Delivering Children’s Mental Health Services – Part 1 Public Health Model

An Innovative Public Health Model

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Abstract

If one is trying to set up a service that’s relevant to a region or a city, completely or almost from scratch, one has to roll up one’s sleeves and be prepared to work very hard for some time – if necessary, all alone.

The Hamiltoni Public Health Department, the venue in which an innovative Children’s Mental Health Service was soon to be situated, is downtown, across the street from the railway station, next door to the ‘Y’ and within easy walking distance of city hall and one major hospital. For several years, the farsighted people of Hamilton had maintained a city-supported clinic for ’emotionally upset kids.’ It had been running sleepily, in very low profile. The year was 1965:

A nice old GP, Dr. Church, was its head. He accepted school referrals and did some play therapy. The Junior League of women, in true form, had provided a beautiful, handmade doll-house. This old gentleman had just retired and quickly moved far away, so we never met and talked together. His staff consisted of a self-trained, but highly experienced lady social worker (off on extended sick leave) and a psychologist confined to psychometric testing by his own proclivity. He too was on his way out, slowly, commuting irregularly from Toronto. The third staff member, effectively in total power over intake, was a city-hall secretary, an old-timer who had been ‘put in Coventry’ at the Health Unit for abrasive conduct. She was disgruntled and almost openly hostile to the young upstart – me. The clinic’s way of doing things was as in the standard office practice of the day: parents were spoken with at the clinic over several weeks by the ‘non-directive’ social worker, children were examined by the doctor and tested as needed by the psychologist. A brief report was written to the referring agent (usually the Board of Education, rarely the Juvenile Court). Virtually nothing specific vis a vis therapy was recorded. No research was done.

Now, if one is trying to set up a service that’s relevant to a region or a city, completely or almost from scratch, one has to roll up one’s sleeves and be prepared to work very hard for some time – if necessary, all alone. And to write an account of such, one must present hard facts embellished with anecdotes and personal opinion. I think the later may be of great help to the clinical reader. Thus, this booklet consists of general facts and methods in ordinary print and endnotes and personal experiences in italics, indents and endnotes. Its intended audience is any physician charged with establishing a service (any kind of service, not just child psychiatry). It also will be useful to the lay-administrator inclined to enable such.

Upon my arrival, there were upwards of 600 children on the waiting list – most of them ‘exports’ from the school system. Nothing but names, no preliminary data. The Director of Education, Dr. Price, expected me to settle right in as things were. He had a phalanx of Pupil Adjustment Officers (an obstructive layer of distorting bureaucrats, as I soon found out) who ‘by long tradition’ made most of the referrals to the clinic. The school nurses, all Health Unit PHNs and case-finders in other medical areas, were very pointedly excluded from seeking consultative help or making outright referrals. The question was: To settle in to a cozy job for 30 years, or to do something new? To act or not to act? What to do?

It seemed that a steel-city of 300,000 that had the vision to operate its own clinic for disturbed children deserved better – something that would touch every part of the community. The schools certainly, but perhaps yet more? This tiny clinic, as it was, might just as well be located in any hospital’s out-patient department. And further, should not any clinical service within a public health (PH) venue at least pay lip-service to the notion of prevention? How could that be done? Certainly records encompassing a wide, easily tapped database must be part of it. And what should the service be called?ii Was not the departure of the old guard the ripest time to make changes? While pondering these questions and ideas and beginning to explore those of other key people, I promptly began to set up a deliberately undefined, one-man something-or-other as a frail stopgap.

As little could be made out from the waiting list and as I did not want to get locked into a preset model, my hunch was to simply make myself available and keep my eyes open. Hints upon how to act would come. And interventions could be flexibly expanded or contracted as opportunity availed itself.

