It's Nobody's Fault_ New Hope And Help For Difficult Children And Their Parents Part 11

THE TREATMENT.

Here's how one mother describes the treatment that Jacob, her 10-year-old child with PDD, is undergoing. "He's on Dexedrine, a little bit in the morning for his attention span. He's on Depakote twice a day for his irritability and impulsivity. He takes Paxil every night and Xanax when he needs it for anxiety.

"He sees sees a speech therapist who also does NDT-neurological developmental therapy. He really needs help with his articulation. He's a lot better than he used to be, but the kids still make fun of him. A few months ago he saw a behavioral therapist, and she helped him get a little more organized. I'd been trying to get him to clean up his act around here, but I wasn't getting anywhere. She made a chart with a list of things he has to do around the house. Every time he does his ch.o.r.es, he gets a star. When he does his homework right after school, he gets a star. She worked on table manners with him too. Eating properly is hard for him because he's so uncoordinated, but they practiced, and she figured out a reward system for dinnertime too. He trades in his stars for time playing Sega, which he loves. a speech therapist who also does NDT-neurological developmental therapy. He really needs help with his articulation. He's a lot better than he used to be, but the kids still make fun of him. A few months ago he saw a behavioral therapist, and she helped him get a little more organized. I'd been trying to get him to clean up his act around here, but I wasn't getting anywhere. She made a chart with a list of things he has to do around the house. Every time he does his ch.o.r.es, he gets a star. When he does his homework right after school, he gets a star. She worked on table manners with him too. Eating properly is hard for him because he's so uncoordinated, but they practiced, and she figured out a reward system for dinnertime too. He trades in his stars for time playing Sega, which he loves.

"He goes to group therapy too, so he can practice his social skills. He's learning how to talk to people if he goes someplace new. He's also learning how to handle the teasing he gets at school. Kids who are different get positively brutalized by the other kids. Jacob is learning concrete ways to defuse what they say and when to ignore it. He's learning specifically what to say and do when this happens. They don't do theory there. They rehea.r.s.e and practice, with role playing and everything. Group therapy has been great for Jacob."

I've offered up the details of one boy's treatment package not because Jacob's treatment is right for every child with PDD but because it ill.u.s.trates two important facts about any treatment for PDD. The first is that we don't cure PDD; there is as yet no cure. We just fix as many symptoms of the disorder as possible and help a child to reach the highest level he is able to achieve. The second is that with PDD we take a multidisciplinary approach to treatment, going at the disorder with every weapon in the a.r.s.enal. When a child has PDD, careful attention must be paid to his placement in school. Some high-functioning children with PDD may be better off in a regular cla.s.sroom, with normal intellectual stimulation and a garden-variety social life, than in a highly structured cla.s.s filled with other children who have PDD. In all likelihood these kids will need additional attention outside of school, however. Speech therapy, language therapy, occupational therapy-any or all of these may be called for. Lower-functioning children with PDD will need the resources that special education offers, especially speech arid language therapy. The primary goal of a child with autism is to learn to communicate. We try to get him to speak and use language. If he can't speak, we encourage him to write or use sign language or rely on visual cues. Communication is vital, and there's more than one way to communicate. Once a child can communicate, he's in a position to learn a variety of other skills, especially those a.s.sociated with social interaction.

Behavioral therapy has been helpful in decreasing the negative behavior a.s.sociated with PDD. Parents who learn behavior modification techniques can help the process along. Parent counseling is also an invaluable component of the PDD treatment package. Parents of children with PDD may benefit greatly from the company of others who are in the same predicament, who can offer information, support services, and a pat on the back when it's most needed. The Autism Society of America (see Appendix 2 Appendix 2) provides these and other services.

Medication is nearly always recommended in the treatment of PDD and autism, not because it eliminates the core deficits that these children have but because it treats symptoms that interfere with their ability to function. Prozac, Zoloft, and Luvox increase a child's ability to relate socially, decrease repet.i.tive thoughts, and lower aggression. One 16-year-old boy I treated for autism showed marked improvement on Luvox; he stopped banging his head against the wall of his bedroom, started partic.i.p.ating in a day treatment program, and-perhaps most remarkably-signed a beautiful Mother's Day card for his mom.

