Child Psychiatry Observed. A Guide for Social Workers PDF
Preview Child Psychiatry Observed. A Guide for Social Workers
SOCIAL WORK DIVISION General Editor: JEAN NURSTEN Some Other Titles Of Interest BOWYER, R. The Lowenfeld Word Technique COHEN, R. et al. Psych City: a Simulated Community DAY, P. R. Communication in the Social World FRANCIS-WILLIAMS, J. Children with Specific Learning Difficulties 2nd Edition FRANCIS-WILLIAMS, J. Rorschach with Children FROMMER, Ε. Α. Voyage through Childhood into the Adult World GRAZIANO, A. M. Child without Tomorrow HERBERT, W. L. & JARVIS, F. V. Marriage Counselling in the Community HOLBROOK, D. Human Hope and the Death Instinct HOLBROOK, D. The Masks of Hate JOHNSON, R. E. Existential Men: The Challenge of Psychotherapy KAHN, J. H. Human Growth #nd the Development of Personality 2nd Edition MILES, T. R. Eliminating the Unconscious TAYLOR, C.W. Climate for Creativity The terms of our inspection copy service apply to all the above books. Full details of all books listed and specimen copies of journals listed will gladly be sent upon request. Child Psychiatry Observed a guide for social workers Elizabeth Gore P E R G A M ON P R E SS OXFORD · NEW YORK · TORONTO SYDNEY · PARIS · BRAUNSCHWEIG Pergamon Press Ltd., Headington Hill Hall, Oxford Pergamon Press Inc., Maxwell House, Fairview Park, Elmsford, New York 10523 Pergamon of Canada Ltd., 207 Queen's Quay West, Toronto 1 Pergamon Press (Aust.) Pty. Ltd., 19a Boundary Street, Rushcutters Bay, N.S.W. 2011, Australia Pergamon Press SARL, 24 rue des Ecoles, 75240 Paris, Cedex 05, France Pergamon Press GmbH, Burgplatz 1, Braunschweig 3300, West Germany Copyright © 1976 Elizabeth Gore All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, m any form or by any means, electronic, mechanical, photocopymq, recording or otherwise, without the prior permission of Pergamon Press L td First edition 1976 Library of Congress Cataloging in Publication Data Gore, Elizabeth. Child psychiatry observed. (The Pergamon international library : social work division) Bibliography: p. 1. Child psychiatry. I. Title. [DNLM: 1. Child psychiatry. WS350 G666c] RJ499.G681975 618.9'28'9 75-6926 ISBN 0-08-017277-6 ISBN 0-08-017278-4 pbk. Printed in Great Britain by A. Wheaton & Co., Exeter To Mildred Creak Introduction This book aims at an overview of child psychiatry written from the viewpoint of a clinical child psychiatrist. It is based on my experience in child guidance and child psychiatric clinics, but also on teaching contacts with social work students both in the clinical setting and in University seminars. Students have suggested to me, for example, that they find difficulty in linking the different aspects of their training in child development and child psychiatry, and that their reading often confuses them still further since exponents of particular schools of thought write tendentiously and disregard or denigrate other viewpoints. Often they cannot see the wood for the trees. I have attempted therefore to make a linkage between different schools of thought in regard to normal and abnormal child development, clinical picture and treatment, dealing in some detail with those derived from psychoanalysis but also those based on learning theory. The experiences of certain children and their families are followed in the clinical setting during assessment and treatment, in order to bring life into the presentation and to point the practical application of what is being studied. I have devoted a relatively large portion of the book to the subject of treatment. In fact the original idea came from a student who asked me to write a book called 'What is he doing in the playroom?' since he felt that few students have the opportunity of observing treatment in action or indeed children during assessment, and there was a need to remove some of the mystery. From this came the idea of taking the lid off child psychiatry and viewing it as far as possible as a whole and from the outside looking in. Planning a book is rather like budgeting money. You have only so many words to spend, and if you spend lavishly on some aspects you have less to spend on others. Priorities are bound to be decided to some extent by the orientation of the writer. So although I have attempted to cover important schools of thought and research findings fairly, I have dealt in more detail with topics of which I have particular experience or interest and about which xiii xiv Child Psychiatry Observed I am presumably able to write with greater fluency. Sometimes a subject has been dealt with in detail because it makes important points which have wide application or includes work with other disciplines or is of particular topical and general concern. Failure to attend school (Chapter 8) fulfils all these criteria. One question which concerned me was where should be the cut-off point in regard to age. Should this be a book solely about child psychiatry with the cut-off at the onset of puberty? This would tie in with the fact that adol- escent psychiatry is on the way to becoming a speciality in its own right. On the other hand since the standpoint here is work in clinics to which school age children come (add to that preschool children and those staying on after the statutory school leaving age) this seemed arbitrary and from the clinical viewpoint unsound since many clinical entities, for example school refusal, spill over into adolescence. I have decided to deal mainly with children up to the age of 12 but have also included something about early and middle adolescents where appro- priate. A further economy has been that Ï have not gone into details about how social worker students should apply the information in their own work. I am hopefully assuming that social workers with different orientations will read this book and that it will be more fruitful for them and for their tutors to apply the material to their own needs and experience.* I still had to decide where to start. An easy way would have been to start with clinical entities, and this has some merit since it is certainly true that children who are troubled and children who are in trouble need help, and that to offer inappropriate or 'blunderbuss' help may result in 'do-gooding' with- out doing any good. Therefore, as in any medical speciality, assessment and diagnosis are essential; yet when the patient is a child, finding the meaning hidden behind what is overt may be of even greater importance for without meaning we have labelling without prognosis or without a guide to treatment. So questions need to be asked about the origins of the symptoms or behaviour which the child shows, or which families show, the factors which perpetuated it in the past and those which are keeping it going. Thus we look *I have adopted a numerical system of references. As some students may not have access to all the sources, alternatives have been added to the bibliography at the end of each chapter. Some of these are unnumbered and have been inserted in the appropriate place in the numbered bibliography. Other alternatives have been numbered in the text, providing an extra source. Works marked with an asterisk are felt to be seminal material which students should try to obtain if possible. Introduction xv