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STATEMENT OF REGINALD S. LOURIE, M.D., MEDICAL DIRECTOR, HILLCREST CHILDREN'S CENTER, AND PRESIDENT, JOINT COMMISSION ON THE MENTAL HEALTH OF CHILDREN, WASHINGTON, D.C.

Dr. LOURIE. I am Reginald Lourie, professor of pediatric psychiatry at George Washington University School of Medicine, director of psychiatry at the Children's Hospital and Hillcrest Children's Center in Washington.

I am here primarily as the president and chairman of the Joint Commission on the Mental Health of Children, to introduce a statement for the record from the Joint Commission that fits in with and provides some background for this bill and indicates why the Joint Commission is pleased that this bill has been developed and is in the process of being reviewed.

Senator MONDALE. Very well, we will place that in the record following your statement.

Dr. LOURIE. I would like, in addition to this statement, to talk to three areas covered to some extent by the bill, but which might usefully have some elaboration.

One of them is the prenatal period, in terms of services that would be useful. I would like to stress the increasing importance with which we view this period, and how much we would feel that there are needs for greater emphasis on it. We think that a baby should be viewed like the ancient Chinese did, as being 9 months old at the time of its birth. By the time it is born, it has well-developed patterns which will last for the rest of its life.

In fact, some of our observers have felt that by the time a baby is born, it already has established whether its character patterns are going to be basically compulsive or hysterical as it responds to stresses and life situations.

We don't go quite as far as Gilbert and Sullivan, who said that every man now alive is born a liberal or a conservative. But we can annotate the end product of a period of pregnancy as one in which a great many determinants are established such as in the psychosomatic responses of an individual. If we ask when is it determined how an organ will react to stress, we find that in the formation of that organ, it has encountered influences that determine its response to stress.

Suppose its oxygen supply was interrupted, then its structure is threatened. Its response to the stress at that time can become a prototype for its response for the rest of its life when stress comes into the picture.

We have increasing indications of how important the prenatal period is. We have indicators that tell us that we can expect to do more and more about what happens in a distorted way during pregnancy. Increasingly ingenious devices for defining what's going on in the uterus are becoming available as well as interventions that will be diagnostic and corrective.

We are entering a new era from this point of view, and we are very pleased to see that this bill makes provision for prenatal services.

Senator MONDALE. We placed that in the bill-not based on more sophisticated work that you have done-but on the basis of work I did with migrants in which I found in many of these migrant countries

in the South, 60 and 70 percent of the mothers received no help, medical or otherwise, during pregnancy, and none in delivery.

And thousands of children are maimed just for the failure of providing minimum, decent professional care at that time. Many of the mothers have venereal disease, untreated, and that deforms the child. And for the want of $15 or $20 of the right medicine, we have a twisted human being for a lifetime. Maybe more than one, perhaps thousands. And that led us to specifically flag the prenatal question, in this bill, so that it was not ignored.

But the points that you make, of course, go clear beyond that cruder type of observation.

Dr. LOURIE. From the point of view you bring up, the nutrition of the mother during pregnancy has a great bearing on what kind of a baby will result. In fact, probably the one single most basic determinant of what kind of a fetus there will be is the nutritional state of the mother at the point of conception.

I don't know what the implications are there. Does that mean that we will have to change the dating patterns of our young and have a good meal go along with every date?

[Laughter.]

But certainly there is a great deal that can and should be done from a preventive point of view. Otherwise, we are just picking up the pieces of pathology that were created often on a predictably preventable basis.

Another intervention that might be highlighted in the earliest days of life stems from our growing ability to identify individual differences in babies which then provide a basis on which we can prescribe how that baby needs to be handled if distortions are to be prevented.

What this bill can provide from this viewpoint is the availability of skilled diagnosis or evaluation of what every individual baby needs, even from the first weeks of life, as it can be identified. This is a point that should be stressed in the provision of these services.

