Paula Armbruster is an Associate Clinical Professor, Director of Outpatient Services at the Yale Child Study Center and the Director of Social Work Training. She is also an Associate Clinical Professor at the Yale School of Nursing. Professor Armbruster received her Master’s degree in Social Work from the University of Connecticut. She also has a Master’s degree from Yale University in Southeast Asia Area Studies, with an emphasis on Vietnamese History and a minor in Chinese. She consults nationally and internationally on children’s mental health, quality assurance and treatment outcome, comprehensive systems of care, and school and community based child mental health programs.
Professor Armbruster is Chairperson of the Quality Assurance Sub-Committee of the Managed Care/Medicaid Oversight Council for the Connecticut State Legislature. She is also the representative for the National Association of Social Workers to the Surgeon General’s Conference on Child Mental Health. Additionally, she is a member of the National Steering Committee of the Habitat for Humanity International Mental Health Partnership, as well as a consultant to “Making the Grade”, Robert Wood Johnson Foundation. She is past President of the National Consortium of Children’s Mental Health Services.
Professor Armbruster is one of the co-founders and a board member of L.E.A.P. (Leadership, Education, and Athletics in Partnership) for Connecticut’s youth, an intensive social development, mentoring, and academic skill-building program for school children from Connecticut’s inner-city neighborhoods. L.E.A.P. was designated an Ameri-Corps program by President Clinton’s National Community Service program, for which it received the highest score. In March 1995, L.E.A.P. received a national award from the Children’s Defense Fund for the significant impact it has been making in the area of children’s services.
Professor Paula Armbruster can be reached at:
Yale University School of Medicine
230 South Frontage Road, P.O. Box 207900
New Haven, CT 06520-7900
Dr. Cynthia Levin (CL): As the Director of the Yale Child Study Center Outpatient Clinic, can you describe the different types of programs the Outpatient Clinic offers to children and families?
Professor Paula Armbruster (PA): We see a total of about 1,600 children a year: 1,300 in our main clinic and 300 in our satellite clinic. In the main clinic, we started a school-based program in 1992 to provide mental health services to children who may need the services, but were not accessing them.
This idea of a school-based program came out of the research that we had done at the Clinic on investigating who dropped out of treatment; this research is cited in the Surgeon General’s Mental Health Report in the Child Mental Health section. We gathered information on our families who dropped out of evaluation and/or treatment. Then we wanted to try to devise a program that could reach this group. The families were primarily minority, economically disadvantaged, and single parent families. So, that led us to develop the school-based program in order to provide access to our services and to reach children who otherwise might not receive needed interventions.
We collaborated with the New Haven Board of Education because they had to give us permission to go out to the schools. What we do in the schools is to provide the same services that children would receive in the Clinic. In the schools, the children are already there, so parental work schedules, transportation, and all the other barriers that people have in getting to a clinic ceases to be a problem. Also, the school offers a much more neutral setting than coming to a psychiatric clinic. The schools collaborate with us and if the parents trust the schools and the schools say, “We’re ok”, then the parents will generally trust us. Additionally, clinicians have the opportunity to observe the child in a variety of settings including the playground, cafeteria, and classroom. These observations are clinically very informative.
Because we saw how beneficial the school-based program was and how well it worked, we tried to identify other points of entry into the community. This led us to developing mental health services in a homeless adolescent drop-in center, in a recreation/neighborhood center, which includes an after-school and summer program, and in a religious institution. We will also be going into public housing with a team of other professionals who provide health services, adult mental health, recreation, mentoring, tutoring, etc. That’s the breadth of the outpatient clinic.
Within the Child Study Center, we have many other programs or specialty clinics that primarily evaluate Tourette’s disorder, Autism, and Obsessive-Compulsive disorder. We also have an in-home service and a community policing service, but the Clinic is probably the largest service within the Child Study Center.
CL: The school-based programs sound like a wonderful way to bring important services to children. Can you talk more about how these programs work?
