Fortunate children and families in democratic, industrialized societies are healthier and intellectually better prepared than ever. Good prenatal care, immunizations, diet, treatment of diseases, schools with advanced courses, and stable family life is improving the health, life expectancy, and achievement of large groups of children and youth. At the same time, increasing numbers of children and families are facing grave and life-threatening risks that reduce potential and lead to emotional and intellectual dead-ends. Too often, the lucky children with access to health care, eduction and social supports are separated only by short geographical distances from those whose lives are burdened by multi-generational poverty, family dysfunction, and social trauma. More and more, in advanced nations, there are two societies living in close proximity—those who are educated and wealthy, and those who are increasingly alienated. This polarization is not only harmful to both groups of children, it threatens the security of society in their future.
IACAPAP is the international spokes-man for all children, from infants to young adults, and their families, as well as for the professions that serve them. Our special concern is with children who are vulnerable or already suffering from emotional, behavioral, and developmental disorders. Today, the theoretical orientation that guides our work emphasizes the multi-generational nature of developmental psychopathology—the transmission of biological and psychosocial vulnerability and protective factors from one generation to another, and the expression of strengths and impairments in specific communal contexts. For more than fifty years, IACAPAP has been engaged in disseminating advances in clinical and developmental knowledge, helping to supportprofessionalsand to train the next generation, encouraging the advancement of the scientific basis of child psychiatry and psychology, and promoting the welfare of children and families. The 14th International IACAPAP Congress in Stockholm in the summer of 1998 will continue this tradition. Focusing on the care of children by mental health clinicians, the Congress will describe new scientific knowledge and emerging mental health systems. The Congress will describe how the science and therapies of the future will draw upon the concepts and skills of many disciplines– including child psychiatry, psychology, pediatrics, epidemiology, public health, nursing, education and neuroscience. Working in collaboration with families and communities, the mental health clinician of the future will be armed with a broadening range of psychological and biological treatments and a widening scope of theory and concepts. The problems we face will remain very difficult, of course, but the work will become more intellectually challenging and hopefully more effective.
Left on their own, children and families mobilize their own modes of adaptation to stress and trauma; when they are successful, the child and parents can move ahead with new competence and with confidence. Failures in adaptation, however, set the stage for a child and parents to move further off the mainstream and along paths leading to increasing dysfunction.
The scientific study of children’s development, in the context of family and community, can help provide a rational, empiri- cally testable framework for effective intervention. Biological and behavioral methods already are becoming available to analyze the contributions of specific and general genetic and biological factors to the vulnerability for disorders, and the ways in which environmental adversity interacts with constitution in the emergence of specific conditions. This knowledge will increasingly help to pinpoint the sensitive moments for intervention– from gestation through each phase of development–and the precise blend of psychosocial, behavioral, and pharmacological treatments.
Clinicians need to know when to allow children to right themselves and how to provide well-timed, effective interventions when development becomes derailed. All our treatments must, of course, be humane and ethical; as we learn more, they must also be able to withstand rigorous, scientific examination for effectiveness, efficiency and replicability.
For children and families, strengths generally build upon strengths and risks are compounded by failures. Healthy babies in loving families acquire the preconditions for later achievement in school and community. Small, vulnerable, drug exposed infants who are raised in chaotic and dysfunctional families fail to thrive as infants and will be two or three years behind in language and social skills by the time they reach school, where they are likely to fail and drop out. Yet, not all vulnerable children in situations of danger become impaired. By studying children who move ahead, in spite of risk, we also can learn about inborn strengths, protective factors, and what helps children cope with adversity, as well as about luck.
Just as in other branches of public health, this knowledge of the normal tasks of development as well as the threats to individuals and groups provides a rational orientation for prevention and treatment. We already know that support at each phase of development and early detection of difficulties are far more caring and efficient–for the child, family, and broader society–than later attempts at remediation when things have gone badly for too long a time. However, no child or group should be written off. Even in situations of persistent and serious psychosocial adversity– such as the clinical situations that confront us when we deal with street children, abused children, children suffering from AIDS, and seriously delinquent children– communities and clinicians can offer opportunities and hope for self-righting and future achievement. Of course, as clinicians we have a special responsibility for the care and treatment of children and adults with the most severe developmental, emotional and behavioral disorders. For many of these children, our greatest contribution may be the advancement of knowledge that can fundamentally alter their prognoses.
