Sunday, 6 June 1999

PROMOTING RESILIENCE: Changing Concepts of Parenting and Child Care

Sebastian Kraemer, Consultant Child Psychiatrist
International Journal of Child and Family Welfare 3 :273-287, 1999.
Exact date of publication not known.

The most powerful influence on our capacity to manage life's hurdles is the quality of care we received in childhood, especially the earliest years. Other times and cultures have valued different strengths, so that resilience is not a fixed quality. In the modern world, our greatest fortune is the capacity to know our own minds and understand those of others. This is resilience which is truly flexible; the best condition both for personal mental health and for life in a pluralist and changing society. As the history of attitudes to children demonstrates, we are only at the beginning of a child-centred culture. Resilience based on secure attachment is essentially generous and open minded, and is of little value in an unjust or oppressive society.

Resilience of often used as a term of moral approval. The individual so described has triumphed over adversity. Courage and willpower are invoked. Yet these are moral qualities, while resilience is not. The dictionary definition is helpful: "resilient" = recoiling, springing back, resuming its original shape after bending, stretching, compression etc...buoyant (Oxford Encyclopedic English Dictionary, 1991)

In Latin, 'resilire' means to leap back. This paper argues for a resilience that is genuinely flexible, rather than merely resistant. Until the recent past, survival and success in life were usually attributed to the individual's own determination and courage, especially when he or she had an unpromising start, such as poverty, disability or being the victim of cruelty and abuse. Yet new knowledge of child development is beginning to identify the conditions that promote confidence and courage, even in people who began life with serious disadvantages. Human needs have not changed over the centuries, but the way we now understand them is quite different. To illustrate this point, and before describing recent theoretical and clinical findings, I will briefly chart the changing attitudes to child care since the eighteenth century,

Changing attitudes to children
Until the revolution in health care of the twentieth century, children's lives were far more fragile than today, at the mercy both of lethal diseases and parental whim. Consider the likelihood simply of surviving in 1750:

Deaths per 1000 births of children under 5
England and Wales
1750 750
1865 154
1963 21.8(1)

Two hundred and fifty years ago only one quarter of children made it to their fifth birthdays (Newson & Newson, 1974, p54). Our relatively sophisticated notions of child mental health would have seemed quite irrelevant, even absurd. "Child psychology is a luxury which only a small section of the world's parents can afford to consider" (Newson & Newson, 1974) Simply staying alive was sufficient evidence of resilience; it was not distinguished from survival.

In earlier times, and even today in some parts of the world, children were killed because their parents could not look after them, or simply did not want them (especially if they were girls). Although after a few years they could be put to work, infants and small children were a drain on the family, both in time and effort. Because of this - and perhaps also the dread of losing wanted children - past attitudes to children emphasised the need to control their inherent badness. De Mause (1976) writes about the infant as the receptacle for adult projections of evil. Infants are greedy, impatient and demanding, and they will have to learn not to be. Even in the eighteenth century, while philosophers such as Rousseau(2) were beginning to think about children in gentler ways, advice to parents was harsh: "I insist on conquering the wills of children... the parent who studies to subdue self-will in his children, works together with God in the saving of a soul: the parent who indulges it does the devil's work... break their wills betimes... let a child from a year old be taught to fear the rod and to cry softly... at all events from that age make him do as he is bid if you whip him ten times running to effect it. Let none persuade you that it is cruelty to do this; it is cruelty not to" (Susanna Wesley, cited by Newson and Newson 1974, p56).

The justification for such behaviour, which would now be regarded as frankly abusive, was that children would, if unchecked, stay evil and not get to heaven when they died (even if that day came all too soon). We know from epitaphs and letters written about and to children that they were as loved as they are today. Yet there was no notion of child protection in the home. Even as legislation gradually, and even grudgingly, prevented the exploitation of children in mines and other places of hard labour(3), parenthood was still, officially at least, a matter of instilling respect and obedience. The 'mind' of a child was simply wilful, and was to be trained. Children were not meant to think, but to learn(4). Considering the prevailing attitudes to children we can indeed wonder at their resilience! In spite of the gloomy advice they were given, some parents followed their hearts and cherished their children, but others followed God's will and came up against stubbornness that is quite heroic. "I never cried, I never sulked, I never resented, lamented or repented either my ill doings or their consequences, but accepted them, alike with a philosophical buoyancy of spirit which was the despair of my poor bewildered trainers" (Kemble, 1879). This was Fanny Kemble who, "at four... was given a fool's cap to wear at home, but she danced down the driveway and called passers-by to admire it" (Robertson, 1976).

Even in the twentieth century, within living memory, there were experts on child care and development who warned against the dangers of yielding to children's needs. "Nearly all of us have suffered from over-coddling in our infancy. How does it show? It shows in invalidism... coddling is a dangerous experiment... the fact that our children are always crying and always whining shows the unhappy, unwholesome state they are in. There is a sensible way of treating children. Treat them as though they were young adults. Never hug and kiss them, never let them sit on your lap. If you must, kiss them once on the forehead when they say good night. Shake hands with them in the morning... try it out. In a weeks time you will be utterly ashamed of the mawkish, sentimental way you have been handling it..." (Watson 1928).

