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Part #2.

Fifty Years of Psychotherapy, But What about Infant Mental Health and Early Childcare? 1998. Dr. Cook P.S.

(continued)

As with Bowlby, his quest for an explanation was answered as he adopted an evolutionary perspective. He compared the skulls of many species and showed that these movements, demonstrable in most mammals, are normally tooth-sharpening behaviour, often associated with situations involving threat and intense emotion. He termed this activity thegosis, from the Greek thego "I whet", and he founded the discipline of thegotics. He held that, through evolutionary natural selection, our pre-human ancestors' teeth had been progressively improved in their functions as tools and weapons, to achieve in humans the "segmentive" and lethal "bite to kill". This deadly weapon evolved with natural control mechanisms to inhibit inappropriate use. He had irrefutable evidence in dental enamel - the hardest of all biological substances - showing precise behaviour of which his patients and colleagues were not aware, and which must be genetically programmed [17]. Here was demonstrable evidence of genetically hard-wired instinctive behaviour in human beings - an unprecedented discovery! He may yet be recognised as a genius - a "Darwin of oral aggression" - but in his lifetime he was subverting the "dominant paradigm", and it is sad that his death denied us the opportunity to celebrate together.

An Evolutionary Perspective in Childrearing

In the 1960s I began to explore the relevance of an ethological-evolutionary perspective to healthy child rearing and clinical child psychiatry. If there are genetic influences with natural control systems for oral aggression, then what about other human behaviours required for the survival of our species? What about the parent-child relationship? If babies are the refined outcome of this long process of natural selection, what is the significance of their wants and behavioural urges? I observed the development of our four babies, adopting an attitude of respect for possible biological givens, and looking for natural control mechanisms in infant interpersonal behaviour and socialisation. After all, humans evolved and survived as social animals. Perhaps they are innately social; but the current theories of "socialisation" were based on quite different views of the nature of the child.

Traditional childrearing assumed that children were born basically anti-social. I wearied of hearing fearful parents, perplexed that their threats and best efforts to chastise their children into conformity seemed futile. Contemporary notions of discipline were very much a concern to the founders of the NZAP. Bevan-Brown wrote: "Corporal punishment is dangerous to mental health. This is a statement that can be made unequivocally. … The earlier in life it is given the more dangerous it is" [5 p.46]. This is not yet a dead issue and I was appalled to read the 1991 book Spare the Child by Phillip Greven [21], which gives a history of some religious roots of corporal punishment. He often refers to Spare the Rod, by Jane and James Ritchie of the University of Waikato [37]. They had reported that in New Zealand in 1970 "punishment, frank, direct and physical, or verbal in the form of threats, shouting and scolding or berating" were regarded by mothers as "being as necessary for child rearing as the mid-morning cup of tea is for sanity". No wonder that 40% of them felt that the burdens of caring for young children balanced or outweighed the enjoyment they received [36].

In the late 1960's I realised that the childrearing ideas and practices of many parents who consulted me formed a logical contrast in almost every way with those by which my wife and I were rearing our children. They arose from different views of the nature of the child and the childrearing process. I compiled a table of these contrasts, and found that many of the "traditional" childrearing ideas stemmed logically from the doctrine of Original Sin as formulated under Manichaean influences by Saint Augustine [14]. His dogmas were incorporated into the Thirty Nine Articles of Religion, to which Clergy in the Anglican churches have long been required to assent. Article nine teaches that Original or Birth Sin is "the fault and corruption of the nature of every man ... whereby man is very far gone from original righteousness, and is of his own nature inclined to evil, so that the flesh lusteth always contrary to the spirit; and therefore in every person born into this world, it deserveth God's wrath and damnation." It concludes that sensuality, "concupiscence and lust hath of itself the nature of sin" [The Book of Common Prayer, 1662].

This doctrine has been clearly reflected in psychoanalytic theory. Edward Glover, an authoritative figure in British Psychoanalysis, wrote in his paper The Roots of Crime "In fact, judged by adult social standards, the normal baby is for all practical purposes a born criminal" [20].

