattributes in a child. "Re-education" is both in skillsneeded for normal school achievement and adjust-ment to the demands of life in general.

Project Re-Ed has demonstrated several features ofpotential interest. For example, the training and useof "teacher-counselors" in the intensive education-therapy program stresses the importance of selectingworkers whose personal attributes and qualities espe-cially qualify them for working with children. Investi-gators believe that teacher-counselors, working underconsultation with top-level professional personnel, canprovide a therapeutic environment for young patients,at reduced cost and time in residence. The averagelength of stay in the Nashville school is about sevenmonths.

Another type of inpatient school program is op-erated by the Los Angeles County General Hospital inLos Angeles, California. Two teachers from the cityschool system teach in a hospital wing reserved andadapted for adolescents; physical education is offeredthe young patients in the hospital gymnasium.

At Hawthornden State Hospital in Northfield, Ohio,a hospital improvement grant awarded by NIMH pro-vides a group of disturbed adolescents with classroomactivities six full periods a day. Five State-certifiedteachers give the instruction. The program offers ac-credited school subject material, as well as occupa-tional and recreational therapy, and arts and crafts.All children, regardless of diagnosis, are encouraged to

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apply themselves to learning so that they might betterhandle the expectations of school, job, and community,when they return home.

The Washington Heights-West Harlem Comprehen-sive Mental Health Center of New York City, re-cipient of NIMH funds, Ilas projected an imaginativeprogram for children and adolescents. The inpatientunit will provide beds for pre-school children, school-age youngsters, and adolescents. However, they will beinvolved in many activities off the wards and will at-tend the hospital's therapeutic school. The childrenresiding at the hospital and those in the day care pro-gram will receive their classroom instruction together.The center proposes to rotate teachers from the area'sschools, with the Board of Education assigning thestaff.

While classroom instruction should be available toall children of school age, vocational training can beof particular value to the adolescent. Training in vari-ous skills can be offered, in a program of therapy andrehabilitation to enable the young person to enterthe world of work. Helping him increase his confidenceand employability can be important to the success ofthe young adult's return home.

Michigan's Traverse City State Hospital, with an-other NIMH grant, operates a new vocational reha-bilitation program for adolescents and young adults.Facilities include a general shop area, print shop, andequipment for welding, sewing, typing, and cooking.While the program offers activities designed to en-hance the patient's feelings of personal and socialcompetence, it also aims to give the youngsters realisticvocational choices. It provides counseling, training inspecific marketable skills, job placement, and followup.

Projects now underway in several State hospitalswith NIMH support demonstrate active and intensivetreatment programs for young patients. The trend isto f, 7m on the children's strengths, and to estabvshexi einations for normal behavior and good workhabits, to encourage self-care, and basic socialization.Use of child care workers, student volunteers, and re-tired people, with emphasis on small group activitiesthroughout the total program, provides more intensivepersonal experiences and services for the child. Thetreatment goal is generally that of social recovery andreturn home as soon as possible.

For the successful rehabilitation of young patients,community support and cooperation are essential. Themore the community's helping hand is extended withlocal schools providing teachers, libraries lendingbooks, and volunteers tutoring and providing trans-portation to museums, parks, shopping centers, andtheatersthe easier it is for the young patient to re-turn to a normal life.

UV.

Day Care

Psychiatric day care is designed for those who donot need 24-hour hospitalization, but for whom out-patient therapy is inadequate or inappropriate. For thedisturbed child, it permits schooling in a therapeuticsetting and treatment while he lives at home. Daypatients may share educational, recreational, and vo-cational programs with inpatients, as well as grouptherapy sessions.

Several programs have demonstrated the effective-ness of treating disturbed preschool children in atherapeutic nursery school environment. For example,a nursery school at the Child Guidance Home of Cin-cinnati, Ohio, provides day psychiatric treatment fora group of preschoolers, aged three to five, who ex-hibit marked behavioral and emotional disorders. Thecollaborative, multi-disciplinary program offers a fullrange of diagnostic and treatment services for childrenand parents.

The James Jackson Putnam Children's Center inRoxbury, Massachusetts, has reported success in treat-ing antisocial children, aged three to six, who are toodisruptive to attend normal nursery school. The pro-gram, partially supported by NIMH, includes psycho-therapy and nursery school for the children and case-work with the parents.

At The League School in Brooklyn, New York, anursery school for schizophrenic children has enabledyoung psychotic patients who would otherwise havebeen institutionalized to continue living at home.

In Elmont, New York, "teacher-moms" weretrained to work with schizophrenic children, aged sixto nine, in a day care program based in a communityfacility. The cost was only slightly more than the an-nual per pupil cost for normal children. The programused regular school equipment and supplies, and com-munity resources such as recreation centers and busservices. Serving as teacher aides, the mothers helpedthe youngsters significantly by giving each one closepersonal attention and care. After three years in theprogram, half the children were able to return to full-time regular classes. The project has been duplicated inseveral areas.

Among services helping less seriously disturbedyoungsters is a day care program at the Des Moines,Iowa, Child Guidance Center. This provides dailyschedules of education and psychotherapy tailored tothe individual needs of each child. Children with awide variety of disorders have responded positively,many within a short time. Comparison with a con-trol group receiving only outpatient therapy suggeststhat a well-rounded day care service can decrease theduration of treatment.

