Sebastian Kraemer

The fragile male

The human male is, on most measures, more vulnerable than the female. Part of the explanation is the biological fragility of the male fetus, which is little understood and not widely known. A typical attitude to boys is that they are, or must be made, more resilient than girls. This adds “social insult to biological injury.” Culture and class make a difference to the health and survival of boys. The data presented here have implications for the clinical management of male patients as well as for the upbringing of boys. #### Summary points The disadvantages of the male are usually seen as socially mediated Even from conception, before social effects come into play, males are more vulnerable than females Social attitudes about the resilience of boys compound the biological deficit Male mortality is greater than female mortality throughout life The causes are a mixture of biological and social pressures: we need to be aware of both in order to promote better development and health for boys and men At conception there are more male than female embryos. This may be because the spermatozoa carrying the Y chromosome swim faster than those carrying X. The males pole position is, however, immediately challenged. External maternal stress around the time of conception is associated with a reduction in the male to female sex ratio, suggesting that the male embryo is more vulnerable than the female.1 From this point on it is downhill all the way. The male fetus is at greater risk of death or damage from almost all the obstetric catastrophes that can happen before birth.2 Perinatal brain damage,3 cerebral palsy,4 congenital deformities of the genitalia and limbs, premature birth, and stillbirth are commoner in boys,5 and by the time a boy is born he is on average developmentally some …

Something happens: elements of therapeutic change.

To make a difference therapists need a theory with which to understand the patient.1 They choose theories that suit them, and need technique to maintain the therapeutic setting. Psychotherapy developed from healing and medicine, and from our ethological heritage of care for dependants. It happens in a special setting which makes new experiences possible. In this article I list a number of ingredients that are necessary in any effective psychotherapy.

“The menace of psychiatry”: does it still ring a bell?

In 1931 a Chicago paediatrician Joseph Brenneman wrote “there is a menace in psychologizing the school child, psychiatrizing his behavior and overorganizing his habits and his play”.1 He attacked the psychologists of the day for interfering with the innocence of childhood. “What I do object to … is the unwarranted psychiatric injection of sex into child life”.2 Paediatricians could manage the problems of childhood without this kind of nonsense. A decade later the child psychiatrist Leo Kanner, who had already pioneered a joint clinic with a paediatrician at Johns Hopkins Hospital, noted that there was “a tendency to ridicule and resent any psychiatric offerings”.3 Citing Brenneman, later American psychiatrists4 5 have written about their relationship to paediatrics. The theme is familiar: paediatricians are frustrated — even irritated — by child psychiatrists, who seem to live in a world of their own, on a different timescale, speaking a mystifying language. Much has been learned since those days, on both sides of the Atlantic. The pioneering work of many paediatricians, psychiatrists, psychologists, psychotherapists, nurses and social workers has changed the landscape, yet the geology beneath still bears separate strata for medicine and mental health. Although ambivalence is now more muted, the marginalisation of mental health in hospital paediatrics continues into the present century. This is partly due to the fact that mental health provision for some paediatric departments remains uncoordinated, confusing or inaccessible. Even in London, where some richness of resources might be expected, only a minority of departments has a dedicated liaison service.6 Despite a strong desire from the vast majority of paediatricians for more, most of them have not had a satisfactory experience of it. This is a bind. Unless they have worked with responsive and effective liaison colleagues, paediatricians are in no position to …

“What is wrong with emotional upset?” – 50 years on from the Platt Report

James Spence deserves great credit for his work with mothers and babies and his contributions to our understanding of “the purpose of the family”,1 but he was not the first to recognise the need for mothers to nurse their own infants. Perhaps the most remarkable of his predecessors never seems to have received credit for his vision and common sense. James H Nicoll, Surgeon of the Western Infirmary and the Royal Hospital for Sick Children, Glasgow, gave a paper to the Section of Surgery of the 77th Annual Meeting of the British Medical Association in July 1909.2 Drawing on his experience of some 9000 operations on children, he advocated that whenever possible children under 2 years of age should be treated as outpatients. After operation without a mother, he said a child was “all over the bed” and “if splinted his crying and struggling put fresh strain on his sutures”. He concluded that the small child would “do best in their mother’s arms, and nest there more quietly on the whole, than anywhere else”. Perhaps more surprising to the contemporary reader, however, is Nicoll’s statement: > “for seven years I have had a small house, near the Glasgow Children’s Hospital, for the accommodation of young infants and their mothers. The mothers are catered for, and themselves nurse their infants. My experience of the cases so treated has been such as to make me confident in the opinion that no children’s hospital can be considered complete which has not, in the hospital or hard by, accommodation for a certain number of nursing mothers whose infants require operation”. During World War I at the instigation of Miss Geeta Rowell, recently returned to Newcastle from Italy, an anonymous donor purchased a house on West Parade in Newcastle and gave £500 to equip …

‘The dangers of this atmosphere’: a Quaker connection in the Tavistock Clinic’s development

During the Second World War, through innovations in officer selection and group therapy, the army psychiatrists John Rickman and Wilfred Bion changed our understanding of leadership. They showed how soldiers under stress could develop real authority through their attentiveness to each other. From contrasting experiences 25 years earlier each had seen how people in groups are moved by elemental forces that undermine judgement and thought. This article arose from my experiences as a trainee at the Tavistock Clinic, where the method of reflective work discussion, giving individuals seated in a circle the choice to speak or to remain silent, seemed similar to a Quaker meeting. Many decades later I found that this association had a basis in fact. Among other influences on Bion — a childhood in India, distinguished service in the First World War, and a surgical apprenticeship with Wilfred Trotter — there is a little-acknowledged Quaker source, in John Rickman, for Bion’s radical work in the army that led to new methods of training and organizational consultancy in the postwar Tavistock.

