Editor's Note: In 1981 when this article was written, Bert Pepper, M.D., and his colleagues at the Rockland County Community Mental Health Center in Pomona, New York, as well as other clinicians in the public sector had become aware of a large new subgroup of patients—young adults with severe difficulties in social functioning who tended to use mental health services inappropriately. They had diagnoses of schizophrenia, manic-depressive illness, and personality disorders, and many abused alcohol and drugs. In this article, reprinted from the July 1981 Hospital and Community Psychiatry, the authors describe a group of nearly 300 such patients between the ages of 18 and 30. They contrast them with an older generation of chronic patients, who were more docile and apathetic owing to long-term institutionalization. Based on their clinical experience, the authors provide an insightful psychological and developmental profile of this group. A case study illustrates the course of treatment of these young adults, which is often frustrating for both patient and clinician.
A new generation of persistently dysfunctional young adults (aged 18 to 35) has emerged in the community, requiring new programs in community care. This population, which includes a wide range of diagnostic groups, is under study at a suburban New York community mental health center. The center and county are serving 294 such young patients through a variety of programs which include a crisis service, a sheltered workshop, a residential program called the Community Link-Up Experience, an acute day treatment program, an alcohol day treatment program, a case management program, and a Growth Advancement Program that gives patients an opportunity to socialize and share problems with others their age. Residential programs that provide a supportive living situation to young adult chronic patients on both a temporary and a long-term basis are sorely needed and will require an increased outlay of funds. A case study of one young patient who visited the center sporadically over a 12-year period illustrates the treatment problems such patients pose.
Much has been said and written about the direct effect of deinstitutionalization in the United States. The reduction of the population of state and county mental hospitals nationwide from 558,922 in 1955 to 159,405 in 1977 (1) is evidenced by the emergence of shopping-bag ladies, by the growth of the single-room-occupancy hotel, proprietary (board-and-care) home, and nursing home industries, and by the overload on community mental health and state aftercare programs.
The purpose of this article is to raise the consciousness of mental health professionals to the other side of deinstitutionalization: the emergence of a population of young adult chronic patients who have spent relatively little time in hospitals but who present persistent and frustrating problems to community caregivers in mental health and other social service systems. We are referring to people between the ages of 18 and 30 or 35 who are psychiatrically and socially impaired, so seriously that they are continually or recurrently clients of mental health and other social service agencies over a period of years.
Diagnostically, these young adults carry a variety of labels—schizophrenia, other psychoses, and personality disorders prominent among them. Although they present a variety of symptom profiles, they share two overarching characteristics: their severe difficulties in social functioning, and their tendency to use mental health services inappropriately, in ways that drain the time and energy of clinicians yet do not conform to viable treatment plans.
Two decades ago Ernest Gruenberg began publishing a brilliant series of reports of patients in our state hospitals who, despite a variety of diagnoses, could commonly be described as suffering from a "social breakdown syndrome" (2,3,4,5,6,7,8,9). Their behavior was characterized by poor social and psychological functioning, apathy, negativism, and docility mingled with episodic outbursts—seemingly the contribution of institutional life to their behavior, as also chronicled by Goffman (10). However, a decade ago Gruenberg observed the syndrome in individuals who had not had long residence in an institution.
Many in our patient group are less frequently and consistently disabled than Gruenberg's patients, and a high proportion have never required hospitalization. But social breakdown syndrome is one of the dysfunctional patterns we have observed in this, our first generation of chronically impaired, young adult patients who have spent little or no time in mental hospitals.
When such young adults appear in our emergency rooms, hospital admission is a last resort. Our involuntary admissions must meet stricter legal standards than in the past; our voluntary admissions must withstand more careful scrutiny. Diversion of such patients to a day program or other outpatient treatment is a likely suggestion, but one that is often not accepted or not followed by these help-seeking yet help-rejecting young people. If they are admitted to the hospital, their stays are measured in days or weeks rather than months, years, or decades.
Young adult chronic patients living in the community are socially and psychologically different from older deinstitutionalized patients, and from those never-institutionalized, older adult chronic patients who are sometimes included among "new chronics." Younger patients are different because failure is new to them; because they are still struggling to be like their age-mates; because they have not learned, as have deinstitutionalized patients, to be docile and do as they are told; because they act out—many take drugs—in the manner of withdrawn or rebellious youth; and because they are as likely to blame mental health professionals as they are to turn to them for help.
