At the June 1997 Stand for Children march, which focused on hope for the future and the health, security and safety of all children, many of the faces of the thousands of children I have treated came into my mind. I asked myself, Did we help them? Did we make a difference? Could we have done something else? I've met many of the children years later when they were adults. Naturally, because of my professional connections with hospitals, transitional living systems, clinics and the prison systems, I mostly have met again the ones who had not made it.

In several cases, I saw their children who, it seemed to me, were continuing the cycle. After a while, I routinely asked what my former patients thought we could have done differently to have helped them adjust better and make better choices. I learned a lot from these discussions. I learned more from the ones I first met when they came to residential care at eight or nine, and then met them again in various developmental stages of their lives, in various levels of institutional care. The strongest themes that emerged from these discussions were:

Luckily, in my life as a psychiatrist, I also met adults I had treated as children whose lives had happier endings, who were self-reliant, productive and feeling good about themselves. I also asked them what made the difference and learned a lot from their answers.

I started thinking about what would make a better system than what we traditionally know and offer, and what would make services have a better impact.

Children represent a non-voting constituency and they experience their emotions, but do not know what they need to comfort them, soothe them and keep them safe. They do not know how to sort out the social, family problems they are faced with. Often they conclude that they are the bad ones. This is why their lives have so much pain and uncertainty.

To provide the best chance of success, I think an effective, comprehensive system for Children's Mental Health should include the following:

I.] Prevention/Early Intervention: The services under this heading are the core of the system. They include psycho-educational programs in the schools with a different focus for different ages. At all ages, the skill of communication/problem solving and social coping skills are necessary. At the high school age (keeping in mind that Buffalo has one of the highest rates of out-of-wedlock pregnancy), programs are needed that give a strong message that giving birth is easy and simple, but that what follows is very difficult and very destructive to the innocent child when psychological bonding, attachment and basic trust do not take place in a safe, predictable and consistent environment. No 14 or 16-year-old is ready to make this commitment. In addition, there is need for:

A.] a variety of easily accessible after-school programs that focus on the assets and strengths of children will build self-respect, encourage healthy relationships, encourage the continuing involvement of parents, address nutrition and provide opportunities for youth leadership and peer counseling;

B.] in my opinion, all children under the age of 18 should prefer spending three to four hours after school in challenging, creative activities available in their neighborhood rather than hanging out on the street corner or flopping themselves in front of the TV. How do you get the kids to the programs? You need people who will volunteer their time to reach out and be mentors and friends and give the message to the child, "You are somebody." These volunteers can be teachers, neighbors, peers, extended family, church groups and volunteer groups;

C.] for the preschooler, all the programs that come under Head Start and quality daycare are essential;

D.] easily accessible multi-disciplinary assessment teams that respond in a timely fashion and are mobile enough to go where the child is (in his or her home, in his or her school) to provide crisis intervention if needed, make a clinical assessment and provide intensive case management focusing on linkage to appropriate treatment services.

II.] Family Preservation: The second goal of any child-caring system is family preservation. What do we need to accomplish this while not overlooking our duties for child protection? Balancing these two can be very difficult. Rather than deal with the anxieties of taking risks, we might make quick decisions to separate families by removing the children to what we hope is a safer environment. This is a trauma the children never forget. Being with friendly strangers is not enough to soothe the pain or deal with the guilt. What could help?

Every time there is a family crisis, domestic violence or a child protection issue, a crisis home intervention team should get into action. This team should not have a time limit but stay with this family and child through the various phases of the treatment and placement process. A primary therapist a family can learn to trust should also double as the case manager. This person would work with all the systems affecting the identified child's life, with the main goal being to focus on strengthening the assets of a particular family and mobilizing appropriate supports so that the family can be preserved or, if placement of the child is needed, to return her or him to the family as soon as possible. While in placement, the therapist/ICM would not only work with the child, but would teach the foster parents to be sensitive to what the child's behavior means and how to be therapeutic to the child's adjustment process.

We do need a foster care system, residential treatment centers and psychiatric hospitals for children. The problems of some children are too severe and too persistent. However, these systems need to be seen as second best choices, as the best choice is intensive treatment of the child in his or her natural environment. In the very rare cases where families do not exist or are extremely pathological, we need a legal system that moves quickly to secure permanency through adoption while making sure that the children and adoptive parents continue to have access to therapeutic services for as long as they need them.

Investing in health promoting programs for children is not only effective in future outcomes, but cost-effective for society at large.

Program providers need to work together and know of each other's existence and strengths so as to avoid duplication, fragmentation and competition. We must never forget that the only goal is to serve the needs of the individual child and the child's support system in a fashion that is unique and specific to this one child and family.

Many of the people working in the field of Child Health & Welfare share the same philosophy of treatment intervention I have outlined above. Changes are happening. We do have programs that focus on addressing the issues I discussed. We just need more of them.