§ I. Definition and discussion
For the child, good mental health (2)is a state of his psyche and of his behaviour which expresses the existence of three aspects that are « good enough » (3) ( Cloutier, 1966 ; Chiland, 1993 ) :
- The absence of any psychopathological problem or psychiatric illness as is usually diagnosed.
- The coexistence of a reasonable ability to adjust and an ability to rebel against anything which, in the child’s soul and consciousness, makes no sense or is unfair. By suggesting that describing these two potentialities in specific terms might be an indicator of good mental health, we can work around two opposing stumbling blocks (4) :
- The first would be that we refer to « normality » as the central indicator of mental health, according to which the « good » child would be one who conforms to the rules and expectations of his parents and society. In this case, the work done to improve mental health would be of the « hygienist » type (5).
- Confusing mental health and anarchy. There are a number of ( natural ? ) Universal Laws on which human social interaction is based and to which we are all subject. A ( large ? ) part of a group’s rules is of value because it allows its members to coexist without insecurity.
appier being that than the opposite ! »
- For each of the listed dimensions there is a gradient between acquisition and non-acquisition, and thus a grey area between good and poor mental health that is defined by the subjectivity of those children or adults who have to evaluate it : We are used to this uncertainty : the mass of so-called objective criteria to which we regularly refer does not really suppress it in reality.
- There are differences between the perceptions and expectations of children and those of adults. Adults use their power to impose their own representations of mental health. They project, whether consciously or unconsciously, their dreams and their needs in these representations : « The child who works hard and succeeds at school is a child who is in good mental health ! » We need to bear this clearly in mind : no category of human is free of projections that stem from their personal history, culture, etc. with respect to what is good for another person. This applies to professionals just as much as to other people ( Laplantine, 1993 )
- We are also too reluctant to listen to our children when they suggest, at least intuitively, how they « think » about their mental health. We could therefore pay more attention to them, while still not leaving all the power in their hands. The lazy child could tell us « I am fine as I am ; there is no point in working » He could be delightfully egoistical and reject the idea of exerting the least effort to develop his own resources and participate in building the human race.
Of course, this is just not possible. Education with its conversations, invitations and demands still has an essential role to play. It remains a sign of good adult mental health that the parents’ dreams for their children define the path for them … up to a certain point.
- We should therefore try to remain humble, sceptical, open-minded, prepared to listen to what parents, children or colleagues from cultures other than our own are saying to us about child mental health. In this way we will be willing to constantly question, in ourselves, what we consider to be realistic knowledge about the child.
This interrogation and investigation should involve regular and in-depth discussions in the form of « consensus conferences » that bring together the viewpoints of everyone concerned – children, educators, society and professionals – in a non-hierarchical situation. Such discussions should put together the fragile and constantly changing edifice that holds the most valuable representations of child mental health in a given context.
§ II. The foundations of the child’s mental health
I. The progressive elaboration of this health partly depends on the quality of the child’s « equipment »
It is thus a constitutional aspect (6) of his being resulting from the embodiments of his individual genetic inheritance.
With reference to a much more mysterious form of transmission that transcends the material, it is also not impossible for there to be a basic psychic equipment, a non-material gift that makes it possible for everyone to have specific « spiritual traits » These constitutional, genetic and perhaps spiritual aspects make up most of our cognitive characteristics, temperament (7) and our potential mental equipment in terms of aggressivity, sexuality, anxiety or recklessness, etc.
With reference to this mental equipment, we have to assume that all children are « predisposed to » ( depression, agitation, very average intellectual productivity, heightened sexual interest, poor sleep patterns, etc ) Mental health programmes therefore have to aim at identifying and accepting these predispositions that influence subsequent choices and differentiation. Without resignation and stagnation, and with the positive help of friends and family, anyone can make sure, up to a certain point, that their own differences do not weigh too heavily on others.
On the other hand, it is of value not to take a utopian approach : the idea of integrating everyone into the same educational environment or life is very probably a destructive utopian idea. By respectfully providing special locations or moments in life for those who are most different and who cannot keep up with the pace or demands of other people, we are not ipso facto stigmatising them.
II. A child’s mental health is also influenced by his environment.
Specifically this means the positive or adverse stimuli arising from a rapidly-changing material, family or social environment, the relationships that he may cement with other humans and with which he becomes imbued in order to construct his personality.
A. First a few words about the influence of the family, limiting ourselves to the historical perspective of the article. All mental health professionals emphasise just how important the quality of the family is for the child’s development, but they haven’t always been gentle or even objective towards it. In particular, for a long time they have only highlighted the risk factors and psychopathological aspects issuing from the family and, what is more, they have had excessive faith in linear causal links, viewing the child merely as a passive victim (8).
We had to wait nearly until the introduction of systemic thought in the 1980s before we were reminded that the family could also be a place of resources and that the child played an interactive part in determining what happened to him.
Particularly since 1990, the nuclear family has increasingly « fallen apart » and many alternative types of family have appeared. A number of professionals then found their critical spirit blunted and they found themselves unconditionally praising one or other of these new structures, systematically positioned as beneficial for the child’s welfare.As the pendulum returned, we started to condemn the institutional placements that were once used without thinking, and to preach the need to keep the child in his family, at almost any cost. Those who dare to say that this new approach can sometimes be toxic ( such as Maurice Berger in France ) are soon regarded as merely Quixotic.