The functional criteria we have used in defining this group cut across diagnostic and programmatic lines. We are conducting an informal exploratory study at the Rockland County Community Mental Health Center with input from more than 100 clinicians on our interdisciplinary staff. Approximately 900 patients in the age group 18 to 30 were identified as having been served in the three-month period from June through August 1980. Of these 900, a total of 294 were categorized by clinicians and through chart review as members of the group we have called young adult chronic patients. They were readily identifiable as having a characteristic configuration of functional disabilities and of treatment and social service needs. Slightly more than half, 165, are males.
On our records, these 294 patients carry 40 different specific diagnoses. Nearly two-thirds, or 192 patients, have a diagnosis of major mental illness. Of the 294 patients, 169 were diagnosed as schizophrenic, with 97 diagnosed as having schizophrenia, chronic undifferentiated type. Twenty-one others had a primary diagnosis of major affective disorder (manic-depressive illness), while two others had an atypical or other psychosis. The remainder had the primary diagnoses of personality disorders (36 patients), behavior disorders (16 patients), neuroses (24 patients), drug dependence or alcohol abuse (10 patients), and organic brain syndrome, mental retardation, or specific learning disability (16 patients).
The variety of diagnoses in our group indicates the need to view these young chronic patients functionally rather than in terms of their labels. The treatment needs implied by the specific diagnoses must be met, of course. But the presenting disturbances of these young adults and their social and treatment needs are disconcertingly similar, for they spring from the problems all these patients have in common: their acute vulnerability to stress, their difficulty in making stable and supportive relationships, their inability to get and keep something good in their lives, and their repeated failures of judgment, which can be seen as an inability or refusal to learn from their experiences.
These patients provoke an uncommon amount of frustration and distress, not only from their relatives and associates but also from their clinicians and caseworkers. They confound our efforts to treat them by conventional means, they evade yet repeatedly disturb our mental health programs, and they appear again and again in our psychiatric emergency services and police stations. Some, though not all, sojourn briefly in our psychiatric hospitals, where their names are likely to be well known, where they consume disproportionate quantities of staff time, where, like recalcitrant children, they create more than their share of consternation, where they are the subject of multiple case presentations and interagency treatment planning conferences—only to be discharged back into lives that often prove once again untenable.
These patients rarely reward our efforts with improvement. Instead they become, individually and collectively, our albatross. They are functioning persons only in a marginal sense; they manage their lives tenuously at best and disastrously at worst. They are discharged when their most acute symptoms have abated, but typically their remissions are incomplete.
A majority (68 per cent of our 294 patients) are still living with parents or "others," which often means other patients met in hospitals or drug programs. A minority (17 per cent) live alone, which often means they are perpetual transients through the cheerless halls of single-room-occupancy hotels. The remaining 15 per cent live in community residences (9 per cent), proprietary homes (3 per cent), or family care (3 per cent). A majority (57 per cent) depend on some form of public assistance, and many (19 per cent) are still supported by their parents; only 24 per cent are self-supporting.
Most have been able to make only transient, unstable, unsatisfactory relationships with people their own age; their friends and lovers are often other marginally functional people with equally uneven life courses and dubious prognoses. A sizable number abuse alcohol (37 per cent) or other drugs (37 per cent—not necessarily the same 37 per cent); some of them are quite obviously self-medicating to dull the pain of their confusion and despair. At least 24 per cent have been in trouble with the law, usually in ways clearly related to their emotional and social impairment. A high proportion (42 per cent) present a risk of suicide, for reasons that certainly include the simple fact that they see no hope for the future.
The words "young" and "chronic" joined together make an unpleasant phrase. Indeed, the word "chronic" is misleading and prejudicial, for a minority of these patients are eventually able to pursue fairly normal lives, and for many more the term "chronicity" may reflect merely the undeveloped state of our own arts. But these patients are, in a sense, chronically young. They are stuck in the transition from childhood dependence to adult independence, from parental or quasiparental support to self-supporting work, adult autonomy, and an expanding network of relationships—the fundamental amenities that keep our own lives going.
Like the parents of mentally retarded young people, the parents of young chronic patients wonder, "Who will look after him when I die?" Some of the patients simply remain, figuratively and sometimes literally, home in bed. Some are wanderers. Some become known as troublemakers. Some of them try, again and again, with diminishing hopes, to take some step toward greater independence, or at least more stable functioning. Again and again they fall back into the reluctant yet retentive embrace of their parents, back to the arms of psychiatric and social service systems. Too often they slip through our willing but clumsy fingers, until some new calamity brings them once again to our attention.
