Plenary Session P7 - Youth and the Family

Chaired by Gail Slap - Ohio USA

and Neville Butler - Bristol and London UK

Chair person: Welcome everybody, a bit late because the last session ran over some, I am Gail Slap, I am in the Departments of Paediatrics and Internal Medicine in Children’s Hospital Medical Centre in Ohio and I am going to ask Dr Butler to introduce himself. I think his name is well-known to many of you for his child health surveys both in Great Britain and many other countries around the world.

Dr Butler: Good evening everybody. I am usually referred to as the late Professor Butler but this time we were all on time so we had to cut corners and what beautiful corners we have we are going to give these sessions and I am going to introduce some people in the end and Gail is going to slap me down if I may say if I do anything right , probably I won’t and we leave you to do the introductions, if you will, Gail.

Gail Slap: Our topic this afternoon is using the family as you’ll see from the titles that are listed there we’re covering it very broadly. Our fist presenter this afternoon is Pamela McNeil who is Director of the Women’s Centres of Jamaica Foundation.

Women’s Centres of Jamaica Foundation Programmes  Pamela McNeil

We can talk a lot about statistics and figures but it might be better if we remembered that young people we are working for are not statistics, they are people, and if you don’t mind, I’ll read all the information and show you some slides of the young women who passed through our Women’s Centres programme in Jamaica.

I’d like to go back to the year 1977 when in Jamaica we had been watching with dismay the increasing number of births to teen mothers. In that year 31% of the total births were to teenagers and these young mothers were likely of course to follow the usual pattern of repeat pregnancies leading to 3 to 4 children by the time they were 20. Those of us who were teachers can remember the deep distress we felt having to observe the total waste of so many bright girls who dropped out of school due to pregnancy, resigned perhaps to the drudgery of poverty. And they represented a huge loss in national potential. And add to this plight that of their children who in many cases were blamed by their mothers as the cause of all ills besetting them, hence they were very often neglected and sometimes abused. And all this lead to the dream of a day when these young mothers and their children were given the opportunity to achieve their full potential and take their rightful place in the process of national development. The core programme for adolescent mothers was established in January 1978 and we just celebrated our 20^th anniversary and it was lovely to have Diana Birch from Youth Support there with us at that celebration a couple of weeks ago. Today we have implemented the programme in 7 main cities across Jamaica.

Right from the start the main objective was to motivate young mothers to choose education instead of continuous motherhood. Only then could we succeed in delaying second pregnancies and raising the employment potential of these young people, a viable alternative to depending on men for support and consequently having more babies. It’s never enough to say young mothers put them in home economics or sewing projects. This couldn’t be regarded as valid suggestion which could even be considered in the cases where bright, intelligent, promising teenage girls became pregnant before completing their formal education. To obtain quality results a quality programme had to be implemented. Although academic, skill-training areas were key other components of the programme had to be included in order to deal with the young mother, her baby, her baby’s father, her parents in a holistic way. Therefore we had to set up a practical efficient process which would facilitate assessment of each of the participants for academic capability and potential, emotional status, self-worth, economic status or potential, knowledge of sexuality and related issues, nutritional status and acceptability of family planning.

The Women’s Centres of Jamaica Foundations Adolescent Mothers Programme addresses all these facets. The academic skill training instruction is geared towards the girls’ capability and potential. Extensive individual and group counselling, take care of self respect, emotional problems and the child’s grasp of sexual reproductive health and family planning knowledge. You notice I say child because some of our little ones are 12 and 13 years old. All of them are under 16, 16 years and under. Experts from the programme of course are used to deal with the problems which fall outside our usual ambit. Our participants are either pregnant or lactating mothers and we are aware that only a healthy well-nourished mother can produce a healthy child, In the case of the teenage mother we are in fact dealing with 2 growing children. Obviously with these pregnancies there is a risk that neither mother or child will have sufficient nourishment for proper growth and development.