B. The nature of relationships between the child and the school, with other living environments and with society as a whole represents another category of influencing factors to which we can apply the same reasoning as for the family (9). We can never emphasis enough that a high level of instruction that has been well integrated by the child is a powerful factor for human advancement. Therefore, mental health programmes must aim at providing positive schooling that is adapted to everyone’s abilities, creative and demanding, and open to everyone without distinction of sex, race or class.
C. Finally, here are a few words about the influence of change as such on the child’s mental health( Anthony and Chiland, 1983,) (10 )
----- Some people feel that the biological and psychological changes in the world and society have been too fast, to say the least, and are becoming too much to bear for humans, particularly young ones. It leads to pathological structures and conducts that express the human’s stress and disorganisation, including various anxiety, depressive or narcissistic disorders and conduct disorders in adolescents.
Conversely, others believe that children have adapted very quickly and are enjoying these rapid transformations in the flow that carries them along ( children from the most flexible new families; children of the Internet generation, children who believe « You like it? Just do it ! »)
---- Finally, others have adopted a cautious position of uncertainty : the child could adjust and be happy in the new environments, but it is happening too quickly and not everything is to his advantage. For example, when so many adults claim that they have the right to do exactly what they want, whatever the price : leading to a crisis of values in young people.
III. Let us now consider these ultimate individual factors, namely reflective consciousness, freedom of thought and choice and the partial power to create one’s own ideas and own projects ( Harter, 1983 )
Although influenced by his constitutional equipment and his relations with others, the child goes further to differentiate himself. He is constantly building an internal world of thought, aspirations and plans : how can he represent himself and his life ; what does he really expectate from himself and from the others ; which relations to develop with his parents and his friends ; what should be his own values ; how to manage sociability and ego-centration, work and pleasure, and so on.
Rutter (1983) describes this as a« comprehensive psychological consistency, a sort of internal model of cognitions about ourselves, our relationships, our past or our future, that forms the basis for our responses to our perceptions » For example, if this internal world is high in self-esteem, the child will find it easier to appear resilient and will be less likely to be destabilised by assaults from the outside world.
Jammet concluded the 11thInternational Congress of Child and Adolescent Psychiatry and associated disciplines (1986) by stating :« If we think that it would be possible to objectivise how the brain works, the life of relationships, etc, then we are forgetting exactly what distinguishes the human being, namely his capacity for self-reflection and thus his belonging to the world of values » … « It would be illusory and dangerous to underestimate the fundamental importance for every child of giving meaning to his life and being able to integrate in relation to essential references, such as his parents, his family or his culture. » (11)
§ III. The reference models
Two reference models quickly gained acceptance to exactly define and discuss what is meant by mental health. These two models came into conflict in certain periods ( Joshi, 1975 ), but have been regarded as complementary in others. One is the« medical » model, the other is the «psychoeducational ( or psychosocial ) » model.
I. The medical model
is derived from the idea that a cause ( which is more often external than endogenic, is often known, but sometimes remains mysterious ) disturbs the working of a « good » human, physical or psychic « nature » It therefore causes a problem that leads at least to maladjustment.
In some periods, this model was promoted very heavily ( « Specific learning difficulties can only be explained by brain dysfunctions. » ) while in others it leaned more towards the social world ( « socioscientific » moments) ( Amiel – Lebigre, 1993 ) In these more integrationist times, the model referred more to stress as a diffuse social « cause » of disturbance, and to the available social supports, such as remediation factors. More place was also given to the child’s energy, his combativeness and predisposition towards « coping with » ( Blanchet, 1993 )
Looking after mental health using this model is « to do prevention » : both primary prevention ( fighting direct against the cause or his doors of penetration e.g. via education to health ), secondary prevention ( e.g. fighting against the first signs of stress, etc ) and even tertiary prevention. The subject’s responsibility for his own future is assessed in very different ways, and is sometimes limited to accepting or refusing to take medication.
This medical model has increased in popularity once more over recent years, and has been radicalised by the ever-present debate on genetics and its deployment. When they are in the ascendant, the genetic psychiatrists can be the most radical and, through their claims and ultracomplicated diagrams and tables, they choose to objectivise the person as being defined by his genes.
So why is this medical model still so successful ? Because, in good faith and with reference to their culture, doctors have been hard at work lobbying to ensure that it is applied and because the pharmaceutical industry supports them with its disinterested motives. Another reason is that it doesn’t upset the social order and because it is simple compared to the other, unashamedly complex models ( Laplantine, 1992 ) It also has the appearance of being scientific : his data appears to be objective, legitimate and easily-checkable facts ( Frankard, Renders, 2004 )
II. The psychoeducational ( or psychosocial ) models
they represent human life as a much more complex reality. Apart from a few mental illnesses that are unarguably linked to the brain, they regard psychic life as a jungle in which it is almost impossible to decide with any certainty which would be hisnatural healthy components. Rather it is a swarm of forces in a constant state of flux in relation to the social aspect and the body. In this case, the phenotypical application of genetics merely constitutes one element among many others. As for adjustment to the environment and maladjustment, both are regarded as learned attitudes. Promotion of mental health inspired by these models takes this into account as it also relies on the person’s strength, his energy, combativeness and ability to bounce back. Back in 1966, G. Canguilhem emphasised the existence of a « personal normativity » to which the person devotes all his strength.