PA: We have 2 kinds of school-based programs. One type of program is called a School-Based Health Clinic, or as we call them SBHCs. Many of the departments of public health or other state departments in the country now provide funding for school-based health clinics. The school-based health clinics are really a freestanding clinic within a school that provides both health and mental health care. In New Haven we have 14 of these clinics. These clinics partner with a health facility such as Yale/New Haven Hospital, a community health center or another hospital. They provide the medical health care and either our Clinic or another child mental health clinic provides the mental health services. These SBHCs function like a regular clinic with a receptionist and a health-care provider who’s generally a nurse practitioner. A clinical social worker usually provides the mental health component. There is always medical back up for health and mental health services. These clinics offer evaluation and individual treatment, as well as a significant amount of group therapy and crisis intervention.
Our other school-based program is primarily a mental health service. This program is part of the Outpatient Clinic, where one or two clinicians go to a school and bring the services of the Clinic to the school. What we always say before working in a school is “In the school, the principal is in charge.” So, when we go to a school, we meet with the principal and either he or she, or his or her designee is the referral source. In a small school, though, it’s often the principal. In a large school, it can be the special ed teacher, a school guidance counselor, a school social worker, and/or a school psychologist. We do not see the special ed children in the schools because school social workers and school psychologists see those children who need special ed services.
This kind of school-based program is a preventive service in that we see the kids who are having difficulties but don’t quite meet the criteria for special ed. We hope that they won’t need special ed resources after receiving our intervention. In this program, we see the children individually and/or in groups. In the majority of cases, we have the parent’s permission to treat their children. We don’t see the parents as much in the schools, which has a lot to do either with their schedules and the lack of parent involvement in the schools in general. For example, parent-teacher conferences are very poorly attended in some schools. The schools are trying very hard to do more outreach to parents but many parents have had negative experiences in schools and maybe mistrustful.
CL: Do you work closely with the teachers?
PA: We work with the teachers, with a school psychologist, school social worker and when the parents come in, we definitely work with the parents. Providing services on the school site is very helpful clinically because you see the child in the in the halls, the cafeteria, on the playground, and in the classroom. So you have a very multi-faceted clinical picture of that child. That’s very helpful, especially when you have information from the teacher and from the parent as well.
CL: That’s great. And what grades do you work with?
PA: Well, we go right through grades K-12. We do some consultation also for daycare and preschool programs such as Head Start. It has been a real privilege to be able to partner with teams of professionals in the schools whenever that’s possible since that’s what seems to work best for the children. I have so many letters from principals citing many excellent results they have seen from the interventions we have done, such as reducing disciplinary action, improving grades and reducing absences.
CL: Those school-based programs sound like they pull all the pieces together for children by working with teachers and parents within the school systems. You had also mentioned utilizing your Clinic’s services at an adolescent drop-in center. Can you tell us more about what that is and how it works?
PA: Well, we go to a homeless adolescent drop-in center in the community. The clinicians that would evaluate and treat a child or adolescent in the clinic are the same clinicians who go out to the schools and to the homeless adolescent drop-in center. Oftentimes, the kids at the drop-in center have run-away from home, have had multiple placements, come from a substance-abusing environment, and/or have experienced a history of abuse or neglect within the family. At the Center, we either generally see the child individually or run groups, particularly around issues of loss. Some teens receive both individual and group therapy treatment.
CL: Have you found that the teens in the drop-in center have been pretty receptive to these therapeutic treatments?
PA: I think it varies from teen to teen. We’ve had some real success stories where we’ve been able to get teens back into school and on the right track. But these teens have very troubled histories. We are going to be publishing a paper on our experiences with these teens and I believe the average age of leaving home for them is 12. These are teens who have had a very, very rough time and they’re often very depressed, although their presentation is that of the tough and angry kid. It’s a difficult group but we’ve been able to be pretty successful in engaging them.
CL: It certainly sounds like these outreach programs, such as the school-based programs or teen drop-in centers provide an effective means for treating children and teens.