On the third day of my tenure, came an emergency call that, wrapped in the same package, presented a challenge to my authority as well as offering an opportunity to open up the debate to all stakeholders. The principal of a big high school phoned the Medical Officer of Health (my nominal boss) – to send me out to his school immediately. “Get him out here right away! A student has hung herself in the washroom,” was the message. I immediately called back the principal. He sounded both stridently upset and authoritative. I asked if she was dead or alive. “No. She’s disappeared.” And quite clearly no search beyond the school had started. “Do the parents know?” “No.” The principal was terrified of informing the parents. So, surmising that this was a paralysing staff crisis – an opportunity, among other helping things, to do some on-the-hoof self-serving PR work – I ascertained that the school nurse (one of our PHNs) was still out there at the school, and suggested that the principal get her and all concerned teachers together, and I’d be right along. But first, thinking that admission of the girl to hospital might be timely, I called the police to start an area search. Then, in a moment of inspiration, I requisitioned the mayor’s own special car and driver to get me to the school fast and in style. To make a long story short, the PHN and I had a fast crisis conference with the school people, went out to the girl’s home and met with her parents, found the girl before the police could, and drove her to hospital. The PHN stayed with her. Then I went back to the school and did some mop-up work. Three hours, in all, well spent.

The young patient and her family got direct emergency treatment and the teachers (even the police) got a taste of tidy, once removed, front line crisis intervention. Word went up and down and sideways.iii iv The press somehow heard of this episode and, using discretion re privacy issues, credited Mayor Vic Copps for the fine usage of his taxpayers’ car. Not least and in the plural, the public health nurses got some long overdue praise and recognition. And the children’s clinic, such as it was, was poised (at least in my mind) to expand in a new and more relevant direction. Incidentally, this was the first of a long line of ‘roving casualty clinics’ oriented to both active treatment and prevention simultaneously, with front line consultation and on the spot learning thrown in for good measure. It called for professional know-how more than bricks and mortar. It was the best possible model for the delivery of children’s mental health services custom made for a bustling steel-city.

The ‘roving casualty clinic’ idea clearly embodied community outreach, crisis intervention, the family group orientation and on the spot education of front line workers. It seemed perfectly tailored for child and adolescent prevention in a public health setting. The public health nurses could easily and naturally tune in to going out into the community. They had been school nurses for decades. Visiting homes to do maternal and well-baby checks was in their tradition. All that would be needed was to reorient their case-finding and exporting approach to more direct care, later termed case-filtering. Crisis work had the advantage of combining direct treatment and timely prevention of chronic mental health complications. Seminal work at Harvard had demonstrated the efficacy of that. Involving families (as well as focusing on just one child) was sensible. Education of front line workers (and the wider community) was also in the spirit of prevention. And each of these orientations was congenial to developing research protocols.

The big question that would make this dream a reality was: how to get and train enough of the right core staff to do it? To that end, the development of this public health service can be roughly divided into three overlapping phases. The first two phases took some 18 months to achieve: 1. Preliminary groundwork – getting the basic ‘political’ support and money to move ahead; 2. Recruitment, selecting, hiring and essentially retraining an all new staff and designing and building some proper offices (in that order of priority). The third phase entailed a two-year ‘running-in’ period to ensure the service would be flexible enough to be self-sustaining. But, back to beginnings, more was needed to pare down the mounting waiting list at the health unit.v

I rolled up my sleeves and, for more than a year, worked as hard as I’ve ever done in my whole life.

It didn’t take long before I was asked to consult on the paediatric oncology ward at nearby St. Joseph’s Hospital. That began at 7 AM, and more about it later. Soon, paediatricians at the Barton St. General Hospital requested my weekly presence on their general paediatric ward and service. Some very weird requests came in too.vi Getting stretched too thinly, I persuaded the city to hire part-time a just-retired older psychiatrist, Dr. Roy Brillinger, and immediately put him to work consulting at the juvenile court and probation office. At St. Joseph’s hospital rounds I met and recruited a Detroit-trained (in developmental biology) paediatrician, Dr. Murray McGovern of Oakville, to join in (with a future hope of coming on staff when money was available).

As time went on, it became increasingly clear that to be able to do good consultations, one simply had to have a backup clinical resource in which to hone and keep up clinical skills. If not, they they go stale and one gets rusty, in short, one loses competency to consult if always once removed from clinical reality! More on that later.

