Appendix — Parham v. JR
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Supreme Court. U. S
mo FILED
| AUG 15 1977
VOLUME IlI—Pages 718-95:
APPENDIX | MICHAEL RODAK, JR., CLERK
a
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,
v.
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.....................005. Vv
Complaint—October 24, 1975. ................04.. 1
Motion for Class Action..................eeeeeee 17
Testimony of Dr. Wayne Hodges, given in hearing
before Judge Wilbur D. Owens, Jr., in Macon,
Georgia, October 30, 1975:
Direct Examination..................2000008: 20
SD . ... cc ccccvccechensnesses 37
Redirect Examination...... SPAR ER ee Cm om OM 48
Order Certifying Class Action, November 18, 1975... 49
a ee ean abe dewewewawen 50
Affidavit of Janet Scott............0.....ccceeeees 59
Revised Statement of Facts.................-0000: 62
Stipulation of Facts for the District Court Hearing.. 68
Exhibits to Stipulation of Facts................... 76
Deposition of Eli Charles Messinger................ 159
Direct Examination............ccccccccsccees 160
Crogs-Examination.............ccccceeeeeeees 190
Redirect Examination..................e0006- 216
Deposition of Dr. W. Douglas Skelton.............. 217
(EEE OO eT 218
Direct Examination..................ee0000e: 225
Recross-Examination.............ceeeeeeeeees 239
Deposition of Dr. Donald G. Miles and Dr. William
a i ee Be ee ee ee eae 246
Direct Examination of Dr. Miles.............. 247
Direct Examination of Dr. Wieland............ 258
i
TABLE OF CONTENTS—Continued
Page
Direct Examination of Dr. Miles.............. 259
Cross-Examination of Dr. Miles............... 261
Redirect Examination of Dr. Miles............ 269
Exhibit 6—Admission and Evaluation from the
Geographic Service Areas..............+++-: 270
Deposition of Dr. John J. Gates and Dr. W. T.
eS ie ee ee ee ae ee awee Neunal 276
Eo cc bledsaeweteneues 295
ig ccdewsuconecnacsusend 320
Redirect Examination...................2+0+- 321
Recross-Examination..............0eeeeeeeeee 321
Exhibit 4—Example of Admission Program and
Responsibility-Action Format............... 322
Exhibit 11—List of Therapeutic Activities
Sponsored by Central Georgia Regional
inv adcescncsdsseecnubadessvecess 338
Exhibit 12—Minutes of the Utilization Review
Committee and Criteria for Admission to
Regional Mental Hospital.................. 345
VOLUME II
Deposition of Lawson H. Bowling................. 352
Se ES cs cee ceasanceeeeeccvass 353
nn ii cecennesccesbsboncuns 366
Exhibit 2—Policy 2, Part 1, Screening Procedure
—Child and Youth Services...............-. 384
Deposition of Gladelle Whitaker.................. 390
Nn ., ceendeencsoeeeeen ss 391
ar 418
aes TRRMIIIIII. «os ccc cccccveccvnesess 436
ii
TABLE OF CONTENTS—Continued
Page
Deposition of Dr. Eugene C. Jarrett, III........... 438
IN igs o's a bo eke dccu pecan 439
RIS vin ncciccccéccccdcevcsecnecs 454
Deposition of Dr. Wladyslaw P. Mazur............ 475
es ee 476
ce 488
Exhibit 3—West Central Georgia Regional
Children and Adolescents Unit Policies and
ae tl 513
Deposition of Dr. James B. Craig.................. 519
en ic cyuncceusedaus 520
i eee aued 531
Exhibit 2—Georgia Regional Hospital at
Savannah Children and Adolescents Unit
Screening Policy of Children and Adolescents
Dc ceGankedwuda dieser casiesekiercuecksus 548
Deposition of Dr. Everett C. Kuglar............... 551
A ee ee 552
Cross-Examination................ pate aes 569
Exhibit 2—Children and Adolescent Program,
UT IIIS 6. Kvn occ erandaicceiccas aaa 591
Exhibit 4—Georgia Regional Hospital at Augus
Utilization Review Plan.................... 622
Deposition of Anne Etheridge..................... 631
a 632
ed ck aks dc buceamanwed 680
Recross-Examination...............ccccceecc: 682
TABLE OF CONTENTS—Continued
Page
Deposition of Dr. Arthur Falek.................... 686
Ns ctbededviesssenewes®s 687
ns ec ban tneen een cerseuts 702
VOLUME II
Deposition of Dr. John Paton Filley............... 718
ey Ce oes bas aeeeveeuweees 719
2 a ee eae ake 757
Deposition of Dr. Luciano L’Abate................ 795
Nc uvic gtk ureewen eeeanees 796
nc acewaveneecsedanwesie 812
Appendix “‘B” to Defendants’ Supplemental Brief in
Ne so bk sade Vb hse bir h ke eaehvees 822
Attachment ‘‘A”’ to Post-Discovery Brief of Plaintiffs .888
Attachment “B” to Post-Discovery Memorandum of
ee eee ee Ue eee deae whe Uhaine® 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................45. 927
Opinion of the District Court..................45. 934
Judgment of the District Court.................... 935
Order of the District Court Denying the Defendants’
BP BE cs. cc hice ceseadeibedcvcucss' 937
Notice of Appeal to the Supreme Court of the
I. , o'n'c'nnh's-eGeEHNs Kobe deeasestces 947
Order of the Supreme Court noting probable
Ps 9 6a Vc caaecscvasceripes(ietennanes 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 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,
V.
J. L. and J. R., Minors, Individually and those
representatives of a class of persons similarly situated,
Appellees.
718
(1)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF GEORGIA
MACON DIVISION
(Caption omitted in printing)
The deposition of DR. JOHN PATON FILLEY taken
before Phillip Roger Scott, Certified Court Reporter,
commencing at 9.00 a.m., December 10, 1975 at State
Judicial Buiiding, Atlanta, Georgia.
[2]
APPEARANCE OF COUNSEL
For the Plaintiffs:
NANCY LINDBLOOM, Attorney at Law
Georgia Legal Services Programs
Macon Regional Office
653 Second Street
Macon, Georgia 31201
DAVID GOREN, Esquire
Georgia Legal Services Programs
Macon Regional Office
653 Second Street
Macon, Georgia 31201
For the Defendants:
DOROTHY KIRKLEY, Attorney at Law
Assistant Attorney General
132 State Judicial Building
Atlanta, Georgia
719 (4)
[3]
CONTENTS
RE- RE-
WITNESS DIRECT CROSS DIRECT CROSS
JOHN PATON FILLEY
By Ms. Kirkley 4 120
By Ms. Lindbloom 56
[4]
PROCEEDINGS
MS. KIRKLEY: The stipulations are that all objec-
tions, except as to the form of the question and respon-
siveness of the answer, are reserved until the week after
filing when we will file objections in writing.
Whereupon,
JOHN PATON FILLEY
was called as a witness and, having first been duly
sworn, was examined and testified as follows:
DIRECT EXAMINATION
BY MS. KIRKLEY:
Would you state your full name for the record.
John Paton Filley. Paton is (spelling) P-a-t-o-n.
What is your profession? ;
I’m a physician and psychiatrist.
And, where were you educated, Dr. Filley?
I went to Yale University for my undergraduate
education. Yale University School of Medicine, medical
school. Interned in pediatrics at University of Minnesota
Hospital and did two years of general psychiatry and two
r OPO PO
[4] 720
years of child psychiatry training at North Carolina
Memorial Hospital.
Q Are you a Board certified psychiatrist?
A I’m Board eligible.
Q You're Board eligible.
(5)
A I have the training requirements and experience
requirements.
For both general psychiatry and child psychiatry?
Yes.
But, you have not received certification in either?
That’s right.
Is that correct?
(Nodding head affirmatively)
Where was your training in child psychiatry?
At North Carolina Memorial Hospital which is
training center of the North Carolina Medical School.
Q When did you complete that training?
A Completed training in 1957.
Q And, what employment have you held since that
time?
A Iwas on the faculty of the child psychiatry program
there at North Carolina Memorial for one year and then
went to the School of Public Health, University of North
Carolina where I was faculty member and head of the
department of mental health for 16 years until I left last
summer to come here to Georgia.
Q And, so, you’ve been here for about—
A Almost a year and a half.
FOr O F&O PF O
721 [7]
Q And, again what were you the head of?
A I was head of the mental health department for 8
_ _ then a faculty member in the School of Public
th.
)
Q What did that position involve? What were your
duties there?
A The program of the department was addressed to
primarily the teaching of students in the school of public
health about issues related to mental health, aspects of
the field, the development of the field, the approach of
mental health in trying to deal with problems on a total
community basis.
Part of the time our program was for general public
health students. During the latter years of the program we
had a specialty program in mental health; and we were
taking students and training them for masters and doctor-
ate degrees in public health and major in mental health.
Q Did you teach any medical students?
A Only very occasionally was I involved with medical
students. Many of our students in the School of Public
Health were physicians doing post-medical training.
I supervised residents in child psychiatry for a
number of years in therapy and became involved in semi-
nars and so on with the community psychiatry program.
We had a reciprocal relation between our program in
public health and community psychiatry.
Q Have you ever practiced psychiatry privately?
A During the years I was on the faculty of the School
of Public Health I kept a small amount of private [7] prac-
tice going all the time.
(7] 722
Q Do you have any idea what your average case load
was?
A Small, I carried 2 or 3 or 4 patients at any one time.
Q And, what are the responsibilities of your present
job?
A In general to oversee and direct the development of
child and adolescent programs in the mental health field
for the State of Georgia. It’s stimulating, directing, pro-
viding research education. Looking after budgetary con-
siderations; working on the development of the general
program of the Division of Mental health with particular
reference to applications to child and adolescents. I get
involved in division committee activity. I’ve been on the
division committiee on development of information sys-
tem, the committee on the development of confidentiality
policy, division committee on the development of training
policies.
What’s the official title of your current position?
A I’m Director of the Office of Child and Adolescent
Mental Health Services, Atlanta Division.
Q And, could you describe please the present state
program for children and adolescents in the Mental Health
Division.
A As is generally true across the country, it’s lagging
[8] somewhat behind general aduit mental health at this
point. Within the framework of the division we intend to
have a unified system of services that includes hospital
and community services. We have hospital services in 7 of
the 8 regional hospitals and are working towards getting
services in the 8th. We have some representation of child
and adolescent services in all 34 catchman areas in the
state at the community level. These vary from very
Sn -
723 [9]
nominal, a few staff in mental health who work with chil-
dren to quite well developed programs in some of the
areas with a sizeable staff whose responsibility and whose
child and adolescent services are quite extensive.
Q In the present system what are the criteria for hos-
pitalizing children in a regional hospital?
A The intent has been when in the judgment of the
community program a period of hospitalization would be
the most appropriate form of care. We haven’t arrived at
that point fully yet. We still get patients who are referred
directly to the hospital by various people from the com-
munity and sent there by judges and so on without re-
course through the community.
We’re significantly increasing the extent to which
the referrals do go through the community program. When
at the discretion of the community program there’s some
reason in the case that hospitalization would be appro-
priate at that [9] time, then he goes to the hospital.
Q I realize this is a very broad question, but when you
say, “Hospitalization is the appropriate treatment,”
could you be somewhat more specific about the kinds of
situations in which hospitalization becomes appropriate,
what the family situation might be, why hospitalization
is preferrable at that time in the child’s life.
A It can be quite a variety of circumstances that can
make it appropriate for a child to be hospitalized. One
would be a very acute, severe degree of disturbance. The
child’s behavior is quite out of control, and he needs to be
in a contained environment until some stabilization is
achieved through medication, through program and
therapy and so on that brings about a greater degree of
capability on the child’s part to function within normal
controls.
(9] 724
Other situations, due to social circumstances the
child’s interaction with his parents may be in sort of a
vicious circle pattern where it’s getting worse and worse;
and the parents are not able to change or interrupt this
vicious circle; and a disturbance builds. It may be appro-
priate to hospitalize the child as part of breaking that
cycle and achieving a more stable relationship.
The broad general statement would be that these
would be the two major conditions in which we say hos-
pitalization is appropriate.
[10]
Q You described—
A To the extent that one other step, the child who is
not in his own familiar home, the child has been taken
into custody and so on. Very often in that situation there
is less capability of the social group to deal with the child.
A natural family is apt to be more tolerable of this dis-
turbance than foster parents. Then, the social situation
breaks down; and as a way of trying to get some usability
in the situation and enable the child to return and function
in the community, it may be appropriate to hospitalize
the child.
Q You described the first situation as where there was
an acute problem that required hospitalization. Would you
say that was an emergency admission?
A We tend to use emergency admission as one which
within a matter of hours, less than a day, a person ought
to be gotten into the hospital because there is some serious
risk for the child. The child is running away and getting
into a very hazardous situation, violence where there
might be danger and so on. So, we tend to think of emer-
gency in those terms.
ene.
725 [12]
Many of these situations might be tried in the com-
munity basis, in a community program for a number o:
days or even a couple of weeks before a decision was made
that it couldn’t be managed in that way. So, even in that
first category where it’s fairly severe disturbances, it
wouldn’t [11] always be handled as an emergency admis-
sion, say, within 24 hours.
Q Is there a policy that treatment should first be
tried in the community and in the home prior to hospitali-
zation?
A There is a policy that says a judgment should be
made; if possible, treatment should be tried in the com-
munity. I don’t see and I wouldn’t promote a policy that
would say it should always be tried first. A clinical judg-
ment in this case, as I see it, the child from the first con-
tact, the first evaluation shows the most appropriate
treatment as hospitalization.
Q Do you have any written policies that state what
you’ve just expressed as in regard to standards for hos-
pitalization?
A Not specifically in regard to children and adoles-
cents. There’s a statewide policy. We have some general
policies and divisional policies; and they state things of
this general sort; and those are applicable to the child
and adolescent programs. But, we don’t have specific
policies at this time.
Q Do you do training programs for mental health
professionals in children and adolescent programs?
A Yes, we were fortunate in being able to identify
some funds for the last fiscal year, fiscal ’75. We did five
statewide training programs of personnel in child and
[12] adolescent programs.
Q Give—
A We’re less able to do that financially this year.
We’ve just finished one yesterday that was not so much a
[12] 726
training program as a working conference and the develop-
ment of plans for child and adolescent services on a
regional basis. We’re « iticipating conducting a training
conference on the righ ; of children in the mental health
system in January.
Q In training sessions such as these do you discuss
the standards for hospitalization and the use of com-
munity resources when appropriate?
A Yes, there are many discussions around these sorts
of issues. Child and adolescent services has a clearly
differentiated focus of service. They have only been in
that status since my office was created less than a year
and a half ago. There has only been specific funding
identified for the development of child and adolescent
programs in communities for two and a half years in the
State of Georgia. And, when we started the training con-
ferences, last year was really the first time that people
had begun to get together outside of their local programs
very extensively. And, so, we’ve been through a process
over the last year and a half which has been a great deal
of work, trying to work out better and more functional
relationships between community [13] programs and hos-
pitals and guidelines on which services belong in what
place, how to more effectively work out transfers between
parts of the system. It has been a very significant issue
and has been discussed recurrently.
Q Have any written statements or policies come out
of these sessions yet?
A Not general statewide ones. Our focus has been one
of central effect with local autonomy. And, there have
been a number of working agreements and so on that have
started out of these conferences. People have gone back
and worked in their own region between the hospital and
mel
727 (14]
community programs various policies and region agree-
ments and so on of how they would function. But, no
statewide statements of that sort.
Q Are there differences among the 8 regions which
require this kind of local approach?