The Jane Wayland Child Center, Phoenix, Arizona,for many years a child guidance center, is now part of a-comprehensive mental health center, and has expandedits program to include day care. In an NIMH-sup-ported project, two classes were set up for emotionallydisturbed children aged 7 to 11, who had been ex-cluded from the public schools because of conductand learning difficulties. The center had remarkablesuccess and was able to return several of the childrento their former schools at the appropriate age-gradelevel.

Partial hospitalization programs vary widely as dothe facilities 'offering them. At Los Angeles CountyGeneral Hospital, some adolescents spend their daysattending school and therapy sessions at the hospitaland go home at night. At other centers adolescents maygo to school or to jobs in the community by day andsleep at the hospital. Many visit their homes on week-ends and holidays, increasing their home stay as prog-ress permits.

With a small professional staff, the Peninsula Chil-dren's Center in Palo Alto, California, provides daycare for severely disturbed children. The success ofthe program rests on the use of well-trained childcare workers, and high school, college, and older vol-unteers. The director of the volunteer program, whorecently obtained a master's degree in social work, wasfirst introduced to the program as a high school vol-unteer. The Center is part of the Santa Clara CountyMental Health Center.

Outpatient CareOutpatient treatment is the most widely used serv-

ice for disturbed children and adolescents. Some 40percent of all patients seen in psychiatric outpatientservices in the United States are under 18 years of age.Presently, however, about one-fourth of these patientsobtain only diagnostic services.

In the past, outpatient care consisted almost en-tirely of individual treatment of the child and hisfamily; today, effective group programs have beenestablished. Nursery school, educational and activitygroups, family, and multiple family therapy are nowvital elements in many programs.

Family participation is the basis of a treatmentmethod being used successfully at the MaimonidesComprehensive Mental Health Center to treat dis-turbed adolescents. Maimonides calls the techniqueMultiple Impact Therapy. It involves an initial inter-view with the family of the young patient. The theoryis that seeing the family as a unit and observing itsdynamics, provides an opportunity to build the strength

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of the family as well as its individual members. Thosefound by the professional team to be most in neednot always the referred patientreceive individualor group treatment. In some instances the family meetsin group sessions over a period of months.

A five-year project supported by NIMH at the NewOrleans Regional Mental Health Center demonstratedthe effectiveness of an outpatient clinic-school fordisturbed children with learning problems, in con-junction with special sessions for their parents. Thechildren, a group of six- to twelve-year-old boys, at-tended regular classes in the public school in the morn-ing and were tutored at the clinic in the afternoon.The mothers met in group meetings during the day,and the fathers met in the evenings in weekly one-and-a-half hour sessions. Consultation concerning the chil-dren was provided to their public school teachers. Theprogram for each child was limited to five-and-a-halfmonths, at most. A one-year follow-up indicated thatabout ninety percent of the children were adaptingsuccessfully in their regular schools.

A different type of outpatient service is being imple-mented at the Washington Heights-West HarlemComprehensive Mental Health Center. There, aneffort is being made to bring neighborhood-basedservices to parents and children, away from the Centerbuilding whenever possible. Comprehensive care teams,responsible for their own sub-community, work in vari-ous places, such as a YMCA, a neighborhood servicecenter, or a community hospitalwhichever is mostconveniently located for service.

Emergency CarePsychiatric emergency services are essential to a

comprehensive program for children. A delinquentact, destructive outburst, or suicidal attempt requiresimmediate attention. Emergency service may also beneeded for children in panic, or for a disturbed childin a home crisis. Prompt professional attention in crisissituations can often prevent family disorganizationand serious disability.

Ideal emergency programs offer walk-in and tele-phone service 24 hours a day, and home visits. Anemergency service is most effective when staffed bypersonnel who have had specific training in handlingpsychiatric emergencies.

The Massachusetts Mental Health Center in Bos-ton offers 24-hour emergency service for patients under18 as part of its child psychiatry program. A child maybe brought in or an adolescent present himself at anyhour of the day or night. Immediate attention is fol-lowed by referral to a service of the Center or to anothercommunity agency, if needed.

An emergency telephone service at the D.C. Gen-eral Hospital, staffed by specially trained personnel,reports success in providing therapeutic counselingon the phone. The majority of callers are advised tocome to the area's mental health center for an evalu-ative interview or are referred to other communityagencies.

Home visits in response to emergency calls may elim-inate the need for hospitalization or dramaticallyshorten required treatment. In familiar home sur-roundings, people may be more reachable than in ahospital or clinic. One emergency service reports thatits policy of a home interview for every referral oftenresults in help for other family members, as well.

Suicide preventi6 Jervices can reduce the alarmingincidence of preventable tragedy in this countryoneout of every hundred deaths in the U.S., of whichthree percent are children and adolescents. In 1958there were three suicide prevention centers in theUnited States. This number has grown to more than80. Each center provides a telephone answering-refer-ral service for potentially suicidal persons or their wor-ried relatives or friends, who may telephone at anytime during the day or night for assistance.

Another kind of emergency service, which stressesearly intervention and prevention, is the "crisis familyinterview" technique employed by the Julia AnnSinger Preschool Psychiatric Center in Los Angeles,California. Recognizing that critical events in a child'slife may foster unhealthy reactions, the Center pro-vides family counseling when crises occur. Familiesare helped to deal with transition to school, with ill-ness, divorce, or death.