Anyway, afternoons were reserved for meetings: with politicians at the city’s Board of Control, with key people at the Social Planning Council (notably Mr. Sid Bloom), with front line agency directors (to discuss their wishes and my priorities), and with whatever else came up, including the press. Not so incidentally, two, sometimes three, evenings a week, I gave public talks or sat on panels.

Thus, an initially indistinct pattern of levels of approach became the prime template of preventive child psychiatry in a public health setting. These were: 1. a fast on-the-hoof clinical assessment service and 2. direct consultations, educating front line workers, 3. engineering specific programs for key children’s outlets (CAS, probation, etc.), 4. wider public education through the media and in talks to local clubs and organizations and eventually, 5. development of a high quality assessment-treatment backup. The latter was surmised from the start as needed – not only as a speciality resource, but also for the ongoing education of consulting staff – to constantly hone skills in practice.

Not so incidentally, anyone who is setting up professional programs and commuting simply must give equal consideration to one’s personal and home life. Nowadays, I do not see (or am unaware of) young doctors leading this sort of hectic ‘double’ life.vii What with Health Maintenance Organizations in the USA and Medicare in Canada, it’s the bureaucrats and lay-managers that are doing almost all of the peripheral running around nowadays. For a number of reasons I think this is a terrible shame. Foremost is that virtually all medical delivery systems are being shaped by accountants and businessmen, not doctors. Medical input is essentially perfunctory; nurses and doctors are increasingly marginalized. And recently in Canada, the provincial politicians are often in semi-secret partnership with big corporations arranging privatization of many public medical resources. Huge mistakes are being made – but that’s another issue altogether. Let’s get back to developing our PH service.

Getting money

The mayor and Board of Control were informed that the city deserved more than it had and that I’d mount efforts to get it for them. Good luck! A press campaignviii was started and the local Member of Parliament (MP) got interested. He presented Hamilton’s case to Parliament in Ottawa and, low and behold, they promptly, with no debate at all, granted a substantial sum, renewable yearly.ix But the Hamilton town fathers, being a very independent bunch, didn’t jump at it right away. As it took me a while to find out, they did not want Federal bureaucrats looking over their shoulders, managing any of their budget or telling them what to do. So, they looked the gift horse in the mouth and dickered for six months. When things suited them they accepted.x

Front line workers

These are the people who deal directly with children and adolescents in their everyday work. In several instances their parent organizations are legally mandated to alter behaviour. Being consultants to front line workers we perceived ourselves as secondary, or, tertiary when we took on referrals.

The main front line organizations are, 1. the Educational system – teachers in the schools, 2. the Legal-Protection system – police in the juvenile-domestic section, judges in the juvenile and family court and reform schools, and probation officers, 3. the Social-help system – children’s aid societies and family service agencies (social workers, mostly) and Big Sisters and Brothers, 4. public Welfare assistance and, 5. organized Medicine – public health nurses, practising GPs and family doctors, and pediatricians and nurses on hospital paediatric floors. Two other front line sources, without a strict legal behaviour-shaping mandate, were 6. Recreation departments, little leagues, and the ‘Y’ and, 7. various Religions and associated clerics. (The latter for centuries had legal sanction to shape child behaviour, which was removed by separation of church and state.) Of course the mainstay of children is the home and parents which, from the start, was given direct access. Aside from that, I figured that if we specialists at the children’s clinic could consult with and at the same time teach key people in these front line sources about children’s mental health we would have it made. Perfectly logical, but it wasn’t all that easy.xi

Recruiting and organizing staff

A Public Health Department has one huge potential advantage in the field of children’s mental health. It has Public Health Nurses. PHNs have direct access to the homes of new (and old) mothers, newborns and toddlers through wellness checks and immunization programs and, as assigned school nurses, they have indirect access to all children from kindergarten through high school.

