Clinical Commentary

This paper describes a lengthy period of psychotherapy with a child. This treatment began only after a prolonged contact with other child and adolescent mental health services during which the child's difficulties, which had initially seemed to be ordinary behavioural problems, had proved puzzlingly intractable to a variety of interventions. Subsequent psychotherapy revealed a profound disorder of development which lay bath the Surface presentation. In a climate where Asperger's syndrome is often felt to be untreatable, this paper argues that some children, at least, can benefit from psychotherapy and can be helped towards real mental growth. Asperger's syndrome in children bears some striking similarities to narcissistic personality disorder as described in the adult psychoanalytic literature and this paper discusses some of the theoretical and clinical implications of the innate origins of Asperger's syndrome.     

Working Through Physical Disability in Psychoanalytic Psychotherapy With an Adolescent Boy

The narcissistic injury that may be caused by physical disability in infancy and the possible familial traumatization may block the integration of the infant's body and self-image, and can consequently hinder the child's identity formation. This article presents how an adolescent boy with cerebral palsy in short-term psychoanalytic psychotherapy works through the mental impact of his physical disability using a story. Transference and countertransference reactions are discussed. The positive impact of short-term psychoanalytic psychotherapy highlights the importance of caring for the mental health of children with physical impairments.     

Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health

This article describes the interface between the fields of attachment and child trauma, their respective contributions to an understanding of infant mental health disturbances, and the clinical applications of an integration between attachment theory and trauma‐informed treatment and research. The organizing theme is that a dual attachment and trauma lens must be used in the assessment and treatment of infants and toddlers with mental health and relationship problems. The quality of attachment is an important factor in children's capacity to process and resolve traumatic experiences. At the same time, traumatic events often have a damaging effect on the quality of existing attachments by introducing unmanageable stress in the infant–parent relationship. It is argued that trauma in the first years of life needs to be assessed and treated in the context of the child's primary attachments. Reciprocally, the etiology of attachment disturbances should include an assessment of possible exposure to trauma in the child and in the parents. Current conceptualizations of attachment and trauma are reviewed from this perspective, and a clinical illustration is presented to highlight how a traumatic stressor can trigger behaviors reminiscent of disorganized attachment.     

Children birth to three entering the state's custody

Children entering the state's legal custody are a high‐risk group. They have experienced, not only maltreatment of some form and usually separation from attachment figures, but often have also witnessed domestic violence, been exposed prenatally to alcohol and/or drugs, or been in attachment relationships with substance‐abusing and/or mentally ill parents. This paper presents data on the developmental and mental health status of these children, including diagnoses using the Diagnostic Classification: 0–3. Over half the children received referrals for additiional needed developmental or mental health services. The importance of assessing these children early in their time in foster care is emphasized.     

A Goodness-of-Fit Approach to Informed Consent for Pediatric Intervention Research

As children and adolescents receive increased research attention, ethical issues related to obtaining informed consent for pediatric intervention research have come into greater focus. In this article, we conceptualize parent permission and child assent within a goodness-of-fit framework that encourages investigators to create consent procedures “fitted” to the research context, the child's cognitive and emotional maturity, and the family system. Drawing on relevant literature and a hypothetical case example, we highlight four factors investigators may consider when constructing consent procedures that best reflect participants' rights, concerns, and well-being: (a) the child's current assent capacity and the likely impact of study information on the child's mental and physical development, (b) parents' understanding of their child's treatment needs and distinctions between treatment and clinical trials research, (c) the family's history of shared decision making, and (d) the child's strivings for autonomy within the context of their parents' duty to make decisions in the child's best interest.     

My Child Is Better Than Average: The Extension and Restriction of Unrealistic Optimism1

The purpose of the current study was to determine whether parents make unrealistic evaluations of children and what factors predict these evaluations. Parents of 5‐ and 6‐year‐olds rated their child's risk for various positive and negative outcomes, temperament, and health and behavior problems. Parents also completed an adult attachment measure. Parents appeared to give relatively little consideration to realistic constraints when predicting their child's future. Parents scoring higher on attachment avoidance were less optimistic that their child would attain positive outcomes and avoid negative outcomes, consistent with the view that optimism is a motivated phenomenon. Greater child internalizing behaviors also were associated with less parental optimism for positive outcomes. Findings have implications for the delivery of health messages to parents.     