Just as Gruenberg looked at the contribution of institutional life to social breakdown syndrome, we must explore the roles played by the family and society in the formation and persistence of our young chronic patients' repetitive behavior. For those whose behavior springs from the ego deficits involved in serious mental or emotional illness, we also have to reflect that this is the first generation of mental patients to have to cope, from the beginning and during most of their lives, with the tasks and the stresses of community living.
The career of mental patient used to offer, like army life and like some families, at least a measure of stability to make up for the disadvantage of confinement. Our mental hospitals were built and peopled on the assumption that mental patients needed protection from society, just as society needed protection from them. Lately the life course of patients has become much more fluctuating and uncertain.
Of our group of 294, at least 55 per cent received mental health treatment before the age of 18. These were emotionally troubled youngsters who grew up to be chronically dependent young adults. They may have functioned fairly well in childhood and even part way through adolescence, only to become symptomatic when confronting the task of separating from families and achieving an adult identity. They have no refuge to enter now, as deinstitutionalization has rendered many of them essentially homeless.
We estimate that, for every dysfunctional young adult we see, there are two to ten in the community who never arrive at our doorstep but are hidden in dysfunctional families or in jails, or wander unnoticed in our city streets. In a recent conference on the young adult chronic patient sponsored by our center, data on a New York City population of young chronic patients showed an appalling rate of death by suicide—five in one year from a group of 119 patients newly discharged from a state hospital (11). In a moderate-size and richly served community like Rockland County, young chronic patients tend to be more visible and somewhat less at risk.
These young adults more often describe themselves to us as social casualties than as victims of mental illness or personality disorders, just as they prefer to remember an episode of disorganized thinking as the result of an incidental ingestion of drugs—the fabled "bad trip"—rather than as an upsurge of psychosis. Many do not define themselves as mental patients, and this, of course, is one of the intended benefits of their being in the community.
But this benefit has other implications. Impaired young adults who do not view themselves as patients are reluctant to acknowledge an ongoing need for medication, and are resistant to seeing themselves as particularly vulnerable to the alcohol, marijuana, and other mind-altering drugs enjoyed recreationally by their age-mates. They sense, quite correctly, that weekly one-to-one therapy is insufficient or irrelevant to their needs; those who do establish a relationship with a therapist may fail to keep appointments when feeling well, yet present themselves on impulse, demanding and indeed requiring attention on a crisis basis. On the other hand, they frequently reject day programs, saying, "That's not for me," "I'm going to get a job and make some money," "I'm going to go back to school," or "Those people are all too sick for me. I'm not that sick!"
This reluctance to see themselves as different from anyone else functions as a barrier to accepting treatment. Yet their persistent lack of success in achieving the goals that are socially appropriate to their age—education, mating, a steady job—does set them apart in their own despairing perception, not as patients or impaired people with special needs, but as social failures. Viewing themselves as "just like anybody else," they have to experience, again and again, the pain of difference, the despair of failure. They take refuge from this perception by acting out, by aggressive outbursts, by taking drugs, by taking to their beds, and by blaming and raging against their parents, their landlords, their therapists, the police, the hospital, and society.
An example of the patient group we are describing is a young man we will call Mr. J, who has been known to our center for 12 years. He first came to one of our outpatient clinics in 1968 at age 18, complaining of "failure to meet with school requirements, due to my feelings about people I deal with…. School puts me uptight." At that time he was still in high school, where he had been doing poorly since early adolescence. He was living at home with his mother, whom he described as "overworried about everything, always complaining and pressuring me." His father, "a cold and violent person," had been out of the home for two years. The patient was described in the psychiatric evaluation as showing a classic disturbance in thinking, affect, and relating to others and a very disturbed communication system. There was also tentative evidence of paranoid symptomatology.
Mr. J was diagnosed as schizophrenic, chronic undifferentiated type. Since his only effective communication seemed to be with his peers, adolescent group therapy was recommended, to be started after a period of preparation. The next entry in Mr. J's chart is a copy of a letter from his therapist: "Dear Mr. J: I'm sorry you have been unable to keep your appointments with me…." In response to the letter, the patient's mother appeared at the center, worried and tearful, saying that her son was her whole life, but that "he just sleeps all day and doesn't go to school or work." After numerous attempts to engage Mr. J in treatment, his case was closed until he initiated further contact.
