Emotionally Disturbed is the first work to examine not only the history of residential treatment but also the history of seriously mentally ill children in the United States. As residential treatment centers emerged as new spaces with a fresh therapeutic perspective, a new kind of person became visible—the emotionally disturbed child. Residential treatment centers and the people who worked there built physical and conceptual structures that identified a population of children who were alike in distinctive ways. Emotional disturbance became a diagnosis, a policy problem, and a statement about the troubled state of postwar society. But in the late twentieth century, Americans went from pouring private and public funds into the care of troubled children to abandoning them almost completely. Charting the decline of residential treatment centers in favor of domestic care–based models in the 1980s and 1990s, this history is a must-read for those wishing to understand how our current child mental health system came to be.
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When medical journalist Albert Deutsch visited the Illinois State Training School for Boys in the late 1940s, he was told that corporal punishment was not used as a tool of discipline for the delinquent children who lived there. Yet he later learned that boys who misbehaved received so-called hydrotherapy, for which they were forced to strip, face a wall, and have a fire hose sprayed against them. As one boy explained, "It's like needles and electricity running all through you. ... You yell bloody murder and try to climb the wall. Your blood freezes. It lasts a few minutes, but it seems like years." The Illinois State Training School for Boys was just one of fourteen highly reputable training schools, or reformatories, that Deutsch visited for his 1950 exposé of institutions for delinquent youth, Our Rejected Children. In it, he explicitly detailed for the American public the horrendous conditions persisting in many training schools.
Despite continuing assurances from administrators that the institutions had undertaken major reforms, Deutsch found quite the opposite. Instead, he found a new euphemistic vocabulary wherein "whips, paddles, blackjacks and straps were 'tools of control.' Isolation cells were 'meditation rooms.'" Psychiatric care was nonexistent at most of the schools he visited. At the Indiana State School for Delinquent Boys, Deutsch was introduced to a fifteen-year-old boy who had a history of physical abuse, child labor, and multiple orphanage and foster home stays who had killed his foster mother. When Deutsch asked a staff member if the boy should be seen by a psychiatrist, the staff member replied, "Psychiatry for what? He doesn't misbehave and that's all we ask." At the Indiana State School, delinquency was a criminal problem with a disciplinary solution; psychological treatment played no role.
Amid the despair of the children he interviewed, Deutsch found reason for hope. In a chapter on private training schools, he noted that some institutions specifically sought out the most troubled children and attempted to better understand the roots of their delinquency and administer meaningful treatment. A specific subset of private institutions was notable: "One of the most interesting and significant developments ... has been the establishment ... of small 'study homes' and 'treatment centers' where delinquents with especially marked behavior disorders can be subjected to intensive study and/or treatment by highly qualified experts." Even to Deutsch, a critic of psychiatric institutions, something about these "treatment centers" was very different from the other places he had visited.
These residential treatment centers, as founders and staff members called them, were unlike any existing institution for children. They were small, sometimes serving fewer than twenty children at a time, and equipped with a staff that outnumbered the children staying there. They housed children from across the socioeconomic spectrum, with some centers focusing on middle- or upper-middleclass children who likely never would have been sent to a training school or orphanage. Most importantly, RTCs were therapeutically oriented. They employed a psychiatric model to understand and actively treat a new population of children they targeted and labeled as emotionally disturbed. This goal, they believed, differentiated them from many of the more custodial institutions to which children might be sent. While children might remain at an RTC for several months or even one or two years, these were short stays compared to the multiyear stays at many institutions like orphanages or training schools.
The emergence of residential treatment centers occurred in the context of several related developments in child welfare and psychiatry. Growing attention to child mental health and welfare, coupled with increasing public and private funds to care for dependent and mildly troublesome youth in the community, left many existing institutions for children aimless. At the same time, these processes also led to a recognition of a new population of children whose needs were not met at home, in school, in juvenile courts, or even in child guidance clinics. These children, grouped under the vague label "emotionally disturbed," were often defined by their rejection in every other arena of care. Guided in part by the perception of a leftover group of children who fit poorly into the existing landscape of social welfare and influenced by the work of psychoanalysts who had established therapeutic environments for troubled children, many administrators reimagined their struggling institutions as therapeutic, short-term centers for these disturbed children. The processes of institutional transformation and recognition of the emotionally disturbed child as a new kind of person went hand in hand; emotional disturbance and residential treatment developed as codependent ways of organizing people and their care.