In other words, while there is an understandable stress in the bill on preschool programs, there is plenty of evidence even from the Headstart programs that by three, four and five, years of age, remedial programs are already too late for a great many children. When the distortions are already built in, they often can make it impossible. for these children to utilize the corrective remedial approaches and services that are made available.

With Mr. Sugarman you brought up the whole concept of critical periods, when can changes still be expected to take place. We have information indicating that in the earliest years, in the human's first 2 years particularly, there are critical periods of developmentmaybe it is best to call them optimal periods, because in contrast to the other mamals, the human is more flexible and can recover function even if during the time that function is supposed to be developing, appropriate experience is not available to the baby, there can be recovery.

The best information we have at this point is that if you bypass the optimal period for development of a function, even though the individual can recover some of that function its optimal development or potential often can no longer be achieved. Therefore the timing of appropriate intervention is important.

The other important information we should keep in mind is that in the first 18 months of life, the brain is growing faster than it ever will again. It is then also more plastic and most available for appropriate experience and corrective interventions.

This is best illustrated by the experience of our colleagues in England who have been able to diagnose babies with cerebral palsy in the first months of life, and with intensive treatment for the first 18 months, they are able to prevent the spasticities in most cases. They are even able to correct the skeletal deformities.

That is taking advantage of the time in the individual's life when it is most flexible.

So that again I would like to stress that the services that you are making available through this bill will be emphasizing not only the period of pregnancy but the most important first 2 years.

When a few of us were called together to try to do something about the children who weren't able to learn in school which evolved in the program called Headstart, we said even then that for a great many of the children it would be too late.

Senator MONDALE. Even Headstart would be too late?

Dr. LOURIE. Even Headstart would be too late. We have had to set up treatment programs for children who were dropouts from Headstart.

Another dimension I'd like to direct some attention to in relation to this bill is the fragmentation of services as they now exist.

As we take a look at the services for children, we find that by no means are they only in the programs for health, education and welfare. A great many Federal agencies have programs for children, even the Department of Defense and, the Department of Justice have large programs. Agriculture, Labor, Commerce, Interior, et cetera, all have programs for children."

When we look at what happens by the time these programs are established at the local level, we find that they are not infrequently in competition with each other.

One can drive up 14th Street in the District of Columbia, and on many blocks see store front youth programs, a variety of HUD, Labor, HEW and OEO programs, often overlapping.

Some of our families at the Children's Hospital tell us that it is not unusual for a half dozen people to have knocked at their doors and saying, "I am your community representative, and I will take care of your (comprehensive) needs."

Unfortunately, even with all of this, many children and families fall between the cracks and have no services.

Hopefully there can be a mechanism in this bill for coordinating these sources of service, and their funding. Particularly troublesome are the problems of territoriality, agencies, protecting their turf. This goes on from the top level in the Government down to the neighborhood. Only, unfortunately, by the time it reaches the neighborhood level, it's exaggerated.

The people at the neighborhood level don't know that, at least at the top level, the agency people are talking to each other. At the neighborhood level, they too often are competing with each other.

I would hope that there would be some thought to including in the comprehensive approaches that are so much needed, and would be

made available through this bill, correlation with the Senate bill, 1414, introduced by Senator Ribicoff, the child advocacy aspect.

Senator MONDALE. Yes.

Dr. LOURIE (continuing). Of the children's programs. There need to be the coordinating devices that are outlined in this bill, State councils, mayor's councils, parents' councils, and so on. But these groups need to have the clout the mechanism that can pull together the disparate forces and service patterns to insure that they work together. Partnerships for service and joint funding, are needed instead of competitive funding and services.

Senator MONDALE. I believe you mentioned to me once the suggestion that there ought to only be one person, say, per family, per child, who is assigned, and that all the services and so on would flow through that person, so that you don't have eight or nine different. "directors" of that child. So that you have a program designed for that child in an overall sense.

Can that be practically done, in your opinion?