III. Does an integrative bio-psychosocial model remain a utopian dream ?
Although many professionals support the idea of our bio-psychosocial nature (12) – « The human being is his body ; he is his psyche ; he is society » – they are reluctant to accept any reference model that might radically follow from it. This is a complex model shot through with uncertainty. It rejects the principle of hierarchies, ever-apposite laws and equiproportionality between « causes » Each person is a DIY project or patchwork, and we have to rebuild the identity of each individual subject.
If we apply this model, research into and promotion of mental health would largely be subsumed into the same programmes for general health ( Lebovici, p. 38 ff in Chiland, Young, 1993 ) This practice is starting to gain ground in Europe in certain medical centres or « homes » for young people. In the emerging countries, many primary health centres are attempting to implement it to better effect.
§ IV. Applications in the field
Let us now review the main resources used to promote child mental health, listing them by their target public and objectives.
I. Many applications are directed at children
They aim to :
◊ - Make use of their potential : early years stimulation programmes ; workshops that promote creativity, self-expression, artistic or sporting abilities, communication, etc.
◊ - Help them to acquire a well-integrated knowledge. Educating children is the basic mission of any school, but governments often assign additional tasks to them ( e.g. civics or sex education ) There are also broader or multifocal information or consciousness-raising campaigns ( e.g. prevention of physical or sexual abuse; promotion of the rights of children ) Adolescents as a target group have received considerable investment : campaigns against racism, homophobia, all types of addiction ; small groups meeting to discuss non-violence or girl/boy relationships, sexuality and responsible parenting. Unfortunately, whatever method promoters use to get their message across, these encounters with their public all too often appear to be a hierarchical transmission of knowledge, just like at school.
◊ - Listen to them talk about their mental health and take on board what they are saying ( e.g. « advice » from young people in certain schools, residential institutions, and even in towns and villages ) As we have already mentioned, it is relatively rare for adults to really listen and take account of what they hear, even when they do not exclude the possibility of sharing ideas and continuing to educate.
And if, by chance, the children have been heard, they often notice that their point of view is not taken on board because their expectations will upset the existing social order too much or will require money that is earmarked for other priorities.
◊ - Use the children themselves ; turn them into mental health practitioners. This is also unusual. The child to child programmes that do exist, particularly in emerging countries, relate more to the promotion of physical health. Nevertheless, certain practises in Latin America do concern mental health. These confer on mature and intelligent adolescents the status of lideres ( leaders ) for the more ignorant members of their community.
II. Many other applications are aimed at the adults in charge of day-to-day education, starting with the parents.
The objectives that we have reviewed with respect to the child also apply to these adults, with a few minor differences :
◊ - For example, listening aimed at adults is much more common and diversified than listening aimed at children. On the Internet, in particular, there are a vast number of forums that offer a listening and supportive ear, and allow affected adults to come together and develop their own ideas about mental health, sometimes with the help of professionals. These professionals often feel it is important to encourage parents to express exactly what they mean by a « successful » child and to discuss their mutual representations ( Frankard and Renders, 2004 )
◊ - With respect to the transmission of knowledge, it is important to remember that, in the 1970s in France, a number of high-level professionals such as Françoise Dolto decided to pass on information to and communicate with parents using the mass media ( Dolto, 1985 )
◊ - Finally and more specifically, many programmes encourage the adults concerned to improve the affective and educative contribution that they make to the child by increasing the protection factors and reducing the risk factors ( see also below )
III. Finally, some programmes are directed at the social community as a whole.
Their objectives are similar to those described in the paragraphs above, again with a few minor differences :
◊ - As far as improving living conditions is concerned, we sometimes concentrate on marginalisation and poverty in a rather too reductionist manner. We should ask ourselves more about the impact on the child of numerous contemporary social aspirations, at least in industrialised countries. These include performance at school and in general and the need to achieve the desired results at all costs ; the right – almost the duty – that everyone has to do what they want and the weakening of parental authority ; the equivalence of all new forms of family ; a sort of negation of the condition of child ( e.g. over-consuming children, sick children asked to personally take key decisions, young adolescents allowed freedom to manage their current ideas of transsexuality, recriminalisation of Justice for minors, etc )
◊ - As far as improving information is concerned, there are many campaigns aimed at raising the awareness of the community as a whole in the field of child mental health.
On the other hand, it is much more unusual for childhood professionals to come together and take the initiative to inform or question the decision-makers, particularly the political decision-makers, about the needs of children. Nevertheless, the decision-makers’ main motivation is rarely child welfare ; they are more preoccupied with making savings or upholding their image in society by emphasising the security aspects, for example.
This security ideology sometimes percolates through without the scientists’ awareness, and sometimes with their active collaboration ( Foucault, 1992 ) (13). It can be seen, for example, in plans for early screening for delinquent « tendencies » or in the broad-brush recriminalisation of adolescents. It also exists in some programmes to rehabilitate young people in difficult urban environments, in which collaboration between the police, local authorities and social works sometimes resembles tight social control (14).
Ultimately secure : a Soviet prison for minors ...it is currently out of order, of course ...