Relationships,Environment, and the Brain: How Emerging Research is Changing What We Know about the Impact of Families on Human Development

Recent research is providing family therapists with new information about the complex interaction between an individual's biological makeup and his/her social and physical environment. Family and social relationships, particularly during sensitive periods early in life, can affect a child's biological foundation. Additionally, stress during the early years can have a lasting effect on an individual's physical and mental health and contribute to the onset of severe mental illness. Community programs have been developed to intervene early with families who have an at‐risk child to prevent or minimize the onset of mental illness including providing partnerships with at‐risk mothers of infants to shape attachment relationships. Programs are also developing individual and family interventions to prevent the onset of psychosis. Practicing family therapists can incorporate emerging neuroscience and early intervention research and leverage the growing base of community programs to enhance the effectiveness and sustainability of mental health outcomes for clients. Additionally, family therapy education programs should broaden student training to incorporate the growing body of information about how family relationships affect individual mental health development.     

Internal working models of caregiving and security of attachment at age six

This study describes the relation between internal working models of caregiving, child attachment, and maternal behavior in the home. Thirty-two mothers of 6-year-old children were observed in the home and subsequently interviewed regarding experiential and affective dimensions of parenting. Interviews were examined in order to assess the quality of the mother's thinking regarding two dimensions of caregiving (secure base, competence) which we hypothesized to be related to attachment security. Results indicated a strong correspondence between internal working models of caregiving and child mental representations of attachments as measured from the child's response to a laboratory reunion. The correspondence between mental representations of caregiving and maternal behavior in the home was limited. Representation ratings were most strongly associated with competence-supporting behavior. Implications for infant mental health research and program evaluation are discussed.     

Children's response to community violence: What do we know?

This article presents a framework for understanding the developmental significance of violence-related trauma in the lives of young children. It emphasizes the importance of the distinction between acute and chronic trauma. Acute trauma is more readily dealt with through “psychological first aid” and a “therapy of reassurance.” Chronic trauma requires a more systematic reconstruction of the child's “social map” of the world. The socioeconomic and demographic correlates of violent trauma predict an accumulation of risk factors in the child's life that compounds the problem of developmental disability. The problem community violence poses for the child must be understood in the larger context of greater risk for family disruption (including less than secure attachment) as well as domestic violence, poverty, and minority group status. The increasing incidence and prevalence of community violence poses a major challenge to the mental health of children.     

Adoption Counselors' Perspectives of Counseling Postadoptive Families

This study was conducted to explore the mental health needs of families who adopted from the state welfare system. Using consensual qualitative research, the authors examined the perspectives of 8 clinical mental health counselors who provided counseling services to postadoptive families. Findings represented by 5 domains and supported by 15 categories include the counselors' perspective of (a) strength of the current program, (b) families in crisis, (c) parents' construction of their child's problem, (d) programmatic limitations, and (e) systemic limitations.     

Clinical Assessment of Prementalizing Modes of Psychic Functioning in Children and Their Parents in the Context of Trauma

ABSTRACT

As psychoanalytic psychotherapy for children depends on their capacity to mentalize, it is essential to integrate this dimension in their psychological assessment. Mentalization refers to the capacity to identify and comprehend the mental states (feelings, thoughts and intentions) underlying and explaining one’s own behaviors and those of others. This vital ability, which develops during the first five or six years of life in the context of a secure parent-child attachment, is often impaired in children subjected to neglect and maltreatment. Based on rigorous and systematic clinical observations made in youth protection and child psychiatry services, the authors suggest that the children in these settings, along with their parents, frequently present a prementalizing mode of psychic functioning. Further, the authors propose operationalizing the teleological, psychic equivalence, and pretend modes as they might be observed in older children and their parents. To this end, they begin by identifying behaviors, attitudes, and relational patterns potentially linked to each of these modes within a theoretical framework. Next, they describe the characteristics of these children’s narratives, play, and artistic productions. Lastly, three clinical vignettes are used to illustrate how the prementalizing modes are manifested. The results of this clinical assessment can guide the choice of techniques to be used in child psychotherapy.     

