Doctors' Toughest Diagnosis: Own Mental Health
Erica Goode, New York Times- 7/8/2003

In the summer of 1995, Dr. Steven Miles, a well-known specialist in internal medicine at the University of Minnesota, fell into a deep depression. At night, he lay in bed unable to sleep. He became preoccupied with suicide. "This bridge has a low railing," he would think, or, peering over a banister into a five-story drop, "This is a convenient stairwell."
    Dr. Miles, 45 at the time, realized that he was ill and sought help from a psychiatrist, who diagnosed a nonpsychotic form of manic depression and prescribed medication. A month later, with no interruption in his teaching or his clinical work, he was well on the way to recovery. And that might have been the end of it, a small rough patch in a career of otherwise uninterrupted success. But the medical profession, Dr. Miles and 14 other authors contend in a recent article in The Journal of the American Medical Association, has been slow to accept that depression and other mental disorders are illnesses like any other, at least when they occur in its own members.
    Many doctors fail to seek treatment for psychiatric conditions out of fear that doing so will damage their careers. And those who do get treatment can suffer very real professional penalties. Dr. Miles, for example, spent three years battling state licensing officials who wanted access to his private psychiatric records. In the journal article, Dr. Miles and his colleagues, who gathered last October to discuss doctors' mental health at a workshop convened by the American Foundation for Suicide Prevention, noted that the profession's sluggishness in addressing the issue stands in contrast to its involvement in other public health problems.
    In combating tobacco, for example, medical practitioners have taken the lead. Deaths from smoking-related illnesses like cancer and heart disease are lower among doctors than in the population at large, and they have dropped 40 to 60 percent over the last four decades, the authors noted. But the rate of depression among doctors — about 12 percent suffer an episode of clinical depression at some point in life, according to one study — parallels that of the general public, and research suggests that they are at higher risk for suicide. An analysis of 14 international studies conducted from 1963 to 1991, for instance, found that men in medicine had a risk of suicide 1.1 to 3.4 times as great as that of the general population. Among women, the risk was 2.5 to 5.7 times as high.
    Johns Hopkins researchers have been following a group of 1,300 doctors who entered medical school from 1948 to 1964. Of those doctors, 26 have taken their own lives, said Dr. Daniel E. Ford, a professor of psychiatry and medicine at Johns Hopkins. The average age of the doctors at their deaths was 45, Dr. Ford said. Psychiatrists had the highest suicide rate of any specialty.
    Part of the difficulty, Dr. Miles and his colleagues say, is that doctors are, in general, unskilled both in recognizing the symptoms of depression and in treating the illness. The findings of a national survey published in June indicated that only 40 percent of Americans in treatment for depression received adequate care. Other studies have found that doctors fail to identify depression in their patients 40 to 60 percent of the time. "They don't pick it up in their patients and they don't pick it up in themselves," said Dr. Herbert Hendin, the medical director of the suicide prevention foundation and an author of the journal report, which summarizes the findings and recommendations emerging from the workshop last fall.
    Even when doctors do realize that they are ill, Dr. Hendin and others said, they find themselves trapped in a professional culture that discourages them from discussing their illness openly. Medical training puts a premium on physical stamina and emotional resilience. Young doctors are taught to set aside delicate sensibilities, to accustom themselves to illness and death, to put the needs of their patients before their own. In such circumstances, revealing vulnerability — especially a problem with depression or another mental disorder — is not a recipe for career success.
    "The message is, Don't talk about it, don't mention it," said Wendy Hansbrough, a nurse whose husband, John, a prominent surgeon, committed suicide in March 2001 at age 55. "It's perceived as weakness." Ms. Hansbrough, also an author of the report, said that her husband, the director of the Regional Burn Center at the University of California at San Diego, was in many ways no different from other doctors she knew. He carried a heavy load of research, teaching and clinical care. "He worked 365 days a year," Ms. Hansbrough said. "He rounded on his patients at 7 a.m. every day except on Saturday, when he did it at 6:30." Also like many other doctors, she said, her husband found it hard to talk about feeling depressed or stressed. On a bad day, he would simply go out and spend hours clearing the trees and brush from the yard of their house in Rancho Santa Fe.
    Dr. Hansbrough's closest colleagues were aware that 15 years before he took his own life he had suffered a serious episode of depression. Yet no one registered the visible strain he showed in the period before his death, Mrs. Hansbrough as a cause for particular concern. "Physicians are unbelievably busy," she said. "None of them have much time to sit around chitchatting. They're all running, they see each other in meetings or whatever. And they don't look for it. They're very blind to seeing stress in their colleagues." Dr. Miles said he once, while teaching a class of medical students, brought up the recent suicide of one of their classmates. "You could have heard a pin drop," he said.
    Reluctant to call attention to their plight, doctors who become depressed often try to act as their own psychiatrists, in many cases prescribing for themselves inadequate doses of antidepressants. "Most of the physicians who come to see me for their depression fight it out themselves first," said Dr. J. John Mann, a professor of psychiatry and radiology at Columbia. "They come in because the treatment wasn't working and the depression became so severe they couldn't handle it."
    Nor is seeking help always a guarantee that effective treatment will be given. Treating a colleague is a delicate business, and sometimes patients' professional credentials can work against them. In one case, Dr. Hendin said, a psychiatrist gave in when a doctor who had attempted suicide argued strenuously that he should be allowed to leave the emergency room and go home. The doctor later killed himself. The psychiatrist was still troubled by the case more than 10 years later. Had the man not been a doctor, he felt, he would have been more adamant about keeping him in the hospital.
    Yet the biggest obstacle to depressed doctors' dealing openly with their illness, experts say, is that such openness carries the risk of serious consequences, as Dr. Miles discovered when, several months after his episode of depression, he filled out the annual renewal form for his state medical license. The form asked if he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling or other psychiatric conditions. Dr. Miles answered the questionnaire honestly. He had, he thought, nothing to fear. His illness had not resulted in impairment. He had never been the subject of a patient's complaint, his name appeared regularly on lists of the state's "top 100 doctors," he published prolifically, and he had earned a national reputation for his work in health care reform. In the midst of his depression, he had asked his psychiatrist if he should stop seeing patients, and she had unhesitatingly endorsed his continuing to work.
    But upon receiving his renewal form, Dr. Miles said, the Minnesota Board of Medical Practice began an investigation, demanding a letter from his psychiatrist and full access to the records of his psychotherapy sessions. "They wanted absolutely everything," he recalled. Over the next three years, a battle of wills ensued. Dr. Miles refused to provide his psychiatric records. He threatened lawsuits. He sought a ruling from the federal Department of Justice, under the Americans With Disabilities Act. He wrote publicly about his illness and his struggle in a prominent medical journal. "The irony was that to protect the confidentiality of my records, I had to blow away the confidentiality of my diagnosis," he said.
    In 1999 the board changed its licensing form. The new form asked only whether the doctor had, since the last renewal, suffered from a mental disorder that impaired the ability to practice medicine with reasonable skill and safety — the same question asked about physical illnesses. While many states now use a similar "impairment" criterion, Dr. Miles said, other states still ask about diagnoses. In one case, he said, a young doctor was investigated because he admitted on a licensing form to having been hospitalized 10 years earlier, before he had attended medical school. In another case, the grief counseling sought by a doctor who had lost his child to a genetic illness "became a signal of potential disability," Dr. Miles said. Dr. Miles said he was not arguing that state medical boards should be lax about investigating doctors who were in fact impaired. "But I think patient safety is best served by having a pathway by which docs can get the help they need," he said.
    In the journal article, Dr. Miles, Dr. Hendin and their colleagues called for more research on depression and suicide among doctors, for increased attention to the issue by institutions like hospitals and medical schools and for educational efforts stressing "the public health benefits of encouraging physicians to seek treatment for depression and suicidality." Meanwhile, Dr. Miles said, doctors themselves can begin by taking responsibility for their own mental health. "Docs who think they are depressed should get help first, and worry about sorting out the career issues second," he said.