My immediate idea – and plan – was to recruit the 90-100 PHNs, that had their home base right upstairs, in the service of children’s mental health. This would take a crucial shift of paradigm on the nurses’ part. In physical medicine they are trained and skilled in case-finding (of tuberculosis and the like) and exporting newfound illnesses to the doctor or sanatorium for treatment and public protection. In children’s mental health they would need to learn how to filter cases and hold onto many children and help them themselves. Exporting to the doctor would not be a primary goal. This was achieved, but not without a lot of sweat.xii

A single child psychiatrist is not enough. There had to be a cutting edge, surgically precise, team to do what I had in mind. Thus, I was interested in flexible people capable of quickly acquiring a broad range of skills, people capable of taking some real responsibility and acting independently. While respecting the classical disciplines, I did not want the children’s service broken up into little sub-departments. The Health Unit and the City, however, required the standard job descriptions, but they had been satisfied with Baccalaureate-level employees, so I took this as an ideal occasion to raise the entry bar to master-level social workers and doctoral-level psychologists. During interviews, my emphasis was: “I’m more interested in what you can do than what you call yourself.”

Within half a year the very best, from near and far, were recruited. Some 15 pros consisting of a child care worker, a PHN liaison, a speech pathologist, three social workers (including the one who had been on sick leave), two psychologists, three psychiatrists (including me) and a pediatrician. In addition to the older secretary (who soon changed her tune to become a real gem), two hot-shot younger ones were brought on. Soon, several psychology and social work interns from Guelph and Waterloo were added to this core group. How we organized ourselves, democratically, within an authoritarian public health unit is a story in itself.xiii

We became, basically, an ‘xy-type’ work group (as in the Archimedes spiral diagram at left) operating independently within the traditionally vertical ‘x-type’ military command structure commonly found in public health organizations. It was not always easy and I constantly had to act as a buffer between these distinct command structures.

The xy-structure has the child-patient at its central nexus with all staff strung out along the spiral. As director, ready to respond to any request, I was located at the extremity of the x-axis. In this setup there is no need to go through a vertical hierarchy or any bureaucratic nonsense. That is, any staff member can promptly cut red tape and cross over lines to deal directly with the child. It is a highly recommended way of setting up a high quality staff.

The only time I had to act authoritatively and arbitrarily was in the assignment of sub-team leaders. The staff wanted an election, but I insisted on a selection. At all other times we stuck to the xy-model. Three mobile ‘roving’ teams (for schools, social agencies, court and probation) and a home base resource team were put together. The pediatrician, a lady psychiatrist and I kept ourselves available to help out on any of these teams as well as consult with hospitals and the medical community.

In-service training and ongoing education

In addition to diagnostic-therapeutic skills inherent in their disciplines (social work, psychology, speech pathology, medicine, etc.), every staff member was required to acquire several additional skills to make it possible to do consistent work in the field. Most mental health pros in those days were educated in the mentalist monadic-intrapsychic orientation, i.e., surmising what goes on inside just one patient’s head. Physicians in addition could do neurological examinations. Staff soon developed an orientation enabling them to see what goes on between people. Skill in fast family group assessment would be a beginning, a crucial part of in-service training. Knowledge of crisis intervention, particularly relevant to prevention, was also necessary. An ability to relate easily and with sound authority to any front line person, individually and in groups – in the consultative role – was also required. All staff met together for two hours every week, early on strictly for learning and practice, later for sheer fun. Every once in a while, a brilliant world-class figure was brought in as a bonus (e.g., the great neurologist, Warren S. McCullough, gave everyone food for thought).

Volunteers

Within two years, thanks to our psychologist Mrs. Mary Blum, the Children’s Service had over 100 lay volunteers attached to it.

Research

Virtually every project was designed to collect data for ongoing clinical use or future publication. The very first was, as earlier noted, in connection with case-filtering by PHNs. One early study collated data on child abuse. Another clarified eye preference and dyslexia (a method and tool was published). From then on most research had to do with families: Emotional Distance; The SF:RS in Anxiety. These 1960s seminal studies led to a decades-long study of human communication, eventually culminating in, Cracking the Family Code (soon to be published in book form). One notable joint research project was a two-year community conferencing effort involving all agencies in Hamilton. It was originated by Mr. Sid Blum of the Social Planning Council. Lieutenant Jim Paterson, head of the police Juvenile Bureau, took care of all the data. Our Children’s Service at the Health Unit hosted it. That project led to my own paper on Socially Induced Hyperactivity in Children. All of this research entailed no grants! All costs were incorporated in the organizational setup of the Children’s Service.