Something had changed, however. It was now thought that the early years of a child's life were indeed formative ones, and that it was therefore a public matter how children were brought up. "The neglected toddler in everyone's way is the material which becomes the disgruntled agitator, while the happy contented child is the pillar of the state" said Gwen St Aubyn, in a parenting manual published in 1935 (cited by Humphreys and Gordon 1993). All this was in the context of enormous losses of men in the Great War and in South Africa, and an explicit concern that we needed to replenish stocks of obedient fighting men in case there was another war. Resilience would then be defined in terms of acts of courage on the playing - or battlefield (and its opposite as cowardice; the movement to seek psychological reasons for the effects of trauma gathered ground between the wars).

Note how the task of childrearing is related to the prevailing moral code. In earlier times God's will was the driving force, but by the early twentieth century it was the survival of the nation that mattered most. The most influential expert of those days was Dr Frederic Truby King, originally based in New Zealand, who launched a successful movement to convert mothers to breast feeding. Besides this laudable aim, almost everything else he preached was quite horrific. The key to the Truby King method was to feed your baby by the clock every four hours and never at night. If you gave in to him he would become spoiled and spineless and, by implication, no use as a soldier when he grew up. To toughen them up, babies were to spend much of the day on their own outside in the fresh air, and should not be cuddled or comforted even when in distress. Mothers were not encouraged to play with babies, because it would excite them too much. Fathers had no role except earning money.

Middle class mothers were particularly taken by this method, in the expectation that they could produce perfect children, but it was heartbreaking. Only a decade later, but with a world war in between, Benjamin Spock published the first edition of Baby and Child Care. It was a liberation from the harshness of prewar methods, and sold millions of copies. Spock advised mothers to trust their own judgement about what the baby needs. He did not say that one could let children do anything that they liked. "Children are proud to think that they can be truly useful and will rise to the challenge. This can begin very young. A baby of 9 months shouldn't be allowed to get the impression that it's alright to pull mother's hair or bite her cheek but that he owes her respect...." (Spock, 1968). In the meantime John Bowlby, who with Donald Winnicott and Emanuel Miller had protested in a letter to the British Medical Journal at the evacuation of children during war time(5) , had began work on what was to become attachment theory. He was, inevitably, preoccupied with the effect of separation, because it so often happened and was easily measured. But by the time his bestselling book Child Care and the Growth of Love (1953) was published he was talking about the nature of the intimate relationship between baby and caregiver - usually, but not necessarily, the mother.

"...all the cuddling and playing, the intimacies of suckling by which a child learns the comfort of his mother's body, the rituals of washing and dressing by which through her pride and tenderness towards his little limbs he learns the value of his own.. " (Bowlby 1953 p18).

This is the beginning of an entirely different approach to the study of children, in which they are not simply a bundle of desires and needs but are essentially engaged in a relationship with a caregiver. "There is no such thing as an infant" said Donald Winnicott(6) . In the following half century it has of course become much clearer that attachments may be formed with a small number of significant caregivers besides mothers. Within a generation of the publication of these texts, parenthood in Britain and other Western countries has changed. There is now greater recognition that infants are not simply selfish, but sociable, and need the company of a few responsible and committed adults for much of their waking lives. Published advice to parents emphasises this understanding, but it tends to evaporate rapidly under economic pressures. As a result of progressive reforms over the past 180 years children have of course become less useful economically. In terms of cost they may be regarded only as a burden. They need to be educated, clothed, and cared for, all of which are expensive. Public policy in some modern states does not reflect the knowledge gained during the last twenty years. While children may be better protected than they were, they are not necessarily better cared for.

Changing concepts of resilience: from passive acceptance to active involvement.
In earlier times, when war was uppermost in the minds of governments, we needed obedient children who were prepared to die for their country when they grew up. Their training would therefore be unreflective and unquestioning. You did what you were told at home and at school the teacher was always right. Trust and generosity were not useful attributes, neither in peace nor in war. Indeed, children caught up in conflict may well be better off if they know how to steal, and even kill. Although there may be 'honour among thieves', in modern states where there is great poverty, deprivation and danger resilience depends on little more than stubbornness and guile. Children who manage to keep out of trouble in high risk neighbourhoods, for example, seem to have needed rather harsh parental discipline to do so: "amongst disadvantaged children living in dangerous environments, favorable outcomes have been found to be associated with restrictive and authoritarian family patterns rather than with democratic ones" (Luthar 1993).