PA: We try to be where the child is. You know Hillary Clinton used the African proverb when she said, “It takes a village.” I say, “Join the village.” And that means going to where the families are; not always waiting for them to come to you.
CL: That sounds like a good approach to have. So, in terms of treating some of the children and families that come to your Clinic, can you talk more specifically about the clinical treatments that you provide?
PA: Sure, we try to provide a comprehensive range of services. We evaluate the child and based on their particular clinical needs we provide services. We offer individual treatment for the child, group therapy, family therapy, parent therapy, parent guidance, psychological testing, and psychopharmacological interventions. If a child needs psychological testing, we first try to have that conducted at the school, but if that is not possible, we also have a psychological testing service. So, we offer a broad range of clinical services.
CL: Who are the professionals that offer services at the Clinic?
PA: Well, we are a training center so primarily most of the professionals are child psychiatry fellows and child psychology fellows who are here for two years, and our post-master’s clinical social work fellows. The clinical social work fellows probably render 60-70% of the care in the Clinic, because it is the largest training program here. The fellows are all postgraduates: the psychology fellows are pre and post -doctoral, social work fellows have completed the master’s level, and the MD’s have completed medical school and are doing a 2 year residency. There are also some faculty members who see children in the Clinic.
CL: Are there any specific patient populations that tend to come to your Clinic?
PA: We have a mixed population now, which was not always the case. I’ve been here for about 26 years and it was a very small clinic back then. I took over as Director in 1984 and at that time we served about 100 children. We primarily treated a very middle-class population, many people from the Yale community, etc.
As the demographics of New Haven began to change, which we became aware of in 1982 when New Haven was identified as the 7th poorest city in the country, we began to see more and more underprivileged children and that very much changed the profile here. Reasons for referral were fewer for depression, anxiety, and enuresis and more for the oppositional defiant or behaviorally aggressive problems.
So, we moved from the more internalizing disorders towards the more externalizing disorders and presently we are more of a 50/50 mix of internalizing and externalizing problems.
CL: How has Managed Care affected the number of sessions you can provide to children and families?
PA: I just did a study that compared the years from 1994-1995 vs. 1996-1997 before and after managed care, and the average number of sessions decreased from 35-16. However, we have many cases in the Clinic to which we make long-term commitments. Kids who have Pervasive Developmental Disorder and other serious psychiatric disorders we continue to see up until 18 years of age and sometimes beyond that. We don’t turn people away.
CL: Paula, have you noticed any notable differences between providing services outside of the Clinic in the outreach programs as compared to when you treat patients who come directly to the Clinic?
PA: This is an important issue. The clinician who prefers to work in an office setting is very different from the clinician who will work off-site. In the office you generally have control; off-site, you don’t. You have to give up control and take on a partnership. Because you’re partnering, say with the school, with the church, or with the agency that runs the homeless adolescent drop-in center, there is a collaboration that must take place between the community and the clinic.
Plus, you have to be extremely flexible because it’s often not a well-equipped office. You simply go where there is space. Particularly in the drop-in center these kids generally are not very trusting. Life has not dealt them a good card. So, the whole issue of trust and how you build up the trust takes perseverance and you won’t generally start by saying, “Come into my office, we have an appointment.” You may start by playing pool or just being somebody who comes regularly X number of times a week; the kids gradually then begin to think this person may be ok. Then they’ll be more willing to meet with you.
CL: Now, in some way, I would imagine, that by actually going to them and seeing the kids in a more natural setting it would provide for a more authentic type of relationship.
PA: Well, I don’t know if you’d say authentic, but that’s an interesting way of framing it. I’d say that it’s different. You still need to keep the professional boundaries, but it’s definitely more informal then say at the Clinic where you don’t start the relationship by playing pool. The whole issue of cultural sensitivity or what people are calling cultural competence is also a big issue in these settings.
CL: Can you say more about how cultural competence becomes a big issue at the drop-in center?