Dr. LOURIE. It would be the ideal.

Senator MONDALE. That is really what we have in middle-class family life; we have the mother who is in charge, and she doesn't allow too many others to mess around. She runs it.

What do you do in the poor, disadvantaged home where the forces have just overwhelmed and defeated the family?

Dr. LOURIE. The mother should always be the integrator, in a sense. In the middle-class family, she is helped often by the pediatrician who is given the role of being the integrator of the professional services. In spite of some pediatrician's complaint, they became more and more involved, even in the educational system.

The principle underlying this is that if you take responsibility for the development of the child, one must be concerned about his total development.

What is available now to most families in the middle-class sector of our society needs to be made available for the families who are less able to mobilize resources. This includes the overwhelmed, unavailable mothers, who are depressed, or unaware or feeling helpless and hapless.

In other words, we can't separate children from the problems of the families. One example of this is in the problem of lead poisoning in poor children. Why are the children eating the paint from the walls or woodwork? If we take a look at what is happening, it is unavailable mothering.

We are not going to solve the problem simply by taking the old paint off the walls. The basic problem to be in tackled is why that mother is unavailable and what needs to be done to really meet the needs of that child.

The lead poisoning is a signal that something is not working right in the family.

Public health programs that would force the landlord to take the paint off the walls, disregard the real intent of this bill, the desire to reach into what the children and families really need.

To do this one must have access to these families. In other words, the system has to be one that knows every child, knows what he needs and then sees to it that all the services are available to meet those needs.

Senator MONDALE. And is there any effort under way in any other society of which you are aware that is able to structure itself in that personal way to the needs of the child?

Dr. LOURIE. They are thinking along these lines in the Soviet Union. On one of our missions there, one of the cultural exchanges, where a group of scientists were sent over, we were told "it is true that we are classless society, children are our privileged class." Much as we might have questions about many other facets of the Soviet philosophy, this is one that we could well keep in mind. The goal is for child to be as normal as possible. Every woman who is pregnant has to have prenatal examinations, and if she doesn't turn up for them, the police go out to get her.

She has special additions to her diet during her pregnancy. If she is working, she gets the 6 weeks off from work with full pay before and after the baby is born.

In other words, the program in action there reflects basic concern for health and welfare the child.

Urie Bronfenbrenner expressed it in a recent book as "the concern of one generation for the next."

That really could be the subtitle of this act.

Senator MONDALE. In your work you deal, I gather, with a lot of families and children from those families of economically disadvantaged backgrounds; do you not?

Dr. LOURIE. Yes; our hospital is in the middle of the inner city. The riots of 1967 took place all around us.

Senator MONDALE. How important do you believe the comprehensive early childhood approach of the kind suggested in this measure and recommended by your Joint Commission, is to a society which truly equal opportunity to be available to each child?

Dr. LOURIE. I think is it essential. I don't think there is any other way to go about dealing with the basic problems in the community. Senator MONDALE. Would it be fair to say that most American institutions stand neutral during the period of most dynamic growth; and most dynamic damage to children? That is, the schools start at say, age 6, possibly 5. Even Headstart you point out, which is only really a pilot program, starts out at 5, maybe 4. I don't know. In a sense it seems we have decided to stay out of that early childhood period.

Dr. LOURIE. Yes.

Senator MONDALE. And for many, you say it's too late by the time they enter into the services of one of these.

Dr. LOURIE. Yes, there is no question in our minds about this. The community says, you have to make your child known to us, register his birth. But the next time the community says you have te produce him, create visibility for him, is when he has to go to school. And that time in between is the time when many children get lost. For example, let us look at a major problem facing our society, the problem of racism. When did the problem of racism begin? One large factor is when a child takes a look at himself and says, "is black or red or white or yellow good or bad, clean or dirty, beautiful or ugly?"

We can annotate that between two and four is when the children are asking those questions of others as well as themselves. In other words, this is when the fundamental answers are developed by the child.

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