On the local level, a series of circumstances often worked to gradually transform orphanages, schools for intellectually disabled children deemed "feebleminded," and training schools into RTCs. Though these processes often occurred by happenstance, staff members developed institutional origin stories that characterized their centers as progressive, treatment-oriented institutions, providing care for children otherwise doomed to life in a custodial training school or state mental hospital. Of course, these portrayals were often oversimplistic, ignoring advances being made in other institutions. However, these origin stories allowed administrators to fashion themselves as pioneers with little precedent to follow, granting themselves freedom to experiment with novel therapeutic techniques. By the mid-1950s, residential treatment as a concept and profession had coalesced, with growing numbers of RTCs, a representative organization and publications, and a large professional network of individuals exchanging ideas and experiences.
The Web of Child Welfare
Residential treatment centers emerged in the context of several generations of child welfare work that initially sought to place children in large institutions away from home in the mid- to late-nineteenth century before struggling against this model in the 1920s and 1930s. The result was a continued push to help a wide variety of children without a clear place for them to go.
Starting in the mid-nineteenth century, an enthusiastic generation of mostly women reformers had become concerned with ensuring the physical and emotional wellbeing of neglected and dependent children. They founded organizations opposing cruelty to children, built lodging houses for working boys and girls, and sent poor children to live with families in rural areas in the Orphan Train Movement. Before then, many unwanted or dependent children had lingered in houses of refuge, punitive institutions where they were often subject to abuse and horrid physical conditions. In the mid-nineteenth century, reformers constructed orphanages to provide a more kindly place for dependent children to stay. These children, considered unfortunate and blameless, ranged from true orphans to children of impoverished single parents.
By the late nineteenth century, reform efforts swelled into a full-fledged child-saving movement, which focused on improving the welfare of dependent and neglected children by ending child labor, promoting compulsory progressive education, and creating a multitude of agencies designed to help dependent children. In 1912, the federal government announced its involvement in child saving with the creation of the U.S. Children's Bureau, which quickly became an authoritative voice on child welfare. In the 1910s and 1920s, state governments also began to provide a modicum of financial support to "deserving" single mothers (typically widows) and their children, a program that was expanded by the 1935 Social Security Act under the new title of Aid to Dependent Children. As Linda Gordon has argued, these federal and state reform programs promoted the dominant family ideal, with a breadwinning father (even if he was absent) and a dependent mother and child.
While federal aid policies promoted the preservation of the family, early twentieth-century reformers were growing wary of the very institutions their predecessors had erected to "save" neglected children. Many believed that institutions were often impersonal and devoid of the love that made family life so important for children, more than a hundred thousand of whom were living in orphanages by 1910. At the inaugural White House Conference on the Care of Dependent Children in 1909, several hundred child welfare workers expressed their strong belief that children should remain at home if at all possible. Many declared their strong opposition to placing children in institutions. In many cases, explained the secretary of the Indiana State Board of Charities, institutions "simply boarded" children without truly caring for them. Rabbi Emil Hirsch of the National Conference of Jewish Charities of Chicago went further, declaring that children in institutions "are of necessity trimmed and turned into automatons. ... Spontaneity of the emotional and volitional sides of child nature certainly is dwarfed, if not destroyed." Reformers almost universally proclaimed that options like foster care and direct financial aid to families were superior solutions, which would help keep children situated in families, even if they were not their own.
Institutions like orphanages attempted to counter this growing criticism by promoting a family-like atmosphere in small cottages led by staff members called housemothers. However, change came slowly, and in many cases, these reformed institutions were no better than their original incarnations. Governmental aid and foster care served as alternate means of keeping families together. In particular, placing children into foster or adoptive families became an increasingly common practice for social workers in the 1920s and 1930s. If they could not be part of their biological families, children would at least belong to some kind of family. In 1921, the Child Welfare League of America (CWLA) was founded for the express purpose of establishing standards for foster family care to keep children out of institutions. Ultimately, CWLA officials hoped to reunite each child with his birth parents, but frequently endorsed foster care as the optimal stopgap measure. Still, the number of institutionalized children continued to rise, with over 132,000 living in institutions by 1923.
Anti-institutional sentiment increased in the 1920s and 1930s as physicians became concerned about the implications of institutional care for a child's development. Pediatrician and child welfare reformer Henry Chapin found that children raised in institutions were more likely to become intellectually disabled or die young. In 1941, child psychiatrists Lauretta Bender and Helen Yarnell of Bellevue Hospital described 250 dependent young children who had been raised in institutions, many of whom had few opportunities to play or interact with others. When these children were moved to foster homes, they were hostile toward other children, "hyperkinetic and distractible," and "unable to accept love, because of their deprivation in the first three years." In summary, they argued, children "cannot be raised in an institution without risking [their] normal personality development." Research such as this contributed to a growing backlash against children's institutions.