There is no point in being ill if there is no one to care for you. In a peaceful modern state where childhood (and dependency) is respected, being ill is part of life and is catered for (as in the European Union Parental Leave Directive), but in a survival economy the danger of being a burden to parents and peers is obvious. In such a world resilience is really no more than keeping out of danger. Compulsive self reliance (Bowlby, 1981) may well be admired by employers and by parents who have little concern for their charges, but it is not healthy, nor a sign of resilience. Being able to look after yourself means knowing when you can't.

Family relationships, too, require skills if people are to stay together, but modern expectations of intimate relationships are far more ambitious and demanding than they were. Although marriage for love has been acknowledged for centuries, it is only in the twentieth that it has (at least in the western world) become the primary reason. In the past it was more often a business arrangement than a romantic one (Richards 1995). Couples stayed together because they had to. The interdependence of married couples was far greater, and of course women had far fewer exits than they now have. Was this resilience, or simply lack of choice? Nowadays we would regard couples who manage to stay together as both lucky and emotionally resourceful. They have the capacity to weather the inevitable storms, to deal with conflict without being destroyed by it.

At school, although rote learning is still required for some exams, modern teachers are trained to encourage curiosity, thoughtfulness and even originality in their pupils, and the emphasis on coursework through the school year reflects that. In the past this attitude was more the exception than the rule.

Resilience is not, after all, simply a matter of survival or even of 'toughness', but one of flexibility. Looking at it this way questions also the easy assumption that men are by nature more resilient than women. They are of course usually physically stronger, but this refers only to muscle power. In general the male is less resilient than the female. From the very beginning boys are at a disadvantage. They are more likely to be be spontaneously aborted, to be born with chromosomal abnormalities and congenital deformities and to suffer brain damage before and during birth (O'Dowd & Jewell, 1998), are generally more demanding and fussy as babies (Haviland & Malatesta 1981)7, to have seizure disorders at all ages, and are at greater risk of a whole host of disorders of development, such as autism and related problems, dyslexia and hyperactivity, and from the damaging effects of postnatal depression in their mothers (Murray and Cooper 1997)(8). "At every developmental stage, the male is less mature than the female" (Gualtieri & Hicks, 1985, p428). Later on boys are more likely to have conduct disorders, to get into trouble with the law and more likely to kill themselves, or others (Lewis & Slogget,1988). In Britain the national publication of school test results shows how consistently superior girls are in literacy and other subjects that imply, or require, social skills. Overall their performance at GCSE level (public examination at 16 years) is about 10% better. Boys are not significantly better at anything, except in sports, and non-linguistic abstract skills such as maths and science. It is possible that one of the factors making mid-adolescence harder for boys is the intensity of their sexual drive. In girls this tends to peak later, after the exams are over. Fewer young men than women are now going to university, and more are unemployed. Men are more vulnerable to the damaging effects of unemployment. In adulthood most of the diseases that kill are more frequent, or come earlier, in men, so that on average women live the longest lives.

Parenting for resilience
How does care promote resilience? Some people still assume, like the old parenting manuals, that one is weakened ("spoiled") by care and attention. This seems to be proved by people who, in spite of deprivation and abuse in early life, can escape from the apparently inevitable fate of repeating the lives of their parents, and thrive as adults and parents themselves. Overcoming early hardship is, on this view, entirely a matter of personal determination. Yet, though temperament and intelligence certainly make a difference, will power is not simply inborn, and there is a great deal of clinical evidence to show just how powerful the past can be (eg Byng-Hall, 1995). In spite of our best efforts we often turn out to have many of our parents' least admired qualities. Heroic attempts, much exploited in popular narrative, to 'put it all behind you' are often doomed, as greater works of literature often reveal. The work of Fonagy and others (1994) has shown that those who manage to survive abuse and neglect achieve this not by putting early experience out of their minds but, on the contrary, by being able to remember, reflect and make sense of it(9). The resilient individual is one who can understand what has happened to him, and this of course requires understanding of what happened to others too, particularly his caregivers. Such individuals are able to break the cycle of sorrow, and bring up their children more successfully than their parents did them. Sometimes it is necessary to forgive one's parents, especially when it becomes clear what kind of upbringing they themselves had. The capacity to "put oneself in the other's shoes" is an essential condition of resilience in a modern pluralistic society. But where does this come from?

Optimal parenting
It seems on the surface to be an entirely moral matter. Parents usually want children to have 'good manners' which means, amongst other things, putting the needs of others before their own. But this is not a skill that can be conjured up in adolescence or adulthood when required, unless the seeds have been sown earlier on. The normal, and best, way of acquiring it is in infancy. This may cause surprise as it is often assumed that there is nothing you can teach babies about other people's states of mind until they can talk and think for themselves. But infants are profoundly social beings, and are just as much in need of conversation as they are of food and warmth. It is in fact quite difficult to meet a baby without trying to talk to him and touch him(10). We are, like other mammals, drawn into intense social contact with small and apparently helpless creatures. The conversation between an adult and the baby she (or he) is caring for is quite familiar. The adult speaks in a high tone, and tells the baby about himself: "that's nice, isn't it", "ooh, listen to that tummy rumbling", "here it is", "you are a grumpy boy", "no you can't have that", and so on. Most attached caregivers will sing to their babies. This, if it is consistent and continuous, is the basis of a secure attachment. The caregiver follows the infant, often in a playful way, helping him to make sense of his own states of mind and body. Babies come to expect patterns of responses from their principal caregiver, almost always the mother, so that strangers, however skilled, are unlikely to be able to take over without difficulty (Beebe, 1992). Note that, as well as understanding what the child is about, such care also includes limiting his behaviour. 'Containment' creates boundaries for both thought and action (Miller et al 1989).

