Box 7.

1: Challenges at different stages of the life cycle

Birth and infancy Parents must make space in their relationship for new individuals, develop a new
co-operative relationship to cope with child-rearing, and realign with the extended family, particularly
grandparents

First school The main caregiver and the child have to cope with separation, the child has to
develop social relationships, and both child and parent have to cope with being compared with other
children and parents

Adolescence Both parents and offspring have to balance freedom and dependence, the
adolescent has to develop a sense of identity (in opposition as well as in alignment to parents), the
parents may have to cope with career changes and changes in their relationship, and possibly having to
look after their elderly parents

Leaving home Young people have to cope with the demands of higher education or getting a job
and finding somewhere to live, and they need to develop more of an adult-to-adult relationship with
their parents. Parents have to cope with being alone again, possible work-role, financial or physio- logical
decline, and perhaps becoming grandparents themselves

Cohabiting Young people have to form a co-operative relationship between two people, deal
together with financial needs and household tasks, and realign relationships with friends and family

Box 7.2: Practical applications of family therapy ideas in primary care

 For any illness, think about its function for the family, as well as its cause.
 Think about repeated patterns of interaction, rather than one person causing another’s
behaviour. For instance, a mother’s behaviour towards her difficult child will be as much effect
as cause.
 Does the parental subsystem need to be strengthened? If so, seeing both parents together may
be invaluable.
 Try to find opportunities to reframe things positively, while still paying attention to feelings. For
instance, of a teenager who is depressed after her grandmother’s death you could say ‘She’s
doing a good job of showing how sad you all are’.
 Try thinking about the power imbalances, subsystems and boundaries within the primary care
team. This can be particularly useful when you are caught in the trap of thinking that
interprofessional problems are due to personalities.

Attachment theory

John Bowlby (1907–1990), child psychiatrist and psychoanalyst, was the first to describe the importance
of attachment in human development. His interest in ethology (the study of animal behaviour) led to his
theory that human children, like young animals, have a need for a figure who provides a source of safety,
comfort and protection.
Bowlby’s early research focused on the effect of separation on young children in residential care and
hospital. In the 1940s and 1950s, parental visiting was extremely restricted and sometimes forbidden in
hospitals, because of the belief that contact with the parents would upset the child. Bowlby and two
other researchers, James and Joyce Robertson, filmed young children over periods of separation lasting
a week or more, and demonstrated that the children were highly distressed by the experience. (Such
research could not be conducted now, for ethical reasons.) The results may seem obvious today, but
they were revolutionary at the time. These researchers observed that during lengthy separations the
child went through three stages of response. First, he protested at the mother’s absence, usually by
crying. After a few days he became withdrawn, often refus- ing to eat or play, and seemed to despair.
After several more days, detachment set in, so that the child began to eat and play again and appeared
not to react if the mother returned. Before this stage, the child might react by clinging and being upset if
the mother returned. Bowlby’s legacy is summarised in Box 7.3.

Box 7.3: The main points of Bowlby’s theory of attachment

 Human beings have a need for attachment to specific others throughout the life cycle.
 During the second half of the first year of life, specific attachment behaviours develop,
namely clinging to and following of the attachment figure.
 Unwilling separation from an attachment figure leads to emotional distress.
 In young children this distress is manifested as protest, despair and detachment.
 Loss of an attachment figure in adults leads to a grief reaction, with shock and anger followed
by numbness and finally acceptance and reorganisation.

Box 7.4: Practical applications of attachment theory

Use your knowledge of families gleaned over time, and your observations of relating within the
consulting-room, to hazard a guess as to whether a child is securely or in- securely attached. The history
of response to separations may also provide you with a clue. Insecure attachment can be one risk
factor among many for a variety of child mental health problems.

Be aware of the attachments that your patients make to you. This is likely to be influenced by their
internal models of childhood attachment figures.

Be on the lookout for multiple pathology in ‘looked-after children’. These are children who are likely to
move from one carer to another, and may not be registered with one general practice for long. They are
likely to have had disrupted attachments, and they may have an attachment disorder.