§V. A few words about the topic of mental health in emerging countries
Basically, everything described above concerns these countries as well ( Graham, 1980 ) We have already said that, in the primary health centres, the idea of global health could be at work, sometimes more than in the industrialised countries. And this is a very good thing. The same applies to the aim of community health, managed by the community that is directly affected.
A great deal will still have to be energetically invested in the long term : literacy, early years stimulation, schooling, fight against poverty and child labour when it takes place without dignity or involves exploitation, the search for true equality between boys and girls and the promotion of responsible parenting.
There is also the need to battle the scourge of physical diseases and inadequate hygiene, since these can impair mental functioning ( mental retardation, epilepsy, motor damages of the brain, etc )
These initial investments can be followed by large-scale campaigns like those run by UNICEF and other well-known NGOs, including the promotion of the children's rights, fight against abuse, domestic violence, addiction, etc.
§ V. A few historical milestones
To describe these milestones we shall first identify the three main lines that sometimes cross or superimpose along their length (15) :
◊ - child mental health as an integral part of public health and a society’s aspirations ;
◊ - the child’s « moral » suffering, whether psychopathological or sociopathological, as the object of concern for carers ;
◊ - child and adolescent psychiatry as a specific medical discipline.
I. Before and around the 2nd World War
A. No specific concept of child mental health
1908 : C.W. Beers, a former psychiatric hospital patient, established the first mental hygiene society in Connecticut (USA) to raise public awareness of the unenviable lot of the mentally ill ( cited in Cloutier, 1966 ) His initiative spread across the world.
1948 : The international committee for mental hygiene changed its name and become the World Federation for Mental Health.
The WHO put forward its famous definition of health ; no longer as the absence of disease, but as an overall state of physical, mental and social well-being.
In the 1950s, respected researchers such as M. Jahoda in the United States and F. Cloutier in France developed the concept of positive mental health which attempts to recognise and develop the person’s resources, rather than prevent the raising of pathology. They also emphasis the limits and the risks associated with the concept of normality. Finally, according to them ( and many others … ), it is an internal state of well-being or perceived happiness that defines mental health. They also attempt to find objective and identifiable criteria to « break down » what this state of overall satisfaction means ( Cloutier, 1966 ; Jahoda, 1950, 1958 )
B. Birth of child and adolescent psychiatry
In France, the individual initiative of Itard (16) is often mentioned. He attempted to re-educate Victor, the wild ( autistic ?) child from Aveyron, and therefore believed it would be possible to mobilise the child’s failing and deviant psyche. In the early 20th century, the French psychiatrists who were writing about the child did so in an adultomorphic way, with strongly organicistic / constitutionalistic (17) beliefs ( Lebovici, 1995 )
Georges Heuyer breaks away from this background to bring child and adolescent psychiatry to the baptismal font. From 1925 onwards, he managed an « annex clinic of neuropsychiatry » intended for children at the Salpetrière hospital in Paris.
Despite his conventional training, this enlightened spirit surrounded himself with people whose thinking was very different to his own and he soon invited the psychoanalyst Eugénie Sokolonicka to come and work beside him. As it received a difficult welcome from the medical world, the experiment did not last long. But he started again more positively after the War with Sophie Morgenstern, and this was the prelude to the Parisian School of Child Psychoanalysis. In 1937, Heuyer organised the first international conference of child psychiatry ( as part of a mental hygiene conference ) with the Swiss Tramer and North-American Leo Kanner (18)]. In 1948, he took the first university chair of child psychiatry, at the same time as E.J. Anthony in Saint Louis (USA)
C. The initial influence of psychoanalytical psychotherapies applied to the child
Nevertheless, as a side issue and even before this medical discipline had been established, the mental suffering of children had already been identified, invested in and cared for by a new category of psychotherapist – the psychoanalysts. Very quickly, Freud established a link between the marks derived from childhood and the current suffering of adults. The founding father had even analysed little Hans (19). This encouraged his pupils to take an interest in children using an approach that is anything but medicalised: straight away they started to listen to each child as a unique subject, capable of identifying his inner world, and considered whether appropriate media could be used to communicate with him. It was also very quickly understood that an active interest needed to be taken in the family and social situation.
As a matter of interest, Anna Freud published in 1927 her « Introduction to the Technique of Child Analysis » and in 1938, after emigrating to London, she established the Hampstead Clinic dedicated to child therapy. These were therapies in which she was convinced of the need to introduce educational aspects and to aim to achieve psychosocial adjustment.
Around 1920, Melanie Klein published her « Notes on the development of a small child » while, in 1927, she theorised on her use of play techniques in her sessions, from which she interpreted the symbolic aspects.
These major founding fathers and mothers quickly gained a following and we cannot cite all the early accepters who acted towards the child with great respect and enthusiasm on both sides of the ocean, even as far away as Argentina.
II. From 1950 to 2000
A. Child mental health is given a name and studied
- In 1948and around the time of the definition of health by the WHO, child mental health came on the scene as the result of a serious social problem: the United Nations Economic and Social Council, having become aware of the suffering experienced by war orphans, asked John Bowlby, an expert at WHO, to research into the needs of «homeless » children. Up to 1950, Bowlby worked very actively and his results, which were published in 1951 in English and 1954 in French, remain incredibly significant ( Bowlby, 1951, 1954 ) He described the attachment drive, the great importance of material care, the existence of early sensitive periods needed to benefit from this care and the syndromes associated with maternal shortcomings. He probably appeared too harsh in his criticism of what the residential institutions could provide as a parental substitute.