The success of any emergency service, for child oradult, depends on people's awareness of its availability.Therefore, cooperation with other agencies and pro-fessionals in the community is necessary. The teacher,physician, or welfare worker confronted by a psychiat-ric emergency needs to know where he can turn, justas the person answering the phone at a mental healthcenter needs to know what community resources canprovide prompt assistance when psychiatric care isnot appropriate to a particular "emergency."

Continuity of ServiceThe range of mental health services described above

makes possible continuity of service and care, and earlyattention when children need help. Coordinating thecommunity's mental health services within a centerprogram also serves to avoid duplication of effortamong agencies. The center may develop as a centralpoint of referral to other services in the community.

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The child or adolescent may be the concern of anumber of persons and agencies other than his family.Early consultation with the family physician or teacheror welfare worker, can be especially valuable in plan-ning treatment or referral.

For young patients discharged from a State hospi-tal, the mental health center can provide the followupservices so often needed and so rarely available upontheir return home. Liaison with the State hospital per-mits planning ahead for the desired aftercare. Thechild 'or adolescent leaving the hospital may needplacement in a foster home, or in a halfway house;he may need day care or outpatient treatment. Provid-ing for his needs in a home-based program may shortenhis stay at a hospital or help to prevent his rehospi-talization.

The mental health center can provide an importantbase for the services required.

Infants To AdolescentsThe needs of a child at a particular level of growth

make special demands. For instance, family therapyis being used widely in treating the young school childas well as the teenager. While many adolescents wouldprofit, however, from a vocationally oriented rehabili-tation program, younger children ordinarily wouldnot.

The infant benefits most from the center's preven-tion programs, as discussed in the following section.These include guidance to parents and physicians inrecognizing the signs of possible mental and emotionaldisturbance, and education toward positive mentalhealth in family life.

Consultation and training sessions for pediatricianshave proven valuable in detecting early problems insuch programs as the Kaiser-Permanente Medicalgroup seminar in San Francisco and the Cedars-SinaiMedical Center in Los Angeles.

Counseling to parents in mental health and well-baby clinics is also important. A mental health centeraffiliated with a general hospital or public health de-partment is in a good position to provide such help.

The pre-school child, who may suffer problemsranging from mild behavior disturbance to severeautism, may require, in addition to individual therapy,

a therapeutic nursery school. At the Julia Ann Sing^rPreschool Psychiatric Center a three-to-four monthnursery school experience for the child is supplementedby group therapy for the parents and by multiple fam-ily therapy for some of the families with severely dis-turbed children.

The young school child, aged six to twelve, maysuffer any one of a range of mental and emotional dis-turbances, from learning and discipline problems towithdrawal, depression, and psychosis. The center'svariety of treatment services makes it possible to treata range of disturbances. Research indicates that tenpercent of school children who need help can beidentified as early as the third grade. Collaborationwith the public schools is vital in setting up specialeducation classes in the school or the center.

The adolescent is a fast-developing young personmaking his own particular way to adulthood. This pe-riod of maturation entails vulnerability to emotionaland mental difficulties. In this age group, half of thosewho enter treatment suffer illness serious enough to bediagnosed as psychosis, and require inpatient care.

In the mental health center, group therapy for ado-lescents may take the form of a "club," its membersmeeting regularly and becoming involved in projectsof their own choosing. These kinds of sessions give thetherapist the opportunity to observe interactions, andgive the young people a chance to share with othersin facing and working out some of their problemsas they pursue their joint activities.

Serious "acting-out" problems may bring the ado-lescent into conflict with school or legal authorities.In such cases, the community mental health center,locally based and cooperating with other communityagencies, can provide vital assistance. It can help theadolescent avoid the frustrating round of referralsfrom school to social agency to court to detention cen-terthat frequently confronts him.

The San Fernando Valley Community MentalHealth Center in Los Angeles, California, has an inno-vative Drop In Clinic for adolescents which meets twoafternoons a week (11/2 hours each session) . Adoles-cents who are concerned about any problem may at-tend. The parents are seen in a separate group. Theyoung person who may need treatment over a periodof several months is then assigned to another programin the center.

Prevention: The Community's Goal

The key attack against mental and emotional ill-nesses lies in prevention : in whatever can be done tohelp assure the healthful development of the young,during life's most formative years. Children need aclimate of love, of mutual respect, of appropriate limits,of being cared for. They need an environmentathome and at schoolwhich fills their need for guid-ance, for discipline, for enrichment of their potentialas creative and productive human beings.

"Preventive psychiatry," therefore, can perform auseful purpose by signalling those elements of childrearing, of school practices and community programs,which foster the healthy growth of children into matureadults.

The community mental health center can offer di-rect services for the prevention of mental illness andthe promotion of mental health, as well as consulta-tion and education programs. Intervention throughschools, physicians, and agencies can be a vital con-tribution to child mental health. But prevention beginseven earlier. It begins with family planning and withthe healthy attitudes of those who will marry and be-came parents. it begins with their competence andcaring, and with the world in which their child willlive and grow.

Family planning is an obvious and vital element inpreventive psychiatry. The child who is eagerly wel-comed by his parents begins life on the best possibleterms. Community mental health centers are en-couraged to include education and consultation forfamily planning as a preventive service. Such a serv-ice should be offered selectively and sensitively, and infull accord with the desires and values of the family.