We use the existing facilities in other agencies, whether these be educational or provision of services as it’s important not to duplicate any services that are already there. But also as a part of cementing relationship between the agencies.

I’d like to go through the various programmes that we deal with in the Women’s Centre Programme. Of course the core programme as I’ve said is the Adolescent Mothers Programme. The mandate of this is of course to continue the education of young women who get pregnant in school and place them back into the regular school system after the birth of their babies Delaying subsequent pregnancies until the young woman has reached her professional or vocational goal. I’d like to tell you that many many of these young women move easily through secondary school into tertiary institutions eventually serving their nation as teachers, nurses, we have 4 doctors that have graduated, lawyers, administrators or entrepreneurs.

As well as the 7 main centres we have 5 functioning out-reach stations, the outreach programme provides assistance to those women in deep rural or inner city areas who cannot often get to our main centre. The main centre in Kingston, Jamaica also provides O-level examination courses to facilitate 11^th graders, fifth-formers who become pregnant in their crucial examination year. This Kingston centre has been given the status of examination centre by our Ministry of Education, so the students are not only coached towards the exams but can sit the exam at that centre. Dormitory and it’s the only residential aspect of the programme, we do not believe in institutionalising our children. But the small dormitory is provided for those fifth-formers from the rural centres who wish to enter O-level classes. Each centre operates a day nursery of course where are babies of the teen mothers are cared for, breast-feeding is facilitated and good parenting habits for both the baby mother and the baby father are encouraged. We’ve had to expand 2 of these day nurseries in Kingston and Montego Bay to facilitate babies of poor working mothers who can’t afford the private nurseries, the costs are very high.

Several counselling strategies are used in the centre but the main thing is the importance placed in ancestry and pride in being a Caribbean woman. The dignity of womanhood is stressed as is human development and its effect on future generations. Pride in our children and careful planning of our families is also given equal importance. The effect of the change in the perception of themselves as individuals is best understood by seeing the vivid contrast between the girls just entering the programme who are quiet, shy, reticent and those leaving who are relaxed, cheerful, outspoken and optimistic. Having discovered a new dignity they hold their heads high and talk easily on all subjects including sexual and reproductive health. They are happy to have their baby but do not want another child until they have established themselves in career or job. It does not require much encouragement on the part of the staff for the young women to accept a method of contraception. Each of the 7 centres, the main centre offer some vocational training as well as academic curricular, for example one centre offers cosmetology, another - home economics, all centres do chicken rearing and some fish-baking, bee-keeping and vegetable growing, the main thing here is when the girl goes back to school she has another string to her bow, if all else fails she can do something like that to be economically viable. Kingston centre concentrates on drapery, quilting and the production of baby clothes. At all centres counselling and referral service are given to the parents of the teen mothers particularly to her baby father and actually any other woman who happens to see the sign Woman’s Centre and wants to walk in gets some help.

To date over 22 thousand young women have been returned to school in the island of Jamaica and 1.4% second pregnancy rate has been maintained throughout the programme. Figures for 1997 show that of the 3,016 births island-wise to mandated age group 16 years and under the programme accommodated 1546 in that year or 51% of these young women and I don’t think it’s too bad when you can see we only have 1 centre per 2 parishes across the island.

We have another programme for older women skill-training and these pilot projects have been quite successful in the urban areas of Kingston and the rural townships of Morant Bay in St.Thomas and in Clarendon. Over 600 young men and women over 17 years to 25 years have been trained in this particular project to date and most of them are now either employed or self-employed and we are in the process of expanding this programme to other rural centres. We also provide academic instruction and counselling to children aged 9 to 13 years in a well-integrated homework programme. This programme is operated out of the main urban woman’s centres and it is an attempt to delay first pregnancies and steer the young towards education rather than early sexual activity.