More detail on roving casualty clinics

As time went on, the roving casualty clinics required some degree of formalization to fit the talents and limitations of a diversified clinical staff. Not every psychologist and social worker could be expected to have the quick thinking of a medical doctor trained in dealing with life and death emergencies. Ultimately, there were school clinics, court clinics and social service clinics, to name three. Each had its own special customized design.

The typical school clinic lasted for a half day and was designed to do several things: 1) A 30-minute meeting with school staff, including the teacher (who was encouraged to address what help s/he wanted around the child’s learning level and classroom behaviour), the vice principal (who was almost always interested in dealing with disciplinary issues and, as the Principals proxy, administrative matters), the pupil adjustment officer (most of whom wanted to become junior psychiatrists and get a few tips), the school nurse (who often had an insight into the particular child’s feelings as opposed to most others whose complaints were chiefly around controlling unwanted conduct), special education people, the Board’s psychologist, the Truant Officer, etc. Toward the end of this meeting, most saw their disparate wishes and were encouraged to narrow them down a bit – and focus on the child. But all expressed concerns would be somehow addressed in the examinations to follow. 2) Next, the child in question was surreptitiously observed during his/her play with peers – usually through a window overlooking the playground at recess time. 3) Then the child would be seen together with its parents for 20-40 minutes. 4) The child was next seen alone, privately, for whatever one-on-one chats or screening tests were indicated and possible. 5) Finally, all of the actors of the first session were brought back together, along with parents and family doctor (whenever possible), in order to field more questions and offer recommendations. It later was common at this last meeting to invite in a key person from some other venue – a CAS worker, a policeman from juvenile, a probation officer, etc. A written report followed, always within the same week. Obviously, this protocol demanded a lot from the consultant. Some could carry off a school clinic on their own, but most went out in complementary teams of two or three. With this format it quickly became apparent that most children could be dealt with perfectly well at school – exportation to the clinic was not needed. On the other hand, the school clinic was a superior device to screen in children that needed the intense and extensive services available only at home base.

These roving clinics were expensive in and of themselves, but far cheaper in the long run, and more timely, than if every last upset child were seen in depth at home base. Obviously, they also carried with them the possibility – actuality – of educating front line workers more than ever before. Prevention! Word filtered back that a scheduled school clinic or CAS or probation office clinic was relevant and live ‘in-service’ training.

***

It is remarkable that for thirty years after my departure this structural-functional organization stayed intact. It was only when McMaster University medical school unwisely changed its philosophy to begin a retrogressive centralization (forcing all child referrals through one telephone line!) that the children’s clinic was decimated outwards and dispersed inwards.xiv

Notes

iHamilton, a steel city (Dofasco, Stelco) with population (300, 000 in 1965, 500,000 now) sits on the St. Lawrence Seaway at the western tip of Lake Ontario. It has a natural harbour that accommodates ocean going vessels. The Niagara Escarpment (called ‘the mountain’) cuts through the city, dividing it into a middle class residential area above and below is downtown. The heavy industrial area abuts the harbour and on calm, moist days can cover the entire hollow below the mountain with heavy smog. On the good days it may blow out over the lake. McMaster University (no medical school in 1965) is located in the city’s west end below the mountain. It has a high reputation in science, especially physics. There are two school systems, regular and Catholic. A full range of charitably supported social agencies relates well with the city’s Social Planning Council. Welfare is city-supported and distinct. Medicare while not covering doctors’ fees in 1965, did pay other hospital expenses. A large regional public mental hospital, paid for and run by the province, is on the mountain brow, overlooking most of the city centre. There are four general hospitals, very strategically placed, two on the mountain brow, two below.

iiWhat are you going to call it? That was the first question asked of me. And I’d given it some thought. My teachers at UT felt that a spade should be called a spade and had strongly recommended that I call it a Child Psychiatry Clinic. But they were touting child psychiatry. Medical names are generally given to active treatments as in “Surgery is on the second floor.” But I was about to build a service located in a public health department where prevention is paramount. The word ‘health’ is associated with the idea of prevention. So, better it be called the Children’s Mental Health Service. That it was, formally, but it finally became known simply as the Children’s Clinic.