Two Types of Brain Problems Are Found to Cause Dyslexia
Bonnie Rothman Morris, New York Times- 7/8/2003

Dyslexia appears to be caused by two distinct types of brain problems, a new study has found. The researchers, from Yale, used scanning devices to examine the brains of 43 young adults with known reading disabilities while they performed reading tasks. Another group of 27 good readers were also studied. All the subjects had been tracked for reading ability since elementary school. One group appeared to have what the researchers called a "predominantly genetic type" of dyslexia. These students had gaps in the neural circuitry that the normal readers used for the basic processing of sound and language, but had learned to enlist other parts of the brain to compensate for the difficulty. They still read slowly but can comprehend what they read.
    The second group had what the researchers called a "more environmentally influenced" type of dyslexia. Their brains' system for processing sound and language was intact, but they seemed to rely more on memory than on the linguistic centers of the brain for understanding what they were reading. These students had remained persistently poor readers, scoring poorly on speed as well as comprehension.
    The two groups of poor readers were from similar socioeconomic backgrounds and had comparable reading skills when they began school, according to the study, which was published this month in the journal Biological Psychiatry. But there were two differences: the students who compensated for their problems tended to have higher overall levels of learning abilities, and the students whose problems persisted were twice as likely to attend what the researchers called disadvantaged schools.
    The study's lead author, Dr. Sally E. Shaywitz, said the discovery that the neural systems for reading are intact in the students with the most serious reading problems came as a surprise. It also implies that their problems are more correctable than may have been thought, she said. "The persistently poor readers have a rudimentary system in place, but it's not connected well," Dr. Shaywitz said. "They weren't able to develop and connect it right because they haven't had that early stimulation." A large body of research has shown that intensive tutoring can correct this kind of reading problem, especially if begun while the children's brains are still developing. "If you can provide these children early on with effective reading instruction, these children can really learn to read," Dr. Shaywitz said.
    For the study, participants lay in a brain scanner known as a functional M.R.I. device, and peered through a periscope at monosyllabic words flashed on a computer screen. As they read, pictures were taken of what parts of their brains were doing the work, and how they were working together. Good readers used three areas in the left side of the brain, to decode letters into sounds, fit them together to make words and process them fluently. The readers who had compensated but still read slowly did not use the same brain regions for those tasks. Instead, they created an alternate neural pathway, reading mostly with regions on the right side of the brain — areas not as well suited for reading, the researchers said. Paradoxically, the poorest readers in the study used the same parts of the left side of the brain that the normal readers did to begin the reading process. But instead of connecting that work to other language centers, they then activated a portion of the front right side of the brain that is used primarily for memory to help them along.
    That overreliance on memory could help explain the persistence of these poor readers' problems. "Once the brain makes the connections it needs for certain tasks, it tends to stick with them," said Dr. Gordon Sherman, the executive director of the Newgrange School and Educational Outreach Center in Princeton, N.J., an expert on dyslexia who had no connection to the study. "But those connections aren't necessarily the best ones." Rote-based learning of words can get a student to a certain point, but "then it fails quite miserably; there's too much to memorize," Dr. Sherman said.
    J. Thomas Viall, executive director of the International Dyslexia Association, said that the study's findings underscored the need for intensive educational intervention, but that more work was needed before its findings of subgroups could be translated into practical applications. "Dyslexia is a disorder whose treatment is education," Mr. Viall said. He called the notion of using functional M.R.I. data to identify types of dyslexia "exciting" but added, "We don't have F.M.R.I.'s in grocery stores like blood pressure machines."
    Dr. Shaywitz acknowledges that giving such tests to every child is impractical, but says researchers will now begin to use the brain connectivity studies to develop other kinds of diagnostic tests. "It is possible from all that we've learned about the science of reading to identify all children who are at risk for experiencing reading difficulty," she said. The next step, she added, will be to design early strategies that are tailored to each child's particular type of disability.

Counseling at Phillips Academy, and Its Consequences
Michael Winerip, New York Times- 7/9/2003