Whatever it was, his work not only gave rise to a large number of other, sometimes polemic, studies around theories of attachment ; it also inspired, and still inspires, massive programmes of prevention ( he called it « prevention of family failure » ) associated with the quality of mothering and care for the babies and infants.
The late 1950sonwards saw the rapid growth of mental health centres, initially in the industrialised countries. When they started, many put a lot of work both into the care they provided ( which we shall discuss below ) and into mental health promotion (20), often on behalf of groups that were geographically close together ( conferences, groups of parents, homework clubs, etc )
Over the course of time, many mental health centres placed ( much of ) the emphasis on their care mission and reduced, if not totally dropped, the prevention aspect.
The promotion of mental health thus largely passed into the hands of more specific teams, made up of professional categories other than psychotherapists. Unfortunately, these services became very diversified, if not fragmented ( by location, reference culture, objectives and social mandate ) Many splits and rivalries developed. Even though general and agreeable coordination is most likely an angelic illusion, it is important to remember that the opposite is not always very far from the truth: the road to hell is paved with idiosyncratic intentions.
Nor ignore the idea that, in the choice of major themes considered to be important, there are non-logical phenomena of mode and repetition by one side of what the others say. Some topics have become rather unpopular for no particularly deep reason, while others are on the up: maternal care, addiction prevention, stress, abuse in general ( which was quickly reduced to sexual abuse ) and today the new « social warning lights » of behavioural disorders and security.
From the 1970s onwards in France, Colette Chiland was a figurehead for the promotion of child mental health. She led this promotional work alongside her work as a therapist for suffering children, often in association with other clinicians, such as C. Koupernik in France, or E. J. Anthony in the United States. Together they drew up a number of basic concepts.
First, C. Chiland drew attention to the risk of establishing an ideal picture of the child in good mental health, since this ideal can be infiltrated by religion or moral thinking. Rather she suggested referring to detailed descriptions of children who feel that they are healthy, who are developing well and appear happy. She thus comes down firmly on the side of positive mental health.
As a corollary, Chiland and the other members of her team explored the subject of the child’s vulnerability and strength, with its opposite extremes – great fragility and invulnerability ( Chiland, 1970, Anthony, Chiland, Koupernik, 1980, 1982 ) The authors emphasise the strong constitutional aspect of these « states of mind » ( 2nd op. cit., 1980, p. 538 ) and, in this respect, they describe a very close relationship with temperament (21). However, they also emphasise the influence of external factors that quickly become known as risk or protection factors (22) ; one key protection factor is still the quality of mothering, and the climate of confidence in which it takes place.
Many later studies concentrated on the description of these risk and protection factors in particular situations. They were followed by prevention programmes, although these were sadly fewer in number than the research studies.
In addition, the concept of resilience to a large extent replaced the concept of strength or invulnerability, although it did lose some of its initial, more restrictive meaning as used to describe the way of bounding back after major unhappiness.
Many other psychiatrists and therapists developed important projects centred on promoting child mental health: early stimulation, raising awareness in the community of the needs of children, against maltreatment, etc. Others concentrated on defending the rights of children as they felt that recognising their rights would make a powerful contribution to improving their mental health.
There are too many to mention them all ! On behalf of all, I will mention three names : Françoise Dolto and her communication with the general public ; the original and creative Briton Donald Winnicott, a free-thinking and optimistic man who believed in the natural tendency towards health present in all of us, and in man’s capacity to find a solution – his own solution. And finally, in Boston, Raquel Cohen and her considerable work about mental health and disasters.
B. Child and adolescent psychiatry becomes accessible and moves away from the medical model.
---- Let us return to the outpatient centres for mental health and the other similar institutions referred to in other terms that have been established and grown up since the 1950s.
These have always been intensely dedicated to their care mission, and therefore assumed responsibility for recognised psychiatric illnesses or serious psychopathological problems. But they have also been asked to help maladjusted children, to smooth off the annoying relational rough edges and return the power to the expectations of adults ( parents, school, etc ) They are all too often expected to do this at little cost and with no questioning of their behaviour by the adults who run these centres Many teams had a policy of welcoming all such requests, but of subtly working to give back to the child his status as subject and to bring into play the attitudes of adults.
Very quickly, these centres understood the need for multidisciplinary work (23) and work in networks with the other professional partners in their geographical environment who are responsible for children. In many countries, they have even been wholly or partly integrated, either flexibly or by coercion, into public health policies in which the State divides up the available care by geographical sector (24) ( Duché, 1995 )
These centres and the private consultations had to be supplemented in order to look after cases too serious for outpatient treatment. This period thus also saw the appearance of the first hospitals specifically offering child psychiatric services or very similar therapeutic residential centres. They were often located on a dedicated site and looked more like large, welcoming building than austere hospitals. At the start they were very inspired by the ideas of psychoanalysis, overlapping somewhat with those of institutional therapy ( for example : Bruno Bettelheim’s orthogenic school in Chicago ) Sometimes they were original, wild and bordering on Marxist ( the communes of Fernand Deligny in Corrèze ) Sometimes they were not far from being an unpleasant totalitarian ideology ( Maud Mannoni and Bonneuil )
All of them at least had the merit of taking very disturbed children into a highly dynamic and enthusiastic environment, and greatly increasing the effort and resources devoted to improving their condition.