Psychostimulants, such as Ritalin and Dexedrine, are used to treat the attentional problems and hyperactivity a.s.sociated with PDD and autism. Once their attention span has been increased, kids with PDD are more receptive to other interventions, such as behavior modification and language therapy. These kids can be very sensitive to medication, so we start with low doses. Catapres, an antihypertensive agent, has been used to decrease irritability, hyperactivity, and impulsivity. The most common side effect of Catapres is sedation. Depakote helps the irritability, insomnia and hyperactivity that are seen in certain children with PDD and autism. The side effects of Depakote, which are infrequent, are stomachaches, increased appet.i.te, and drowsiness.

The child with autism may improve over time-50 percent of children who are mute in preschool eventually do speak, and some learn to play near other children-but autism cannot be cured. The best thing we can do for these kids is to help them learn how to work around these deficits and even use them to their advantage in their daily life.

PARENTING AND PDD.

There was a time not long ago when parents of kids with autism had an additional burden: being blamed for their child's disease. The thinking was that mothers who were cold to their babies caused them to have autism; it was called the "refrigerator mom" theory. At least parents today don't have to suffer the agony of that guilt. Now we know that parents don't cause autism. In fact, they can't can't cause the disorder. We have seen children who have been horribly abused, neglected, mistreated, and misunderstood, and they don't develop autism any more than the general population. No matter how bad a job parents do, they can't create this disorder. Unfortunately, no matter how good a job they do, they can't cure it either. Parents of these kids often search for a cure and therefore are very susceptible to unorthodox and unproven treatment recommendations. These treatments are not only ineffective but can at times increase financial, parental, and family stress. cause the disorder. We have seen children who have been horribly abused, neglected, mistreated, and misunderstood, and they don't develop autism any more than the general population. No matter how bad a job parents do, they can't create this disorder. Unfortunately, no matter how good a job they do, they can't cure it either. Parents of these kids often search for a cure and therefore are very susceptible to unorthodox and unproven treatment recommendations. These treatments are not only ineffective but can at times increase financial, parental, and family stress.

Children with autism don't do many of the things that make babies and children lovable and emotionally rewarding. They don't coo or smile or curl up in Dad's lap. They're not affectionate; they don't cuddle or light up when they see Mom come home from work. They rarely make connections with anyone, not even their parents. It's not surprising, then, that the parents of kids with autism become very demoralized. On an intellectual level parents may understand that their child has a devastating brain disorder, but the reality that they might never be hugged or kissed by their own child is something they find much harder to accept.

Faced with the bizarre, often unpleasant behavior of a child with autism, many parents lose patience with their situation, and it's not unusual to see friction in the household. In the typical scenario the mother of a child who has autism is the "good cop"; she lets the child go through his rituals without making a fuss. Dad is usually more strict and angry-the "bad cop." For instance, one little boy I treated liked to play with the VCR, popping a video in, hitting the Eject b.u.t.ton, then popping the video back in again. He could do this for hours. The VCR game enraged the father, and he took his anger out on Mom.

"Why do you let him do that?" he shouted.

"He's not hurting anyone, and it keeps him occupied," answers the mother, who had been following the little boy around all day. "I need a break."

Now Dad is even more frustrated and angry. "But he's acting crazy! Can't you get him to stop?"

Anger, frustration, sadness-all of these feelings are common in parents whose children have a serious brain disorder, and this is why I tell parents that it's essential to take a break now and again. Parents cannot and should not be caretakers all of the time, even when circ.u.mstances demand their constant attention. They have to take time out once in a while to be alone together as husband and wife. I highly recommend an evening out on a regular basis. If parents can spend the night away from home, so much the better. Treating PDD and autism is a marathon, not a sprint, and parents must conserve their emotional resources so that they'll be able to go the distance. That's the only way they'll be able to maintain the energy to see that a child gets the treatment he needs.

There's one final thing that a child with pervasive developmental disorder sorely needs, and that's a cheerleader, someone who will encourage him to stop thinking about what he can't do and feel good about what he can do. Jacob's mother describes what I mean.

"My main goal is to make him feel as good about himself as possible, because if he feels good, all the speech therapy and the other stuff is going to work better. He has to meet us, maybe not halfway but somewhere. I don't let him get down. I won't let him lie in bed and get depressed; I rip him out of bed and make him do something. The hardest thing for me about this whole disease is getting him to accept himself, to see that he is a good person. I want him to know that he's worth something.