ANDOVER, Mass. — Phillips Academy is one of America's most prestigious boarding schools, known for educating the rich and mighty (both President Bushes are graduates) and sending a third of them to Ivy League colleges. Even on this fiercely competitive campus, Cathy Rampell — an A student with perfect 1600 SAT's and a weekly column in the student paper — stood out. In her junior year, Cathy had her first true romance. "My boyfriend and I declared each other as our first loves," she wrote in one of her final columns for The Phillipian. "We had a rocky relationship, breaking up and reuniting several times in the seven months that we dated, but we always assumed that we would be together in the long run."
    Then in April 2002, during a bumpy stretch, the boyfriend told Cathy he was leaving school — the next day. Crushed, she went to the counseling center. "She's devastated," a counselor's note said. "Didn't sleep last night. Sees no point in going on if love isn't enough to keep him here." Cathy would later write that over the next week she behaved like an "idiotic teenager," including pulling an all-nighter on the phone to the ex-boyfriend. She fell behind at school for the first time, and because Andover is strict about class attendance, she used a visit to the counseling center to get an excused absence.
    That week, she had several sessions with Dr. Margaret Jackson, a school psychologist. They did not get along well. "I attempted to end a session early," Cathy wrote, "telling the counselor that I found our talks unconstructive and that my time would be better spent doing the work that I whined to her about." Cathy wrote that she started to leave but that Dr. Jackson "grabbed my arms from behind and pushed me back down on the couch." "Terrified, I began to cry," she wrote.
    In her notes, Dr. Jackson described Cathy this way: "Didn't want to stay. `Too much work to do.' Got up to leave abruptly and I caught her and made her sit." A few days later Dr. Jackson's notes describe Cathy as "teary," "upset," "feels worthless." After an hour and a half, Dr. Jackson wrote, Cathy's "mood lifted." But when asked if she had thoughts of harming herself, Cathy "didn't want to talk about it. I informed her in light of that I'd have to assume the worst." For the next two nights, Dr. Jackson ordered Cathy held in the infirmary as a suicide risk. Cathy described that session differently, saying that she'd been kept waiting for hours by Dr. Jackson, and that by the time the therapist arrived she was fuming. "I brattily refused to answer her questions," she wrote.
    Dr. Jackson contacted Cathy's parents. Richard Rampell, a Palm Beach, Fla., accountant, and his wife, Ellen, were on a Mediterranean cruise, and immediately left the ship to fly to Andover. When they arrived, they were surprised. "Cathy was upset, but didn't seem depressed," Mr. Rampell said. Though the only person to assess Cathy was Dr. Jackson, the Rampells were informed that no second opinion was required, that the rule in the school Blue Book on students at risk for suicide was inflexible. Cathy had to leave campus immediately and wouldn't be eligible for re-admission for 16 months. "They had effectively expelled her," Mr. Rampell said. "We begged for the chance to get a second opinion." "I had a college friend who's a psychiatrist at Harvard," said Mr. Rampell, a Princeton graduate, "and others I knew with connections and asked them to help us find the best adolescent psychiatrists."
    In the next weeks, they had Cathy examined by four psychiatrists, three of them Harvard Medical School professors. While noting Cathy was "high strung" and had a bout with anorexia as a younger teenager, all four concluded she was not suffering depression nor at risk for suicide. One of the psychiatrists, Dr. John Maltsberger, a national expert on suicide, wrote, "The patient never had a correct suicide risk assessment" at Andover, adding that Dr. Jackson's "alliance with this patient broke down and the patient fell into a rage with her and refused to answer questions." He indicated surprise that Cathy was not also assessed by a psychiatrist. Another, Dr. John Julian, wrote, "in conclusion, the patient is suffering from the loss of an adolescent first love. All four recommended she withdraw for the rest of spring semester, get therapy and return in the fall. Not letting her return, wrote another, Dr. Eugene Beresin, "would be a serious mistake," one that would "hurt Cathy in many ways."
    The family offered to sign a liability waiver, and have the mother live in an apartment off campus with Cathy, but the school would not budge, pointing out no one had ever appealed a suicide-risk determination. The Rampells were the first. For $600 an hour, they hired Robert Popeo, one of Boston's most influential lawyers, to write the appeal. Suddenly the school was willing to budge. Within weeks, the school reversed itself and agreed to let Cathy return in September. This did not come cheap; Mr. Rampell says getting Cathy back in school cost him $100,000 in legal, medical and other fees. That fall Cathy got a report card full of A's. Her residence counselor wrote, "It is a real pleasure to have Cathy in the dorm." In December, she was admitted early action to Princeton.
    Sharon Britton, an Andover spokeswoman, said privacy issues prevented her from discussing the case. But she pointed out that during Andover's 2000 accreditation review, the mental health staff (three psychologists, plus two consulting local psychiatrists) was described as "superbly trained." It is standard practice to have a person examined by two psychiatrists before being judged suicidal for hospitalization purposes, and I asked why school policy didn't require a second opinion. "Bringing in another person for an evaluation at this point doesn't make any sense," Ms. Britton said. "We're not giving a psychological diagnosis. We're observing behavior that suggests a kid is at risk. This is a boarding school. You have to accept the rules of the community. You can't expect to be treated as just an individual, you also must consider your effect on others in the dorms."
    As to the Blue Book mandating a year off, she said, "It's a conservative approach, but the stakes are high. You might be upset you have to leave, but at least you're alive. It's safety first." She said situations could not be decided case by case. "It's important to stick with a policy and be consistent, so people with money and influence don't have more rights." But wasn't that precisely what happened? "They spent $100,000 to flog us with the results — this is shock and awe," Ms. Britton said to me, "and you're part of it."
    In May, once she was sure to graduate, Cathy told her story in a three-part series in The Phillipian. She wrote that the way the school had treated her would discourage students who needed help from seeking counseling. Indeed, nine former and current students have since contacted her and described similar experiences. School officials wrote letters to The Phillipian criticizing Cathy's series, but privately have been interviewing the nine others. "Are some upset and unhappy with the way they were treated?" Ms. Britton said. "Yes." She said efforts were under way to have the counseling center "better communicate what we do." However, she added, "we found nothing that indicated we want to change policy."

Michigan Battle For Parity Long From Being Over
Sharon Emery, Ann Arbor News- 7/9/2003