A Very considerable differences. Atlanta Regional
Hospital serves 10 almost entirely metropolitan catchman
areas. They do reach out a little bit into the non-metro-
politan areas out in Douglas County, for instance, which I
guess is still part of the standard metropolitan district
although it gets quite rural. But, southeast Georgia, the
Savannah Region has 2 huge catchman areas that are
extremely rural and a third which is largely rural and
only one metropolitan.
These require different approaches in how you reach
[14] the people and how you place facilities close to them
and resources you have to call on and so on.
Q So, you have worked mostly in outlining the general
approach and helping the different regions—
A Develop their own perspectives, yes.
Q_ Is part of the standard for admission of children to
the hospital on the application of their parents or guard-
ians that they’re dangerous to themselves or others?
A I would say that is a fairly rare thing for children,
There are certain examples where a child is excessively
aggressive and he’s dangerous. Or, has a pattern of running
away where he could easily get himself into situations
where—that are dangerous to himself. Rarely do we see a
child who is suicidal. It occurs, but it’s not a common
danger. So, the frequency for that kind of condition for
hospitalization is probably less with children than it is
with adults.
(14] 728
Q And, if the children are not dangerous to themselves
or others and excluding for a minute that type of admis-
sion to the hospital, when in the professional judgment of
the psychiatrist especially in the state system is hospitali-
zation indicated?
A You could almost take the word dangerous and
translate it somehow—when the child-parent interaction
for whatever reasons, whether it’s some factor in the
child that may be unavoidable or some pattern of inter-
action the parents [15] and child have gotten into, is
thoroughly blocking his development, so he’s not pro-
gressing. This can be very dangerous to the child’s life
situation, although it’s not acutely a hazard to his life;
but, a significant disruption of a progressive growth
oriented child-parent interaction, we would view as quite
a dangerous thing in the longer perspective of the child’s
life. That would be one of the major considerations.
Q Is it important in your opinion that a child be
given psychiatric treatment at that stage rather than
waiting until it becomes eminently dangerous?
A We would like to become involved earlier than that,
if at all possible, when the pattern may have started
developing. This is one of the reasons we emphasize as
much as we’re able to outreach programs. We make con-
taets with school teachers and other people working with
children in the community, so as early as possible there
ean be an identification of some insipient problem and
hopefully some kind of intervention then. That may not
be in the form of psychiatric treatment. It’s more with
the teachers or with the social workers or parents to try
to interrupt the pattern which is building.
Q What is the basic reason for the expansion of ser-
vices to children and adolescents?
Midi ne
729 [17]
A Well, the basic reason for the expansion is because,
[16] as we have come to see the situation, it appears that
provision of these services can be helpful to children and
their families and can make significant differences in how
their lives progress and be more effective and satisfied
people. And, we’re not doing nearly enough of it.
The child and adolescent services proportionately
are, as I said earlier, quite a bit less developed than
general adult services. I did some figuring a year ago on
the basis of the 1974 out-patient statistics; and there
were, I think, catchman areas in the state that were pro-
viding roughly proportionate services in the terms of the
size of child and adolescent population, which would say
we ought to be providing about 35% of services to chil-
dren and adolescents. Actually, in many of the catehman
areas it was one-tenth or less as much service for children
and adolescents as for adults.
Q. Is one of the reasons for expansion the early inter-
vention might prevent problems that later in adult life
would become more dangerous?
A This is still one of the hypotheses we’re working on,
not that it’s really documented or proven. There haven’t
been enough of these services or long enough to really
know. That’s a problem with social experiment; when you
try to do something of a major sort of a change in society,
it’s years before you know what’s really done. [17] I think
there are sufficient reasons to believe that it’s an appro-
priate direction to be going with that intent. With the
intent that intervention in its early stages can reduce the
difficulties later. But, I’d say it’s still in a stage of a
hypothesis. We don’t have sufficient documentation to
stand on absolutely.
[17] 730
Q I'd like to talk for a few minutes about diagnosis in
children and adolescents. And, we have gotten ail the
statistics from the 7 regional hospitals and the certain
categories of mental illness that show up that will perhaps
be helpful if you describe what those mental illnesses
involve.
The first one is schizophrenia.
A Schizophrenia is a complex idea in any mental
health field. It has—The term has been applied to a
variety of situations in children; some of which for, say,
an adolescent child might be quite closely analogous to
what we call schizophrenia in adults. The word is used
with younger children specifiying childhood schizophrene,
but the picture is quite different.
Childhood schizophrenia is diagnostically what we
use for some conditions in which from birth the child is
one to which the parents can’t form a close relationship.
The child is in a variety of ways less flexible. The child
is sometimes physically even rigid. You pick the child up
and try to cuddle it, and he’s just stiff. In other ways when
[18] the parents try to interact with the child, they don’t
get the responsiveness. He is less responsive than normal
children. And, some of these children, we usually don’t
see them until their a year and a half, two or three
ears old. The parents give a history of the child having
een unresponsive, stiff, untouchable almost from birth.
Now, in other circumstances we see children who
may have developed apparently quite normally through
say the stage of beginning to learn to talk, 15 to 18
months; using some words and then for some reason the
child stops using words and becomes more and more
withdrawn from the usual, expectable behavior of a child
731 [19]
of this age, and may get further into a situation where he
goes about his activities during the day maybe in ways
that show no significant difference in human beings and
physical objects. He treats people as if they were objects,
and he doesn’t show a difference. He has not somehow
further developed those patterns of functioning that say
a person is something unique; and you respond to it one
way; and you respond to chairs and tables in other ways.
And, such children may get into patters of repetitive head
banging and very highly repetitive activities. We refer to
this as autistic. We’re saying that the child is contained
within himself and involved with his own inner processes,
rather than sensitive to and responsive to the processes
going on in the world around him.
[19]
There are several patterns of this sort that we lump
together as childhood schizophrenia. We say that in some
sense they are analogous to what we see in adult schizo-
phrenia.
In the long run we may find that it is a very different
condition. The notion of common path comes up in a lot of
notions. There may be a variety of things that have led to
it. But, there aressome things about them that are similar.
In this case, theffailure to interact with the surrounding
world with the tiftal sense of reality of what the world is.
Autistic children are not interacting in a realistic way
with the world around them. The conventional notions of
reality, just as an adult is hallucinating and expressing
delusionary ideas, he’s not interacting with the world in a
realistic way. But, that analogy leads to the use of the
same term. It may not be the same condition.
Q Is autism—
[19] 732
A Autism is within the category of childhood schizo-
phrenia.
We also speak of the symbiotic child who has a very
special and limited social limitation, intense interaction
with the motherhood figure. When the child’s behavior
becomes very severely disorganized when he is removed
from that one interaction, then it’s not a usual develop-
ment of social interaction, although there is a limited
situation with that [20] one person.
Q What about when you get to adolescents with
schizophrenia?
A The diagnosis of schizophrenia in adolescents is
much closer to the diagnosis used in adults. It’s based on
typically on evidences of a distortion of reality and
thought processes and changes in affective behavior to a
degree when the usual ups and downs of mirth and sorrow
and fear and so on, just sort of a steady unresponsiveness.
But, in adolescents we would see delusional thoughts that
would be definable; hallucinations is among the indicators
that would lead to the diagnosis of schizophrenia.
Q Another major mental illness that appears from the
records is adjustment reaction of childhood and adjust-
ment reaction of adolescents. Would you describe what
those are?
A In child mental health almost everything that has
been done started from people who worked with adults
and then began working with children in trying to see how
to move the concept in mental health to apply to children,
It doesn’t work. Just taking notions of adult mental health
and applying them directly to children just doesn’t work.
People begin to see youngsters who might show
quite significant evidences of disturbance which seem to
Nt
733 [22]
be very much related to their developmental stage, where
they were in their growing up processes ard when observed
over a [21] period of time would resolve themselves in
some sort of way over a period of time. Sometimes a
fairly short period of time. :
And the developmental disturbances of childhood
or adolescence, there are ways of trying to characterize
those. Occasionally, particularly in later adolescence we
may even see something for a period of days or a week as
the manifestation of a psychosis or schizophrenia but
resolves itself fairly quickly.
More characteristic what we see is a very aggres-
sive, intense, aggressive response, withdrawn response, a
variety of different behavioral patterns. In effect the
statement is a prognostic one. It’s an effort on the part o1
the ciagnostician to say, “As far as I can judge, putting all
the picture together, the behavior I see and the history I
gain, the evidences I see of the parent-child interaction
and so on, this is a condition that I predict will clear up
with not too much intervention.” I think again it’s
somewhat hypothetical to say that when a condition like
this occurs a variety of outcomes can follow. And, inter-
vention at that time is intended to see that the outcome
is a reasonably healthy, progressive one. It may be acute
manifestations of the adjustment reactions may disappear
with the child settling into a more fixed behavioral pattern
of overt rebellion or of submission or something of that
sort, which probably would [22] not be a healthy or as
healthy an outcome. So, intervention is designed to try
to assure when the expected reso.ution occurs, what comes
out will be a reasonably good one for the child’s continuing
development.
Q You mentioned one of the symptoms might be
[22] 734
intense aggressive behavior or manifestations of what
looks like schizophrenia. Are there any other kinds of
behaviors or moods that might appear for a child who has
beén diagnosed as having an adjustment reaction?
A Yes, the child could just be showing a lot of anxiety.
This could be a nervous mannerism, overt anxiety, profuse
sweating. Probably not in a child much under adolesence
would you see that sort of reaction. It’s more typical as
the child gets older. Withdrawal, excessive fantasy in-
volvement, imaginary companions, almost any kind of
behavior that a child is capable of can appear in excess.
Q What about depression?
A We see very little overt depression that we can
compare well with depression in adults in children before
adolescence. You begin to see some in adolescent children.
I’ve seen, I guess, in my entire career one child who was
probably at the time 10 or 11 who was overtly suicidal ;
and he took a rifle and managed to put a bullet through
his shoulder. But, young children don’t—Well, their
capability to be depressed seems to be a developmenta]
thing that hasn’t [23] arrived.
Q As we've discussed and you’ve mentioned some
differences between children and adolescents with regard
to adjustment reaction. Can you think of any other that
might make the diagnosis different between children and
adolescents?
A Well, the primary reason for the difference in the
labeling is simply the developmental stage of the child.
It has to do with the developmental capabilities of the
child and what kind of social interaction he’s apt to be
engaged in. No gross depression in younger children.
People somehow interpret depression in the younger child.
735 [24]
They say this withdrawn behavior we say is because of
an inner depression. But, this is not because the child
says, “I’m blue; I’m down in the dumps,” or that the
child cries or does the kinds of things that we would say,
“that’s depression.”’ So, some people say of a quiet with-
drawn child that he has an inner depression.
Q Does the diagnostic label of adjustment reaction in
and of itself say anything about the severity of the
symptoms?
A No, unless that’s qualified.
Q What about hyperkinetic reaction of the child,
what symptoms?
A This is a somewhat confused term, because the
notion of hyperactivity associated wh minimal brain
damage [24] which was developed relatively recently
comes into the picture. But, hyperkinetic simply means
overactive. Anything in which there is a degree of motor
activity that is considerably greater than normal could be
classified as a hyperkinetic reaction. There’s nothing in
that diagnostic counterclaim that says there has to be
brain damage in that particular pattern.
Q It’s a description of symptoms?
A Yes.
Q Of behavior?
A Yes.
Q There is a classification of personality disorders.
Do these usually appear in children and adolescents?
A I think the term is considerably less used since
TSM2 came out in 1968 or something; revision of the
diagnostic statistical manual introduced a much more
(24] 736
extensive way of looking at adjustment reactions. The
difference in the ideas behind these is that a personality
disorder is seen as one in which a pattern of functioning
has become quite fixed within the person’s makeup and as
a persistent way of that person’s interacting, with other
people. It’s likely to go on over years. It’s a part of the
makeup.
I think this is not very commonly used now in chil-
dren. It is used to some extent in adolescents and probably
a more applicable term for adults when personality quali-
ties [25] are more fixed and do tend to persist longer.
And people have used the adjustment reaction of
childhood as a much more relevant way of looking at what
you see in a child who seems to be changing anyway with
this developmental progress.
Q But, at the time that label is fixed is that basically
a statement that from everything known those symptoms
are not fixed and probably will go away eventually?
A The personality disorders?
Q Adjustment reaction.
A That’s a prediction that’s made looking at the total
picture. Whereas, diagnosis of personality disorder would
be because the history indicates that this has been per-
sistent through a variety of circumstances over a period
of time and it looks as though it’s likely to keep on char-
acterizing a personal functioning.
Q So, you might first give a diagnosis of adjustment
reaction of childhood or adolescence and then later, if the
same pattern persisted, change that to a personality dis-
order.
A Correct.
——
737 [27]
Q As it became fixed.
A Right, that would be probably a quite appropriate
change of diagnosis. The tendency that is present in the
field to try to make the least pejorative diagnosis at
the first instance. I think this has not been true of the
[26] field forever when people were looking for more rig-
orous ways to classify things and trying to get them in
categories much harder, working at it much harder than
we are now as a way of trying to understand what we’re
dealing with. They perhaps did tend more to say, “Uh-
huh, I see a little bit of a sign here that says it ought to be
classified as schizophrenic.” Whereas, the tendency more
recently has been in the direction of trying to put the least
pejorative, severe label on things. So, people will tend to
say adjustment reaction to child and adolescents and only
in the light of early experience. You say, “well, that was a
bad estimate at that time; or something else has gone on :
and now we have to change it to a more persistent,
serious kind of labeling.”’
Q So, would you categorize the adjustment reaction
diagnosis as being a conservative one?
A Yes.
Q Can you think of any other major categories of
mental illness of children and adolescents which need to
be described?
Q We haven’t talked at all about neurosis. This is
another concept which generally refers to a less serious
condition than a psychosis, which refers to a condition
that is seen as probably being more transient than a per-
sonality disorder, on the average more transient, which is
thought of as being more of an intrapsychic distortion,
say, than the [27] typical adjustment reaction.
[27] 738
Adjustment reaction tends to be more in a variant
social behavior that’s fairly extreme. But, the neurosis
may be such a thing as a conversion reaction, a hysterical
neurosis in which—well, an extreme case say blindness.
A person acts and believes himself to be blind. They deny
any ability to see things in front of them. As far as we can
make out, they’re not lying. They’re not faking it, al-
though if you get them up and lead them across the room,
they will somehow or another manage to sidestep an
obstacle on the way. But, as far as their consciousness is
concerned, they’re not seeing.
There are a variety of other neurotic reactions.
Q Would these become a diagnoses for children or
adolescents?
A Hysterical conversion reaction is probably a fairly
common circumstance of early teenage youngsters. It’s
an interesting thing it was a common diagnosis 75 years
to a hundred years ago. When I came to North Carolina
for my psychiatric training, it was at a time when most of
the leading working psychiatry in this country had been
done in the Northeast, northcentral states, the West; and
there hadn’t been a great deal in the South. And, people
were saying hysteria used to happen back in Freud’s day;
but it doesn’t any more. It’s a very rare condition.
[28]
A study was done in North Carolina that showed
something like 13% of the teenage kids coming through
the out-patient mental health program there in the psy-
chiatry department had behavior and functioning that
was appropriately diagnoised as hysterical. It seems to be
associated with more fundamentalistic religious views,
less advanced modern social circumstances. You find it in
rural populations where there’s a high level of fundamen-
talist belief and so on.
739 [29]
Q You mentioned blindness is one type of hysterical
reaction. Are there other common ones?