In the setting of increased governmental aid, more adoption and foster care placements, and growing anti-institutional sentiment, the number of institutionalized children finally began to fall by the mid-1930s. As a result, a leftover population of children began to emerge who were too troubled or odd to be kept at home and did not qualify for placement in a foster or adoptive family. As the staff of the Chicago-based Illinois Children's Home and Aid Society observed in 1946, they had been left to care for the most troubled children because "the needs of the normal dependent child are being progressively better met by such public resources as aid to dependent children ... [and] by the public child-placing services of the Children's Division of the Chicago Welfare Administration." The normal children, they believed, had been accounted for; those who remained needed more than they were equipped to offer.
The Preventive Model
This leftover group of very troubled children also became more visible because adults were looking harder for them. In the first half of the twentieth century, leaders of the mental hygiene movement were bringing psychiatry out of the asylum and into the larger community, shifting their attention from treatment to prevention. Because of its preventive focus, mental hygiene was especially directed toward children, who were simultaneously deemed the most vulnerable and the most promising sector of American society. The primary target of mental hygiene experts was the problem known as "juvenile delinquency," fundamentally defined as illegal activity committed by a minor.
Prior to the rise of mental hygiene, children deemed delinquent had been sent to reform schools or houses of refuge, punitive institutions which hoped to instill in their inmates middle-class moral values by demanding hard physical labor. Despite reforms like the introduction of cottages and housemothers, these institutions retained a prisonlike atmosphere. This approach changed in the early twentieth century with the introduction of juvenile courts. These unusual institutions were conceived as rehabilitative agencies, with judges who redefined delinquency as a representation of psychological and socioeconomic stressors. Working-class children were sent to juvenile courts for both petty and serious crimes and for status offenses, or age-inappropriate behaviors like drinking, gambling, or running away from home. In the court, which had no jury or lawyers, the judge would offer individualized guidance and a probation officer would serve as the child's mentor. Sadly, some juvenile courts became mere detention or distribution centers for unwanted children. Still, they signified an important shift in the way delinquency was understood. By the time the White House Conference on Child Health and Protection was held in 1930, the Committee on Delinquency declared that "delinquent acts are but symptoms of deeper stresses and difficulties," a "natural and expected sequel of some deeper trouble." No longer were delinquent children merely lawbreakers; their behavior had become an expression of psychological stress.
Mental health experts hoped to use their institutional clout to create programs that would not only treat but also prevent delinquency. In 1922, the National Committee for Mental Hygiene, the flagship organization of the mental hygiene movement, collaborated with the Commonwealth Fund, a philanthropic organization interested in child welfare, to found the Program for the Prevention of Delinquency. The program placed social workers in schools to identify children in need of help, created the Bureau of Children's Guidance in New York City to train psychiatric social workers, offered psychiatric consultation to juvenile courts, and used public outreach to raise awareness of the importance of good mental hygiene. As part of the program, the fund and the National Committee for Mental Hygiene set up demonstration clinics to treat delinquent children. Between 1922 and 1942, the number of child guidance clinics had grown from two to sixty.
Child guidance clinics were initially intended to treat delinquent children referred there from juvenile courts. But almost immediately, clinic professionals also began to identify a new population of patients: "predelinquent" children. These typically middle-class, troublesome, or problem children had minor emotional and behavioral problems ranging from bedwetting to temper tantrums and truancy. Most importantly, experts believed these children had a better prognosis than delinquent children, many of whom came from poverty and tended to be repeat offenders. At child guidance clinics, teams of psychiatrists, psychologists, and social workers worked with children and their parents to understand the origin of the problematic emotions or behavior, often tracing it to a child's relationships with his parents, especially his mother.
The efforts of mental hygiene experts, including child guidance professionals, to identify and treat a vast, previously unidentified population of troublesome children had important consequences for the burgeoning field of child mental health. With increased efforts to identify and work with problem children, experts identified a large number of children requiring help. One psychiatrist observed in 1935 that, "with the excellent work accomplished by [child guidance], or rather in spite of it, there is a steadily increasing number of children under 15 years of age requiring ... treatment." This phenomenon, he explained, might also be due to a rising number of children with problems. However, the active work of the National Committee for Mental Hygiene and other mental hygiene organizations to promote mental health and identify at-risk children in schools certainly contributed to the perception of this increase. Moreover, the "delinquent" children who were no longer the primary target of child guidance clinics were still in need of treatment.(Continues…)
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Table of ContentsList of Illustrations
One O Pioneers!
Interlude: The Road to Residential
Two Disturbed Children, Disturbing Children
Three Playing by Ear
Interlude: Therapeutics in Residential Treatment
Four The Special Relationship
Five A New Home
Six Building the Normal Child
Interlude: Homeward Bound
Seven The Breakdown of Emotional Disturbance
Eight Discarded Children: The Last Thirty Years in Child Mental Health
Key to Archives and Manuscripts