We have set up a counselling clinic at our Kingston centre and this clinic services children and adolescents of any age with any problem whatsoever. Those children who are already sexually active are assisted in choice and provision of a contraceptive method. We don’t have any problem in providing contraceptives to our youngsters who are under the age of consent under 16. And this clinic now has part-time voluntary medical personnel conducts peer-counselling training session for school children during our summer vocation periods and that is where Dr Birch came with us last summer and handled quite a few of those sessions for us. We also run parenting education classes. USAID has given us some money so we decided to look at the street children and we have quite a few in Jamaica. And out of 5 rural centres for children who have already dropped out of schools or those at risk of dropping out we have what we call an “upliftment programme”. Remedial work is done in those classes but the goal is to keep them at school, return them to school or place them either in training institutions or employment.

We are constantly attempting to develop new methodology in our programmes, we have text-books and teaching aids in abundance but lecturing alone as you know does not work with this generation. The accent is on the visual. The attention span of the young is shorter, they need family life sex education programmes which are compatible with the life-style of the majority of our young in Jamaica. And the background factors of poverty, poor and overcrowded housing, incest, matri-focal households, prostitution and drugs can’t be ignored. The teen mother comes to us at the centres as a product of a negative society and family background. A profile of a typical; student could show a bright 15 year old who comes from a low income housing usually headed by a single parent with additional six children living in a crowed home, she attends a secondary or all-age school, her mother usually was also a teen mother. She enrols through referral from another agency, usually a school or a clinic, or by word of mouth now, and by this time she is in her second trimester. A product of the “it can’t happen to me” syndrome. She may or may not have had much knowledge about her sexual and reproductive rights. Her mother and herself usually agree that the baby will not be given up for adoption and she wants to go back to school. Her baby father would be a young man under 25 and not working. He accepts paternity, is apologetic, knows about family planning, would like the girl to continue her education and he promises to help in any way he can to facilitate her going back to school. He looks forward to having his cut. 

One of the most tragic consequences as you know of teen pregnancy is the curtailment of the young woman’s academic education. The practice of throwing the young women out of school is bad enough, but to victimise them further by action or implication in placing them in school training or in essence making her a good house-wife for some lucky man is not worthy of our societies whose representative signs for many international documents dealing with the rights of children and women’s rights and reproductive rights. The right of a girl to education is not dependant on whether or not she becomes pregnant prior to the completion of her schooling, it is an inalienable right and must be upheld.

A recent tracer study in 1995 showed that the average second pregnancy rate over the years from the programmes inception in 1979 has fluctuated between 1.3 and 1.4%. That the young mothers who have had another child waited an average of 5.5 years before embarking on the second pregnancy. Abortions are nil. Their children, those teen mothers’ children are now in school and amongst the girls the children of those children of the teenage mothers who are now teenagers themselves no pregnancies at all have occurred. I think this programme therefore completes that very necessary component of childhood that of academic education ensuring that the young woman grows as she should into a responsible well-educated adult. It breaks the cycle of successive generations of women bearing children in their early teens and it’s a prime example of a social programme extending its positive effect to the next generation. And it produces for the nation a cadre of well-adjusted well- educated professional instead of single mothers with many children requiring constant handouts.

If we were to be asked today of real achievements of the Women’s Centre we would list the decrease in the destructive negative societal attitudes formerly displayed towards teenage mothers and poor women on the whole by the middle and upper classes in our society. The breakdown of the barriers from the Ministry of Education and the change which we’ve got working in the education code to allow teen mothers to return to the normal school system. The increasing co-operation and acceptance of the programme by ministries of Government, the private sector, schools and society at large. The many young women who are graduated from our programme, the scholastic achievement of the children of our former teen mother, all of those of school age are now in school.

The results of our appeal, and this is important I think, to the relevant authorities in Jamaica regarding the criminalising effect on our young men of the age of consent law. In the case of consensual sex young baby father below the age of 23 we have got written into the law that judicial discretion be exercised before sentencing. And to have carried this through to the international stage last year in Ethiopia at the UN expert group meeting I think is a feather in our cap. Because the young men are just is much in need of our help and assurance as the young women. Of course we are presented daily with the abortion problem and surely we think the surge of abortion can only prevented by early access to sex education. and if young people are sexually active to contraceptive techniques and quality service and counselling.