A The term is used to apply to situations in which
there is change in the person’s perceived sensory function
or their voluntary motor activities, that is, as far as one
can make out, due to psychological factors, not to any
somatic changes. So, it can involve pseudoconvulsions of
motor activity. It can involve paralysis, or lack of motor
activity, a paralyzed limb. It can ‘avolve unusual or
strang’ sensory experience such as perception of and re-
porting of pain or anesthesia, inability to feel anything
with the hand, say. It can mimic many neurological con-
ditions. But, when the evaluation is done, no neurological
evidence is found. For instance, neurological damage can
result in anesthesia of a part of the hand; but there’s
almost no neurological condition—there is no neurological
condition that can result {29] up to this point (indicating)
and going no further. There are persons who say that I
can’t feel anything from here down. And, you can stick
them with pins; and they don’t jump. Yet, there’s no way
neurologically that it can happen on that basis. So, that
covers that range of conditions.
Q You think that pretty much covers, say, 90% of
the diagnoses?
A The psychosis, neurosis, personality disorders and
adjustment reactions. We could get into some psychoso-
matic disorders, childhood dermatitis, a variety of psy-
chosomatic disorders in which there is pathological change
in the body tissue and so on, which appear to be to a
significant extent due to psychological reactions in the
person’s life.
Q Would these be admitting diagnoses to the regional
hospital in the psychomatic illnesses?
[29] 740 ’
A Iam not aware of that being admitting diagnosis
to the regional hospital. That would be more often seen in
a pediatric hospital. The pediatrician might call in psy-
chiatric help. It wouldn’t be one of the things for admis-
sion. It very rarely crops up. I’m not aware of any case
that has been admitted since I’ve been here.
Q Doctor Messinger who testified in this case char-
acterized adjustment reaction of childhood and adoles-
cence and hyperkinetic reaction as being rather benign
and common diagnoses. In your opinion, would the fact
they’re common [30] diagnoses affect need for hospitaliza-
tion in individual cases?
A No, depending on the total judgment of the circum-
stances and the sort of condition are grounds for hospitali-
zation. There’s no reason why it shouldn’t be appropriate
for hospitalization; some of the time the diagnosis is not
that important in the hospital decision. It’s the judgment
of the total circumstances.
Q Well, how important is it that two psychiatrists
might put a different diagnostic label on the same symp-
toms?
A Well, I don’t think it should be too important.
Certainly, we ought to be trying to standardize diagnoses,
so we can arrive at better judgments, where we can be
more consistent. That will be the millenium when we can
do that, when we know what these things are all about so
well that we can put a clear common label that has mean-
ing in terms of what we do and so on.
Unfortunately, I think we’ve been overfocused on
the medical model as the only consideration. That is we
have looked for conditions that were analogous—But, it’s
increasingly apparent that the conditions we’re talking
741 [32]
about are ones that have multiple factors involved and
complex reaction patterns to a total somatic, social, psy-
chological context. And, we probably haven’t gone far
enough in adding diagnoses of family or action patterns or
other things to our categories, [31] ways of characterizing
as we see them. If the family interaction pattern is really
side-tracked, and the overt manifestations are relatively
mild in the child, that can be a very serious circurnstance,
although the label itself looks very benign.
Q For example—
A 1! think almost anybody in the field today is really
looking at things as much as they can in that kind of a
way. We have to go back to using labels that have a long
history of evolution and derived at a certain point. The
Joint Commission Standards on Accreditation of hospitals
—we have to have diagnostic labels, and those diagnostic
labels have come about from a medical framework, a
medical perspective and assume a certain form that’s
obligatory to meet certain standards and that has a certain
utility.
Q But—
A It isn’t the whole picture, and we need to go very
much beyond that. So, you’re going to get variations in
diagnoses. Probably if you ask many psychiatrists who are
using different labels what they’re going to do about a
thing, what they think would be the appropriate action,
you'll find that many cases there’ll be much more agree-
ment than in labelling of children. They’ll say, ‘‘Yes, this
child belongs in the hospital,’ although they might be
using different labels to say so.
[32]
Q Well, then how would the child be treated once
[32] 742
he was in the hospital? What difference would the label
make with respect to treatment?
A Certainly, in cases where the dianosis is quite clear
and where many people would agree on it, the label would
make some difference in diagnosis. Even in more uncertain
cases the labeling may suggest some direction in trying
treatment. There are certain drugs that are by experience
considerably more effective for people who are psychotic,
the major tranquilizers. The minor tranquilizers would be
more appropriate to use in cases of anxiety, hyperactivity
and so on. If the hyperactivity is specifically the kind
that is associated with minimal brain damage, there are
other things. So, the diagnosis can make some difference
In terms of a general psychological or social minute treat-
ment of achild, there probably is ostensibly less difference.
An environment that is concerned about disorders
of behavior, that is interested in feelings, that encourages
constructive interaction with your peers or with the au-
thority figures around you is probably more generally.
applicable to almost anything we see. We may make some
differences depending on individual circumstances. A
severely inhibited child, we'll try to more actively bring
out in the open; and a hyperactive or hyperaggessive
child, we might try to draw out certain things while con-
trolling others. Try to teach [33] the child the difference
between total expression and expression of certain por-
tions. So, we do make some differences. Again, not so
much related to the diagnosis in the management of the
child as related to his particular circumstances, particular
areas in which he appears to be having problems in inter-
action with other people and so forth.
Q Would the diagnostic lavel of adjustment reaction,
which can cover a number of behaviors and symptoms,
what kind of treatment would be indicated?
—
743 [34]
A There’s a range of treatments that might be con-
sidered appropriate under various circumstances. It
would depend partly on—Well, say a private facility that
could limit the number of patients it took and provide a
long term treatment, they might take a child like that and
over a period of a number of weeks or even a number of
months involve the child in individual play therapy +o
express as much of what was behind his behavior problem
and try to resolve it with that sort of approach. Where we
have to—Well, ry oa program might also be function-
ing On a private basis with as much resources as
needed to do it and be using a behavioral ime
approach where they would try to as clearly as possible
identify where the child’s behavior is going wrong and
then foster alternative behaviors, positive reinforcement
alternative behaviors. This probably is on the average a
more rapid kind of treatment. And, empirically [34] I
don’t know of any evidence there’s any as good. There are
certain theoretical positions from which people say that’s
bad and this is good. But, it seems to work. And, I don’t
know if we know enough about the total progress of a
person’s life to really say—
Q One child that’s diagnosed with adjustment reaction
— be aggressive, and another child might be with-
wn.
A Uh-huh (affirmative).
Q And, their treatments would be based o i
ular behavior that they’re showing. oe
A Uh-huh (affirmative).
Q Disregarding diagnostic—
A What’s needed to get them back to a f i
al way of behavior. Tena
Q In treating children and adolescents what difference
ati
[34] 744
does it make to treatment that the child initially does not
want to be treated, does not want to come to a psychia-
trist, or does not want to come to the hospital?
A My experience, it’s very rare for a child to ever
want to be treated to begin with. Children in our society
and probably in most are very used to being pushed
around a good deal by their parents. They are taken to
school because the parents say, “you’re going to school;”
which may in some instance be because the law says, “Tf
you don’t take your kids to school, we'll do something to
you.” But, there is a [35] whole set of things in leading to
why a child goes to school and what’s expected of a child
in school. Children, depending on their age and families,
go on vacation with no decision in the process. They are.
treked around where the parents want them to go. When
children are brought for treatment, it’s part of this whole
context.
I’ve found children who after some several visits
begin to find it’s kind of fun to go see the shrink. He’s
kind of a neat guy; and, you know, they enjoy coming.
But, it’s very rare to find a 7 or 8 or 9 year old child who
even after quite a long time and quite positive relation-
ships could say why he is coming and be electing to come
to deal with his symptoms, to deal with his disorder.
Q What about an adolescent, say, a 14 or 15 year old?
A By around 12 or 13, 14 certainly, you find that some
kids who can make the election, who can in a positive
sort of way say, “I have something wrong with me; I
want somebody to help me with it.” I’d say it would be
very rare before 12, becoming of some significance be-
yond 12.
Q What about treatment of sdolescents who are say-
ing that they don’t want to come?
4
745 [37]
A If I’m treating a youngster of that age, I would
very much like to fairly quickly arrive at the point where
he says, “Okay, you know, I’m with it;” and treatment
will progress better. But, I have to go by my best judg-
ment of [36] the situation as to how disordered the child’s
functioning is. And, if my clinical judgment is that it’s a
serious disorder, that it’s going to be significantly impair-
ing of the child or if the manifest disorder is relatively
mild but the interaction in the family is of the sort that’s
likely to perpetuate or aggravate and develop into some-
thing more serious, then I would go along with the par-
ents’ wish to have the child treated, whether the child
wants it or not. And, that would be my job to work
through that resistance as well as I could and get the
child involved in positive progressive treatment pro-
cesses.
Q In your training in child psychiatry were you
trained to get through their resistance?
A Yes, this is a normal part of the approach in train-
ing. This is something that you have to do.
Q What about other mental health professionals,
other than psychiatrists, would they also have received
training in how to get through the resistance of children
and adolescents?
A A huge discussion of literature, much involvement
in training and so on is how you work with this type of
putient.
I remember one person in a training session when I
Was presenting a case I was working with, specifically, the
question, “Do you ever expect to have any sickness in-
sight on [37] the part of this patient; do you expect this
patient to know that ‘I am sick’ and to receive treat-
[37] 746
ment?” It was a very severely disturbed young child.
There’s no way that—That was a childhood schizophrenic.
Q Are you familiar with an article by Rosenhan
called ‘‘On Being Sane in Insane Places?”
A Yes, it appeared—
Q Could you just describe briefly what that study was.
A This a study which is minimally reported in Science
in terms of the detail of how the detail of how the study
was carried out in which 8 people who functioned as
voluntary subjects in the experiment made appearances at
hospitals. They requested a chance to come in for evalua-
tion. They went for the evaluations. It doesn’t report the
details in terms of—he says 8 people went to 12 hospitals.
Some of the people must have gone at least twice. I don’t
know how many of them. Whether one of them went 5
times and all the others went 1 time or what. They ap-
peared at the, I suppose, the admissions office of the hos-
pital. Ke didn’t specify whether it was the out-patient
clinic or the hospital or whether it was the admissions
office or what. And, they said, “I am hearing voices.”
When asked, they said the voices said, ““Thud, empty—’”’
There was another word. And, at some point in what went
on, they don’t indicate in the report [38] how long the
jnterviews were or anything else; but at some point hos-
pitalization was recommended. And, the people who vol-
unteered accepted hospitalization; and they were admitted
to the hospital for a period of time.
Q Do you have any opinion with regard to the method-
ology used in that study?
A It’s a pretty limited methodology, because it tried
one thing and based the findings on what happened. Now,
there is no comparison of what would happen if alterna-
a Dern 8 tite deel ob Renae) een E oe a.
747 [39]
tives had been attempted. The report, as I say, is a very
limited report and very little detail given. They report
certain things that were done and certain consequences
that followed but almost nothing about all of the sur-
round that must have been there. I can’t conceive any-
body going up to hospital admissions office and saying,
“I hear a voice and thud;” and somebody saying, “Gee,
you'd better get in the hospital.” It must have been a
much more extensive process.
Q Well, in your experience would you have expected
a& sane person to come to the hospital reporting such
symptoms with the purpose of getting into the hospital?
A No, I wouldn’t expect a sane person, no. Well, that
gets into what you mean by sane. Sane is a legal term
really, not a psychiatric term.
Q Well, in psychiatry—a psychiatrist’s experience,
do they expect a healthy person to walk up and to report
[39] symptoms of a serious mental illness and to be dis-
trustful of what is reported to them?
A There is a level of concern in the profession about
that sort of thing, that is addressed to that kind of thing
jn training and so on. The whole issue of malingering, and
which perhaps has been most acutely focused on in war-
time situations of that sort where somebody might be
malingering to get out of a very high hazard situation—
Most people in the field have come to view that malinger-
ing is probably far less common than was earlier thought
or even the average layman would be inclined to say.
Some of the things that we deal with, say the
hysteria that we were speaking of before, there are still,
I’m sure, many layman who would say that person is just
faking. We are as a profession quite concerned about the
[39] 748
issue oi malingering in insurance situations. There is
psychological malingering as well as things like low back
pain and other things that members of the medical pro-
fession see. So, there is concern about the issue of ma-
lingering. And, I would suppose that if somebody came
along with some kind of odd symptoms that some place
down the line they would begin to wonder, “Hey, is this
person in an insurance situation or some other kind of
situation where he’s faking for a certain advantage?”
But, that would be the framework from which I would
think of somebody faking something.
[40]
Q If a patient, prospective patient presented himself
to you with signs of a psychosis, what action might you
take at that time?
A I would think if I were in a hospital context, if
that were available to me, I might offer it as a possible
alternative. I might at the same time suggest another
possibility, suggest trying to work this out without leav-
ing the home, community, job, whatever; try to work it
out on an out-patient basis with the hospital as a reserved
alternative that could be available at a later time.
Q But, you might offer some kind of treatment and
then worry about malingering later on?
A Uh-huh (affirmative), with an adult I would typi-
cally, unless there’s a major social risk and so on involved,
I would leave it up to the person. Tell him what the
alternatives were and leave it up to him and see which
one he wanted to do. Use it to try to get a handle on
what’s going on.
Q One of the contentions that’s been made in this
case is that parents sometimes attempt to scapegoat
Relnlitabitish igen iain Dumler geaianaaiee —_"~
eee a ae
749 [41]
certain children in the family by labeling a particular
child as mentally ill and everybody else in the family is
healthy. In your experience is that a phenomenon that
you’ve seen?
A [ll qualify the way you worded it by saying or
taking out the words, “parents try to.” Parents certainly
do. Any social group, there’s some risk of this happening.
[41] When a group can’t work out certain problems within
the group, a group consensus develops that it’s all so and
so’s fault. And, some hopefully wiser more objective out-
side observer might be able to say that’s an inappropriate
judgment on their part. And, that person did such and
such kind of thing to focus attention on him ; but this
person over here was in the meantime subverting the
group’s effort. So, everything would be turned around:
and they identified that as what was going on and recog-
nized that that person was also causing trouble. Three
other people in the group were causing trouble. This
kind of thing does go on in families.
The alcoholic may be making very significant
efforts to deal with this; but because of his alcoholism,
they scapegoat him and blame him with everything else.
Q Or, it might be an adult member of the family, the
husband or the wife?
A Yes.
Q Or, someone else?
A Yes.
Q In your experience how often does this occur?
A That’s very very hard to answer. I can’t put a per-
centage figure on it. There is probably some minimum of
it in every group that interacts very extensively. When it
(41] 750
becomes significant, when it becomes an important factor
in what’s going on, when it becomes fixed on one person,
it’s[42] probably fairly common in terms of families in
general of patients we see in child psychiatry ; more com-
mon probably than in the average family. But, it is a part
of what’s going on.
Q Have you received training in how to determine the
actual dynamics of the situation as by what the parents
present to you?
A This is certainly a major part of psychiatric train-
ing, child psychiatric training is to try to do this. It can
be exceedingly difficult. But, it’s a part of what child
psychiatric training is all about. It’s how to look beyond
what you’re told, what’s on the surface of the situation
and try to see what’s going on in subtler ways.
Q Would it be part of psychiatric training in general
as opposed to child psychiatric training?
A Yes, again, this is a changing situation, because if
you look back 25 years, psychiatric training was generally
still considerably oriented toward the problem with the
individual. Twenty-five years ago there was a very clear
difference between psycho-analytically based training
programs where people were being trained to look inten-
sively and dynamically into family context and so on and
non-analytically based programs which were looking
much more for disease condition in the individuals. I
think the dynamic perspective has spread to become essen-
tially part of the ground work for [43] everybody in the
field. And, people are going considerably beyond the
psycho-dynamic/psycho-analytic perspective on dynam-
ics and become much more aware of other social dynam-
ics.