PA: Well, initially it’s probably very helpful to have our clinicians who go to the drop-in center come from backgrounds ethnically that are more similar to the kids who come to the drop-in center. Even though the educational level and the socioeconomic background may be very different, this, at least, is kind of an initial bridge to begin to relate to each other.
I will tell you, though, that we had a clinician here who had the blondest hair, the bluest eyes, the fairest skin and she was extraordinarily successful in working with children of color and in working in settings outside of the clinic. Actually, she had never really treated Caucasian children until she came to the Child Study Center. Kids really trusted her and she was very comfortable working with and being sensitive to people who were different from her. She really preferred working in offsite settings. So, it’s not always an issue, but it can be helpful.
During our orientation for new Fellows in July and August we offer a lot of training on cultural competence. We give tours of the neighborhoods that these kids come from. We also bring in people from the neighborhoods who really educate our clinicians about some of the circumstances in which many of these children live.
CL: These types of hands-on interventions are what sound like they really set your clinic apart. You are actually going out there and being clinically active with the children or the adolescents in their own familiar settings.
PA: That’s what we really are trying to do.
CL: Since you’ve had the privilege, Paula, of working with children, adolescents and families throughout the years, I’m wondering if you have felt that this rise in childhood behaviors and disorders that they talk about in the media is real in terms of children having more psychological problems than children faced before? Studies cite that 1 in 5 children now have an emotional or behavioral problem. What do you think of that?
PA: The number of children experiencing these problems used to be smaller. I think several years ago it was like ten or twelve percent, now it is up to between twenty to twenty-five percent in certain environments. The increase in psychological problems for children and teens might also be a result of better identification of these psychological problems than we had in the past. But, even a decade ago we knew that kids living under circumstances of psychosocial adversity were more in need. As you know, our society has lots of stressors and the kids are not immune to them and their behavior reflects that.
I think there are several factors that are influences affecting children’s behavior. Look at the increase in the amount of violence on television and in the media, as well as the availability of firearms; kids respond to that. It’s a different world and we have different role models who are our heroes. We need to look at who kids currently model themselves after.
I think that there’s another issue, too, which is lack of identification with the mainstream culture. Amongst some teens the sense of alienation and having their own group sub-culture is very prevalent. Lots of times parents are unaware of that phenomenon. Our ability or inability to reach out to adolescents is a very important issue right now.
CL: Paula, considering how much you have been a part of mental health for children and families on so many levels, what kinds of factors would you like to see change in the future to be able to more effectively treat children and families?
PA: First and foremost, I would like to see funding for mental health increase. Child and adolescent mental health is under funded, which is a major issue. Also, there needs to be not only funding for the services, but also funding for the training. For example, I had two grants from the National Institute of Mental Health for training post M.S.Ws for clinical work with children, but Congress cut the funding for training, an unfortunate situation.
In fact, at a recent meeting with the Surgeon General where he wanted to hear from people in the mental health field, the issues of funding and training were right up at the top. The social topography is different now; very complex multiple issues exist and you need a multi-faceted approach to be really effective. One size does not fit all and you need to use all of the armamentarium that you have to intervene. You can’t intervene effectively if you don’t have the funding or the trained personnel. That is so critical.
When I started out here at the Outpatient Clinic we had one therapist for the parent and one therapist for the child. We met weekly; one therapist met weekly with the child and one with the parent and it seemed to work well.
But now, we’re much more constrained. We used to do an eight-session evaluation and now generally we do a two-session evaluation, which means we have to learn more about the child and family as treatment progresses. Whether you choose a psychodynamic approach or a cognitive behavioral approach depends on the presenting problem and the individuals involved. For some children and families you need a full spectrum of care where you provide mental health in partnership with health, mentoring, an arts program, a recreational program, or a big sibs program. We need to work in creative ways to really try to engage the family and also to assess the family’s strengths and capabilities.