Counseling for parents at prenatal and well-babyservices is being tried in some preventive programs. AnNIMH-supported project at the Group Health Asso-ciation of Washington, D.C. demonstrated the valueof counseling parents who were expecting their firstchild. The counseling service was made available inthe obstetrical-gynecological department of GHA,a comprehensive, prepaid group practice health plan.The project reported that preventive mental health

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services can be operated effectively in conjuTlction withother services where crucial developmental milestones,such as a first pregnancy, are encountered.

ConsultationThe mental health center's consultation services for

the community can become a key resource for pre-venting illness and promoting mental health.

Consultation provided professionals, agencies, andinstitutions dealing with children and families canmake possible early detection of problems, and pre-ventive care before and early in parenthood andthroughout the life of the child. The services mayrange from lending assistance to a teacher in handlinga particular child, to seminars for physicians, teachers,clergymen, or police. Mental health consultation pro-vided for prenatal and well-baby clinics, nurseryschools, and day care centers can guide the healthydevelopment of children from their earliest years.

The family physician or pediatrician is in an ex-cellent position to observe mother-child relationshipsthat may be detrimental to the child, and to provideon-the-spot assistance. Recognizing this fact, theKaiser-Permanente Medical Group in San Franciscohas conducted seminars for pediatricians to help themdetect early signs of mental disturbance in children,and to help them modify harmful family processes. Inanother program, a social worker is assigned to theGroup's department of pediatrics where she is avail-able to the physicians for consultation, and to parentswho are referred to her for help.

Exerting an influence on the developing child sec-ond only to that of the family, the school has a specialresponsibility for fostering healthy growth. When givenassistance by mental health specialists, school admin-istrators and teachers can detect and deal with manyearly signs of disturbance in children and their families.Mental health professionals can also consult withschools on special education classes for disturbedyoungsters.

I.K.-40.0.1.10

The NIMH Mental Health Study Center in PrinceGeorge's County, Maryland, helped set up a schoolproject to assist a group of nonachieversseven boys

who had repeated first grade or failed the second.Consultants aided in screening and evaluating the stu-dents and their parents. A special class was organizedat the school to improve the boys' educational andsocial achievement, aiming toward their return toregular class. Three other services were brought to bearon the problem: a mental health nurse visited theboys' homes monthly, a psychologist held weekly groupsessions with the parents, and consultation confer-ences were held regularly with the teacher and otherschool personnel.

Maimonides Comprehensive Mental Health Centerprovides several consultation services for children. Inone program, assistance is at hand when a teacher re-ports difficulty with a child in the classroom. A socialand developmental history of the child is given to oneof the center's staff, who is invited into the classroomfor observation, and for appropriate follow-up.

Some centers must deal with special mental healthproblems, such as a high incidence of drug abuse andbehavior problems among children and adolescents.In response to these needs, the center can providecounseling services for neighborhood groups such asschool drop-outs and youth clubs.

Another NIMH project in Maryland stressed theimportance of a consultant's being sensitive to thespecial problems encountered by other professions.Before offering their services, two psychologists firstspent about two weeks riding in county police cars toobserve the problems policemen face daily. Followingthe "consultation-on-wheels" the psychologists con-ducted a thirteen-week seminar to help the officersbetter understand the behavior and emotions of chil-dren and parents.

Another kind of consultation service emphasizes theuse of existing community resources for treating thedisturbed child. Educational therapists of the JuliaAnn Singer Preschool Psychiatric Center frequentlyvisit the area's nursery schools to determine theirsuitability for children who may need special attention.The Center has found that a regular monthly con-sultation program with nursery school teachers makespossible the placement and maintenance of some dis-turbed children in regular schools.

At the Center, consultation is also provided throughdemonstration and discussion, When a child is re-ferred for diagnosis, the person making the referralteacher, doctor, or agency workerobserves the initialfamily interview through a one-way mirror, and par-ticipates in the diagnostic conference. Every effortis made to keep the child under the guidance of hisregular teacher and doctor.

Education

The aim of the center's educational activities is tohelp the community understand the nature of mentaland emotional illnesses and principles of good mentalhealth. Education programs vary according to com-munity needs and resources. Often, they are developedin response to requests from parents, teachers, clergy-men, police, or others who work with children. Suchprograms may take the form of informal workshops,seminars, or lectures. The first step in a center's edu-cation program is to make the community aware ofthe services it can render.

An example of an education program for schoolsis one provided by the Maimonides ComprehensiveMental Health Center, in which a clinic psychologistconducted a course of weekly discussion sessions withsmall groups of teachers. In addition, the members ofthe Child Psychiatry staff led discussions at regularfaculty meetings on topics related to child mentalhealth.

The best way to prevent mental and emotional dis-turbances in children is by providing a healthy environ-ment at home. Education programs for parents canperform a useful service. One effective program is thetwelve-session Parent Education Group at the JuliaAnn Singer Preschool Psychiatric Center, for parentsof children undergoing treatment. In another, theMaimonides Center conducted a program for parentson family life. The Parent-Teacher's Association, localservice organizations, and merchants in the communityhelped distribute fliers publicizing the education pro-gram, which consisted of weekly discussion sessions.

In a program that combines the benefits of parenteducation and the nursery school experience, the GrandRapids Child Guidance Clinic has been offering a suc-cessful prevention service for several years. Twelvemothers and their pre-school children come to theWell Child Center one morning a week for ten weeks.The mothers' group discussion combines explanationand discussion on child development,

Particularly valuable in the area of prevention t.,reprograms providing information to expectant parents,especially those about to become parents for the firsttime. Such programs may be undertaken by a cen-ter in collaboration with health or welfare agencies,or civic groups.