From an evolutionary perspective, this dogma makes no sense for a social primate like Homo sapiens, where the selection process must favour qualities required for individual survival, but counter-balanced by the imperative to do so in ways that gain full acceptance by a breastfeeding mother and also a co-operating social group. I suggest that if children's emotional needs are met, they may be constructively be regarded as naturally age-appropriately "socialized" from birth onwards, but they need help to manage their conflicting impulses to gradually become civilised in ways that meet the requirements of citizenship of an over-populated planet which is losing its biodiversity through human exploitation. Ainsworth and Bowlby in their 1989 APA Award Address [1] said:

"In regard to socialization, the findings suggest that infants have a natural behavioral disposition to comply with the wishes of the principal attachment figure. This disposition emerges most clearly if the attachment figure is sensitively responsive to infant signals, whereas efforts to train and discipline the infant, instead of fostering the wished-for compliance, tend to work against it."

Yet historically, ideas deriving from the above interpretation of original sin have determined the whole way that babies and children were perceived and reared. These ideas readily generated self-fulfilling prophesies, whether perpetuated through Susanna Wesley's 18th century advice to beat babies without mercy to break their wills in order to save their souls [40] (fearing they might die unsaved in infancy and spend eternity in hell), or as transmuted later throughout New Zealand in the teachings of Sir Truby King [26], who advocated strict regimes to mould the infant from birth. In the 1950s in New Zealand and elsewhere, there were widespread fears of children becoming increasingly unmanageable. To avoid "spoiling" children it was essential for mothers, also, to be disciplined -- for them to win the inevitable battle of wills and suppress their impulses to pick up or respond to their infants' cries, except for feeding at four-hourly intervals. Babies should sleep in their own rooms from birth, and routine toilet training should begin at six weeks. Corporal punishment in due course was often a natural sequel. And so on.

In many of the problems presenting clinically, the pathogenic parental behaviour was under-pinned by such fears, combined with the belief that it was necessary to intervene early, with coercion and physical punishment, to prevent future delinquency. Such notions were widely disseminated in the English-speaking world and elsewhere. By fostering a basic distrust in the human biological "givens", the doctrines led to a mis-match between many Western childrearing practices and these biological givens, often leading to parent-child frustration, conflict and later rebellion or personality distortion. The history and long-term impact of the Augustinian doctrine of original or birth sin on the mental health of children in Western societies is an important topic waiting to be well documented. An account of this mis-match was published in 1978 in Childrearing, culture and mental health: exploring an ethological-evolutionary perspective in child psychiatry and preventive mental health [14], covering the areas of childbirth, lactation, early mothering, attachment, childrearing and the social settings in which we expect these functions to take place.

A biological perspective suggests areas for corrective action, and ways to make our culture fit our genetic biological givens. A corollary of Darwinian theory concerns the outcome of those deviations from the conditions of the environment of evolutionary adaptedness which cut across important biological mechanisms. If the changes are not severe enough to cause extinction, or gradual enough to allow genetic adaptation by natural selection, then they may lead to stress and maladjustment, first affecting the more vulnerable, like the canaries in the coal-mine. Much medical and psychological illness may be understood in this way. In such cases, corrective remedies to deal with the cause of the maladjustment are generally better than antidotal remedies which just aim to treat the symptoms [14].

Early Childcare as a Symptomatic Remedy

Institutional early child care may be viewed as a symptomatic remedy for certain social problems, such as poverty or maternal isolation, and, like many symptomatic treatments it can bring its own complications. Corrective remedies are usually preferable, and in the care of young children they are both healthier and possible.

It is paradoxical that while many practices towards young children have improved, academia, the bureaucracy and the media have been largely dominated by people committed to universally available early non-parental childcare as their preferred way of advancing the cause of women. Underpinned, in part, by the ideology of cultural determinism, a corollary has been a denial of the importance of good mothering for emotional health in the early years, as was central to the teachings of the founders of the NZAP.