Hidden meaning of an early loss. The common ground of attachment and social character assessments and their clinical applications

All contemporary psychoanalytical theorists are concerned with the common problem of how to account for the preeminent importance of relations. John Bowlby, the founder of attachment theory, suggests that “instinctive” behavioral systems underlie much of the emotional life of man and have developed because they were necessary for survival. The system with which he was almost exclusively concerned was the multitude of behaviors and experiences constituting the child's “attachment” to the mother. This “strikingly strong tie, evident particularly when disrupted”, has systematically been observed by attachment researchers, through the development of a series of instruments that gauge interpersonal communication. These interpersonal communications have on their part been found to “contain traces of developmental history”.

Bowlby's theory is based on clinical accounts of cases of important loss experiences. A transcendental role is given in Bowlby's theory to the experiences of loss. It stresses that the construction of mourning processes can be seen as a manifestation of search and as a general gradual mental reorientation. The paper introduces the methodological perspectives, which are observable derivations of Bowlby's psycho‐ethological ideas. We will argue that becoming acquainted with these attachment‐research tools and with socio‐psychoanalytic assessment can enhance the development of the clinicians' observational skills, their insight and their scientific research practices. A clinical vignette seen through the lenses of the attachment assessment of loss is presented. It points in addition to the socio‐cultural‐ethnical basis that serves as an underlying structure for the development of meaning.     

Light and color in a void: The analysis of a special needs child

This clinical report comes from the five year, four day a week analysis of a male child. What is special is that this treatment is of a child with marked mental retardation. I have retained this nomenclature because that is how Ricardo's parents described his mental capacity. What they meant was that he was greatly impaired in his cognition and this could be seen in Ricardo's severe cognitive, social, behavioral, and relational improprieties. I have privileged the function of psychoanalytic understanding and the role of transference to bring about modifications in this child's internal world. And I have considered the patient's psychotic mental state to be in need of psychoanalytic treatment not withstanding his psychosis's connection to his cognitive handicap. I have also added information I have received after the analysis, information that demonstrates continued integration coming from the analytic process. Owing to Ricardo's limited mental capacities, this article advances clinical information that is not often found in analyses of children. There are possibly many other children like him who nonetheless would benefit from dynamic psychoanalytic understanding. On the other hand, I shall not discuss this matter theoretically, even though some theoretic considerations are necessary. Clinical practice and the transferential relation are this report's principal material.     

Growth in emotional intelligence. Psychotherapy with a learning disabled girl

This paper describes the once-weekly psychoanalytic psychotherapy of a girl, called Ellie, aged eight at the start of her treatment. Ellie had a learning disability and displayed difficult behaviour at school and at home. In her therapy, Ellie grew in emotional intelligence, more in touch with and able to express her feelings. Her behaviour improved and so did her capacity to learn. In the therapy there were certain limitations to progress and this is discussed in terms of how Ellie's disability affected the basic achievements of emotional development, including a mind with a solid ‘reality ego’, able to contain anxiety, and able to maintain depressive functioning. The importance of parallel parent work, to share observations and understanding of the child's functioning is discussed. Difficulties for both child and parents in dealing with the pain of difference and how this limits emotional intelligence are discussed. The author hopes that this paper will encourage the offering of psychoanalytic psychotherapy to children and young people with learning disabilities, who are significantly more likely to suffer from mental health problems than their peers.     

Prenatal trauma and autism

Through the clinical history of a little girl, this paper explores some possible traumatic prenatal experiences of children who have autistic features from birth. It establishes a tentative connection between the precocity of the onset of pathology and potentially traumatic prenatal situations such as threats of miscarriage or pathological mental states in the pregnant mother. It is suggested that a psycho-physical retreat from the auditory experience of the mother's voice, which normally stimulates foetal proto-mental activity and may lead to the development of a 'sound-object', might contribute to the later autistic child's isolation and non-mental clinging to tactile sensations.     

