Mental Health and the Child By T.
A.
RATCLIFFE, M.A., M.B., D.P.M., D.C.H.
Consultant Children's Psychiatrist Nottingham Children's Hospital, Notts. County and Derby Borough Child Guidance Services
Although a growing interest in child psychology was apparent long before 1946 (and indeed the first Child Guidance Clinic in England was in existence some 15 years before that date), the
present pattern of Child Guidance in this country can be said to have begun in the immediate post World War II period. For it was then that each Local Education Authority was given the responsibility to provide a Child Guidance Service in its own area. be understood, such a wide, and rapid, expanbasis of far too few trained or experienced had its obvious dangers and disadvantages. The conpersonnel, siderable variations of standards and staffing of Child Guidance Clinics today bear witness to the continuation of these stresses. Yet this mode of development has had also a profound influence on the pattern of British Child Guidance, and on the attitude which it has taken towards the more general problems of mental health in the child. As sion of
can
a
readily
service,
on a
This association of the Child Guidance Clinic with the Local the Clinic into contact with the School Health Service, with the Education Department and the Schools, and with the welfare and social work agencies of the Authority. The problems which were presented to these Clinics were educational and social and psychiatric; their approach to such problems could only be successful on a team basis, and by a study of the whole child in relationship with his total environment. It is true, of course, that the early pre-war Clinics had pioneered these same concepts. But these were techniques which were expensive in professional manpower, time, and money; and it is doubtful if such methods would otherwise so readily have found acceptance from those Authorities who had to finance the service, and who were sometimes understandably suspicious of this new development.
Authority brought
Other, and
more
long-term,
of development, tive in their ultimate results.
early pattern
consequences have followed
some
disruptive
but many
this
construc-
A number of Child Guidance Clinics had been developed of the Local Authority Services. With the introduction of a National Health Service, the number of these "independent" Clinics increased, many coming to be based on paediatric, psychiatric or general hospitals. Once that both Health Service and Education Authority had a duty to provide Child Guidance Clinics, inevitable rivalries appeared. In many areas the problem was solved
independently
124
by
close
professional (if often "unofficial") liaison between the two clinic; in others there was a more formal union in that both Regional Hospital Board and Local Authority combined to provide the one service. Yet some rivalry persisted; and even the long types
of
deliberations of the Underwood Committee and the terial "blessing" given to the concept of a and joint Health and Education approach entirely healed up this basic dichotomy.
recent
Minis-
mutually complementary to the problem, have not
It is not just a question of which setting is the best in which to Work, though this is relevant to the issue. Indeed, the rivalry is not entirely between Local Authority and Hospital Clinics, though it fends to follow the boundary between these two. It is a rivalry, too, which the child psychiatrist is much more closely involved than are his other colleagues in the team. The fundamental dispute can be seen more clearly perhaps in the "rival" concepts of "child psychiatry" and "child guidance", both these phrases being used here in their normally accepted leaning and despite the tendency in some quarters to regard both outmoded terms. Is child psychiatry to remain wholely (or even primarily) a speciality of medicine with an increasing link with Paediatrics? Or, whilst retaining its link with medicine is it to move
further into the social and education fields? The same basic conflict may be expressed in another vital question. Is the function of child psychiatry (and, by implication, of child guidance) to be
mainly, the provision of highly specialised therapy for the disturbed child; or should it concern itself also with those relatively superficial reaction patterns of childhood where the main need is to modify the environment? In simpler, and more practical terms, the Child Guidance Clinic in a hospital setting will need to prove its value to, and ultimately receive its clinical material from, the paediatrician, the surgeon, the family doctor, and so on. This will not mean that all the problems are "medical'; but inevitably the presenting symptoms, and the type of underlying disturbance, will be coloured by the main sources from which referrals come. By contrast, the clinic team in a Local Authority setting must serve a wider, and much more varied, group of sources of referral? schools, doctors in both family practice or working with the Local Authority, the probation service, the child care officer and many ethers; and last, but not least, from the parents themselves. Not ?nly does this more varied source of referral modify the pattern of both presenting symptoms and basic problems, but it inevitably widens the task of the clinic team. Any specialist agency can have a dual function?the provision of highly skilled specialist treatment when this is necessary, and of a diagnostic and consultative service for other agencies. But, with the greater diversity of sources of referral, the second of these two functions comes into greater prominence. Such a clinic team must solely,
or
deeply
125
skills, and move further into a preventive role. Inevitquite frequently in such a setting, the clinic team will be faced with the child who is not so much deeply disturbed within himself, as reacting to present environmental stresses; in brief, the basically normal child and the basically normal family, faced with [ a situation which they do not understand and with which they ' learn
ably,
new
and