Case study 7.1

William, by the age of ten years, had been in seven foster placements and had had one failed adoption.
He was brought to the general practitioner by the key worker at his children’s home. His behaviour was
proving challenging, and his social worker wanted him to have individual therapy. The general
practitioner referred him to the local child and adolescent mental health service.
After a long wait for an appointment, William and his key worker and social worker were seen jointly
by a psychologist and clinical nurse specialist. By this time, his class teacher was finding him a
disruptive influence in the classroom. The psychologist who saw him discovered the early care history
from the social worker. William’s father had left when he was born, his mother had neglected him, he
and his siblings had been adopted separately (he still had yearly contact with them), and his placements
had broken down partly because his behaviour was so challenging.

The psychologist and nurse made a diagnosis of attachment disorder and oppositional defiant disorder.
There were features of attention-deficit hyperactivity disorder at school, and the nurse arranged for the
clinic psychiatrist to prescribe a trial of stimulant medication, which was unsuccessful. The psychologist
said that she thought individual therapy would be inappropriate, as William would need to be in a
stable placement for this to work. The social worker was planning to find a long-term foster placement.

William’s school problems continued into secondary school. The psychologist identified specific learning
difficulties, and with the aid of extra special needs help in school, William was just able to avoid
exclusion. After a couple of introductions to potential foster carers, William stated that he would prefer
to stay in the children’s home, but with respite foster care for one weekend per month. This was
eventually arranged.

The psychologist then agreed to involve the clinic’s child psychotherapist. After four assessment
sessions, she agreed to see William for weekly individual therapy. He found it dif- ficult to express his
feelings in these sessions, and felt ashamed that he was having therapy while the other inmates of the
children’s home, mostly short-term residents, were not. After a few months it became clear that he was
becoming angry after holiday breaks, and must be developing an attachment to the therapist. After an
18-month period, he and the psycho- therapist agreed to end the sessions.

William remained in the same children’s home. By 14 years of age, he was finding the school
environment too challenging, and his social worker found him a place at a sixth- form college that had a
small unit for under-sixteens. His social worker was changed, but he and his psychologist subsequently
complained, and he was allowed to have the same social worker back. He had developed good
relationships with the staff at the children’s home, and kept in touch with some of the resident children
who had moved on. He was settled.

The court has to decide whether or not the child should be returned to his parents, or whether he
should be returned to some other family member, or whether alternative arrangements should be
made permanent. This may involve making a care order, which gives Social Services parental
responsibility until the child is 18 years of age, or freeing him for adoption. Experts are often involved in
advising the court on parenting capacity and the nature of the child’s difficulties – these are usually child
psychologists or child psychiatrists. There may be a phase of attempted rehabilitation, depending
partly on what the experts advise.
The relevance of all this to primary care

Children in the care system are likely to move from one placement to another, which means changing
general practitioners frequently. This makes it difficult for the general practitioner or health
visitor to get to know the child’s situation. Moreover, they are very dependent on the foster carer, who
may know even less than they will when they get the records. If the child is on a care order or interim
care order, it is necessary to talk to the social worker if possible, if only to agree that the foster carer can
make day-to-day decisions. If the child is accommodated, then it is necessary to talk to a parent, unless
you are shown written authority from the parent delegating day-to-day management to the foster carer.

If you refer a child anywhere, consent is needed from someone with parental re- sponsibility (only
one individual is necessary). A foster parent is not usually in a position to give consent.

Box 7.5: Practice points with regard to the care system

 If a child attends with a foster carer or children’s-home key worker:

- try to find out who has parental responsibility. At least one such person needs to be
informed of any health service involvement
- make sure that the social worker is aware of what is happening, even if they do not have
parental responsibility. They tend to resent not being informed (e.g. about a hospital
referral or an unusual choice of medication).
 It is worth trying to find out why the child is in care, although this may prove more difficult than
it sounds.