iiiNow, not everyone is ‘lucky’ enough to be handed a chance to do good and get positive PR at the same time. But, PR of the grandiose self-serving kind is anathema to medicine. The only kind doctors in private practice should have is by shy and discrete word of others mouths – that’s OK. But everyone setting up a service for the wider community should keep a bold eye out for chances to move ahead fast. They are always there. That’s one important difference between private and public medical work. Along this same line I soon discovered that, amongst all doctors, with the exception of official medical bodies and associations, the Medical Officer of Health is the only MD who can – and should – make public announcements in the interest of public health. That is, publicizing epidemics, polluted swimming areas, and the like. I decided to capitalize upon this duty to inform as a means to really get necessary things going. So, with the blessing of the MOH, I did not hesitate to prudently talk with one particular science reporter from Hamilton’s main newspaper, the Spectator.

ivNot all was positive. A disagreeable doctor who had been hired to set up an adult service and who instead was running what amounted to a private practice in a fashionable residential area on top of Hamilton mountain, materialized out of the blue and accused me of ‘self-aggrandizement’ and insisted that child psychiatry had always been supervised by adult psychiatry. Face to face, he flashed a knife by reflecting sunlight off its blade into my eyes. Under those circumstances I refused to talk with him let alone be supervised by him. Some months later he quietly folded his tent and took up the job of developing services at the Greater Niagara General Hospital. After several years, his licence to practice medicine was revoked for cause. The reason I mention this nasty episode is to show that small ‘power struggles’ can crop up in unlikely places and that psychiatry is not immune to such. One simply has to be ready for any eventuality.

vIn emergency medicine, triage deals with reducing errors at the front end of a visible queue by direct screening. Queue Theory has ways of dealing with long, stop and start, lineups, the end of which may be out of sight. The idea is to get a steady, regular, predictable trickle or better going. The worst way, of dealing with a long lineup, of course, is to put up more barriers than there already are to the swiftest, steadiest passage. For example, governments tend to create layers of bureaucrats along the lineup and hope for the best, but, almost inevitably they foul up the lineup yet more. Better, is to look at sources to see what can be done there. The on-the-spot roving clinics were a partial answer. Many children would be handled at school or elsewhere rather than sent to clutter our lineup. But, that hoped for effect would take time. In the meanwhile, as our waiting list still accrued and put too much time between referral and help, we needed something that would work at our end also. Right at our intake. It had to be constructive in the right places and mildly, but rationally obstructive in key ways too. One idea was to get the disparate and disconnected front line sources working together in better harmony. That is, to give priority to multiple problem families and hence, by feedback, facilitate joint referrals. Some hope! But even that, a multi-problem focus, encourages impasses and can bog down the works entirely. Another idea is to give priority to acute crises. But that, timely but exclusive crisis intervention, while in keeping with preventive principles, would keep us constantly running, without surcease. After some thought, I came up with a new combination: looking for emergent crises within chronic impasses. Such might be implemented at our end, and have a subtle back-up-the-line influence, without endless, contentious negotiations with the contenders for service. By logical deduction, not by time-consuming trials, I first drew up a weighted intake-screening tool. Then I drew up a simple corresponding form for consultation-referral. The latter was distributed to all front line sources; it was mandatory; no applications for service would be accepted without it (the single exception being family self-referrals). The former, the screening tool, I kept all to myself for a long time; frankly, I kept it a secret, even from my own staff. Then, every Tuesday morning I personally presided over our intake conference, ticking off the weighting tool as the meeting proceeded. Everyone had their say, but I had the final word, deciding whether we would send out a roving clinic or assign the case directly to our in-house team. And it began to work. Later, by teaching and encouraging ‘case-filtering’ by PHNs and with the much later inception of a community conferencing project, the whole mass of disturbed children waiting to be seen directly was thinned down to a manageable steady trickle of a predictable number each week, yet not a child in the city went without proper attention.

