Children and adolescents have always experienced trauma leading to emotional and behavioral difficulties. Yet this has been overlooked throughout history. As I reviewed the history of mental health treatment in Oregon for this series, this was the most striking gap: there has been no organized account of what mental health problems and treatment looked like for kids throughout the history of this state.
For instance, there was no information about children in Olaf Larsell’s “History of Care of Insane in the State of Oregon,” a major 1945 article that formed the basis for much of my understanding of Oregon’s mental health treatment history. There was a brief section on children in Karen Unger’s comprehensive paper, “History of Mental Health Services in Oregon: 1945-1999,” and brief mentions in other histories, but that is all.
Yet the treatment of children and youth in Oregon’s mental health system throughout our state history is a worthy subject for a book and deserves much more illumination than I am able to provide here. What this article can do is provide snapshots from that history, and hopefully that will stir interest in further investigations of this history.
Orphan Trains
Perhaps the first recorded instance of children’s emotional and behavioral difficulties in Oregon begins in the mid-1800s. At this time, the plight of many children in the eastern states was one of neglect and worse. Some had parents—often destitute or alcoholics—who couldn’t care for them. Others were orphans, often homeless and suffering abuse of all kinds.
Starting in 1853, these children caught the attention of several charitable organizations. Their solution was to organize trains to transport these children to the Midwest and the West Coast, with the thought that settlers in this part of the country would be able to provide better homes. These so-called “orphan trains” transported a total of 250,000 children to these distant parts of the country, and Oregon was one such landing spot.
Once the train arrived, the children were displayed like animals before local families who could opt to pick a child on display. If a child wasn’t taken at the first such public event, they were taken to another site and once again put up for selection by local families.
While many such children were adopted by well-meaning parents, others were placed with cruel and exploitive families and often forced to work outdoors for long hours on newly developing farms. Even to the end of the 1800s, children in the nascent “foster” system were most often not legally adopted but instead were indentured servants, working in exchange for having their basic needs met.
A series by Oregon Public Broadcast on the orphan trains included a first-person account by an orphan train child brought to this state. He told of how he was crudely examined for placement by a farmer, and how he bit him and kicked him as he was being herded off the stage that had been set up to display the children to the locals. After the child grew up, he said, “Everybody in the audience thought I was incorrigible.”
This mistreatment of children ultimately led in later years to what might be called “residential” care for disturbed children. By the early 1900s, philanthropic organizations began to shuttle some of the children into large houses in rural settings where the children were cared for in some fashion. A few of these nascent “mental health” programs still exist today, like the Children’s Farm Home now operating as Trillium Family Services. Beginning in 1923, the Children’s Farm Home provided a family-like environment with recreational activities and even vocational training for the kids.
Yet during that time, the children and adolescents residing in these homes were not seen as youth with psychiatric problems, but rather as children with behavioral and emotional difficulties. Today, of course, these children would be given a psychiatric diagnosis and medicated.
In contrast to these residential-type programs, Oregon’s first state mental hospital opened in 1862, and children began showing up in asylum records as well.
Life in the State Hospital
Hawthorne Asylum, opened by John Hawthorne in Portland in 1862, was based on the moral treatment model. It was intended to provide a calm environment with respectful relationships, exposure to the outdoors amid peaceful grounds, and minimal use of physical restraints. It even received the support of famed hospital reformer Dorothea Dix.
The youngest patient on record was a six-year-old boy; there was at least one girl, aged 15. In the late 1800s, Abigail Scott Duniway (considered Oregon’s first suffragette) reported that there were 23 children among 195 patients. It is not known why these children were committed or how that came about, although in all likelihood their families could not cope with the problems and simply abandoned them. We do know from later state hospital records that many of the children who ended up in the asylum were considered developmentally disabled.
In 1883, the Oregon State Insane Asylum (later renamed Oregon State Hospital) opened in Salem, and while there is no good count of the number of children and adolescents that were placed in that asylum during its first decades, histories do tell of their living in wards with troubled adults.
In her book Inside Oregon State Hospital, Diane L. Goeres-Gardner writes that the children on the wards were exposed to a number of serious health problems including measles, whooping cough, mumps, scarlet fever, jaundice, and dysentery. She reported that between 1900 and 1902 “eight children had come down with diphtheria, one had died.”
