The Division of Child Psychiatry of the Department of Psychiatry, Harlem Hospital Center offers a partial recapitulation of the species of services offered to adults - partial, particularly because of the absence of available inpatient services for children and adolescents. The renovations necessary for the provision of space for these services have remained on the drawing boards. Partial also in the nature of those understaffed programs which approach but do not reach adequate proportions for partial hospitalization. (See Table 1.)
The remainder of our services needs no apology. As Samuel Johnson said of the lady who questioned the clarity of a performing dog's speech, "Madame, the wonder is the animal performs at all." The Division is very much part of a city hospital; poor itself, serving the poor - often frustrated.
The point of view of the Division of Child Psychiatry is necessarily developmental, with subdivision of various responsibilities, including teaching, community child psychiatry, partial day hospitalization program, group activities, psychiatry clinics, emergency and ward consultation. In the 10 years for which the Division has been in existence there has been an increasing degree of specialization in services to the children of different age groups, reflecting the special knowledge of specific staff members of the problems experienced by the families of children of different ages, the community resources available to children of different ages, the particular look of psychopathology in that age group and the feel of family strengths available to children of different ages.
This specialization reflects a wider acceptance of the importance of developmental stages in determining services offered and runs counter to trends toward the generalist position taken in certain community mental health centers.
The specialization of services has developed in response to increasing demands made on staff. It is difficult to be knowledgeable about the latest crisis in family day care affecting threeyear-olds while responding to the pressure of shifts in prenatal clinic planning for adolescents. Specialization of services has then moved to emphasize the importance of developmental stages occurring in the child for the family, at the school and in the street.
The range of services makes teaching exhilarating in spite of pressure and the shortness of time. There is an approved residency training program in Child Psychiatry, and teaching and clinical experience is provided as well to beginning medical students, medical students in their major clinical year, first, second and third year general psychiatry residents, pediatric residents, social work students and student nurses. In addition, Dr. Margaret Lawrence has recently begun a special training program including staff of different disciplines in training at the Psychiatric Institute, Harlem Hospital and the Washington Heights- Inwood Mental Health Center.
Research has not flourished. The forces operating in the well-known inner city (of which the city hospital is very much part) militate against the structure necessary for the research project, even when these projects might be life-saving to patients and staff.
Our clinical services have been divided into an Adolescent Psychiatry Clinic, a Child Psychiatry Clinic and a Developmental Psychiatry Clinic. The Child Psychiatry Clinic takes the chief responsibility for the collection of statistics, the keeping of records, emergency consulation service, and Pediatric Ward consultations.
TABLE 1. STAFF AVAILABLE TO PROGRAMS IN TERMS OF FULL-TIME EQUIVALENTS DIVISION OF CHILD PSYCHIATRY
Developmental Psychiatry Clinic:
Two teams, with child psychiatrist, social worker and psychologist, are working with the director of the Speech and Hearing Clinic and offer evaluation of the children referred. Every attempt is made to carry out the most appropriate treatment plan with a realistic shift to less and less satisfactory plans depending on the parents' ability to join in the resources available. Treatment plans vary from individual psychotherapy for the mother and child through therapeutic education to placement in a day care center with consultation services from the staff of the Developmental Clinic. From the beginning emphasis has been placed on the need for therapeutic education, and we have been fortunate in having Dr. Lawrence to develop models for: (1) the consultation to day care centers or Head Start Program through child study conferences which allow for the growth in that setting; (2) a therapeutic nursery; and (3) the special classes of the Board of Education utilizing the services of a clinical team which is hospital based.
Sheltering Arms - Harlem Consultation Program:
This program, under a special grant, currently provides consultation to eight day care centers. Each day care center is provided with a team of two consultants, usually a social worker and a psychologist or a psychiatrist. Child study conferences are held once monthly in each of the eight day care centers following discussions with individual teachers, directors, and family workers and after observations of a child under study. Sheltering Arms provides a social worker for supportive social services in all eight day care centers. The Therapeutic Nursery, which has been given an office and classroom, provides insights and knowledge which are useful in the consultation program. It is the goal of the Sheltering Arms Consultation Program with Harlem to provide mental health consultation to large numbers of preschool children in the Harlem community through shared knowledge and insights of educators and mental health team.
Partial Hospitalization Programs:
1. Therapeutic Nursery
The Harlem Hospital Pre-school Project, a therapeutic nursery, is housed with the Sheltering Arms Harlem Hospital Developmental Center in the crypt of St. Andrew's Church, 2067 Fifth Avenue. It provides services for 12 children (and their parents) ages 2-5 years of age who are in need of therapeutic education. (Serves as a partial hospitalization program for 12 children, 3 hours/day, 4 days/week and includes group therapy for 12 mothers, one meeting/week.) Referrals to the nursery are made by the Developmental Clinic, Division of Child Psychiatry, Harlem Hospital.
