Learning our lessons. Some issues arising from delivering mental health services in school settings

This paper describes some of the complexity of providing Child and Adolescent Mental Health Services (CAMHS) input into school settings. Some reference is made to previous writing about psychotherapeutic work with schools, and also to recent government policy changes which are impacting on service delivery. There is discussion of the multiple levels at which interventions need to be conceptualized, and the issues arising when working within systems and organizations that have very different drivers, tasks, aims and cultures. It is argued that, given the complexity of the therapeutic task, clinicians need a high level of experience and robustness, and to be armed with understanding gleaned not just from individual psychoanalytic psychotherapy but also from psychoanalytic thinking about organizations, as well as about therapeutic communities, in order to function effectively. There is discussion of some of the typical institutional defences against anxiety and distress that arise when working with the most complex children and families in schools, and in particular the pressure to locate problems within individuals and to attempt to address such issues on an individual basis while leaving the institutional and systemic issues unaddressed. I suggest that such work demands a complex view of the role of the therapist, which includes taking on a role which has some similarities to working in therapeutic communities. Some vignettes are used to illustrate how one can do effective and useful clinical work with individual children, and with their families when wider systemic issues are taken seriously

Containing not blaming

The article presents a reprint of the article "Children and Young People," by Graham Music, which appeared in the June 2009 issue of 'Counselling Children and Young People'. The article was based on the author's experience of delivering therapeutic services in schools in London, England. It described a philosophy of how therapeutic interventions in schools can best be approached

Evolutionary perspectives on neurodevelopmental disorders

We discuss evolutionary perspectives on two neurodevelopmental disorders: attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Both have a genetic background, and we explore why these genes may have survived the process of natural selection. We draw on the concept of evolutionary mismatch, in which a trait that may have conferred advantages in the past can become disadvantageous when the environment changes. We also describe the non-genetic influences on these conditions. We point out that children with neurodevelopmental conditions are more likely to suffer maltreatment, so it is important to consider both the genes and the environment in which children have grown up. In hunter-gatherer societies, ADHD may have favoured risk-taking, which may explain why it has survived. The contemporary model of schooling, in which children are expected to sit still for many hours a day, does not favour this. Understanding ADHD in terms of an evolutionary mismatch therefore raises ethical issues regarding both medication and the school environment. ASDs are far more heterogeneous and are characterised by high heritability and low reproductive success. At the severe end of the spectrum, ASD is highly disadvantageous and often co-occurs with intellectual disability. On the other hand, high-functioning ASD may have been adaptive in our evolutionary past in terms of the potential for the development of specialist skills and can still be so today in the right environment

How evolution can help us understand child development and behaviour

The traditional disease model, still dominant in psychiatry, is less than ideal for making sense of psychological issues such as the effects of early childhood experiences on development. We argue that a model based on evolutionary thinking can deepen understanding and aid clinical practice by showing how behaviours, bodily responses and psychological beliefs tend to develop for ‘adaptive’ reasons, even when these ways of being might on first appearance seem pathological. Such understanding has implications for treatment. It also challenges the genetic determinist model, by showing that developmental pathways have evolved to be responsive to the physical and social environment in which the individual matures. Thought can now be given to how biological or psychological treatments – and changing a child’s environment – can foster well-being. Evolutionary thinking has major implications for how we think about psychopathology and for targeting the optimum sites, levels and timings for intervention

Strengthening field-based training in low and middle-income countries to build public health capacity: Lessons from Australia's Master of Applied Epidemiology program

BACKGROUND: The International Health Regulations (2005) and the emergence and global spread of infectious diseases have triggered a re-assessment of how rich countries should support capacity development for communicable disease control in low and medium income countries (LMIC). In LMIC, three types of public health training have been tried: the university-based model; streamed training for specialised workers; and field-based programs. The first has low rates of production and teaching may not always be based on the needs and priorities of the host country. The second model is efficient, but does not accord the workers sufficient status to enable them to impact on policy. The third has the most potential as a capacity development measure for LMIC, but in practice faces challenges which may limit its ability to promote capacity development. DISCUSSION: We describe Australia's first Master of Applied Epidemiology (MAE) model (established in 1991), which uses field-based training to strengthen the control of communicable diseases. A central attribute of this model is the way it partners and complements health department initiatives to enhance workforce skills, health system performance and the evidence-base for policies, programs and practice. SUMMARY: The MAE experience throws light on ways Australia could collaborate in regional capacity development initiatives. Key needs are a shared vision for a regional approach to integrate training with initiatives that strengthen service and research, and the pooling of human, financial and technical resources. We focus on communicable diseases, but our findings and recommendations are generalisable to other areas of public health