Abstract
The current child mental health system in the USA is hampered by underfunding, a lack of resources, and little public attention. It was not always this way. Between the 1930s and 1960s, mental health institutions supported children’s growth and individual needs, providing them with environments intended to replicate the traditional American nuclear household. In Emotionally Disturbed: A History of Caring for America’s Troubled Children, Deborah Doroshow provides an in-depth account of the experiences of America’s troubled children leaving home for these residential treatment centres (RTCs), acclimatizing to life with other troubled children in a structured environment, and receiving therapy to help them act like a ‘perfectly average’ American child (p. 4). Tracing the paediatric RTCs’ decline from targeted therapeutic milieus addressing idiosyncratic needs of patients to their current neglected state, Doroshow underscores the necessity of improving public mental health services for children.
She begins by detailing the emergence of RTCs during and after World War II, and this increases the book’s readability by informing historians less familiar with the origin of American juvenile mental health institutions. Fuelled by a need to provide neglected and emotionally unstable children with a nurturing home environment, a group of mainly female reformers sought to house them with efforts such as ‘the Orphan Train Movement’ (p. 11), shuffling orphans from cities to rural families rather than sending them to the abusive child care institutions of earlier years. This interest in child welfare led to new laws being enacted, greater government support and increased public attention. These and other factors contributed to the start of child guidance clinics used to treat juvenile delinquents coming from juvenile courts (p. 15). Children who had epilepsy or intellectual disabilities could not be treated at the child guidance clinics, so they would be taken in by institutions. In summary, child mental health systems were composed of reform or training schools for delinquents, orphanages for disadvantaged or destitute children, state mental hospitals (which rarely accepted children) and institutions for mentally handicapped children (p. 16). RTCs arose out of this mixed backdrop in child mental health care, as a response to providing a safe ‘haven’ for these children.
Doroshow narrates the next five chapters with either a case report of a patient or opinions from a staff worker; this is one of the book’s strong points. These individual experiences allow readers to experience vicariously the daily functioning of the RTCs from the viewpoint of a resident or a staff member. One case report of a Southard School patient, Tommy, features dialogue between him and the psychiatrist, revealing the flexible and individual care of patients in the RTCs. This compassion and care for each resident, coupled with the idyllic American childhood environment offered at the RTCs, characterized the post-World War II era of child mental health care systems in the USA.
Doroshow balances her praise and criticism of these RTCs by describing their strengths and flaws. These institutions could not treat all the young delinquents; in addition to shortages of psychiatrists who specialized in working with adolescents, RTCs required a high ratio of staff to children, making it more difficult to admit every child. Also, RTCs relied heavily on donations as well as community and governmental endorsement, leaving them markedly underfunded. Moreover, both government and independent child welfare specialists claimed that RTCs obstructed ‘family preservation’ by treating children outside their homes (p. 216). Pennsylvania’s Child and Adolescent Service System Program and similar systems believed that children should be in the ‘least restricted, most normative environment that is clinically appropriate’ (p. 211). In response, community centres, group and foster homes, day treatments at hospitals, and school counsellors began providing more accessible, family-oriented care that did not require the child to live away from home. To better integrate their clients back into society and respond to public opinion, RTCs included group homes and inpatient/outpatient programmes. However, its efforts were not sufficiently comprehensive, and use of these facilities declined.
After the 1980s, the US child mental health care system ‘decentralized’, shuffling children among ‘agencies, hospitals, institutions, and . . . the criminal justice system’ (p. 233). Training schools, increasingly populated with so-called ‘disadvantaged’ minorities, had not provided adequate care to meet the mental health and special education needs of children, leading to an increased number of suicides. These state institutions used restraining techniques, punishment and seclusion to curb suicide attempts. Furthermore, reform schools provided spartan living arrangements, lacking the furnishings of a typical child’s room. This system did not address the root cause of misbehaviour, contributing to a disjointed treatment environment for children.
Doroshow takes a compelling stance in support of returning to a child mental health care system akin to the one in the immediate post-World War II era. She demonstrates how the history and growth of such instructions and programmes reflected the escalating needs of America’s emotionally disturbed children. There is a growing need to recognize that individuals with mental illnesses should not simply be sent into the criminal justice system, and that comprehensive programmes integrated with the passionate spirit of RTCs could help further improve the long-term care of these adolescents. Providing more perspective regarding hospital systems and protocols for treating emotionally disturbed children will further highlight the advances that medicine has made. Doroshow’s work stands as a strong pillar of support for psychiatric reform of today’s mental health institutions. This book should be recommended to all historians of medicine due to its dualistic approach, educating those unfamiliar with US paediatric mental health systems as well as expanding the knowledge of advanced scholars with its many detailed case discussions, anecdotes, and insights. We would recommend it as a source of reference for anyone wishing to study the history of post-war American paediatric psychiatric care.