Dr Arnon Bentovim Hello, I am Arnon Bentovim,  a Child and Adolescent Psychiatrist and my   presentation will be on the evolution of child  and adolescent mental health services from 1960   to 2010 and influences on our practice today.  Just something about myself. I qualified in 1959,   so just before the period we’re considering. I  was trained at the Maudsley in the 1960s. I had   a psychoanalytic and a family therapy training  and I was a Consultant at Great Ormond Street   Children’s Hospital, the Institute of Child  Health and the Tavistock Clinic from 1968 to   94. I established a child and family practice  and a child and family training organisation,   still going strong. I’m a Visiting Professor  at Royal Holloway, University of London,   and I chair the ACAMH ACEs Special Interest Group. I published a chapter in this text, “Mind, State  and Society in Britain 1960-2010” edited by George   Ikkos and Nick Bouras, published by the Royal  College of Psychiatrists in 2021. This is a   social history of psychiatry and mental health in  Britain and of course, the period coincides with   major changes in UK politics, economy, society  and healthcare. The text reflects how these   changes impacted on the development of mental  health services and thinking during this period. My chapter, “Children, Adolescents and Young  People,” reviewed the societal and political   context and the evolution of approaches to meet  the mental health needs of children and young   people. So, the 1960s and 70s were aligned  with the post-war years. It was a phase of   national growth, the development of the National  Health Services and the welfare state. There   was a post-war fertility and a baby boom, the  demographics tilted in the 1960s and the 1970s,   and there was a youth culture developed, quite  anti-establishment. And I took a part in that,   playing jazz and poetry, and you can see in  the concert that we gave at the Festival Hall,   that it was associated with some very  well-known names. I then went back to   the day job. It was a period when feminism  grew, women were in leadership roles,   there was a sexual revolution, easier birth  control, gay liberation. But it was also a   time of increasing stresses, break-ups,  divorces and single parenthood families. My objectives in this presentation is  to review the societal and political   context and the evolution of mental  health approaches. In the 60s and 70s,   there was socio-cultural changes and innovations,  family therapy, cognitive behaviour therapy and   the growth of research. The 70s and 80s  very much concerned with social problems,   forms of child maltreatment and the development  of multidisciplinary management frameworks. The   90s and noughties, interventions to reverse the  impact of social exclusions, such as Sure Start,   many developments in research and  training. And finally, I want to give some   reflections on current concerns, particularly  trauma-informed approaches across services. I first want to look at the traditions of  child and adolescent mental health which   greeted me when I started my training  in the 1960s. The Child Guidance model,   which had been introduced in the 1930s,   was very much the way of working. In the 1960s,  the classic trinity of the Child Psychiatrist,   Social Worker and Educational Psychologist.  There were over 300 clinics across the UK. The   Psychiatrist delivered regular sessions for the  child or young person, using play and artistic   material, helping expression of feelings.  There was casework with mothers, supporting   parenting, managing children’s challenging  behaviours. And the Psychologists supported   the child or young person in the educational  context. A successful and approach that worked. Another tradition which greeted me in the 1960s  was the – were the psychoanalytic traditions   from the 1930s. Anna Freud came to the UK in 1938  with her father and she established a war nursery   for children separated from their parents. She  subsequently established a clinic and a training,   the first psychoanalytic clinic in the UK.  She very much advocated the importance of   creating a strong, trusting alliance with  the child through activities, storytelling. Melanie Klein had come to the UK earlier,  in 1926, and she very much focused on   children’s play and activities. And this is an  illustration of her play material as the focus   for interpreting and understanding unconscious  conflicts. She very much made interpretations,   even with very young children, and focused on  transference and countertransference responses. And there was quite a tension between these  two different approaches and indeed, within the   psychoanalytic community, there was a difference  between the Kleinian model, which was trained   at the Tavistock Clinic, and Anna Freud’s in the  Hampstead. And a centre way, an independent middle   group, represented by Donald Winnicoat – Donald  Winnicott, a Paediatrician and Psychoanalyst. He   introduced the theme of the “good enough mother”  and also, the supportive thumb in mouth transition   to help children and young people manage  separation, to maintain an image of their parent   through activities. And Winnicott developed this  notion into the transitional space and created   the ‘squiggle’ game, where the Therapist and the  child build on each other’s images, a creative   encounter, to really access unconscious feelings,  particularly around traumatic experiences. Over the years, of course, work has developed  with special populations of children in   residential and care contexts, with children  in the autistic spectrum, with learning and   intellectual disabilities, and of course, a  set of related, creative forms of therapeutic   work has developed. Play therapy, art, drama,  music, educational therapies, all so important in   terms of the variety of therapeutic work available  for children and young people over the years. So, what about my experience of these traditions?  At the Maudsley Hospital, I had the opportunity to   work in the extensive services in outpatient work  and inpatient work, with children, adolescents,   young people, forensic work. The model was  very much the traditional Child Guidance. We   had a tremendous advantage that Michael Rutter had  just been appointed, so we began to see a range of   young people, particularly with autistic spectrum,  one of the interests which he had at the time. I was appointed subsequently as a Senior  Psychiatric Registrar at Great Ormond   Street Children’s Hospital, which had more of  a dynamic tradition. I received supervision   with Child Psychotherapists,  trained at the Tavistock Clinic,   and I really began to understand the  process of therapeutic work, engagement,   the use and interpretation of play, appreciating  transference and countertransference responses. So, a valuable experience and in a sense, I had  both the best of the training at the Maudsley   Hospital, with its research beginning and with  the very significant range of experiences,   and then beginning to understand work with  children and young people. It was an exciting   time to be working in a children’s  hospital. There was open visiting,   play working had started. It was sharing shared  ward rounds with Paediatricians and beginning   to have a much broader understanding of  the role of psychological and physical   factors with children and young people  in their development. I was subsequently   appointed at Great Ormond Street in 1968 and  subsequently, in the Tavistock Clinic in 1975. I now want to speak about developments  in research and practice. First,   I want to speak about attachment. John Bowlby’s  earlier review of “Maternal Deprivation” in   “Maternal Care and Mental Health,” was the core  role of developing the important – importance of   maternal attachment for the secure development  of the child. And he worked with Ethologists   like Robert Hinde, and really brought a very broad  ethological perspective to children’s development   and particularly the issues of attachment and  the impact when attachment was less secure.   Psychoanalytic colleagues criticised John’s  emphasising the role of real-life experiences,   rather than the inner world. Professor  Rutter praised the positive consequences,   for example, parents staying  with their children in hospital,   but criticised the notion that brief  daily maternal separations were harmful. The controversy generated significant research  on family relationships and the nature of good   qualitative alternative care. The attachment  concept has played a key continuing role in   professional and public awareness about the care  of children, security and a target for therapeutic   work. And the illustrations are of some of John  Bowlby’s important work. The texts, “Trauma and   Loss,” were part of the bibles that we consulted  in that period, remaining an important influence. The attachment categories, which have had  a longstanding and meaningful history,   are as follows. “Securely attached children  experience their caregivers as available and   they see themselves positively. Ambivalently  attached children experience the caregiver   as inconsistently responsive,” sometimes  positive, sometimes negative. They, as a result,   are “dependent, clinging and they see themselves  as poorly valued. Avoidantly attached children   experience the caregiver as consistently rejecting  and see themselves as insecure and needing to be   compulsively self-reliant. Disorganisedly attached  children experience the caregiver as frightening,   or frightened, and themselves as helpless,  angry and unworthy.” Powerful categories   which have significant meaning and which have a  very continuing key role in our understanding. Robert Marvin introduced this model, the “Circle  of Security,” parents attending to children’s   needs, and described the secure base, secure  haven, “protect me, comfort me, delight in me,   organise my feelings.” And then, the secure  base, “I need you to support my exploration,   watch, delight, help me, enjoy, welcome me coming  back. I need you to protect, comfort, delight,   always be bigger, stronger, wiser and kind.  Whenever possible, follow my children’s needs.   Whenever necessary, take charge.” Powerful model  which has been highly influential and valuable. Right, I’ll start again, then. I now want to  say something about the research methodologies,   assessment and measurement which  emerged during the 1970s. The   influence of Michael Rutter was  predominant over this period. First, the assessment and the measuring of the  nature, extent and severity of mental health   difficulties, family life and parenting.  The introduction of various checklists for   children and young people to fill in about their  worries, about their feelings of depression,   about their capacities to focus and concentrate.  Comments by children and by parents, were valuable   in terms of our work in day-to-day with children  and young people. He described longitudinal   research, cohorts of children following through  to adulthood. Romanian orphans adopted into the   UK were a very good example of what one  could learn about the – about remediation,   of the extreme deprivation of these young people. The Isle of Wight Study, initiated in 1970,   led by Michael Rutter, with Jack Tizard, was  very much the model of epidemiological research,   screening a whole population and interviewing.  It was a very valuable experience for me to be   one of the interviewers in the  Isle of Wight and we all learnt   an enormous amount about the context with  children and young people were living in. He introduced the multi-axial approach  to diagnosis, introduced in 1975 as a way   of describing complexity and looking at the  presentation of the child and young person,   looking at the intellectual issues, looking at  social contexts, looking at medical factors. And   of course, this helped to assess the effectiveness  of therapeutic approaches. And of course, we have   to make the point that he and Lionel Hersov  edited Child and Adolescent Psychiatry, first   published in 1976, which established child and  adolescent psychiatry as a singular profession.   Now reached its sixth edition and we were all  enormously proud to be asked to contribute. I want to say something about disorders  of public interest that emerged during   these early years. Self-harming, suicidal  behaviour and anorexia nervosa and other   eating disorders were of considerable public  interest because, of course, they’re the child   and adolescent mental health disorders which  can lead to death. And self-harming behaviour,   self-starvation, counting calories,  trying to live up to the images of models,   all had significant role on young people.  And the self-harming, anorexia patterns,   were areas of significant interest and also,  of course, the development of significant   therapeutic services, inpatient care  for eating disorders, for example. Another area of significant and continuing  interest are autistic disorders,   neurodevelopmental orders – disorders  characterised by deficits in social skills,   problems of empathy, problems of speech  and language, non-verbal behaviours,   repetitive stereotype behaviours. And this –  the tremendous range associated with highly   skilled responses, as well as very significant  difficulties. And also, of course, the social   vulnerability of these young people, school  contexts, great interest in the emergence of   attention deficit hyperactivity disorder, ADHD.  A neurodevelopmental disorder with a classic   pattern of short attention span, inattentiveness,  hyperactivity and impulsiveness, and the role of   medication, which emerged, which had a significant  impact on children’s behaviour in the classroom. And of course, recently, the development  of the concept of neurodiversity has   emerged. A framework that argues about the  intrinsic diversity of human brain functions,   resulting in, as you can see under the umbrella,  autistic spectrum disorders, attention deficit,   development, co-ordination, language, tics,  dyslexia, intellectual disability. And these   are intrinsic diversity, not deficits, but to be  celebrated and to be responded to appropriately,   with compassion. So, it's interesting the way  that these specific disorders have remained   in the public consciousness and the way in which  they are beginning to be thought about currently. Now, I want to speak about the winds  of change and the emergence of family   systemic approaches. This started in the 60s,  went through to the 70s and 80s. We were all   very excited in our training by the publication  of “The Double-Bind Theory” of schizophrenia,   by Gregory Bateson and colleagues, which  described the way “disordered communication”   could lead to “pathological outcomes,  interconnected systems, individuals, families,   cultural contexts.” And this gave a very different  flavour to understanding mental health disorders.   “The Pragmatics of Human Communication”  published by Watzlawick and colleagues,   was a study of interactional patterns, pathologies  and paradoxes, and the text was one of our bibles. In 1960, the Humanist, existential thinker, R.  D. Laing, Ronnie Laing, published “The Divided   Self” and based on The Double-Bind Theory,  a different understanding of psychosis.   He was very much influenced  by the Bateson project,   but had advocated for a far more human approach  to mental health, against hospitalisation,   ECT. Very much taking a therapeutic approach,  day hospitals. And his critique of psychiatry   at the time introduced a popular anti-psychiatry  movement, which had a tremendous influence amongst   young people at the time, and of course,  has had an influence on mental health. And in the child and adolescent field,  although effective, the Child Guidance   model was proving static and unresponsing –  unresponsive to changing societal dynamics.   And linked to the systemic models introduced  by Gregory Bates and his colleagues, was the   growth of family therapy systems approaches.  Earlier, John Bowlby had introduced family   meetings to reinforce individual therapy  at the Tavistock Clinic. And interestingly,   this was part of a process which led to different  training streams for individual psychotherapy,   for family systemic treatments,  which has had a profound influence. Robin Skynner, Child and Adolescent Psychiatrist  and Group Analyst, worked with the family as a   group and his publication, “Families and  How to Survive Them,” with John Cleese,   had a very considerable influence on  introducing the notions of family work,   rather than individual work,  to the country as a whole. Salvador Minuchin, working in the  Philadelphia Child Guidance Clinic,   introduced structural approaches to working with  the family. He published the highly influential,   “Families of the Slums” and “Families  and Family Therapy,” illustrated here,   and he worked with family communications,  with boundaries and alliance. He directly   altered interactions between family members,  make this conversation come out differently.   And he worked directly to help families improve  and support the functioning of the child. He had   a highly active supervision style. He would come  behind the one-way screen and say to the trainee,   “Look, I think if you asked the father to do  this and the mother to do this and to get them   to have a different sort of conversation and  not allow the child to interrupt and interfere,   that might be better.” His work was  videoed, large-scale events and had   a – very much popularised the value and  power of a systemic family approach. Milan group, Mara Selvini,   Boscolo, Ceccin and Prata, very much close to  the Bateson model of circular epistemology,   understanding processes within family. They  developed a team model, working with the family,   sitting behind the screen. Creating a model  of trying to hypothesise and understand the   role of the symptom and the family system.  They used a model of circular questioning,   “What would your dad say if he was here, your  late father?” And they were very interested   in the notion of paradoxical interventions  introduced by the Bateson Group, of course,   positively denoting symptoms, the value of the  symptom for the family, don’t change too quickly. From other influences, Therapists were trained  in experiential approaches, understanding the   role of families by sculpting, by creating  roleplays and facilitating the development   of skills and understanding in a highly active  way, a very much contrast to the traditional   psychoanalytic model of free association, but much  more direct. And of course, across – instead of   the trinity of the Psychiatrist, Social Worker,  Educational Psychologist, there was far more   broader approach to training across different  disciplines which emerged from this development. In the UK, there was tremendous excitement  to learn about these development. At Great   Ormond Street, we established study groups. We  tried experiential approaches, moving sculpts,   roleplays and we initiated a process of live  supervision. Robin Skynner convened a group of   Family Therapists across London, and we trained  with Salvador Minuchin and then with the Milan   Group during the 1960s and 70s. We powered the  development of an Association of Family Therapy   with colleagues who were experimenting across the  country. We established large-scale conferences,   demonstrations of family therapy and in 1976, we  established an Institute of Family Therapy and   established in London, founded – established  a clinic, developed a training programme,   and a qualification in family systemic treatment. Fortunately, there was the establishment of the  United Kingdom Council for Psychotherapy in the   UKIP in 1993, which helped to accredit  trainees across different disciplines in   these new skills, as well as, of course,  the developing skills with individuals,   groups and other modalities which were emerging  at the time. We published a series of texts,   complementary frameworks of theory and practice  from 1982, 1985 and the illustrations of Volume   One of Family Therapy and an applications of  systemic therapy and the image of the Institute   of Family Therapy. So, a very exciting time  of development during the 1970s and the 1980s. At Great Ormond Street and the Institute of  Child Health, we established a Family Research   Team for the description and measurement of family  interaction. Valuable support from our colleagues   at the Institute of Child Health, Professor Otto  Wolff, Professor Philip Graham in our department,   and the development of a team led by Warren  Kinston, applying these new models of   measuring and describing families to a variety of  contexts, children with asthma, obese children. We developed a Focal model trying to link the  Systems Theory emerging with psychodynamic   understanding. And I wrote a text, “Trauma  Organised Systems,” to try to see the way in   which traumatic responses and traumatic actions  created a complex web within the family and   within society, trauma organised systems, ways  of relating based on traumatic experiences and   their responses. We were also able to develop  the Family Assessment of Family Competence,   Strength and Difficulties, subsequently, and  there are some of the illustrations here. I now want to say something about a parallel  development to the family systems approaches,   which is the introduction of cognitive behaviour  therapy. Cognitive behavioural therapy is an   amalgam of behavioural and cognitive theories  of human behaviour, founded originally by Aaron   Beck in the 1960s. In the 1970s, there was an  awareness of the role of cognition, internal   thought processes. Self-taught – talk became the  targets and mechanisms of change, very much in   parallel with behaviour therapy. Very much noted  in parent training, the promotion of positive   behaviour and managing negative behaviour which  had developed earlier. So, this was a parallel,   not only behaviour, but thought processes. And  you can see here that the image of “thoughts,   feelings” and “behaviour,” which became very much  the target of CBT. Psychological disorders were   conceived of as maladaptive cognitive processes  and psychological vulnerabilities. Specific CBT   approaches developed, parenting training, helping  children’s mastery over their own environment. And let me show you one example of this.  This came – this comes from our – the   model of therapeutic work, which I’ll describe a  little later, but this is managing low mood. So,   individuals who’ve sustained many losses, or have  experienced multiple stressors, often have a sense   of loss of control, feelings of helplessness,  hopelessness, pervasive low mood, pessimism,   suicidal thoughts. And children and young people  are described as having “dark moods, being sulky,   cranky, losing interest in activities,  changes in sleeping or eating habits,   feeling negative about themselves, self-harming.” The steps to counter their mood include using a   feeling thermometer, “When are you happy? When  are you sad? What contributed to you choosing   that temperature rather than this? What are you  like when you’re down?” And here’s an image,   one of the worksheets, “How I show my feelings  when I’m in a bad mood/when I’m in a good mood.”   And “What makes you feel down? What makes you feel  in a good mood?” “Changing feelings, changing how   you feel, what you think, what you do, maybe  that would help you manage these low mood,   changing our thinkings. There may be blue  catastrophic thoughts to substitute true,   more realistic thoughts. Maybe it’s not so  bad after all. I know you’ve been through   a terrible time, but it may be that things are  better now and you could build for the future.” Changing behaviour, presenting a positive,  optimistic mood, can improve the way you   feel generally. Exploring difficult situations,  hotspots, which you can really try to confront   and deal with. Importance of restoring  the past, capturing positive memories,   so important with mourning and loss. Capturing a  positive memory can link you with your pos – with   the positive areas of your life and  help you move forward in a positive way. Very important development, of course,  was the impact and spectrum of stress   and trauma. Post-traumatic stress was  described in the 1960s and toxic stress   was described – defined by Shonkoff from the  Harvard Developing Child organisation in 2000,   and he described “Extreme, prolonged and  unpredictable stress during vulnerable   periods” as toxic. There was vigorous and chronic  activation of biological responses to stress,   which was detrimental. Post-traumatic  stress symptoms, re-experiencing,   avoidance and arousal, fight or  flight, and a latent vulnerability   which resulted from longstanding coping responses,  fight-flight arousal, ready to fight at any time. And there’s an image here on the right of how  trauma affects the brain. The amygdala wired for   survival, when hard to think rationally, defends,  puts in a fight-flight mood, but when hyperactive,   signs of PTSD are present and overwhelming.  