Den
TUT
ll Pe cy DEB ht
PS ee Oe ee PORTO eT Oi Oe en nies eS oe ee en ee, era eo See
a Ty ate —
751 [44]
Q Would this—
A This is pretty much a normal part of training that
everybody is taught to look at things in terms of the com-
plex system of dynamics in which people function.
Q Would this also be true of other mental health
professionals, psychologists, psychiatric social workers
and nurses?
A Yes, it’s sdrt of a standard part of the perspective.
Q How, say, in an interview situation or in a series
of interviews do you deal with these problems, the prob-
lem of scapegoating, determining true family dynamics?
What techniques in interviewing do you use?
A I hardly know how to put it in terms of technique.
Theodor Reik who entitled one of his books Listening
With a Third Ear, this is trying to be an independent ob-
server of what goes on,.trying to look at the totality of the
context and see things that other people are overlooking,
human communications. There is a good emphasis on
paying attention to the words people say. But, there are
many other indicators of what’s going on in a situation.
If I’m seeing a family in a family group, then I have
a chance to see not only what the mother is saying, but
[44] the tricky little points at which father interrupts; and
his choice of repetitive circumstances of the same context
in which he interrupts may clue me to a significant dy-
namics of what’s going on.
Seeing a patient individually—lI recall one woman
I was seeing one time. Just all kinds of explorations and
inquiry led to no indication of any fluctuation of feelings
about the things she was talking about. Everything was
just sort of flat, this was it. I noticed, as I was talking, that
[44] 752
at times her leg muscles contracted in a way that the toe
of the foot that was crossed over the other leg was pointed
severely down; and at other times it was hanging relaxed.
I drew this to her attention. She had been completely un-
aware of this as a thing that was going on. She couldn’t
explain.
Finally, I said, ‘““Well, look, I’m going to guess that
that’s an indicator of tension and anxiety.’”’ And, I began
to say every time I saw that toe go down, ‘‘What are you
tense and anxious about?” And, gradually she began to
be able to identify in herself other indicators of tension
and anxiety. And, we began to be able to get them out.
And, what you’re trying to do is to look for just those sorts
of subtle behavioral cues in a person in his own processes
or in interaction with a group. To be able to identify
things that are under current to what people are saying
and what’s [45] on the surface.
Q Have you visited all of the children and adolescent
programs in the regional hospitals?
A Yes.
Q Have you visited the Children’s Building at Central
State Hospital?
A Yes.
Q In your opinion is the physical plant of the physical
building at Central State similar to the physical plant at
the other regional hospitals?
A It’s quite similar to most of them. At this point the
exception is Southwestern Regional Hospital which is
using an old army hospital facility, and the physical layout
is quite different. The quality of construction is very
Ai ot ewe 6 ce)
2 Mt. Stes BM
REM A re
abies bey
ie ee ee iP SD ee RS eat AE te 8. be OO ee ee BLO OR btm
.
753 [46]
different. It’s quite a different plant. All the others are
very much similar, modern cottage for 24 or 40 or so
many patients; but with separate areas that can be divided
up for different groups of children and adolescents and
so on.
Q At Southwestern is there a separate children and
adolescents building?
A There is a separate unit, separate building for chil-
dren. At present they’re operating a day program for
adolescents who are housed in the general wards. It’s a
pattern they’re using in the Atlanta Region and have not
arrived at the point of having a separate building for
adolescents.
[46]
Q Are you familiar with the treatment programs at
the various hospitals for children and adolescents?
A To some degree. I’ve had a chance to participate in
the staff meetings and interact with the staff at each of the
hospitals and to get some sense of the treatment programs.
Q Are they fairly similar?
A There is some variability; some heavier use of be-
havior modification approach in some than in others.
GMHI with the history of the association, with Emory
and the psycho-analytic perspective, they’ve had a history
of more of a long term expressive therapy. They all, I’m
sure, are using some behavior modification. They all have
quite well developed activity programs for children while
they’re in the hospital.
Q What about school?
A They all have school facilities and provide educa-
[46] 754
tional activities for the children while they’re in the
hospital.
Q Do the schools use specially trained teachers?
A Yes.
Q Are they hospital employees, or do you know?
A This varies. In some cases they aic. Title I or Title
V of the Education Act provides teachers who can be
assigned from the education system to the hospital. When
that’s the case, they’re paid 9 months a year from educa-
tion [47] funds. But, because the hospital is a 12 months a
year activity and the educational component is important
year round, they’re paid by mental health for the other
three months. In some cases they are directly hospital
employees.
Q Are you aware of any particular problems with
parents not taking their children home when the staff of
the hospital recommends discharge?
A I think this is probably a very occasional problem.
This is most often the case with really quite seriously
disturbed children. With a child who’s schizophrenic, the
parents may have a great deal of concern and apprehen-
sion about caring for the child as a memory of what
happened earlier and so on. And, the hospital feels that it
really would be in the child’s best interest to be at home
and to continue whatever is going on in a family and
community context. The parents may still be unwilling
to do that. But, other than extreme cases I’m certainly
not aware of that being a problem. The natural parents
would be willing to come and get the child at the time the
hospital says it’s appropriate. Parents are pretty used to
doing what doctors tell them.
ax guide +
755 [48]
Q You’ve recently been working on developing a list
of children who might need to be placed in specialized
foster homes.
A Uh-huh (affirmative) >
[48] 1
Q Would you explain please how that list was devised
and what the reason for it was.
A Well, this is a concern that I had been aware of
since I came to this position. There were some children
around who hospitals were having great difficulties find-
ing proper placement for. Hospitals have been largely
dependent on Department of Family and Children’s Ser-
vices for making such arrangements. The legal conditions
around providing child care facilities and so on are orga-
nized in that way. And, the hospitals have sometimes been
quite frustrated in trying to work out an arrangement,
feeling that they could do it themselves. But, they don’t
have the legal authority and so on.
With the many problems that have existed in the
development of child and adolescent services, it’s one I
haven’t put a great deal of effort into myself until re-
cently. Now, over this past summer I have been involved
in some activity that we’re pointing in this direction.
And, the Department of Social Services began to express
some concerns this fall joined in with the other things
that were going on.
We recently had an interdivisional committee that’s
prepared a series of recommendations including a signifi-
cant expansion of these specialized foster care capabilities
of the state to submit to Mr. Parham. In this context of
this all this going on, the issues around this case brought
[48] 756
it [49] again to quite acute attention. And, the combina-
tion of these motivations, we put together a list. We asked
each of the hospitals to report to us on the kids they had
for whom they felt such a resource might be appropriate.
** ** *
[54]
*_* &© * *
Q One of the essential contentions in this case is that
there’s a necessity of judicial or administrative hearing
including a right to counsel and independent psychiatric
exam, confrontation and cross examination of witnesses
prior to the decision to hospitalize a child. In your opinion
is there a necessity in each case for a judicial or adminis-
trative hearing with those attributes?
A_ I would think in many cases it would be quite dis-
ruptive. The child is already going through difficulty with
his problem that he started with, and these are not good.
If he needs to go in the hospital, that’s certainly a change
[55] from his normal life circumstances. That’s true if he
has to go into a hospital for tonsilitis or a mental hospital.
It’s another kind of thing and certainly has significant
differences than a few days’ stay in a general hospital for
a medical condition. But, going to the hospital because
you have something wrong with you is not that strange.
Most kids as they grow up know and have found out
that you go to a hospital because you have something
wrong with you and consult with the doctor; and that
seems to be the best thing to do. It’s not that strange, I
would say.
Due process proceedings in the court, witnesses and
so on are much more alien in a child’s life and airs all the
dirty linen, not all of it probably, but it airsa significant
amount of dirty linen in the child’s life and parents’ lives.
And, all sorts of people sitting around passing judgment
- % dew ————
757 (56)
on what’s going on. And, it would be considerably more
alien to the child’s life than the somewhat familiar from
the medical participation in dealing with problems.
Q If it became necessary for parents to anply to a
court or to a hearing officer prior to the admission of
children to the hospital and following the recommendation
by the community program that the child needed hospitali-
zation, do you believe that a number of parents would
simply fail to file such ». petition or request for hospitali-
zation?
A I would think so, yes. There might be quite a num-
ber [56] of parents who would not want to get into that
sort of a situation, but who would be able to work quite
effectively with a hospitalization and return after a
period of treatment and so on.
Q That’s all the questions I have. Want a few minutes?
{Break}
CROSS EXAMINATION
BY MS. LINDBLOOM:
Q You mentioned before in your direct testimony that
the community treatment centers, the community pro-
grams would determine whether hospitalization was ap-
propriate and would make those recommendations to a
regional hospital. Are there any written regulations or
policies that you’re aware of that speak to that or describe
that?
A I believe so. They’re not policies that say that
that’s absolute. Policies that say that’s the preferred way
of functioning. I don’t think we would evershiave policies
that would say that’s absolute. If it was clear that hos-
pitalization was the need in the clinical judgment of
(56 758
responsible physicians, then hospitalization would occur at
that time. The procedure at that time would be to inform
the community center that the hospitalization occurred to
involve the community center with the parents or with the
planning for the eventual disposition and so on.
Q) Assuming—
(57)
A But, the admission might have occurred at the
hospital without having gone through the community
center,
Q Given that that situation might exist, is there any
written guidelines, policies or regulations that speak to
that, in other words, that you’re aware of?
A I’m not certainly aware of any that do speak to
that. I’d have to review hospital policies. I’d have to
review division policy statements to check and see if that
is specifically included.
( You spoke of two general criteria that are used
when hospitalization was appropriate. One was acute,
severe degree of behavior. The second was social circum-
stances. Okay, assuming emergency situations, emergency
admission would be appropriate, are there any other situa-
tions where acute—Can you think of any other situation
where you mentioned an acute, severe behavior problem?
In other words, can you think of anything else; did you
mean anything else by that, anything that wouldn’t be
covered by an emergency admission?
A I made the distinction between emergency which
would usually be within 24 hours or less for getting some-
body into the hospital and severe behavior disturbance
where an attempt might be made to manage it in some
759 (59]
alternative way. Then the decision is made to get them in.
Where that stops being an emergency and becomes a
social circumstance judgment, [58] it’s a mixture of both
probably, most of the time.
Q Okay, specifically when you talked about the social
circumstances, your second criterion, you spoke about
breaking of the vicious cycle that you described, that
you described.
A Yes.
Q Again, in a non-emergency situation would there be
any other alternatives to hospitalization in that instance?
In other words, to break this cycle you spoke of.
A There could be, yes. You might try a foster place-
ment,
Q Okay.
A I think probably in the present situation the hos-
pital is a more expedient and quicker way to get the cycle
broken and the child back into the home than going
through the crisis of negotiating a foster place. There are
some situations where there are emergency foster facilities
where a child can be placed for a fairly brief time, over-
night or up to a couple of weeks. And, this might be appro-
priately used at times. That would have to be, again, a
clinical judgment as to whether just moving the child out
of the existing situation with a relatively low level of other
intervention, treatment and so on would be sufficient or
whether you want to couple it with a fairly intensive
treatment program.
[59]
() How many of these emergency foster facilities you
spoke of are available within the state?
A I don’t offhand know. Clayton has quite well
[59] 760
developed emergency foster capabilities. There are some
in other places. I don’t know the details.
Q When you speak of the foster facilities, are those
facilities that the local DFCS, the county DFCS office
would have knowledge of and have recruited one as op-
posed to one specifically recruited by the Division of
Mental Health, let’s say?
A The ones I knowmost about are the ones in Clayton
County—are described there as a protective services
commission, police, court workers, social services, mental
health; organizationally it’s under DFCS.
( You mentioned a training conference coming up in
January.
A Uh-huh (affirmative).
Q Concerning the rights of children. Are there again
any written policies or regulations now on the rights of
children in terms of admissions or treatment in the state
mental health facilities at present?
A No.
Q Okay.
A Except as they’re included in hospital policy state-
ments and so on.
(60)
Q Are there presently children hospitalized right now
in the 8 regional hospitals in the state who hospital per-
sonnel in those specific hospitals indicate do not need
to be institutionalized?
A Yes.
© How many?
A We mentioned the 14 or 15 whom the hospital has
judged to be in need of specialized foster placement. I
761 [68]
don’t offhand know the number. It might be something
approaching that number whom the hospital has judged
needs residential treatment programs over a much longer
period of time.
Q Do you regularly request that information about
children in that position from the hospitals on a regular
basis, systematic basis?
A We have not regularly requested it, because we have
no capability of affecting the situation. I’m sure when we
do have tet capability, it will be a regular requested item
of inform ition from all of the hospitals.
\ ** eK *
ss * *£ + *
\
Q Okay, ‘again, going back to when you talked about
adjustment reactions, you talked about it in terms of be-
havior, social'pehavior. Because of that, because of its
being social behavior, would not the placing of the label
of adjustment reaction be dependent on the mind ef the
labeler. In other words, whether the person who's placing
the label, is going to place the label deems the behavior to
be socially unacceptable or not>-- na o
A It certainly would have - io true,.yes, that the
person would agree that the intensity, the level, inna
tent of his behavior was socially unacceptable. What
social unacceptability means; it means that the social
group is not accepting; and that’s why they brought them
there in the first place.
Q Again, you were referring to, in discussing the im-
portance of the diagnosis itself and correspondingly the
treatment in terms of drugs that would be given, if there
was a misdiagnosis and a wrong drug was given—Let’s
say an inappropriate drug was given on the basis of a
(68] 762
misdiagnosis, would there be an adverse effect on the
patient?
A At the present state of the art most of the medica-
tions we use have a high level of—There is a high level of
tolerance to these. The specific medication, the dosage
and so on [69] is almost known by trial. Now, that’s not
entirely true. As I said before, a diagnosis of psychosis
would make certain drugs the ones you try first. But, in
specific cases a particular drug may have little or no bene-
ficial effect. And, you’re only going to know that by try-
ing it.
We’re not in the situations we are with anti-biotics
where they can take a culture of the organism and test the
drugs on a culture plate and see which one is most effec-
tive. The only way we have to test is to test in the person
himself.
Q But, you can get an adverse reaction from using a
drug that’s inappropriate based on a misdiagnosis?
A No, I wouldn’t buy that statement.
Q Okay, I just want to clarify what you were saying.
A There are adverse effects of such drugs. You run a
risk any time you try a drug that has capabilities of pro-
ducing significant effects. It may have adverse effects.
For a person for whom it has benefici ;-you're
balancing out ti.c nst the beneficial.
—$——————
a
© Are there any statewide policies or regulations,
again basically within the Division of Mental Health, of
which you are aware that speak to the separation of
adolescents from adults in the 8 regional hospitals?
A There are no—
Q Are there any being developed at the present time?
ws
763 [71]
A Not as policies. We’re programmatically working in
[70] that direction to achieve that.
Q Okay.
A We’ve only recently in the Atlanta Region been
able to work things out so the staff—staffing and so on
made it possible to provide 7 hours a day in which the
adolescents are in an adolescent group with staff especially
focused to work with adolescent problems. And, they
return to the adult units for the remainder of the hours.
Q Then, you’re familiar, I would assume based on
your last statement, with the practice at Atlanta Regional
that 12 year olds are considered adults; and they would be
placed on adult wards?
A I don’t think it’s 12. I think the 12’s are included in
the children’s group, if I’m correct. If I’m remembering
right, it’s not till 13 that they’re moved.
Q Okay. Would you agree, in other words—
A Incidentally, I have stressed in my conduct with
all the regional hospitals that I feel they should use these
kinds of age limits-flexibly and in functional terms. And,
a 13 or+4 year old who is still very childish in many ways
ought to be selected to be managed in the children’s unit.
And, only those who are in a more mature level of func-
tioning should be treated as adolescents. That would be
true if they had an adolescents’ unit and children’s unit.