For most of human history such moments have been of no more interest than any other domestic activity to any but the participants. That's just what people (almost always mothers) do with children. But it is now known just how important these interactions are, and how important that they go on daily throughout the early years. Infants cannot manage on their own, not just because they cannot feed, clothe and clean themselves, but because they cannot think without anyone there to help. They must first practice with another person, preferably with someone who loves them. When this goes well it is touching, but in many respects unremarkable. Hence the lack of historical and scientific interest in the process. When it goes wrong, even in quite subtle ways, we now know that the result can be quite damaging. Work with mothers who are depressed, for example, shows how the mismatch between the child's social offerings and the mother's gloomy responses leads to the child eventually 'giving up'. It is very painful to watch this on the video recordings that have been made for research purposes, but like the work of James Robertson (1952) that preceded it by forty years it is unforgettable(11). Besides frankly abusive or negligent care, other examples of misattunement can arise if the baby is too placid or too active for his particular caregiver. The former can contribute to failure to thrive (Skuse et al, 1994) while the latter may lead to hyperactivity (Stiefel, 1997). Babies can also remind their mothers of their own mothers. When this is an unhappy memory, the child will be experienced as a persecutor, with damaging consequences ('ghosts in the nursery', Fraiberg et al 1975). None of this is to blame parents, but to identify the sort of attentiveness that is required to bring up a baby. Most people can manage it, but a significant minority find the task difficult, even overwhelming, often because their own early care was lacking in similar ways. For all caregivers, though the rewards may be profound, looking after children is demanding and exhausting.

Many researchers and clinicians have tried to pin down the ingredients of a successful parent-infant conversation. Metaphors from the performing arts are often used to describe it (Trevarthen 1979). The infant and the caregiver are said to be in a dance; but who is in the lead? It is the infant who leads, while the adult responds, naming the child's efforts. His agency is acknowledged. Trevarthen emphasises babies' capacity to create theatre, to tease and make mischief with their caregivers. Another term to describe this relationship is the musical notion of 'attunement', which also implies close attentiveness to the other (Stern 1985). Follow-up studies of children who consistently have such care show that they are themselves more attentive and in tune with others. In order to understand one must first have been understood. Along with this goes greater curiosity about the world around, including wondering about how people think, why they do what they do, and so on. This is essentially a generous state of mind in which the child is open to new ideas and experiences.

Besides these cognitive and emotional developments there are also biological ones. The stability of body systems, such as those regulating hormones, temperature, blood pressure, is dependent to some extent on the quality of care (Hofer 1995), as is the optimum development of the central nervous system, which is necessary for the capacity to regulate affects and the the capacity to pay attention, and to think. "The growth [of the baby's brain] literally requires brain-brain interaction and occurs in the context of a positive affective relationship between mother and infant" (Schore, 1997, p1). Conversely: 'prolonged negative states are too toxic for infants' [and]..disrupt 'state regulation' (p15).

A securely attached child is more stable neurologically, physiologically, emotionally and intellectually, but this does not mean that everything is tightly regulated. Resilience is the capacity to get back in balance after being pushed out of it, to tolerate greater challenges without breaking down. Clearly this is most easily acquired in early infancy (and probably even before birth) but not everyone has such a lucky start.

Resilience through disadvantage
As we have seen, consistent, attentive and confident care is a powerful predictor of later resilience, but the term also implies qualities that may emerge in spite of deprivation or abuse. People who overcome serious disadvantage usually credit one or more supportive people in their lives, such as schoolteachers, friends or sexual partners who respect them and in whom they can confide. Others owe their resilience to belonging to a community. This may be a neighbourhood, a group of friends or an association of colleagues with common interests, a school or college, the armed services, or a faith.

There is always, as both modern research (Quinton et al, 1993) and traditional wisdom has it, a tendency towards either virtuous or vicious cycles: "good or bad fortune usually comes to those who have more of the one than the other" (La Rochefoucauld, 1665). Yet to some extent all of these turn up by chance. It is almost a tautology to say that resilience depends on luck. In the first place there are inherited(12) qualities of temperament, looks and intelligence (and the absence of genetic disadvantages), but none of them is much use if they are not cultivated in the child's upbringing. This too is a matter of luck. We do not choose our parents, yet the way they care for us is strongly determined by their own experiences a generation earlier (Steele, et al 1996).

