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It is common knowledge that experiences in the first years of
life have a profound influence upon later mental health. In
particular, it is known that to ensure good social and emotional
development the young child needs a stable relationship with a
responsive mother figure (Bowlby, 1951). This is an experience
that most young children find within the security of their
families.
An implication of this knowledge is that if a young child has for
any reason to lose the care of his mother, it is essential that
his experience of responsive mothering be maintained. But at the
present time, if a young child goes into hospital without his
mother, he will be handled by a succession of nurses, and if he
goes into residential care he will rarely find there a stable
mother substitute.
Why does this happen? Why is it that although the importance of
meeting the emotional needs of young children is well established
by research, and is taught in many trainings, this requirement of
mental health is not well attended to in our child-care practice?
Why is it that although we know it to be imperative that young
children have stable relationships, we still fragment their care
among many people when they come into hospital or other
residential settings?
If the relevant professions had a serious concern to meet the
mothering needs of young children in their care, practical
difficulties arising from staff shortages and the short working
week might be found to be hard to overcome. But scanning the
journals of the paediatric, nursing and other caretaking
professions reveals that, although there is an endeavour to
provide play and education, there is little or no reference to
the much greater need for mothering-type care.
Systems of care that disastrously fragment relationships can
operate in institutions busy with 'child-oriented' activities,
and are more likely to result from planning for work efficiency
than from staff shortage. It is well known, for instance, that
even in large teaching hospitals where there is no staff
shortage, nursing is commonly organized on a 'job assignment'
basis in disregard of the emotional needs of the young patients,
even though in the same hospitals the nurses are likely to be
taught the importance of stable relationships.
The major obstacle to suitable care is neither practical
difficulty nor lack of knowledge. It is that, whatever level of
intellectual understanding may obtain throughout the professions,
the appropriate sense of urgency and alarm is missing, or is
dampened down. There is a tendency for even the best-educated
and the best-motivated of people working with young children to
become to some extent habituated to the states of distress and
deviant behaviour that are commonly found in young people in
hospitals and other residential settings.
Thus the medical or nursing student, who in the beginning may be
seriously affected by the distress of the young patients
separated from home, will in time develop a 'second skin' against
being upset by these painful sights and sounds. Later encounters
with similar distress make less and less impact than did the
first, and to some extent sensitivity is blunted.
Similarly, at more senior levels those who are all the time
associated with situations of stress for young children - the
executive officer with absorbing administrative responsibilities,
the child-care officer with a heavy case load - may become
distanced from the problem and lose the sense or urgency which
goes with full awareness.
Intellectually there may be good understanding of the typical
distress responses in newly separated toddlers and of the
personality impoverishment that results from lengthy experience
of discontinuous relationships common in residential care and in
long-stay hospitals; but because concern is blunted the reality
situation has a certain psychological distance even for those
working within it.
Paediatricians, child care officers, policy-makers and
administrators may understand very well that the behaviour of
bright and disarming, deprived young children is unsatisfactory
development, yet take comfort from the bland behaviour just
because it is superficially reassuring and fits into the need for
peace of mind.
The worker's defence against pain may cause him unwittingly to
avert from the newly admitted child whose extreme distress is
painful to see, accepting with resignation that this is
inevitable and that in time this child, too, will merge with the
others who are bright and unattached. Young children tend to be
seen en masse or only fleetingly as people, with little awareness
of their individuality and less of their extended individual
experience. Although this may be imposed by the nature of the
job, the fleeting contact or the view en masse can only be a way
of defending against the hurt of coming close to the plight of
the individual in distress.
It has to be acknowledged that this defence against hurt is not
confined to the professions. It is used by all human beings as a
way of dealing with persistent threats to comfort, becoming deaf
or blinkered as the situation requires. But when it becomes
insidiously effective in the caretaking professions, a
consequence is not only reduced stress for the worker but the
sense that the problem itself seems less pressing.
Even the literature comes to have less meaning than in student
days when it was first learned that separation from the mother
into hospitals and residential institutions commonly results in
overwhelming distress - in protest and despair. These phrases,
so evocative when first encountered during training, come in time
to be barriers against the empathic pain they once aroused.
Familiarity gives a palatable gloss to the case material.
A degree of fatalism enters in. The problems may seem too
immense, and the detriments inevitable and unavoidable. Without
putting the reservation into words, or even into clear thought,
the consoling notion may be harboured that young children in
long-stay wards or residential institutions are in some way
different from our own more fortunate children - not to be
compared to them. So, with these elements of defensiveness and
rationalization, many within the services acquiesce more or less
in child-care practices that are an affront to their
understanding and training and that endanger the well-being of
the young child.