Q Okay, are you familiar with the policy at Central
[71] State Hospital where if the patient is under the age of
17 and if they are pregnant or have a child, they can be
sent and placed in an adult ward? Are you familiar with
that?
A I’m not familiar with this as a policy, no.
(71] 764
Q If you were developing regulations as to—You
know, you said you were going at that; that was a basic
future goal or objective. Would you include such a policy
as a general guideline?
A I would want a functional judgment to be made
again.
Q Okay.
A If the having of a child involved the young woman
in a much more adult perspective on her own life in the
circumstances, then I think she ought to be processed as
an adult. If she is a very young 17 year old, immature,
who has had a child or who is pregnant and is very childish
in her whole response to it, then I think she ought to stay
in the adolescent unit.
Q Are all the physicians who work with children and
adolescents at the 8 regional hospitals within the state—
are all those physicians certified child psychiatrists?
A No.
Q Are they all certified general psychiatrists?
A No.
Q Are you aware in terms of numbers the number of
those physicians that are certified child psychiatrists and
[72A] also speak to the number that might be certified
general psychiatrists.
A There are very few who are certified child psychi-
atrists any place in this state in terms of Board certified.
Q Right.
A There are, I think, only several who are trained in
child psychiatry in several of the institutions. Some of the
institutions have eligible trained certified child psychia-
765 (73A]
trists who are available on a consulting basis part of the
time. But, one of the physicians effectively involved in
the Columbus Region is a pediatrician, not primarily
trained in psychiatry but trained in pediatrics and with a
number of years’ experience in psychiatry, child psy-
chiatry.
We’re seriously limited in terms of having anything
like as many child psychiatrists as we would like to see in
the regional hospitals.
Q You say, when you were speaking about scapegoat-
ing before, that sometimes it was difficult to see through
to be able to understand the family situation to see if this
was actually taking place. Would that be compounded
then—in other words—that difficulty, would that be
compounded by an admitting physician who would have
problems understanding and speaking the English lan-
guage?
A I’m sure it would.
Q Okay, again, you spoke that normally—
(73A]
A That is also a problem say with a northerner who
comes down here and does not understand southern
idioms.
Q Okay.
A That’s part of what we have to work with.
Q You spoke also before about the fact that usually
the natural parents of the child who had been admitted
would take the child back in your experience, when the
question was posed to you. But, you say that sometimes
is not the case. Would you then say that parents can act
[73A] 766
against the best interest of the child; that some parents
can act against the best interest of their child?
A Yes.
Q Okay, is it—Assuming the natural parents of a
child who have voluntarily admitted that child to an
institution will not take him back, is it harmful for that
child to be continued to remain hospitalized? In other
words, assuming then the hospital personnel have stated
that they feel he’s no longer in need of that hospitaliza-
tion.
A .’m sure, you know, a long persisting continuation
in the hospital has some deleterious effects, yes.
Q Does your experience change—The question was
asked you about whether or not natural parents take the
child back when the hospital indicates to them that the
child is ready to leave the institution. Is the same true
with children who are in the Department of Family And
Children’s Services’ [72B] custody?
A My impression is that the problem is considerably
greater in that case. Natural parents, they have for the
life of the child generally taken the position that that child
is part of their family and they must deal with it. Foster
parents would be more likely would be inclined to extend
themselves to a degree for this foster child. But, they set
a shorter limit on how far they go. There are some excep-
tions. There are some foster parents who are fantastic.
But, I'd say on the average the child in DFCS’s custody or
foster placement who has these sorts of problems is more
likely to be ejected from the family. Dumped on the
mental system; dumped on the Human Resources System.
Q What would happen—Let’s take a situation such
as that. Let’s say a local Department of Family and
767 (73B})
Children’s Services has voluntarily admitted a child; the
hospital personnel involved with that child all conclude
that he should be released from the hospital. What
happens there? What procedures would happen? What
would happen? Let’s assume the hospital personnel have
concluded that. What would happen?
A The basic step is the hospital personnel would
contact the DFCS and say it’s time for the child to leave
the hospital. Get busy with it.
Q What if the Department of Family and Children’s
[73B] Services were unable to take the child right now?
A Then, it may be that there are further contacts,
further efforts made; but the child stays in the hospital
technically.
Q What efforts aside from what efforts the Depart-
ment of Family and Children’s Services might make after
this point, after they’ve been notified—what further
efforts would the hospital and/or the Division of Mental
Health make for that child, if any?
A There have been efforts on the part of some of the
regional hospitals staff to negotiate the DFCS so the
hospital staff could seek out and recruit foster parents who
would take these children and use the DFCS for the ap-
provals and clearances. And, offers by the hospital staffs
to provide continuing support, training supervision to
these parents when they get the child. So far these efforts
haven’t been very successful. They have succeeded in
some instances in getting some outside life for the child.
I don’t know of any that have created a lasting foster
home as yet.
Q IfI—
A The problem here in part is the history and tradition
(73B} 768
of mental hospitals which have been dumping grounds in
the past. As we try to move out of this, there are a lot of
people who still treat them as dumping grounds. There are
juvenile court judges who say, “I want this kid to be kept
(74] in a hospital from here on out until he’s grown.”’ The
DFCS takes the child to the hospital and says, ‘Now, it’s
off our hands.” They’re besieged with oversized case
loads and so on to try and do things; and to take on the
tough problem of a kid who’s been through a period of
hospitalization and is still not normal, back te regular who
needs community living to get there, it’s going to take
some extra work. And, to take it on at a time when they’re
already carrying 70 or 80 normal foster cases is a huge
requirement on them.
The community mental health programs have only
been gradually been coming to the position of saying that
the patient who is still in the hospital is still our patient.
With a notion of the mental health center taking respon-
sibility for all of the people in its catchman area and their
mental health needs and having an on-going resporsibility
no matter where that person is, is a pretty new idea. And,
they’re only just gradually becoming involved in this.
A year and a half ago when I was here on a pre-
employment visit, I heard a delightful story at Atlanta
Regional. They said they’ve got one social worker out in
the community program who keeps bugging them, saying,
“When are you going to give me back my patient?” And,
their reaction was, “‘Beaufiful, we’ve got one who’s doing
it. Now, let’s keep it going. Let’s get them all doing that.”’
Q But—
(75)
A This is only gradually happening in the total social
process.
769 (76]
Q Specifically, going back to the hypothetical that I
gave you.
A Uh-huh.
Q Assuming DFCS was the admitting person for the
child and DFCS won’t take the child back for one reason
or another, assuming I’m the social worker in the hospital
and the child is on my caseload, are there any regulations
or policies that when I’m confronted with this situation
would tell me what—specifically, what actions I might
take, who else I might contact?
A I don’t know of any policies or regulations. Atlanta
Regional Children’s Unit has worked out a practice where
when a child of that sort is admitted, they enter into an
agreement with the DFCS as to what their responsibilities
are and what DFCS’s continuing responsibilities are; and
before the fact when the child comes to the hospital to set
up the mechanism for getting the child out.
Q Those are policies?
A This is practice.
Q Practice at which hospital?
A Atlanta Regional I know specifically.
Q How about the other hospitals? Has this practice
been adopted in other hospitals, the other 8 regional
hospitals?
(76)
A I can’t say that it is adopted with certainty. I
don’t know that kind of detail.
Q Okay.
[76] 770
A I believe this is operating at Augusta Regional in
the children and adolescent program or something anal-
ogous to it. I’m not sure about all the others.
Q You mentioned—
A Another approach that is commonly used is for the
hospital to contact the local mental health center and
have them work with the DFCS to try to negotiate and
work out a foster placement.
Q Is that written down, again? If I were a social
worker, would I find that written down anywhere that
that’s a contact that I should make?
A I doubt it.
Q Okay.
A It may be, but I doubt it.
Q You spoke of a priority list that was developed this
fall in terms of priority for specialized foster home place-
ment.
A Un-huh.
Q When exactly, specifically, was that list—Can you
give me in terms of a date or approximate date?
A A couple of weeks ago.
© November?
(77)
A About two weeks ago.
Q November?
A Uh-huh (affirmative).
© Okay. You mentioned also the two plaintiffs in this
case, J.L. and J.R., were on that list. When were they
placed on that list?
ein tte a atin
wre a Bek tee BEES Hr aw Bk
_ a
771 [78]
A At the time it was developed.
Q Again, two weeks ago?
A I requested this information from the hospital and
put together the list. Both of those cases were on the list.
Q Okay. When you spoke of the 40 specialized foster
homes, now are we speaking here about actual homes or
are we talking about slot for homes?
A Slots.
Q Okay. How many actual specialized foster homes
are within the state at present?
A I understand this is two children per home, 40 slots,
20 homes.
Q Okay.
A Probably with some of the kids you would place in
those foster homes it would not be appropriate to put two
children in.
Q Okay.
A_ So, we would probably have to operate at less than
the 40 level, because we’re limited to 20 homes.
[78]
Q Right.
A My understanding from the people in social services
is that there are, I believe it’s 15 or 16 homes currently
operating and something in the neighborhood of 30 chil-
dren placed in those homes. Those are approximate
numbers.
Q In the letter of correspondence that you sent to
the regional hospitals in order to form this priority list
for specialized foster care, were they asked to indicate
[78] 772
the number of children—solely the number of children
that needed specialized foster homes; or did they also
indicate those children that were presently in their own
hospitals that needed group homes? In other words,
group homes as well as regular foster homes and the
far. 'y care foster homes? Was that information given to
you?
A Earlier I had requested information on children
needed specialized services, continuing services. And, I
had some general statistics.
Q Uh-huh.
A Across the state on how many the hospitals felt
needed residential treatment care, how many needed
specialized foster homes. Some of them mentioned cases
they felt could fit into regular foster home where a group
home was appropriate.
Q Right.
A But, it was more or less the figures I’ve given you,
14 or 15 specialized foster homes, about that number; and
almost {79} that number for residential treatment, and a
few odd cases ihat. would perhaps be manageable in other
resources.
Q Other types?
A Yes. We’ve had a reasonable capability of getting
kids into group homes, institutional foster care, places
such as St. Joseph’s Methodist Children’s Home and so
on. They have been pressed, as I understand it, because
they used to take, you know, fairly normal kids who,
because of family circumstances, didn’t have a place to
live. They’re being pushed more and more to take troubled
kids. And, they’re having a great deal of difficulty with it.
They’re doing the best they can. But, they are taking
ee ee ee es
ee ee Cees
CigtR ino. a tae 4 ~
773 (80]
them. And, we have some fairly good working relation-
ships with mutual support, hospital personnel providing
support and assistance to them in doing this. They’re
having to work with the school systems, because a lot of
these kids need behavior disorder classrooms in the school.
When they got to those homes, they have to go to public
school. So, there’s pressure on the school systems to pro-
vide enough behavior disorder classrooms in Decatur to
take care of the children from Methodist Children’s
Home, for instance. ‘s
Q Uh-huh. You mentioned in terms of recruitment of
foster homes, I think you were specifically addressing
specialized foster homes, that the local county system of
recruitment, in other words, where the case worker, the
local DFCS county case [80] worker was actually doing
the recruitment, I believe you said, was unsatisfactory.
A I believe—
Q Could you elaborate on that?
A Well, particularly in the smaller counties of which
there are a lot of them in this state.
Q Yes.
A Very small DFCS staff, they have to do a little of
everything. They’re not able to specialize. A particular
social worker may be carrying a case load of 70 or 80 foster
placements that she is supposed to be supervising; man-
aging disbursement of welfare relief funds of various;
looking after handicapped adults and others; and what-
ever the responsibilities are across the whole range of
services. And, on top of that whatever is done to recruit
new foster homes, because there’s an inevitable turnover
on people who are willing to do this sort of thing. Some
people are willing to do it for a period of time and reach
[80] 774
another stage in their life and say, “I can’t do it any
more.” So, it’s—Those people are stretched very thin. To
get a need for a specialized foster home, it is going to take
more effort and so on, more time. It’s a big imposition.
Most of them have been recruited from people who have
been doing foster home work who have shown what
they’ve done, the interest, the care, the capability to deal
with a more serious problem; [81] and then they make a
transition from being a regular foster home and providing
a specialized foster home.
x**x* kK kK *
[95]
xx ke *
Q Specifically—Let me ask you a specific question
here. To your knowledge would a social worker who has
like a child on her case load within the hospital, does she
send, you know, regularly and on a systematic basis re-
ports about that child to the DFCS office? Is that a
written understanding? Is that an oral understanding that
the hospital personnel will do that for a DFCS office that
is concerned with that child’s case?
A I don’t think there’s any written statement of this.
I’m sure that 10 years or more ago it was standard practice
that it was not done. The kid was there. That was it.
They took care of him until they were ready to send him
out, and then they tried to do something. Increasingly,
the hospitals are actively soliciting on-going participation
of DFCS personnel. When they have a child in the hos-
pital, they are invited to come in for case reviews of their
children. They’re including them in the whole process as
much as possible of evaluating how the child is progress-
ing, when the circumstances [96] are going to be appro-
priate in trying to get, you know, the arrangements for
placement established before the time comes for place-
—— as ee -
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775 [97]
ment to occur. And, DFCS workers were regularly in-
volved in case conferences.
Q Are you aware of, again, any obligation that’s
written down or any legal obligation that a local Depart-
ment of Family and Children’s Services county office
would have to children who are patients in one of the 8
regional hospitals that are located within that county. In
other words, is there any agreement, either written or orai
understanding, that you’re aware of for children who are
patients there?
A I don’t think the system is worked that way. I’m
not sure quite what your question is. If a child comes from
one county to the regional hospital, does the local DFCS
have responsibility?
Q Right, I’m basically trying to find out if there’s
written down any kind of divisional guideline.
A I don’t think there is any policy or intent that a
county, say Baldwin County, would have responsibility
with regard to all the children at Central Hospital. They
would have responsibility only for Baldwin children.
Q Okay. Are you aware of any policy within the 8
regional hospitals to review particular child’s, say juve-
nile’s, child’s or adolescent’s case systematically? In
other words, on a regular basis. I’m talking specifically
now about his need— [97] to determine his need for hos-
pitalization and alternative placement.
A Any of our hospitals that have standard hospital
accreditation have requirements of that sort for the
Commission on Accreditation of Hospitals. Any hospital
aspiring to that will have to be in line with that when they
do. We are actively encouraging, and as a divisional
policy or a division code we have accreditation of hos-
[97] 776
pitals down as something to be achieved within the next
few years.
Q Uh-huh.
A We actively encourage all the hospitals to have
developed such policies. And, I believe all of them cur-
rently have some form of utilization review committee or
some such procedure that’s in their policy as on how all
cases in the hospital will be checked at intervals after
hospitalization.
Q But, this, in other words—
A The first interval being checking on the appropriate-
ness of the hospitalization in the first place and its con-
tinuation. Then, at some fixed interval after that a re-
check to be sure that the continuing hospitalization is
still appropriate.
Q There would then be, in other words, there’s a
variation. In other words, each of the regional hospitals
has their own way of dealing with that, their own way of
dealing with review.
A Yes.
[98]
Q There’s no, like, regulations statewide that they
are required to follow in that respect?
A This is a place we haven’t gotten to at the division
level.
Q Okay.
A I’m sure it’s a direction we’re moving in.
Q Okay.
A We’re trying to get things to that point where we
~~ s ne
-. Pew — iin
777 [99]
will have clear statewide policies. We’re working through
the process of getting there.
Q Okay. I’d like to turn now, going back to your
direct testimony again, you talked about salaries and pay
scales of professionals in private hospitals. Do you feel
that the salaries that the state would offer let’s say a
psychiatrist or any mental health personnel to work in
their facilities, that in comparison to what mental health
personnel might get at a private facility might—
A Disincline them to take—
Q Thank you very much. That’s just what I would
have liked to have said.