LANSING -- It's been a heady few months for supporters of a move to make Michigan insurers provide the same coverage for mental illnesses as they do for physical problems. After five years of trying to get a full hearing before lawmakers, mental health advocates got not just one, but five opportunities to make their case before the Senate Health Policy Committee during May and June.
    Scores of mental health patients and workers came to "put a face on the problem," as committee chair and bill sponsor Sen. Beverly Hammerstrom, R-Temperance, vowed to do. But while Hammerstrom, who says her brother and father suffered from mental illness, was able to make the hearings finally happen, sustaining momentum on them is proving difficult.
    Business groups say the bills amount to a government mandate. If approved, they say the upshot would be increased benefits for some, while others would lose benefits completely as employers struggled to provide expanded coverage. "The bills won't pass as is," Hammerstrom acknowledges, promising to work over the summer to come up with legislation that can be signed into law.
    Charles Owens, director of the National Federation of Independent Business-Michigan, said the bills would affect some 30 percent of the insurance plans in the state, mainly those run by businesses with fewer than 50 employees. Bigger businesses that self-insure are exempt; they fall under federal mental health parity guidelines. "Small businesses and individual policy-holders -- groups that can least afford health care -- would suffer in this misguided effort," Owens said.
    Even Gov. Jennifer Granholm seems to be backing away. Her spokeswoman Liz Boyd said that while Granholm campaigned on "moving toward parity," she has not taken a position on the legislation. "We will be sitting down with (Hammerstrom) and looking at all of the issues in her proposal to see if it's something we can flat-out support," Boyd said. She said it was too early to say if Granholm would be amenable to narrowing the bills. But Boyd did acknowledge a sensitivity to business' cost concerns. "Since they have raised the issue, that's an issue that will need to be addressed," Boyd said.
    Mark Reinstein, of the Mental Health Association in Michigan, said he can live with the delay, adding that he is "cautiously optimistic" that the committee will pass some kind of parity bills this fall. Depending on the particulars, he said the association "probably" would support a narrower version of the legislation. "We're used to the need to compromise; that's not unexpected," Reinstein said. Legislation might be tailored to include only specific, widely recognized and treatable illnesses such as bipolar disorder, for example, or it might omit substance abuse treatment. And Reinstein noted that parity legislation was also introduced in the House on June 25, with some three-dozen co-sponsors.
    Still, the timing isn't good. With the economy in the doldrums, no one wants to saddle job-providers with policies that business says would be an unfair burden. An analysis of the legislation by the nonpartisan Senate Fiscal Agency says that enacting parity would increase the cost of health care policies by between 0-3.4 percent, although business questions those estimates.
    While 35 states have some form of parity for mental and physical health care, Michigan is among the 15 without it. An April study by the National Mental Health Association gave Michigan failing grades for allowing higher fees and more restrictions on mental health services than on physical health care, among other shortcomings. The study evaluating mental health policies ranked Michigan last among all the states and the District of Columbia.
    The legislation would require private health insurance providers to cover mental illness and substance abuse disorders at the same levels they cover physical illnesses. Mental health coverage varies among insurers and employers, but insurance companies often have lower annual and lifetime limits for mental health than for physical health care.
    Supporters of the bills argue that the social stigma attached to mental illness is the only reason insurers don't provide equal coverage, and that it's discriminatory for insurers to offer lesser coverage for mental health care. Since worker productivity would increase and absenteeism would go down if employees could get the mental health care they need, business' costs would actually decline, supporters say. Still, when asked what kind of changes would meet business' concerns, Owens was blunt: "Nothing. We can't afford any mandate."
    The bills would also include coverage for substance abuse treatment, which riles Owens as well. He notes that there are hundreds of psychiatric illnesses, some of which he calls "marginal." "Once you start with parity, every interest group comes in every year to get their malady covered," he said. Advocates of the bills say it's time to recognize that substance abuse is not a choice or a character flaw, but a physical problem involving the brain.
    Ironically, a strong voice for parity is that of Waltraud Prechter, widow of one of Michigan's most successful entrepreneurs. Heinz Prechter was the founder of American Sunroof Co., and a top fund-raiser for the Republican Party. "Why do we treat illness from the neck up different from the neck down?" Waltraud Prechter asked in testimony before the committee on May 28. "...Illnesses of the mind have been shrouded in fear, shame and misunderstanding for as long as man has walked the earth." Unknown to few beyond the family, her husband suffered from manic depression, which ended with his suicide in 2001. Since her husband's death she has become an outspoken advocate for the mentally ill. "It isn't about him anymore," she said, "it's about all the others who have this."

Acutely Mentally Ill Children Face Delay of Care in Massachusetts
Alice Dembner, Boston Globe, 7/12/2003

Janis Dacey's son was manic and bleeding from a self-inflicted intestinal wound when crisis workers sent them to Brockton Hospital's emergency room in late May. Hospital staff and state psychiatric workers began combing New England's psychiatric wards for a place that could help the 13-year-old, who also suffers from post-traumatic stress disorder. But day after day, the answer was bleak. Adolescent psychiatric units were either full or said they could not handle this boy, with his difficult constellation of problems. Sinking into what his mother describes as a catatonic state, the boy waited in the emergency room for six days until a bed opened at Westwood Lodge.
    Although his wait was unusually long, the most distressed children often face delays in getting care through the state's troubled mental health care system. A new study of mentally ill children initially treated at Children's Hospital shows that suicidal children were twice as likely as others to have to wait for a psychiatric bed, while severely homicidal children were 3 1/2 times as likely to wait. ''It's a big problem that needs to be looked at,'' said Elizabeth Wharff, director of emergency and outpatient psychiatric services at Children's. ''The sickest kids are getting the poorest care.''
    Statewide each year, hundreds of children ''board'' in emergency rooms or on pediatric wards awaiting a psychiatric bed because of the gridlocked mental health system. At Children's, the first stop for many youths in crisis, researchers found that one-third of the 315 patients who came to its emergency room requiring psychiatric hospitalization in fiscal 2000 ended up boarding. Boarded children get medical care, but rarely receive the psychiatric treatment they need.
    'The boarders are the tip of an iceberg,'' said Dr. Kenneth Duckworth, a child psychiatrist who stepped down as acting state mental health commissioner two weeks ago. ''When you get into a system that is stretched thin, this is one of the possible consequences.'' A shortage of community mental health services means more children require hospitalization, he said. But psychiatric beds are full because many children are ''stuck'' there awaiting residential placements.
    Although hospital and state officials have expanded the mental health system's treatment capacity, the Children's study, published last month in the journal Pediatrics, suggests that lack of space isn't the only problem. In what researchers called ''reverse triage,'' they found that the more severely homicidal the children's thoughts, the harder they were to place. Nearly two-thirds of the severely homicidal children in the study ended up boarding. ''Some of the inpatient units will cherry-pick among the patients,'' said Wharff, one of the study's authors. ''They'll choose the patients who are the easiest to manage and the least acute.''
    Brockton Hospital officials working to place Dacey's son said several psychiatric units told them that they had an empty bed but couldn't accommodate him. ''They said, `I'm sorry; our acuity is too high. We can't manage this patient in a safe way,' '' said Ellen Lundin, Brockton's coordinator of psychiatric emergency services.
    State mental health officials say there may be good reason for some selectivity. Many psychiatric units are understaffed and may not be able to handle one more difficult or violent children safely. Nonetheless, they said Children's findings will be investigated. ''It's obviously not an acceptable practice,'' said Joan Mikula, director of child and adolescent services for the state Department of Mental Health.
    David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, which represents the state's psychiatric units, said the findings need further analysis. ''Psychiatric hospitals do not screen out for suicidal or homicidal patients,'' he said. ''These are the kids that the units treat.'' Similarly, Dr. Joseph Gold, clinical director of children's services at McLean Hospital in Belmont, said they give priority to the children in the most danger and have worked with the state to create units to serve children with complex problems.
    There are no statewide statistics on children who board at hospitals while awaiting psychiatric care, but there are figures for children on Medicaid, the state-administered insurance program for the poor. The number of children on Medicaid who were boarded dropped by about half in 2001 when several children's psychiatric units opened, the state began pushing psychiatric hospitals to admit boarders, and Medicaid started paying hospitals for one-on-one care for children with more acute problems. But the numbers shot up again last fall: In October alone, 47 Medicaid children were boarded. Children's Hospital saw a similar pattern, despite efforts to divert some children from hospitalization using intensive counseling.
    Officials at the Massachusetts Behavioral Health Partnership, which manages mental health care for Medicaid, said they are now having more trouble placing children with pervasive development disorder, a condition that typically includes mental deficits and violent behavior. But they said children typically wait no more than a day.
    Doctors said that even one day's delay can be harmful to a child in psychiatric crisis, likening it to telling someone having a heart attack to come back later. Forty percent of the children studied by Children's Hospital waited only one day, but many were held two to six days and one waited seven weeks. Brockton Hospital officials said Dacey's son was the longest boarder they could recall.
    During the six days, Dacey stayed with her son in an emergency department room, playing cards and watching television. She asked that the Globe not identify him by name. The boy was seen daily by a psychiatrist, and Dacey says Brockton Hospital staff worked tirelessly to help the family. But she says the delay set her son back. ''He needed help that first night,'' she said. ''He had all this guilt and feelings of disgust, and he just sunk into himself. The fact that he had to wait there was unacceptable.'' The boy spent several weeks in Westwood Lodge and is doing better. But Dr. Jonathan Mansbach of Children's Hospital, the lead author of the study, worries that a boarder will some day commit suicide, and says the state has to push harder for solutions. ''My worry is nothing will happen until there's a tragic event,'' he said.