Social learning in the digital age: Associations between technoference,mother-child attachment,and child social skills

Technoference refers to incidents in which technology use interferes with interpersonal exchanges (e.g., conversations, playing). Although research on technoference is in its infancy, there is preliminary evidence that mothers believe technoference has a detrimental impact on the social-emotional functioning of their child. The current study investigated the degree to which technoference was associated with attachment between mothers and their elementary-aged children. A second aim was to determine if the relationship between technoference and children's social-emotional functioning may be moderated by mother-child attachment. Surveys were completed by a sample of 80 mothers and their elementary-aged children. This study is unique in asking elementary-aged children to report their perceptions of parental technoference and the impact it has on their relationship with their mother and their own social-emotional functioning. More frequent technoference was associated with less secure mother-child attachment as rated by children, but not as rated by mothers. That is, frequent technoference may not significantly influence a mother's attachment to their child, but it is associated with a child's attachment to their mother. More frequent technoference was associated with decreased ratings by mothers regarding their child's social-emotional functioning. Furthermore, maternal attachment moderated the relationship between technoference and child externalizing behaviors, such that a more secure attachment served as a protective factor against the negative impact of technoference on child externalizing behaviors. However, attachment did not moderate the relationship between technoference and most social skills assessed in our study. Implications from this study are discussed, including ways to increase awareness of technoference among school personnel, parents, and youth.     

Integrated treatment of co-occurring mental illness and addiction: clinical intervention, program, and system perspectives

Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems. This combination results in increased risk for frequent psychiatric relapses, poor medication compliance, violence, suicide, legal problems, and high utilization of the emergency room or inpatient services. Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to clinical interventions, programs, and system flaws that have not addressed the individual's needs. Integrated treatment requires both an understanding of mental illness and addiction and the means to integrate and modify the traditional treatment approaches in both the mental health and addiction treatment fields. There is strong evidence to support the efficacy and effectiveness of integrated treatment in this population. All mental health clinicians should become experienced and skilled in the core psychotherapy approaches to treating substance use disorders, including motivational enhancement therapy, relapse prevention (cognitive-behavioral therapy), and 12-step facilitation. In addition, integrated treatment includes integrating medications for both addiction and mental illness with the behavioral therapies and other psychosocial interventions. This article reviews the clinical intervention, program, and system components of integrated treatment and specific clinical interventions for this population.     

The Relation of Exposure to Traumatic Events and Longitudinal Mental Health Outcomes for Children Enrolled in Systems of Care: Results from a National System of Care Evaluation

This study examined the relation between children's history of exposure to potentially traumatic events (PTEs) and clinical and functional mental health trajectories over a 18‐month period among a national sample of youth referred for services in children's behavioral health systems of care (SOCs). Using data from the national evaluation of the Comprehensive Community Mental Health Services program for communities funded from 1997 to 2000, the study sample included 9556 children and their families. Latent growth modeling was used to assess the effect of history of exposure to PTEs on trajectories in a number of behavioral health outcomes during the 3‐year period following referral to services, controlling for child demographic characteristics (gender, race, and age). Results revealed that, on average, children in SOCs exhibited significant improvements over time on all four outcome measures. Children with a history of exposure to PTEs had higher rates of internalizing and externalizing problem behaviors and functional impairments and fewer behavioral and emotional strengths at baseline, but experienced improvements in these outcomes at the same rates as children without exposure to a traumatic event. Finally, child race, gender, and age also were associated with differences in behavioral health trajectories among service recipients. Implications for SOCs, including approaches to make them more trauma‐informed, are discussed.     

The school psychologist and early education: An ecological view

An ecological view of psychological services to preschool children is described here as a proactive, seeking-out, mental health delivery system that concentrates its effort on prophylactic activities rather than the “diagnosis recommend” or “diagnosis psychotherapy” ritual. Activities for psychological services, training of staff, and competencies for effective delivery are described. Staff competencies to facilitate children's mental health are also described.     

Challenges of patient‐led mental health services to psychoanalytic clinicians

This paper considers implications to psychoanalytic psychotherapy of the British Government's decision to implement a patient choice agenda for state‐funded mental health services in England and Wales. It places the patient choice agenda in the context of consumerist society and argues that the complex nature of psychoanalytic psychotherapy leaves it more vulnerable than other psychological therapy modalities to compete in the current reality of ‘consumer’‐led public mental health, which, in turn reflects a profoundly changed social context from that to which psychoanalysis traces its roots. Unless psychoanalytic clinicians recognize and find ways to adjust to this context they will jeopardize the survival of psychoanalytic psychotherapy in an increasingly market‐orientated model of mental healthcare provision in the public sector, eager to promote more ‘consumer friendly’ psychological therapy models.