# Appendix — Parham v. JR > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385005_0830%3A03 ## Record - **Collection:** Supreme Court brief - **Document type:** Appendix - **Published:** January 1, 1979 - **Citation:** 442 U.S. 584 ## Text VOLUME Il—Pages 352-717 APPENDIX IN THE Supreme Court of the United States October Term, 1975 NO. 75-1690 T. M. “JIM” PARHAM, Individually and as Commissioner of the Department of Human Resources, W. DOUGLAS SKELTON, Individually and as Director of the Division of Mental Health and W. T. SMITH, Individually and as Chief Medical Officer of Central State Hospital, Appellants, Vv. J. L. and J. R., Minors, Individually and those representatives of a class of persons similarly situated, Appellees. APPEAL FROM THE JUDGMENT OF THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF GEORGIA APPEAL DOCKETED MAY 21, 1976 JURISDICTION NOTED MAY 31, 1977 TABLE OF CONTENTS VOLUME I Page Relevant Docket Entries... .. 2.0... ccc cccccccees Vv Complaint—October 24, 1975. ..............00eee- l ee te ED In rug cnnsigescsncsoneeueese 17 Testimony of Dr. Wayne Hodges, given in hearing before Judge Wilbur D. Owens, Jr., in Macon, i s canceesenes 20 Neen aces 37 PD MII... vcccwccceeestuvatecus: 686 Direct Examination............---+++eeeeeees 687 Cross-Examination...........:0-++seeeeeeeees 702 VOLUME Iii Deposition of Dr. John Paton Filley..........-+--- 718 Direct Examination...........--+.++eeeeeeees 719 Cross-Examination...........-05++eeeeeeeeees 757 Deposition of Dr. Luciano L’Abate.......-.-.-+--- 795 Direct Examination............---++eeeeeeees 796 Cross-Examination...........0+++seeeeeeeeees 812 Appendix “B” to Defendants’ Supplemental Brief in the District Court. ..........ceeeceeeeceeeeees 822 Attachment “A” to Post-Discovery Brief of Plaintiffs .888 Attachment “B” to Post-Discovery Memorandum of the Plaintiffs.............ccccceccececcccceeees 893 Report of the Study Commission on Mental Health Services for Children and Youth............--+++: 899 Affidavit of Judge Romae Powell. ..........--++++- 918 Affidavit of Judge Dennis Jones. .......---+++++++> 927 Opinion of the District Court. ....-..-..-+++se+5+> 934 Judgment of the District Court.......-- 0 --++++++5 935 Order of the District Court Denying the Defendants’ Motion For a Stay........--.e cece cece ee creer 937 Notice of Appeal to the Supreme Court of the United States. .....c cc ccc cccccccccsccscccsccss 947 Order of the Supreme Court noting probable jurisdiction. ........-- eee eee e erence eee eeeeees 949 iv IN THE Supreme Court of the United States October Term, 1975 NO. 75-1690 T. M. “JIM” PARHAM, Individually and as Commissioner of the Department of H uman Reso W. DOUGLAS SKELTON, Individually and as Director of the Division of Mental Health and vis W. T. SMITH Individually and as Chief Medical Officer of Central State Hospital, Appellants, v. J. L. and J. R., Minors, Individuall , " . y and those representatives of a class of persons similarly situated Appellees. 352 (1) IN THE UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF GEORGIA MACON DIVISION (Caption omitted in printing) eposition of DOCTOR LAWSON H. BOWLING, taken poy 4th day of December, 1975, in Room 534 of the Georgia Department of Health Building, 47 Trinity Avenue, 8.W., Atlanta, Georgia, before Jean M. Wall, Court Reporter T-24, 1521 Mercer Way, Decatur, Geor- gia APPEARANCES: intiffs: GERALD R. TARUTIS, ESQ. — DAVID GOREN, ESQ. STEVE GRANBERG, ESQ. Georgia Legal Services Programs Macon Regional Office 653 Second Street Macon, Georgia 31201 nts: DOROTHY Y. KIRKLEY, ESQ. saaiesiecias Assistant Attorney General Department of Law 132 Judicial Building Atlanta, Georgia 30334 [2] io MR. GOREN: The stipulations are all formalities are waived and objections are reserved until the time of trial . MS. KIRKLEY: Except as to the form of the question and the responsiveness of the answer. NOTE: (The signature of the witness was specifically ponte by his attorney of record, Ms. Dorothy Y. Kirkley, Esq.) 353 [3] LAWSON H. BOWLING, HAVING BEEN DULY SWORN AS A WITNESS, TESTIFIED AS FOLLOWS: EXAMINATION BY MS. KIRKLEY: Q Would you state your name for the record, please? A Lawson H. Bowling, M.D. Q And where are you employed, Doctor Bowling? A I am the superintendent of the Georgia Regional Hospital at Atlanta. NOTE: (Defendant’s Exhibit Number One was marked for purposes of identification.) Q Would you identify Exhibit One? Just state what that is, please, Doctor? Just state what that is. A This is a curriculum vitae on myself. Q And how long have you been superintendent at Atlanta Regional, Doctor? A Since May of 1968. NOTE: (Defendant’s Exhibit Number Two was marked for purposes of identification.) [3] Q Now if you would just identify briefly Exhibit Two and its component parts, then we’ll go back into each of them in some more detail later in your testimony. A All right. This is a looseleaf notebook which con- tains the following lists by patient number of the children admitted—of the persons admitted age seventeen and under to the Georgia Regional Hospital of Atlanta since January 1, 1969. It shows the diagnosis made on these persons and whether they were voluntary or involuntary patients. It shows the date the person was separated from (3) 354 the hospital, whether they were on convalescent leave, and it shows the discharge date and to whom they were released. It also contains a list by initials of children who were denied voluntary admissions, including referral to the Comprehensive Community Mental Health Centers in the hospital’s service area. It contains written policy and procedure of the childrens—child and adolescent pro- gram for periodic review of patient cases. It contains the written admission policies of the child and adolescent program, and it contains the hospital’s policies and pro- cedures for periodic review of patients by the hospital’s quality review committee, which is a committee of the medical staff, and this is commonly called a utilization review in which the committee undertakes to see if the utilization of the bed is proper, that is if the person oc- cupying that bed should be occupying it. Q Okay. Let’s go back for a minute to the first thing, the itemized list of patients. [4] A All right. Q We were discussing that off the record a minute ago, and we determined, did we not, these were done, manually and they’re not in any particular order according to date or patient number? A That’s correct. Q Who prepared that summary, Doctor? A That—that summary was prepared by the staff of the Patient Affairs and Records section of the Atlanta Regional Hospital. Q Could you describe, please, what your role and duties are as the superintendent of the hospital? - neal 355 [5] A Yes, as superintendent of the hospital, I am directly responsible for the entire operation of the hospital, for its administration and for the treatment programs and for establishing policies and procedures for the proper opera- tion of the hospital. Q Okay. What counties does Georgia Regional Hos- pital at Atlanta serve? A It serves Cobb County, Douglas, Fulton, Clayton, and the central and south services areas of Dekalb County. Q Are there also community mental health programs within this area? A In that area there are nine established and operating comprehensive community mental health centers. Q Do they have satellite offices, also? A Some of them do. Q And what is your relationship with the community mental health centers? A We have written agreements with each of these centers as to [5] the function of the center and the function of the hospital. The basic philosophy of those agreements is that—which is the basic philosophy of the hospital, is that persons will be treated in the comprehensive com- munity mental health centers in every possible instance, rather than being hospitalized. The hospital’s philosophy on hospitalization—this applies to all patients, including the children and adolescent patients, is that hospitaliza- tion is to be carried out only when the person is, by reason of mental illness, unable to control his behavior, or con- stitutes—by that—for that reason, a threat to his and other person’s physical safety, when all alternatives to hospitalization have been exhausted, and discharge [5] 356 planning is begun upon admission. I’d like to add a state- ment of fact to that, and that is that the hospital has been critized in the public media for not admitting patients. We’ve had statements come out in the press that the patients who are taken to the Atlanta Regional Hospital often beat the person back home that took them. The hospital’s philosophy, then, is not to admit unless it is required for stabilization of out of control behavior and dangerous behavior. I’m talking about admitting—well, that is essentially the basic philosophy. We handle volun- tary or involuntary applicants in a similar manner, and then relating to the comprehensive mental health centers —well, the basic policy of the hospital is to either admit to a bed or find a suitable alternate, and we seek out a suitable alternate to hospitalization in every possible instance, and the comprehensive community mental health centers that I mentioned, are [6] principle places” that we make referrals to—if a person is not requiring hospitalization. Q What are you—just in your own words, what are your policies with regards to admissions, and—with specific reference to the admission of children and adoles- cents? A That they’re admitted only when their behavior is unstable and out of control and constituting a danger to themselves or others. Q What process would they go through to get ad- mitted? A When any contact is made with the hospital to admit a child, and this is true, also, with most adolescents, they are referred to their comprehensive community mental health center initially. The purpose of that is to = 357 (7] try all non-hospital alternatives first. The primary source of such patients is the—are the county departments of family and children services, and we have established relationships with them in such a way that when they have a potential—when they have a disturbed child before them, they—the Departments of Family and Children Services contact the comprehensive community mental health centers first, before calling us. We have that understanding with them. The purpose of that is to try to ensure inappropriate hospitalization does not occur. Q Are there ever situations where a child would not go first to the community mental health clinic? A Yes. Yes. I would like to add first before I answer that, that not all comprehensive community mental health center referrals are admitted, because the hospital has a screening procedure, even after they are referred to us from the mental [7] health centers, and the estimate as to how many of those are turned back is approximately twenty-five percent. Q Excuse me, that’s even from the community mental health clinics? A Even from the community mental health centers. We do have direct calls, and when that call comes to the hospital—I do have a document here that gives a run- down or those kinds of contacts as from January the 22nd, ’75 up until the present time. It just covers that one-time period. . NOTE: (Defendant’s Exhibit Three was marked for purposes of identification.) A Then the hospital’s childrens programs screening procedure is carried out, of which there is a copy of that written procedure in this looseleaf notebook under the tab (7] 358 that’s called admission policies and procedures. That pro- cedure is carried out—the purpose of that is to make doubly sure that inappropriate hospitalization does not occur. Q Who would be involved in that screening process at the hospital? A The staff of the childrens unit. Then the kinds of persons that are involved in that are called screening coordinators, who are appointed by the program director of the child—of the children’s service, and it includes these kinds of personnel, social workers, psychologists, an assistant director of education and a psychiatrist. Q And this procedure is done after a referral is made but before the hospital—the child is admitted to the hospital? A That’s done before the child is ever admitted to the hospital. Q You stated a minute ago what your philosophy was and what some of the criteria were for admitting people to the hospital, [8] that is if they were dangerous to them- selves or others. Do you use that standard for children? A Yes, we do. Dangerous to themselves or others, or behavior that is out of control. Q Do you have any policies with regard to the joint treatment of a family while a child is in the hospital? A It’s standard procedure in the children’s program to immediately involve the available—the parents in the treatment process. Q Are you aware in any percentage of cases, of reluc- tance of parents to become involved in the treatment program? id eta od oceans Paice 359 [9] A I don’t know a percentage. There are a certain number, that it is difficult for us to get them and keep them involved. Q Would you say that that would be—in ballpark, say a quarter of the time, ten percent of the time . . . A No, I’d just guess that it would be ten percent. Twenty-five percent or less. The majority of the parents cooperate on that. i Q And that treatment program would be carried out for the family by the community mental health centers? A Not necessarily. It’s—I would say primarily, on the hospitalized children, it’s done by our own staff, but it may be done by the community mental health centers. Q Once a child is in the hospital, are there any pro- cedures for reviewing his case? A Yes, and these are set forth in this looseleaf note- book in the form of copies of those standing official hos- pital and children’s program policies and procedures. One is entitled “Rounds”, which is a regular meeting of the staff which takes [9] place once each week, in which they take a reading on the situation, the progress, and what is known as the “Staffing procedure”, which involves— which involves a number of things. It involves an initial assessment of the problem, the formulation of the treat- ment plan, and—that is carried out—that is followed up by the regular rounds at which that is reviewed. Q How often does one of these reviews occur, is there a stated time? A There’s a review of each case once a week. Q By the—this policy on staffing procedures? (9] 360 A Staffing procedure is done on the initial admission primarily to formulate a treatment plan for the patient, and there’s a third part of that policy which is called “Termination conference”, which takes place about the time the staff is of the opinion that the person—the child should be discharged. Q Do you know how many in-patients you currently have on the children’s unit? A Yes, there are fourteen. Q Does that include adolescents? A No, it does