And the child psychiatrists continued to work their way into all the networks intended to help children with psychological problems : institutions for re-educating handicapped people, those for social cases and into general hospitals, on paediatric and maternity wards, or even into the world of Justice for minors.
Has child and adolescent psychiatry moved away from the original medical model ? Yes, in a large number of countries up to the early 1990s, it was primarily a psychotherapeutic and social world, and it did not truly centre on identifying specific morbid entities (25). The medical discipline was almost annexed by the psychotherapy schools and methods.
We illustrate this using the metaphor of the ocean, with its succession of waves and underwater currents :
a) Up to the 1980s, the predominant waves were still those of psychoanalysis.
Psychoanalysis by the grand masters : Anthony, Solnit, Cohen, Graham, Cramer, the founding fathers of the Paris school ( Lebovici, Diatkine, Soulé, Kreisler, Chiland, Misès ), Gautier and Lemay in Quebec and all those I could not mention by name.
For them, the relationship between the child and his family was always a cause for concern, as were the introjection of parental imagos and genesis of his intrapsychic conflicts but, as we have already said, the family was most often regarded as a seat of psychopathology, rather than a place of positive resources.
Psychoanalysis as they conceived it could be very open to the school and society, but sometimes barricaded itself into a psychotherapeutic ivory tower that could be equally purist and recondite.
Unfortunately, the psychoanalysis of discord also arose; this occurred mostly in France with the Lacanian school: Françoise Dolto was part of this while having taken liberties in relation to the sometimes extreme ideas of the master – and, more particularly, those of his sons and daughters.
This psychoanalysis (26) regularly appeared all-powerful, contemptuous towards other approaches and inflationist in its desire to explain everything about people on the basis of its models and concepts. One of its most dramatic errors related to the way it modelled autism and the associated pathologies. Other more recurrent and common errors related to its underestimating of the part that the body « in itself » plays in the child’s moral suffering ; this is all too often reduced to conflicts between instances or dysfunctional introjections of parental images.
b) Above and below this impressive, but sometimes too well-ordered, ocean of ideas there are threaded modest underwater currents :
◊ - the models and methods of « institutional therapy » which had been applied to certain residential centres for disturbed children. We have already mentioned them briefly.
◊ - the discovery in 1952 of the first specific psychotropic drug of the modern age ( chlorpromazine ) and the developments in the field of psychopharmacology that followed. For a long time, many child psychiatrists have remained quite reticent about the use of psychotropic drugs in children, with a very few exceptions ; the strongest neuroleptics for the clearly psychotic, weaker neuroleptics for certain aggressive/impulsive disturbed children and medication for Tourette syndrome. Things have changed radically since 1990.
◊ - In the 1970s, it was the British ( a.o. Laing ) who were behind a sort of revolution that shook the institutions, but it did not last very long. Their movement was known as anti-psychiatry. It claimed that it was the dysfunction of the family and society, even the care institutions, that were primarily responsible for the problems experienced by the mentally ill. The movement did not, however, have a great direct influence on child and adolescent psychiatry, which was already frequently open to society. One exception to this rule is Italy, where it had probably been the cause of de-institutionalisation and a desire for radical integration of the handicapped and mentally ill of all ages into ordinary society.
At this time of the great rise of psychoanalytical orthodoxy, we have to salute the independent spirits who had the courage to affirm their truly « somatopsychic » convictions, as they were well and truly integrated into their writing and practises. Prime examples of this are Julian de Ajuriaguerra and his Geneva school, and Yvon Gautier and Michel Lemay and their school in Quebec.
c) Between 1970 and 1980 we saw the appearance and blossoming of systemic theories. As a term borrowed from cybernetics, the system essentially refers to the circularity and retrospective effects associated with the phenomena that occur in the organised whole.
The systemists promoted family therapy as the main means of helping children with problems. They used very diverse techniques, but they all ultimately attempted to improve family relationships as a whole ( via communication. for example ), and they refused to centre on the so-called ill person who, in their eyes, is never anything more than a « designated patient » for the convenience of the system.
Systemic professionals rapidly split into quite a few « tribes » which never really attempted either to unify their thoughts or to enter into conflict with one another. Typical examples are the work of S. Minuchin, M. Bowen and V. Satir in the USA ; the Palo-Alto school ( Watzlawick et all ) ; Bosromeny-noch in Hungary ; M. Selvini and M. Andolfi in Italy, etc. Occasionally even they could get carried away and became exaggerated in their models ( schizophrenia and the double parental message; excessively rigid concept of the symptomatic patient, etc )
The systemists were slower to gain acceptance in the French-speaking world than in North America or Italy, but, little by little, they created « another » recognised place « beside » the psychoanalysis movement, without entering directly into conflict with it (27).
C. Child and adolescent psychiatry becomes medicalised again
In the early 1990s, psychoanalysis with the other psychodynamics-inspired therapies snapping closely at its heels started to be attacked with increasing vigour.