at the child's early life, the family situation past and present, the school situation. It is necessary to distinguish between those factors which are immutable (mainly organic and constitutional), and those which can be changed or ameliorated (mainly developmental and environmental). Happily the age-old controversy between nature and nurture is becoming less acute and many child psychiatrists and researchers prefer to emphasize the Tit' between the child and his family and his environment (or the emphasis may switch entirely to the family). This more fruitful approach also takes into account that just as the bones of the child remain flexible and will bend rather than break so, except in rare instances of serious physical or emotional trauma, the feelings of the child are flexible and responsive and that maturation will usually contribute to the on-going development of childhood. All this gives child and family psychiatry a hopeful and favourable orientation. We start then by looking at child and family psychology and pathology. This will make the sections dealing with diagnosis more meaningful and help us to understand the problems of the children and families seen in our clinics. P A RT I Developmental Tasks and Hazards, Pathological Aspects The importance of the early years of life for healthy emotional development has long been established. It is claimed that the Jesuits considered the first 7 years to be paramount, and the poet Wordsworth expressed the same view when he wrote 'the child is father to the man\ Today such divergent groups as the psycho-analysts and the behaviourists lay stress on this period, although their emphasis differs. Each stage in a child s development has its own tasks and hazards, needs and opportunities. Some periods are more stressful than others either because the stage of development itself is critical (some prefer the word 'sensitive') or because the parent is vulnerable in regard to that stage; for parents vary in the pains and pleasures they experience as they relive their own childhood through their growing child. Each stage in development requires certain facilities and favourable ex- periences and if these are seriously lacking the loss cannot often be made up later. The needs of the infant are very different from those of the toddler or school entrant or adolescent, but the whole process is continuous and the successes and failures of each stage are cumulative and set an indelible seal on the personality of the child. Where failures or damage occur very early in life the effects are likely to be long-lasting, e.g. in severe emotional deprivation of the infant. One modern contribution is the emphasis put upon influences starting even before what Susan Isaacs called 'the Nursery years', ie. during prenatal life.Q ) Far from 'trailing clouds of glory \ the infant carries the legacy of past maternal (and paternal) experiences, plus his own genetic endowment and acquired constitutional characteristics. Methodology By dealing fully with the first years of life, we are stressing the importance of this period for future development. It is necessary therefore to have a clear 1 2 Child Psychiatry Observed idea about the scientific status of statements about infancy. Although precise statements about infantile experiences are often made, we must accept that they may be empirical. They have often been reached by reconstruction from present behaviour by the observation of the behaviour of psychotic and regressed children or by the retrospection of older children and adults undergoing psychoanalysis. Many such statements do, in fact, seem to fit the results of the more modern observational methods. Observation of the pre-verbal infant, which has been developed particu- larly during the past 20 years, is probably the only reliable technique, though even here observer bias may reduce objectivity and the presence of the observer in the field must change the situation to some degree. Infants have been studied in natural settings (among their families in their homes or foster homes) and artificial settings (clinics, hospitals and institu- tions) and some of these studies are utilised in this section, as are retro- spective studies, and it behoves the reader to distinguish between them. Where research findings are mentioned in this section, and throughout the book, the student is advised to study these in the original whenever possible. They will then realise that research methods and results must be scrutinised closely, since different research findings related to the same subject may be at variance with one another. C H A P T ER 1 Psychobiological A. Pregnancy and Birth So we begin even before the nursery years with pregnancy, which is an emotional as well as a physiological preparation for motherhood. Changes in the mother's feelings have been well described by Helene Deutsch.( 2) Ideally, during pregnancy the woman's femininity becomes expanded to encompass the growing foetus with enough left over to include the father in shared experiences and positive phantasies. During this narcissistic state of wellbeing many women claim that they feel happier and more contented than ever before. 2 Child Psychiatry Observed idea about the scientific status of statements about infancy. Although precise statements about infantile experiences are often made, we must accept that they may be empirical. They have often been reached by reconstruction from present behaviour by the observation of the behaviour of psychotic and regressed children or by the retrospection of older children and adults undergoing psychoanalysis. Many such statements do, in fact, seem to fit the results of the more modern observational methods. Observation of the pre-verbal infant, which has been developed particu- larly during the past 20 years, is probably the only reliable technique, though even here observer bias may reduce objectivity and the presence of the observer in the field must change the situation to some degree. Infants have been studied in natural settings (among their families in their homes or foster homes) and artificial settings (clinics, hospitals and institu- tions) and some of these studies are utilised in this section, as are retro- spective studies, and it behoves the reader to distinguish between them. Where research findings are mentioned in this section, and throughout the book, the student is advised to study these in the original whenever possible. They will then realise that research methods and results must be scrutinised closely, since different research findings related to the same subject may be at variance with one another. C H A P T ER 1 Psychobiological A. Pregnancy and Birth So we begin even before the nursery years with pregnancy, which is an emotional as well as a physiological preparation for motherhood. Changes in the mother's feelings have been well described by Helene Deutsch.( 2) Ideally, during pregnancy the woman's femininity becomes expanded to encompass the growing foetus with enough left over to include the father in shared experiences and positive phantasies. During this narcissistic state of wellbeing many women claim that they feel happier and more contented than ever before.
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