"Last summer he took a giant step forward. We finally found the perfect camp for Jacob. He wasn't the highest achiever there, but he wasn't the lowest either. He was involved in all sorts of activities, and he made a lot of friends, and his letters were full of great things he was doing. He had never said those kinds of things before. When we went for Parents' Day, I could see from a distance how happy he was. He walked up to us and didn't even say h.e.l.lo. He just said, 'I'm coming back back here next summer!' I think that was one of the best days of my life." here next summer!' I think that was one of the best days of my life."

Afterword.

"WORKING WITH SICK kids every day must be really sad. Doesn't it get to you?" Hardly a day goes by that I don't hear that question. I certainly understand what makes people ask it of someone in my line of work. Of course, it is sad, very sad, to see children in pain. Seeing any living thing experience distress and dysfunction-we're back to those two D's again-is upsetting. When the distress and dysfunction belong to a child and the treatments don't work, it can be heartbreaking. I'm a father as well as a doctor, so I know full well that the troubled children I treat every day could just as easily be one of my own three sons. Hardly a day goes by that I don't hear that question. I certainly understand what makes people ask it of someone in my line of work. Of course, it is sad, very sad, to see children in pain. Seeing any living thing experience distress and dysfunction-we're back to those two D's again-is upsetting. When the distress and dysfunction belong to a child and the treatments don't work, it can be heartbreaking. I'm a father as well as a doctor, so I know full well that the troubled children I treat every day could just as easily be one of my own three sons.

Nearly 20 years ago, when I decided to become a child and adolescent psychiatrist, I thought that I'd be able to help certain kids have an easier time growing up. I guess I saw myself as the Judd Hirsch character from Ordinary People Ordinary People, the wise, kindly, hip psychiatrist whose very special relations.h.i.+p with a teenager helped the boy get through a difficult period in his life. I didn't know then that the field I chose was about to take a giant leap forward, that I was going to do a lot more than help children and adolescents cope with their troubles. The progress that has been made in our understanding of the brain's involvement in children's psychiatric disorders and the use of medication has meant that my colleagues and I have been able to change, and sometimes even save save, the lives of young people, just like neurosurgeons and cardiologists. I ended up getting a lot more than I bargained for.

So I tell people no, my job isn't isn't sad and most times it sad and most times it doesn't doesn't get to me, because I know there's almost always something I can do to make a child's pain go away. I can relieve the suffering of his or her parents as well, first by rea.s.suring them that what's wrong with their child is not their fault and then by telling them how we can make the child better. I hope I've gotten that message through loud and clear in these pages. get to me, because I know there's almost always something I can do to make a child's pain go away. I can relieve the suffering of his or her parents as well, first by rea.s.suring them that what's wrong with their child is not their fault and then by telling them how we can make the child better. I hope I've gotten that message through loud and clear in these pages.

I'm in the business of helping troubled children live normal, happy, productive lives, and there's nothing sad or dispiriting about that. On the contrary: working with sick kids every day is a joy. I hope you find the same joy bringing out the best in your child.

APPENDIX 1.

A Definition of Terms WHAT FOLLOWS is a list of some of the terms used frequently in It's n.o.body's Fault. It's n.o.body's Fault. I describe them here not as they are defined in textbooks or medical dictionaries but as they apply to the field of child and adolescent psychiatry and suit the purposes of this book. I describe them here not as they are defined in textbooks or medical dictionaries but as they apply to the field of child and adolescent psychiatry and suit the purposes of this book.

BEHAVIORAL THERAPY. A goal-oriented approach based on the principle that all behavior is learned and that undesirable behavior can be unlearned through training. The focus is on the here and now, on figuring out how to change behavior, not on finding out why why the child feels or behaves a certain way. the child feels or behaves a certain way.

BEHAVIOR MODIFICATION. The core of behavioral therapy, this is the therapeutic approach by which undesirable behavior is "unlearned" and replaced by different, more desirable behavior. Positive and negative reinforcement play an important part in behavior modification. A system of rewards and mild punishments (usually loss of privileges) can be a big help in motivating a child to change the way he reacts to a given situation. The role of parents is extremely important in behavior modification.

CAT. Computed Axial Tomography. This is an advanced form of X-ray that permits us to look at structures of the brain.

CO-MORBIDITY. A situation in which a person is diagnosed with two or more disorders at the same time. One disorder is said to be co-morbid with another. Co-morbidity is extremely common in the brain disorders of children and adolescents. Few of these disorders are completely "clean."

