Harold Eist MD

Speech for the National Coalition of
Mental Health Professionals and Consumers

June 22, 2001, NYU Medical Center

The title of my talk is “Without concerted action, the great unrealized future of children’s mental health services will continue to lie behind us.”  It’s a little complicated.

In a recent address to the Massachusetts Psychiatric Society, Senator Edward Kennedy declared that President Kennedy made high quality, community based care to the mentally ill one of his highest priorities, introducing and ultimately signing into law an act to create mental retardation facilities and community mental health centers.  The special message to Congress on mental illness and mental retardation includes the words “we as a nation have long neglected the mentally ill and the mentally retarded.  This neglect must end if our nation is to live up to its own standards of compassion and dignity.  Today,” Senator Kennedy continued, “four decades later, we still struggle to meet the challenges President Kennedy posed.”

Senator Kennedy correctly asserts we fall far short of providing the compassionate and effective mental health care our citizens in need require.  Nowhere is this truth more glaring than in the cases of our children.

Over the past two decades, said Senator Kennedy, we have made great progress in determining the causes of mental illnesses and developing strategies to treat them.

Two decades ago, almost to the day, on a beautiful June afternoon, my daughter – a high school senior at the time, and now a tenured University professor – and I were in Senator Kennedy’s office in Washington, arguing with Senator Kennedy’s staff about the cost-effectiveness of psychiatric care and the significant cost offsets of providing prompt, high-quality psychiatric care.  For several hours, we were engaged in heated debate.  We brought charts that cost thousands of dollars to have commercially produced and as I made my presentation, my daughter flipped them

I’m tremendously pleased that now, twenty years later, the skepticism of Senator Kennedy’s staff has given way to a shared agreement on these critically important issues.  I know that my daughter’s disappointment at our not convincing the Kennedy staff that day would give rise to joy today.  She would strongly agree with Senator Kennedy that mental illness is a national crisis but our treatment of the mentally ill is a national disgrace.

I’m told that when the Japanese had destroyed Pearl Harbor, actress Joan Crawford said “Oh, dear.  Who was she?”  Regrettably, this sort of ignorance characterizes the lack of awareness of child mental health needs in America and the world.

We are appalled at the violence of children, but blind ourselves to the violence against them.  We choose not to see the violence of a society that treats only one in ten of its psychiatrically ill children and only provides one in three to one in five of these youngsters with appropriate and necessary care.

We don’t recognize that widespread social failures of empathy model insensitivity and communicate valuelessness.  Those who do not feel valued, those whose daily portion is misunderstanding, and who all too often receive harsh unfair judgment, will experience pain and withdrawal, or experience anger and learn cruelty and become anti-social.

We hide our sense of this behind the tenacious retrospective falsification that childhood is idyllic.  We tend not to see the sadistic cruelty to which youngsters who are perceived as different are subjected by their peers.  There is zero tolerance for children who make angry threats, but endless tolerance of the sadistic merciless teasing and bullying of those that are shy or seen as odd, off or mental.  Kids will be kids, we are told.  Children are resilient, we are informed.  They are indeed, and it is a marvel that so many turn out so well.

Winnicott applauded the fact that we have, since the end of the First World War, provided our kids with adolescence, a relatively new phenomenon in human development.  He cautions that the price of that adolescence would be a significant number of breakdowns, which would require treatment to allow for growth into solid, mature adulthood.

It is inexcusable that so many of our children flounder during development and unacceptable that too large a number of these youngsters do poorly.   A bi-polar youngster from a multi-problem family in one of the most educated and affluent counties in America had to wait for over two years for county services, even though the family was on Medicaid and was below the poverty line.  By the time she obtained the institutional placement she needed, she had run afoul of the law, she had abused drugs, had fractured her tenuous family relationships and had developed a negative identity.  She was bright, but had become foul-mouthed, defiant, and disrespectful of all authority.  In a word, a bad kid.  So-called “bad kids”, are angry at their worlds and their worlds are angry back and often, excessively punitive.

It all too often works the other way around.  Innocents are born into a harsh world.  They are born into a Harry Potter world. A world of infanticide and abuse, where the cruel Voldemort tried to kill the infant Harry Potter after murdering his parents.  After that, Harry lived a life of abuse, neglect and ever-increasing danger.  We’ll find out what happens to him in Volumes 5, 6, and 7.  Little wonder that these novels have such universal appeal with virtually every child and the child in every one of us resounding to their theme.  It simply rings true.