In this situation it is not only that the children are cared for
in ways which are detrimental to their good social and emotional
development. Their caretakers, mostly young girls with little
intellectual understanding of the problem but with affection for
children, are also denied the conditions of work that would fully
utilize their potential to be good substitute mothers. They in
turn tend to become defended against disappointing relationships
with the children and frustrated in the expression of their
mothering concerns. Their natural empathy becomes blunted and
they grow less perceptive of the needs of the young children
whose care they share with others. Their ability to help and
support the younger children is thereby diminished.
Thus, in the everyday handling of young children in hospital and
other institutions the rank and file develop defensive attitudes
to distress and deterioration similar to those in the higher
levels of the professions, pressed upon them by work situations
that deny them adequate involvement with the children.
Although there is everywhere goodwill and good intention towards
young children in care, with great resources and knowledge and
understanding of their needs, and although statements of
principle issue from the Ministry of Health and the Home Office,
the field situation stagnates because the common defence against
pain allows the acuteness of the problem to be dulled as by a
tranquillizer.
Without a sufficient degree of anxiety in the professions there
can be little improvement, no matter how much knowledge is
available. The problem is how to bring pain and anxiety back
into the experience of professional workers, but in such a way
that these are put to constructive use instead of being
defensively sealed off by the constant pressure in all of us to
escape hurt.
Our way of focusing attention on the problem was to turn to
narrative film.
The advantages of a narrative film record are twofold: first,
presentation on film gives the nearest approximation to actuality
and the visual medium is much more effective than the spoken or
printed word in piercing resistance in the field of child care.
Secondly, by focusing on one child it is possible to show the
sequence of events from first day to last, noting shifts and
changes in significant areas of behaviour, and to condense the
related factors within a relatively short presentation. This
allows the child's experience and behaviour to be perceived in a
longitudinal way that is not possible for staff caught up in
multiple duties and diversions or for the occasional visitor open
to impressions from the entire child group.
JOHN
Age 17 months
In a Residential Nursery for Nine Days
Silver Medal, Venice Film Festival
Silver Medal, British Medical Association
1971 B.L.A.T. Trophy for a Film of
Outstanding Educational Merit
43 minutes VHS B&W
(Available in Canada from the CSPCC)
SYNOPSIS OF FILM
At 17 months John was a placid child and easy to manage. He and
his parents had moved into the district a year earlier, and there
were neither kin nor close friends to care for John while the
mother was in hospital to have a second baby. Father would
ordinarily have stayed home to look after John, but in that very
week an insuperable circumstance prevented him. The family
doctor recommended placement in a local residential nursery.
There in the toddlers' room John joins five other children
between 15 months and 2 years of age. Four of these children
have been in the nursery from the first few weeks of life, and
because of the frequent changes of nurses have never known stable
loving relationships; they are aggressive and unattached. The
fifth child, Martin, had spent his first year in foster care and
continues to see affection - the only child apart from John to do
so.
During the first two days in the nursery John behaves for much of
the time as he did at home, confident that people in the
environment will respond to his needs as his parents had done.
When this does not happen he is increasingly bewildered and
confused, but he does not immediately break down. He makes more
determined efforts to get attention from the nurses, but he
cannot compete with the more assertive institutionalized children
and his quiet advances are usually overlooked.
When John fails to find a nurse who will take the place of his
mother he turns to teddy bears almost as big as himself. But
clinging to these gives only fleeting comfort, and John gradually
breaks down under the cumulative stresses of loss of his mother,
the lack of mothering care from the nurses, strange foods and
institutional routines, and attacks from the aggressive toddlers.
He refuses food and drink, stops playing, cries a great deal,
and gives up trying to get the nurses' attention.
His distress becomes so obvious that it can no longer go
unanswered; the nurses pick him up and hold him more, but they
are on shift duty and have also to attend to other children.
Because of the work-assignment system, they cannot give
sufficient individual attention to help John sustain the
temporary loss of his mother.
When his father visits John revives briefly and gives a glimpse
of the normality behind his distraught behaviour. But as the
days go by he turns away from the father who does not answer to
his wish to be taken from the nursery, clearly shown by John's
gestures. Father is painfully aware of the deterioration in his
son, and is distressed that he cannot take him home. John
withdraws more and more from the busy life around him. For long
periods of the day he lies with thumb in mouth, enveloped by a
large teddy bear. He is overwhelmed by a situation with which he
has tried to cope using all the resources of a normal healthy
17-month old child, and has withdrawn into apathy. Throughout
his stay in the nursery the young nurses have been kind and
friendly, but none has looked after him for any length of time.
When on the 9th day his mother comes to take him home, John
screams and struggles against her attempts to hold him.
