Table Of ContentAdolescent and
Pre-Adolescent
Psychiatry
JOHN EVANS
The Young People's Unit
The Royal Edinburgh Hospital
Edinburgh, UK
1982
ACADEMIC PRESS London Toronto Sydney
GRUNE & STRATTON New York San Francisco
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Copyright © 1982 by ACADEMIC PRESS INC. (LONDON) LTD
All Rights Reserved - No part of this book may be reproduced in any form by photostat,
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British Library Cataloguing in Publication Data
Evans, John
Adolescent and pre-adolescent psychiatry
1. Adolescent psychiatry 2. Child psychiatry
I. Title
616.89Ό22 RJ503
ISBN (Academic Press) 0-12-791168-5
ISBN (Grune & Stratton) 0-8089-14731
LCCCN 81-71578
Text set in 10/12 pt Linotron 202 Times, printed and bound in Great Britain at
The Pitman Press, Bath
Preface
This book, based on my 25 years' experience in child and adolescent psychiatry services, is
designed to meet the needs of the community and a variety of referring agents. It consists of
observations, concepts, and treatment approaches derived from my clinical experience combined
with information from the relevant literature. It contains material I have found useful in lectures,
seminars, and individual supervision of trainees, whether they be psychiatrists, social workers,
psychologists, nurses or members of the teaching profession.
On the assumption that the majority of readers, whatever your practices, are dealing with
similar issues, this book is designed to be pragmatic, functional and relevant to the next case that
you have to deal with.
A textbook such as this could easily be a multi-author publication. Indeed, it would have the
advantage of containing more specialized knowledge in each particular subject. However, the
accompanying defects are a variety of styles and approaches, re-duplications and often omissions
of important fundamentals, and, therefore, I believe the advantage of a single author approach is
that the text becomes an interlocking whole. In this book there are numerous cross-references;
for example, the concepts described in the chapter devoted to normal personality functioning are
an essential background to the chapters on psychotherapy. Their presence simplifies the
presentation of the understanding and management of neurotic and personality disorders as well
as the borderline states. Again, the chapter on normal family functioning is an essential
background to the chapter on family therapy.
Being aware of the problems which I experienced in my own training, I have attempted to
present material so that it is of immediate clinical relevance to those who read it, and so that some
of the confusions are diminished, or at least shared. Particular attention has been paid to
presenting psychoanalytic concepts and ideas in as clear a manner as possible, and highlighting
their clinical relevance with brief illustrations. In the chapters dealing with treatment, I have
attempted to assist neophytes in tackling some of the difficulties that exist with greater
confidence, and to help them to realize that some of the problems encountered do not lie with
their relative inexperience, but in the task itself.
It is quite legitimate for a textbook concerned with young people and families to devote itself to
a review of the literature, together with critique. However, this approach is impersonal and
would have inhibited me from sharing with readers' ideas and solutions which I find applicable to
my work.
There are many outstanding monographs and scientific papers. Some enthusiastic trainees
vi Preface
tread the time-honoured path and read these historical statements and the subsequent amend-
ments and improvements. However, this task is a daunting one and, without guidance, the
neophyte can wade through important but exhausting research reports and emerge blinking into
the daylight of the ordinary world, clutching an accumulation of facts, but wanting in wisdom
(except perhaps for an awareness of the sophistication of the methodology or its lack).
Alternatively, others may succumb to an excess of psychoanalytic theory, be impressed with its
erudition, but fail to apply it to their immediate clinical work. There is an enormous gap between
psychoanalytic case reports describing successful treatment of highly suitable patients by highly
experienced therapists and what the average clinic does for the average patient. Reading about
ideal cases is always exhilarating, but they can leave the average clinician feeling simultaneously
confused and deskilled.
It is for the reader to decide whether this book fulfils the purpose that I set out to achieve,
which is to help the clinician in his day to day work, not only by providing knowledge about
particular conditions, but also about how to make the best use of the locally available resources.
In that sense it should be thought of as a cookery book which contains not only recipes, but also
solutions to culinary confusion. It aims at describing not only what is available and how results
can be achieved with adequate resources, but also what can be done when such resources are
limited, either within the patient or the clinic.