An effective education program can also disseminategeneral mental health information to the communitythrough pamphlets and other printed matter andthrough the imaginative use of local radio, television,and press.

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Ii

Other Special Programs

Mental illness is a major concern at all levels ofsociety; it strikes rich and poor, educated and unedu-cated alike. However, the deprivation associated withpoverty, a disrupted family life, and inadequate school-ing plays a considerable role in the development andexacerbation of mental and emotional handicaps. Thepoor are subject to the greatest amount of familybreakdown through separation, death and divorce.They are most often the under-educated, the unem-ployed. Their children are more likely to be under-nourished. These circumstances are obstacles on theroad to sound mental health.

A large number of Americans are adversely affected.Based on a poverty index for 1965, 34 million peopleare living in poverty. Fifty million are classified as lowincome. Included in this group are from 21 to 31 per-cent of the Nation's children.

Responding to the special needs of disadvantagedchildren, a variety of programs across the country areattempting to correct the defects of a deprived en-vironment. Working mothers, for example, need agood day center program for their children, offeringaffection and mental stimulation.

A community mental health center that is responsiveto the needs of its catchment area will participate in orinitiate the necessary programs.

Authorities now recommend that children's serv-ices give high priority to the first three years of a child'slife, rather than to later stages of development, sincechildren under three already show severe marks ofsociocultural deprivation.

Research has demonstrated that infants reared inculturally deprived, low-income homes can show alower intellectual level than other infants as early as15 to 18 months of age. A recent project in Washing-ton, D.C., under the direction of Dr. Earl S. Schaefer,an NIMH psychologist, demonstrated that "tutoring"can raise the I.Q.'s of infants from deprived families.A group of 14-month-old infants were tutored bywomen college graduates experienced with young chil-dren. They spent an hour a day with the youngsters,usually in the children's homes, talking with them,reading to them, playing with them, or taking themon walks or trips. Preliminary results show that thechildren given this enriched stimulation have a sig-nificantly higher intellectual level than those in an un-tutored control group.

Tutoring programs such as these provide an ex-cellent opportunity to use community volunteers, notonly the college-trained, but also high school students.A community mental health center may furnish thenecessary professional supervision.

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Whereas special programs for infants may preventthe development of problems, older children may al-ready show signs of mental or emotional difficultiesthat call for help. Secondary prevention efforts forthe preschool or school-age child involve early iden-tification of problems and therapeutic intervention.Two NIMH-supported projects have demonstratedthe effectiveness of screening culturally deprived pre-schoolers needing "emotional first aid" before enteringfirst grade.

The Child Study Project in Sumter, Soiith Carolina,screened youngsters starting school and provided coun-seling, consultation, and treatment in cases callingfor intervention. Special summer sessions for the trou-bled children were established in three demonstra-tion schools. Most of the children made dramatic prog-ress in adjusting to school. The project received theAmerican Psychiatric Association's 1967 Gold MedalAchievement Award. A permanent staff of 33 "inter-ventionists," including social workers, speech ther-apists, and home visitors, have been added to theSumter school system. Preschool screening programsmodeled after the Sumter project have been estab-lished in a number of other States.

A project in Quincy, Illinois, tests and interviewschildren entering kindergarten in four elementaryschools which have a high percentage of later schooldropouts. The children are checked again in the fourthgrade. Those lagging in mental, emotional, and socialdevelopment are given individual counseling. Testinghas revealed that the IQ's of some children in theprogram have risen several points between kinder-garten and fourth grade. Absenteeism has dropped,and student and parental interest and participation inschool and extracurricular activities have increased.

Both programs stress the importance of screeningyoungsters in high-risk communities. Such programsare best based in the schools, but require professionalconsultation and assistance which a community men-tal health center can provide.

For the child with adjustment difficulties in schooldue to deficiencies at home, direct intervention is re-quired. An NIMH-supported project in Wood lawn,a predominantly low-income Negro area of Chicago,is designed to improve adaptation in first-grade young-sters. The program consists of weekly classroom ses-sions with children and their teachers, as well as con-sultation sessions with school administrators, teachers,and parents. An important feature of the programis the active participation of the community. Residents,including parents of the children, are members of theBoard of Directors which guides center policy andsupports the educational effort.

The success of school programs such as these de-pends on the involvement of key people in a child'slifeparents, teachers, physicians, etc.in a con-certed effort to provide a better environment for allchildren. Good schools and good homes are vital foroptimum child development.

Preventive intervention must reach disadvantagedand handicapped children of all ages. An adolescentlacking necessary educational and vocational skills ismost likely to have adjustment problems. Center staffcan provide counseling to youth clubs and communityrehabilitation programs designed to meet this need.

Among efforts in this area, NIMH investigators havedemonstrated a successful new approach to rehabilitat-

ing disadvantaged, delinquent boys. They providedthree servicesjob placement, remedial education, andpsychotherapyto a group of ten 15- to 17-year-oldyouths who had either just withdrawn or been sus-pended from a Maryland school. The ten-month pro-gram was effective in returning all but one of the boysto school or job. The researchers recommend thatmental health agencies develop services along multi-disciplinary lines to help deprived youth.