The damaging effects of early loss or abuse can be overcome, provided the lucky break somehow makes up for the conversations that were missed. Another way of putting this is that some friendships (Pahl, 1996), whether individual or as part of a community, give one a second chance for mutual affection and reflection, and the opportunity to test these even when conflict arises, as it inevitably does in close relationships. While research shows that "the caregiver's capacity to reflect on mental states in describing their own childhood predicts [their] child's security of attachment" (Fonagy, 1999, in press), we have to rely on clinical knowledge to find out where this comes from. If the ordinary caregiver-baby conversations were absent or inadequate how are reflective skills obtained? Sometimes it becomes clear that quite badly abused children had a few months or years of devoted care in infancy, which we can suppose provided a kind of 'immunity' to later harm. Because people do not remember the earliest months of life this may only emerge after lengthy psychotherapeutic work. In other cases it is evident that the individual was not wanted from the beginning, or was simply too demanding for the caregivers. Some such people finish up as the loneliest adults, unable to sustain close relationships of any kind. Others are more resilient. In my clinical work I ask adolescent and adult patients who in their lives do they feel cared most about them. The answers are often surprising, even to the patient, who may not have identified their champion to anyone before. A fifteen year old girl who was often beaten in childhood and is now in care speaks of her cousin, ten years older than her, who would often rescue her from her parents' rows and abuse. A woman who had suffered years of sexual abuse told me of an older brother who she felt understood her plight as the family scapegoat. She also remembered her maternal grandfather with affection, while her mother (his daughter) is beneath contempt for failing to believe her disclosures of abuse. A middle aged alcoholic man, now a grandfather, who has stayed dry for ten years spoke of an uncle who took an in interest in him and "showed me things". The mother of his children left long ago and he had to care for them alone. He feels he has failed his daughter and her baby, but has done well with his youngest, a son. A woman in her mid-thirties has successfully brought up two girls, while their father is in prison. She cannot recall any love or support until adult life, when she met a nurse in the psychiatric ward where she was a patient. This led her into psychotherapy. How did she keep going until then? "Anger". All show something of Fanny Kemble's stubbornness. They are argumentative. They have not given up the hope that someone will respond, if only to fight back. It is hard to resist the conclusion that all of them were born with something of this spirit, but there is more to it than that.

The social context
This kind of resilience is admirable. As I understand it, I can admire these individuals because someone, however briefly, admired them before. In spite of everything, they were lucky (and one of the primary tasks of psychotherapy is to find that quality in the client or patient, however sad, bad or mad they may appear. This has nothing to do with being reassuring (Kraemer, 1994)). A social policy that sets out to promote resilience has to increase the chances of every child to be admired, whether by parents or other relatives, or by childminders, nannies and teachers. This means greater support and training for the increasing army of childcare professionals, who spend far more time with their charges than a generation ago. This is a trend that is unlikely to be stopped, though there are signs that some parents are beginning to wonder whether wall-to-wall work to pay for wall-to-wall childcare is so rewarding after all. It would be far better if both fathers and mothers had more time to care for their children in the earliest years, but this will require a change of culture in which such care is valued, and paid for out of public funds, as it already is in many European countries. All EU member states are now obliged to allow parental leave for up to three months to be taken at any time during the child's early years. Although this is paid in Belgium, Denmark, Germany, France, Italy, Luxembourg, Austria, Finland and Sweden the British government has refused to consider payment. In effect this reduces the measure to the promise that a worker can keep his or her job during three months unpaid leave, if they can afford it. Few mothers will take this up, and even fewer fathers. Having small children is expensive. Even when it is paid, the takeup of parental leave takes many years to get established, but the benefits in terms of the quality of children's attachments to both parents, and the corresponding reduction in the social costs of poor attachment will pay for the provision within a generation (Wilkinson 1997).

Meanwhile the trend continues. More parents are employing others to look after their preschool children. Rather than protest (in vain) about this it is better to use the moment to press for better trained and more professional childcare, so that those children whose parents are already overwhelmed have a earlier chance of making links outside the home. From family centres to therapeutic communities there is, potentially, a whole range of skilled care that has hardly any status at all in our rich modern societies (Kraemer, 1999). Fewer young people in Britain, for example, are choosing the caring professions, because they see low pay and high stress. (They go for computing and marketing instead.) In any case residential and day care staff have the least training, and the most demanding jobs. Registration of childminders is resisted by the UK government because it might remove thousands of perfectly capable people (mostly women) from the work force for lack of formal training qualifications. Yet in spite of a National Childcare Strategy to improve quality of care, looking after children is still regarded as a low-key domestic task that anyone can do, like house cleaning.