2. Pre-school Readiness Program
The Pre-school Readiness Program is a specially funded program of the New York City Board of Education, Office of Special Education and Pupil Personnel Services. One of the centers of the project is located in Harlem Hospital Center in affiliation with the Division of Child Psychiatry, Developmental Unit, through which complete clinical services and on-going consultation are provided. The project serves children ages three through five who have developmental problems and are in need of a special readiness approach that involves highly individualized therapeutic education. The child's response to the experience becomes an important aspect in differential diagnosis, programs, and planning. As the children reach school age, recommendations for special class placements will be facilitated through the Central Screening Unit of the Board of Education, and, where necessary, new special classes will be formed to meet the needs of children identified through the Readiness Project. Some children will be able to move on to regular Head Start Projects, nurseries, and public school classes with follow-up and consultation available. This program is compatible with the approach of the Developmental Unit and provides a much needed additional resource for our patients and a valuable link with the Board of Education. There are currently 14 children being served in two groups with two teachers and one assistant. (Serves as a partial hospitalization program, 14 children, 3 hours/ day, 5 days/week - group therapy 14 mothers, one meeting /week.) The Division's clinical team for this program involves a psychiatrist, a psychologist, a psychiatric nurse and a social worker; there is a weekly group meeting for mothers.
Child Health Station Consultation, Comprehensive Care Clinic and Pediatric Developmental Clinic:
A Developmental Clinic team consisting of the nurse and senior psychiatrist consulted with the Child Health Station based in the Pediatric Outpatient Department in this last year. This consultation has included collaboration with Health Station nurses, pediatricians, child neurologist, and the Hope Day Care Center through our consultation team there. In the past, we have offered consultation to four other child health stations in rotation but are presently awaiting reorganization of these city services tor well babies by the Board of Health. (Indirect consultation. One conference and one to two patients q. two weeks.)
Our same team is available to work with the Comprehensive Care Clinic whose staff is available to see pediatric patients on an on-going basis. Referrals are made to the Developmental Psychiatry Clinic through these contacts and young children seen in Child Psychiatry are referred to the Comprehensive Care Clinic for pediatric care. A joint conference is held once a month.
The Pediatric Developmental Clinic has acted as a pediatric screening clinic. Various senior consultants in child psychiatry, pediatrics, speech and hearing, child neurology, pediatric rehabilitation, etc. serve this clinic.
Developmental Child Community Psychiatry:
Consultation - Consultation to Head Start and day care centers with the use of a multi-disciplinary team joining with families to effect positive changes.
Emergency Consultation - On weekdays, 9-5 p.m., the Child Psychiatry Clinic is notified of the arrival of any child or adolescent under 16 years in the hospital as a psychiatric emergency.
If the patient has been first seen in the Pediatric Emergency Room, he is then transferred to either the Child Psychiatry Clinic or to Psychiatric Emergency Room depending on circumstances, and is then seen in consultation as an emergency.
A patient brought directly to the Child Psychiatry Clinic as an emergency may be seen there, a consultation form made out and a disposition made, or the patient may be translerred to the Psychiatric Emergency Room and seen there. Similarly, the patient brought directly to the Psychiatric Emergency Room may be seen there or in Child Psychiatry Clinic but is not brought to Child Psychiatry Clinic unless so requested by Child Psychiatry. These patients may need to be referred to the Pediatric Emergency Room in the King Building and seen there with the pediatrician, as they do not have medical clearance.
On nights, weekends, holidays and at any other time a child psychiatrist is not available, children and adolescents are seen in both the Pediatric Emergency Room and the Psychiatric Emergency Room.
There are no psychiatric inpatient services for children and adolescents under to at Harlem Hospital Center. Children and adolescents who must be hospitalized in an emergency are transferred to Beilevue after permission has been obtained from the proper ward service (9 a.m. to 5 p.m.) or from the Psychiatric Admitting Office (5 p.m. to 0 a.m.). Planning for patients who have been seen as an emergency most usually involves referral to the appropriate clinic in Child Psychiatry. They are then seen as clinic patients, although the emergency may be prolonged over several days and the necessary planning is carried on in the clinic setting.
Patients seen in the emergency room at night or over weekends or holidays are always referred to Child Psychiatry at 9 am. on the next week day.
Children in this age range are not transferred to state hospital units on an emergency basis.
Other Special Programs:
Girls Activity Group - The Girls Activity Group includes approximately 12 girls, aged 11 to 13 years, about six of whom meet weekly to carry out planned activities and talk over common topics of interest. Many of the girls have not had successful peer group experiences, and find within this group an opportunity to try out socializing skills and make friends. (Group therapy, 12 girls, oncea week.)