The mental health center can be one of many com-munity partners engaged in combating the adverseeffects of poverty and other handicaps. Its role is asvaried as the needs of the children it seeks to help.

Research and Evaluation

The community mental health center offers a uniquesetting for innovative and imaginative approaches tothe treatment and prevention of mental illness.

For example, it is ideally situated to conduct popu-lation studies to determine its community's particularneeds. It may institute new modes of therapy, con-sultation, and education. Its ties with other com-munity agencies enable the center to discover whatkinds of cooperative activities are most effective.

To illustrate, a center may sponsor a fact-findingstudy to determine the incidence of delinquency ordrug abuse in its area. If the problem warrants at-tention, the center may wish to collaborate with youth

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organizationsboys' clubs, YMCA'sto study theeffectiveness of youth action programs.

A system of program evaluation, based on compre-hensive and unified record-keeping, is necessmy toinsure efficient and effective operation and the mostproductive use of professional and non-professionalpersonnel.

NIMH supports a variety of research projects inthe field of child and family mental health. Informa-tion and consultation regarding such support is avail-able from the Center for Studies of Child and FamilyMental Health, Division of Special Mental HealthPrograms.

Training

The mental health center also offers a valuable train-ing ground for various types of professionals and sub-professionals. Centers near universities or teachinghospitals can arrange for training affiliations. On theone hand, extension courses from a nearby universitymay provide training for staff members such asteachers, nurses, social workers, and therapists whoneed special instruction in working with children.Conversely, a center can provide valuable clinical ex-perience for those training to work with children.

Some centers offer training programs for profes-sionals in the community. For example, the Cedars-Sinai Medical Center in Los Angeles has a trainingprogram for physicians and child psychiatrists, pro-viding clinical experience in its well-baby clinic. Todemonstrate that the normal nursery school can be aneffective therapeutic setting for very young disturbedchildren, the NIMH is supporting a one-year train-ing program at the Center for experienced nurseryschool teachers.

The children's services of a mental health centerare an ideal training resource for students preparingfor careers in child mental health. Among children'smental health centers providing training programs forstudents is the Craig House-Technoma Workshop inPittsburgh, Pennsylvania. The center 'offers profes-sional training to students enrolled in university pro-grams related to education, rehabilitation, mentalhealth and public health.

Recognizing the need for many types of personnel,some centers offer training to child care workers andparents. For example, the Convalescent Hospital forChildren in Rochester, New York, recipient of anNIMH staffing grant, is a training resource for a vari-ety of persons in the community. In addition to train-ing programs for students from a nearby medical schooland for teachers of emotionally disturbed children,the center has instituted a training program for childcare workers. These aides are a valuable addition tothe Rochester center's staff.

The Maimonides Comprehensive Mental HealthCenter also conducts a variety of training programs,including in-service training for clinic staff and grad-uate students, field work experience for social workersand psychiatric nurses, and training to prepare a se-lected group of parents to teach remedial reading inthe community's schools.

Recognizing the widespread need for children's serv-ices and qualified personnel, the NIMH administersan extensive support program for training personnel inthis field.

The Institute currently supports a number of pro-grams which offer training in disciplines related tochild mental health. More than 100 child psychiatrytraining programs, and a variety of training programsin psychology, social work, and nursing are receivingsupport. Information on these programs is availablefrom the Division of Manpower and Training Pro-grams.

State institutions for the mentally ill are eligiblefor support to improve the services of staff caring formentally and emotionally disturbed children. NIMHsupport of such training has stimulated the develop-ment of increasing numbers of institution-based in-service training programs and focused attention onthe need for ongoing inservice training activities. In-formation is available from the Technical AssistanceBranch, Division of Mental Health Service Programs.

Experimental and special training projects sup-ported by NIMH include training for personnel whoserole or function is related to the mental health of chil-dren, and training for new kinds of mental healthworkers. In this category are projects, such as theprogram at Cedars-Sinai, for teachers of pre-schoolemotionally disturbed children. Also supported areprojects for training educational administrators andchild development specialists. Information is availablefrom the Experimental and Special Training Branch,Division of Manpower and Training Programs.

t,aliVerfat

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Staff

Basic staff for children's services ideally includes arange of personnelthe child psychiatrist, pediatri-cian, psychologist, social worker, nurse, occupationaland recreational therapist, educator, child care worker,and aide--all trained in the treatment of children.

As indicated in the previous section, community men-tal health and family aides can provide valuable as-sistance and serve to augment staff. Young people,parents, and retired individuals can be trained forchild care and classroom help. Volunteers and othersub-professionals may also be trained to serve as re-search assistants, group leaders, family counselors, andas assistant therapists.

Student aides, particularly graduate students in thebehavioral sciences, have worked successfully in manyprograms for children. Several centers, in cooperationwith local colleges or universities, have integrated stu-dent volunteers into various parts of their program.The volunteer aide can help provide the individualattention, warmth, and sense of security so importantto children who are ill. They can also assist in therapysessions, excursions, field trips, and other activities. Inareas where transportation to the center is to be fur-nished, volunteers may be organized to operate carpools. The youth and enthusiasm of student helpers isa most valuable asset in efforts to rehabilitate the dis-turbed youngster.

A program in Vermont, for example, is using collegevolunteers to work with slow learners in elementaryschool. The goal of the project, which is supported byan NIMH grant, is to help prevent severe emotionaldisturbances in children by early identification of slowlearners.