For example, when you have kids coming in younger and younger who are using chemical substances it is important to treat the whole family. If you have a 10 year old come in who’s using drugs or alcohol, chances are he comes from a family who’s using also. But, where do you go to treat the family in its entirety? There are usually child programs and adult programs, but how can you have an effective substance abuse treatment program for a younger child unless you target the whole family?
CL: Yes, these are all critical issues that need to be addressed.
Now, Paula, from what I understand you came to the field of social work with a fairly unique background that has helped you to get involved in the field of mental health on many different levels. Please fill our viewers in about your professional background and what brought you into the field of social work.
PA: I originally came to Yale for my Master’s degree in Southeast Asia Area Studies with an emphasis on Vietnamese History and a minor in Chinese. I had been recruited by U.N.E.S.C.O. (United Nations Educational Scientific and Cultural Organization) in Paris to foster international communication through the arts.
Then I married an academic, so I went on to finish my doctoral course work with a major in Vietnamese 19th Century Chinese 20th Century studies. However, funding for positions in Southeast Asia Area studies dried up as a result of the war in Vietnam ending. The other students and myself in the Ph.D. program were told that there were no job positions available in Southeast Asian history. This information gave me pause. Then, the wife of one of my professor’s, who was a clinical social worker, said to me, “I love my job so much, I feel I should pay my employer.” I listened to what she said and entered an M.S.W. program at the University of Connecticut.
So, I went from the macrocosm of international relations to the microcosm of intra-psychic. I went to the school of social work because at that time I was primarily interested in learning about human behavior. I really wanted to work with individuals and social work seemed the best choice for me. My first year field placement was on an inpatient psychiatric unit at the VA hospital where I saw adult psychopathology. As an ex-historian, I was interested in how this psychopathology evolved and what were its roots.
I asked for a second year placement where I’d be able to work with kids and was told that the best training was at the Child Study Center. I came here as a trainee and they asked me if I would stay on as a faculty person. I’ve been given extraordinary opportunities here to develop a training program, to develop the clinic, to publish, and to be creative.
CL: That is a very interesting way that you came about working in the field of social work.
PA: Yes, it seemed indirect at the time. However, a portion of the graduate school curriculum in social work focused on anthropology, sociology, and social policy; areas of study that were very familiar to me because of my previous Master’s degree. Fortuitously, I am able to combine these interests today in the work that I do focusing on policy. I’ve also tried to combine my background in Asian Studies by leading a group of child mental health professionals to China and to India. I have also consulted to Vietnam and Cambodia, so I’ve always strived to integrate past and present.
Actually, because of my background, I have a bias about what kind of an academic and training track I would recommend to others. I feel that if you’re interested in doing neuro-psychiatric research and developing an expertise around medication, than an M.D. degree is very attractive. If you’re interested in providing psychotherapy you can definitely get a Ph.D. degree in Clinical Psychology, which additionally includes research training and the administering and interpreting of psychometric testing.
However, if you’re interested in social work I have a favorite track I would encourage people to take. It involves getting an M.S.W., working with children and families for approximately 5 years, and then getting a Ph.D. in Epidemiology and Public Health. That’s my ideal degree. I think it’s a great Ph.D. because it will prepare you both for research and policy. You will be able to view mental health within the whole context of healthcare, as well as receive training and research. That is the track I would recommend to people who want to do the kinds of work that is similar to mine.
Now, there are people who just want to be clinicians and do some teaching. To teach in a graduate school of social work you must have a doctorate. So, I would suggest that they go to a Ph.D. or D.S.W. program in clinical social work, whichever program they prefer. But, those tracks are for the pure clinician who will teach clinical practice. For myself personally, I think policy is important. I haven’t given up on the macrocosm.
CL: That information will be very helpful to those who want to pursue combining social work with policy, but maybe had not known what the best academic track would be for them to get there.
I also want to thank you, Paula, for sharing with the viewers all about the successful programs your Clinic offers, as well as your expertise and knowledge about working with children and families.