HOW TO USE THIS BOOK
The first chapter, Clinical Examination and Assessment, is intended to help trainees understand
in depth their purpose, and appreciate the number of factors that impinge, so that they may see
more clearly the gap between what is desirable (the ideal treatment) and what is possible, and,
therefore, how one has to adjust to the reality and make the most effective use of the resources
available. The second chapter is briefly concerned with diagnostic classifications.
The three chapters that follow are of central importance to this book. They are concerned with
normal personality and family functioning and form an essential background to the understand-
ing of disturbed young people, in the same way that physiology illuminates the understanding of
pathology and helps to define one's treatment goals. It is for that reason that repeated
cross-references are made linking normal personality with the abnormal functioning that is
described later.
They are followed by Chapters 6-13 which deal with the range of clinical disturbances and
diagnostic categories that is seen by child and adolescent psychiatrists.
The final section (Part III) comprises six chapters concerned with the range of treatments
available. It contains material which I wish I had known in my first fumbling years of work in this
field.
It is with some regret that there is no summary of Piaget's developmental theories or the work
of other developmental psychologists, such as Bandura. Neither is there a chapter on behaviour
therapy. The reason is that to present such material so that it was integrated with the rest of this
textbook would have led to a further delay in publication.
In contrast, a chapter on residential treatment was written and re-written as befitting its
importance. Eventually, realizing that the style required to make such a contribution interesting
and effective clashed with the style of the other chapters, I decided that it should be published
separately.
vi Preface
tread the time-honoured path and read these historical statements and the subsequent amend-
ments and improvements. However, this task is a daunting one and, without guidance, the
neophyte can wade through important but exhausting research reports and emerge blinking into
the daylight of the ordinary world, clutching an accumulation of facts, but wanting in wisdom
(except perhaps for an awareness of the sophistication of the methodology or its lack).
Alternatively, others may succumb to an excess of psychoanalytic theory, be impressed with its
erudition, but fail to apply it to their immediate clinical work. There is an enormous gap between
psychoanalytic case reports describing successful treatment of highly suitable patients by highly
experienced therapists and what the average clinic does for the average patient. Reading about
ideal cases is always exhilarating, but they can leave the average clinician feeling simultaneously
confused and deskilled.
It is for the reader to decide whether this book fulfils the purpose that I set out to achieve,
which is to help the clinician in his day to day work, not only by providing knowledge about
particular conditions, but also about how to make the best use of the locally available resources.
In that sense it should be thought of as a cookery book which contains not only recipes, but also
solutions to culinary confusion. It aims at describing not only what is available and how results
can be achieved with adequate resources, but also what can be done when such resources are
limited, either within the patient or the clinic.
HOW TO USE THIS BOOK
The first chapter, Clinical Examination and Assessment, is intended to help trainees understand
in depth their purpose, and appreciate the number of factors that impinge, so that they may see
more clearly the gap between what is desirable (the ideal treatment) and what is possible, and,
therefore, how one has to adjust to the reality and make the most effective use of the resources
available. The second chapter is briefly concerned with diagnostic classifications.
The three chapters that follow are of central importance to this book. They are concerned with
normal personality and family functioning and form an essential background to the understand-
ing of disturbed young people, in the same way that physiology illuminates the understanding of
pathology and helps to define one's treatment goals. It is for that reason that repeated
cross-references are made linking normal personality with the abnormal functioning that is
described later.
They are followed by Chapters 6-13 which deal with the range of clinical disturbances and
diagnostic categories that is seen by child and adolescent psychiatrists.
The final section (Part III) comprises six chapters concerned with the range of treatments
available. It contains material which I wish I had known in my first fumbling years of work in this
field.
It is with some regret that there is no summary of Piaget's developmental theories or the work
of other developmental psychologists, such as Bandura. Neither is there a chapter on behaviour
therapy. The reason is that to present such material so that it was integrated with the rest of this
textbook would have led to a further delay in publication.
In contrast, a chapter on residential treatment was written and re-written as befitting its
importance. Eventually, realizing that the style required to make such a contribution interesting
and effective clashed with the style of the other chapters, I decided that it should be published
separately.