To promote optimum emotional health and well-being, parents, students and policy-makers need to understand some of the issues involved in early child care from the point of view of what is best for infants, young children, their mothers and families. Non-maternal care in early childhood by unrelated women having no lasting commitment to the child, is without successful long-term precedent in the history of our species. A child can spend 12,500 hours in day care by the age of five (50 hours X 50 weeks X 5years). This is more than he or she will spend at school by the age of 17. Concerns about the impact of this on infants and young children have been countered by assurances that there is no evidence of harm from quality early child care, and that in some cases it might be beneficial, but the evidence certainly suggests that mediocre child care - which is widespread - can be harmful.

In fact, there is accumulating robust evidence to suggest that risks of a variety of serious and perhaps lasting undesirable outcomes are associated with early group child care as it exists in reality, even in "high quality" child care [16], and infants' actual experiences in real life child care situations are often very different from the ideal picture. The many contributions that home-caring mothers or fathers make to society are currently undervalued. Society offers them little in return, and they are handicapped on seeking to re-enter the work-force.

Thus, in 1992 Belsky, noting the quality of childcare used by increasing numbers of parents from early infancy, and reviewing evidence of associations between early child care and increased risks of insecure infant-mother attachment, later aggressiveness and non-compliance, said: "On the basis of this developmental and social ecology of daycare in America, I conclude that we have a nation at risk" [4]. In 1995 a survey of 400 American child care centres concluded that "most child care is mediocre in quality, sufficiently poor to interfere with children's emotional and intellectual development." [25]

A Swedish study showed that, despite a national reputation for the world's best childcare, many Swedish infants starting long day care in the second half of the first year reacted "with a significant negative change in mood, sadness, and a low activity level", and at one stage half of them were assessed as sad and depressed in the day care setting. Some infants fell behind in tests of speech and cognitive development, with a few some remaining depressed at the end of the five-month study period. All these findings were in comparison with matched controls who were cared for at home by their mothers [24].

In 1996, a multi-million study sponsored by the American National Institute for Child Health and Development validated the Strange Situation procedure for assessing infant-mother attachment security/insecurity, and clarified the interaction of various child care factors associated with this security. Findings included: boys are more vulnerable, and boys in more than 30 hours of non-parental care per week had the highest proportion of insecurity; the 25% of infants whose mothers rated in the lowest quartile in "Sensitivity" had increased risk of insecurity in more than just 10 hours in childcare, regardless of childcare quality, and "low quality child care, unstable care, and more than minimal hours in care were each related to increased rates of insecurity when mothers were relatively insensitive". It appears that children who are already disadvantaged are the ones most at risk to be further disadvantaged by early day care, in some cases independently of the quality of care [34]. The second NICHD Report, with findings to 36 months, confirmed that non-maternal childcare carries increased risk of adverse outcomes in many facets of the mother-child relationship [34].

A meta-analysis of all the 88 adequate childcare outcome studies published between 1957 and 1993 showed "significant and robust evidence of undesirable outcomes associated with non-maternal care in the areas of socio-emotional development, behaviour and infant-mother attachment. The findings gave no support for the belief that high quality day care is an acceptable substitute for parental care" [39].

Though a causal relationship is not established, the evidence is becoming stronger that these disquieting outcomes are indeed effects of early day care, and the risk of adverse effects on infants certainly exists.

This material is presented in Early Child Care - Infants and Nations at Risk [16], where I suggest some remedial measures including community recognition of infants and their parents as a discrete and vulnerable group, with special needs during a limited period. With early long day care, as with young children in hospital in the 1970's, it is arguable that far more emotional disorder is being initiated by the placing of infants in non-parental early childcare - as it mostly exists - than all the psychotherapists and child psychiatrists could undo if they did nothing else!