Massachusetts Launches a Program to Offer Youths Psychiatric Aid at Home
Alice Dembner, Boston Globe- 7/12/2003

The state is launching a program designed to keep mentally ill children out of psychiatric hospitals and residential facilities by providing intensive services in their homes, the Romney administration announced yesterday. The pilot program will serve about 300 children on Medicaid over the next year, including 50 each in Brockton, Lawrence, New Bedford, Springfield, and Worcester, and 50 in Malden, Medford, and Everett combined. It will provide 24-hour crisis counseling, respite care, specialized after-school programs, and managers to coordinate services provided by doctors, school staff, and other professionals.
    The effort will target children at risk of needing institutional care because of mental illness and disruptive behavior at school, but will exclude those who are a danger to themselves or others, said Abigail Josephs, special assistant to Ronald Preston, health and human services secretary. ''We hope to get them before they get to the hospital door by asking `What does this child need to succeed at home?' '' Josephs said.
    Hundreds of children in the state are stuck in hospitals or residential programs because of the lack of coordinated community services, and the state contends that thousands of children might benefit from the services the pilot program will offer. The state is currently fighting a class-action lawsuit accusing it of violating children's rights by forcing hundreds into unnecessary hospital stays because of the lack of home-based care.
    Yesterday, Donna Welles, executive director of the Parent Professional Advocacy League, which advocates for children with mental illness, praised the new effort. ''This program will help keep children with their families,'' she said in a statement.