A Note on Later Events
For several weeks after returning home John showed extreme upset,
often refusing his mother's comfort and the food she offered. He
had severe temper tantrums. For some time any reminder of his
stay in the nursery threw him back into the earlier distraught
behaviour. Many months later he continued to be acutely anxious
if he did not know where his mother was, and to have outbursts of
unprovoked hostility against her.
John is a simple story of a type found in journals, short case
notes which make little impact before the page is turned over.
But, as with A Two-Year Old Goes to Hospital twenty-five years
earlier, when told by the visual medium the story was powerful;
it pierced defences and caused much disturbance in viewers. The
reactions of a few colleagues convinced us we had a bomb on our
hands...
In July 1969 a special edition of the Bulletin of the Home Office
Inspectorate devoted all of its thirteen pages to John, accepting
its message and considering the implications for policy (Home
Office Children's Department Inspectorate, 1969). This marked a
turning-point in the provisions for young healthy children in
care in Britain. Moreover, the great number of reviews in
professional journals in Britain and around the world were
without exception keenly appreciative. A leading medical journal
predicted, "This film is a landmark. What A-Two-Year-Old Goes to
Hospital did for paediatrics, John will probably do for
residential care" (Lancet, 1970).
Below is a selection of quotes from the great number of reviews:
A horrifying film which forces us to look at what despair is for
a young child...What is so frightening is that the behaviour of
the young nurses is kindly, but the system results in total
failure to meet John's needs of a stable substitute mother
(British Journal of Psychiatric Social Work).
Should be compulsory viewing for everyone engaged in child care.
It forces the observer to identify with the plight of this little
boy, and through him with that of all young children in care
(British Journal of Medical Psychology).
No words could convey John's stress reactions as powerfully as
the camera does. The impact of John's hour by hour increasing
misery and deterioration becomes almost unbearable (Journal of
Child Psychotherapy).
Superb photography, a disquieting film which upsets our
complacency (Nursery Journal).
John is an individual who is defeated by a system which fails to
recognize or meet his needs. The nursery can be seen as a
microcosm of many other caring institutions, and perhaps of
society itself and the many thousands who are damaged (Child
Care).
Shows with disturbing clarity that institutional care is not
geared to meet the emotional needs of small children. The camera
dos not allow us to ward off John's mounting misery or to
disregard his desperate need for comfort. It becomes quite
harrowing to watch (Mental Health).
Again, as with the first hospital film, it was when John reached
the rank and file that the impact brought varying reactions. Two
principals of a national children's charity, whose name is
tainted in the community because of its large-scale use of
institutional care, react positively and invited us to conduct a
weekend seminar for staff who would be brought in from the
regions. But the plan was aborted by a prominent psychologist
who acted as consultant to the charity; he advised strongly
against the film and the seminar was abandoned.
The dangers of early separation had long been known
intellectually. Every social worker and child-care officer had
answered examination questions about separation. But it had not
been known with appropriate affect. A story that could be told
in twenty lines of textbook without causing comment, in its
visual form struck deep and provoked emotional turmoil in most
viewers. Although we had many grateful communications we also
had others which verged on the abusive. Some said the film was
'obscene'. Some reacted as bereaved persons can do, searching in
their pain for someone to blame - the parents, the nurses, the
authorities, the Robertsons. We were accused many times of
having sacrificed John to research, of having sat by without
doing anything about his plight, about being heartless; some
thought the nurses could have played more with John and were
critical of the parents for having left him in a nursery, etc.
All this was avoiding the essential communication about the
vulnerability of the very young. The film touched upon childhood
fears of loss and, in some, activated forgotten memories of
events that had scarred their lives. The hostile reactions were
classic examples of "shooting the messenger".
A university tutor wrote that she would not use the film again
for teaching, because it had been too upsetting for her social
work students; I replied that if she could not help her students
to learn from this piece of reality in the classroom, how would
they fare when they entered the field and were exposed to
situations which could set up defences? A committee which
recommended films for use with church groups blacklisted John as
"unethical" - as if we had caused John's distress, instead of
merely showing it.
Those who could use the experience of seeing John were helped by
it, but some others seem to lock into their irrational responses.
These ignored the fact that the four minutes shown of John's
behaviour each day were focused on the stages of John's
deterioration under fragmented care and gave no basis for making
judgments on what, for instance, the Robertsons did or did not
do. For some people reality was more than they could bear,
whether for John or for forgotten parts of themselves. Even some
consultants in psychiatry and psychoanalysis could not see
through their defensive antipathy. "I could kill you", said a
distinguished psychoanalyst...
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The Problem of Professional Anxiety
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