Modelled on the famous HeadStart programme in the USA, the Sure Start and Early Excellence schemes now proceeding in Britain are milestones in child policy. Yet there is a real danger that while the greatest effort will (rightly) be put into supporting families most at risk, other families may be left to the vagaries of the child care market. UK Government policy is to be socially inclusive, but it remains to be seen how this can be achieved without a massive political shift in attitudes towards children and parenting, which have up to now been effectively privatised. In effect the British class system, which privileges a small elite in private schools, putting the state system at a constant disadvantage, is likely to be built into the child's development in early care too. Comprehensive provision at any age must be so good that the private, so-called 'independent', alternative is put out of business.

A further problem is that child care is almost exclusively regarded as a job only for women. The Equal Opportunities Commission reports that 97% of those wishing to train for child care (precisely the same proportion as are aiming for hairdressing) are women. These opportunities pay significantly less than the jobs that attract boys, such as information technology and engineering. ('Girls fail to bridge gender gap on jobs', Guardian 9.4.99) Moss (1997) calls for a generic training in the care of children, similar to the profession of pedagogue found in many European countries (Jones 1994).

Resilience in the modern age
In a world in which individuality is acknowledged, even celebrated, resilience is best understood as the experience of agency (Rutter 1993): that what you do or say makes a difference, that it is worthwhile making plans for your life; that you are not simply a helpless victim of forces entirely beyond your control. Those who feel so powerless are more likely to become victims of scapegoating in their families or bullying by their peers. People who feel that they can make some changes in their lives if they need to are less likely to become ill (Blane et al 1996). The paradox is that such individuality can only be fostered in a good society. In very detailed cross-national comparisons Wilkinson (1996) has demonstrated the ill effects of social inequality. In a society with steep differences between the rich and poor everyone is less secure, the rich because they can see what might happen to them if they lose their place, through unemployment, illness or accident, the poor because they lack money, which makes them overestimate the protection that wealth provides. Unequal societies promote a more aggressive and selfish culture. In more equal societies, anxieties at both ends of the social scale are reduced and mortality and morbidity is lower overall. They also tend to be more prosperous (Glyn & Miliband, 1994). Social equality is good for business, too. In the United Kingdom, inequality increased during the Thatcher years. The proportion of the population on less than half average income was below 10% throughout the 1970s, but had increased to over 20% by 1985.

Children are still relatively powerless. They can shout and argue more loudly than they used to. They have 'ChildLine' and liberal minded teachers. But they are even more confined to their homes than a generation ago, for fear of collision with cars and bullying or abuse by strangers. It is no longer thought safe for a child under 10 to travel to school alone, for example. And they are still at the mercy of our adult terror of helplessness. Public (and private) discussions about children tend to veer from the sentimental to the negligent. When we talk about children we talk about everyone, yet there is, especially amongst politicians and journalists, a subtle but pervasive contempt for children, often disguised with condescending words, as if they were a different species. (The term "kids" for children sometimes conveys this). Quite apart from the scandalous levels of poverty in one of the richest countries in the world ('Two in five children born poor' UK Government figures, reported in The Guardian, 29.3.99) there are still far too many neglected children, at all levels of society. They may look as if they don't need anyone to help, but that is because they think that no one is bothered (Winnicott 1958). The streetwise young person wears a facade, but it can be a very impressive one. Such people can find their way into political power. After sexism and racism, we still have to confront 'childism'.

The millennium is an opportunity for a real shift in our political centre of gravity. If it means anything at all, it is the anniversary of the birth of a baby whose parents were in difficulty. In mentioning this I am not proposing a return to a supposed religious golden age, but a leap forward to an honestly child-centred one.

Most people would agree with this statement that "..healthy, happy, and self-reliant adolescents and young adults are the products of stable homes in which both parents give a great deal of time and attention to the children" (Bowlby, 1988, p2), yet it is not often stated so openly. Some might even cringe at Bolwby's simple faith in good parenting, as if we were wiser now, and knew that the reality is always different. It is not. The majority of children are brought up this way, but the majority of social and psychological problems arise in families that are not like this. Paradoxically, one of the serious political obstacles to promoting secure attachments is the fear of causing offence to parents who fail their children. Attachment theory, precisely because it delineates so clearly the conditions for healthy development, has always run into criticism from those who assume it holds parents responsible for everything that happens to a child. Parenting is indeed an immense responsibility, far greater than most people entering it can possibly know, but the purpose of this paper is not to blame parents but to show that pain and loss need not be passed mindlessly from one generation to the next. Blaming parents is in any case futile, both clinically and politically. The moral development of children is not, as was formerly believed, dependent simply on obedience to adult authority, though that is often necessary on the way. It requires years of negotiations between caregivers and children, beginning with the apparently simple conversations we have with our babies. Parents should play the major part in this, but they cannot do it alone. Childminders, nannies, teachers, and others all need the reflective skills that make all the difference between power which is abused, and authority which is necessary.