Conclusion

Primary prevention is in the best traditions of those who founded the NZAP, with a role for psychotherapists to use their insights as a basis for advocating reform. I have been much encouraged by Dr Elliott Barker [2], a Canadian Forensic psychiatrist, who, after long experience with criminals and psychopaths, decided that early primary prevention is imperative, with emphasis on good nurture during infancy. He founded The Canadian Society for the Prevention of Cruelty to Children, and for 18 years has produced its journal Empathic Parenting, which is reminiscent of the Child Family Digest mentioned earlier. For more information, or to subscribe, see that Society's Internet Home Page on http://cnet.unb.ca/corg/ca/e/pages/prevention_cruelty
I hope some of you will read the evidence and be willing to publicly raise concerns. You will be in good company, as shown by a large anonymous survey of members of the World Association for Infant Psychiatry and Allied Disciplines, to which 450 members responded. It was outlined in The Anna Freud Centenary Lecture by Dr Penelope Leach in London in 1995 [27]. When asked what was best from infants' viewpoint, most of these professionals thought that, until infants are at least 12 months old [with a mean of 15 months], it is "very important" for them to have their mothers available to them for most of each 24 hours; and it is best for them to be cared for principally by their mothers, until they are over two years [with mean age of 27 months]. By 2yrs 6 months 94% still did not think that full-time group care was the best arrangement. Leach said "the findings were consistently at odds with the kinds of care infants in Western countries now receive and which parents and policy makers desire for the future" [27].

A 1996 British review Who Needs Parents: the Effects of Childcare and Early education on Children in Britain and the USA by Dr Patricia Morgan also gives much evidence for concern about child care [31]. She demonstrates (p.109) that the goal of "'affordable, universally available, good-quality, easily accessible childcare' (to use the popular mantra) is a chimera, unrealisable in the real world. Affordable care is low-quality care. Universally available high-quality care is achievable nowhere on earth". Our society must abandon the fictive goal of universal, affordable, high quality child care for very young children, and do whatever is needed to help parents provide high quality mothering and fathering without unduly jeopardising their own futures.

I thought of rephrasing the title of a book and calling this paper "Fifty Years of Psychotherapy - and the world is getting worse!" So I hope the present generations of professionals will consider these matters, and continue the tradition of speaking out in the interests of the emotional health of the infants and young children, who will be the young women and men of tomorrow.

References

1. Ainsworth MDS, and Bowlby J. An ethological approach to personality development. 1989 American Psychological Association Award Address. American Psychologist 1991; 333-341.
2. The Australian and New Zealand College of Psychiatrists. Position Statement No. 2: Admission of mothers to hospital with their young children. Carlton, Vic: ANZCP, Dec 1971.
3. Barker E. Review of Early Child Care - Infants and Nations at Risk by PS Cook. Empathic Parenting 1996; 19:3, 22-23.
4. Belsky J. Consequences of child care for children's development: a deconstructionist view. In: Booth A. (ed.) Child Care in the 1990s: Trends and Consequences. New Jersey: Erlbaum,1992.
5. Bevan-Brown CM. with Allan RS. and Cook EF. The Sources of Love and Fear. Christchurch, NZ: Raven Press, 1950. Also published in New York: Vanguard Press and simultaneously in Toronto, 1950.
6. Bevan-Brown CM. Mental Health and Personality Disorder: a Selection of Essays. Christchurch, New Zealand: Dunford, 1961.
7. Bevan-Brown CM. A plea for correlation - a broad and tolerant attitude is required between schools of psychological thought. Presidential address to the Medical Society of Psychology, London, 1936. In [6].
8. Bowlby J. Maternal Care and Mental Health. Geneva: World Health Organisation, 1951.
9. Bowlby J. Attachment and Loss. Vol. 2: Separation and Anger. London: Hogarth Press and the Institute of Psychoanalysis, 1973. Also Harmondsworth, Middlesex: Penguin, 1975. Bowlby J. (1980) Psychoanalysis as a Science . The Freud Memorial and Inaugural Lecture. University College, London.
10. Cook PS. The care of the mentally subnormal: some recent trends, with special reference to the services in Northern Ireland and New Zealand. New Zealand Medical Journal 1958; 57:27-31.
11. Cook PS. A two-year-old's mother goes to the maternity hospital. New Zealand Medical Journal 1962; 61:605-608.
12. Cook PS. Ante-natal education for parenthood as an aspect of preventive psychiatry. Medical Journal of Australia 1970;1:676-681.
13. Cook PS. Children in hospital - some overseas developments. Mental Health in Australia 1973;1:8-12.
14. Cook PS. Childrearing, culture and mental health: exploring an ethological-evolutionary perspective in child psychiatry and preventive mental health, with particular reference to two contrasting approaches to early childrearing. Medical Journal of Australia, 12 August 1978; Special supplement, 2:3-14.
15. Cook PS. The early history of the New Zealand Association of Psychotherapists and the related movement for primary prevention in mental health: some recollections. Australian and New Zealand J. Psychiatry 1996; 30: 405-409.
16. Cook PS. Early Child Care - Infants and Nations at Risk. Melbourne: News Weekly Books, 582 Queensberry Street, North Melbourne, Vic 3051, 1996. [Tel: (3) 9326 5757; Fax (3) 9328 2877.A$24.95. Obtainable in NZ from T. Williams, PO Box 18 583, Christchurch 7. Phone (03) 388 0867].
17. Every RG. Sharpness of teeth in man and other primates. Postilla, Journal of the Peabody Museum, Yale University, New Haven, 1970, 143:1 (with references to Every's publications in The Lancet). Publications further documenting important aspects of thegotics are pending from Christchurch. A bibliography on thegotics may be obtainable from the present author, or through Mr Kevin Scally, email address kevin@8.co.nz
18. Freeman D. The debate at heart is about evolution. In Fairburn M & Oliver WH eds. The Certainty of Doubt; Tributes to Peter Munz. Wellington: Victoria University Press 1996. See also the 1996 Foreword in Freeman D. Margaret Mead and the Heretic: the making and unmaking of an anthropological myth. Ringwood, Victoria: Penguin, 1996. See also The Fateful Hoaxing of Margaret Mead: An historical analysis of her Samoan researches. Westview Press, 5500 Central Ave., Boulder, Colorado, 80301 - 2877. ISBN 0-8133-3560-4. Available: Fall 1998 .
19. Freeman D. (1996b). Letter Human nature is an evolutionary process in The Australian, 5 June 1996.
20. Glover E The Roots of Crime in Selected Papers on Psychoanalysis, Vol. 2. London: Imago, 1960.
21. Greven P. Spare the Child. New York: Alfred Knopf, 1991.
22. Hadfield JA. Psychology and Mental Health: A Contribution to Developmental Psychology. London: Allen and Unwin, 1950.
23. Hadfield JA. Childhood and Adolescence. Harmondsworth, Middlesex: Penguin, 1962.
24. Harsman I. Daily separations and early entry into day care (Dagliga separationer och tidig daghemsstart). HLS Forlag, Box 34103, 100 26 Stockholm, 1994. This a Ph.D. thesis published in Swedish, with a Summary in English.