not include adolescents. Q Do you have a separate adolescent unit? A Wedo not. The adolescent patients are admitted to the adult units, which are based on a geographic service area. They—there is an in-hospital day treatment pro- gram for adolescents. Q How many adolescents are there currently in the hospital? A Idon’t have that number. Yes, I’m sorry, I do have it. [10] The current in-patients, adolescents, twenty-two, and 1 gave the wrong number earlier for children. I said fourteen, it’s seventeen, so that there are a total of thirty- nine adolescents and children combined. Q What is the day treatment that you spoke of for adolescents? A That is a treatment of activities, group therapy, which takes place during the hours of approximately eight A.M. until four-thirty P.M. Q Is part of that a school program for the adolescents? A Part of that is school, yes it is. 361 [11] Q You spoke about geographic units. You mean like each county in your area is represented in your hospital by a ward? A Yes, it is. There are one or more buildings in the hospital whose staff in that building are designated for patients from the—from these several counties that we mentioned earlier. Q Is there a separate unit for each coun ty th mentioned? compas A Some counties have one unit, there is one—and others have two. That has to do with the numbers of the patients that are admitted from the different areas be- cause there are more people in some counties than others. Q Okay. And the adolescents would be disbursed among those different units? A They are, as far as their—as to where their treat- ments plans are formulated, they are formulated by the staffs of those geographic units, and the patients—and the adolescent patients live in those units, that geographic area. Q But during the day they’re all brought together? A They are all brought together during the day in that day program. (11) Q Do you have any idea what the curren t average length of stay is for the children and the adolescents? ? A I’m sorry, I don’t. s he tay bay! a spoke about a utilization review , and that’s different, is it not, from the staffin the rounds conducted .. . om — [11] 362 A Yes, it is. That is outlined in the looseleaf notebook. That is a overall hospital policy and procedure which is part of the proceedings of the quality review committee of the medical staff, which—which committee is appointed by the president of the medical staff, who is appointed by me. Q And how often would this utilization review occur? A It occurs—they meet monthly to review utilization of beds in the entire hospital, including children and ado- lescents. Q Would they review each case every month? A No, they do not. They review a representative sample of cases. They would not review every case in the hospital every month. NOTE: (Defendant’s Exhibit Number Four was marked for purposes of identification.) Q Would you identify that Exhibit, please? A These are the admission documents and admission instruments on all patients who are currently resident patients at the Atlanta Regional Hospital, and it includes data regarding their social history. That’s what it is. Q And that’s for each child who is presently a patient... A That’s for each child and adolescent who is presently a patient in the hospital. [12] Q Does this include social summaries? A It’s supposed to include the social data that we have. We do not collect a specific document that is called en ee ee 363 [13] social history. That—we have a data base that’s collected on every patient and that includes social information, plus additional notes that may be made by social workers who are working on a particular case, and in instances where that was the case, that was attached to these individual admission instruments. Q Would this include information gathered by the community mental health program if someone had been through a community program? A It would include—yes, it would, although it would not be in the form of a document submitted from the center. It would include information that they may have obtained prior to the person’s admission. Q You were talking a bit ago about a screening com- mittee even after a referral had been made by a mental health clinic, is that right? A Yes, the screening procedure that’s outlined in this written policy and procedure in this booklet is carried out, even on those patients who are referred by the community mental health centers before a final decision is made to actually admit the person. Q Well, when... A I’m talking about pre-adolescent children. I’m not talking about adolescents. They’re handled by—in the same manner that adults are in those adult units. Q Okay. In this screening process, does the screening committee [13] have additional information from the community mental heaith clinics like prior treatments and psychological examinations and psychiatric inter- views? [13] 364 A They do have additional information, and some of which may—some of which may be in writing, and some of which may have been obtained by them directly over the phone. Q So the information in Exhibit Three would not necessarily be all the information upon which an admis- sion decision was made? A Wouldn’t necessarily be all of it, that’s right. Q In this screening process, is another psychiatric interview conducted by the admitting physician? A The pre-adolescent children—the pre-adolescent childrens unit has a psychiatrist who participates in the admission procedure, and he—he interviews—he at least sees personally—I’m sorry, that’s not correct. He does not necessarily see the patient in person each time before he is admitted, but he makes the decision as to whether a person shall be admitted or not. That’s done by the phy- sician—by the psychiatrist. And the same is true of the adolescents in those adult units. All patients are admitted to the hospital on the decision of the hospital physician. Q But you're saying it wouldn’t necessarily be on the basis of a psychiatric interview by the admitting psy- chiatrist? A Not necessarily. Would admission be preceded by a psychiatric einen by a psychiatrist at the mental health clinic? A I don’t specifically have that knowledge. Okay. Do you know of any problem with regard to aan who [14] are reluctant to take their children back home when your staff recommends discharge? iii ese belli ede am 365 [15] A I can’t quantify that, but there are—there are problems in a certain number of cases. Q Have you got an estimate as to what percentage of cases that might be? A Twenty-five percent would be an estimate of that. Q And how do you handle that reluctance, or that problem? A The staff works intensively with those parents on a continuing basis, and where that’s a problem, they address that as a problem, and if they’re absolutely unable to place the parent—the child with the parents, or if it is determined by the psychiatrist that it would be undesir- able for that child to be—in the interest of his mental health, that he be placed with those parents, then we seek an alternate foster home type placement in collaboration with the county Departments of Family and Childrens Services. I might say that on occasion our staff has—has sought out a foster home themselves, gotten the county Family and Childrens Services to certify that home as being proper to receive a child, and that was done in one instance just recently, a child in Fulton County, who had been in the hospital for two years. The staff sought out a foster home and that child was placed in that home just before Thanksgiving of this year. Q But the resource you would use primarily for that would be the county Department of Family and Childrens Services? A That’s the primary resource we use to place those children. Q And then sometimes—do they go into juvenile court to remove [15] custody from the parents? (15] 366 A That happens in some instances, yes. By the way, I’m not sure about that child I mentioned, but a certain number of these children have no natural parental figures, so that we—we seek out surrogate parental figures, and family—home settings. Q One of the contentions in this case, Doctor, is that there is a necessity for judicial proceedings in juvenile court prior to the admission of children to the hospital. As superintendent, do you believe that such proceedings are necessary? A I happen to be of the opinion that they are not necessary, that there are many mechanisms to protect a child from, shall we say, just being thrown into a mental hospital. I’ve described a number of them, and how we do it at Atlanta Regional Hospital, how we undertake to do it. I—it’s my opinion that where mental illness exists, that physicians and staffs of community mental health centers are trained and experienced in recognizing those condi- tions, and that the subjecting of a mentally ill child to a courtroom procedure, could be detrimental to his—could eause him anxieties and tensions, fears, that in my opinion would not be necessary. Q That’s all the questions I have. EXAMINATION BY MR. GOREN: : ee 7 — Doctor Bowling, I’d like to ask you, initially, a a relationship with community health centers. Could you describe how they might get a referral and how that would lead someone to coming to your institution? k directly A Yes, I—you understand that I do not work with [16] them in those centers, but the—they might get a referral from an adolescent either presenting himself at that center with a problem, a parent presenting an adoles- 367 [17] cent with a problem, or a parent presenting a child with a problem. They might get a referral from a family phy- sician, pediatrician, they might get a referral from the department—county Department of Family and Chil- drens Services. I guess those are the principle ways that people might approach them wanting a service. Q Do you know what criteria the community mental health centers use in deciding whether or not to refer kids to your hospital? A As far as I know, because of the relationships that Mr. Baeszler, who is the director of the hospital’s program has developed with these centers, it is essentially persons whose behavior is out of control and constitutes a physi- cal danger to themselves and others, that’s the primary criteria. Q Is that the same criteria that your hospital uses? A Yes. Q Do you know on what basis the community mental health clinics arrive at that decision? A Ido not. I don’t know how they reach that decision, other than, I presume, overt behaviors on the part of the child or adolescent. Q Do you know how they get that information about that overt behavior? A No, I don’t. I don’t know whether they get it by hearsay from other persons, or whether they actually observe it. Q But however they arrive at the conclusion that a child or an [17] adolescent is exhibiting dangerous be- havior or behavior that’s out of control, they then would refer the case to your hospital? [17] 368 A (No audible response.) Q And specifically how would they do that? , , —— A They would call the hospital childrens uni state the shine. whereupon we would have them enter the child into our screening procedure which I tried to describe earlier, and which is outlined in this booklet. Q You don’t know if that child was first examined by a psychiatrist at the community clinic before the case was referred to your hospital? A I donot specifically know that. I do know that those centers have psychiatrists. I do not know whether they specifically have an examination by a psychiatrist in each instance. I just don’t know that. Q Do you know if they are psychiatrists who work in the center, or are they consultant psychiatrists? A My—I should think that in most instances they are consulting psychiatrists on a part-time basis. I don’t know specifically of any of those centers that have a full-time child psychiatrist. Q You also mentioned that you believe that your hos- pital rejects about twenty-five percent of the referrals from the community clinics? A Yes. Q Do you know what percent the community clinics themselves reject? A Ido not. Okay. In the screening review at your hospital after a » is nied there, do you know exactly what that screening review [18] consists of? ae? eS ae dhe ea Ps s Wiliteatteiccitcte tort ticcme sins Winditie ag oh pat nnd. pe 369 [19] A Well, it consists of—of everything that’s outlined in this type of procedure. I don’t know how do give you a capsule summary of that because the. . . Q Well, how long would the screening procedure take before it’s finalized and before a decision is made? A Those—the decision is made at the—at the screen- ing appointment, which is referred to in that policy pro- cedure, and prior to that time there are considerable amounts of data gathered about the child, which is out- lined in there, and I would say that the screening appoint- ment and the actual procedure would consume about two to three hours on the average. Q Is it important to gather such data? A To gather the data prior to that appointment? In my opinion it is. Q Why is that? A To—to obtain as much information as the staff can as to what has happened to that child in the past and what may have happened to him prior to him—as to the reason for referring him for hospitalization. The informa- tion, of course, is accepted from other persons. It’s not a direct experience of the staff of the hospital. Q How is this information verified by your screening procedure? A It is accepted on the basis of any verbal information that’s given, of the staff of the hospital knowing or ac- cepting the statement of the person that they are talking to, that they are staff of the centers, and they—members of our staff spend a certain amount of time in these centers, so that [19] many times the persons know each other personally and know that they are on the staff of these treatment centers, and the written documents would usually bear the letterhead of the referring center. Who would you believe would be the primary is of information when a child or adolescent is to be admitted to your facility? A Who would be the primary source of information? Q Yes. A You mean as to who—as to who would be the person that would best be interviewed? Q Right. | ild’ ts or A I would say that probably the child 's paren parent surrogates, but not—wouldn’t limit it to that. It should be—there should be additional information ob- tained from such persons as a family physician who may have made observations of the child in a professional manner. n regard to the parents or the surrogate parents, a. Bo none that with a certain’ percent of the cases, and I believe you used somewhere between ten percent and twenty-five percent, you noticed that parents were reluctant to participate in their responsibilities for their children, is that correct? A That’s what I said, yes. Q Okay. Why do you think this might be? A I think there can be a variety of reasons. It can be such things as the parents feel guilty about having a 4 turbed child. They may wish to have some serene or other [20] persons to make this child different in behaviors from what he is. They may feel guilt that they did not—that they did something wrong in rearing - child. Those would be the principle reasons that I thin they might be reluctant. It’s possible that they might not _ Sar ¢ : 4 ; F : ? 