The Oedipal myth is as alive today as it was in ancient times.  Its enduring and universal appeal and pertinence will assure its perpetual existence.  It is often forgotten or ignored that this story begins not with the threat of a child against a parent, but with the murderous threat of a parent against an infant, who later begets violence.

Since the beginning of history, humankind has been violent.  From the dark ages to the nineteenth century, infants and toddlers were denied both childhoods and adolescences as they moved at age 5 or 6 directly into the workforce where they either survived or died.

The move to regulate child labor began in England, where the very young children were being exploited in mining and industrial work.  In 1802, a law was passed aimed at controlling the apprenticeship of pauper children to cotton mill owners.  It proved ineffective because it did not provide for enforcement.  This was not corrected until 31 years later, in the Factory Act of 1833.

It is a shame upon our dignity that in a nation that spawned the healthiest document for freedom in human history, we have not heeded President Kennedy’s forty-year-old plea to free our children from mental illness.

In fact, since the advent of managed care, the state of our children’s mental health has worsened.  Fewer children are now being treated, and recently in the nation’s capital, a child psychiatry-training program was shut down by managed care.  The managed care companies have adopted the attitude of the Mafia don in Mario Puzo’s novel “Omerta” who says, and I quote “Children are useless and live by our sufferance”.

A taxi driver in Boston taking my wife and I to the home of a colleague during my campaign for the APA presidency, with his heart and soul was complaining about his HMO.  My muted and sympathetic response led to his describing a discussion he had recently overheard in his cab between two men who he guessed where from the insurance industry.  One he reported said, “If it was your kid you wouldn’t complain about a million dollars being spent on his health care”.   He became indignant as he repeated the reply of the other passenger, “no kid is worth a million dollars”.

DeMause presents a psycho-historical perspective on the treatment of children dividing it in to an Infanticidal stage until AD 400 when killing unwanted children was acceptable through an Abandonment stage during which it was no longer acceptable to kill children, but it was acceptable to abandon them. Abandonment, as exemplified in the “Three Little Pigs” fairy tale, gave way to an Ambivalent mode, in which the task of parents was to shape or mold their children. This was replaced by an Intrusive mode, then a Socialization mode, and finally after the Second World War, a Helping mode.  According to the DeMause, the Helping mode is the first time in history that the needs of children were placed ahead of the child meeting the needs of the parents. Clearly all modes are active and present though there may be a shift in the direction of increasing beneficence.

The deplorable state of mental health care and other care for children in America finally reached at least a threshold level of awareness at the end of the last Clinton administration with the passage of the State Children’s Health Insurance Program or SCHIP.  Under this program, the number of children under 18 without health insurance decreased from 15% to 14%.  We applaud this small advance, but need to emphasize that without a true Patients Bill of Rights most insurance plans will discriminate against mentally ill children and provide inadequate treatment coverage.

In most instances going from the ranks of the uninsured to the ranks of the insured is a cruel hoax that raises false hopes, since there never, never, ever, ever has been adequate coverage for the care of children. Those needing services and their families have suffered endlessly and those struggling to serve them have had to deal with frustration, anger, and demoralization.

Little wonder then, when the “storm troopers” of managed care banged down the doors, attacked our professional dignity, and our institutions, that many of us just gave up.  Little wonder that after years of continuous neglect and gross and subtle abuse, all too many of our leaders and role models surrendered too quickly.

Having learned that bad things can get worse, we understand the importance more than ever before of advocacy.  We understand now, better than before, that we can never stop advocating for the needs of children in our profession.  We understand we must do this for current and future generations importantly even if we have to endure repeated defeat, something we have generations of experience at.  We have to fight to keep the spark of hope within ourselves alive.

Too many of our colleagues, particularly those entering child psychiatry practice feel abandoned by their leaders and elders and live with professional anomie.  I speak of leaders of all levels of our society.  In our legislatures, in our universities, and in our professional organizations.  What an appallingly sorry record we all have.  We must keep our indignation alive to battle our defeatism and professional dysthymia.

Our indignation must energize our unrelenting efforts to guarantee the building of a caring and responsible social accord that assures that all children will get the passionate care they require and deserve.  Thank you.

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