Whilst it is reasonable to believe that a continuation of would produce a more serious emotional disturbance within the child himself, there can often be a stage at which removal of the stress, with comparatively little direct help for the child himself, may prove a valuable therapeutic and preventive task. Many child psychiatrists, and some Child Guidance Clinics, concentrating on the (to them) more important task of intensive therapy with the deeply disturbed child, view the treatment of these Yet it more superficial "reactive" patterns as outside their scope. seems difficult to disassociate so completely the more superficial and deeper levels of help by the Child Guidance services. For even if the clinic is to confine itself to a diagnostic assessment of these relatively superficial problems, and leave their relief to other agencies such as the Probation Officer, the Child Care Officer and so on, the clinic will still need to function in a consultative role towards these agencies. And, where the Child Guidance Clinic believes (as the majority probably do) that such "modification of the environment" forms part of their own task, the clinic team's role vis-a-vis the parents will, in a special sense, become a consultative one also. If this is true, then the Child Guidance professional worker needs to give thought to such basic concepts and problems as child rearing patterns, mother-infant relationships, the role of the father in the family, discipline, educational methods and many others. In some of these fields, research has already produced results of great significance; but, on various other topics, the professional worker has been tempted from time to time to make pontifical statements, not always with adequate consideration of all the implications. Or, at the other extreme, he has sometimes refused to "come off the fence" and express any specific view on either side. The present great demand for "advice" from parents, and others, is illustrated in the numerous books and articles published on these topics; and in those many "expert" answers to questions given in our newspapers and magazines. Yet, these publications in fact can provoke on occasions more anxiety and sense of failure, in parents, than they can help. The future of this preventive work would seem to lie not in the realm of giving "good advice," so much as in applying our casework and therapeutic skills (if in modified form) to help the "normal" parent to cope with the "normal", if anxiety provoking,
cannot cope. such stresses
126
,
|
problems of child rearing and handling; to give this same parent the sanction for, and confidence in his or her own handling techniques; to indicate the very wide range of normality in child development and, through this, help the community to see, and avoid, the many ^ell-intentioned, but often disruptive, social pressures which society Puts upon parents in this day and age. Thus, without minimising in any way the specialist therapeutic tasks of the Child Guidance Clinic, perhaps the greatest contribution that we in these clinics can make to the mental health of the child (and the future adult) lies in our increasing provision of good consultative services to the Child Welfare Centre, to the paediatrician and the family doctor, to the family case-work agency and the marriage guidance counsellor, to the probation officer and the children's department, to teachers and education authorities. And ln the help we can give, both through these other agencies and directly by ourselves, to that remarkably common, but rarely publicised, figure, the fundamentally good parent.
A.
RATCLIFFE, M.A., M.B., D.P.M., D.C.H.
Consultant Children's Psychiatrist Nottingham Children's Hospital, Notts. County and Derby Borough Child Guidance Services
Although a growing interest in child psychology was apparent long before 1946 (and indeed the first Child Guidance Clinic in England was in existence some 15 years before that date), the
present pattern of Child Guidance in this country can be said to have begun in the immediate post World War II period. For it was then that each Local Education Authority was given the responsibility to provide a Child Guidance Service in its own area. be understood, such a wide, and rapid, expanbasis of far too few trained or experienced had its obvious dangers and disadvantages. The conpersonnel, siderable variations of standards and staffing of Child Guidance Clinics today bear witness to the continuation of these stresses. Yet this mode of development has had also a profound influence on the pattern of British Child Guidance, and on the attitude which it has taken towards the more general problems of mental health in the child. As sion of
can
a
readily
service,
on a
This association of the Child Guidance Clinic with the Local the Clinic into contact with the School Health Service, with the Education Department and the Schools, and with the welfare and social work agencies of the Authority. The problems which were presented to these Clinics were educational and social and psychiatric; their approach to such problems could only be successful on a team basis, and by a study of the whole child in relationship with his total environment. It is true, of course, that the early pre-war Clinics had pioneered these same concepts. But these were techniques which were expensive in professional manpower, time, and money; and it is doubtful if such methods would otherwise so readily have found acceptance from those Authorities who had to finance the service, and who were sometimes understandably suspicious of this new development.
Authority brought
Other, and
more
long-term,
of development, tive in their ultimate results.
early pattern
consequences have followed
some
disruptive
but many
this
construc-
A number of Child Guidance Clinics had been developed of the Local Authority Services. With the introduction of a National Health Service, the number of these "independent" Clinics increased, many coming to be based on paediatric, psychiatric or general hospitals. Once that both Health Service and Education Authority had a duty to provide Child Guidance Clinics, inevitable rivalries appeared. In many areas the problem was solved
independently
124
by
close
professional (if often "unofficial") liaison between the two clinic; in others there was a more formal union in that both Regional Hospital Board and Local Authority combined to provide the one service. Yet some rivalry persisted; and even the long types
of
deliberations of the Underwood Committee and the terial "blessing" given to the concept of a and joint Health and Education approach entirely healed up this basic dichotomy.