Preface vü
All that remains to be said of the contents, is that in the traditional manner, all names of
patients have been changed to avoid recognition.
In conclusion, what attitude do I hope that readers will adopt towards this book? The
statement made by Tom Main in his superb paper Knowledge, Learning and Freedom from
Thought (1967)* cannot be bettered.
Some people have a tendency to value knowledge for its authority, rather than for its usefulness in
thinking, and it is difficult—perhaps impossible—to create [a book] which will enable
them to use ideas rather than be used by them. Certain trainees seek in knowledge a system of
law-giving, a guide about what they are allowed to think. They install knowledge, concepts, theories
and techniques in the morality areas of the mind rather as regulating parents, and not as co-equal
friends available for ego work.
This book has been designed to function as a companion, to help trainees tackle the problems
which disturbed youngsters and families present. The ideas put forward are to be used as
facilitating agents. Should they become so dominant that they control the trainee's thinking, then
this book has failed in its purpose. It is intended to encourage growth.
August 1982
John Evans
Edinburgh
* Main, T. F. (1967). Aust. N.Z. J. Psychiat. 1, No. 2 (June), 64.
Acknowledgements
I welcome the opportunity to thank colleagues and friends who have helped me to organize my
thoughts into a book.
First, I would like to acknowledge those who taught me when I was younger and have left a
lasting influence on me. In the field of medicine, Professor Harold Scarborough, in Cardiff,
taught me that it is possible to take effective action when all the relevant facts are lacking, if one
maintains an open mind and continues to check on the effect of those decisions. It was the late Dr
William Philips who showed how compassion and warmth towards patients can be employed
without sacrificing a high standard of clinical competence.
In London, Dr Leslie Hilliard showed me that a clinical preoccupation with the physical and
psychological abnormalities of the mentally handicapped is of limited value compared with
ensuring that they are helped to obtain adequate education, employment and support, so that
they can function in the community.
Of those who taught me and directly influenced my current psychiatric practice I wish to thank
especially Dr John Bowlby for the clarity of his thinking and the quality of his conceptualization.
I would also like to thank Mrs Elizabeth Irvine, former head social worker of the Children's
Department of the Tavistock Clinic. Although she claims she taught me nothing, although she
tried—for I insisted on learning it all myself—I still disagree with her.
Next I must thank Dr Tom Main who allowed me to develop an adolescent unit in the Cassel
Hospital and thereby laid the foundation for my later work. The excitement that his ideas
produced continues.
My psychoanalytic training was the keystone to my personal development and present work. In
this context my analyst, Pearl King was of central importance as she enabled the fragments to
come together so that I could become what I am. The late Donald Winnicott also encouraged and
stimulated me, not only with his original ideas, but in his supervision of my analytic work he
actually had more respect for my skills and thoughts than I had. His capacity to see positives
within me when I was more in contact with the reverse was of enormous support.
In Edinburgh I have obtained a more subdued, but equally important support from Morris
Carstairs, former Professor of Psychiatry, and Dr James Affleck.
I believe that in the chapters of this book I have acknowledged the sources of particular ideas.
However, it is here that I must thank those who have read chapters of this textbook and made
useful comments and criticisms. In particular, I wish to acknowledge the help that I have received
X Acknowledgements
from Peter Brüggen, Marion Mackenzie, David Will, Rusty Framrose, Terry Bruce, Dorothy
Fiddes and others.
It must be said that this book could have been completed without the help of my secretary, Mrs
Margaret Brown, but it would have taken longer, the style would have been poorer, the fun and
sense of satisfaction would have been less, and the intermittent exhaustion greater.
Finally I wish to acknowledge the way in which my wife and my children have tolerated the
long hours spent on this book and continued to recognize me as a member of the family and not
mistake me for a stranger.
chapter 1
Clinical Examination
and Assessment
INTRODUCTION
The purpose of this chapter is to describe in detail the process of examination so that a
competent assessment can take place, which, in turn, allows the most appropriate and effective
action to follow. Whether a neophyte or a respected elder, all practitioners are expected to assess
the youngster's problems in an effective manner, for this is justly regarded as the key to treatment
procedures. However, examination and treatment procedures are influenced by a number of
extraneous factors which are not always fully appreciated. Their importance is such that they
merit discussion in depth. They include factors such as the expectations of the various
participants, the age of the youngster, and the factors that influence decision-taking as well as the
purpose of the assessment.