The next 11 years of Mr. J's history as a patient in our system include the following events:
In 1971 he requested admission to our inpatient unit, where a friend was hospitalized and where Mr. J felt he could "talk to someone." He complained of having no place to go. He was using heroin, speed, and marijuana and was seen by our staff as anxious and withdrawn but not in need of hospitalization. He was referred back to the outpatient clinic, which he attended during the next several months, breaking many appointments and showing up at unscheduled times. He became belligerent and actively paranoid, and thioridazine was prescribed. He contracted hepatitis caused by his use of heroin. In April 1971 his case was closed again because he refused help of any kind.
In 1972 Mr. J was arrested for armed robbery, which was probably related to his use of drugs. Six months later he appeared at the clinic, stating he had had methadone treatment but now felt jumpy and craved heroin. He was taking 10 mg of diazepam t.i.d., prescribed by his family doctor, and was also drinking. He complained of being unable to build a relationship with a girl. Following this visit he kept no further appointments, despite many efforts to contact him.
In 1974 Mr. J again requested admission as an inpatient, saying he couldn't stand living at home. He was offered admission to the day hospital. He promised to return later to begin the program, but did not return for two years.
For a six-month period in 1976, Mr. J became a habitual user and abuser of the center's emergency service, calling the service frequently to complain of physical symptoms, depression, and boredom. He was referred to the county's social rehabilitation service (now the community support center, described below) and attended for only one day, continuing to call the emergency service. He was clearly decompensating and was addicted to diazepam. Once he called to say he had taken pills and wine and had broken up a girl's apartment "for revenge." A week later a bomb threat to the mental health center was made in a voice that sounded like Mr. J's although he hotly denied making the call.
In 1977 and 1978 the patient formed a relationship with a therapist at the clinic and also began attending the acute day treatment program. He was still taking 5 to 20 mg of diazepam daily, prescribed by several general practitioners. He continued to take the drug after a brief, voluntary admission to our inpatient unit for detoxification.
By 1979 Mr. J had left day treatment and was willing only to continue with his outpatient therapist, but even there his contacts were increasingly sporadic. He was referred to a new center program for young adults (the Growth Advancement Program, described below) but did not attend. He attended some Alcoholics Anonymous meetings, but continued to use diazepam. When a more structured program was again suggested, he became angry with his therapist and walked out.
In 1980 he was hospitalized involuntarily in our inpatient unit following a call from someone in the community who reported that he was expressing paranoid, suicidal, and homicidal ideation. He showed classic symptoms of thought disorder and was preoccupied with relationships that seemed largely based on fantasy. He had recently had his 30th birthday, and learning that a friend a few years older had died, he suspected suicide. He saw himself as following a similar life course.
Unfortunately, this story has neither climax nor ending. At discharge clinicians again urged Mr. J to attend a residential program and to resume day treatment and vocational training. He refused all these options, and although he said he wanted his life to be different, he was unable to undertake change. He continues to live with his mother, to be unemployed and socially isolated, and to abuse drugs in order to assuage the anxiety and tension he lives with constantly. At 30 he has the despairing sense that his life will never change.
We wanted to find out where young adult chronic patients in Rockland County are now being treated and how we can serve them more effectively. We have the advantages, both in research and in treatment, of an extensive, multiprogram system of service. The Rockland County Community Mental Health Center, which began as a federally constructed and funded facility, comprises more than 50 separate programs. In recent years it has become the core agency of a unified service network for the total care and treatment of the mentally ill, mentally retarded, developmentally disabled, and alcoholic and drug-abusing residents in our county of 270,000 persons.
We have had mixed success in ensuring that our young chronic patients actually use the services available to them. The crisis service is a typical point of entry. Besides a full range of immediate and intensive crisis interventions at the center or in the home, it offers short-term treatment in frequent sessions over several weeks. This brief intensive treatment functions as one alternative to hospitalization for a disturbed young adult. Twenty-three of our patients have recently been treated by the crisis service although they are not involved in other programs—usually because they reject outpatient treatment and do not meet legal standards for hospitalization.