A Yeah, I’m sure that if we could increase the pay
scale, we could recruit more people to work within our
system to some extent. This is like the situation of the
academic psychiatrist who typically makes less than he
could make on the outside. We are still relying, I think
unduly, on a [99] person’s dedication to a particular kind
of job to get them there, rather than a salary scale. I’m
making a hell of a lot less than I would be making in
private practice and doing something that I consider
much more exciting and am glad to be here. Wouldn’t
want to be in private practice. But, it would be nice to
make something closer to what they’re getting.
Q Okay. The next couple of questions I want to
ask you, I want to make clear to you these questions are
framed assuming these are non-emergency situations.
We're not speaking here about a situation that would
warrant emergency admission.
A Uh-huh (affirmative).
Q Do you believe that representation of a juvenile,
or a child or an adolescent, at a pre-commitment, either
(99] 778
an administrative or judicial hearing, by having an at-
torney there who was speaking for his interests—again, in
a non-emergency setting—would be harmful to his well-
being or his interest?
A I’m not sure I understand the question.
Q Would you like for me to—
A I’m not sure how elaborate the process would be or
if the juvenile is there, how long this takes, what goes on.
If somebody went to the judge’s chambers and said, “Hey,
we got this kid out there that some of us think needs to be
in the hospital; and there was an attorney and the
parents; and they discussed it, you know, that probably
wouldn’t [100] be harmful to the kid.
Q Okay, I think you’ll understand more by my next
few questions here.
A Okay.
Q You mentioned that in arriving at a decision, in
other words, as a psychiatrist if a child or adolescent is
in front of you and you’re trying to make a decision on
whether hospitalization is appropriate, you said in arriv-
ing at that decision you would want as complete and
thorough a background information on that child as
possible in order to make that decision. Is that a correct
statement of what you said?
A I don’t think so. It would be some situations where
I could sit down with the parents and see the kid and in
20 minutes I could say, “I think hospitalization is going
to be necessary. We’ll get all that background information
as we go along. We’re going to need that in the total
effort to help you and the child to work this thing out.”
Q Uh-huh.
Po ea Fon
a
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Be
779 (101]
A But, it’s obvious that hospitalization is needed now.
Q Given the fact that with certain people that you
could not make a diagnosis fairly quickly, in general
would it not be helpful as a general rule—would it not be
helpful to get as complete and thorough a background as
possible on the child?
[101]
A I agree with that.
Q Would not a hearing, an administrative hearing in
which information would be brought out on both sides,
information would be obtained from the school, let’s say,
as the child was in school as to his behavior?
A If it’s a non-emergency situation we’re—
Q Excuse me.
A If it’s a non-emergency situation, we’re going to
ordinarily have time to get that. That’s pretty routine to
get that information.
Q Right. But, that would be information that you
would want to have and that would be helpful?
A Yes.
Q Okay. If, again, when you mentioned the difficulty
of being able to sit back and take a neutral view of seeing
the dynamics of what exactly is happening within a
family, above and beyond what is actually told to you by
the parents or by the child, would—can you see a process
such as a hearing being helpful in being able to collect
more information that might be—that potentially would
be important, that might be, let’s say, embarrassing for
the parents to admit. Now, specifically, I’m referring to,
let’s say, there was an incident of child abuse with the
parents and the child. Would not it be helpful to have a
hearing or a process similar to that in order that that in-
formation could come out?
780
[102]
A My only experience is that a great deal of informa-
tion is going to come out through a long slow process and
is only going to come out by establishing a relationship
between the mental health professional and the child and
parents and so on. It isn’t going to come out in any hear-
ing, no matter how many questions are thrown at people.
I’ve had many situations that I’ve dealt with my-
self with families where the really essential things for full
understanding were things they couldn’t conceptualize
themselves at the beginning of the situation and couldn’t
have told you no matter how you cross examined them.
Q Let me clarify my question. I’m not envisioning—
My previous question was based on the idea of at this
hearing, be it administrative or judicial, that whoever was
presiding would have access to information, let's say,
concerning the report on child abuse or further informa-
tion that would help in this situation as opposed to having
legal counsel available who would grill the parent on the
stand and this type of thing. Do you see what I mean?
A Supposing there was enough such information float-
ing around where people could get at it—The kinds of
things we have to deal with are so often things that aren't
in that realm. I can’t really imagine a more extensive
information system, gathering system than we have now
in dealing with families. We’re using schools, using the
family physician and [103] other resources, the family’s
reports and what not—which is going to be able to elicit
information that can be presented within a couple of
hours of hearing that’s going to be of any significant help
to me, except in very rare cases. Something might crop up
that would go beyond what I would get in a normal
evaluation process.
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781 [104]
Q Would the admitting psychiatrists—again, speak to
all of the 8 regional hospitals here—have the resources
available, in other words, to track down this information?
Let’s talk about the school record of a child; speak about
a teacher who might see him 8 hours a day—in other
words, to supplement the information that they’re getting
from the parents.
A Of course, when you're talking about the hospital
psychiatrist—
Q Right.
A You're probably talking about the emergency situ-
ation where the decision is not going to depend on getting
all that information. That’s going to come as a supple-
ment. He could either get a release, write to the school for
the information. He can contact the local mental health
center, and this will help him much more. The local
mental health center will go out and get that information
and pass it on to the hospital even in an emergency ad-
mission case. If it’s not an emergency admission and has
been referred back from the hospital to the [104] community
center or has come through the community center, they’re
in the position to get that information and do routinely.
Q Do admitting physicians in the hospitals have a
series of written guidelines that dictate, again, set out
information that should be gathered, in other words,
before they make a decision; in other words, is this set out
anywhere in a written policy? Again, assume I’m an
admitting hospital psychologist, not an emergency; I
appreciate your distinction for the emergency; but, in a
non-emergency case that would dictate to me what
actions I should take?
A I think probably I would assume all of the hospitals
have some sort of standardized written-out statements as
(104] 782
to what goes into a basic work-up and so on. This is so
much a part of one’s professional education.
Q Sure.
A To know that what you do is to take a history, find
out what the presenting problem is, evaluate the history of
that, evaluate the social and family history of the person,
find out about previous diseases, family indications of dis-
order, do a mental status examination, do a physical
examination. This is standard practice.
Q Certainly.
A This is built into the training of the professional
that this is the way you work. This is the way you do the
job. And, I think that probably all the hospitals do have
some [105] sort of, maybe not written as policy, but just
the format that exists. These are the forms, you know. You
fill these forms out. They have a policy on filling out forms
on an emergency basis, what has to be filled out promptly
after that before the first staff conference. Okay, we let
this patient in. Here’s the picture we have.
Q All right, I appreciate what you’re saying, that an
individual, specific individual, admitting psychiatrist in a
hospital will draw on his professional background in order
to make that decision. But, what you’ve said is you would
assume that each hospital might or might not have policies
that are written down that might help, in other words,
that help that particular psychiatrist.
A I would assume that they all have some sort of
procedure manual that sets out some kind of standards.
Q Right.
A On this.
Sane 6 ne od AO i 20a anid
be emt ed
ee oe ee ee een eee ees eee ee rts ee es te te
783 [106]
Q That would be determined by each regional hos-
pital?
Yes.
As opposed to having like a statewide book.
Right.
As a set of regulations.
Yes.
Okay. One other point that you made—
-r OF O PO PY
I am also sure that as we move ahead with the
system [106] that the state office is going to be making
periodic reviews of those and may come up with some
policies, if it turns out that some hospitals aren’t coming
up with what we consider adequate standards.
Q You spoke of, again when questioned about the
possibility of a hearing, the effect of a hearing of airing
dirty linen. Might also there be another side to that in
terms of clearing the air, if you will, rather than masking
family difficulties or being therapeutic in that both sides
of the story might be told?
A I would sure a lot rather do that in a more thera-
peutic environment than a hearing.
Q Okay.
A With bunches of people sitting around. I don’t know
how many people you’re thinking of. Even 2 or 3 extra
people will—the risk that there might be somebody over
there behind that mirror looking would get in the way of
people’s being able to communicate. As back in the days
when I was on the faculty of the medical school or a
resident in psychiatry and took the medical student into
an interview with me some time. This took very careful
[106] 784
work to clear the air on what right that person had to be
there, what role they played and the confidentiality of
what went on and so on in order to get people to be able
to open up to things and talk about them. There was a
marked discomfort.
(107]
Q You mentioned you thought a hearing might be
disruptive. Wouldn’t it also be a serious disruption in a
child or an adolescent’s life to be hospitalized?
A I think I’ve said that.
Q I just wanted again to confirm it.
A Yes. It’s a serious disruption in a child’s life to have
a disorder.
Q Are children and adolescents, again speaking of
what you’re aware of in terms of statewide regulations or
variations among each of the individual 8 regional hos-
pitals, are they admitted under a specific time limit
category, in other words, for a set period of time?
A I think in all cases, and the hospitals are now trying
to make a particular statement, assuming after admission,
as to how long they think the child will need to be in the
hospital. As a generality, probably the programs we’re
able to offer in regional hospitals are most appropriate for
kids to come in and stay not more than 3 to 6 months. To
organize a program that can serve as a long term con-
tinuing useful service at the same time that is providing
for a fairly reasonable rate of turnover to deal with the
acute situations almost requires two different organiza-
tions. And, so in general I would say where we are at this
point, 3 to 6 months might be the general range that we
would aim to contain it within. There might be particular
—
ee. Se a a od ee
785 [109]
cases where beyond that and [108] up to a year would be
appropriate.
Q Are there any statewide either regulations or policies
within individual or any of the 8 regional hospitals for
informing children and adolescents of their rights as
voluntary patients under the specific Georgia code sec-
tions?
A Yes, this is standard.
Q Could you describe—
A The—No, I can’t describe in detail. Just before I
arrived here, the Advocacy Section of the Division Office
had to file a rights statement for adult mental health
patients in the hospitals. And, this little booklet is avail-
able, and as I understand it, is routinely provided to
patients when they come into the hospitals. It’s available
in all of the units and so on.
I think there has been some attempt to use this
with children, and it’s not written in children’s language.
Q Okay.
A But, the staff are well aware of the issues involved
and the rights.
Q Would a child—
A The rights booklet—are expected to inform children
of their rights.
Q Orally inform them, you mean?
A Yes.
Q Okay.
[109]
A Now, those rights at this point include rights to
have their clothing, rights to make telephone calls within
{109} 786
reason, correspondence, various and sundry things like
that. For children at this point we don’t include the right
to leave the hospital until parents say so, until the hos-
pital and parents agree. In that sense it’s different from
adults.
€ Specifically, concerning the right to discharge, in
other words—
A Yes.
Q Whena child—Would a child be told then what you
explained to me that should his parents consent and the
hospital also decides he should be released that he would
be released? Is that approximately what he would be
told?
A I couldn’t say. I don’t know that that is actually
conveyed to any child in that specific detail.
Q Again, we’re not talking about a written regulation;
we're talking about an understanding of what your under-
standing of what would take place.
A I guess what would come closest to regulations is
what’s in the law on that.
Q I'd like t show you something. This is a notice to
voluntary patients of rights to discharge. It’s dated
November the 4th, 1970; and it’s to J.L., one of the main
= It’s Exhibit Number 3 to the stipulations of
acts.
(110]
A Should I read all of it?
() Well, I just wanted you to glance at it. The named
plaintiff, one of the named plaintiff’s in this case, J.L.;
note there’s a signature down at the bottom of that page.
A Uh-huh (affirmative).
hbnd eu tee) pa ie a
787 [111]
Q By the name plaintiff. Do you feel—He was 7 years
old at the time he wrote that. Do you feel he could under-
stand that?
A No. i
( Okay. You mentioned the children’s rights, in
other words, a right to discharge would be conditioned on
a consent of their parents.
A Ifa child is in the custody of the parents, yes.
Q Assuming that his discharge is conditioned on
his parents’ consent, and his parents don’t want him and
refuse to take him, what position is the hospital in at that
time? And, again assume also the hospitalization is no
longer required for this child, that that’s the uniformed
consensus of the hospital personnel that are directly in-
volved. What would the hospital then do?
A I think probably the most appropriate thing the
hospital would do would be to seek to have custody re-
moved from the parents, if the parents are inflexible in
their attitude that they’re not going to take the child
back. Probably also the hospital staff ought to be in some
cases [111] sizing parents up and say it would be dis-
ruptive to send this child back to the parents in whatever
we might be able to do during the time the child’s been in
the hospital, it might at times be appropriate for the hos-
pital to raise the issue and initiate proceedings to have
custody removed.
Q Specifically, what person in the hospital—Let’s as-
sume a situation like that existed, and you said that it
would be appropriate for the hospital to check into having
the parents’ rights terminated, what person would be
charged with that responsibility, in other words, to
initiate action?
[111] 788
A I suppose it would be most likely the director;
within a particular hospital they may choose to have
somebody of a high administrative level take respon-
sibility. The unit director might delegate it to a social
worker or something of this order. I would think the
director would probably be the focal person.
Q Would that unit director have any guidelines or
memorandum directives that would speak to his role or
the role of another person within that hospital structure
that would say, “This is what you should do, you can do
in this instance to initiate this, contact this person.”’
A I don’t know of any guideline statements.
Q Is it your—Go ahead; excuse me.
A This is almost a new issue, because of the history of
where the hospitals have been and so on. A conservative
[112] view about disrupting family relationships which
has been promoted by the courts and all sorts of people,
mental health people have not been in the forefront of
perhaps of coming out and saying, “We ought to break up
families.”’
Q You mentioned the possibility in the future of
developing guidelines for periodic review. You touched
on that briefly before. Would you elaborate on that, in
other words, what you anticipate.
A What I anticipate is that the division will—I think
Doug Skelton has already sent out some requirements
that the hospitals have periodic review practices and
policies. I think probably—I think they all do. I’m sure at
some point the division will be reviewing all such policies
and exploring whether they seem sufficient, whether we
need a general formulation from the state about such
things.
acne
es
Sa ate oe
789 [113]
I was involved, as I mentioned earlier, in the
developing of a policy in confidentiality which has been
blocked from being put into effect because the Depart-
ment of Human Resources was behind us in developing a
department policy in confidentiality; and they didn’t
want to have us put one out that would be out of line that
would come out as a whole department policy. At some
point in the near future I hope they may get clear enough
on where they want to go that ours is going to go out as a
department policy on confidentiality. It deals with it in
some very broad general [113] terms, but has specific re-
quirements that each hospital, each unit, each mental
health center have its own policy and its own practices
within these general guidelines for effectuating a confiden-
tiality policy and seeing to it that all staff are informed
adequately in training in regard to confidentiality, And,
I’m sure we'll be doing similar things with utilization
and review.
Q Is there anyone who acts specifically as an advocate
for the rights of children and adolescents in state mental
health facilities within the Division of Mental Health?
A We have an Advocacy Office that has responsibility
to respond to any advocacy issues in regard to any patient.
Q In other words, their responsibilities go to the entire
patient population.
A Yes.
Q How many people are within the advocacy unit
that you mentioned?
A Three.
Q Is there any recourse or remedy for a child or ado-
lescent who believes that he or she has been inappropri-
ately committed? In other words, is there anything that
[113] 790
he would be informed of or any regulations, specific hos-
pital or statewide regulations that you are aware of?
A The rights booklet.
Q The rights booklet.
(114)
A Which is not written in children’s language and,
therefore, hasn’t been as useful in child and adolescent
services as adult services. It includes the advocacy unit
as a resource that any patient can call on. To the extent
that the child is able to understand either the booklet or
the verbal interpretation that’s given to him, the child
knows of the advocacy unit. He knows of his right to call
on them.
Q At present are all diagnostic procedures conducted
on an out-patient basis?
A No.