This battle was centred in the USA and the countries in its sphere of influence. Why was this ? There were probably several factors all at the same time: the conflict of generations between scientists (28), the new discoveries about the brain and genes, the subtle lobbying from the pharmaceutical industries, the arrogant intransigence of some psychoanalysts, their refusal to have their work assessed, etc. The child psychiatrists thus started to adhere more and more strictly to a medical model, the main tenets of which are listed below :
◊ - Many child problems can be explained primarily by the special features of the way their brains work and, even more basically, from the random factors arising from their genetics.
◊ - It is important to make « objective » nosological classifications. The diagnostic and therapeutic procedure must be based on robust statistical proofs ( evidence-based medicine )
◊ - The only valuable research is the experimental family. Clinical research based on simply describing cases and interactions is not scientific.
◊ - What needs to be improved is the disturbing symptom, which will have rapidly perceptible results, and not the structure of the personality.
◊ - The treatment is thus based on medication, often brief periods of cognitive or cognitive-behavioural therapy and, if necessary, education for the parents.
The cognitivist ideas and the therapy methods that they inspire are thus very well integrated into this new way of looking at problems. There were already some famous forerunners back in the 1990s ( for example M. Rutter in Britain ), but they did not really form a school. Today, on the other hand, when many psychological phenomena (29) have been rechristened « neuropsychological », cognitivism is royally positioned. It works not simply to describe this neuropsychology, but also as the therapeutic means of choice to identify and change ideas and emotions which, according to them, are only effective or at least workable in the conscious field. It is therefore applied to children, either individually or in small groups, sometimes rather simplistically. And discussing education with the parents with a view to improving effectiveness in the short term may also be referred to as applied cognitivism.
As for behaviourism, this is another therapeutic complement to the neuropsychological and cerebral perspectives of mental illness, but it will probably never become used as an isolated corpus of specific techniques. It will remain as a complementary therapy to the cognitivist method.
In the French-speaking world, the psychotherapeutic and medical paths continue to be equally popular. It is impossible to predict whether the complementary aspects will be researched, whether a sort of polite split will persist or whether one will consume the other.
Some of the statements made by the neo-organicists are probably well-founded. Psychiatrists/psychotherapists have for too long underestimated the part played by the brain and genes, and the usefulness of medicines. Many are now returning to this aspect. We can nevertheless fear for the status of the child as subject ; he is often encountered in an individual therapeutic relationship and is always full of surprises. The medical model is too keen to objectivise him through the medium of its questionnaires and standard evaluation matrixes and its research into behavioural indicators. Although it might be interesting to attempt to resolve the symptoms, looking to rally the personality might also be a passionate, enriching and even essential adventure.
§ VI. Conclusion
Did the year 2000 bring with it any significant changes ?
In its 2001 report on health around the world, the WHO states that everywhere mental health policies are a sort of poor relation and are even non-existent in 40 % of countries. The situation is even worse when we consider the mental health of children and adolescents.
The WHO recommends having a global vision of health, and integrating responsibility for « mental health » problems right from the start, from the primary health care stage. In industrialised countries this will involve improved training for general practitioners, paediatricians and other front-line actors.
The WHO also recommends relying more on community mental health, specifically returning the health of the community back under the responsibility of that community. It is likely that emerging countries will be able to go much further in this direction than other countries, quite simply because, in many places, life communities remain active in a consistent manner. Everywhere in the world, schools may take a positive part.
More could be done in the field of citizenship and mental health, provided that the time is really freed up to allow them to do this.
This important WHO report still contains a double message with respect to the human being. It reads : « The single important thing needed to understand the human being is his biology and, essentially, his genetics which accounts for what becomes of the brain. And it is only the brain that counts. » And a few pages later: “The body and the mind are as important as one another. The human being is fundamentally psychosomatic ( we have even suggested “ bio-psychosocial ”). » Every day, we see the effects of this dual message in the field. It works at the very heart of our concept of care and our programmes of prevention. In our actions, we vacillate from one concept to the other ; the latter is more « theoretical » than specifically operational. A few very top-flight professionals ( almost philosophers ) are looking for correspondence and complementarity between the language and realities of the neurosciences and psychoanalysis. But we are still a long way from being able to provide clear results and, even less, applications for the field. Those who believe that psychogenesis is the dominant factor are not dead, however, even if this is not mentioned by the WHO. So when will there be greater integration ?
Acknowledgements : My grateful thanks to Professor Anne-Christine Frankard, PhD ( Université catholique de Louvain-Belgium ), who has helped me to establish the central concepts of this article.
1 Jean-Yves Hayez is a child/juvenile psychiatrist, doctor of psychology, Professor Emeritus at the Faculty of Medicine of the Catholic University of Leuven (Belgium), e-mail: , website: www.jeanyveshayez.net
2 Good enough ? This is a new application of D.W. Winnicott’s famous expression when he affirmed that the really good mother is nothing more than one who assumes she is good enough (Winnicott, 1971)
Likewise E. Erickson suggested that, “As always in the health field, we can only hope to get close to something that appears to be optimum in the way of things. Such an optimum is never achieved in poor health” (p. 26 in Anthony, Chiland, 1983)
3 Unless otherwise specified in this article, the term “child” is used to describe all minors, babies, children and adolescents.