viOne Alderman ‘ordered’ me to come out to his neighbourhood and ‘certify’ someone he disliked. As it turned out, the man in question was in a domestic dispute involving his children, so the police and CAS were soon involved also. One reason this episode is even mentioned is to emphasize how important it is to take ‘concerned’ people, even demanding ones, at face value. The Alderman turned out to be a young lawyer on the City Board of Control, specifically relating to public health. His callow demand (really testing me out?) had been arbitrarily turned down by the psychiatrist in charge of adult services. This posed a dilemma that was decided in favour of public health in consultation with the MOH. If children are at risk I should go out! By treating the Alderman with respect and educating him in proper medical protocol, he became a strong ally in the development of children’s services. As a bonus, the police, once again in just a short interval of time, experienced working with a ‘sensible’ shrink. Along with the CAS request, the door to multiple front-line cooperation of agencies was eased a bit open. (When I came to Hamilton, the various child-related agencies were hardly talking with one another.) And finally, some public health research into a ‘new’ kind of problem, the ‘battered child syndrome,’ then barely recognized let alone understood (1965), was set in motion. A psychology student, soon assigned to us from the University of Waterloo, made a review of the then scanty literature part of her thesis. This is how things can evolve in any kind of community work if you keep an open mind and open eyes.

viiFortunately, my wife was also a doctor, finishing off her anaesthesiology residency training in Toronto. She was busy too. Our home was in Toronto, but I had to get a small apartment, as well, in Hamilton. We got together weekends. Although we had no children, we quickly decided to live halfway between Toronto and Hamilton in Oakville. I could then get home during the week and each morning we parted by heading down the QEW in opposite directions. Instead of buying a weekend cottage-escape up north, we got a floating one – a boat. And once a year, no holds barred, we headed across the ocean to her homeland of Slovenia, Yugoslavia for a complete change of pace.

viiiThe editor and the science writer of the Hamilton Spectator played a big role as did the MOH. I deliberately played a low profile in this part of our PR. First, with the MOH’s blessing, I compiled statistics to show that untreated children’s mental health problems, by any other measure, were truly epidemic. In retrospect this may have been stretching a point, but it worked. The MOH formally announced it as a public health problem. It was published, with fanfare, in the paper. The sad event of a child from Welland being certified and admitted to the adult male ward at the big mental hospital was horribly serendipitous. Then a series of editorials, facilitated by a prominent privately practising psychiatrist, ensued. Next, letters to the editor from other doctors and social workers were published. Finally, the Spectator’s talented science writer talked with me and decided to do a series of articles on various aspects of children’s mental health. I worked very closely with him. Incidentally, he won an award for the series and got a job with the New York Times. The point of all of this is that the pioneering clinician who is working for the public weal should take every fair advantage of every chance to promote a good goal. It’s also helpful to be young and brazen.

ixThe MP from Hamilton Mountain picked up on the chance for good publicity and eventually got Federal funds. It is all documented in Hansard. Of interest: Lester Pearson (who later fostered Medicare) was the Prime Minister and one of his rising lights was Pierre Trudeau, who, later as Prime Minister, I got to talk with while on a visit to Hamilton. He told me, laughingly, that one of the reasons money was so readily forthcoming was that his buddy, who travelled with him on his earlier China trip, was, like me, also one of the few child psychiatrists then in Canada. So, things may happen in strange and unexpected ways.

xSetting a double bind and getting kudos: It is important that politicians be informed of one’s goals at the outset. They all must know that one is acting in earnest and honestly. “Support this good cause and you’ll get ALL the praise later; but, if you obstruct or ignore it, you’ll be taking the chance of being seen as a villain.” That’s the double bind, a deliberately set paradoxical injunction. The latter part of it is best implied, not stated. It cannot be delivered as a noxious threat and hope to succeed. A sense of warm-hearted, friendly mutual gain is best. When the bricks were built and new staff coming on, young Alderman Dudzic, with the Mayor’s smiling approval, got to cut the ribbon – and, at his own last-minute request, I wrote his speech for him. They were the heroes and I got the makings of what would eventually become a world-class children’s service and, admittedly, a steppingstone to a professorship.

