Bringing child mental health into “mutual focus”

David Taylor, Professor Emeritus, Child Psychiatry
University of Manchester, England

“The botanist, the forester, the artist, and the carpenter do not see the same tree.”

Our professional reputations, the possibility of good practice, the chances for successful research, the propagation and the influence of our ideas, our whole career in effect, depends upon the work situation we create, or choose to join.

Creating a work situation and ambience that attracts people with good ideas is, in itself, a challenge, and to create a great and enduring one is a mark of genius.  Dan Offord was such a genius.  He arrived at McMaster University in the year of my first sabbatical here in 1978-79.

I was here at the original instigation of Angus McMillan later enabled by Nate Epstein.  My task was to “Do some Developmental Medicine!”, the subject in which I had been appointed the sole (ever) National Health Service Consultant in Developmental Medicine.

There is a journal of Developmental Medicine and Child Neurology.  People know what Child Neurology is; but Developmental Medicine was (and is) an enigma.  I thought it was a good euphemism for the study and care of several of the sad outcomes of having children.  A child’s development had been deviated and limited in ways that affected its behaviour.  My task was to parcel out the nature of the deviation and suggest remedies.

As a guest, my situation was as perilous as my subject was anomalous. I was to join with the paediatric neurology teams at Chedoke and the general paediatric teams at McMaster and also to participate in the Child Psychiatry programme that was then dominated by a Family Therapy approach.  The danger, in each situation, was to seem either an ignoramus or a smart aleck. 

My “super” specialty was the psychiatric aspects of epilepsy.  My impression, in that year, was to see strong teams struggling with similar problems sometimes accidentally referred to one rather than another location.  Although much effort went into trying to create syntheses, each of us tended to be limited by our perspective.  As Martii Sirala put it, “The botanist, the forester, the artist, and the carpenter do not see the same tree”. 

I saw that it was possible to concentrate too much on the physical substrate, or on the pathological changes, or on their expression through the symptoms, or on the situation that might have given rise to the problem and might be part of its continuing, without meaningful communication and connection between those varying points of view.

In consequence of my experiences that year I wrote a Lancet article on “The Components of Sickness: Disease, Illness, and Predicament” later expanded in “One Child”.  This was philosophy of medicine; ‘Things’ were conceptually different from ‘Sensations’ and both were different from ‘States of affairs’ or ‘Situations’.  Disease is about things, tangibles with which medical training is much occupied and which we consequently so much value.  Illness is about sensations and roles, as well as changes in physiology.  Predicaments are about how we are placed in the world, how we are understood, what has happened and is happening to us.  Each of these requires expertise and that requires research.

I argued, in a recent paper, that child mental health could not be addressed solely by putting a cadre of assorted mental health professionals on to it.  The wellbeing of children requires a society that values them equally and a political will that enables them to maximize their potential while realizing that we are not equally gifted.  Schools are in chaos because there are too many children who are opposed to the whole concept of learning and the discipline that requires.  They graduate to the low paid jobs, or the streets, or the prisons.  They are forming an “underclass,” an alternative to the society to which we think we belong.  I am reminded of the shock it was to the authorities, in 1914 and again in 1939, to find out how many young men there were who were not fit, even to die for their country.  They called them “The Lost Battalions”; “Divisions” more like.

Total fertility rates in most ‘Western’ societies are below the population maintenance rates. Mothers are older and relatively inexperienced.  Parental couples both expect to work.  To produce viable offspring who are both autonomous and safe to be with is a problem to us as it was to the parents of Oedipus.  We have countries where the leading cause of death of young people is homicide with the various consequences of self endangerment coming close behind; physical illnesses are well in the rear.

So, nowadays, in the matter of the “seeing of trees” we need to employ botanists and foresters, artist and carpenters and probably finishers and polishers and designers, too.  Not only that but we need them to have a mutual focus and to be able to communicate as between themselves and to the outside world, the world that will fund their enterprises if they understand them.  We need, in effect, The University, scholars “associated together as a society”.