25. Helburn S, Culkin ML, et al. Cost, Quality, and Child Outcomes in Child Care Centres: Executive Summary. Denver: Department of Economics, University of Colorado at Denver, 1995.
26. King F. Truby Feeding and Care of Baby. London: MacMillan, 1925.
27. Leach P. Attachment: facing the professional demands of today's research findings. Anna Freud Centenary Lecture, London, 30 November 1995. J. Child Psychotherapy 1997;23:1 5-23. The study is fully published in Leach P. Infant care from infants' viewpoint: the views of some professionals. Early Dev. Parent. 1997; 6:47-58. 9.
28. Liedloff J. The Continuum Concept. London: Duckworth 1975. Also, London: Futura (1976), and Revised Edition, Middlesex: Penguin, 1986.
29. Lighthouse Series of Booklets (1945 - 1948)
1. Bevan-Brown CM. War neurosis: - designed for the guidance of relatives and friends of ex- service men and women. Christchurch: Lighthouse Series No. 1, 1945.
2. Bevan-Brown CM. Nerves, nerviness and neurosis - a non-technical discussion of the nature of neurosis. Christchurch: Lighthouse series No.2, 1945.
3. Allan RS. The nature of war neurosis. Christchurch: Lighthouse Series No.3, 1946.
4. Cook EF. Towards re-adjustment: the woman's part. Christchurch: Lighthouse Series No.4, 1945.
5. Cook F. Ex-servicemen talk it over - a group discussion on war neurosis. Christchurch: Lighthouse Series No.5, 1945.
6. Cook EF. Sex "education". Christchurch: Lighthouse Series No.6, 1945.
7. Beaglehole E. Mental health: discusses the position in New Zealand. Christchurch: Lighthouse Series No.7, 1945.
8. Allan RS. Testimony to psychotherapy. Christchurch: Lighthouse Series No.8, 1946.
9. Cook EF. The psychology of childbirth. Christchurch: Lighthouse Series No.9, 1947.
10. Cook EF. Psychological preparation for childbirth. Christchurch: Lighthouse Series No.10, 1948.
11. Bevan-Brown CM. Stammering and its psychology. Christchurch: Lighthouse Series No.11, 1948.
30. Moloney JC. Fear: Contagion and Conquest. Philosophical Library. New York, 1957.
31. Morgan P. Who Needs Parents? : The Effects of Childcare and Early Education on Children in Britain and the USA. London: Institute of Economic Affairs, 2 Lord North Street, SW1P 3LB, 1996.
32. New South Wales Branch of the Child Psychiatry Section of the Australian and New Zealand College of Psychiatrists. The admission of mothers to hospital with their young children. Medical J. of Australia 1970; 2:650-651.
33. New South Wales Branch of the Child Psychiatry Section of the Australian and New Zealand College of Psychiatrists. Some aspects of the welfare of infants and children aged under three years, whose mothers are in full-time employment. Medical J. of Australia 1971; 1:446-448.
34. NICHD Early Child Care Research Network. Infant child care and attachment security: results of the NICHD study of early child care, April 1996. Mother-child interaction and cognitive outcomes associated with early child care. Results [to 36 months] of the NICHD Study. April 1997, Bethesda, Maryland: The National Institute of Child Health and Human Development.
35. Read GD. Revelation of Childbirth:-the Principles and Practice of Natural Childbirth. London: Heinemann, 1947. Based on Childbirth without Fear. London: Heinemann, 1942.
36. Ritchie J and J. Child Rearing Patterns in New Zealand. Wellington: Reed, 1970, pp.39, 43.
37. Ritchie J & J. Spare the Rod. Sydney: Allen and Unwin, 1981.
38. Suttie I The Origins of Love and Hate. London, Kegan Paul, 1935. Reprinted, Harmondsworth, Middlesex: Penguin, 1960. See also Suttie I. & IJ. (1932). The mother: agent or object? British J. of Medical Psychology 1932-3.
39. Violato C, Russell C. Effects of nonmaternal care on child development: a meta-analysis of published research. Paper presented at the 55th Annual Convention of the Canadian Psychological Association, Penticton, British Columbia, 1994. Reprints obtainable from Professor C. Violato, Ph.D. or C. Russell M.Sc., Department of Educational Psychology, University of Calgary, Calgary, Alberta, Canada, T2N 1N4. The revised paper will be published in 1997-8, analysing 101 studies.
40. Wesley S. Letter to her son, John Wesley, quoted with approval in his sermon On obedience to parents in Sermons on Several Occasions, Thomas Tegg and Son, Cheapside, 1836. Cf. Wesley J Journal, entry for August 1, 1742. Cited more fully in Cook (1978).


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