There are good reasons for clinicians and researchers to emphasize the first years of life when behavioral and biological templates are being laid down. During the first years, children take in the care they are provided. They metabolize these experiences and make them a part of themselves. This process is both psychological and biological. Children’s experiences affect their feelings, thoughts, and the internal emotional portraits of their family. These experiences, we are now learning, also determine how the brain matures, the density of synaptic connections, and the relations among different parts of the brain. All future emotional and cognitive development is built upon these psychological and biological foundations.
The care of the children in loving families is ideally suited to fertilize and mold their emerging competencies. This care facilitates children’s intellectual and emotional development, their language and thinking, their sense of personal value and autonomy, and the depth of their inner lives. The cognitive and attentional abilities that emerge from the interactions between inborn endowment and experience prepare children to enter school and make use of what they are taught to acquire the formal academic skills that are necessary for success in technological societies. Yet, there is no single, magic phase of development. Children who have started well require continuing affection, stimulation, protection and education. Some children cope remarkably well with adversity and early strain to become productive, competent adults, especially if they are provided suitable care.
To an increasing degree, children’s opportunities for continuity of nurturance by parents and extended families are being eroded. Broad social changes are affecting families of all social classes. One century ago, in the U.S. and Europe, the average family had many children (seven in the U.S.), two parents, and a mother at home to care for the children; divorce was rare. Today, the situation is vastly different. In Europe and the U.S., the average family has two children, both parents work, and infants are placed in day care during the first year or two of life. With many children born out of wedlock and divorce rates of 50%, most children will live with only one parent sometime during childhood.
As families have become smaller and more mobile, many young families can no longer turn to their own parents for help and guidance. Increasingly, there must be social systems to support young families and intervene when there are problems. New models of intervention are available. They emphasize the importance of prevention, family support, and the availability of an integrated spectrum of community-based services for those with serious problems. These models draw upon collaborations among different disciplines and between professionals and parents. The future mental health professionals will require knowledge about these new systems and the skills to work with other professionals and with families and the community.
Child mental health professionals have been immersed in the lives of children in many contexts—in hospitals, clinics, schools, and in the consulting room. Each context calls upon expertise in the understanding of development, as well as new types of knowledge. To work in hospital settings and with severely disturbed children, mental health professionals will require knowledge of clinical neuroscience, genetics, pharmacology, and cognitive and behavioral strategies, while preserving their sense of the child’s inner experience and family relationships.
To work in the community will require greater understanding of systems and of the methods and goals of other professionals, such as teachers, probation officers, judges, police, and social service agencies. For those who work in the most high risk situations—the impact of urban violence and war, drugs and AIDS; abuse and neglect; child labor and sexual exploitation; and the impact of parental physical and psychiatric illness on children—a range of clinical, advocacy, and political skills are called upon, in addition to broad clinical knowledge.
IACAPAP has special commitments to the most threatened children, such as those who are caught in war and urban violence. Today, millions of children are refugees and live in camps or as undocumented aliens, often separated from their parents. Trauma-tized by war at home, they are then exposed to illness, danger, lack of schooling, and risks of exploitation. In this domain, IACAPAP has been an international spokesman for the rights of children as well as deeply immersed in supporting clinicians and organizations who are directly involved in providing care.
IACAPAP also has an important role in providing leaders in government and international organizations with authentic knowledge that comes from clinical work and from research. The daily, intimate engagement of clinicians with families and communities is a rich source of information about the state of children, of institutions that serve them, and of what is useful for treatment. We need specialists who can integrate all types of epidemiological, biological, and clinical knowledge and provide this information in ways that are useful for legislators who must make the final policy decisions about allocation of resources.
This domain has taken on increasing importance in relation to the future security of nations. Throughout the world, leaders are recognizing that a nation’s most critical natural resource are its children. In the United States, President and Mrs. Clinton convened a special working group in the White House to discuss brain and behavior in the first years of life; they, like other leaders, are increasingly concerned about the implications of new scientific knowledge for how society cares for and educates children. To succeed in the future, nations need to optimize the development of children—to launch them down paths that will lead to physical and emotional health and the capacity to deal with the tensions that are arising from the increased polarization within society between those who are prepared for modern society and those who are pushed further and further to the margins. This polarization will prove to be as great a threat to security as political dangers from without.
At the beginning of the twentieth century, child advocates and government leaders talked about this being the century of the child. At the end of the century, we can see that this has been a grim century indeed for children and nations. The work of IACAPAP is to help assure that mental health professions—child psychiatry, psychology, social work, nursing and the other allied professions—can contribute to knowledge and services that will offer more hope and optimism for the next decade and century.
Donald J. Cohen, M.D.President, IACAPAPDirector, Yale Child Study CenterNew Haven, CT USAemail: Donald.Cohen@Yale.Edu
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