COGNITIVE. Having to do with thinking. Cognitive functions include remembering, understanding, judging, and reasoning. Cognitive behavioral therapy requires an ability to talk about your own thoughts and feelings, so it is more likely to be effective for older children than it is in the treatment of the very young.

CONCORDANCE. This term, which is usually used in genetics, refers to the similarity in twins with respect to the presence or absence of a disease or a trait. Higher concordance rates in identical twins than in fraternal twins indicate that there is a genetic component to that disease. Twin studies of the brain disorders in these pages all show a higher concordance rate in identical twins than in fraternal twins.

DNA. Deoxyribonucleic acid. The stuff of which genes are made. DNA is largely responsible for the transmission of inherited characteristics, including brain chemistry.

DISINHIBITION. An increase in hostility, aggressiveness, irritability, and impulsivity. This reaction can be caused by certain antianxiety agents, specifically the benzodiazepines. This side effect usually disappears when the dose is lowered and always disappears when the medicine is discontinued.

EEG. Electroencephalogram. This is a graphic depiction of the brain's electrical impulses. Since 1929 the EEG has been used to detect the presence of brain malfunctions, including the seizures a.s.sociated with epilepsy.

FAMILY THERAPY. Psychotherapy in which problems are understood and treated in the family. How a child's disorder affects all the members of the family and how the family affects the child are addressed. The goal of family therapy is to bring about a change in the way family members interact. Unlike parent counseling, where a therapist advises the parents, family therapy requires the cooperation of the entire family to make changes and find solutions.

INTELLIGENCE. A person's ability to learn and to understand and process information for problem solving. An intelligence test is used to measure those aspects of mental development that are relevant for academic achievement. A person's IQ-his intelligence quotient-rates his intellectual ability, according to verbal skills and performance skills.

MRI. Magnetic resonance imaging. MRI is a neuroimaging technique that uses magnetic fields instead of radiation and allows us to examine the structure of the brain, especially the existence of tumors, vascular malfunctions, and brain deterioration.

NEUROANATOMY. The structures that compose the brain and the nervous system.

NEUROIMAGING TECHNIQUES. Techniques that provide data on brain activity and function. As far as the brain disorders of children and adolescents are concerned, these techniques are useful not for the purposes of diagnosis but for increased knowledge of how the brain functions and how it reacts to medication, among other things. Some of the most commonly used neuroimaging techniques are MRIs, PET and CAT scans, and SPECT.

PARENT COUNSELING. A therapeutic approach in which parents are educated about their child's brain disorder and given information and advice on general issues and on the specific problem they may be having with the behavior of their child.

PARENT TRAINING. This is a systematic goal-oriented process in which parents are taught, quite specifically, how to manage the behavior of their troubled child by means of positive and negative reinforcement. For instance, parents might be taught how to encourage alternatives to such negative behaviors as temper tantrums, aggressiveness, and destructiveness. This technique is used for children of all ages; but it is especially appropriate for parents of young children.

PERFORMANCE ANXIETY. The apprehension and nervousness that come before an event requiring the demonstration of a child's or adolescent's abilities-a test, piano recital, oral report, and so on. Simple performance anxiety, which is a perfectly normal response, does not negatively effect the youngster's performance. Pathological performance anxiety, which is not normal, does impair a child's ability to perform.

PET SCAN. PET stands for positron emission tomography. This neuroimaging technique produces images of the brain's activity as a patient is directed to complete specific tasks, such as reading or naming objects. Measurement of brain metabolism with the use of PET scans has been helpful in identifying differences in the brains of adults with specific brain disorders and showing us how the brain responds to various medications.

PSYCHOTHERAPY. The treatment of mental or emotional disorders by psychological means, usually involving communication between patient and therapist. Psychotherapy may involve individuals, families, or groups, and there are many different methods employed to bring about change.

PSYCHOTIC. This term describes someone whose ability to distinguish what is real from what is not real is impaired. A person who is psychotic creates his own "reality"; he may have delusions and hallucinations. Faced with concrete evidence that what he believes is true is not true, he stays with his own version. (See reality testing) reality testing) REALITY TESTING. A person's ability to distinguish reality from fantasy or his inner wishes and feelings from the external world. For example, a paranoid person believes that somebody out there is trying to get him. He doesn't recognize that his fears are in his mind. When someone has hallucinations, he truly believes that the voices are real. When he's treated with medication and starts to improve, he begins to wonder if the voices are real. Once he's better, he'll say that he used to hear voices that he thought were real, but now he knows they weren't. Having good reality testing means being intact again.