The inpatient unit is a short-term, crisis-oriented unit (mean stay, 17 days) that focuses on rapid resolution of severe presenting problems and return to the community. Often in the course of a hospitalization, a young adult who has remained dependent on his family is encouraged to move toward greater independence, and in some cases to move out of the family home by applying for public assistance and seeking new living quarters while still in the hospital. Our records show that 41 of our group of 294 have been hospitalized one or more times in our inpatient unit but are not currently involved in any of our outpatient programs. Another 178 patients have had one or more hospitalizations (on our inpatient unit or elsewhere) but are recorded as having been seen most recently in an outpatient program.
A minority of our young adult population are referred to the Community Link-Up Experience (CLUE), a 20-bed, two-phase residential program operated by the Rockland Hospital Guild, on the grounds of Rockland Psychiatric Center. The program offers housing to both young adults and older patients who are involved in a day program or other all-day activity. During the first phase patients live in CLUE's halfway house, and in the second phase they share private apartments also located on the grounds. The CLUE program is an example of the kind of supportive residential placement that we believe is sorely needed. Many young chronic patients could benefit from such alternative living arrangements because they simply do not function alone in the community or make, without intensive support, the kind of steady relationships that enable them to work out arrangements with roommates.
Our acute day treatment (day hospital) program is used as a transition from a short-term hospitalization or as an alternative to admission (12). It offers a structured 14-week experience, four days a week, and includes daily group therapy and educational and recreational activities, as well as individual and family therapy and chemotherapy when indicated. Thirty-eight of the 300 patients are presently being served by this program.
Staff consider acute day treatment and its counterpart, the alcohol day treatment program, the treatment of choice for many young adult chronic patients. But, as might be expected, many whom we try to refer will not accept such intensive, all-day programs.
The services of our outpatient clinic range from weekly individual or group therapy to medication visits and also include crisis and walk-in services. The six branch clinics have the advantage of being conveniently located in various neighborhoods in the county. Currently 145 patients are being seen in the clinics. But the services were not designed for our young adult chronic patients, and are often inadequate or inappropriate to their needs. Yet the link to an outpatient clinic is often the single support that young patients will accept.
Many young patients use the services of the outpatient clinic only sporadically or temporarily. Others may try to use the clinic for years of support, draining the time and energy of a single clinician, who may feel frustrated because of a desire to treat actively to a successful termination of therapy in a year; in such cases, the clinic administrator may face the difficult task of resolving, on an individual basis, the problem of the patients' overutilization of services.
Also part of the network are two community support centers, operated by staff from state, county, and voluntary agencies. They provide long-term day programs, social rehabilitation, psychotherapy, crisis intervention, and medication to the more severely impaired patients—those whose baseline of functioning is lower, who have been hospitalized more frequently, and who are less able to benefit from a more intensive, crisis-focused program. Dovetailing with the community support centers' programs is the Jawonio sheltered workshop, operated by the Rockland County Center for the Physically Handicapped; it provides prevocational and vocational training for psychiatrically disabled, physically handicapped, and some mentally retarded clients. Forty-seven of our group are currently served by the centers or the workshop.
In 1979 the Rockland center began the Growth Advancement Program as a specific response to the needs of young adult chronic patients. Operating as part of the community support centers, it offers such patients an opportunity to socialize and share problems with others their age. The program is designed to help young patients acquire the skills necessary to develop a system of community support and contacts outside the agency.
This is only the beginning of our response to the young adult chronic patient, and we are acutely aware of the need for new initiatives. We should note, however, that 25 per cent of our group (75 patients) have never been hospitalized; another 14 per cent (40 patients) have been hospitalized only once; 16 per cent (47 patients) have been hospitalized twice; and 45 per cent (132 patients) have been hospitalized three or more times.
While this low rate of hospitalization is gratifying insofar as it may reflect the effectiveness of our outpatient programs, it also has another consequence: a problem in meeting the need for case management services. We have in Rockland County, as part of the community support system, a program of case management services designed for patients who need help in handling activities of their daily lives and in maintaining their connection with treatment programs. For many of our young chronic patients, the relationship with the case manager is crucial to maintaining their functioning in times of stress—for example, when they lose a room or job and need a swift, helpful response from a trusted person.