xiThe original children’s clinic had set an unfortunate precedent in which the education system not only had been extended (really given) exclusive access to clinical service but also dictated-out all other referral sources, even to demanding the kind of service to be provided. In other words the PH children’s clinic, a medical operation, was seen as the educational system’s exclusive domain, a referral resource for which they also dictated priorities and treatment types. Even the very worthy Juvenile Court was excluded. And the PHNs, working as school nurses, were actually forbidden to access the clinic located within their own department. Dr. Price, Director of Education, was adamant – “there will be no changes! Our Pupil Adjustment Officers will continue to make all referrals” to the Health Department’s clinic, “they are the only ones that know what a disturbed child is.” Even “family physicians and parents, if they want to use the clinic, must go through my people.” He refused to negotiate and quickly went to the city’s Board of Control to literally finger-pointedly complain about my proposals for improving things. The loud debate was over in an hour. Common sense ruled in favour of an autonomous children’s service that would progressively serve all front line sources. But the retrogressive Director of Education and his Pupil Adjustment Officers (Mr. Ray Spoar) fought a rearguard battle of sabotage lasting over two years before their own longterm ‘sensible’ self-interest won out. In the meantime, we had plenty to do. We educated and retrained the PHNs in case-filtering in the schools and with assistance from CMHA under Mr. Don Sinclair held regular seminars for all the principals of the Separate School Board (much as William Glasser was doing in California). And we got source screening going in the courts and probation office and on-site programs into both Children’s Aids.

xiiCase-filtering by PHNs: Getting the PHNs on board in the right way was critical to the success of the entire preventive and public health approach to children’s mental health. The school’s Pupil Adjustment Officers were oriented to finding all acting-up kids and getting them to the clinic. They were oblivious to shy, withdrawn, anxious and depressed children who caused no overt trouble in class. The nurses, particularly those at the high schools, were tuned into upset as opposed to upsetting children, and they clearly saw that these children were being deprived of help. That was a helpful starting point – giving them the privilege of referring them. Within a month of my arrival in Hamilton, the nurses were offered and given (in groups of 20) a crash course on intelligent screening. A serendipitous conversation with Bruno Bettelheim the year before served to set the backbone of this front line screening method. It consisted of five observable-measurable signals of severity. Incidentally, the school’s Pupil Adjustment Officers were offered but declined the same crash course. Ultimately and ironically, they became the control group to the nurses’ study group, when results were published a year later in the Canadian Journal of Public Health. See, The Case-Filtering of Children’s Mental Health Problems by Public Health Nurses. The beauty of this ‘coup’ was that, within three months, I had upwards of a hundred enthusiastic PHNs finding and personally counselling upset children all over the city of Hamilton. It was a big step ahead, but not the final answer.

xiiiShifts and compensating time: Most of the staff were so independent and reliable that I extended each clinician freedom to decide his/her hours on trust. They had to coordinate with their own team and attend planning meetings and in-service training. But otherwise, if a morning person work mornings, if a night person work nights. The upshot was that instead of being open from 9-5, the ‘Children’s Clinic’ was a bundle of activity from 7 AM until well after midnight, Saturdays and Sundays included. Everyone also was expected to respond to requests for public appearances and speeches. It was an important aspect of our educational-preventive mandate as seen by me. Many did so two or three evenings a week. It was understood that they would not take the next morning or any part of the next day off, but save up this extra time and tack it onto their winter or summer vacation. You can imagine what a dilemma this compensating time posed in an old-fashioned rigid organization like a health department! How I acted as the buffer for my staff is a story in itself, that for some time yet must remain confidential.

xivIt should be noted that, although I knew it was coming, McMaster medical school did not yet exist when I first went to Hamilton. Step by step, before the undergraduate program started, in came a flood of specialities. Under Nate Epstein, child psychiatry was thought to be quite unnecessary, “the family’s enough for understanding a child.” I taught a course on the merits of seeing children as developing, autonomous little individuals, but it was hopeless to overcome excessive family group hype. A tertiary family centre at Chedoke Hospital became the fixed centre and eventually won out over an outreach through public health.