Who needs child and adolescent psychiatrists

Child psychiatry is a relatively new specialty. It is inevitably a hybrid, containing elements of its ancestors (and cousins) - paediatrics, psychiatry in asylums, care of the mentally retarded, psychoanalysis, psychology, psychiatric social work, remedial education and criminology (Parry-Jones, 1994, pp. 794-812). One of the privileges of our profession is that it is a ‘broad church’, reflecting the fact that, in spite of the immense scientific advances of recent decades, there is in most cases no ‘right’ way to work. This is a precious freedom but it is also a problem. There is no other medical specialty that contains such a range of views about the nature of our task, and how it is to be carried out. (Perhaps obstetricians come closest, in that they do argue quite fiercely about methods of delivery, but not so much about their primary task).

A tribute to the legacy of John Bowlby at the centenary of his birth.

This last issue of Attachment & Human Development of 2007 begins with a special section compiled to note with honour and gratitude the 100 anniversary of the birth of John Bowlby. This editorial is jointly authored by the three of us who planned and convened a daylong conference to discuss Bowlby’s legacy at his centenary. The meeting took place at the Tavistock Clinic, London, where John Bowlby was appointed Head of the Children’s Department in 1948, forerunner to the current Child and Family Department. The contributions to this special section come from people who had much direct contact with John Bowlby at the Tavistock Clinic, first as trainees and later as leaders in their domains of clinical work with children (Rustin) and couples (Clulow, 2001), and consulting with John Bowlby on matters of theory and research (Stevenson-Hinde). The conference chairs and presenters of the main papers, Howard Steele, Judith Trowell, and Peter Fonagy, had also worked with Bowlby. We include here an original paper from Richard Bowlby showing how he has applied his father’s theory to consult to and support those who provide care to children in non-parental day care setting. This special section also contains a probing interview with Robert Hinde about the pioneering ethological work he has pursued over more than 50 years, much of this period acting as a guide to and influence upon John Bowlby, just as Hinde was also influenced and supported by Bowlby. Starting from his first articulation of attachment theory, we briefly describe Bowlby’s revolutionary contribution to the understanding of parents’ influence upon their children’s mental health.

Institutional blind spot around mental health needs of paediatric patients

“In brief” cites the new Care Quality Commission (CQC) survey of children in hospital: “87% rated their overall experience as seven or above out of 10.”1 This gives a false impression. I hope a more detailed report from The BMJ will follow. In its report, the CQC states “Less than half (49% of parents …

Early intervention for first episode psychosis: paediatrics has a role too.

EDITOR—Shierss and Lesters review should have mentioned the role of acute paediatrics in picking up young people with …

Mental health: needs go beyond RCTs

www.thelancet.com Vol 385 May 9, 2015 1831 counted promptly and properly, as in Scotland. On RSS’s behalf, I wrote in February, 2015, to fi ve UK party leaders (and to Scotland’s First Minister): “Late registration of deaths is an affront to the statistical system in England and Wales; and seriously handicaps record-linkage studies, which fundamentally need to know—without delay (as in Scotland)—when deaths have occurred. If in government, will you please commit to legislating to end the late registration of deaths in England and Wales?” To date, with the exception of Scotland’s First Minister, none of the fi ve replied. In Scotland, fact-of-death is registered within eight days of death having been ascertained. National Record of Scotland knows for how many deaths the determined-cause is outstanding and for what proportion of deaths, in 2013 say, the waiting time for determined-cause has exceeded 91, 182, or 365 days. For England and Wales, ONS can answer neither question; nor can the Chief Coroner, although preliminary data suggest that the Coroners Court Reforms in mid-2013 may have halved the proportion of deaths that wait more than one year for determined-cause, which is welcome news for bereaved families but fails to fix a deathregistration system that is not-fi t-forpurpose for statistics or epidemiology. Late registration of deaths is age-related (see appendix); it is also cause-related. One in fi ve premature deaths (between 5–44 years) in England and Wales is not registered for at least six months. Half of all drugs-related deaths and suicides registered in England and Wales in 2014, will have occurred in years preceding 2014. Reporting these mortality statistics by registration-year seriously confounds calendar-year trends. As the ONS has been at pains to point out, reporting mortality statistics by registration-year, rather than by calendar-year of death, disguises rather than fi xes late registration of deaths. When research teams ask the ONS or Health and Social Care Information Centre about the survival-status of those whose data we are privileged to analyse, we are told about registereddeaths—not about all deaths in England and Wales that actually occurred prior to the analysis-date. In the N-ALIVE trial, we want to know about drugs-related deaths that occurred within 12 weeks of participants’ prison-release, essentially by 8 March 2015, but—due to late registration of deaths—we shall not know this for sure even by the end of 2016. Record-linkage studies have enormous potential but almost always require linkage to death registrations which, by being unfi t for purpose in England and Wales, undermines or delays their discovery potential. Will The Lancet readers and UK’s Farr Institute of Health Informatics Research lobby for this basic and inexpensive reform—for the dead to be promptly registered in England and Wales, and thus properly accounted for UK-wide, which matters not only for offi cial statistics but for the timeliness of record-linkage and randomised studies alike.