The training of new types of mental health work-ers, currently being explored under special NIMHtraining grants, is designed to create a new source ofsemi-professional help to meet staffing needs.

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In some of these projects, students are being trainedas mental health aides in two-year programs at juniorcolleges leading to an Associate of Arts degree.

In other projects, local people are being trained towork in their own communities as mental health aides.A project in Washington, D.C., for example, hasdemonstrated that school dropouts in a poverty areacan be trained as effective workers. The program atBaker's Dozen, a youth center in a ghetto area of thecity, trained a group of deprived Negro adolescentsaged 17 to 21 to help themselves and others in theirneighborhood. The young people, some with no morethan a fifth-grade education, work with children aged12 to 16 in activity groups. While the aides provide aneeded service, they gain confidence and a sense of re-sponsibility which enriches their own lives. The proj-ect leaders believe that the trained indigenous workeris an important link in bringing mental health servicesto people in deprived poverty areas.

In neighborhood health or service centers whichwork with community mental health centers, the com-munity or family health aide may receive training inmental health concepts and principles, and participatein providing help or referral.

The NIMH provides assistance to community men-tal health centers to help meet their cost of staffingnew or expanded services. Grants to help pay thesalaries of professional and technical personnel areawarded on a declining scale during a center's first51 months of operation. These may cover from asmuch as 75 percent of the eligible staffing costs duringthe first year to 30 percent in the final year of support.

Information regarding Federal staffing assistance isavailable from the Associate Regional Health Directorsfor Mental Health, Regional Offices, Department ofHealth, Education, and Welfare.

Facilities

A center's facilities and physical environment playan important role in the child's therapy. Attractivesurroundings and ample, well-designed space adapt-able to their needs contribute to the therapeutic milieuto which children can respond and grow well. Even thetreatment of landscape is important in defining well-marked boundaries and tangible limits without creat-ing an atmosphere of restriction and confinement.

Facilities for children's services should be conven-iently located and where possible, should be near otherchild-caring institutions, such as schools, and near out-door recreation facilities, such as parks and play-grounds. Outdoor play areas are particularly impor-tant in high-density neighborhoods.

Some centers may wish to provide mental healthprograms at the public schools if special educationclassrooms are available. Recreation programs canmake use of public playgrounds, swimming pools,movies, and bowling alleys. Using community fa-cilities gives the disturbed youngster important con-tact with the community.

Ideally, a community mental health center pro-vides special or separate facilities for children, whetherlocated at various places or housed in one building.If a children's treatment center is affiliated with ageneral mental health center, the entire range of chil-dren's services may enjoy separate facilities.

Children's services may be housed apart from thosefor adults because treatment programs, staff, and en-vironmental needs of the two groups differ. If, how-ever, young children and adults are served in the samefacility, a separate entrance and waiting room de-signed as a play area are desirable.

Since a complete program for children includes thefive basic servicesinpatient and outpatient care, par-tial hospitalization, emergency care, and consultationand educationa variety of rooms and spaces arerequired to provide them. For example, small roomsare needed for diagnostic interviews, individual ther-apy, and staff offices. Large rooms are needed forgroup, educational, and vocational therapy. A special

education program requires space for desks. Playroomsand outdoor recreation and play space are alsoimportant.

The design of the facilities should allow for un-scheduled, as well as scheduled, activities. Areas forquiet, such as a library, and areas for activity, suchas a playroom, should be available. Quiet areas allowchildren to retreat from activity as needed. Also de-sirable are special areas for hobbies and club activi-ties for the older children, such as a photo lab orworkshop.

Since young people tend to gather at certain spotssuch as those associated with recreation or foodspe-cial attention should be given to these focal points ofactivity. For example, accessibility to a kitchen snackarea, where they can prepare some of their own food,or to a record player, encourages group interaction.

A young patient should be given opportunity tomodify his environment. The facilities should allow forhis individuality by providing basic movable furniturethat he can arrange, and wall space for hanging hisown pictures. An environment that a child has helpedto create is one that he can more readily accept andenjoy.

Space and equipment needs for children are manyand varied. They include ample storage room, privatelockers, and cupboards for toys and play equipment.Lavatories with larger-than-average sinks and lowtoilets for younger children are needed near activityareas. In addition, noisy activity and treatment roomsrequire sound-proofing. Rugs and carpeting help tomuffle sound and lend warmth to the surroundings.Acting-out problems among young patients requiresturdy furniture and some "damage-proofing" of fur-nishings. Play and gym equipment are as desirable forthe disturbed child as for any other youngster.

Facilities for research may include a one-way visionwindow to permit staff observation.

Ideally, separate facilities should be provided foryoung children and for adolescents since their needsdiffer. However, dual- or multi-purpose rooms permit

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alternate use of space. One important considerationis the location of such rooms. A centrally located rec-reation room, for example, accessible to children fromboth the young children's and adolescents' units, usesspace more economically and effectively than onelocated in either unit. In addition, scheduling is animportant factor in maximizing available space. Flex-ible scheduling is facilitated by adequate storage space,allowing toys from a day nursery and chairs for parent

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counseling, for example, to be stored and used asneeded.

The main consideration in planning facilities foryoung people is what, in terms of environment, willmake life enjoyable for them and adequately providefor their needs.