3 4 z x & 3 a « | & 371 [23] want the child. But all of those things would have to be determined on each individual case, on an individual basis, and that is what the staff is trained to do in their professional practice. Q Sure. You mentioned that one of the keystones is involving the family itself in treatment? A That is axiomatic in the treatment of children, is to treat the parents and the child. It’s considered to be a constellation of disturbance that exists, that where there is a mentally or emotionally disturbed child, that it relates to the parents. Q And therefore the parents themselves require treatment? A Yes, they do, they require—the parents and the child are all treated in the treatment plan for the child. Q Because of these kinds of situations, is it possible that parents may misperceive or misinterpret or distort facts when they are asked information about their chil- dren? A Yes, that’s possible. ** kK kK * [22] * * kK kK * Q But one of the things you said, I believe, was that it’s often difficult to get parents to volunteer some infor- mation. An example that might come to mind is, if the child—excuse me, if the farent had a record of child abuse, do you think that would be information that they would readily make available to the screening .. . [23] A I would say they’d be more likely not to readily make that available than they would but there would be [23] 372 a certain number of them that might volunteer that in- formation. Q And for those who wouldn’t, would it be helpful in making your decision to hospitalize if a court could dis- cover that information and make it available? A If that information were available to the staff, it would enrich their data base, in making their decision. Q Okay. When you were describing the admission procedure, I don’t know if I misunderstood you or not, but is a child, before he’s admitted to your hospital, always examined by a psychiatrist at your hospital? A He is always examined within twenty-four hours after admission. The psychiatrist may decide to admit based on the findings of the screening procedure, without necessarily directly examining that child. I would say that in most instances he actually does. Q Would this bea... A He definitely does it within twenty-four hours, which is the requirement of the Georgia law. The Atlanta Regional Hospital has a one-half-time child psychiatrist on the staff of this unit. The back-up to him is the psy- chiatric and other medical staff of the hospital. Q Okay. You made a distinction before concerning— it seems like you make an important distinction between children and adolescents. At what age is the dividing line? A The—what we call a pre-adolescent person is a person through the age of eleven, and an adolescent is a person age [24] twelve through sixteen. Those criteria were established by the Division of Mental Health of the Department of Human Resources. 373 [25] Q Okay. How are pre-adolescents or children treated differently than adolescents? A There is a separate building and staff for pre-adoles- cent children, and the adolescents are treated—I should say the—in both cases the treatment plans for these persons are developed—the treatment plan for the adoles- cents is developed in the geographic units. That is a major, essential difference in the way they’re treated. In both instances—in the instance of both pre-adolescent and adolescent persons, there is a development of a specific written treatment plan for each individual, and in the—another difference is that in—although in the instance of both the pre-adolescents and adolescents efforts are made to work with the parents, that is inten- sely pursued with the pre-adolescent children. Those are the essential differences in the way these two groups are treated. Q Is there a difference in admission procedures? A There is a difference in the admission procedures. Q What is that difference? A The difference is that the adolescent patients are not—do not go through this elaborate screening procedure that the pre-adolescent patients go through. Q Why would that be? A The geographic units have—have their admission policies and provedures which are not—which do not include this [25] —this very elaborate screening pro- cedure. Why do you make the distinction between children und adolescents? [25] 374 A Well, I suppose it’s because that those units, being essentially adult units, they—there’s never been a special admission procedure for the persons who are less than seventeen. Q Okay. A child in the scheme at your hospital who reaches the age of twelve is considered an adolescent? A Yes. Q And a twelve-year-old would then’ be put on a geo- graphic unit? A That is the basic policy and practice. It is not fol- lowed in every instance because the staff on the pre- adolescent unit will sometimes retain a person a bit beyond that age limit in the interest of his treatment. Q And on the geographic wards are adult patients? Say there might be situations where you would have a twelve-year-old on a unit with adult patients? A Yes, that’s correct. Q What is it, in a child or adolescent which would make your hospital want to treat them so differently? A That situation arose through a series of cireum- stances that goes back some years. The hospital never opened a separate unit for adolescents with a separate staff, and until 1973 the hospital did not receive and treat any adolescent patients. The—in 1973 the Division of Mental Health established a policy that all persons in the geographic area of the hospital would be treated, and we began to receive adolescent patients in the adult pro- grams, and that’s—that’s how that situation, as it now exists, occurred. [26] NOTE: (Brief off the record.) 375 [27] Q Doctor, we were discussing the difference in your hospital between how children and adolescents are treated, and you were describing that children are considered to be persons between—up until the age of eleven, and are con- sidered adolescents from the age of twelve to sixteen. A It’s through eleven and from twelve to sixteen. Q Okay. Is it your opinion, then, that adolescents are developed to the extent that they could function most properly on an adult ward? A They—there is disagreement in psychiatry and in child psychiatry as to whether adolescents require a separate unit and a separate staff. There is no disagree- ment that each adolescent person requires a specific treat- ment plan, and that most professionals believe they should have a special treatment program, but that they do not have to live in a separate unit. Or they may or may not live in a separate unit, and they are—that is an issue that the experts will disagree on. Q Okay. Did you say that you felt that a hearing that might be provided for a child, might have some detri- mental effects on that child? A I did say that. Q Do you think those same effects would be present in an adolescent? A Yes, I think they could be. Q How about an adult? A Let me modify my statement about adolescents to say that I [27] think it would be less so in an adolescent who had his personality more formed, and I would not equate the experience in the three groups. I’m giving you my opinion. My opinion would be that it could stimulate (27) 376 —you might want to know in what way would I think it would be harmful. I think it would stimulate fantasies in a pre-adolescent child that he—that might would cause him to wonder what was going on or what might happen to him, and that—well, excuse me. Q Wouldn’t he also wonder what was happening, what was going on, when his parents take him to be ad- mitted to the hospital and he finds himself—and he is accepted by the hospital and he finds himself in the hospital? A Yes he would. Either procedure is a ritual or scenario which could stimulate fantasies that would produce— could produce anxiety or fear in the child. Q Okay, but these wouldn’t.. . A Uncertainty. Q These wouldn’t necessarily be present in adoles- cents? A I think they might be present—I think that they could be present, but that their impact on the person would more likely be less. The person could handle it better, so to speak. In a more realistic manner—handle it in a more realistic manner. Q Okay. Do you know how many adolescents there are on the adult wards at Atlanta Regional? A Yes, it would be the number that we have in the house at this time. Twenty-two. [28] Q I know it’s hard to try to reach specific ages, but would a child or an adolescent at the age of twelve be able to handle a hearing without too much detrimental effect? - et 377 [29] A I would not be able to set an arbitrary age on it, because there would be individual variations. Q Okay. In other words, a twelve might—a particular twelve year old may be able to function fine, whereas one who would be older might have more problems? A That’s possible, because there’s a tremendous variation among individual human beings. Q Do you know if there are any twelve-year-olds on adult wards? A Yeah. I don’t specifically know that as of today, but there very well may be, and there certainly have been. Q This policy for distinguishing between persons through the age of eleven and persons through the age of sixteen, is that a policy specifically of your hospital, or is that a state-wide policy? A That is a policy of the Division of Mental Health of the Department of Human Resources. It’s not a specific hospital policy. Q Okay. Excuse me, you said it’s not a specific hospital policy, but the entire .. . A It is a policy of the Division of Mental Health of the Department of Human Resources. You asked if it was state-wide, that would make it state-wide. Q It’s your impression that all of the regional hospitals make this distinction? A That’s my understanding. I don’t specifically know that to be [29] a fact, but that is my impression, yes. Q Do you have any written policies from the division that spell out—making this distinction? (29) 378 A I don’t believe I have a written policy that spells that out. Q But that policy was told to you? A That policy was told to me by Doctor Charles Bush, who was the former Deputy Director of the Division of Mental Health. Q And does the same policy... A And it’s never been rescinded. Excuse me. Q Okay. Do the same distinctions between children and adolescents at the admission stage, come from policies that are also told to you to be state-wide? A The—you mean in the procedures for admission? Q Yes. A Those procedures that I outlined to you are the procedures of the Atlanta Regional Hospital. I’m not aware of the specific procedures of the other hospitals. Q Okay. Doctor, concerning the admissions of chil- dren, do you know the percentages—excuse me, let me ask first, is there a certain standard for diagnosis, a standard document that you refer to to make diagnosis? A There is, and it’s—it’s the International Nomen- clature of Disease, I believe is what it’s called. Q You do not use D.S.M.-2? A Is that the—what is D.S.M.-2? Q The Diagnostic and... A Yes, yes, yes, we use that terminology that’s listed n the Diagnostic and Statistical Manual of the American Psychiatric |30] Association, I believe, and that list is 379 [30] contained within the International Nomenclature of Disease. Q Okay, I see. Using those diagnostic categories, do you know which percentage—or what percentages of various categories that children who are voluntarily ad- mitted to you hospital, fall under? A I don’t have that breakdown. I don’t have that collated. Q Do you have any idea as to—any approximation as to which category would be more prevalent than other categories? A Yes, I would say that the—that the two—two most prevalent ones would be number one, schizophrenia, and number two would be behavior disorders of childhood and adolescence. Q What would they include? A Well, the Nomenclature has seven separate classes that come under that heading. Do you want me to name those off? Q Only a few who would think that—some particular ones of those would be the most common in that category. A I would say that probably the hyperkinetic reaction would be the most prevalent. Q Okay. Upon admission, are children and/or adoles- cents informed of their rights as patients? A They are. Q How is that done? A That is done by the admitting staff in the admitting process on a verbal basis to the child. [30] 380 Q Are there any written policies, procedures describ- ing how to effect this information? (31) A I don’t believe we specifically have that. There are written policies and procedures in the hospital that—that do require staff to impart such information to all patients who are admitted. Q And that would include children? A That would include children and adolescents. Q Are they given any written notice of these rights? A The—each patient that’s admitted to the hospital is given a copy of a booklet that is put out by the Division of Mental Health. It’s called Your Rights Under Geor- gia’s—in Georgia’s Mental Health Facilities. Q Is that written especially for children? A No, it’s not. It is written for—it is written for any patient admitted, but it is not written especially for children. Q Okay. In your experience have you ever observed, say, an adolescent objecting to his confinement in the hospital? A I can’t cite you a specific instance, but we—he has every right to do so and there are written hospital policies and procedures as to what is to be done when a person does raise such objections. For instance, there is a right to apply for discharge, and there are written policies and procedures in all units in the hospital’s manuals that are on all units, that spell out that procedure. Q A child can do that also? lO A OR ee it ae en EA 0h ye an Ee = a a St . 