Thirty-one per cent, or 90, of our group are receiving case management services. Sixty-three per cent of the 294, or 185 individuals, do not have a case manager. (For the remaining 6 per cent, the presence or absence of a case manager was undetermined.) While we do not know specifically why each of the 63 per cent lacks a case manager, we do know that 55 per cent are not eligible for case management because they are not eligible for the services of the community support system according to New York State criteria: three ten-day hospitalizations or three months' cumulative hospitalization within the past two years, or six months' consecutive hospitalization in a lifetime. Obviously, these criteria must be reconsidered if we are to provide more functionally disabled patients with case management and other vital services supported by community support system funds.
We asked our clinicians to indicate whether our present treatment and service programs were meeting the needs of young adult chronic patients. Their clinical judgment was that for 68 per cent of these patients, treatment needs are currently being met in the community, and that for 70 per cent, financial needs are being met. The clinicians' assessment is gratifying as far as it goes. But there remains a sizable minority whose treatment and financial needs are not being met, according to clinicians' assessments, or for whom the answer is unknown.
We also sought clinicians' judgments of the need for residential programs. They believed that 42 per cent of the group (122 patients) need a crisis residence occasionally. In spite of this considerable need, no crisis residence beds have been available to our patients because of state-imposed freezes on hiring staff for the community support system. Thirty-two per cent (95 patients) are seen as needing long-term residential treatment—again, too many for our county's one residential program of 20 beds.
There is a crying need for residential programs for our young adult chronic population. In addition to those 217 perceived as needing a supportive place to live, either continually or on occasion, there may be a good number of others who would benefit from a residential program tailored to their needs, but who are instead living with their families as dependent children. The alternative, for those who cannot cope with single-room-occupancy hotels, is usually the proprietary home, in which middle-aged and elderly deinstitutionalized patients predominate, and where these younger patients are likely to feel that their despair of the future is confirmed.
The staff of our center, especially inpatient staff involved in discharge planning, see a need to test out residential programs with a supportive staff and well-defined structure, designed specifically to meet the developmental needs of young adults and to mesh with their treatment programs. Such residences could offer a refuge separated from the repetitive tragedies of family life and the accumulated weight of failed expectations. The hitherto impossible task of young adult development could be, if not completed, at least addressed with some consistency and hope for progress. Such residences could play a valuable role in ensuring continuity of care.
Such residences might also serve as locus and agent of real changes in family dynamics. They could offer, on the one hand, a realistic alternative to perpetual care of young patients by their parents. On the other hand, they might include family treatment to help parents to deal with their own sense of frustration and failure and to relate to their offspring in a way that encourages rather than impedes the process of separation. We cannot really expect families to "let go" until their impaired sons and daughters have somewhere else to go besides the street.
The creation of residential programs on a scale sufficient to make some impact means addressing and overcoming some formidable obstacles. One, of course, is community resistance to dealing with our young chronic patients in neighborhood residences, rather than as troublesome but isolated individuals wandering the streets. Another more fundamental problem is funding, both for residences and for other community mental health programs.
There is still a severe discrepancy in most states between the location of patients and the allocation of public mental health funds. In most cases the money to provide patient care has not followed patients from the state hospitals to the community systems that are now responsible for their treatment. While the massive discharge of patients, diversion of admissions, and policy of brief hospitalization have resulted in a dramatic reduction of census for most state hospitals, many hospitals now have larger budgets, even corrected for inflation, than they did ten or 20 years ago. Publicly funded community mental health systems, on the other hand, have not been granted the increase in funding required to provide clinical and social support to the older deinstitutionalized population, let alone our large and growing group of young adult chronic patients.
This discrepancy must be corrected, and it is up to us as administrators and clinicians to advocate reallocations of funds, pressing for changes in state legislatures and departments of mental health so that more effective treatment and residential programs in the community can be supported by adequate funding. While it has been fashionable until recent years for mental health professionals to eschew activist roles in the political process, we cannot continue to wait for others to demand the resources needed to ensure good patient care.
State and federal courts, in numerous right-to-treatment cases, have proven they can accomplish a great deal in reducing hospital populations and retaining patients in our communities, but they have been unsuccessful so far in guaranteeing monetary support for necessary community programs. While test cases that address the need for improvement of community resources might be encouraged, we cannot passively await these developments. Nor can we expect patients to press successfully for the additional money needed for their care. Demanding funds is up to us, and is fundamental to the development of new programs.
The work of developing more effective ways to meet the needs of our young adult chronic patients will be a major challenge in the coming decade. It is a challenge that, in social and human terms, we cannot afford to refuse.