recent
Minis-
mutually complementary to the problem, have not
It is not just a question of which setting is the best in which to Work, though this is relevant to the issue. Indeed, the rivalry is not entirely between Local Authority and Hospital Clinics, though it fends to follow the boundary between these two. It is a rivalry, too, which the child psychiatrist is much more closely involved than are his other colleagues in the team. The fundamental dispute can be seen more clearly perhaps in the "rival" concepts of "child psychiatry" and "child guidance", both these phrases being used here in their normally accepted leaning and despite the tendency in some quarters to regard both outmoded terms. Is child psychiatry to remain wholely (or even primarily) a speciality of medicine with an increasing link with Paediatrics? Or, whilst retaining its link with medicine is it to move
further into the social and education fields? The same basic conflict may be expressed in another vital question. Is the function of child psychiatry (and, by implication, of child guidance) to be
mainly, the provision of highly specialised therapy for the disturbed child; or should it concern itself also with those relatively superficial reaction patterns of childhood where the main need is to modify the environment? In simpler, and more practical terms, the Child Guidance Clinic in a hospital setting will need to prove its value to, and ultimately receive its clinical material from, the paediatrician, the surgeon, the family doctor, and so on. This will not mean that all the problems are "medical'; but inevitably the presenting symptoms, and the type of underlying disturbance, will be coloured by the main sources from which referrals come. By contrast, the clinic team in a Local Authority setting must serve a wider, and much more varied, group of sources of referral? schools, doctors in both family practice or working with the Local Authority, the probation service, the child care officer and many ethers; and last, but not least, from the parents themselves. Not ?nly does this more varied source of referral modify the pattern of both presenting symptoms and basic problems, but it inevitably widens the task of the clinic team. Any specialist agency can have a dual function?the provision of highly skilled specialist treatment when this is necessary, and of a diagnostic and consultative service for other agencies. But, with the greater diversity of sources of referral, the second of these two functions comes into greater prominence. Such a clinic team must solely,
or
deeply
125
skills, and move further into a preventive role. Inevitquite frequently in such a setting, the clinic team will be faced with the child who is not so much deeply disturbed within himself, as reacting to present environmental stresses; in brief, the basically normal child and the basically normal family, faced with [ a situation which they do not understand and with which they ' learn
ably,
new
and
Whilst it is reasonable to believe that a continuation of would produce a more serious emotional disturbance within the child himself, there can often be a stage at which removal of the stress, with comparatively little direct help for the child himself, may prove a valuable therapeutic and preventive task. Many child psychiatrists, and some Child Guidance Clinics, concentrating on the (to them) more important task of intensive therapy with the deeply disturbed child, view the treatment of these Yet it more superficial "reactive" patterns as outside their scope. seems difficult to disassociate so completely the more superficial and deeper levels of help by the Child Guidance services. For even if the clinic is to confine itself to a diagnostic assessment of these relatively superficial problems, and leave their relief to other agencies such as the Probation Officer, the Child Care Officer and so on, the clinic will still need to function in a consultative role towards these agencies. And, where the Child Guidance Clinic believes (as the majority probably do) that such "modification of the environment" forms part of their own task, the clinic team's role vis-a-vis the parents will, in a special sense, become a consultative one also. If this is true, then the Child Guidance professional worker needs to give thought to such basic concepts and problems as child rearing patterns, mother-infant relationships, the role of the father in the family, discipline, educational methods and many others. In some of these fields, research has already produced results of great significance; but, on various other topics, the professional worker has been tempted from time to time to make pontifical statements, not always with adequate consideration of all the implications. Or, at the other extreme, he has sometimes refused to "come off the fence" and express any specific view on either side. The present great demand for "advice" from parents, and others, is illustrated in the numerous books and articles published on these topics; and in those many "expert" answers to questions given in our newspapers and magazines. Yet, these publications in fact can provoke on occasions more anxiety and sense of failure, in parents, than they can help. The future of this preventive work would seem to lie not in the realm of giving "good advice," so much as in applying our casework and therapeutic skills (if in modified form) to help the "normal" parent to cope with the "normal", if anxiety provoking,
cannot cope. such stresses
126
,
|
problems of child rearing and handling; to give this same parent the sanction for, and confidence in his or her own handling techniques; to indicate the very wide range of normality in child development and, through this, help the community to see, and avoid, the many ^ell-intentioned, but often disruptive, social pressures which society Puts upon parents in this day and age. Thus, without minimising in any way the specialist therapeutic tasks of the Child Guidance Clinic, perhaps the greatest contribution that we in these clinics can make to the mental health of the child (and the future adult) lies in our increasing provision of good consultative services to the Child Welfare Centre, to the paediatrician and the family doctor, to the family case-work agency and the marriage guidance counsellor, to the probation officer and the children's department, to teachers and education authorities. And ln the help we can give, both through these other agencies and directly by ourselves, to that remarkably common, but rarely publicised, figure, the fundamentally good parent.
