Therapeutic intervention presupposes a framework of care and order in the child's life. Only when there is a stable home, providing affection, continuity of care and some basic social standards can a psychotherapeutic approach alone be helpful.
For a totally rejected child, for a neglected child from a family in which social standards are grossly lacking, or for a child who has lost his family and is being cared for under conditions in which he has no parent figures at all, psychotherapy as such is not appropriate. What such children need more than anything else is an adult who will assume parental responsibility. They do not need a doctor, they need a parent. But, because of their past deprivations and experiences of stress, such children need a very special kind of parent. They need a person or group of people who will guarantee unconditional affection and support, who are prepared to forego, often for many years, the satisfactions that parents normally get from their children and who will bring to their task professional understanding not only of childhood behaviour but of their own responses both to the children in their care and to the parents whose inadequacies have brought the children to this plight.
These are enormous demands and it is not surprising that the care of deprived and delinquent children in our society is often at variance with the treatment principles and techniques recommended by professional experts such as psychiatrists educationalists and social workers. While neurotic children on the whole get competent treatment based on professionally accepted principles, the same is not generally true for deprived and delinquent children.
1. The deprived child
Psychiatrists are often consulted about children in foster care, in children's homes and in various special residential schools. Some of these children have behind them prolonged periods of maternal deprivation in infancy; many were reared by uniformed nurses in institutions governed by strict routines; many have experienced a series of separations from people to whom successively they had become attached. Such children present very special problems. Not only are they poor at forming relationships with others, not only are their capacities to express themselves in words limited and their ideas about the world in general immature for their age, they usually display marked behaviour disorders too. Aggressive outbursts, bed-wetting, soiling, stealing and running away are common among all children who find their way into foster homes or residential care. Grossly deprived children in addition often show obsessional patterns of behaviour. They may be compulsive masturbators; they may be obsessionally preoccupied with sexual topics and swear words; they may be fascinated by keys and locks; they may be fire-setters.
The basic need of such children is to have a permanent home, yet their symptoms, distressing enough in themselves, often make them quite unacceptable to foster parents and even to some children's homes. In this situation psychiatric help must be directed both to the home and to the child. Foster parents and house-parents require at least as much professional help as ordinary parents do. But the children themselves can often benefit from individual psychotherapeutic treatment. Lavery and Stone have stressed that grossly deprived children respond best when they are not required to enter into a close one-to-one relationship with the therapist all at once. The fear of yet another broken relationship prevents such children from coming close to their doctor and every approach from the other person evokes anxiety and retreat. In a less intensely emotional situation, for example in a play group with other children, the deprived child may more readily be able to make his initial contact with his therapist. For substitute parent and therapist alike it is important to let the child decide how much he can trust the adult and how much of himself it is safe to reveal. Given a stable substitute home, able to tolerate the child's disturbed behaviour and not make excessive demands on him, deprived children can make considerable gains in personality development.
Often quite old children who have at last found a permanent home need to retrace their development steps, adopting for example at eight or nine years of age infantile dependent forms of behaviour. Psychological treatment aims to help the substitute parents recognize this behaviour as an attempt at self-cure, as a recapitulation of an earlier stage of development that failed to provide satisfactory experiences. Sometimes parent surrogates can then with support supply the needed satisfactions for the child; sometimes the psychotherapist is able in his treatment sessions with the child to provide the intense infantile satisfactions he craves, nursing him for example like a baby, feeding him from a bottle, making no demands on him at all. Such needs for infantile gratifications, if fulfilled, are gradually outgrown by the child. Oral behaviour may be followed by an anal stage, pleasure in messing and in testing out capacities for destruction, or by genital stage activities.
In summary, psychological treatment with such children has two aims: (1) to provide them in the present with experiences they have missed out in the past, and (2) to allow them to correct their distrust of human relationships.
It is less a matter of interpretation, of undoing defence mechanisms, than of providing stable supplies which the child can use to make good the gaps in his personality. This process takes many years. The main agents in treatment are, of course, the substitute parents and the psychiatrist’s chief functions are to help them in their task and to supply directly for the child those experiences his particular substitute parents are unable to provide.
Next month: Treatment of the Delinquent Child.
These are two brief extracts from Wolff, S. (1973) Children under stress (Pelican Books)