4 Back in 1976, A.J. Solnit wrote that “Mental health is) a relative concept … a balance that constantly has to be reinvented between experience and individual expression and adjustment to the demands of family and community and to changes in the environment, which varies over time and across cultures.”
5 A.J. Solnit also said (in 1976) : “We misuse and abuse knowledge when we attach unjustified importance to norms and standardised objectives and when we regard achieving such objectives as a proof of mental health and not achieving them as a proof of illness.”
6 With respect to what is “truly” constitutional, we can add the earliest marks derived from our initial relationships with our first caregivers: given their repetitive nature they can fix in us, in a largely irreversible manner, the initial outlines of images and representations that will have the same effect as the genetic components of the temperament.
7 Temperament? Back in 1993, J. C Young noted that “Clinicians struggle to objectivise the psychobiological equipment that derives from the prenatal genetic matrix, using concepts such as temperament that can never be entirely satisfactory”. (P. 98 in Chiland, 1993).
8 In 1980, P. Graham emphasised that “(Our) interventions are intended to reinforce the feeling of power in parents and children have towards their lot in life, and not to suppress this power. Too many therapies are applied … in such a way that reduces their ability, rather than increasing it.”
9 A. J. Sameroff stated in 1985 that, “The (interhuman) experience can be explored, not only as something that moderates biological organisation, but also as something that contributes fundamentally to the adjustment of the individual; if it is well-organised and synchronised with the biological functions, the end result will be (overall) health…”.
10 In this work, Neuhauer lists the main macro-societal changes: overpopulation, migration, industrialisation, mass education, the sexual revolution and the transformation of family structures. He also mentions the changes in our biology (earlier puberty). He is not yet aware of the impact that environmental damage will have on life on the planet.
11 We must be careful not to use this reality of the self-system for perverse purposes. Indeed, in the world, the most conservative political forces grumble at the idea of intervening in the family and society, and strenuously insist on the concept of individual responsibility. They nearly go as far as to claim that, even if there is a mental suffering, it is because the individual is unable or finds it difficult to motivate himself, without consideration for the social responsibility. (Sameroff, 1982).
12 In this respect, P. Jammet said: “The respective domains of the innate and the acquired must be conceived as potential and more or less open futures, which are determined only as a result of more or less random encounters with the environment. The weight of any structure, whatever the level on which it is organised, can only be evaluated as a function of the response from the people around.” (Page 593 in Chiland, Young, 1993).
13 Bear in mind the strong and still-relevant assertion that A. Solnit made in 1976: “The current state of our knowledge is not yet enough to justify the use of diagnostic or prognostic criteria for mental health or mental illnesses as the basis for coercive State intervention into the intimate family situation.”
14 Our concern does not mean that we support the complete opposite : indeed, mental health programmes cannot ignore the topic of social adjustment. To a certain extent, we have made it one of the criteria for good mental health.
15. We are aware of the limits of our erudition in describing this vast field, particularly with respect to the work carried out in distant countries of the globe. We therefore ask that the reader forgive us for being a university practitioner and not an historian. We would love to hear from our readers if they are able to fill in any gaps or correct inaccuracies in this part of the paper.
16 Itard published his work in 1801 and 1806.
17. Sancte de Sanctis, for example, talks of dementia praecocissima to describe infant/juvenile schizophrenia, by analogy with the concept of dementia praecox put forward by Kraepelin.
18. A few years later (1943) he would identify autism. His primary study of cases remains an incredibly up-to-date document.
19 He did this indirectly via reports from his father. This doesn’t really matter as he regarded the child as a subject speaking for himself…
20. As already mentioned, “mental health promotion” refers to a positive concept of mental health and to the psycho-educational model. “Prevention” refers more to the medical model. For the sake of simplicity, the two terms are used interchangeably in the rest of the text.
21 Temperament will later be defined better (Pichot, 1995), and other authors will continue to study these relationships (e.g. invulnerability – easy-going temperament (Maziade, 1986, Thomas, Chess, 1977).
22 For example, read M. Rutter (1987) : “ People’s reactions to stress and adversity are modified by prior experiences which either increase their vulnerability or protect them from deleterious effects.”
23. With “ the ” fundamental trinity : child psychiatrist – psychologist – social worker, occasionally joined by other re-education and therapy of the body specialists.
24 . In France, for example, with Serge Lebovici and Roger Misès in the 1970s.
25 . Apart from the field of psychosis, perhaps, in which for a long time each practitioner has worked more or less on the basis of his personal classification.
26 . This is almost inevitable for a discipline that is in the ascendant. What happened with psychoanalysis was not its sorry privilege. It was merely surpassed by the new single reference medical models that were occupied with moving along the same lines.
27 . There are, moreover, some psychoanalysts who want to work with the entire family group, but without recourse to systemic models. Nathan Ackerman was a pioneer of this in the United States, and there are still small schools of “psychoanalytical family therapy”.
28 The importance of this irrational factor appears obvious to us, but is not always easily admitted by the fighters…
29 . Neuropsychologists? Of course, they have always existed! The human being does not think and does not experience his emotions independently of activation by his brain, and it is not always possible to detect which is the chicken and which the egg in what we produce as ideas, feelings, behaviours and brains’ activation.
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