The hippocampus, responsible for memory,   differentiating past and present, makes sense of  what’s going on, but with exci – with consistent   exposure to trauma triggers. The prefrontal  cortex, rational thinking, regulates emotions,   but with PTSD, constant stress, cortisol  floating around, has a reduced volume. In training, I like to show the image developed  by the Harvard Developmental – Developing Child   context about toxic stress and  I’d like to show this video now. [Video Commences] Narrator [Music] Learning to deal with stress  is an important part of healthy development. When   experiencing stress, the stress response system  is activated. The body and brain go on alert.   There’s an adrenaline rush, increased heart rate  and an increase in stress hormone levels. When   the stress is relieved after a short time, or a  young child receives support from caring adults,   the stress response winds down and the body  quickly returns to normal. In severe situations,   such as ongoing abuse and neglect, where there  is no caring adult to act as a buffer against   the stress, the stress response stays activated.  Even when there is no apparent physical harm,   the extended absence of response from adults  can activate the stress response system. Constant activation of the stress  response overloads developing systems,   with serious lifelong consequences for the  child. This is known as toxic stress. Over time,   this results in a stress response system set  permanently on high alert. In the areas of the   brain dedicated to learning and reasoning,  the neural connections that comprise brain   architecture are weaker and fewer in number.  Science shows that the prolonged activation   of stress hormones in early childhood can  actually reduce neural connections in these   important areas of the brain at just the  time when they should be growing new ones. Toxic stress can be avoided if  we ensure that the environments   in which children grow and develop  are nurturing, stable and engaging. [Video ends] Dr Arnon Bentovim And what has, of course,  emerged from the understanding trauma has been   trauma treatments and probably the most valuable  and powerful is trauma-focused CBT, a form of   cognitive behavioural therapy introduced by  Judy Cohen and Mannarino in the 1990s. So,   trauma-focused CBT is delivered to  parents and their children because   of the difficulty processing complex  and strong emotions from exposure to a   traumatic event. The goal is to create  an emotionally supportive environment.   Children and their parents learn  strategies for managing difficult emotions. So, PRACTICE is the notion based on  the TF-CBT model, psychoeducation,   understanding the nature of traumatic responses.  Parenting skills to help parents manage children’s   extreme anxiety and distress. Relaxation skills  to manage overwhelming emotions. Affective   modulation skills, ways of managing feelings.  Cognitive processing skills, to understand that   sen – a feeling that you were to blame for a  traumatic event, to help them find other ways   of thinking. To develop a trauma narrative and  to process and to put experiences into memories.   In vivo mastery of trauma reminders when they  occur. Relaxation, visualisation, positive   responses. Co child-parent work and E, enhance  safety. It's proven to be a highly effective   model developed in a variety of context, complex  PTSD, grief, loss, many different contexts. And associated, and perhaps looking at  the same area, was the development of eye   movement desensitisation and reprocessing, EMDR,  introduced by Shapiro in 1987. The model states   that “Fragmented perceptions of stressors are not  integrated with other memories and inadequately   processed,” and therefore, are “triggered by  reminders or memories of experiences, resulting   in traumatic responses.” So, EMDR was based on  the theory of Adaptive Information Processing.   New experiences are processed by connecting and  integrating them and with their related emotions. The goal is to access inadequately processed  information through alternating bilateral   stimulation, either tapping or the movement of the  finger, which was the classical ways introduced.   Bilateral stimulation to restimulate, process and  integrate. Identify a target memory, a distressing   image, a situation. Visualise the goals that  you want to achieve. Focus on this memory. Think   about positive goals and continue until distress  reduces. Bilateral movements have proven to be a   valuable form of activity to relieve stress and  trauma. Fast feet forwards, chin exercises to –   and then, thinking about a distressing context,  until it begins to dissolve. The butterfly hug,   tapping, which is a self-soothing measure that’s  relia – associated with bilateral stimulation.