Q Okay, how—At present have you or your division
ever recommended a change in the child and adolescent
voluntary admission statute? In other words, any of your
predecessors or are you aware of anyone else in the past
within the Division of Mental Health who has made such
a recommendation that there be a change in this partic-
ular statute?
A I’m not aware of any, no.
Q Are you aware of any reports by any dependent
bodies or anyone within the division that address the
issue of the appropriateness of a ‘“voluntary”’ admissions
statute for children and adolescents?
A The only group that I think might have done that
would be the Child and Adolescence Study Commission
which functioned, I think, in ’73 or ’74 for about 6 months
791 [116]
and [115] made quite a large number of recommendations.
I don’t recall a recommendation with regard to changing
the statute being among the recommendations. But, it
might have been. I can’t say it wasn’t.
Q@ Do you remember any of the report that you just
referred to—Do you recall any of the recommendations
that were made by that commission at that time, specifi-
cally, that stand out in your mind?
A In general I would recall several, I think. One that
stands out clearly in my mind was there be no further
development of the community system until a lot more
study had been done, which struck me as the most asinine
recommendation that I’ve ever heard of in my life. Here
they were talking about improvements in the hospital
system but blocking any further community program
development—and completely ignored that reeommenda-
tion.
Others were primarily focused in some cases in rather
microscopic details about hospital services; that there be
better work with parents of children in the hospital; that
there be—I can’t say I recall others in specific detail. I
know I have reviewed it a couple of times since I started
in this position. And, I’ve seen we’ve made considerable
progress on a number of points. I haven’t reviewed it—
Q Can you be specific about the progress that’s been
[116] made on the number of the points that they raised
since the time the report came out, specifically with rela-
tion to the points in the recommendations?
A No, I can’t.
Q Okay.
A We have significartly reduced the hospital—We
{116} 792
have higher staff-patient ratios, because of the less
patients. We are providing much closer working between
the hospital and the community system with a lot more
continuing work with the parents of children who are in
the hospital.
Q Okay. were you aware of any of the findings that
that particular commission made in that report regarding
the population, the patient population of children and
adolescent units statewide?
A I have examined the report.
Q Are you familiar with their finding of the similarity
in the types of behavior that led to hospitalization and
state mental facilities with the types of behavior exhibited
by youths who were involved with the juvenile court as
juveniles, excuse me, as delinquents and status offenders?
A Iam aware of that as a general consideration. To
say that I remember it from the court, I can’t say.
Q Were you—
A It’s a truism that probably applies to most every-
where in the country.
{117]
Q Okay. Were you aware of the finding that that
commission made as to the percentage of children and
adolescents that were hospitalized that either had no
family or a severely dysfunctional family or in state
custody?
A lexamined it. At the time I was aware of it.
Q Going back just for a moment to diagnosis. Is it
possible for a psychiatrist to err in diagnosing a child or
adolescent, in other words, in their concluding he was so
seriously mentally ill as to warrant hospitalization or
institutionalization. Is it possible?
inline Caste. = Wnt RE ABEND 20 tas
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PE Be MBL RA ow De es EN Fe te ne ae Ot eet
793 [118]
A Yes.
@ Can the orientation and the training of a psychia-
trist have any effect on his diagnosis to make the deter-
mination of mental illness?
A I’m sure it can, yes.
Q Are there different schools of thought as to mental
illness concerning cause and cures which may strongly
influence psychiatric judgment? In other words, is it
possible that a psychiatrist would—Do you see what I
mean?
A I’m not sure I see what you mean. There are differ-
ent schools of thought that would lead some psychiatrists
to say the only way we’re doing any good is if we do it on
a very long term intensive treatment and to reject and
derogate any treatment that doesn’t fit that pattern.
There are other schools of thought that would say
[118] the reverse. There are other ways that are important.
Q That’s what I was getting to. Can the context of a
psychiatric evaluation have an effect on the diagnosis?
In other words, if the diagnosis was being made let’s say
in a community treatment clinic as opposed to right
within the hospital itself, can that have an effect?
A Yes, I’m sure it can have some effect. I think since
most diagnosis is based—Well, the diagnosis is not finally
assigned until a significant amount of time has gone by
and a fairly complete evaluation is made. You may make
a preliminary diagnosis.
Q Uh-huh.
A And, that might be conditioned by the circum-
stances under which it’s made. But, within a particular
school of thought when an adequate evaluation is done, I
(118) 794
doubt that it would make—well, a fairly small amount of
difference.
Q Does a single unstandardized interview by a psy-
chiatrist—the results of which assuming a psychological
testing supplements—present an adequate sample of this
person, of his possible potential patient’s behavior?
A In some cases it can be an adequate sample for at
least initial decisions. You’re asking a question that is
just as applicable in general medicine.
Q Okay.
A When you take a history; you do a physical exam;
{119} you do preliminary lab tests. All that may indicate
is that the person needs to be in a hospital for much more
extensive testing.
Q Okay. Is it possible that a psychiatric judgment
may be influenced by the socio-economic background of
both the doctor and the patient, the doctor’s value sys-
tem, personal preferences, these types of things? Is it
possible that they would influence a decision?
A There are some good studies in the past that have
pointed very clearly in that direction. There have been
some more recent challenges, recent questions as to how
true it is. I think it’s possible, yes.
Q Based on the questions and the answers you have
given to these last few questions, considering the factors
that we’ve discussed that might influence particular
doctors, isn’t it possible that doctors could disagree on,
fer instance, the severity of a mental illness or the label
of a mental illness that would warrant hospitalization?
A Yes.
*_*s* © *
aati scion 2
795 [2]
(1)
IN THE UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF GEORGIA
MACON DIVISION
(Caption omitted in printing)
Deposition of DOCTOR LUCIANO L’ABATE, taken
on the 15th day of December, 1975, in the offices of
Georgia Legal Services Programs, 15 Peachtree Street,
N.E., Atlanta, Georgia, before Jean M. Wall, Court
Reporter T-24, 1521 Mercer Way, Decatur, Georgia
APPEARANCES:
For the Plaintiffs: DAVID GOREN, ESQ.
Georgia Legal Services Programs
Macon Regional Office
653 Second Street
Macon, Georgia 31201
For the Defendants: DOROTHY Y. KIRKLEY, ESQ.
Assistant Attorney General
Department of Law
132 Judicial Building
Atlanta, Georgia 30334
[2]
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 witness was advised of his right to read and
sign his deposition, and he specifically waived
that right.)
[2] 796
DOCTOR LUCIANO L’ABATE, HAVING BEEN DULY
SWORN AS A WITNESS, TESTIFIED AS FOLLOWS:
EXAMINATION BY MR. GOREN:
Q Please state your name and address?
A My name is Luciano L’Abate and I live at 2079
Deborah Drive, Atlanta, Georgia 30345.
NOTE: (Plaintiff's Exhibit Number One was marked for
purposes of identification. )
Can you identify Plaintiff’s Exhibit Number One?
This is my curriculum vitae.
What is your profession?
er O &
I am a teacher.
Q And could you describe for us essentially—excuse
me, what do you teach?
A I teach psychology in the Department of Psychology
at Georgia State University. I’m also Director of the Child
Development Laboratory in The Family Study Center,
and I’m Director of the Family Study Program — the
Ph.D. Family Study Program in the [3] Psychology De-
partment of Georgia State University.
Q Okay. Are you also in private practice?
A Yes, I’m also in private practice . . . and I practice
mostly of marital and family therapy.
Q What is your educational experience?
A I have a Ph.D. from Duke University and a Post-
Doctoral Fellowship with USPHS—United States Public
Health Service, at Michael Reese Hospital,; Psychiatric
and Psychosomatic Institute. I have been essentially work-
ing in a hospital—in hospital-like places since I was grad-
ee eee 2 we ee =
797 [4]
uated from college—from Tabor College in 1950. I worked
for a whole summer as an attendant in Canadian Psychi-
atric Hospital. Then during my work toward a Masters
Degree at the University of Wichita, Wichita State Uni-
versity, I worked as an attendant in a psychiatric ward
of a general hospital, Wesley Hospital; and since then
I’ve been associated with Duke University School of Med-
icine, Michael Reese Hospital, Washington University
School of Medicine, Bernard Hospital, which is the psy-
chiatric hospital. From 1959 through 1964 I was con-
sultant to St. Louis State Hospital, which is a state psy-
chiatric hospital in Missouri. I was Chief Psychologist,
Department of Psychiatry at Emory from 1964 to 1965.
From 1965 through 1973 I was Director of the Psychol-
ogy Laboratory in the Department of Pediatrics at Emory
University School of Medicine. I’ve been in my present
position at Professor of Psychology at Georgia State
since 1965.
Q Okay.
A In 1965, and since then, I’ve been consultant to
Alto Juvenile [4] —Juvenile Institution for First Offen-
ders, I’ve been consultant to various school systems, vari-
ous private schools, and hospitals, and I’m presently on
the current staff of Tucker’s Doctors Hospital.
Q Have you had any publications or articles?
A Yes, I’ve had a few publications, and they are in
this list here.
Q In your vitae?
A Yes.
Q Have you had any articles published specifically
referring to children?
[4] 798
A Approximately fifty percent of my articles deal with
children. In the last few years, I’ve had fifteen, twenty
publications dealing with children and the family mostly.
I’ve recently published a book, Teaching the Exceptional
Child, which is a standard textbook in colleges in the
United States.
Q Okay. In your experience have you ever been called
upon to observe and evaluate a child’s behavior in regard
to his or her parent’s request for help and possible hos-
pitalization?
A Hundreds of times, and in my practice I’ve eval-
uated upward of approximately five thousand children.
Q Is it your experience that problems which lead
parents to seek hospitalization of their children can be
traced to family difficulties and not just the illness of the
child?
A Well, it depends on the nature of the illness. If
you're talking about a severe organic problem or in terms
of extreme retardation, in some cases I—especially if it’s
clear that the child not only detracts from the family’s
function and ability [5] as to the stress, clearly that might,
in some cases, be relevant of hospitalization. Outside of
these very extreme conditions, I don’t consider hospitali-
zation as a viable alternative.
Q You think that family difficulties have something
to do with these other problems with the children?
A Well, one way or another, all of us live in a context,
and to deny that context, which is the family, I think,
is a grievious, theoretical, emperical, clinical mistake.
{ What types of dynamics exist which could con-
tiibute to psychiatric problems of children?
799 [6]
A As I see it, in terms of what the outcome I’ve seen,
in the kinds of cases that I’ve studied over the years,
seem to be based on the parents inability to deal with
their own selves, and their own marriage, so that they—
either inadequate or the relationship between themselves,
which is their marriage, makes it very difficult to deal
with a child, and if they do deal with a child, they deal
in inappropriate ways, mostly negative, it will eventually
produce negative behavior on the child, because that’s all
he has learned.
Q Are you familiar with the term scapegoating?
A Yes.
Q In what way, if any, do you see that or any other
types of interactions relevant to a child’s psychiatric
problems?
A Well, I see scapegoating as based on mechanism
which I personally call externalization, which I think has
experimentally been found in a work of a social psycholo-
gist, especially I refer to the work of Duval and Wick-
lund, which published in 1972, and they were able to find
two different kinds of awareness. One [6] they called sub-
jective awareness, the other one they called objective
awareness, and they discovered that fairly well consis-
tently people see two different—these two kinds of aware-
nesses. The objectively aware individuals are able to see
themselves as part of any kind of interaction. The sub-
jectively aware individuals are individuals who cannot
seem to realize the impact on others. And their work
pretty well would seem to agree with hundreds of studies
done by a fellow called Witkin, which divides individuals
between feel dependent and feel independent, and the
work of another psychologist called Rotter, who talks
(6) 800
about internalizers and externalizers. And essentially they
seem to be talking about the fact that there are individu-
als who really are externalized in most of their percep-
ions, most of their behavior on outside sources and out-
side targets, so my general feeling, which is—theoretically,
I think, can be empirically demonstrated. Most of the
parents of children who have problems are individuals
who will fall in the category of subjective awareness. They
don’t seem to have an awareness that they have an impact
on a child, the child’s behavior or pathology is in some-
way related to their own pathology.
Q When you’re going to evaluate a child’s mental con-
dition, who is the primary source of information on the
child?
A Well, let me think—I think that’s an important
question. Let me answer in terms of the fact that for
twenty years I did just that, evaluated children, and
evaluated hundreds and thousands of children as a child
clinical psychologist. My awareness, in working with chil-
dren and doing therapy with them [7] as individuals, and
by-passing the family, and not obtaining results, got so
extreme that I finally quit doing what I was traditionally
doing; that is, evaluate a child and then report the results
to the parents, because I found that I was part of what
I would call a collusion, the collusion that the parents had
in making the child the scapegoat, making him what is
called the identified patient. And before I was agreeing
with them by evaluating him as a patient, I was agreeing
with them in that he was the problem. Since 1972 I have
pretty well quit evaluating single children, and I only will
evaluate the child with the family, and if the family is
not willing to come in as a whole family, that is children,
siblings, and so forth, I will not see that child. So I have
801 [8]
drastically revised my practice. This is why from child
clinical psychology practice I am now working mostly
with the family or the parents. That is why I am a mar-
riage and family practitioner.
Q Whois the primary source of information about the
child when you are going to work with the family?
A Mostly the mother, is mostly the major source of
information.
Q In getting these principles of subjective awareness
that you described for us, could those circumstances cause
a mother, or both parents, to mask their true feelings and
distort or misperceive facts concerning their child?
A Very much so. I don’t only think just the parents
do this, I think there is plenty of research to indicate
that many people who are interviewed, including schizo-
phrenics, will very much depend, because of the feel de-
pendent orientation of people who seem to be more vul-
nerable to mental illness, that they [8] will look at cues
into the interviewer, and they will try to fit and please
the cues the interviewer gives, and I suggest the work
of the Braginskys — Braginsky, Braginsky and Wren,
1969, that indicate that’s a process that goes — that is
present in many interviews; that is in many cases the
clients want to appear sicker than they really are, espe-
cially at first blush, which is usually the first interview.
So there seems to be assets, for many people, and the
parents of children who have problems do not differ in
terms of wanting to make the child sicker in some cases
than he is.
Q Okay. In trying to ascertain what is really going
on in a family situation, given these problems that you’ve
just described, is it difficult for mental health professionals
[8] 802
to try to understand exactly what the true facts are in a
given situation?
A Yes, it is difficult. In some cases it takes years, to
work with the family, to get all of the information. This
is with most cases, treatment consists of finding—I would
not call facts, but all of the various relevant skeletons
that there are in a closet in which many families keep
very, very close locked door on.
Q Would these difficulties be increased if-the person
who is doing the evaluating had difficulty with the lan-
guage of the—say the child, or the family, that the per-
son evaluating—or was not familiar with the cultural
background of the person that he’s evaluating?
A Well, all I can think about is my experience, and I
know that I clearly see a certain kind of families, and
I’m more successful with some of them than others, and
I would presume if they are [9] middle class American
Protestant, as an Italian Protestant, I would say I have
much better luck working with them, than, I’d say, if it
were some other kind, so clearly there i is a great deal of
research to indicate that the closer the similarity between
the therapist and the client, that the better the chances
of therapeutic success. So there is a similarity factor in
there too, which indicates that I would be very unsuited,
and I’m sure I am, to work with certain kinds of families.
Q Okay. In your experience, have you found that it
is possible—that there will be occasions, when, for the
best interest of the child, he or she will have to be re-
moved from the home?
A If four or five different other kinds of things fail.
In other words, I see the removal from the home for what-
ever reasons, whether it’s foster home or hospital, as be-
803 [10]
ing the result of extreme failures of trying other methods,
and we do have at this point, a significant technology of
a variety of procedures that can be worked out, so I
found, really, no excuse to jump from a child in a home
to away from the home, unless four or five different pos-
sibilities have been explored, and there are many of them.
Q Are you saying that these possibilities ought to be
explored before hospitalization?
A Definitely. Definitely.
Q What kinds of possibilities?
A Well, first of all, the reports from teachers working
in the school, the classroom with the parents learning how
to manage the child, behavior modification procedure, to
train them to use positive rather than punitive approaches,
structural methods [10] of dealing, of enrichment of meth-
ods that we have developed to work with families, of
classes for the parents to take with other parents, like
P.T. There is a tremendous amount of preventive ap-
proaches that are available these days, that parents can
be and should be in a way forced to take if the alternative
is clearly, you know, take the child away. Before you do
this, the parents should be forced, in a way, to partake
and learn more about what it takes to be parents.
Q Suppose there is a situation where those types of
things have been attempted, is then the next alternative
hospitalization?
A It would be very difficult. It would depend on what
alternatives, with whom and so forth. It could be, but it
seems to the hospitalization, in terms of the work of
Skeels, it’s really, to me, like a sentence of death. I think
Skeels’ work clearly indicates, in his follow-up of chil-
dren who were hospitalized and children who were not
[10] 804
hospitalized, very clearly indicated, that if we hospitalize
infants or children, the outcome is going to be really,
diliterious, and that it’s better, let’s say, to put children
in foster homes. So for instance, if you had another choice
in terms of taking a child away, well, then, it would be
that the child would be in a foster home, and hospitaliza-
tion be, let’s say, the outcome of failures in fostering, in
taking care of the child, or even halfway houses or cluster
homes. We know that the whole State of Tennessee, for
instance, has been able to do away with hospitalization
through the model of what they call the—the rehab model,
so that that work, I think, is important [11] to indicate
that hospitalization should only be the result of failure
in a variety of alternatives, that we have in many, many
cases failed to explore and use to the fullest extent.
NOTE #300
Q Okay. Do you believe that because of problems that
may be within the family itself, the parents can at times
act against the best interest of their children in seeking
their hospitalization.
A Oh, I think there’s enough literature to support
that. If we all take the literature on the battered child
syndrome we realize that, first of all, it does happen, and
secondly, that of course unfortunately many of the bat-
tering parents were battered children themselves, and I
think there is pretty much that kind of vicious circle in-
volved in—in many parents have been unable to become
full-fledged parents and know how to parent, because
they did not have any better parenting themselves.
Q Is it also possible that parents may seek to hos-
pitalize their children, and that that hospitalization would
be against their best interest?
A The parents? It seems to me it’s evident, because
first of all, my accepting a child in the hospital or taking
805 (12]
the child away, we are agreeing that that child is a patient.
Well, by doing this and agreeing with the family, we’re
essentially colluding with the family, and we are agreeing
with them that if the child’s behavior changes, the family
will be okay. Well, to me that is the position that is log-
ically and emperically impossible, because, what we’re
really saying is, if the child is a product of a system, which
is the family system, then the whole system [12] has to
change together with that child. However, if we take the
child away then we’re also agreeing that the system will
not change. And this is what I’ve seen for twenty years,
and this is why I finally gave up my practice of dealing
with the child. When I took the child in treatment, the
rest of the family said we’re okay, they took that com-
munication to represent that we’re okay. When I con-
fronted the rest of the family, “Hey, this family has to
change,” the... says, ‘““Now wait a minute, he has to
change, we don’t have to.’”’ And so hospitalization with-
out attention to the family, is a red herring. It’s a... We
agree—we agree with the family that the child is the
patient, is the problem and that they should not be
considered.
Q Okay. Do you have an opinion in regards to whether
or not mental health professionals can make errors in
recommending hospitalization of children?
A In terms of emperical data—in terms of the spe-
cific problem of hospitalization versus non-hospitalization,
I don’t know that we have data to support it. I do know
that we have hundreds of papers of a hundred diagnostic
witnesses we have in our every day life, so I am perfectly
aware of the fallibility of our diagnostic labels, our own
diagnostic tests, and in many cases our tests that we use
in clinical psychology are not better than the criteria we
[12] 806
use, which are mostly psychiatric diagnosis, and realize
that any time we have that kind of criteria in our tests
they are really not very good.
Q Are there any tendencies that may be inherent in
screening done [13] by mental health professionals which,
for instance, may cause them to over-diagnose mental
illness?
A That is definitely one of the major aspects, especially
in psychological reports, many content analysis is made
of psychological reports indicate that we tend to over-
emphasize liabilities and limit the assets.
Q Were you present at Daniel Offer’s deposition?
A Yes.
Q And are you also familiar with his work of the Psy-
chological World of the Teenager?
A Yes, I reviewed it in General Personality Assess-
ment, 1970.
Q What is your opinion of his statements in that book
and his testimony in regards to the voluntary commit-
ment of children in mental hospitals?
A I’m sorry, but I really fail to see the significance of
that work in terms of the issue of hospitalization. His
sample was drawn from what I would consider forty-
eight percent or fifty percent of the population, that was
the middle class population. That means that any of these
figures that are present in this book, have to be halved—
cut in half, to have any kind of statistical significance, so
that if he says there are three types of adolescents, well,
first of all he eliminated out of his sample twenty-three
percent of the adolescents that would have troubles. Well
they were not part of his book. Well, these are the kinds
of adolescents that indeed would have trouble and would
807 [14]
come up for some kind of psychiatric or mental health
evaluation. The other three [14] kinds of adolescents that
he describes, the continuous growth, surgent and tumul-
tuous growth, which have twenty-one and thirty-five, I
think, and twenty-one percentage of his sample, in terms
of the fact that he took a sample from fifty percent of
the population clearly indicates that any kind of generali-
zations can be made from those samples as to half of the
total sample. In other words, any kind of conclusion he
makes in terms of the general population, would have to
be—if you take—if you total that up you get seventy-
seven. Well, actually half of that would represent any
kind of generalization for the general population. Fur-
thermore, it would not address itself to minority groups
except—it says fifteen percent for his sample. But lower
class was eliminated, upper class was eliminated, so there
are a variety—well, it’s clearly urban sample, so despite
all the problems of mental health of the adolescent, that
book, in my personal opinion, seems to be irrelevant to
the issues.
Q Are you saying he also found that twenty-one per-
cent of the group that he studied exhibited adolescent
turmoil?
A Yes, in fact he did consider that the tumultuous
group, which is his third group, which had tremendous
ups and downs, also had twice as much counseling and
psychiatric referrals as the next group, which was the
surgent, which was the major thirty-five percent, with
the continuous grow group of twenty-one almost have no
referrals whatsoever.
Q And in spite of this high and low swings that he
described for this group, he still considered these boys to
be normal, is that correct?
808
[15]
A Yes, indeed. Yes.
Q Do you believe a hearing prior to commitment is
necessary for the non-emergency admission of
a mental hospital? srroe
A I think it would be helpful. It would be certainly
at this point, as things are, imperative.
Q Why is that?
A Because I feel that as things are, the best interest
of the child lie in due process, and if there is no due pro-
cess, that is if there’s no attention to the child’s rights
I don’t think that even the mental health profession are
aware of what these rights are, and in many cases due
process 1s not really followed. In some cases attention
may not be given to distortions in the parents possible
biases in the mental health personnel, especially as if
they have an investment in filling the hospital beds. If
state allocations are made on a basis of how many patients
are there, or how many criminals are, then we’re dealing
with a system which has an investment in numbers of
people admitted, and I as a teacher, have an investment
in people coming to Georgia State, because if there were
not enough students, I would not have a job. So it seems
to me that people who are in hospitals, and work in hos-
pitals, have an investment in having patients, and that
in itself, is to me a fact that speaks for itself.
: pag do you think a hearing could be beneficial for
A Well, first of all there would be safeguards of com-
plete evaluation. If we’re talking about a successive
kind of approach that is various alternatives. then you
have all the [16] information of people who have been
809 [17]
involved with the family, let’s say a study of the family,
of the home situation, a history. There would he a va-
riety of mental health professionals, not just one or two
single ones. There would be different professions present.
There would be the history of the attempts to deal with
that child and the family with all of the possible failures,
so that we would make sure that various alternatives and
various . . . be present, and the people who have partici-
pated throughout the process be there to address to the
issue of hospitalization. So that at this point, then, the
hearing would guarantee that a variety of viewpoints be
heard, which in a way would correct the children, so that
there is the guarantee of checks and balances which at
this point, as far as I know, is absent.
Q Is it necessary for a child to have an advocate?
A 1 think it would be extremely important. I'd like
to bring to the attention the book on Child Clinical Psy-
chology by Williams and Gordan which I have reviewed
recently, I think it is still to come out of the press, in
which this viewpoint of advocacy for the child is very
strongly emphasized by most of the authors in that book.
Q Do you think that, for instance, personnel who work
for a state mental hospital or who work in a state mental
health clinic, could act as advocates for the child? Or
would it have to be someone outside that system?
A Oh, I would say they should have somebody out-
side, because [17] clearly we are as limited aspects of our
own profession as any profession is, and I would certainly
feel much more comfortable if the legal aspects, the rights
of a child, be safeguarded by a non-mental health pro-
fessional.
Q Okay. Do you think that even if a child is deter-
[17] 810
mined to be in need of hospitalization, that it’s necessary
to have a periodic review by one independent of the
hospital?
A Well, this, I think, would be part of the process, if
there is an advocate which is not mental health oriented,
then he would not only be objective, but he also would
make sure there would be a periodic review. I think that
this is one of the frightening aspects of hospitalization,
that once the child is put behind doors, he is forgotten,
and is forgiven, and that trauma at that point is really
followed by the trauma that perhaps nobody else will
care for him, and no matter how therapeutic the hospital
may be, some link to the outside world still would be very
important to have.
Have you had—I believe you mentioned you worked
at Alto, is that right?
A Yes.
Q And therefore you are familiar with the behavior
of persons who have been labeled juvenile delinquents?
A Yes. I also worked as a consultant to Coweta County
public schools where I was given to work with the most
serious offendant in the system—the school system, in
addition to Alto. (sic)
Q Okay. And have you been made aware of any sit-
uations where parents [18] filed petitions in juvenile court
to get help for their children whom they consider unruly
or incorrigible?
A I’m aware there must be some kind or process. Ac-
tually, I’m more aware of the fact that the parents will
let go many situations until the child is in so much trouble
that he himself will call attention to the problem. To me
= ae
811 [19]
that is the—most—most of the process is done by omis-
sion rather than the parents themselves committing the
child. They’ll let the problem go until the child gets in
trouble.
Q Have you been able to compare the behaviors of
persons who are labeled juvenile delinquents with the
behavior of persons or children who are labeled mentally
ill?
A The only thing that Isee that kind of behavior, is
that the mental illness manifested itself in criminal be-
havior. In some kind of social strata that will bring at-
tention to the police. In the middle upper class youngsters
I’ve seen and I still see in my private practice, there is
some protection in a sense that if the police picks up the
son of a middle class white child, they will probably try
to protect that child in many more ways that just put-
ting him into the legal procedure of declaring that child
a criminal.
Q Do you see any similarities between the types of
behaviors that lead one to be labeled mental delinquent
and one labeled mentally ill?
A Anytime I examine, and I’ve examined, I forgot
how many juveniles at Alto, everytime I examined them,
if I had been blind to the fact that they were in an insti-
tution, I would have probably agreed to put on them
some kind of a psychiatric diagnosis.
[19]
Q So there are similar behaviors?
A Well, if they are not similar, there is a tremendous
overlap.
Q I have no further questions.
[19] 812
EXAMINATION BY MS. KIRKLEY:
Q Are you a consultant at Alto?
A 1 was for a year.
Q Alto is not for juvenile delinquents, is it? Isn’t it
for youthful criminal offenders?
A Yes.
Q Sentenced by the Superior Court...
A Yes.
Q ...rather than juvenile delinquents sentenced by
the Juvenile Court?
A lam not familiar with all these aspects, but I know
they were criminals, yes.
Q Okay. I think as you reviewed your private prac-
tice in the last few years, perhaps since 1972 explicitly,
you said that you had started to look at a child in the
context of his whole family and to threat the family
rather than just one individual member of it?
A Uh-huh. (Affirmative.)
Q Do you have any evidence that the Georgia Public
Mental Health System treats the problems of children
any differently than you do?
A The only knowledge I have is that most of the—
that some of the system in some cases, follow the tradi-
tion of team approach, in which you have a psychiatrist,
a social worker, [20] and a clinical psychologist in which
the child is evaluated, and then «a history is obtained
from the parents and so forth, so that although I’m aware
that in some mental health clinics, the families are being
seen, and the identified patient is seen together with the
Qc Vr A ewe Oc Oe 2a >
813 (21]
family, I’m also aware that many of these practices vary
from clinic to clinic and from individual to individual.
That’s the best I can tell you.
Q But you are familiar with the practice in some clin-
ics that try to treat the family?
A Oh, yes, definitely. There is some of it. I’m aware
of the fact that at least at G.M.H.L., they still will—in
the children’s ward, which I visited as recently as six
months ago—they still will accept a child individually
and not require treatment of the rest of the family, so
that, again, they will—they will accept the child but not
foree—you know, make sure that the family does get
treatment too.
Q But do you know that G.M.H.I. has a policy of not
accepting the child for non-emergency admission unless
there has already been treatment of the family in a com-
munity mental health center?
A No, I’m not aware of this.
Q So you are only familiar with respect to the hos-
pital admission decision, is what you’re saying?
A Right. Well, what I’ve seen as I visited and what
I asked.
Q What about emergency admissions? Do you see
some situations in which children need to be admitted
because they’re suicidal, for example, and then you would
treat the family later?
[21]
A I have not seen many suicidal children, so I really
can’t say that there was a kind of emergency that I would
deal through hospitalization.
(21] 814
Q But you can conceive of situations in which chil-
dren are so suicidal that that would be a treatment of
choice?
A I can’t say. I have not seen it. I would probably ,
before getting that kind of step, I would probably ask
the help of some other professional, I would ask a psy-
chiatric consultant to see whether we could use some
other medicines or drugs, which I—you know, I don’t. . .
() Isn’t suicide a leading cause of death in children
and adolescents?
A It’s certainly getting to be one of the high reasons
for it, yes. We have some of it. In whatever it seems to
be the possibility of suicides, and there are very few cases
I’ve seen, it’s the ultimate results of a child’s helplessness
in controlling the family, so I feel that in the midst of
the—what seems to be the reasons for the suicide, the
child—this is the child’s ultimate weapon, to blackmail
the family. Suicide in many cases, at least as I see it, is
a form of blackmail. It’s a very deadly form of blackmail,
and many adolescents will use threats of suicide, rather
that the actual suicide. Naturally, no family, on the basis
of threats is going to not do anything. They’re going to
try to deal with it, but in some cases, and I can’t speak
because I haven’t seen it that many, I prefer to still deal
and take the danger of the possibility rather than going
through the hospitalization. In some cases I dealt with
suicide with adults, and my answer to that kind of threat
is to call the police.
*x* * * * *
[38]
* * * * *
Q Are you familiar with the drop in the patient pop-
ulation in Georgia’s regional hospitals since 1964?
815 [39]
A Iam very aware of the drop at Central State Hos-
pital since I have visited that hospital once a year for
the last ten years as teacher of my exceptional child class,
and so that teaching those classes I wanted my students
to become very aware of the—you know, what happened
to our children, so I have regularly visited Central State
Hospital. My last visit, however, was not in terms of that
kind of teaching. I was there as a member of the board
and Vice President of Georgia Psychological Association,
so nonetheless, I certainly have been very pleased by the
changes that have occurred at Central State Hospital,
and I hope there are going to be much more, many im-
provements made. There are many to be made yet.
Q From this yearly examination of Central State Hos-
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