It is no good arguing for resilience based on secure attachment if we do not also argue for a society that welcomes it. In a world in which trust is possible, in which ordinary life is not constantly undermined by threats of instability, loss, oppression, or worse, the securely attached individual has greater freedom of social action, at home, at school, and later in adult relationships, both with intimates and with colleagues. But there is little value in having a generous and open mind if life is primarily a struggle for survival, where there are few or no trusted neighbours, and where it is better not to think about other people's states of mind. If you have to steal from others to survive, for example, it is a hindrance to be bothered about their feelings. Thoughtfulness is not useful in a thoughtless culture.

"Enabling and facilitating social competence, self-esteem and secure attachments is likely to create the conditions for a post-industrial society where relationships are based on mutual recognition and respect rather than on fear and deference" (Svanberg, 1998)

Dr Sebastian Kraemer
Child & Family Department
Tavistock Clinic
120 Belsize Lane
London NW3 5BA


1 in the African country of Niger, death rates of children under 5 are 318 per 1000, ie at the levels of 18th Century England. (1996 figures, The Guardian (London) 11.5.98)

2 Jean Jacques Rousseau published Emile or On Education in 1762. " your scholar [child] well before you say a word to him; first leave the germ of his character free to show itself, do not constrain him in anything, the better to see his as he really is".

3 the Earl of Shaftesbury (Anthony Ashley Cooper 1801-1885) did a great deal to protect children from abuse, but his motives were as much political as humanitarian. He was afraid that such children, if not rescued, would become revolutionaries when they grew up (Hendrick, 1994)

4 Charles Darwin and Mrs Gaskell were honourable exceptions, but his sensitive observations of his own infant were published in the learned philosophical journal Mind (II, 1877, 286-294), and her diary was not published (Gaskell, E.C. My diary; the early years of my daughter Marianne, privately printed, London, 1923).

5 a similar letter to The Times was not published (Van Dijken, 1998)

6 This statement was never published, but Winnicott recalls that he said it in a scientific meeting of the British Psycho-analytical Society in about 1940.

7 It is also interesting to note that parents tend to imitate boy babies more than they do girl babies, (Trevarthen et al. 1999) suggesting that parents might have to work harder with boys.

8 They are also more obviously affected by parental conflict, but this may be evidence of resilience, since some of their sisters, who "cope" at the time, are probably at greater risk of depression later on, when they themselves become parents.

9 Many survivors of the Nazi holocaust were obliged to keep quiet about their stories, because no one wanted to hear them (Haas 1996). This was not in the end helpful. As is well known, survival from such horrors is on its own not enough, and some of these victims later took their own lives.

10 English is a difficult language for this kind of writing. "her" would do just as well, but not both together.

11 Murray and colleagues' recordings are not publicly available, to protect the subjects of the study, but many professionals have seen them and the impact should, in time, be as influential as the Robertsons' work in changing attitudes to the care of small children.

12 The mother's nutrition before her baby's birth is also a crucial determinant of the offspring's lifelong health (Barker 1992)


Barker, D. (1992) Fetal and infant origins of adult diseases. London: British Medical Journal (BMJ) Books

Beebe, B, et al (1992) A dyadic systems view of communication, in N. Skolnick & S. Warshaw (eds) Relational Perspective in Psychoanalysis Hillsdale NJ: Analytic Press

Blane, D., Brunner, E., Wilkinson, R.eds (1996) Health and Social Organisation: Towards a Health Policy for the 21st Century, London: Routledge

Bowlby, J. (1953) Child Care and the Growth of Love. London: Pelican

Bowlby, J. (1981) Attachment and Loss, volume 3: Loss, Sadness and Depression. Harmondsworth, Penguin Books, chapter 21

Bowlby, J. (1988) A Secure Base, London: Routledge

Byng-Hall, J. (1995) Rewriting Family Scripts. New York: Guilford Press, ch 3

De Mause, L. (1976) The Evolution of Childhood, in (ed) L. De Mause, The History of Childhood. London: Souvenir Press

Fonagy, P., Steele, M., Steele, H., Higgit, A. & Target, M. (1994) The theory and practice of resilience, Journal of Child Psychology and Psychiatry, 35(2) 231-257

Fraiberg, S., Adelson, E. & Shapiro, V. (1975) Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships, Journal of the American Academy of Child Psychiatry 14, 387-421

Glyn, A. & Miliband, D. (eds) (1994) Paying for Inequality: The Economic Cost of Social Injustice. London: IPPR/Rivers Oram Press

Gualtieri, T. & Hicks, R. (1985) An immunoreactive theory of selective male affliction, The Brain and Behavioural Sciences 8, 427-441

Haas, A. (1996) The Aftermath: Living with the Holocaust. Cambridge, England: Cambridge University Press

Haviland, L. & Malatesta, C. (1981) The development of sex differences in non-verbal signals: Fallacies, facts and fantasies. in C Mayo & N. Henly (eds) Gender and Nonverbal Behavior, New York: Springer

Hawkins, J. & Allen, R. (eds) (1991) The Oxford Encyclopedic English Dictionary. Oxford:Clarendon Press