SEDATION. The state of being sleepy. Sedation is a side effect of many psychiatric medications, including the antianxiety agents, some antidepressants, and certain neuroleptics.

SELF-MEDICATION. Using alcohol and illicit drugs, such as marijuana, in an effort to improve one's mood and general feeling. Untreated adolescents with brain disorders frequently turn to self-medication.

SOCIAL CUES. The facial expressions and body movements that express a person's intentions and reactions. Some kids with brain disorders are impaired in their ability to recognize and respond to social cues in their family and friends.

SPECT. Single photon emission computed tomography. This neuroimaging technique measures blood flow in the brain and the utilization of glucose, the form of sugar used by cells. It also highlights which parts of the brain are active and determines whether or not blood flow and activity are typical. SPECT is used primarily as a research tool for brain disorders in children and adolescents.

TEMPERAMENT. A set of character traits that an infant is born with. Sometimes thought of as a child's basic disposition disposition, temperament is the foundation of his personality.

t.i.tRATION. The process of determining the exact dose of medication needed for a child or an adolescent with a brain disorder by evaluating his response to the medicine. Specifically, we look for a decrease in symptoms and the presence of side effects.

TRAUMA. An event, injury, or emotional shock that has a negative effect on a person's mental or psychological state of mind.

VISUAL IMAGERY. A technique used in behavior modification in which the child or adolescent pictures himself in a certain situation and, guided by a therapist, learns how to cope with the feelings that the situation brings on. Guided visual imagery is especially useful in combating phobic reactions and anxiety.

APPENDIX 2.

Resources and Support Groups THE FOLLOWING ORGANIZATIONS and other resources-categorized according to type of disorder-can be very helpful to children and adolescents with no-fault brain disorders and can offer information and support to their parents and other loved ones as well.

ANXIETY DISORDERS.

Anxiety Disorders a.s.sociation of America 6000 Executive Blvd, #513 Rockville, MD 20852 Phone: 301-231-9350 This group promotes the prevention and cure of anxiety disorders (generalized anxiety disorder, obsessive compulsive disorder, separation anxiety disorder, and social phobia) and works to improve the lives of people who suffer from them. Members are individuals with anxiety disorders, clinicians, researchers, and other interested individuals. A network for parent support groups is being developed. The group publishes a newsletter.

OC Foundation, Inc.

P.O. Box 70 Milford, CT 06460-0070 Phone: 203-878-5669 This organization is dedicated to finding a cure for obsessive compulsive disorder and improving the welfare of people with OCD. It provides education, research, and mutual support and publishes a bi-monthly newsletter for families (The OCD Newsletter), a semiannual newsletter for and by kids ( semiannual newsletter for and by kids (Kidscope), and a videotape called The Touching Tree The Touching Tree, which describes OCD to children.

Selective Mutism Foundation, Inc.

P.O. Box 450632 Sunrise, FL 33345-0632 This organization offers support for parents of children with selective mutism. It is also open to adults who have the disorder or who have had it in the past. The group provides information and referrals as well as a quarterly newsletter. For information send a self-addressed envelope with two stamps.

ATTENTION DEFICIT HYPERACTIVITY DISORDER.

Children and Adults with Attention Deficit Disorders (CH.A.D.D.) 499 Northwest 70th Avenue Suite 101 Plantation, FL 33317 Phone: 954-587-3700 or 1-800-233-4050.

web site: http://www.chadd.org/ This international organization offers information and support for families with children with ADD and ADHD and gives guidelines and a.s.sistance to parents and others interested in starting support groups. CH.A.D.D. publishes a quarterly newsletter and magazine.

AUTISM.

Autism Research Inst.i.tute 4182 Adams Avenue San Diego, CA 92116 web site: http://www.autism.org/ This is a network of parents and professionals concerned with autism. The group conducts and fosters scientific research designed to improve the methods of diagnosing and treating the disorder. It publishes a newsletter.