The Literary Freud
Daphne Merkin, New York Times Magazine- 7/13/2003

Adam Phillips doesn't do e-mail. It's not clear whether this is a Luddite impulse, a shrewd maneuver designed to enhance his glamorously elusive aura or simply a pragmatic decision not to squander hours at the beck and call of everyone with a keyboard and a screen name. "I don't want to be in touch," he explains. "I want less communication."
    That may sound like a decidedly antisocial remark for a man who trades in human connectedness. But then Phillips, an idiosyncratic literary talent and the celebrated maverick of contemporary British psychoanalysis, is nothing if not defiantly self-contradictory. He has made his name by questioning the orthodoxies of hard-line Freudianism, yet his most recent role is general editor of the first major new Freud translation to appear in 30 years. This month, four volumes of a scheduled eight are being issued here as part of the Penguin Classics series. These hip-pocket paperbacks are each translated by a literary scholar, and the visually witty covers take their images from Magritte and other Surrealist masters. They are as removed in tone from the weighty and astronomically expensive 24-volume version edited by James Strachey as Freud's office in London's solidly bourgeois Hampstead neighborhood (now the Freud Museum) is from Phillips's office in trendy Notting Hill.
    Phillips gives the bulk of his time, four days a week, eight hours a day, to his analytic work. "Therapy provides an opportunity to talk to people the way you don't do anywhere else," he says. Wednesdays are reserved for writing, and over the last decade and a half of Wednesdays, Phillips has produced 10 books of nonfiction. Most are collections of essays and reviews, with the exception of several more sustained meditations, including "Darwin's Worms" and "Houdini's Box," which focus on a single theme or set of questions. The books' provocative titles -- "The Beast in the Nursery" or "On Kissing, Tickling, and Being Bored" -- hint at the uncategorizable contents within, which are characterized by Phillips's droll humor, his penchant for the epigrammatic and his wide-ranging, interdisciplinary affinities. The curious thing about reading Phillips is that he makes you feel smart and above the daily grind at the same time as he reassures you that are not alone in your primal anxieties about whether you are lovable or nuts or, perhaps, merely boring.
    It is hard to think of another writer who, in the guise of intellectual inquiry and dazzling erudition, manages to always come back in some way or other to the conundrum of why our longings so often end in acts of self-sabotage. "People have traditionally come for psychoanalytic conversation," he observes in the introduction to "On Kissing," "because the story they are telling themselves about their lives has stopped, or become too painful, or both."
    What do therapists talk about when they talk about love? If you're Adam Phillips, you are likely to talk about the infinite human capacity for mangling desire -- for hating what we love most. It is a Thursday evening at the end of May, and I am waiting for Phillips in the Walmer Castle, a packed bar around the corner from his office. The bar is on hippest Ledbury Road, amid shops that carry high-end bath gels and clothes in a range of sizes from small to smaller. Everyone is 25, and no one seems to have caught on to the dangers of smoking. Phillips has sent me off to read a book called "Love of Beginnings," by his favorite fancy French theorist, J. B. Pontalis, while he finishes up with his last patient of the day.
    I am sipping an outsize mug of draft beer when he comes in, a slight, graceful man with a ragged mop of hair and several days' worth of stubble, wearing a leather jacket, pointy suede shoes and the rushed air of someone passing through the world incognito. Lighting up a cigarette, Phillips launches into his thoughts on the vexed subject of human relationships.
    "Sexual desire leads us awry," he says, speaking softly yet authoritatively in his impeccable Oxbridge accent, the ideas spilling out in fluid sentences. "The erotic life is ashamed, conflicted, awkward, embarrassed, uncertain. The way to survive psychically is to find people to love. But in order to feel safe enough with other people, most of us feel we have to control them. If you fear losing somebody who you think you need; you try to enslave or addict them." It is as though Phillips has taken Freud -- whose emphasis on the vicissitudes of libidinal life was second to none, thereby casting him as suspect from the start -- and given him a contemporary gloss, a kind of play-it-as-it-lays panache. So where, I wonder aloud, does all this amorous conflict leave us after the hostile passion subsides? Phillips shrugs, like a man who's seen too much to be overly impressed by peoples' ability to handle hard-core reality. "Then," he says, pausing for a moment, "you fall into ordinary life."
    Phillips combines the energy of the great Victorian polymaths like Thomas Carlyle and John Ruskin with the radical belief in the indeterminacy of all truth that defines the postmodernist sensibility of Walter Benjamin or Jorge Luis Borges. ("There are no deep truths about human nature," Phillips maintains. "There are more or less interesting or inspiring descriptions.") His writings have brought him a cult-like following among serious readers (although not among serious psychiatrists, few of whom seem to have read him). Part of his appeal is that he is a graceful stylist, who writes airy yet charged prose. In the essay "On Translating a Person," he glides from arcane references (Marx's "Eighteenth Brumaire of Louis Bonaparte" and Raymond Williams's "Problems in Materialism and Culture") to poignant vignettes culled from years of clinical experience. In "Clutter," he writes about a 14-year-old boy who annoys his otherwise-tolerant bohemian parents by dropping clothes all over his room because he believes "our clothes should come and find us." In one of his teasing, aphoristic asides, which is characteristic of his amused disengagement from domestic dramas, Phillips points out that "the art of family life is to not take it personally."
    Freud, who virtually invented the art of taking everything personally, loved a good joke as much as anyone and would no doubt have appreciated the deadpan wit of this remark and might even have chuckled at Phillips's claim that the founding father of psychoanalysis was himself "resistant to therapy." But Freud was also a man singularly of his own time, steeped in Old World culture and moral gravitas, informed by the classical, premodernist perspective of his literary heroes, Goethe and Schiller. As such, his pessimistic interpretations of his patients' conflicts were inseparable from a dark, if not tragic, view of civilization. Phillips, on the other hand, blithely asserts that the invention of therapy, in its emphasis on "suspending internal censorship," neutralized the judgmentalism of "what used to be called the moral life."
    Phillips is an odd choice to edit the Freud translation on many counts, not least because he doesn't know German, the language in which Freud wrote. When I mention this fact to the eminent literary critic Frank Kermode, who is a Phillips enthusiast, he is somewhat taken aback. "That's a tremendous bit of cheek, isn't it?" he says, half-admiringly.
    This lack of a seemingly essential credential, however, seems not to have bothered Paul Keegan, the former editor at Penguin Modern Classics in the U.K. who conceived of the project. (In the U.K., 15 volumes are planned, and 6 have already been published.) Keegan knows Phillips from their student days at Oxford, where they both studied English literature. He was interested, as he explains it, in publishing a Freud "free of the fetters of the Freud industry." Phillips, with his constant venting about "the institutional hypocrisy of psychoanalysis" (and, no less important, his unparalleled ability, as Keegan sees it, "to work the angles"), was just the man for the job. "He's his own one-man band," he remarks. "It's all been done on a harmonica."
    The Penguin translations aim to present a more accessible and vernacular Freud, freed from the straitjacket of Strachey's dowdy and somewhat creaking rendition. It is a prospect that Phillips gave thought to over the years, well before the new edition became a gleam in his publisher's eye. "By pooling the language of psychoanalysis rather than hoarding it . . . psychoanalysis can be relieved of the knowingness that makes it look silly," he writes in "On Kissing," "the knowingness that comes from its `splendid isolation,' the fantasies of inner superiority in the profession."
    To this end, Phillips has boldly dispatched with internal consistency and a uniform technical lexicon and has imposed a thematic rather than chronological organization. You might wonder how a craft as facilitating (and, ideally, invisible) as translation can change the basic thrust of a book. "All translation is to some extent misrepresentation," observes Louise Ady Huish, in her preface to "The 'Wolfman' and Other Cases." With Freud, however, it appears that the effect was to make him less -- rather than more -- lucid. "Freud was not the father of psychobabble," Huish acerbically notes. "Very few of the terms he coined required a dictionary to make them comprehensible to the ordinarily educated reader."
    Phillips has written the introduction to only one of the books ("Wild Analysis") but was in charge of selecting the translators and the writers of the introductory essays; the essayists include specialists in literature, philosophy and the history of science, as opposed to writers on "hot" topics dear to psychoanalytic journals like psychic trauma or boundary violations. There isn't a shrink in the bunch, and none of the translators were given instructions beyond the one to follow their own noses. Some of them hadn't read Freud before. One, Michael Hoffman, who had signed up to do "Wild Analysis," decided not to go ahead after reading it in the original.
    The idea to update and condense the magisterial standard edition -- sometime referred to, tongue-in-cheek, as the King James Version -- was spurred by the expiration of the Strachey copyright. His Herculean labors, under the watchful eye of Anna Freud, Freud's youngest child and the only one to follow in his footsteps, took place over a period of 21 years (1953-1974). Strachey's work has long been regarded as an exhaustive triumph of fastidious scholarship. "We must fall back on square brackets and footnotes," he vowed, "for we are bound by the fundamental rule: Freud, the whole of Freud, and nothing but Freud."
    Still, there have always been questions about the aptness of some of the vocabulary -- for example, Strachey's use of "instinct" instead of "drive" for the term "Trieb" -- as well as the possibility that he denatured Freud's vivid style into the polished and stately prose of a Victorian gentleman: "A cross," as the Cambridge historian of science John Forrester characterizes it, "between Thomas Hardy and Julian Huxley." Some criticized the translation as a well-meaning but essentially falsifiying effort to present Freud as an empirical and systematic (indeed Darwinian) thinker rather than a subtle and allusive poet of the unconscious life. In the hope of making him more acceptable to a skeptical medical community, Strachey set about "scientizing" Freud, adding concrete qualifiers like "degree" and "level" to Freud's metaphorical imagery, and introducing clanking Greek words like cathexis and parapraxis into the text in place of Freud's more colloquial and plainspoken German.
    It was Bruno Bettelheim who first brought these concerns to wide attention 20 years ago in an essay in The New Yorker in which he suggested that Strachey had literally taken the soul out of Freud. Bettelheim focused particularly on Strachey's translation of das Ich (the "I"), das Es ("the it") and das Uberich (the "above-I") into ego, id, and superego, which, he proposed, set up a depersonalized paradigm of mental processes that was colder and sharper-edged than Freud's more organic conception.