381 [32] A I can’t specifically tell you how that’s handled. A child would have that right, but I can’t tell you that we systematically practice that as a procedure. [32] Q As far as adolescents are concerned, do you know the procedures that are involved and how they would effectuate their rights? A Yes, they can—they can say to any staff member at any time that they do not wish to be—that they wish to leave the hospital, and whereupon the standing policy and procedure is to be carried out. Now the essence of that is, that the person or his parent or guardian puts that in writing, and we actually have forms that they can use for that purpose, which the procedure calls for the staff making available to them, and then that document is dealt with so that the case physician reaches a decision as to whether, within a specified period of time, as to whether or not that discharge shall be granted, or whether the hospital shall take steps to prevent it. Q Can that request for discharge only be done by the parent or guardian in the case of a voluntary admission of a juvenile? A I believe that—that that’s correct, because that is the—the way that we understand that the law is presently structured. Code Section 88-5 is what I’m talking about. Q Okay. And this—and it’s possible that this could be the same parent or guardian who you said might have a conflict of interest with the... A That would be possible. *xe kee * 382 [36] ** * * * Q What would the effect be if there were, say, an advocate for the child or adolescent at these rounds or at the reviews that you [37] have, an advocate who would not be there to disrupt the proceedings, but just to speak on behalf of the patient? A I would say no—no objections to that. Q Okay. A And it could be helpful. Q In the same sense, do you think it might be helpful to have an opinion of someone who is outside of the sys- tem, someone who in the same sense could give a different perspective like an advocate... A Well, that wouldn’t hurt anything. That wouldn’t hurt anything, and it could be helpful. NOTE: (Brief off the record.) Q Doctor, how many physicians do you have in your facility? A We have eleven full-time and the half-time child psychiatrist. Q Are these physicians board certified in psychiatry? A There are three of us who are board certified, three out of the eleven who are certified in psychiatry. Q And are all the others licensed to practice medicine? A Yes, they are. Q Are there any licensed only to practice in a state institution? A There are two physicians who are licensed to practice only in the institution. ee lee Sl 383 [38] Are there any foreign born or trained physicians? Yes, there are. How many are they? - O F Four. Q Do any of these physicians have difficulty with the English language? [38] A These particular ones do not with the exception of one, who has, I would say, minimal difficulty, in one phy- sician whose primary language is Russian. *“* & * * j pepmemuee | January 20, 1975 I. II. 384 EXHIBIT 2 Screening Procedure CHILD AND YOUTH SERVICES Policy # 2, Part I Referral taken by Screening Coordinator. If coordinator is not available, the referral will be channeled to any one of the following team mem- bers. A. Social Worker B. Psychologist C. Assistant director of Education D. Psychiatrist Phone Contact Sheet During the referral (Initial contact) the team mem- ber taking referral will complete the Phone Contact Sheet. Each team member will have xeroxed supply of Contact Sheets (sheet attached page # la). Determine as soon as possible if the referral is ap- propriate (i.e., has been referred to GRHA by private psychiatrist or psychologist or has been through a mental health center). If referral is appropriate complete all questions on Phone Con- tact Sheet. If it is not a correct referral, supply person with name and phone number (see attached page 1B) of the mental health center in his area. File original Phone Contact Sheet of those referred elsewhere in manila file folder located in secretary’s file cabinet (drawer labeled ‘“Screening”’). The folder is labeled “Phone Contacts Referred”’. Contact sheets of those not referred will be filed under ‘Phone Contacts—Appointment Scheduled.” Location for this file will be the same file cabinet labeled “‘Screening”’. — =—_ ~——— —— a os — OP RO ne A OC A me Ota a - NS see ee es ae ~_ +t _ im — —- — et ne Le EEN oe oe 385 Policy # 2, Part I III. Scheduling the screening appointment. If the referral is appropriate, schedule a screening appointment at GRHA no sooner than four work- ing days after date the contact call is received. The minimum four day period is to allow the screening team to gather all the information needed to assist in the disposition. Record appointment date on blackboard and in the screening appointment book located at Ward Clerk’s desk. Xerox copies of contact sheet. Place one in each team member’s communication mail box, place one in the folder established for child. Folders to be established for each child scheduled for screening evaluation. The folders will be located in the same file cabinet. as Phone Contact Sheets (drawer labeled “‘Screening’’). After the screening appointment, the original phone contact sheet in folder labeled “Phone Contacts— Appointment Scheduled” will be (1) put in chart if child admitted, or (2) stapled to folder on child if child is referred elsewhere for treatment. The team member taking the call is responsible for getting (1) contact sheet xeroxed, (2) getting copies of contact sheet to all other team members, (3) starting folder on child, (4) recording appointment on blackboard, (5) recording appointment in screening appointment book, and (6) putting original phone contact sheet in correct folder. The screening team members are: (1) Coordinator (2) Social Worker (3) ee (alternate: Psychology Techni- cian (4) Psychiatrist (5) Assistant Director of Education (alternate: Teachers) CT a Ee IV. 386 Policy # 2, Part I Each team member will be responsible for gathering certain information pertaining to their particular area. Assistant Director of Education: Information; responsibilities. (1) Contact present or last school attended. — (2) Visit the school and observe the child in the classroom, if possible. (3) If a visit to the school is not possible, contact the teacher by phone. Counselors or school social workers are alternates. (4) If the school is closed (summer, holiday) con- tact area office, caseworker or parent for in- formation. Complete 1 page or less hand written xeroxed report of findings. Distribute copies to team members no later than 1 hour prior to screening appointment. Put copy in child’s folder. Put copies of any reports received from schools, etc. in folder. V. Psychologist: Responsibilities (1) Contact the referring agency or doctor to deter- mine testing information (extent of) available. (2) Psychological tests will be administered if need is determined by the psychologist. Criteria for testing: (a) No testing available within last six months. (b) Question as to validity or prior scores. (c) Determine if child in in TMR, EMR range. (d) Psychometric services not available at the community level. (e) Question of LD problem. ee TE TE! ee en eee ae ee a ee A — A A A a I a ee ee oe ee _ — “Oe. VI. 387 Policy # 2, Part I (3) Possible need for condensed battery of tests. Though not as thorough as administering com- plete tests, the condensed version would give staff a general idea of where the child is funce- tioning. (4) Testing, ete. can be administered by the Psy- chology Technician. If the Psychologist determines need for testing (by above criteria) and it is not available on the com- munity level, the testing is to be completed during the four day period ; (a) on one of the four days prior to the screening appointment, or (b) on the same day as the screening appointment. Complete a one page or less handwritten report of findings. Xerox, distribute copies to team members prior to screening appointment. Put copy in folder. Screening Coordinator. (1) Receives phone contact. (2) Schedules appointments. (3) Periodically checks to see if appointments are: (a) on board (b) in notebook for appointments (c) folder established on child (d) phone contact sheets in correct location. Team members have xeroxed copies. (e) responsible for getting information from referring agency. (f) involve community mental health center in screening appointment; determine if repre- sentative from mental health center will be at screening appointment; coordinate in- volvement of community mental health centers and their contractual agreements with other agencies and staff member re- sponsible for implementation of contractual agreements at GRHA. 388 Policy # 2, Part I VII. Social Worker/Social , Work Technician VIII. After taking phone contact or receiving notification of contact and appointment scheduled, the follow- ing items are to be completed: (1) Make or coordinate home visit if possible. (2) Gather as much information as possible on family. Get reports from DFCS, Juvenile Court, ete. if involved. (3) See that agency representatives tro attend screening are treated professionally. (4) One page or less hand written report on family, social history. Distribute to team members no later than one hour prior to screening appoint- ment. (5) Xerox copies of information to child’s folder. Screening appointment. (1) Thirty minutes before screening appointment the team members assemble to discuss findings Primary Therapist tentatively assigned at this point. If Primary Therapist is not team mem- ber, is notified to attend screening appoint- ment. (2) Client arrives and secretary assists parent or guardian in completing face sheet. (3) Team members meet briefly with community mental health representative, caseworker, and other involved service workers. (4) Client and parent or guardian (unless is above mentioned caseworker, etc) meet with team members and other agency representatives. (5) Interview child with parent in room, (6) Child, parent/guardian asked to remain in lobby while team members make disposition. (7) Parent/guardian informed of disposition. If referred elsewhere, the name and phone number of referral agency is given to the parent. Dis- 389 Policy # 2, Part I position is discussed with mental health repre- sentative. If admitted: (1) Primary Therapist above assigned com- pletes data base with parent’s assistance. (2) Secretary has parent/guardian complete all consent forms, other necessary paperwork. (3) Parent meets with Social Work Technician to complete research forms. (4) Staffing coordinator assigns staffing date. If there are no beds available the child is placed on a a list. Admission will be upon availability of a Final decision for admission will be with the con- sulting psychiatrist. 390 (1) IN THE UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF GEORGIA MACON DIVISION (Caption omitted in printing) DEPOSITION OF GLADELLE WHITAKER Taken on behalf of the Defendants. APPEARANCES: For the Plaintiffs: MS. NANCY LINDBLOOM Attorney at Law Macon, Georgia For the Plaintiffs: MR. GERALD R. TARUTIS Attorney at Law Macon, Georgia For the Defendants: MR. DOUGLAS LACKEY Attorney at Law Atlanta, Georgia [2] This testimony came on to be heard in the District Office of the Department of Human Resources, located in Gainesville, Georgia, at approximately 3:00 p.m., Decem- ber 4th, 1975. MR. LACKEY: This is the deposition of MRS. GLADELLE WHITAKER, taken for the purpose of evidence in the matter of J.L. and J.R. versus Jim Par- ham, et al. The parties hereto have agreed to reserve all objections, except as to form. (Signature of the witness is waived.) Pe Ne TT 391 [3] GLADELLE WHITAKER, being first duly sworn, was examined and deposed as follows: EXAMINATION BY MR. LACKEY: Would you state your name for the record? Gladelle Whitaker. What is your address? 223 Lucille Lane, Toccoa, Georgia. What is your occupation? rr OF © © Director for Stephens County Department of Family and Childrens Services. MR. LACKEY: Council for the Plaintiffs and counsel for the Defendants stipulated that Mrs. Whitaker is the custodian of the file—(To the reporter.) Off the record. (The parties went off the record for a brief (3] period of time.) MR. LACKEY: Counsel for the Plaintiffs and counsel for the Defendants have stipulated that Mrs. Whitaker is the custodian of the record of Jimmy, a child, a minor child, who will be identified throughout this Hearing either as J.R. or Jimmy or James. We further stipulated that certain documents, which have been excerpted from that record, are true and correct copies of the documents contained in that record and that parties will stipulate that these documents are being included in the Court’s records with this deposition, subject to the objections, which the Court has directed the parties to reserve. The documents themselves are broken down in [3] 392 this fashion: There is one white folder of materials, which refer to the psychological examination given to the child; there is one white folder, which contains documents re- lating to placement attempts, attempts to place the child; one white folder, which relates to reports of the child’s behavior in various foster homes and other situations; there is one group of documents, not in a white folder, which are the reports of the case worker assigned to Jimmy, beginning in December of 1974, and continuing through the present date; there is one set of documents, which constitute the Court order, the Petition, and sup- porting documents, which resulted in Jimmy’s custody being given to the Stephens County Department of Family and Childrens Service. I don’t know [4] how to identify the materials in the documents any more clearly than that, unless you have something you want to add. MR. TARUTIS: You can say that counsel further agrees that these documents will not be attached to the deposition itself, but will be submitted under separate cover and will be numbered consecutively by counsel, jointly. — MR. LACKEY: We have stipulated that any ob- jections to these documents will only be to their relevancy and not to their—and not to the form of admission. In other words the documents have been properly tendered, subject to your objections as relevancy. MR. TARUTIS: Off the record. (The parties went off the record for a brief period of time.) MR. TARUTIS: Councel further agrees’ that Mrs. Whitaker is the custodian of the documents, that the documents have been properly identified and placed into 393 [5] evidence—have been properly identified and tendered for placement into evidence. MR. LACKEY: Subject to your objections? MR. TARUTIS: Right. Counsel has further agreed that Mrs. Whitaker is the custodian of these records and that these records have been properly identi- fied and tendered into evidence, subject to the objections of Plaintiffs in this matter. [5] Q Mrs. Whitaker, you stated your position was County Director of the Department of Family and Childrens Services of Stephens County; how long have you been in this position? A Seven and a half years. Q Where were you employed before you became County Director? A Asa case worker with the Stephens County Family and Childrens Services. Q How long were you in that position? A Nine and a half years. Q As County Director, what are your responsibilities particularly with respect to adoptions and foster care in the county? A The Department of Family and Children Services has a responsibility for adoption, foster home placement, working with protective services for children, which in- cludes abandoned children, children neglected or referred to us. Q Without referring specifically to this case, can you tell us generally what the procedure is in Stephens County = \ \ (5] 394 for the placement for adoption or for foster care for children in your county? A Children that are in custody of the department or who are voluntarily released to the department, are the ones we actively seek foster homes for or if we have per- manent [6] custody—you would, you know, consider for adoption, if they are an adoptable child—we try to use for foster care a placement of an approved foster home within our own county. If it’s an adoption, with permanent custody, we submit material to the District Office, which engages in finding the adopted home. We don’t seek adoptive homes for specific children. Then getting back to the foster care in our own county, foster parents have the right to state what type of children, age range, etc., they can provide or care for in their own home. In the event that we have a home that is full or does not meet the needs of a specific child that needs placement, we come to our District Office stating that we have this child that needs foster care and that we do not have a home for him in our county, and would she explore the district foster homes. She keeps the central file here. A lot of in- formation is not given to her, such as specifics in homes. They just make a referral that this home has a vacancy within this age range. We contact a worker in the other county giving them some background information, some information on the child, to see if maybe their foster parents where the vacancy occurs could take care of this child. We either get a yes or no answer. If this doesn’t materialize, then we let her know this, that we need to try to explore some other source over the state, then she handles it from there. [7] Q How do you go about securing persons to operate foster homes in Stephens County? 395 (3] A This is an open decision—always we are open for people to file an application for foster care. We may have speaking engagements there at the Civic Club, programs on the radio or spot announcements, advertisements in the newspapers. We have been known, say, to run a cam- paign, but we’re always open for people who may want to apply to become foster parents. Q You said that there were speaking engagements and this type of thing, do you personally do that sort of thing? A Yes. We involve either myself and maybe, you know, some of the caseworkers in the services department also. —~ Q Do you know how many foster children you have in the county now for instance? A No, that’s handled by the specific caseworker assigned to that responsibility. Q I believe you stated that you went to the district and then went to the state. Do you have any connection as to what occurs at the state level? A Not really, it’s—you know, we make the request and the Social Services Director may tell us to get the material together and mail it directly to a person in the state. We are responsible for getting the summaries to- gether and information on the child, that is our respon- sibility. [8] Q Okay. Let’s talk specifically about the matter at hand, that being Jimmy. Can you tell us when you first became acquainted with Jimmy? A Jimmy was brought to my department by a rela- tive— [8] 396 Q Before you do that—are you going to refer to those notes? If you want to look at them, feel free. MR. TARUTIS: Off the record. (The parties went off the record for a brief period of time.) Q Do you recall when you first became acquainted with Jimmy’s case? A Yes. Jimmy was brought to our department by one of his relatives and a close neighbor of the family when he was three months old. Upon observations from, you know, lay people, because there was more than me involved, he seemed to be malnourished and not fully developed for three months as a child should be. This seemed to be an emergency as the child seemed listless, his head was larger than his body, his stomach protruded, his hands and his legs were just—no flesh, just very small. So, we carried the child to the Juvenile Court Judge, who made an observation and gave us an emergency order at the time to place him in foster care and get medical examina- tions. The parents were notified and he set a date for a Hearing, but the child was placed in an emergency situa- tion at that particular time and he [9] was carried to a pediatrician, who gave a written report to the Court, the Judge, for the specific Hearing when the parents were in- volved. The Judge gave us the order for temporary custody; at the time he was about three and a half months old. He was placed in a foster home in Stephens County. The home was an approved home for us for infants, it was a widow lady. James was hard to discipline, he was a head-banger and he didn’t seem to be fully developed, as far as developmental charts. And, this lady, as I said, was only approved for infants, so when he reached two years Oro PHP Oo PO A Georgia Regional Hospital at Augusta. Q And what’s your position there? A Iam the superintendent. 553 (4] Q How long have you been the superintendent? A Since 1969. Q When was that hospital opened? A In 1969. I essentially came on board about the time the hospital opened. Q All right. What are your roles and duties as super- intendent of the hospital? A The roles and duties are the direction of all pro- grams at the Georgia Regional Hospital at Augusta, and also those mental health programs for which the hospital and the division in the department, contracts with local health departments in our area. Q How many counties are in the area? A Thirteen counties. Q And how many community mental health clinics are there? A There is one complex of community mental health clinics located at the Augusta area. This means more than one center site. We also have—of the twelve remaining counties that we serve, we have a satellite-type program in ten of those twelve counties. Q But the community program is centered in Au- gusta? | A Yes, with satellites in the small—the way we are geograph-[4jically located . . . catchment area of three hundred and twenty-five thousand. Approximately two hundred and twenty-five thousand of those people either live in or within ten miles of Augusta. The other hundred thousand live in these twelve rural counties, a distance which is approximately one hundred and thirty miles by (4) 554 sixty miles wide, pretty well scattered with no population density, counties ranging from two thousand with the next largest county being eighteen thousand. Q Are you also affiliated with the Medical College of Georgia? A Yes. Q And what is that affiliation? A Okay, the affiliation is that I hold a title there | Clinical Associate Professor of Psychiatry. We, the hos- pital and the division, also have a contract with Medical College, so that students in the—during their rotation in psychiatry, residents in psychiatry, residents in family practice, rotate through our hospital. Q Allright. Now, would you describe, please, Doctor, the admission policies for the hospital, with spécific reference to voluntary admissions of children and adoles- cents. A Specificaily to those. There are the following ways that I see it that we can be approached regarding admis- sion. This might simplify going through all the admission policies. First of all we can receive a court order for the admission of a child. Generally we are notified by the court or by some type of case service worker on this, and the child is brought to the hospital. Upon this type of admission the child is always admitted for an evaluation and the court is notified within [5] a reasonable period of time, usually one to two weeks. That is one type of ad- mission. The other type of admission we want to talk about is voluntary admissions to the hospital. In volun- tary admissions to the hospital, most of the time the people who are seeking admission would be the parents. This is not necessarily always true, it could be a guardian 555 [6] or this kind of thing. Insofar as is possible, all of the chil- dren, prior to any admission, are brought to the C.A.A.P, or Children and Adolescent Program. We use the initials C.A.A.P.—C.A.A.P., which is part of our mental health center. This part is located in a separate building on the grounds of the hospital, where they are evaluated prior to the admission. This program was opened in April of 1974. We have statistics from April of 1974 to November of 1975 that shows that we evaluated three hundred and fifty-eight patients in this program. Forty-nine were ad- mitted to the hospital, and three hundred and nine were either treated as an out-patient or some other alternative to hospitalization was used. Q Doctor—do you have those statistics with you? A Ihave this. I called and got those from my secretary since they left those out and I knew we had them. (Indi- cating notes.) Q Who prepared those figures, Doctor? A These were prepared by—basically prepared by Doctor Dorothy Wood and her staff, who is the director of our children and adolescent program .. . Q Excuse me, the director of the program at the hospital, or the community level? A She is—she is the director of the overall child and adolescent program. The sub-parts are in-patient care, for [6] which the in-patient unit chief, who is a Master’s degree nurse, Mrs. Mamie Hammock, and the director of the community program is a Ph.D. psychologist, Doctor Jessie Hawk. Q So for all the voluntarily and non-emergency admis- sions, they would be screened first by the community component of the program, is that correct? [6] 556 A Right. There are an estimated—and all we can do is estimate this—in the past—same period of time from April of ’74, there were approximately twenty-eight ad- - missions where these children were brought, mostly by their parents, to the hospital, after five-thirty P.M., and they were admitted to the hospital for an evaluation. We have some bar graphs, statistics somewhere—you have them— I have them here, showing how long admissions were to the hospital, etcetera. NOTE: (Defendant’s Exhibit Number One-A was marked for purposes of identification.) Q All right, Doctor, would you identify Exhibit One-A? A Yes. This is a bar graph representation of the length of stay in terms of days in the hospital spent by patients in the children and adolescent year—children and adoles- cent unit during the fiscal year 1974-’75. Q And you were discussing, just before we introduced that, admissions for evaluation. A Uh-huh. (Affirmative.) Q Does the graph show that? -A What I was showing here is that each one of these blocks represent a patient for this period of time, and it may, [7] instead of—we can count them, I guess, since I didn’t write this down—one, two, three, four, five, six, seven, eight patients stayed from one to five days, sixteen patients stayed from six to ten days, eleven patients stayed from eleven to fifteen days, twenty patients stayed from sixteen to twenty days, eight patients stayed from twenty-one to twenty-five days, six patients from twenty- six to thirty days, six patients from thirty-one to thirty- yg — 557 [8] five days, thirteen patients from thirty-six to forty, six patients from forty to forty-one days, three patients from forty-six to fifty days, nine patients fifty-one to fifty-five days, three patients fifty-six to sixty days, four patients sixty-one to sixty-five days, three patients sixty-six to seventy, two patients seventy-one to seventy-five, two patients seventy-six to eighty, four patients eighty-one to eighty-five, the next patient—there was one patient who stayed from ninety-one to ninety-five, three patients ninety-six to a hundred, one patient a hundred and one to a hundred and five, three patients a hundred and eleven to a hundred and fifteen, there was one patient that stayed from one twenty-six to one thirty, one, one thirty- six to one forty-five, (sic) one, one forty-one to one forty- five, one, one forty-six to one fifty, one, one fifty-one to one fifty-five, one patient one sixty-one to one sixty-five, two patients one seventy-six to one eighty, and one patient two hundred and fifty-one to two hundred and fifty-six days. Q Okay. Now the ones for these short periods of time, like say less than two weeks, would that basically be your evaluation? A These are—these are primarily evaluations and short-term [8] treatment patients. Many times we feel that—we personally have a philosophy that’ children should stay in the hospital no longer than necessary, and we have, as you see, a fairly large number of kids who are out, certainly within two weeks to sixteen days. Q What procedures and steps are gone through when a child is evaluated at the community component? A Okay. At the community component, which we will see any patient during the day they call, or if people feel they can wait till the next day, or they can walk into the [8] 558 program itself, a person is seen by an intake worker. This always occurs. If we are doing a complete evaluation at that time—the person is always seen by a psychiatrist. A complete psychological evaluation on this child may or may not be done on that given date depending on whether it was an emergency or not. There is a decision between the team members as to what is the best alternative for this particular individual, be it hospitalization, out- patient treatment, or other alternatives which would be used. Q Who would be involved in that team decision, Doctor? A The intake worker who is either a Bachelors or Masters level individual, the psychiatrist, the director, who is a Ph.D. psychologist, and the testing psychologist, who is usually a Masters degree psychologist. Q After their evaluation, if they felt like hospitaliza- tion was indicated, would they be making a recommenda- tion to the in-patient component, or would it be an actual admission decision? | A They would be making a recommendation to the parents of this particular child. [9] Q And then would the papers be sent—if the parents decided to apply, then the papers from the community component would be sent to the hospital? A Oh, yes. Basically it’s all the same program. Q It’sall... A Weare a little unique in that we probably, I think , have the most unified system as far as community-hos- pital program. 