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Submission to the Joint Standing Committee on Treaties Inquiry into the Status of the United Nations Convention on the Rights of the Child.

August 1997

No 7 - The adequacy of programmes and services of special importance to Children

The rights of the child must include those of emotional well being, or health and if this is not present, for whatever reason, then these children have an inalienable right to have available to them the treatment that will most effectively benefit them.

Emotional difficulties in a child can impede normal developmental processes and we know from clinical experience, as well as research, that many emotional and psychiatric problems in adulthood have their origins in childhood. A troubled child rarely tells us he is sad, depressed or worried. An anxious child may present with frequent stomach aches or headaches, wet the bed, appear hyperactive. A child who is depressed may be unable to play or demonstrate behaviour problems, show school failure and learning difficulties, anti-social behaviour or aggressiveness with friends or family and is sometimes at risk for suicide. Many adolescents who take drugs are trying not to feel their depression or despair. Some troubled children withdraw into their own world of fantasy.

Children do not just grow out of significant emotional difficulties. If left untreated, their development is impeded, with significant consequences for their family, school and social relationships, their ability to play and work and the problems are often carried forward to their adult life with implications for the next generation as they become parents. Apart from the emotional cost, it is difficult to treat troubled children and to repair the emotional and often physical damage they inflict on themselves, society and their families.

Modern neuroanatomical and developmental research (Daniel Stern 1985) has confirmed that experience, in the first three years of life, is the architect of the brain. Children who are emotionally deprived or cannot play develop brains that are 20% to 30% smaller than normal for their age and one of the most common causes of such deprivation is a mother who is significantly depressed for prolonged periods.

Troubled children can be vulnerable children who are reacting to the strains of their developmental tasks or to traumas in their life, or the strains in a child's life may be so significant that even a resilient or robust child may show emotional problems. Such traumas may be death in a family, divorce, environmental disasters, emotional neglect and physical and sexual abuse.

Traumatic events for children often are made worse by lack of opportunity to make stable and secure emotional bonds to a parent or parent substitute in early childhood, or when these bonds are prematurely disrupted by death, separations, illness or abuse.

Which then brings us to the point, how do we best help our troubled children, those with emotional and behavioural problems?

Clinical experience is now backed up by research studies which tell us that anti-depressant medication is not very effective in childhood. Likewise, as more and more stimulant medication is being used to treat a whole range of child behaviour problems, more and more parents and clinicians are becoming aware of the very limited effectiveness of trying to dampen a symptom of a child's anxiety, which ADHD often is, without trying to treat the cause of the anxiety.

To quote Professor Robert Adler (2) "To this day, psychoanalytic psychotherapy remains the most valued form of treatment in many child psychiatric settings". Part of the treatment involves working with parents or guardians to ensure than an overall approach to the problems is taken. It is different to family therapy in that a child's symptoms and troubling behaviour are understood as unconscious communications of some underlying difficulties. This therapy is a working relationship in the context of a predictable setting and regular, frequent sessions, where the individual child or adolescent (or parent/guardian) work together with the therapist. The difficulties that troubled children and adolescents experience often begin in infancy or early childhood and influence their functioning in the present. These experiences are re-enacted in the therapy through the expression of unconscious fantasies and fears, in verbal and non-verbal ways and through a child's play. The observation, understanding and interpretation of the child's communications are part of the unique nature of the therapeutic relationship and involves skills and techniques and theoretical understanding obtained from specialised training. This therapeutic relationship is very different to counselling or talking to a friend. Problems such as conflict, disturbed relationships or behaviours, school refusal, eating problems, unhappiness etc etc are related to the inner world as well as to external events, to unconscious as well as conscious experiences and to the interaction between them. Studies have also shown that psychoanalytic psychotherapy can have profound beneficial effects on serious childhood medical conditions, eg diabetes. Children who are placed in foster care and whose placement breaks down because of their disturbance can often be stabilised when treated with psychoanalytic psychotherapy.

The treatment may be required more than once a week to be most effective.

This treatment, often the only effective treatment for many problems seen in childhood and often necessary to achieve lasting changes, can rarely be obtained in the public health system. Unless parents or guardians are wealthy, they rely on Medicare funding to pay for psychotherapy. This has virtually become an impossibility with the changes to Medicare funding.

Item 319 is impossible to apply to children as the diagnostic category of "Borderline" is for practical purposes not used in childhood, and rightly so. The criteria of having sustained sexual or physical abuse eliminates many or most of the disturbed children we see and it is anti-therapeutic to expect children to have to undergo previous treatment before they have what helps them. The GAF scale as specified to use item 319 is totally inappropriate as it is vital, if possible, to treat children as early as one can before serious symptoms or serious impairment becomes entrenched. There is in fact no provision for children under the new funding arrangement and this contravenes the UN Convention on the Rights of the Child. Children are no longer able to be treated in the only way that helps many of them. Once a week treatment is often less than optimal.

The new Medicare treatment arrangement is discriminatory against children in another way and contravenes their rights when we are no longer able to treat depressed mothers in psychotherapy at an adequate frequency that will help them. There is an abundance of research material on the adverse effects of maternal depression on the developing infant. These infants of depressed mothers are both cognitively and emotionally disadvantaged. There is no provision to be able to give effective psychotherapy or psychoanalysis to these mothers since the Budget in 1996, despite the very serious implications to their children of not doing so. These women often do not respond to anti-depressant medication, even if breastfeeding didn't preclude them taking it, nor to the cognitive therapies. There are often strong unconscious forces acting in the postpartum period which contribute to the depression. This is a vital and often effective time to treat these people.

References:

1. Time Magazine February 3 1997
2. RANZCP - Bulletin of the Faculty of Child Psychiatry, May 1993
3. Marans S "Psychoanalytic Psychotherapy with Children": Current research Trends and Challenges. Journal American Academy Child and Adolescent Psychiatry 1989; 28: 669-674.
4. Information booklet of the Victorian Association of Child Psychotherapists "Won't They Grow Out of It?".

 

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