    Of course, these issues, intriguing though they are to scholars and critics, pale beside the larger issue of Freud's relevance -- or lack of it -- as a figure who speaks to the 21st century. The true believers, like Harold Bloom, maintain that Freud is the central consciousness of our time; he is, as Auden had it, "a whole climate of opinion." For them, the small mistakes here and there -- as in Freud's consistent reduction of women to biologically inferior creatures forever in mourning for their lack of a penis -- add up to no more than a few shadows on the lustrous face of genius. On the other side, there is the hallowed vituperative tradition of Freud bashing, which proceeded in piecemeal fashion with Karl Popper and Hans Eysenck in the 50's and 60's and went on to claim ever more cultural ground. It is perhaps best exemplified by the gleefully sustained attacks of the literary critic Frederick Crews, a reformed believer whose 1980 article "Analysis Terminable" could be considered the first real shot in the Freud wars. For this group, the whole enterprise of psychoanalysis is a colossal con job perpetrated by a wily and ambitious half-baked theoretician on his cowed peers and on a gullible lay public.
    Enter Phillips, the man who, as he himself might say, loves Freud but refuses to be enslaved by him and has thereby succeeded in moving beyond the raging ambivalence (or sadomasochistic "enactment," to borrow from the florid jargon of shrinks) he maintains is inherent in all our relationships. Having long been convinced that "psychoanalysis is only useful as ... one among the many language games in a culture," Phillips is apparently unhampered by unconscious conflict (which invariably results in the need to deify or diminish a chosen object) and is thus left free to rescue an embattled Freud from his champions and detractors alike.
    "Freud is not a sacred text," he told me. "I never thought psychoanalysis had anything to do with science. It has been servile in its wish to meet scientific criteria to legitimize him. I want people to read Freud as you would any great novelist. His books are not accurate accounts of people. Every psychoanalytic text, as Auden said, should begin with: `Have you heard the one about? . . . ' "
    Phillips office is at the top of three flights of stairs in a scruffy whitewashed brick building down the street from Dakota, the chic restaurant on the corner where Phillips and I repair for a late lunch. Phillips's determination not to take himself too seriously (or, at any rate, not to seem to be taking himself too seriously) is disarming. He cheerfully admits that he's "not good at punctuation," and when I ask him why he is resistant to drawing even the most provisional of conclusions, he offers a simple explanation: "I don't know how to elaborate thoughts," he says. "I write sentence to sentence." Dedicated to what he calls "the transformative effect of listening," Phillips is alert to the loopholes in conversation, the dropped questions and trailing clauses, the partly said or the left unsaid. This receptive attitude helps to explain the rapport with children and adolescents that shines so clearly through his writing, in which he comes across as the least patronizing and most charming of allies, one who is willing to acknowledge the hopeless error of grown-up ways.
    Phillips, who will be 49 this September, was the principal child psychotherapist at Charing Cross Hospital in London for a decade before going into private practice seven or eight years ago. He pulled back from working with children after he became a father to Mia, who recently turned 9. (Phillips and his ex-partner, the critic Jacqueline Rose, share parenting responsibilities.) "Part of my internal myth," he says, "is that I could listen to anything. But when I had my own child, I could bear much less about the way children had been treated. I've seen many brutalized children, and it was like losing some kind of protective covering."
    These days he mainly treats adults, who come to him by way of referrals, by word of mouth or from reading his books. He sees most of them for 45-minute sessions, but since he is reliably unorthodox ("anxious practitioners," he points out, "need rigorous technique"), he also sees patients for an hour or occasionally for double sessions. He has been known to sit on the floor and says he works well "on demand," seeing patents when they want to come rather than at regular times. Although Phillips cuts a sufficiently glamorous figure to earn him the sobriquet "the Martin Arms of British psychoanalysis," he firmly states his preference for the common over the uncommon patient. "I don't want to see famous or rich people," he says. His only criterion for treatment is that he be "moved" by the person he is working with and that "there's a conversation that's important."
    I am inclined to believe him. He appears genuinely appalled at the blatant materialism of contemporary life and has few acquisitional habits beyond college-dorm staples like books, CD's and plants; he does like to eat out, he admits, as though it were a fantastic indulgence. He is particularly incensed by the greed of his colleagues: "Any analyst who charges a lot of money is in my view betraying the profession." His own fees are modest, at least by American standards, ranging from nothing to 45 pounds (roughly $75). "If you want to make money," he snaps, "go be a film star." Phillips seems to have led a remarkably charmed life. He grew up in Cardiff, Wales, in an assimilated Jewish family (his grandfather's surname was Pinchas-Levy until a customs official at Swansea decided to replace it with a Welsh one) and remembers feeling "very well-loved" as a child, with parents who indulged his passion for tropical birds. ("National Geographic was my childhood pornography.") He describes his parents - both of their families came from Eastern Europe -- as having suffered from "pogrom anxiety." Although Phillips, who has one sister, lived in a Jewish house in the boarding school he went to and spent a summer picking apples on a kibbutz when he was 16, he insists that his background protected him from feeling the presence of anti-Semitism. "I'm an accidental Jew," he says heatedly. "It's a contingent fact that one is born one thing and not another. I don't believe Jews are the chosen people. I don't believe our having suffered on a colossal, cataclysmic level should be recruited as a kind of special pleading."
    After doing a year of graduate research on the poet Randall Jarrell, he went into training as a child psychotherapist. The catalyst for that change of professional direction was D. W. Winnicott, the innovative pediatrician turned analyst who rendered psychoanalytic dialogue accessible to the skeptical lay reader. (He is responsible for such iconic phrases as "the good-enough mother" and "transitional object.") Phillips had come upon Winnicott's "Playing and Reality" when he was at Oxford. "I remember reading it and thinking, This is it," he says. Years later, after his own "eclectic" psychoanalytic studies and training (which included being analyzed by the mercurial Masud Kahn, who was an analysand of Winnicott and whose sexual peccadilloes and rabid anti-Semitism eventually led to his being ejected from the British Psycho-Analytical Society), he would put that excitement into words. Phillips wrote to Frank Kermode, to ask if he could contribute a volume on Winnicott's work for a series called Fontana Modern Masters that Kermode was then editing. He included a short piece he had written on tickling, which Kermode passed on to Richard Poirier at Raritan, thereby launching Phillips's writing career. "Winnicott," the first of his books, was published in 1988.
    Not everyone, of course, is convinced that Phillips is either a true original or a knockout stylist. "Monogamy," a collection of 121 aphorisms that is short on text and long on blank spaces, was largely savaged. Indeed, it shows Phillips at his worst, clever and obvious at the same time, as if he were writing a self-help guide to erotically challenged readers of The New York Review of Books: "A couple is a conspiracy in search of a crime. Sex is often the closest they can get." Phillips's propensity for post-Lacanian abstractions and flashy linguistic inversions irritates critics like Elaine Showalter, who noted in a review of Phillips's last book, "Equals," that his observations were "pithy rather than persuasive."
    In the end, what remains up for grabs is how many of Phillips's ideal readers -- "those who are curious about Freud as opposed to those who are convinced of his truth or falsehood" -- are out there, waiting to hear a story about something called the unconscious. "The idea of a standard edition," Phillips points out, is "implicitly sacralizing." Instead, this intellectual impresario is offering a new and slimmer model -- a "slightly wicked" Freud, as John Forrester calls him, one who has been snatched from the cult of genius that laid claim to him and dragged into a less rarefied orbit, where he can be seen acting recognizably human. Phillips's Freud is "always torn between being a lover of conversation and a lover of being right." You might say that Phillips wants to restore the radical nature of the psychoanalytic enterprise -- "Freud backed off and got afraid" -- and transform the Doktor into a man for the transgressive moment rather than the calcified ages. "You can no more own Freud," he declares, "than you can own Henry James."
    Certainly this Freud is a less daunting one, more conducive to the insouciant pleasure of discovery than Strachey's weighty entombment allowed for. And perhaps reinventing Freud as a literary figure on the order of Joyce, Proust and Kafka rather than presenting him as a rigorous cartographer of the mind is a canny way to keep him alive in the public imagination. It's a gamble that Phillips, for one, is prepared to make, and he has the charismatic presence to persuade a lot of formidable scholars and writers to come along with him for the ride. Even some of these people, though, have their doubts as to where it will end: "If Freud is simply another writer-philosopher," observes Malcolm Bowie, who was a professor of French literature at Oxford and is now at Cambridge, "there is no need to shackle him with quack-like claims to scientism or, indeed, to the pragmatic alleviation of suffering. But it is also to diminish him."
    The truth is that Phillips has made it clear that he doesn't give a fig whether the institution of psychoanalysis endures, just as he, like Freud, is not all that that smitten with the "romance of cure," preferring to see his sessions with patients as "a pretext for togetherness, a way out of loneliness." Still, I suspect he loves his Freud, the one who encourages a view of complicated selfhood in the same way that Dostoyevsky or Shakespeare do, with the kind of disinterested love he admits, in a touching moment, to feeling for his patients. "They matter to me a great deal," he says, with quiet conviction.
    There is no doubt that they make strange allies -- the pared-back, fast-moving enfant terrible and the serious old professor with his cigar and his beloved collection of antiquities, and it is hard to imagine what would happen if these two men ever ended up sitting next to each other at one of those hypothetical dinner parties. One possible scene is that Phillips would tell Freud to stop worrying what the Joneses and Jungs think, while Freud would tell him to grow up and get an e-mail address. Or perhaps they'd drink a toast to their shared interest in plumbing the depths of ordinary unhappiness -- what remains after the neurotic misery that brings people into therapy has abated.
    "We have to learn to enjoy the things we don't like," says Phillips, in the way he has of making deeply unconsoling things sound seductive. "Our desires are in excess of any object's capacity to satisfy them. But I'm not for this vale-of-tears approach. The point is to find out what it is that makes one's life livable."