Group for the Retarded-A group for retarded children was begun in the summer of 1971 with the help of volunteer students from Departments of Special Education in city colleges and universities. It met daily for three hours, four times a week with eight children and has continued as an afterschool program on a once a week basis. In addition, it has been possible to see two children in individual sessions on a twice a week basis. (One group meeting/week for 4-6 children, 2-4 children individual tutoring weekly.)
Partial Hospitalization Programs: Harlem Center for Child Study
Harlem Center for Child Study is a therapeutic school and group recreational center for emotionally disturbed and socially maladjusted preadolescent male patients, 7 to 13 years old.
The school, P.S. 368 K, is part of a cluster and has a principal and teachers from the Board of Education. Each class is composed of six children, with one teacher and one psychiatric group worker as an assistant. The school has regular school hours, 9:00 a.m. to 3:00 p.m.
In the afternoon from 3:00 p.m. to 5:00 p.m., there is an After School Activity Program, in which the children engage in different activities. These activities include a remedial math and reading program, boxing, football, baseball, basketball, swimming, table games, trips to movies, and other sport events. All of the children of the Harlem Center for Child Study stay for the afternoon program but are joined by another 15 children who need a therapeutically oriented activity program.
The morning program includes a weekly group session in which children and staff take part. Health problems, behavior, feelings about staff and some planning are discussed in these meetings.
During the summer months, all the children are included in a Summer Activity Program, which meets 9:00 a.m. to 5: 00 p.m. daily. There is an educational and cultural program three mornings a week coupled with a halfday trip, and two full-day trips a week around the city and nearby counties; at the end ot the summer there is a oneweek camping trip in which children, group workers and social workers join.
(The Harlem Center for Child Study, et al., serves as partial hospitalization program, 24 boys, 5 days a week; 15 boys, 5 afternoons a week.)
Goals of the Center:
We established a School tor Boys Suspended from School in 1964 to help us deal effectively with the problems presented by a special group of children; we have tried to go beyond these problems to help in the rehabilitation of the troubled children and families whom we have come to know.
Our own administrative structure and the services now offered by the Harlem Center for Child Study reflect the needs of families and children; at times, and inevitably, our Center reflects an orientation to crisis and disaster which is that of many of the families with whom we are working. Our problem is to maintain flexibility of response without permitting our own responses to become chaotic and disordered. The success of our school and our Center depends on the existence of those routines and that structure which tree children from the necessity to work their way through each day as if they were beginning again. The energy which would be so mis-spent can then be turned to learning and feeling and to the coping mechanisms essential to both.
It is the purpose of the Harlem Center for Child Study to establish, at the expected developmental stages, the basic patterns of childhood and to allow the children seen to develop their own special gifts by offering the structure of a therapeutic day program in an educational and recreational setting. Formal therapeutic approaches to child and family are made in this setting with formal case work, and chemotherapy, individual psychotherapy when indicated, but the heart of the therapeutic matter lies with the daily experience for child with adults and peers.
The children are referred from Child Psychiatry Clinic, and their psychopathology is related to their own experiences with family, school and community. Without exception the children have had difficulties in learning in previous schools and have established deficits in and distortions of the learning process.
As we have always wanted all staff to give what they have to give, and as we have wanted to use the gifts and capability brought to the Center by various staff members, we have avoided overly-rigid definitions of roles and responsibilities with the inevitable consequence of uncertainty, confusion and failures in definition for certain staff members.
Classes for the Emotionally Disturbed
These classes were set up in 1972 in clusters of four classrooms with six children to a class by the Board of Education. They agreed to put two such classes on the floor in the Child Psychiatry Clinic to provide the clinic with the beginnings of a Day Hospital Program while the clinic provided hospital space and clinical support. These two classrooms are now in their second year, offering previously unavailable and notably therapeutic education to 12 seriously disturbed children 7 to 11 years with mixed diagnoses. The child psychiatrist in the clinical team available works closely with the educational curriculum consultant.
Consultation and Education:
School visits are made as time permits. Frequent telephone calls with inadequate support offered to harried guidance counselors and teachers take the place of more stately visits with their serendipitous effect on children heard of but not seen. Like home visits, school visits for observation and conference with staff become a luxury and are postponed or left undone to the detriment of good relationships with school personnel who are angry at the small amounts of time doled out to them.
Multi-Level Program P.S. 92:
(Now Pre-placement Class, Evaluation and Placement Unit)
The Multi-Level Program at P.S. 92 is a joint effort of Harlem Hospital's Division of Child Psychiatry, the New York City Board of Education Office of Special Education and Pupil Personnel Services, and a local public school. The program serves children, ages 5 through 9, with learning disabilities related to varying degrees of organic and emotional factors. These are children who are unable to be served in regular classes because of their special needs but, at the same time, are ineligible for already established special classes, such as those for the brain injured, because of factors such as mixed or unclear diagnoses, behavioral problems, and low scores on psychological tests in spite of potential for at least average functioning. The purpose is to provide therapeutically oriented special education and to clarify our knowledge of the children's needs so that they can move on successfully to other programs. Some of the children have gone on to function well in regular classes while others have moved successfully into classes for the brain injured.
The program is in its third year. Teachers are provided by the Board of Education, and full clinical services, in addition to bi-weekly consultation, are provided by Harlem Hospital's Division of Child Psychiatry. The children are all patients of the Child Psychiatry Clinic. The consultation team includes a child psychiatrist, a psychologist, and a social worker. The school guidance counselor participates regularly and is an important liaison person. Mothers of children are seen in a group by the social worker approximately once a month with individual help available as needed. The classes have place for 12 children with the assignment of one special education teacher, one aide, and one student teacher to each class. For the class to function properly, the consultation team must observe the children regularly as well as seeing them for follow-up visits at the hospital. The services of a half-time social worker are essential for program coordination and family services.
Children and the Law:
A new program is in the process of being set up funded by a Task Force on Children and the Law. The program will take the responsibility of establishing liaison with the Family Court to allow referral of children and families brought to the attention of the court. In order to provide treatment services this program was set up to alleviate some of the problems faced by the court in planning for the children, often adolescents, for whom no suitable plans seem possible. Although the current push is to provide for the older children, at the last ditch the expansion of the program to include cases of child abuse, the children of mentally ill mothers placed through the court, and those children placed in community residences without clinical support, provides the greater possibility for realistic service.
Adolescent Psychiatry Clinic:
The services offered the adolescents of our community fremi this particular hospital clinic base are totally inadequate. This was the last of the developmentally determined clinics to be differentiated from Child Psychiatry Clinic. The adolescents have been neglected in spite of their great visibility and propensity for sturm und drang. Coming in crisis, they are necessarily dealt with in crisis, in spite of the following special services:
Regular and irregular school visits and follow-up by a community liaison worker.
Adolescent Activity Group.
Held weekly to increase number of contacts made by a number of staff with many of the adolescents attending clinic in any capacity.
Adolescent Boy's Treatment Group.
More orthodox group therapy.
Adolescent Girl's Group.
Led by a social work associate and oriented to reality experiences.
Open to parents and guardians. Held by a social work associate and oriented to reality experiences. Goal: to diffuse or absorb anger, confusion, pain felt by families.
Adolescent Crafts Groups.
To increase self-esteem, and to improve communication and identification of feelings. Conducted by a community liaison worker with support of activity therapist.
Individual tutoring plus group meeting.
Consultation to Community Group Residence.
By psychologist (and clinic coordinator) in cooperation with Division of Community Psychiatry.
In summary, too many patients, problems and limitations, too few staff, solutions, and ways of expanding our therapeutic usefulness. We lack certain kinds of humility, are scornful of newcomers to the community, proud of our own capacity for exhaustion, our poor tolerance of certain kinds of frustration, etc. It is the "best of times and the worst of times."
We need to consolidate the services we are offering, review the cases seen over a 10-year period and use professional help not yet offered in the establishment of modes of evaluation of services which do not serve as Procrustean beds.
We need an interlocking series of service conferences held on a weekly basis between the special services of the child and adult units. The complexities of establishing an adequate but not stereotyped way of discussing the very complicated families shared by the staff of various services has defeated us to date. Almost all our problems can be blamed on the conditions prevalent in our own particular frontier. We are not slowed down by hierarchical considerations, but the unavailability of busy staff fragments efforts made.
We have worked on, through the 1960s and into the 1970s through the social revolution going on around us and have not always been able to pause to note its passage from stage to stage. The reference to a frontier was not inadvertent, the tracks have now been laid almost to the town and the psychiatric frontier has changed enormously. We have to be careful to maintain a certain vigor of approach while noticing that the environment has changed and will continue to change.
It is reassuring that the thrust of change as seen in almost all children, has always necessitated a change in the nurturing environment in age-appropriate ways. We should be able to organize ourselves to this kind of healthy change and be appropriate in our service to the children of our community instead of leaning on the bar while meanwhile, out at the ranch.
TABLE 1. STAFF AVAILABLE TO PROGRAMS IN TERMS OF FULL-TIME EQUIVALENTS DIVISION OF CHILD PSYCHIATRY