Hendrick, H. (1994) Child Welfare: England 1872-1989, London: Routledge, p 9

Hofer, M (1995) Hidden regulators: Implications for a new understanding of attachment, separation, and loss, in S. Goldberg, R. Muir & J. Kerr (eds), Attachment Theory: Social, Developmental and Clinical Perspectives. Hillsdale NJ: The Analytic Press

Humphreys, S and Gordon, P (1993) A Labour of Love: The Experience of Parenthood in Britain 1900-1950, London: Sidgwick & Jackson

Jones, H D (1994) The social pedagogues in western Europe - some implications for European interprofessional care, Journal of Interprofessional Care, 8(1) 19-29

Kemble, F. (1879) Records of a Girlhood, New York, p 9

Kraemer, S. (1994) The Promise of Family Therapy, British Journal of Psychotherapy 11, 32-45

Kraemer, S. (1999) Obstacles to therapeutic work in the residential care of children and adolescents, Therapeutic Communities 20 (3) 145-156

Lewis,G. & Sloggett, A. (1998) Suicide, deprivation, and unemployment: record linkage study, British Medical Journal, 317, 1283-6

Luthar, S. (1993) Annotation: methodological and conceptual issues in research on childhood resilience, Journal of Child Psychology and Psychiatry, 34, 4, 441-453

Miller, M., Rustin, M(argaret), Rustin, M(ichael) & Shuttleworth, J. (eds) (1989) Closely Observed Infants. London: Duckworth

Moss, P. & Petrie, P. (1997) Children's Services: Time for a New Approach. London: Institute of Education

Murray, L. and Cooper, P. (1997) Effect of postnatal depression on infant development, Archives of Disease in Childhood 77, 99-101

Newson, J. and Newson E., (1974) Cultural aspects of childrearing in the English-speaking world, in M. Richards (ed), The Integration of a Child into a Social World. Cambridge: Cambridge University Press, p56

O'Dowd, T, & Jewell, D. (eds) (1998) Men's Health, Oxford University Press

Pahl, R. (1996) Friendly Society. In (eds ) S. Kraemer & J. Roberts, The Politics of Attachment. London: Free Association Books

Quinton, D. Pickles, A., Maughan, B. & Rutter, M.(1993) Partners, peers and pathways: Assortative pairing and continuities in conduct disorder. Development and Psychopathology, 5, 763-783

Richards, M. (1995) The companionship trap, in C. Clulow (ed) Women, Men and Marriage. London: Sheldon

Robertson, P. (1976) Home as nest: middle class childhood in nineteenth century Europe, in L. De Mause (ed), The History of Childhood. London; Souvenir Press, p 417

Robertson, J. (1952) A Two Year Old Goes to Hospital (film) New York: Concord Films

Rutter, M. (1993) Resilience: Some conceptual considerations, Journal of Adolescent Health, 14, 626-631

Schore. A. (1997) Interdisciplinary developmental research as a source of clinical models, in M. Moskowitz, C. Monk, C. Kaye. & S. Ellman (eds) The Neurobiological and Developmental Basis for Psychotherapeutic Intervention Northvale NJ: Aronson, 1997

Skuse, D., Pickles, A., Wolke, D. & Reilly, S. (1994) Postnatal growth and mental development: Evidence for a 'sensitive period', Journal of Child Psychology and Psychiatry 35, 521-545

Spock, B. (1968) Baby and Child Care. London: New English Library, p29

Steele, M.., Steele, H. & Fonagy, P. (1996) Associations among attachment classifications of mothers, fathers, and their infants: Evidence for a relationship-specific perspective, Child Development 67, 541 -555

Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books

Stiefel, I. (1997) Can disturbance in attachment contribute to attention deficit hyperactivity disorder? A case discussion, Clinical Child Psychology and Psychiatry 2(1), 45-64

Svanberg, P. (1998) Attachment, resilience and prevention, Journal of Mental Health 7(6), 543-578, p567

Trevarthen, C. (1979) Communication and cooperation in early infancy: a description of primary intersubjectivity, in M. Bullowa (ed), Before Speech. Cambridge, England: Cambridge University Press

Trevarthen, C., Kokkonaki, T. & Fiamenghi, G. (1999) What infants' imitations communicate: with mothers, with fathers and with peers, in J. Nadel & G. Butterworth (eds), Imitation in Infancy. Cambridge: Cambridge University Press

Van Dijken, S. (1998) John Bowlby: His Early Life. London: Free Association Books, p108

Watson, J. B. (1928) Psychological Care of Infant and Child. New York: Norton

Wilkinson, H. (1997) Time Out: The costs and benefits of paid parental leave. London: Demos

Wilkinson, R. (1996) Unhealthy Societies: The Afflictions of Inequality, London: Routledge

Winnicott, D. (1958) The antisocial tendency, in D.W.Winnicott: Collected Papers. London: Tavistock

No comments: