Journal MonitorCHILD PSYCHOLOGY SELECTIONCompiled by Jennifer Walters

Clinical Child Psychologyand Psychiatry (2002)

This year has seen a change of editor of

this journal and there is a moving tribute

to the outgoing editor, Bryan Lask, by

Kenneth Nunn to be found in Volume 8,

No.2, 2003. The journal is now in the

capable hands of Bernadette Wren who

will, I am sure, continue the excellent

tradition of clinical papers that are of in-

terest to a wide audience of practitioners.

This journal is such a rich source of

clinical interest that it is always difficult

to pick out which papers to review. The

first papers I have chosen interested me

because they represent parental per-

spectives. Two papers are written by

parents, and a third is about the differ-

ing views between parents and teach-

ers.

K. Yazbak. The new autism. Vol. 7,

No. 4, pp. 505–517.

A. J. Wakefield. Commentary on �Thenew autism�. Vol. 7, No. 4, pp. 518–524.

Jeremy Turk. Commentary on Yazbak

and Wakefield. Vol. 7, No. 4, pp. 525–

528.

A big area of controversy is that of the

MMR vaccine and autism, and specific-

ally whether the MMR can be linked

with bowel disease leading to autism. In

this issue there are three papers devo-

ted to this subject. In the first a mother

of two autistic children, K Yazbak,

writes strongly in support of the argu-

ment that there are links, talks of

regressive autism having a genetic link

to immune fragility, and of autism being

an epidemic. Andrew Wakefield reiter-

ates his original arguments1 (1998)

surrounding the controversy in a paper

following that of Yazbak. He concludes

that �As a first step, there is no substi-

tute for listening to parents.� However,

Jeremy Turk, a child psychiatrist who

listens carefully to parents and is

extremely supportive of parents of chil-

dren with a disability, expounds a clear

and respectful argument as to why he

disagrees with Yazbak and Wakefield.

In particular, he points out that few

people with autistic spectrum disorder

have �been anywhere near an MMR

vaccine� and that �hardly any people

who have received an MMR vaccine

develop autism�.

Deborah Christie & Amita Jassi. ‘Oh no

he doesn’t!, ‘Oh yes he does!’: Compar-

ing parent and teacher perceptions

in Tourette’s Syndrome. Vol. 7, No. 4,

pp. 553–558.

This paper, written from a specialist

Tourette’s clinic in London, discusses

the apparent mismatch between parent

and teacher views of children with

Tourette’s. Parents attending specialist

clinics report that learning and atten-

tional difficulties are their greatest con-

cern, more than the tics. Teachers,

however, are also concerned regarding

attention in these children but report

fewer behaviours as being of concern

than do parents. Those behaviours that

teachers do report are rated as less

severe than parental ratings. These

discrepancies of reporting can lead to

conflict between home and school, with

parents feeling blamed by profession-

als. The authors stress that their role is

not to blame but is to show parents how

they have a role in shaping their chil-

dren’s behaviour. Teachers, on the

other hand, can be helped to under-

stand how certain behaviours are less

controllable at home, and possibly

modify homework demands accord-

ingly. The authors� clinic offers work-

shops to teachers of affected children.

Another paper by a parent appears in

a whole issue on sexual identity and

gender. In this edition the guest editors

state that they wish to redress the under

representation of articles on this topic in

the clinical and research literature

regarding child and adolescent services.

Children who identify as lesbian, gay,

bisexual or transgendered (lgbt) are

presenting at younger ages. The papers

look at many aspects of this subject,

including exploration of issues for chil-

dren of lgbt parents.

M. Griffiths. Invisibility: The major

obstacle in understanding and diagno-

sing transsexualism. Vol. 7, No. 3,

pp. 493–496.

Margaret Griffiths from Mermaid’s

Support Group for children UK talks

very movingly about the dilemmas for

a parent of a transsexual child. The

themes she highlights are common-

place for parents of children with any

form of difficulty – getting referred for

specialised help, school support, deal-

ing with reactions of friends and rela-

tives. The difference it makes if

parents have a strong relationship

with a partner is emphasised. But,

however good the professional help

may be, there seems to be no substi-

tute for meeting other parents in sim-

ilar situations.

Regis Brunod & Solange Cook-Darzens.

Men’s role and fatherhood in French

Caribbean families: A multi-systemic

�resource� approach. Vol. 7, No. 4,

pp. 559–569.

This article refreshingly writes about

the diversity of family structures in

which children can be raised using

French Caribbean families to illustrate

the ideas. It urges mental health pro-

fessionals to apply more flexible con-

cepts of �fatherhood� than those seen as

the nuclear family model. The authors

(who are a paediatrician/psychiatrist

working in the French West Indies and

a family therapist working in Paris)

write about how they wish to emphasise

the notion of �family environment�rather than what they see as the

restrictive notion of �family�. Further-

more, they suggest that positive child

outcomes can be achieved by a wide

variety of family structures. They focus

on the �quality� of the family environ-

ment rather than on the particular

constellation. An idea I found interest-

ing is of the neighbourhood, for exam-

ple, playing a powerful �disciplinarianand socialising� role. The broader social

context provides wide possibilities of

support to families that are not so

available in the nuclear family context.

The authors argue that if fathers do not

reside with their families in the Carib-

bean context it does not mean that they

are disengaged or irresponsible. They

may still spend time with their children

and can be involved with joint decision

making within the family. However, the

authors do acknowledge that girls may

do better in Caribbean families than

boys because of the abundance of

female models. A more positive view of

1Wakefield, A. J., Murch, S. H., Anth-ony, A., et al. (1998). Ileal-lymphoidnodular hyperplasian non-specific coli-tis and pervasive developmental dis-order in children. Lancet, 351, 637–641.

� 2004 Association for Child Psychology and Psychiatry.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Child and Adolescent Mental Health Volume 9, No. 1, 2004, pp 38–41

the matrifocal family is proposed. I do

wonder, however, where this ultimately

leaves the men?

Kasia Kozlowska. Good children with

conversion disorder: Breaking the

silence. Vol. 8, No. 1, pp. 73–90.

This paper from Australia emphasises

the patient’s point of view and gives a

comprehensive overview of the theoret-

ical perspectives in conversion disorder

in children. The author then presents

two accounts by teenage girls them-

selves 18 months after initial presen-

tation. Both these accounts are

extremely interesting in elucidating

the aetiology and mechanisms whereby

the girls presented with symptoms of

being unable to walk. The author feels

that they illustrate cases of compliant,

�good� children who use this behaviour

to manage their attachment relation-

ships. They initially appeared discon-

nected from their experience in the

family. Both families emphasised the

organic aspects of the illness and were

sceptical of psychological interven-

tions. The paper emphasises how ini-

tially a lack of social, family, and

psychological difficulties are acknow-

ledged and the children have appar-

ently �exemplary� functioning. The

solution seems to be for the children

to present with a conversion disorder

as a way of dealing with unbearable

predicaments.

Anne E. Thompson, Carole Morgan &

Irene Urquart. Children with ADHD

transferring to secondary schools:

Potential difficulties and solutions.

Vol. 8, No. 1, pp. 91–104.

Nick Child. Deficient attention and dis-

ordered activity: Child psychiatry’s re-

sponse to ADHD. Vol. 8, No. 2, pp. 167–

178.

Two papers on ADHD caught my eye,

this being a topic of endless debates both

in CAMHS and in the media. The first

concerns ADHDand transition to secon-

dary school, which for many children

can be a difficult time, but for those with

a diagnosis of ADHD particular prob-

lems present. This paper covers the

academic problems encountered, social

problems linked with adolescence in

general, and practical problems such

as takingmedication in school. The need

for joint working between health practi-

tioners and school staff is emphasised.

A second paper is written by a retir-

ing consultant from Lanarkshire, Nick

Child. The paper is thoughtful and

often humorous but has a serious

message – ADHD attracts great busi-

ness for child psychiatry but �like any

business that booms when it is not

ready� it risks going bust. He urges

urgent business planning for services.

Using the analogy of hospital services

dealing with a Terror Bug he recom-

mends that specialist Tier 4 services

should not be the frontline for ADHD

referrals. He suggests that a Tier 3

service with a multidisciplinary

approach is more appropriate and prior

to that, a filtering through Tier 2. A

small proportion of children may need

�the magic label and the pill� but they

will also need much wider support

offered to more general cases.