At the turn of the 20th century, the state hospital was surely a miserable place for a child or adolescent. The Oregon State Hospital was overcrowded, and John Calbreath, who had become superintendent in 1900, stated that the “most difficult problem at the hospital was curbing abuse of patients.” Unfortunately, there are few accounts of how children and adolescents were treated during the next five decades, which saw the introduction of harsh somatic treatments that patients feared: ECT, insulin coma therapy, and lobotomy, for example.
Yet, in contrast to the accounts of abuse, historical accounts also tell of patient parties, Christmas events, and musical recitals performed by the hospital orchestra. A glimpse of this better side of the asylum can be found in an article published by a patient, C. L. Brown. Her article was titled “Oregon State Hospital During the 1960s” and in it she described how she and other children would roller skate in the extensive warren of tunnels at the asylum.
In 1961, the first program for children within the hospital was started when a unit for 10 boys was created. This was the beginning of psychiatric care tailored for children, and by 1964 there were 80 to 90 beds set aside in the hospital children and adolescents, with the state estimating that there was a need for 320 beds. By 1967, a proposed state budget provided funding for the construction of a new building specifically for children. The final decision was to remodel one section within the hospital for children.
The next year saw the first effort to provide community alternatives to the state hospital. A pilot project was set up in Portland for children under 12 to “clarify the needs of the young population.” The effort to move psychiatric care from the hospital into the community was underway by this time and this effort extended to children and adolescents who, in the past, had been hospitalized and often kept there for extended periods of time.
The Rise of Community Services
The history of the asylum tells of societal responses to those deemed mentally ill, or, in the case of children and adolescents, deemed disturbed and incorrigible. At the same time, in the first half of the 20th century, a mental hygiene movement arose in the United States that sought to improve the mental health of the general population, which included efforts improve the development of children. This became a second influence that would morph into community services for children.
In 1926, an article in the American Journal of Public Health told of “The Role of the Child Guidance Clinic in the Mental Hygiene Movement.” The clinics were designed to promote good physical and mental well-being that would help turn children into healthy adults. Six years later, the University of Oregon Medical School (later Oregon Health and Science University) established a child guidance clinic based in Portland that featured “traveling clinics” to provide such services to children and families. In 1941, Oregon created the Division of Mental Hygiene with the goal of “improving the mental health of all Oregonians, especially children, to improve the effectiveness of programs and thus to prevent “insanity.”
However, these clinics never obtained the funding to provide such “mental hygiene” services to the general public, and this community effort began to lag in the 1950s, as state budgets were strained by funding the growing population in the state hospital. However, there were a handful of day and residential programs established in the 1950s to provide such services to children and youth, and that experience fed into the 1967 Portland pilot project, which could be seen as arising both from the deinstitutionalization movement, which was moving care for disturbed children into the community, and the mental hygiene movement, which sought to nurture good mental health in all children, and thus help reduce the risk that they would become emotionally disturbed.
The Medical Model Takes Hold
In 1975, Medicaid funding was approved for mental health services, and services for children and adolescents began to be organized around the medical model. The focus was on assessment, diagnosis, and treatment plans that sorted diagnosed children into outpatient, residential, and psychiatric hospital settings. The use of psychiatric medications dramatically increased in the following years, starting with the antipsychotics and then other classes of drugs, most notably stimulants and antidepressants.
During the 1980s, as the notion took hold in American society that drugs were effective treatments for specific disorders, there was a decrease in inpatient care for children and adolescents. Medicated children stayed with their families, or were put into foster care settings.
In the 1990s, this medical model was softened with a movement toward trauma-informed care. Although the medical model that emphasized prescribing of drugs was still present, there was an attempt in many programs to value patient voices, and the voices of their families and other advocates. Many community programs emphasized the value of multi-disciplinary team treatment, which included peer supports.
In 2008, Medicaid funds for physical health, substance use and mental health were transferred to 15 Coordinated Care Organizations. They were responsible for integrating all-health related services to improve health outcomes and they had to pay for all Medicaid-funded care for all low-income people. They tried to minimize the use of the most expensive services like hospitalization and residential care. Outpatient services became more regionalized, which made it possible for youth to receive services closer to their families and communities.
Here is a story recounted by a therapist that tells of how community care, which brings together schools and existing therapeutic programs, can produce good outcomes.
In one community there was a 12 year old boy who was throwing things at cars. His parents and the school authorities thought he was going to hurt someone so the therapist sat down with him and realized that the issue was that his parents were always busy working. He was an only child, small for his age, and was bullied a lot. He wasn’t good at athletics and didn’t fit in anywhere. Instead of having him diagnosed and placed on medications, the therapist asked him if he wanted to be in the adolescent theater program that had been designed for troubled youth. Even though he was a little younger than the other participants, he soon flourished and stopped acting out because he was listened to and not having a treatment imposed on him that he didn’t want.
Ongoing Use of Psychiatric Medications
While the above anecdote told of a therapist who didn’t pathologize the child, the prescribing of psychiatric drugs to children and adolescents in Oregon became routine in the 1990s, and has remained so ever since.
In 2017, the American Academy of Child and Adolescent Psychiatry posted a document online titled “Psychiatric Medication for Children and Adolescents.” The guidance begins by stating that “Medication can be an effective part of the treatment for several psychiatric disorders.” It includes the full range of diagnoses from bedwetting to anxiety to depression to bipolar to psychosis and more. There is no mention of well-researched outcomes with this paradigm of care, nor any mention that long-term use could have many adverse effects, such as metabolic disorders and emotional blunting. In essence, psychiatric medications are presented as effective, even though there is an absence of well-designed studies to support that belief.
I used a Freedom of Information request to look at the amount of Medicaid spending in Oregon related to the prescribing of psychiatric drugs to children and adolescents. In 2017-2018, Oregon spent $3.8 million on antipsychotics prescribed to those 18 and younger, and $1.3 million for antidepressants. Antipsychotics of course have many adverse effects, and are really being prescribed for behavioral control reasons, as opposed to serving as a disease-specific treatment. As for antidepressants, a black box warning tells of how they increase the risk of suicide in children and adolescents, and most clinical trials in youth under age 18 have found them ineffective.
Yet at least the largest of Oregon’s child and adolescent treatment agencies, Trillium Family Services, has trained staff and adopted trauma informed care as its program’s overall approach. Other service providers are moving in this direction, but are limited by their reliance on Medicaid. However, some Oregon managed care organizations are building contracts to implement trauma informed care. The future for adopting alternatives to the medical model in Oregon and every other state will be impeded by what the federal government is poised to do with major cuts to Medicaid so that in spite of growing hopes for alternatives to services, this may all be short circuited. So many families will still have difficulty accessing such services, particularly those who live in rural areas, and a medical model that pathologizes children and emphasizes drug treatment is still the dominant form of care.
The history writ large is that the orphan trains gave way to asylum care for a limited number of children, with such treatment then moving into community settings in the 1960s, and aimed at a much larger number of children. This push into the community remained after American psychiatry introduced a disease model with its publication of DSM-III in 1980, which in turn made diagnosis and prescribing of psychiatric medications the standard form of treatment.
Unfortunately, this is not a history that tells of care that has been successful in reducing the burden of mental disorders in Oregon children.
Lessons
- Other states would do well to review the history of their mental health services for children and adolescents because they are likely to have been left out in conventional reviews of psychiatric services in their states.
- Most programs and approaches were developed with positive intentions and a belief that programs would work.
- The role of authoritarian dynamics takes place when providers do not listen to families and their children. Grassroots reform must include their voices in such advocacy efforts.
- There must be much greater attention given to the overuse of psychiatric medications. This will take bold leadership because this is a difficult system to change.
- We need to have the courage to stop doing things we know don’t work or may be doing harm, and develop alternatives. There are elements of progress that have been made in our forms of care for children and adolescents, but the pathologization of children and overprescribing of psychiatric drugs tells of a system that has been waylaid by financial and guild interest.
It seems fitting to me that this history of mental health in Oregon ends with an admittedly abbreviated picture of this state’s attempt to grapple with the needs of children and families. Some, if not all of these efforts, started with good intentions. It’s apparent that some worked and others did not. Putting orphans on trains was an example of well-intentioned philanthropy that unfortunately turned into a system of abuse. Putting children and adolescents into the state hospital arose out of desperation to help kids that no one wanted. Medicaid funds propped up a medical rather than a social model for creating a system of care.
This is a history that should inspire Oregon and other states to listen to the voices of children, adolescents, and families about what can best be done to help youth struggling with difficult emotions and behaviors, and to create care that best responds to their needs.
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