Youth Gambling Is Increasing, Worrying Addiction Specialists
David Crary, Associated Press- 7/14/2003

NEW YORK -- Whether with their friends at parties, at school, or alone on the Internet, millions of American teens are taking up an ever-more-accessible national pastime -- gambling. Much of the action is small-time: underage purchases of lottery tickets, playing cards or dice games for spare change. But specialists say the long-term stakes are significant since gamblers who start young are the most likely to develop addiction problems. ''This is the first generation of kids growing up when gambling is legal and available virtually nationwide,'' said George Meldrum of the Delaware Council on Gambling Problems. ''Casinos, racetracks -- they take it for granted.''
    Nationwide statistics on youth gambling are scarce, but regional surveys suggest that more than 30 percent of high school students gamble periodically. Those in middle school are following suit, as evidenced by the uncovering of a sports-betting ring at a Glenview, Ill., middle school last year. In Delaware, Meldrum's agency recently conducted one of the largest-ever surveys of student gambling; nearly one-third of 6,753 eighth-graders said they had gambled in 2002. The survey discovered that those who gambled were more likely than other students to smoke, drink alcohol, use illegal drugs, and commit petty crimes.
    Such trends are the focus of research at the International Center for Youth Gambling Problems, based at McGill University in Montreal. The center's co-director, Jeffrey Dervensky, said studies indicate that up to 8 percent of young gamblers have a problem with compulsive gambling, compared with 3 percent of adult gamblers. Adult gambling addicts may seek help when they realize their job or marriage is imperiled, but young people are less likely to do so, Dervensky said. ''These kids still live at home, and nobody's dragging them in, saying, `If you don't go for help, I'm leaving you,' '' Dervensky said. ''These kids steal money, usually from their family. If you get caught, your parents are not going to turn you in.'' Keith Whyte, executive director of the National Council on Problem Gambling, said more than 80 percent of American adults now gamble at least occasionally -- a possible reason for what he sees as a worrisome tolerance of youth gambling. ''We've had a number of parents say, `Thank God, it's just gambling,' '' Whyte said.
    While most casinos try to keep underage gamblers off their premises, enforcement is a challenge. Ed Looney of the New Jersey Council on Problem Gambling said Atlantic City's casinos evict about 34,000 young people annually. Looney and his colleagues visit dozens of New Jersey schools each year, discussing compulsive gambling and learning about the latest trends. He said sports betting is epidemic at colleges, and he estimated that 40 percent of New Jersey adolescents play the state lottery, which is meant to be off-limits to anyone under 18.
    The recent survey in Delaware found that 9 percent of eighth-graders had gambled on Internet sites offering electronic slot machines and card games. Many specialists believe this type of gambling will become increasingly tempting to young people. ''The Internet provides the holy trinity of risk factors -- immediate access, anonymity, and, with use of a credit card, the ability to gamble with money you don't really have,'' Whyte said. McGill's Dervensky is worried by the Internet gambling sites that incorporate video-game technology. ''They give you an illusion of control, a sense that the more you play, the better you get,'' he said. ''It's training a whole new generation of kids. Once they get their credit cards, they're off and running.''