Clinical Child Psychology and Psychiatry

Facilitating the development of Family Centred Care in a large Moscow children's hospital is described. The two-and-one-half-year period of work demonstrated many obstacles to change such as alien culture, language barriers, extreme poverty, and political problems. The techniques used to work with and overcome these difficulties are described. Clinical examples are given.

As treatment resources for child mental health become increasingly rationed and limited, there exists a growing need for clinical tools to help the practicing clinician integrate complex problems presented by children and families seeking services into a clear focus that facilitates effective treatment planning. A model of interactional child mental-health case formulation is presented and discussed as one possible tool.

This work describes the developmental process of coming out in gay and lesbian youth. The case is made for the need to identify developmental stages during this process. We address how identity formation is affected by societal intolerance during the process of coming out. To explain this process, we present a psychodynamic model within a sociocultural framework. A review of the literature was undertaken to explore the relevance of the social context in which this internal process takes place. Based on the review of the literature and a clinical understanding of the coming out process, a stage model is proposed that describes the chronology of events that characterizes this process. Societal intolerance can be detrimental to healthy identity formation. There is a need to research the process of identity formation in sexual minority youth.

Adolescent sex offenders present a therapeutic problem in that they are both victim and perpetrator. As perpetrator they present a social problem and need containment while the underlying victimization needs treatment. A special unit has adopted an integrated model of systemic, cognitive-behavioural and psychodynamic frame works. To take into account both victim and perpetrator, psychoanalytic psychotherapy needs to be modified by (a) the incorporation of child protection measures and (b) a continuing focus on the offending behaviour. Given this structure the psychodynamic work helps to support a sex offender safely in the community and also produces dynamic material that illuminates the pathological processes from abuse to abusing. Themes that emerge in the treatment include sexualization of attachments, re-enactments of the abuse and a constant testing of the boundaries of the therapeutic relationship. Working actively with these issues can be seen to strengthen creative capacities in the young person as well as to help prevent recurrence of abusive behaviour. Clinic material is presented for illustration of these points.

The importance of maintaining contact between children temporarily or permanently looked after away from their birth parents is now believed to be so important to their psychosocial development as to be written into the Children Act. This position has been argued both on the basis of the rights of children and birth parents and on the claimed strength of the research evidence concerning the positive effects of contact and the negative consequences of its absence. The quality of the research evidence is reviewed. It is concluded that evidence on either the beneficial or adverse effects of contact is not strong and that the design and/or analysis of existing studies contain a number of weaknesses that preclude clear research-based guidance to practitioners.

Using clinical material this article attempts to make some links with symptoms presenting in children in a child psychiatry setting and aspects of their fathers' stories; a particular link is made with depression in the fathers. Hitherto depression in men has been under-researched. This article also attempts to highlight this issue as one of importance in the child psychiatry setting. Following a literature review six clinical cases are presented to amplify the points raised.

This article presents the development and initial validation of an instrument to measure therapeutic engagement in the context of child and adolescent inpatient treatment - the Family Engagement Questionnaire. Despite considerable adult literature on therapeutic alliance and patient engagement, there has been relatively little work done in this area in child and adolescent psychiatry. The general literature on therapeutic alliance is reviewed and the clinical and scientific issues particular to this work in child psychiatry are highlighted, including the need to measure both parent and child engagement with the ward team. The successful development of a clinician questionnaire rating is described along with initial validity studies. The measure we describe is practicable and has the potential to be used both clinically and in further studies of therapeutic alliance within the inpatient context.

This article describes the development of a new technique, the Bag of Feelings to help in the assessment of children's and adolescents' feelings. It is suggested that such an ideographic approach has advantages over more formal, standardized assessment tools because it enhances rapport, creates a unique communication concerning the individual's preoccupations and affective states and facilitates the production of clinical material. The approach is illustrated with clinical examples.

Prepubertal anorexia nervosa and gender identity disorder of childhood, both rare conditions, are described. The aetiology of both conditions is discussed and the relevance of psychosexual problems to eating disorders is explored. A case is reported of a 12-year-old boy with both conditions where there was a clear aetiological precipitant for the onset of anorexia. His assessment, treatment, response and prognosis are described. The ethical conditions relating to treatment of gender identity disorder of childhood are discussed.