In the ensuing presentation the assessment of the youngster, as opposed to the assessment of
the parent-child interaction or family dynamics, will receive priority, as this is in accord with
common practice. However, it is doubtful if any clinic routinely assesses a child completely, that
is noting the phenomenological aspects, their psychodynamic components together with a full
neurological and psychological investigation. In practice, clinics concentrate on one or two
dimensions as a routine, depending on the aims of the service, the facilities available and the
pressures of the waiting list.
For the beginner some confusion is avoided by realizing that there are two fundamentally
different approaches to assessment procedures, the first being the clinical/descriptive approach
and the other being the genetic/dynamic aproach of the Freudian school. In theory, the two
approaches are not mutually exclusive. Indeed, most psychiatrists would claim that they are
eclectic. However, the intellectual effort of using two different conceptual approaches simul-
taneously is such that psychiatrists use predominantly one framework or another. In practice, the
clinical/descriptive approach is more valuable with organic and psychotic syndromes, while the
genetic/dynamic approach is of more value with neurotic and personality disorders and crisis
situations.
We will begin by exploring some extraneous factors that impinge on assessment and
examination procedures, as they have a considerable bearing on the outcome.
4 Adolescent and Pre-Adolescent Psychiatry
EXTRANEOUS FACTORS THAT INFLUENCE ASSESSMENT
Textbook accounts of assessment procedures suggest a standard procedure for examination.
Observation, however, shows considerable variation from one clinic to another, variations in the
clinic staff and in the practice of individual examiners. Furthermore, the assessment of a
disturbed child is influenced by many extraneous factors which merit attention as they affect the
outcome. This section explores these extraneous factors. Because of their complexity, they will
be presented under four headings: the expectations of the various participants, the influence of
the age of the youngster, the general problems of style of assessment of psychiatric cases and
variables in decision-taking which arise from the assessment.
Expectations of the Participants
If one asks how useful a particular assessment is, the answer may differ according to whether
one asks the referring agent, the examiner, the youngster or his parents. Although the desired
outcome is an assessment which satisfies all participants, in practice this may not be possible. But
one should at least be aware that the dimension exists. Any failures stem from the different
expectations of the participants involved in the assessment procedures, and it is useful to examine
these expectations.
Referring agent
A number of agencies request assessments of disturbed youngsters and have differing
expectations. Thus, the desire of many psychiatric colleagues who refer cases is that they
completely relinquish control. More rarely they seek advice on the ongoing management of such
cases. The expectations of medical practitioners are more diverse and they are not often spelled
out. With minor cases advice may be sought and perhaps a recommendation or an appropriate
prescription of drugs. With the more difficult cases, many justifiably expect assessment which
allows the psychiatric team to take over and provide effective management. Some medical
practitioners wish to be effective members of that treatment team but others have no such
interest.
A number of requests for assessment come from residential units. The reason for referral is the
institution's inability to handle such youngsters. It may wish for him to be transferred to another
unit but, most frequently, it is seeking help with ongoing management.
The expectations of the social service agencies vary considerably due to the complexity of the
problems they often have to face. Indeed it is often useful to inquire specifically what help they
are seeking before the assessment is made; that is, the better defined the questions, the more
relevant will be the answers.
A referral from Court comes with the expectation that information and an opinion will be
provided that will enable the Court to make up its own mind about disposal. Therefore an
essential element in the assessment will be to decide whether future management and
responsibility should be with a psychiatric agency or otherwise, and whether it is the former who
will furnish the care.
Finally, a request for an assessment by solicitors is always on behalf of the clients they
represent, and any assessment provided will be used in Court for that purpose, however impartial
the psychiatrist. In the case of criminal offences, the reports are used where possible to procure
their client's acquittal, even if it is not always beneficial to the youngster in the long term. In cases
of parental dispute over custody of the children, solicitors must represent their own client, usually
