The Politics of the Family

I’d just like to draw attention to a comment made by Cockroach Catcher in a previous post, in which he says of his background in child psychiatry:

At least a third of the children we saw were not the real patients.

I’m currently a CPN operating out of an outpatient clinic for Child and Adolescent Mental Health Services (CAMHS). Cockroach Catcher’s comment intrigued me, so I decided to do a bit of a straw poll of 15 kids seen in our clinic over the past couple of weeks. For these 15 kids, I asked myself, “Who’s the real patient?”

Of the 15 kids, five of them have no identifiable mental health problem. Bang on Cockroach Catcher’s estimate of a third. Sometimes those in this category are the children of parents who have a mental health problem. They go to the GP saying their child has a problem and the GP refers them to us, where it quickly becomes obvious that it’s actually to do with the parent’s issues. Technically it’s not part of our role to support mentally ill people to raise their kids, but we usually wind up doing something anyway, whether it be offering some parenting support, giving the kid a referral to a young carers project, or just giving a bit of basic advice and reassurance.

Also within this category comes parents who for whatever reason have become utterly convinced their child has a psychopathology when in fact they don’t. They’re here to tell us such gems as:

“Of course my son has ADHD! Why else would his behaviour be so atrocious?”

and

“My 8 year old avoids walking on the cracks in the pavement. That must mean he has Asperger’s Syndrome, right?”

and my personal favourite.

“My 14 year old boy seems to spend so much time in his bedroom. What do you think he’s doing in there?” (Erm, do you really want us to tell you?)

We do a bit of basic diagnostic work to reassure them. Sometimes this satisfies them. Sometimes it doesn’t.

Two of my 15 are what the ICD-10 would call a “conduct disorder”. I suspect Oldschoolbaby would call them something else. With both of these, it’s the parents for whom the behaviour is a problem (as in, it’s the parents who want the kid to change rather than the kid himself). The kids themselves would probably say they don’t have a problem so long as they get to give some cunt a good kicking.

Two are what are termed “school phobia” cases. I’m increasingly cynical about school phobia. Most of the kids tagged with this just strike me as very skilled at emotionally blackmailing their parents into letting them stay home from school. The most difficult thing with school phobia is dealing with the extent to which the child’s behaviour is so often reinforced by the parents’ beliefs. (”She’s just too afraid to go to school”).

Three are older teenagers in the 16-18 age bracket, experiencing problems with mood and deliberate self-harm. Because they’re older this is closer to adult psychiatry in that you’re dealing more with one individual rather than necessarily the entire family network, though in all three cases it was what went on in the family network that got them to where they are now. We’re doing some individual work with them until they either leave full-time education or turn 18, whichever happens first. Then they’ll no longer be eligible for a CAMHS service. I don’t foresee any of them getting a service from the CMHT when they do. They’ll be dismissed as either worried-well or, worse, as “another bloody PD”.

That leaves four that remain. These four do all have an identifiable psychopathology (eating disorder, depression, aspergers syndrome, ADHD). Even so, with all four except the one with ADHD the family dynamics cause as much headaches and take up at least as much of our time as the actual pathology.

This is why it’s sometimes said that working in child and adolescent mental health is like trying to herd cats.