Autism Society of America 7910 Woodmont Avenue Suite 650 Bethesda, MD 20814-3015 Phone: 1-800-3AUTISM or 301-657-0881 web site: http://www.autism-society.org/ This organization is dedicated to increasing public awareness about autism and the day-to-day issues faced by the patients, their families, and the professionals with whom they interact. It publishes a newsletter, holds an annual conference, and sells books related to autism.

EATING DISORDERS.

Anorexia Nervosa and Related Eating Disorders, Inc.

P.O. Box 5102 Eugene, OR 97405 Phone:541-344-1144 web site: http://www.anred.com/ This organization offers free and low-cost information, distributed through booklets and a monthly newsletter, about eating and exercise disorders. It also provides speakers and programs for schools, agencies, and other groups.

American Anorexia/Bulimia a.s.sociation, Inc.

165 West 46th Street Suite 1108 New York, NY 10036 Phone: 212-575-6200 This organization educates the general public about eating disorders and provides referrals for patients and their families, recommending self-help groups, treatment centers, and health care professionals specializing in this field.

National a.s.sociation of Anorexia Nervosa and a.s.sociated Disorders Box 7 Highland Park, IL 60035 Phone: 847-831-3438 This group seeks to understand and alleviate the problems of eating disorders; to educate the general public and professionals in the health field about eating disorders and methods of treatment; and to encourage and promote research. It offers referrals to health care professionals and support groups and publishes a newsletter.

MOOD DISORDERS.

National Depressive and Manic-Depressive a.s.sociation 730 N. Franklin Street Suite 501 Chicago, IL 60610-3526 Phone: 1-800-826-3632 or 312-642-0049 This organization educates patients, families, professionals, and the public about the nature of major depressive disorder and bipolar disorder/manic depressive illness; fosters self-help for patients and their families; works to eliminate discrimination against people with mood disorders; and improves the availability and quality of help and support. It publishes a newsletter and holds an annual conference.

National Foundation for Depressive Illness, Inc.

P.O. Box 2257 New York, NY 10116-2257 Phone: 1-800-248-4344 This organization provides referrals of doctors and support groups for people with major depressive disorder and bipolar disorder/manic depressive illness. It publishes a quarterly newsletter and conducts regular seminars and conferences.

Depression and Related Affective Disorders a.s.sociation Meyer 3-181 600 North Wolfe Street Baltimore, MD 21287-7381 Phone: 410-955-4647 This organization's mission is to alleviate the suffering arising from depression and bipolar disorder/manic depressive illness by a.s.sisting self-help groups, providing education and information, and lending support to research programs. Support services include publications and educational videotapes.

SCHIZOPHRENIA.

National Alliance for Research on Schizophrenia and Depression 60 Cutter Mill Road Suite 404 Great Neck, NY 11021 Phone: 516-829-0091 This national organization raises and distributes funds for scientific research into the causes, cures, and treatment of severe mental illnesses, primarily schizophrenia and major depressive disorder. It publishes a newsletter.

TOURETTE SYNDROME.

Tourette Syndrome a.s.sociation, Inc.

42-40 Bell Boulevard Suite 205 Bayside, NY 11361-2820 Phone: 1-800-237-0717 or 718-224-2999 or 888-4-TOURETT web site: http://tsa.mgh.harvard.edu/ The members of this nonprofit organization include people with TS, their families and friends, and health care professionals interested in the field. The group funds research, provides services to patients and their families, and offers a variety of publications, including brochures, fact sheets, and a newsletter.

OTHER SOURCES.

American Academy of Child and Adolescent Psychiatry 3615 Wisconsin Avenue NW Was.h.i.+ngton, DC, 20016-3007 Phone: 1-800-333-7636 or 202-966-7300 web site: http://www.aacap.org/ The Academy has a members.h.i.+p of more than 6300 child and adolescent psychiatrists who actively research, diagnose, and treat psychiatric disorders affecting children and adolescents. An excellent referral source for board-certified child and adolescent psychiatrists, the Academy publishes Facts for Families Facts for Families, a series of 53 fact sheets on topics related to child and adolescent psychiatry.

Center for Mental Health Services 5600 Fishers Lane Rockville, MD 20857 Phone: 301-443-1333 This government organization supports the development of accessible and appropriate service delivery systems for children and adolescents with serious emotional disturbance and their families. It offers grants to groups working in the field of children's mental health and supports their efforts to develop community-based services. It distributes several publications.