559 (10] Q Would a separate decision be made by a psychia- trist within the in-patient unit? A No. The psychiatrist who evaluated is the principle psychiatrist on the in-patient unit also. There are con- sulting psychiatrists that come to the in-patient unit, but he is the principal psychiatrist for both the community program and the in-patient unit. Q Would a psychiatrist always see a child in the com- munity program, or might he be evaluated .. . A No, the psychiatrist would always see the child within the community program. This is one of our pre- requisites. Let me add at this point, that a consulting psychiatrist is always present at the staffing of this child, which gives us a second psychiatrist opinion, and this is always true. Q When does the staffing occur? A The staffing of the patient always occurs within ten days, attempted seven days, from the time of admission. Staffings are held weekly, and therefore the longest pos- sible period would be—the staffing is held on either Thurs- day or Friday, I’m sorry, I’m not sure which day, but the longest possible time that could ensue between the com- plete staffing [10] of this patient, the treatment plan, all this is spelled out in the policy, would be if the child was admitted the first of one part of the week to the last of the following week. Q And who would be involved in the staffing of each case? A Involved in the staffing of each case are the follow- ing individuals. The in-patient chief, Ms. Hammock, the out-patient community chief, Doctor Hawk, the unit [10] 560 director, Doctor Wood, the team chief of the particular unit which houses this child, the psychiatric social worker assigned to the unit, the psychiatrist, which is Doctor Clark, and one of our three consulting psychiatrists. Q And a staffing occurs each week .. . A Uh-huh. (Affirmative.) @ ...in regard to each patient? A Right. And the attempt, of course, is to have the child staffed the same week. Obviously if he came a day or two days before staffing he would get staffed the next week. Q Would you identify Exhibit Two, please? ‘A This—these are mimeographed pages from the policy manual of the children and adolescent unit, per- taining to the philosophy, the plan of service, the admis- sion, the treatment plan, etcetera for the children who are in the hospital. Q Does it include a written statement of the admis- sion policies .. . A Yes, uh-huh. Q ... discussed? Does it include any material with regard to the treatment of the family of the child who is admitted? A Yes. Q What is your policy with regard to family treat- ment? [11] A Our policy in regard to family treatment is that we make every effort possible for every child who is admitted into the hospital, to have the family involved in treat- 561 [12] ment. We have a weekly group meeting of the parents who are there as well as individual sessions with the social worker or with others of the family members. We dis- courage, almost, the admission of a child unless we can get the family to participate in this. Now we sometimes would have to admit the child, but we use every mech- anism to try to get the family involved in this treatment process. Q Would you have any opinion or estimate, Doctor, with regard to how many natural parents or families do not participate in treatment? A Yes, about ten percent. Q And this is after you’ve tried to get them involved? A Yes. I think sometimes it takes a little bit of elabo- ration. We have about ten percent problem families in this respect. I don’t think we give up. Sometimes we have to catch the family even if we may have released the child from the hospital and they’re bringing the child to the out-patieut or community portion we try to get them into treatment, even though we couldn’t during the one, two, three weeks the child was in the hospital. Q Do you find any problem with regard to parents being reluctant to take the children back home after you recommend discharge? A On rare occasions we do. I’m sure we could recall a—two or three or four episodes during the last three or four years where this was a problem, but it’s rarely a problem. [12] Q Even with regard to the majority of that ten per- cent that don’t participate in treatment? [12] 562 A Right. This is the kind—the ten percent is the kind of thing, like the parents keep finding excuses why we can’t come, or I can’t get off from work, or this kind of thing. Q Would you identify Exhibit Number Four? A This is the utilization review plan for the Georgia Regional Hospital at Augusta and includes all units and programs including the children and adolescent unit. Q And how does that process differ from the staffing process? A A utilization review is essentially a review program using the patients’ medical record to ascertain that hos- pital-wide policies, goals and objectives, which are spelled out by the hospital, by certain Federal regulations con- cerning Medicare and Medicaid, are being met. Q And who conduets the utilization review? A The utilization review? This is conducted by a com- mittee, with the superintendent and the clinical director being the chairman and co-chairman of this committee, with physicians and other professionals being appointed to this committee. It meets monthly. We brought, and we may want to xerox some of this stuff—but we brought the minutes of the meetings, and the only way to do this would be to xerox the pages—for instance showing the involvement in specific meetings. This was the last one, the November meeting has not been typed and put in here yet, but we notice, for instance, in the October meet- ing that Doctor Hawk, who we’ve identified previously, “informed the group that the explanation of the [13] pa- tient’s right on the children’s unit will be documented by the social worker on the progress note sheet. The medical records department is documenting this information on 563 [14] the back of the admission sheet. We also noted that Doc- tor Hawk has asked that the children and adolescent community services center records be included in the uti- lization review. These are out-patient records, so to speak, to be included in the utilization review. It was the con- sensus of this committee that these records be incorpo- rated in the monthly review.” Of course, it lists which records are. Q It is a random selection of records for each... A Right. Right. Except that there’s a number of days that the patient is in the hospital, and I forget this num- ber, we'll have to dig it out of here somewhere—various time periods that these records have to be reviewed. This is a Federal requirement of Medicaid, and we therefore try to treat. all patients equally, so at some of these in- tervals, whatever it is, a hundred days or something like that. Q So all cases would be reviewed at least that often? A Uh-huh. Now I would point out, as it’s spelled out in the policy, that on the unit, during the weekly—there is a weekly conference, an on-going conference on each child or adolescent who is in the program, because a treatment plan has been devised initially with a goal as to the time of release, an expectations, and each week a conference goes over this to see, you know, if we’re meet- ing the goals or if the treatment plan needs to be checked, and this kind of thing, [14] so basically an in-patient child is reviewed by a team conference consisting of these same members each week. Q Is one of the goals of that team conference to try to make release plans? A Yes, but essentially release plan concepts are made (14] 564 as part of the initial treatment. plan when a person comes into the hospital. It’s currently felt, that in your initial treatment plan, you should also be planning for the re- lease of this patient, with some idea as to how long the person would be hospitalized, and this kind of thing, and therefore we use a weekly monitoring system to follow this treatment plan. © Now would you identify Exhibit Number Three, please? A Yes, Exhibit Number Three is a list of all individ- uals who have been admitted to the Georgia Regional Hospital at Augusta since its opening, who were less than eighteen years of age. It’s through age seventeen. I[t gives the date in which they were admitted to the hospital, the date in which they were released, whether they were di- rectly discharged, placed on convalescent leave, and when, if they were placed on convalescent leave, they were di- rectly discharged from the service, the building they were in, ages and other things like this, and we went through the records and have noted on the side to whom this particular person left the hospital or was released to, the parents or service worker, or what-have-you. Q Initially, was this a printout from the computer at the hospital, is that correct? A Right. Q And then notations in hand were put on by man- ually checking... . [15] A Right, the medical records. We then pulled all of these charts and went through this on this side. We simply used a computer using an age factor to make the origina] printout. And there is, attached to it, a code sheet which ee en ee A EC A OT ae. 565 [16] will identify, give you, I guess, instructions on how to read that bunch of numbers. NOTE: (Defendant’s Exhibit Number Five was marked for purposes of identification.) Q Would you identify Exhibit Four, please? A This is the utilization review plan for the entire hospital which also includes children and adolescent pro- grams. Q This is the policy that we’ve been discussing. . . A (Nods in the affirmative.) Q ... is that correct? A We've been discussing two policies, really. There is the specific policies pertinent to what we’re talking about from the children and adolescent unit, which is in one folder; this is the utilization review plan, which is a spe- cific requirement that covers the whole hospital including that umit. Q And this is the one in which cases are selected at random... A Uh-huh. (Affirmative.) Q ...each month... A For the utilization review committee, and it spells out how this committee is formed and .. . Q And would you identify Exhibit Number Five, please? A Exhibit Five contains the admitting physician’s ad- mitting note and the social history of all children and adolescents who [16] are hospitalized by eight A.M. De- cember Ist. I think there are twenty-three or twenty-four in there. [16] 566 Q What is the size—the number of beds in your C&A unit? A Maximum number of beds is forty. Q And as of December ist you had twenty-nine patients? A On the morn..g—well, we took this on the morn- ing of the first, we had—lI think there’s twenty-three there. Q Oh, twenty-three, excuse me. A I believe that’s correct. There may be twenty-four or something. We run an average for that unit, average daily census of about twenty-seven. Q Are the children and adolescents combined together physically? A They are—they are housed in a building which has four segments. One segment is designated for family liv- ing. This segment of the building is designed as much like home surroundings as possible. Children who are in the hospital for a period of longer than approximately ninety days, live in this unit. Another unit is for younger males. These are males who are generally less than thir- teen years of age. We do have flexibility in that a very small immature fourteen year old might be placed there, or a very large husky twelve year old might go. Another unit houses what we—generally older females, or if a younger female were admitted she would be on that unit, but another definite one is the older males, which are males generally thirteen through sixteen or seventeen years of age. Q Now could you just describe a little bit more in detail the differences between the family living section and the main [17] portions of the unit? OS SEL te terns SBE) a. 567 [18] A Okay. The main portions of the unit where patients are admitted according to sex and age within the living confines of the unit, we consider more our diagnostic unit , our acute treatment unit, this kind of thing. One differ- ence is it’s typically furnished with institutional-type fur- niture such as we see in this room, as compared to the other one, which as a very home-like atmosphere with curtains, wooden tables and this kind of thing. The other —the main unit is staffed—the primary staff, nurses, at- tendants, etcetera, are on a shift-type basis. We try to use a house parent or parent image type of approach in the family living unit. Q_Is there also a school room? A The school is a part of our program not located in this building. We have a school which has six or seven different classes where children are geared through age— soon after admission as possible, this might be day two or three—the child is fitted into the appropriate class- room where he stays during the usual school day, you know, from eight or eight-thirty to two-thirty or three, or something, assuming he can, or he may be there only a few hours a day, and this kind of thing, but a school is a part of our program. Q Do the children and adolescents attend school to- gether? A They attend school together but there are seven different class categories. We’ve got something like ba- sically a first, second and third grade, this being a small number of kids; then there’s a fourth and fifth grade; sixth, seventh and eighth grade, ninth; tenth; eleventh; twelfth. [18] Q How many teachers do you have? [18] 568 A We have one for each classroom .. . teachers. We use our—we either have a teacher’s aide, or by virtue of the children being there we use a nursing assistant-type person to serve as an aide, or as a principal for the school. Q One of the contentions in this case, Doctor, is that there needs to be a judicial proceeding prior to the com- mitment of children to the hospitals. In your opinion as superintendent, do you see any necessity for a judicial proceeding as a screening process prior to the admission of children? A No, I don’t see any reason for this. There are chil- dren who are admitted by this process. My contention for feeling this is not necessary is, first of all I think any program, and certainly we try to do this, no one should hospitalize a child unless this is in the best interest of the child and the total family situation. The goal should always be immediate treatment and release of this child back into the family setting. The big handicap, it would seem to me, if we had a judicial process, would certainly be immediately, in any type of emergency situation, where this would require time, and secondly, if we assume that we have any validity at all in which children should be admitted to the hospital, I wonder about the feasibility of putting the parents through the added necessity of going through a judicial process. It would be rare indeed for us to ever put a child in the hospital whereby the parents didn’t want to. This would be the one time, and I can only think of one occurrence where we’re used it, where we felt this was in the best interest of the child, and [19] had the Family and Children Services workers apply for an admission to the hospital, so certainly one of the things that’s going to be necessary to help ninety-plus percent of our children is the cooperation of the parents ti an Bi ee 569 (20) both in participating in treatment and following their wishes and this kind of thing. Q That’s all the questions I have. EXAMINATION BY MR. TARUTIS: Q Doctor Kuglar, you indicated that—that for the initial admission there is an evaluation team as part of the community component of the C.A.A.P., is that cor- rect? A (Nods in the affirmative.) Q Where do they obtain the information that they rely upon for their initial evaluation? A Well, the information, obviously, would depend upon the circumstances, but the information in general would come from the parents of the child and the child itself. Now there may or may not be court service work- ers, or D.F.C.S. workers or these kind of people involved in the case, so they would gather as much of this infor- mation as they can from these people, so it would ob- viously depend upon why the child was coming there, whether the parents were calling up, or a referring phy- sician might make it, and we would get some information from him as well. Q When a child comes to the community component , I think you said he basically comes from or through the community health clinics in the outlying area first? A Yes. [20] Q This is ninety percent of the cases? A Right. [20] 570 Q What would be the normal situation for someone coming from the furtherest county that your regional hospital would cover? How far would they have to travel to the community health clinic and approximately how far is your hospital? A Right. That’s—all I can do is give you a hypotheti- cal example using this county and this kind of thing. Q Okay. A The furtherest one would be the two southern coun- ties, which are Emanuel and Screven counties, Sylvania and Swainsboro. Now let us assume that the parents or a D.F.C.S. worker wanted a child seen, whether they wanted—may call and say they want the child in the hospital and this kind of thing. In these counties our first line worker, of course, are the public health nurses and some general mental health workers that we have out there. We try to look in on a situation right then. We have teams that go to these clinics once weckly, there- fore if it wasn’t an emergency, they could be seen by this —by a team consisting of a psychiatrist, a nurse and a social worker who goes to this county. If by the phone it was felt that any sort of an emergency existed, then they would bring the child to the mental health center for an evaluation. Q The—the team—let me see if I have this right. The team would then leave the regional hospital and go to the local community mental health clinic . . . [21] A Right. Q ...for an appointment to evaluate or interview the juvenile or adolescent or child . . . 571 [22] A And the family. Let me take a minute or so to clear this up. We have two geographic areas. All right, our adult programs, or our general programs, so to speak, are on this geographic area. We’re primarily talking about the rural counties now. Q Right. A Okay, now this is different from this child team. We have a general psychiatrist, board eligible, unless he has gotten his certification within the last few weeks, a psy- chiatric social worker, a nurse; they are scheduled to go to each of these counties once a week. They are follow- ing patients, seeing patients, and adults or—and/or chil- dren in this clinic, so that the public health department, or an agency such as D.F.C.S., is the normal way, or a family physician—in which normal way somebody would get linked in with the mental health services. What— since we have these public health nurses there that we work with closely, we try to get these people, or some- times the D.F.C.S. worker, you know, immediately in- volved in that county. If it’s not an emergency, when our regional team goes out on a scheduled day, they will see this person. If there’s any feeling that there is an emergency, we would get this person to a mental health center at Augusta, the seventy mile distance, that day or the next day, this kind of thing. Q Pardon me for interrupting, but what would you mean by an emergency? You probably should define that term. (22) A What might we mean by an emergency? Q Right. A Where parents have found an adolescent suicide [22] 572 note, or if some attempt at suicide, there seems to be a great deal of panic on the part of the parents. We con- sider this an emergency. This sometimes happens. Q So then after the evaluation team interviews this person, the family and the child or the guardian and the child, they would—if they then decided that institution- alization might be indicated, would be their next step? A You mean out on the regional .. . Q Right. A To send the child to the mental health center. Q And then they would go through the process that you described? A Of evaluation, right, of gathering up as much data from the child, the parents, and other people or agencies as we can get to validate or assist this, family doctor, D.F.C.S. worker, court service worker, public health .. . Q How would you—how would you get that infor- mation? A We generally get that information by telephone. Q Who would do that, the intake worker, or the. . . A Well, I think they sort of may split this up. If we’ve got a child like this with more than one person to call, they might split this up. Basically a Masters level psy- chologist is usually the person in the childrens unit who tries to round—that person and a social worker, these two people sort of split it up, but we might have all of them according to a given case. () When we were talking about the admission pro- cedures earlier in [23] your direct examination, you men- tioned, or at least I understood from your testimony, that 573 [24] you understood that—that we were discussing it in the context of forcing the institution to take the child rather than acting as a buffer to the institution from being re- quired to take the child. A I’m sorry, I’m not sure I’m following you. Q Okay. Let me rephrase the question. Do you feel that it would be helpful, as part of this intake process, the initial review by the community component, that as part of the team, or as part of the review procedure in regard to evaluation for commitment, there was a non- mental health related person involved in that evaluation? A I don’t know if I think it would be helpful. I don’t know that we object—I would object to it in any sort of way. Q It wouldn’t be—you wouldn’t see it as being harm- ful or detrimental? A Uh-uh. (Negative.) Q Do you—what about the—after the child is then admitted, as I understand it, you said there would be a consulting done—a staffing done within approximately seven to ten days after the admission, depending on what day the child was admitted to the institution? A Yes, and I think this depends upon the complexity of the given child and this kind of thing. As I said, our goal is to have this staffing on the same week that he comes in, and there are certain cases where he may come in the day before staffing and be staffed at the staffing the next day. The maximum time he can wait is till the staffing the next week, in other words, [24] that’s the maximum length of time. Q All right. And basically, the people involved in the [24] 574 staffing are all health professionals, as I understood it, there is the psychiatric social worker, psychiatrist, coun- seling psychiatrist .. . A Yes. I would say in general they were all health pro- fessionals. Now, it depends on your specific definition . . . Q We’re using it in the broad... A In the broad sense of the word, that is true, yes. Q Are there ever—at that staffing stage, are there ever any outside individuals involved, such as a teacher, member from the community, someone along those lines? A No, not at this particular staffing. Now we—the one thing we will do is that we would—we sometimes encourage parents to be at the particular staffing, and as far as the teacher or this kind of thing, we hope that we've made every effort to gather some of this kind of information prior to the staffing. But as far as I know, there have never been any of these kinds of people at the staffing itself. I would say again, that I would find no objection whatsoever to a non-mental health professional being present at the staffing. Q The... A We do have, at the staffing one person that was left out. Each—we have a system for patient’s rights and this kind of thing, and each building has a particular employee whose—has the primary job—and at staffings, if you’ll look under patient’s rights and stuff in the policy manual... Q Right, which is part of Exhibit Two. [25] A Yeah. But we—these people are certainly there. One of their approaches is to make sure that this patient, be en NES ee ae onto ete OR, Meet oT a et 4 Oh ely te A 575 [26] he adult or child, it’s not different with us, that his rights are protected according to the Georgia Code and this kind of thing regarding patients’ rights and policies. Q_ I'll show you part of the packet marked as Exhibit Two, at the top of that page, which is labeled patients’ right. Would you mind reading that first paragraph, re- ferring to... A “The patient, although a minor, is a citizen of the United States of America and the State of Georgia. He is, therefore, entitled to every right and privilege accorded minor citizens of the country and state as specified under the laws governing the rights of mental patients.” Is that what you wanted? A Right. Who is the person that’s assigned to repre- sent or act as—I’m not sure of the term you used—act on behalf of the juvenile or child. . . A You mean the name of this person? Q No, not the name, but what is their status within the overall institution, a social worker, a technician, psy- chiatrist? A Let me—this will vary. First of all, an individual is assigned, that this is a primary job of the entire hos- pital, at the present time this happens to be a clinically trained chaplain, and he has this assignment. Now each building—at the time—these change, but at the—each building has—each cottage, a person for that particular cottage to link in to this one person, since he couldn’t effectively see through the whole hospital, and at the time these are elected periodically, these people are elect- ed by the patients [26] on the unit. There is an election where the patients select the nurse, the nursing assistant, or this kind of thing... [26] 576 Q Would that include the C.A.A.P.? Or what I refer to as—what we’ve been referring to as the C.A.A.P.? A Uh-huh. Uh-huh. (Affirmative.) Right, now I could call and find out—I can’t name the particular person there... Q That’s all right. That person would be elected by the children on the ward? A Uh-huh. (Affirmative.) Q The children—I will use the term children .. . A Okay. Q ...to refer to children and adolescents unless I indicate otherwise. A And then throughout the building there are large visible signs in each building telling you who the person is from this unit and telling you that, say, Chaplain Stout is for the entire hospital. Q Okay. And the—in addition to—your patient rights indicate that a violation of those rights will be grounds for dismissal and they involve representation and informed consent among others. Has there ever been any problems with the individual who is acting as the—under this sec- tion as a patient advocate, the elected representative in terms of asserting what they regard as the best interest of the child against other staff members within the in- stitution? A No, I don’t think so. There have been many times when these people have, through their process of coming to the Chaplain, made specific complaints or recommenda- tions and brought— [27] Chaplain Stout and this person making this then brings this to our general staff meeting of the hospital, and we have, you know, discussed this Ab aE es Sy lta Sn ee ae ae 577 (27] and take corrective action and this kind of thing, but I don’t know if there’s ever been any problem connected with it or any sort of retribution against an employee or this kind of thing. Q Would there—is there, to your knowledge, any in- dividual who acts as a patient advocate from outside the institution, who, you know, could work with the individ- uals already assigned? A The only people that we know here is the Georgia Legal Aid Society, who has come to our hospital repre- sentatives in Augusta, and they have been through the hospital, they are welcome there any time, they have made a film—we have closed circuit audio-visual system throughout our hospital. They have made a film them- selves, different from our film, informing patients of their rights, and this film is shown periodically several times each week. They’re told how they can get in touch with these people, and this kind of thing. Q Do you welcome that, or do you see this as... A No, I welcome this. I think the people there at Augusta will tell you we welcome them with open arms. Q Why would that be? Why would that be? Yes. Because I’m in favor of it. In favor of having outside representation . . . Sure. ... for the individuals... Or? O& &- O YF 578 [28] A Sure. Q And that would include children and adolescents? A Sure. | Q You mentioned that in a certain percentage of cases, approximately ten percent, there is an occasion where the parents will not participate, if I’m correct? A Uh-huh. (Affirmative.) Q In those cases, or in any other cases, is the oppor- tunity or the potential for conflicts between the child who is in the institution and the parent, both in terms of either the initial entrance into the institution or the eventual release of the child? A I’m not quite sur. I specifically understand the question. Can you give it to me again? Q Well, I can try. Could there be a conflict in that the hospital would not desire to release a child or ado- lescent to the parent because the child—the parent may not be ready to receive the child, although the child would be well enough to be released? A No, I don’t think so. I couldn’t see this sort of thing. One of the problems we have sometimes in this case is in getting the parents to take the child back. They, in essence, don’t want the child, and they are running from us and our efforts to try to work out a specific family inner-action that’s gone on in this respect. Q Would that same sort of situation that you de- scribed, the parents running away, I think is the way you put it... A Uh-huh. (Affirmative.) Mee sat sins 0 eve 579 (30) [29] Q ...be present during the admission process itself? A No, I don’t see how it would be present during the admission process. Very often what has occurred here, is that the child is brought to the hospital sometimes, by the judicial process, through the court systems, and the parents feel like they didn’t have any part in the admit- ting of this child to the hospital and aren’t going to have anything to do with it. There are often—is an amount of hostility and antagonism between them and the child which has reached the point where they don’t want to accept this child, and the big problem is very often not getting the child well enough to go home, but getting these parents to essentially, you know, even take this child. And on one or two occasions we had to go back into the court or through D.F.C.S. to get a disposition made. There haven’t been a lot of these, but they do occur. I don’t see any sense—you know, I’m not trying to hide that that sort of thing does occur. Q Uh-huh. So following up on that, in your last point, what action—maybe you’ve already stated it, but what action do you take—do you have any recourse if the parent does not want the child or is running away... A Generally speaking, in this case, we would link in with the D.F.C.S. worker as far as doing something about this child, to get them out of the hospital, either as far as making a foster home placement of some type with this child, or seeking judicial help to get the parents to take this child or something. [30] Q You said two points, let me follow up on each of them, so that I can try to understand both. As to the [30] 580 seeking of some sort of foster home placement or group home placement, have you had fortunate experiences in being able to locate that kind of placement within a reasonable period of time? A They ave very tough to locate. I think the thing we’re fortunate in is that we’ve only had to locate one or two out of several hundred admissions. If we had very many to locate, it would be very difficult, because even the one or two we had, it took us some period of several weeks... Q It took you several weeks? A Yeah, to locate. And remember—as I say, we’ve had very few of them, so I could see a potential problem there, where if you needed several of them. Q What would you do—hypothetically, what would you do if it took you more than several weeks, and your treatment plan and your staffing had indicated release’? A Okay, we would have no choice except to keep the kid until we found adequate placement. I know of no other choice that we would have available to us. One par- ticular case, the parents apparently left the state. The kid was placed in the hospital and —I believe by the courts, we can seek out this case—but apparently the parents couldn’t be found, and the child was ready to go, and it took several weeks to find—you know, I don’t know, three, four, a couple of weeks to find a foster home for this particular child. But I think we have no choice, and of course, we would be as active as possible to find this placement. (31) Q If—your second point was that the possibility of TEAS OA 0 hh OO 581 [32] seeking some sort of judicial release to get the parents to take the child back .. . A I think, and now this is not—I’m not a hundred percent sure, but I think there was one case where, when the D.F.C.S. worker was involved in this thing, it got into the courts that—the court system essentially insisted that the parents take their child back. I believe that there was this one case. It’s one of these things two or three years ago, and I think I remember this. Q Let me ask you this because I am somewhat con- fused. We’re talking about parents that place the child in an institution and then—and I realize we’re calking about a limited number according to your figures—that do this, but then do not want the child back, to try to avoid .. . parental responsibilities, is that correct? A Uh-huh. (Affirmative. ) Q Then do you feel that those same individuals, at the time of placement for the child, are desirous to have the child placed in an institution for the same reasons— for the same basic feelings that they don’t want the child back after he or she has been there for a while? A Sure, I would say that that’s probably true, but let me say this, we’re not going to admit the child to start with unless the admission of the child to the hospital seems in the child’s best interest at the time. Now we have a lot of parents who bring the children to us want- ing to place the child in the hospital for which we, you know, do not place [32] the child in the hospital but say to the parents, ‘‘We will work with you on an out-patient basis to resolve this problem.” Q Okay. And that—those decision—well, the process by which those decisions are made are done through your [32] 582 criteria, there haye been—these policies and procedures that are marked as Exhibit Two? A But the essential criteria for ever placing a child in the hospital is that the child needs hospitalization. Now one could debate forever this particular criteria. I’m sure you know that, but nevertheless, the criteria is based upon the concept that the child needs to be in the hospital, not that the parents want to get rid of him. Q But you have developed, essentially, a process through your policies and procedures, to assure that that decision—the objective of your policies and procedures is an attempt to assure than when that decision is made, it is a valid one... A Right. Q ... that’s why you have set up these policies and procedures? A Right. Q Now, are you aware of any similar policies and pro- cedures of this nature done on a state-wide basis? A No, I can’t answer that, because, you know, I know of no general disbursal of information or of each place policy manual and this kind of thing—each facility has, as far as I know, a lot of these in here, but I can only speak for how we do it and not how it’s done in other places. Q And the policies and criteria that we have in Ex- hibit Two, were these drawn up pursuant to a directive that you received, [33] or did you do them basically on your own initiative? A No, they are drawn up pursuant to the fact that any hospital has to have a set of policies and procedures Ce ate lal a es 583 [34] to operate under, and we, of course, are accredited by the Joint Commission for Hospitals, and they specifically re- quire—and each time we have a Joint Commission sur- vey, they go over these things, you know, spend days reading each page and this sort of thing. Q But—okay. And these policies and procedures that you’ve adopted and that are written up and placed into operation, could be changed by you as—as the adminis- trator of the Regional Hospital, is that correct? A No. They—not specifically. Certain policies, for instance, the utilization review has to be changed by the utilization review committee. Q No, but I’m talking solely about Exhibit Two. A The Executive Committee of a hospital would change... Q Would do this? A Right. I don’t—I cannot—a superintendent can’t change policies by simply administrative action. He would certainly call a meeting and explain why he felt like they should be changed, but there are appropriate committees regarding all types of policies. You’ve got a policy, for instance, for control of infections in a hospital. If you’re going to change something there, you’ve got to get the Infections Control Committee. This approach is required by the Joint Commission, by the way, for someone to be able—for a hospital to be accredited, this approach. Q Which approach? [34] A The approach of having specific committees set out for particular types of policies and this kind of thing. [34] 584 Q One of the things, in looking at Exhibit One-A, if I understand Exhibit One-A correctly, this chart—bar graph, indicates the total number of—well, the number of patients and the longest length of stay for a year period, is that correct? Or a twelve month period, I guess I should say, the fiscal year ’74-’75. A For a twelve month period, right. Q And the longest time that any one child remained in the C.A.A.P. was two hundred and fifty-one to two hundred and fifty-six? A That’s right. Q And then there’s... A And that covers that three hundred and sixty-five day period. Q Right. And then there’s a significant gap and it goes down to one hundred and seventy-six to a hundred and eighty days... A Right. Q ...the bulk of which, I think you indicated here, and I’ll assume this is correct for the time being, that fifty percent of the patients are discharged by day thirty? A Right, that’s correct. Q Have you ever had occasion or do you know of, within your institution, for a child or adolescent to re- main hospitalized beyond the two hundred and fifty-six day period? A No. To the best of my knowledge, no. I would have to check this information specifically, will be glad to do it, but to the best of my knowledge that is the longest stay that a child [35] has ever had. ee ee 585 [36] Q Based on that data, and assuming that you’re cor- rect, would you assume—why would that be? A Why would what be? : Q Why would a child remain—most of the children remain in the institution for a limited period of thirty days, and a child remain there no more—for a year period, than two hundred and fifty-six—two hundred and fifty- one to two hundred and fifty-six days? A Are you asking why, for instance, a child would remain this long period .. . Q No, not why they would remain that long, but why wouldn’t they remain there any longer than that? A Well, that’s simply the longest one that we have had to date since we opened the hospital in terms of severely disturbed children. Q Would it be possible—I guess what I’m trying to get at, probably in too indirect a way—would it be pos- sible for children to remain in your institution longer than that... A Yes. Yes, it would be possible. Q It would be possible? A Yes. It is quite conceivable that we may get a very disturbed autistic schizophrenic child that could stay longer. All I can say is that we haven’t had one. We have been able to get them out within this period of time, but I cannot tell you that it’s—you know, wouldn’t be possible. I think obviously a general statement is that the better the program [36] the shorter period of time people stay, but there is an occasional child who is ex- tremely disturbed that must remain in an institution. There are a very small number of these, but they do exist. We have not picked up and hospitalized one of them. [36] 586 Q This would be the exception, then, rather than the... A Yes, and there is a small number of these kids. It should be a very small number of them. Q Would you agree with the statement that, I believe, one of the individuals whom we have deposed over the past few days, said that it would be—that there would be a great deal of review and question if a child remained in an institution beyond a three month period? A Well, certainly there would be a great deal of re- view. Beyond this three month period, there would be a constant review as to what could be done or why this child was remaining there. Q Why would that be, in your opinion? A Because it should be very rare for a child to have to be there. This is not saying that it cannot occur, or there will net be examples, but it should be rare enough that past this period of time there should be very close scrutiny of any and all cases where this occurs, the rea- sons being very specific. Q And indicated in the record of that individual? A Absolutely. Actually, a part of his on-going treat- ment plan, is an on-going process, as to, you know. Q Talking about your on-going treatment plan, is that when—if I understood you correctly, you indicated that when the individual first comes into the institution or shortly thereafter, [37] this treatment plan is devised, is that correct? A Right. Q And as part of that plan, there’s a—it aims at both treatment within the institution and... Oe es OL ote at es OS 60 tele oube 10 re dy nw _ ee See eee eee nil wi os wor 587 [38] A And release plans. Q ...and release plans. A Exactly. And it’s reviewed and modified weekly depending upon justification, what’s going on with the kid. Q And the family is made a part of this review at certain stages, depending on the case .. . A The family is also seen weekly. Q Okay, that’s where I may have misunderstood you. The family is seen weekly by individuals within the in- stitution? A Right. Q As part of the overall treatment plan for the indi- vidual? A Exactly, working with the family, and also to keep the family much involved, to keep the family appraised of the situation, and to work with the family on problems which may be found in working with the child during the week. Q Okay. In the beginning of your direct examination you indicated the number of staff that you have at the insti—at the C.A.A.P. portion of the institution. About how many cases would the chief psychiatrist of that C.A.A.P. have, the person that—I think it’s Doctor Wood? A No, Doctor Wood is the Ph.D. psychologist who is the director of all of our children’s programs. Q Oh, okay. A Doctor Clark is the psychiatrist. He is the person primarily [38] responsible, the primary physician, psychi- [38] 588 atrist for the twenty-some in-patients plus he is seeing out-patients. We have three part-time psychiatrists, one of which is a child—certified child psychiatrist. They are there for staffings, for review of the evaluation, this kind of thing, but they also have selected children and specific treatment programs. Q What would Doctor—would Doctor Clark’s patient —I use the term case load—the number of patients that he is responsible for, sees on a regular basis and treats as their psychiatrist, would that be limited to the twenty- some children and adolescents or would he — his out- patient case load—he has an out-patient case load? A Yes. Q About how many people would he be seeing on an out-patient basis? A He is primarily involved in the evaluation status of the patient initially and any medication checks which come up. The patients who are being followed as out- patients, the psychiatrist who is involved or supervises these, these are usually the part-time psychiatrists which we have on our staff. I shouldn’t add something, but I want to add this because I’m not sure it’s written down there, but it is our policy and probably should be written down. All children who are admitted to our hospital, where this is at all feasible for the condition of the child, conditions, etcetera, we try to operate the hospital where that when we work with these kids on an in-patient basis five days a week and have them home for the weekends, and then have the parents—we then have a Sunday eve- ning [39] session when the parents bring them back to see how the weekend goes, and approximately two-thirds of all of our kids are home with their parents for the week- ends. 589 [40] Q Okay. We have here, and you’ve been describing basically the way your institution operates, and that method of operation is set out in some detail in your policies and procedures, would you find it unduly bur- densome or do you think it would be inappropriate to devise similar policies and procedures on a state-wide level? A Oh, I don’t think so. I guess I would have to say that similar policies, I think, in general should exist on a state-wide level, but we must keep in mind that there are some differences in the availability of community re- sources and other things throughout our state, and I think thi [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/brief%3Amicro_IA40385005_0830%3A03. Public record. Not legal advice.