Child talks about how, using a

multi-agency approach, differentiation

between core and broad ADHD can be

facilitated. There can be milder categ-

ories of children without labelling who

benefit from, for example, help with

parenting. Specialist ADHD clinics

result in over inclusive labelling.

This is a complexly argued paper

and has some challenging ideas that

could be applied to several other areas

of our work, for example autistic spec-

trum disorder, where diagnoses are

sought. It is worth remembering, how-

ever, those although it may not be a

good idea to have a proliferation of

specialist clinics from the profes-

sional’s point of view, parents would

often like to feel they can go straight to

�the experts�.

Helen Minnis, Eileen Kelly, Hannah

Bradby, Rachel Oglethorpe, Wendy

Raine & Deborah Cockburn. Cultural

and language mismatch: Clinical com-

plications. Vol. 8, No 2, pp. 179–186.

For those who work with ethnic minor-

ity groups of any kind this paper sti-

mulates interesting ideas. The authors�research is based in Glasgow where

there is a high proportion of South

Asian families but few referrals of this

group. All the clinic team members are

white British (and mostly female jud-

ging by the names of the authors) and

experience a gulf between how the chil-

dren referred are experienced by the

families and how they, the profession-

als, perceive them. A large proportion of

the children were diagnosed as having

ADHD compared with the general pop-

ulation. Implications for practice are

discussed. Points emerging are that

workers require specialised training in

cultural awareness. Routine recording

of cultural and religious issues should

be made in case notes and greater

efforts to involve extended family in

the consultations. Obviously, involve-

ment of South Asian workers would be

ideal.

FAMILY THERAPY SELECTIONReviewed by Jenny Altschuler

Families, Systems & Health(2003)

J. Gougreau & F. Duhamel. Interven-

tions in perinatal family care: A partici-

patory study. Vol. 21, No. 2, pp. 165–

180.

Drawing on the views of eight physi-

cians and four couples, this research

explored which interventions were

likely to be helpful in preparing preg-

nant couples for parenting. Overall,

interventions aimed to increase levels

of exchange between spouses. Men in

particular talked about feeling left out

of the process, highlighting the need for

their inclusion in anticipatory guid-

ance, for example raising questions of

the role of fathers to be/spouses during

pregnancy and delivery, balancing the

role of parent and spouse and the

sharing of household tasks. Perhaps

what is most surprising is that this

process is still being reported, despite

increased recognition of the role of

fathers.

C. Sallford & L. R. M. Hallberg. A

parental perspective on living with a

chronically ill child: A qualitative study.

Vol. 21, No. 2, pp. 193–204.

This study explored parents� experienceof living with a child with Juvenile

Arthritis. Drawing on taped, open inter-

views with 22 parents, analysed using

grounded theory, the paper identified

gendered differences in the experience

of fathers and mothers. They focused in

particular on parental vigilance, differ-

entiating between the role of the �man-

aging mother� and the �waiting father�.The former included noting how the

mother’s daily life was closely emotion-

ally and practically engaged with the ill

child, with a sense of constant pressure

that �would never go away�. The �waiting

father� was seen as a �more passive role

and an attitude of wait and see�. Draw-

ing primarily on the notion of a strict

gendered division to family life, the

authors account for these differences

by saying fathers had minimal chance

of participating in the routines of car-

ing. The authors also discuss the emo-

tional challenges faced by parents

including the need to response continu-

ally to adjustments.

Journal Monitor 39

Although some of the issues dis-

cussed may need to be reconsidered

for families where there is a less rigid

gender division, the notion of the re-

sponses of one parent having an effect

on the actions of the other is an import-

ant issue. The authors conclude that

parents in this study wished profes-

sionals in health care units and schools

would understand the position of par-

ents and provide emotional support in a

non-judgmental way. Lack of control

with less support, information and

communication results in increased

uncertainty, anxiety and an inability to

manage. This paper highlights the need

to recognise the position of parents in

the child’s response to illness and treat-

ment: it therefore has much to offer all

professionals dealing with parents car-

ing for ill children.

CHILD PSYCHIATRY SELECTIONCompiled by Nisha Dogra

European Child & AdolescentPsychiatry (October 2002–September 2003)

David C. Taylor. Whatever happened to

child and adolescent psychiatry? (Edi-

torial). Vol. 12, Issue 2, pp. 55–57.

David C. Taylor. The concept of mental

health in children. Vol. 12. Issue 3.

pp. 107–113.

The articles appeared in different issues

due to a publishing error, but I have

chosen to review them together because

the issues are very clearly related. In

the first paper, the editorial, David

Taylor provides the rationale for his

views about the National Assembly for

Wales� strategy document, �Everybody’sBusiness: Improving Mental Health Ser-

vices in Wales; Child & Adolescent

Mental Health Services Strategy� (Sep-tember, 2001). Taylor states that the

objective of the document is to measure

the distance between serious practi-

tioners in the field and their govern-

ment. The advisory committee on which

the Assembly relied was national but

had only one practising child psychiat-

rist among its 16 members. Taylor

expresses concern with the use of the

term, �child and adolescent mental

health services�, feeling that this is

perhaps a way of avoiding the term

�child and adolescent psychiatry�, there-by sidelining medically qualified staff.

He also argues that there is a confusion

of issues between clinical and political

action on behalf of children. The docu-

ment uses a series of euphemisms such

as �troubled children� and �damaged

young people�, and Taylor feels that

these euphemisms are unhelpful. He

also criticises the concept of tiers that

has been widely accepted in the UK

following HAS 1995.

Taylor disagrees very strongly with

the introduction in the document,

which states that �both mental health

problems and disorders in children and

young people are symptoms of a deep

malaise in society generally�. Taylor’s

main concern with the strategy docu-

ment is that �it lacks a clinical, diag-

nostic, perspective and hence it

confounds political and clinical activity.

It confounds the general effect of pov-

erty and deprivation with the problems

of parenting and child management. It

then confounds these poor, deprived,

badly managed children with those

children whose behaviour comes to

notice because of a health problem�.Taylor also states that the disassocia-

tion of the management of health, social

services, and education has added to

the problem. Health Trusts, he argues,

create illogical boundaries and artificial

difficulties that prevent patient mobility

in their choice of clinic. He states that

each of the participants who worked

together in producing this strategy

document has to account for why they

would accept financial liability for the

management of a child who might more

happily land elsewhere. Taylor argues

that the deepest malaise that affects the

services available to children in Wales

has been in the government of health,

education and social services, hitherto

to the responsibility of the UK Govern-

ment. If the Assembly could do some-

thing to change it, it would be useful to

Welsh children.

Taylor criticises the document for not

discussing the eccentric location of

available services clearly enough to

solve the problems of coping with chil-

dren who need close observation or

intensive care but who reside far from

the meagre resources that are available.

Taylor also feels that, worst of all, the

plan redefined adolescents to include

people up to 18 years. His argument is

that humans now mature much earlier

and the move is totally in the wrong

direction. Taylor feels that child psychi-

atry, for far too large a number, is still a

forum of child guidance. �Many people

who qualify in medicine regret doing so.

My view was that child psychiatry

allowed too many qualified doctors the

privileges of a professional career with-

out the continuing responsibility of

practicing medicine�. He claims that it

behoves the physician in the team to

take a clinical approach to the topic and

that clinical means dispassionate, diag-

nostic, giving close attention to detail so

that the case can serve as a matter for

study. This should be a detailed,

systematic enquiry that produces regu-

lar and reliable data, rather than a

casual conversation. Taylor concludes

that child psychiatry in Wales needs a

plan of how to interest students of

relevant disciplines to train them to

high levels of performance and then

put properly trained staff in place to

treat the children who need psychiatric

treatment. For him, �Everybody’s Busi-

ness� is a management document out-

lining the proposal to be taken forward

by other managers and it is evidence of

political intention but is formed without

content and fails to discriminate be-

tween political action, public mental

health and a proper child and psychi-

atric service that will ultimately do

nothing to rescue �the wasted children�.The second paper, The concept of

mental health in children, is based on

some early work that Taylor had done in

the 1970s as part of a teaching lecture-

ship in Oxford. Taylor first of all pre-

sents his position in 1975 and the

definition of child mental health at that

point. He then discusses some of the

problems of defining mental health in

children, including: accepting patient

status, the status of symptoms, third

party accounts, and the inapplicability

of conventional clues to mental health.

There is then a section on choice and

health, with the final section being an

envoi to update the article. It is perhaps

the envoi section that is most relevant

to the editorial reviewed above.

In this section, Taylor argues that

maintaining mental health, as with

physical health, is mostly a matter of

public hygiene and agreement to gov-

ernment by rules. He states that not

much thought is given to child psychi-

atry because all the institutions that

govern it are political, involving the

financing of the poor, the management

of those claiming various benefits, child

care, and education in its broadest

sense. He describes this as leading to

an �underclass� that is not a moral

category but a sociological statement

about a grouping of persons who re-

quire practical help. The underclass

also defines itself in most health sur-

veys as those most likely to have the

worst health on most measures. He

argues that members of the underclass

are alienated from the values and insti-

tutions of the majority to such an extent

40 Journal Monitor

that it is difficult to stop intergenera-

tional perpetuation.

To effect change, there has to be a

recognition of the distinction between

treatment and prevention. Mental ill-

ness is treated when it is recognised

and it can only be prevented by being

considered part of public health. By

public health, he refers to those advan-

tages that are in place to permit a

society to live, as far as is feasible, free

from diseases. Taylor argues that chil-

dren in particular have benefited from

an epoch of physical care where they all

enjoyed close and detailed observation

by several different medical profession-

als from babyhood, and that these

benefits are now slipping away. The

scale of provision, however, for the

invigilation of physical health is still

massive in comparison with resources

allocated to the public health aspects of

child mental health. A public health

approach would mean that intervention

should be with parents-to-be. Taylor

concludes that school teachers, educa-

tionalists, psychologists and school

medical staff must give proper recogni-

tion to the innate and acquired varia-

tions between children attending school

and must provide regular monitoring of

their attendance and performance. All

children should be treated with proper

consideration but children should not

be treated equally for the very good

reason that they are not. A public

health approach would require that

the local records of children with mental

illness, problematic behaviour or brain

impairments be a matter of public

record and concern. These would reveal

areas of the country with institutional-

ised educational and behavioural fail-

ure and these in turn would attract

attention and could at least hope to

command the attention of politicians

and the appropriate resources to deal

with it.

One reason for choosing both these

articles was that I was struck by the

lack of any references for either article. I

found this particularly striking in an

age where we are supposedly more

evidence-based for our stances. How-

ever, that apart, I thought that both the

articles were very interesting. I was

struck by the passion with which Taylor

conveyed his thoughts. I was also

struck by how the debate in his papers

had mirrored the debates that had

taken place within our service over the

last few years. When I started as a

lecturer 10 years ago, we were a child

and family psychiatric service and for-

mally, a few years ago, became the child

and adolescent mental health service.

The removal of the word psychiatry

from our service title caused consider-

able discussion and concern that it was

about sidelining the medical profession

from the service. The points that Taylor

raises are very valid and important for

services and the professions, especially

psychiatry, to address as a whole. The

papers highlight that in compromising

and negotiating, we should not sell out

on the most important principles. It is

important to recognise that terms are

being used euphemistically and at

which point it is worth sticking to the

principle and not changing terms. As a

psychiatrist I accept the concept that

child mental health should be every-

body’s business but I do not accept that

anybody and everybody is able to make

equally competent judgements about

when children have mental health prob-

lems and the impact of these. Unfortu-

nately, the concept of �everybody’sbusiness� appears often to mean that

anybody and everybody has equal capa-

bilities in assessing and managing child

mental health problems. This is irres-

pective of whether they have been

appropriately trained or not. An indi-

vidual’s opinion counts as expertise in

child mental health when it does in no

other area of clinical practice. I do not

necessarily agree with all the points

made by Taylor but I did feel very

strongly that these articles are timely

and an indication to child psychia-

trists – but also to other child mental

health specialists – that we need to

ensure we are very clear about what

our roles and responsibilities are. It is

important that we do not see our pro-

fessional roles confused with our polit-

ical ones but that we also recognise

when the two impact on each other. I

was also left with a feeling, however,

that it is important that we do not

polarise the role of psychiatrists as

being either biological or psychosocial.

It is important that we keep a balanced

view of the nature of children’s prob-

lems and do not seek to provide solely

medical or social causes for issues that

are more complex. It would have been

interesting to have another perspective

because although I identified with the

issues when reading it, I was unsure of

its relevance to professionals outside

the UK. A multi-agency forum may be

an interesting place to discuss these

articles.

Journal Monitor 41