Consultation regarding physical plans for children'sfacilities is available from the Division of MentalHealth Service Programs.

VIM

Establishing a Center

The community mental health center aims at aunified and continuous program of comprehensivecommunity care for children and adults. Plans andmethods of forming a center differ widely, reflectingthe needs and extent of existing facilities in the areasto be served.

Children's services may be incorporated or ex-panded within the total program of a center in a varietyof ways. They are often provided by existing facilitiesa child guidance home or residential treatment cen-ter, a children's psychiatric service in a general hos-pitalin affiliation with other agencies, clinics, orinstitutions.

Examples of successful joint efforts include:The Community Mental Health Center of Rock

Island, Illinois, was formed through the collaborationof the Child Guidance and Mental Health Centerand two general hospitals. A Federal constructiongrant enabled all three agencies to provide new andexpanded services for children and adults in newfacilities.

The Convalescent Hospital for Children in Roches-ter, New York, recipient of Federal construction andstaffing funds, affiliated with the adult psychiatricservice of a general hospital to form a comprehensivecommunity mental health center.

The Child Guidance Home in Cincinnati, Ohio, re-ceived a construction grant and affiliated with a gen-eral hospital and an adult outpatient psychiatric clinic.The three agencies added services for children whichhad not been available before.

The Jane Wayland Child Center and St. Luke's Hos-pital in Phoenix, Arizona, joined forces with an adultpsychiatric clinic in order to provide more extensiveand high quality comprehensive care for children andadults.

A children's residential treatment center may bebuilt to serve several community mental health cen-ters. This plan takes into account the usefulness ofpooling scarce personnel and facilities for special edu-cation. Ideally, the treatment center would providenot only inpatient care, but the entire range of chil-

dren's services. At a minimum, it could be the site ofinpatient treatment, day care, and schooling.

Federal assistance is available to community mentalhealth centers to help meet the costs of constructingor renovating facilities for new or expanded services.Funds for this purpose are allotted to the States, whichdetermine priorities for community projects under aState Centers Plan. Local applicants apply to theirdesignated State agency for approval of their project.Grants may cover from one-third to two-thirds ofthe center's building or remodelling costs.

As indicated in the section on Staffing, grants arealso available to help centers meet the cost of staffingnew or expanded services in their first few years ofoperation. These funds, which are awarded directlyto local programs, enable a center to evaluate operat-ing costs and explore long-range sources of operatingrevenue.

Since regulations for Federal aid require that areasonable volume of services be provided below costor without charge to patients unable to pay the fullfee, a center must have sources of revenue other thanpatient fees. Applications for building and staffingassistance must show that a proposed center has othersources of support.

Some mental health centers are operated by private,nonprofit foundations to which community organiza-tions and United Fund drives contribute. Others aresupported through city and county tax revenues, witha percentage of funds contributed by the State.

In recent years, health insurance coverage for psy-chiatric care has become more widespread. Voluntaryhealth insurance plans such as commercial insurancecarriers, Blue Cross-Blue Shield prepayment arrange-ments, and comprehensive prepaid group practicehealth plans have broadened coverage to include serv-ices for mental and emotional problems which hadbeen excluded or for which benefits had been morelimited.

As a result of developments in health insurance pro-tection, families and children who are insured seekpsychiatric help early and receive inpatient and short-

19

term outpatient services before a youngster's problemsbecome increasingly intractable to treatment.

A major advance under some new contracts is theinclusion of benefits for collateral visitsthat is, cover-age for treatment services for parents and other familymembers when a child or adolescent is the focus oftreatment.

Increased psychiatric benefits under voluntary andindustry-wide insurance plans, as well as public healthcare programs, reflect recognition of the potential ofcommunity mental health services and demonstratethat the treatment of the mentally ill is now consideredan insurable risk. The comprehensive programs of themental health center make mental illness "insurable"by concentrating on acute illness and short-term care,and insurance benefits, in turn, make it possible forcenters to serve a broader population.

Mental health benefits for children's services arealso now available under various Federally financedprograms. These include the Military Medical Bene-fits Amendments of 1966, under which dependents ofactive, retired, and deceased members of the uniformedservices may receive psychiatric care in communityprograms. In some States, under the Medicaid pro-gram, indigent and medically indigent children andfamilies are receiving mental health services.

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,..

Information and consultation regarding center proj-ects are available from the designated State agency andthe Associate Regional Health Directors for MentalHealth, Regional Offices, Department of Health,Education, and Welfare.

Programs cited here are examples of interestingprojects that have come to the attention of NIMHstaff, and are not intended as an exhaustive survey ofnew and effective approaches to serving children. TheNIMH welcomes further suggestions and reports ofchild mental health programs. Write to Center forStudies of Child and Family Mental Health, NationalInstitute of Mental Health, 5454 Wisconsin Avenue,Chevy Chase, Maryland 20203.

Prepared by :Public Information Branch,Office of CommunicationsandCenter for Studies of Child and Family Mental HealthNational Institute of Mental HealthHealth Services and Mental Health AdministrationPublic Health ServiceU.S. DEPARTMENT OF HEALTH, EDUCATION, ANDWELFARE

U.S. GOVERNMENT PRINTING OFFICE: 1968 0312-117

12,111.1-u-,,t, - ..

U.S. DEPARTMENT OFHEALTH, EDUCATION, AND WELFARE

Public Health Service

Public Health Service Publication No. 181,1