We listen to many of the young women who’ve been assisted by our Women’s Centres and we find common factors running through all of their poignant stories. How casual these boy-girl relationships are, there is no stability at all in this episode, nothing deep-rooted, no thinking through, no positive decision to have children. On the one hand the young  women appear to want to continue the relationship, however there is rarely such an implicit response from the young man. And we note their comments some of the young men, if I have to pay out money I will pay her money, but that’s all, everything else is with her. To be fair the lack of gainful employment might be the cause of the avoidance of responsibility by the young men, but I think there are other ingrained societal attitudes in play. Another common threat appears to be the apparent relationship between the age of the teen mother and her own mother at first pregnancy. In one case at our Kingston centre we saw both the young mother’s mother and her grandmother being first pregnant at 15 whilst other sisters were also pregnant in their teens. We seem to be living with a norm here.

But we wonder if that is the norm, why then throughout the interviews with the young moments we were given the impression that everyone connected with this young woman in the family, at school, in the community and the young woman herself is so disappointed when she becomes pregnant is the pull therefore of historical and cultural tradition so at variance with the hopes and dreams of those involved or does poverty and its attendant social melodies and emotional neglect and ignorance win in the end. What is very clear is that all players involved are convinced that education is the key to upward mobility. Participants who are now at one of our Women’s Centres will talk to you of taking my examinations now I still have a chance. Parents clearly come across as being disappointed when their daughter has to leave school and delighted at the prospect of her getting another chance through a Women’s Centre. Even her baby father, if they are sorry about anything at all they are sorry about their girlfriend’s having to leave school.

In all the evaluations on our programmes there appears a clear difference between client and control groups. Women’s Centres of Jamaica Foundation clients are able to complete their education, are higher achievers, find different career path, find jobs as twice the rate and fetch much higher pay than the control group. Doctor Handa of the University of the West Indies did what we requested him to for many years and that’s a cost benefit analysis and I think this should be done much more often with social programmes. Because his cost benefit analysis of Women’s Centre Foundation states that the social and private benefits of the back to school programme for the adolescent mother in the year 1993 due solely to increased education was a 136 million Jamaican dollars. There was in that year a reduction of 323 births due to the programme and the implied savings to the health centre was 13 million Jamaican dollars. We are very glad with his analysis because of course  it helps us all the time when we are applying to the Government of Jamaica for our budget. But he rounds off his analysis by stating that each dollar invested in the Women’s Centre programme results in $7 worth of benefit to the society and that’s sort of analysis is very important as I say for social programmes. I think if we really believe that reproductive rights are human rights as women and then we have to recognise the synergy that links reproductive rights and education to the empowerment of young women. And I think it is this that has been demonstrated time and time again in all of these 20 years of the Women’s Centre of Jamaica Foundation. Thank you very much.

Gail Slap: We are going to have to hold on questions because of time but I want to say that it was a very moving and beautiful presentation, an example of hands-on strategy that has truly made an enormous difference that varies with the kind of data that we’ve seen multigenerations coming from other investigators and I think is gone even a step beyond and has given us some cost-effectiveness data which is as you say one of the most powerful pulls we can have as we try to advocate for young people. So congratulations, I thought it was beautiful.

Our next presentation will be given by Fiona Subotsky who is a consultant child and family psychiatrist at King’s College in London. And the title of the presentation is “Working with families where there has been abuse”.

Working With Families Where There Has Been Abuse Fiona Subotsky

Hello everybody, just a word about myself, I am child psychiatrist working in a general hospital and we see a range of children with different kinds of problems, different ages, it links up with the Maudsley and it’s in quite a deprived area in South London. I was going to focus down on one particular aspect of abuse I mean almost one might think the word not should have come in the title it’s working with families in whom we didn’t realise there was a question of abuse. But the reason I am doing this is that earlier in the year I was asked by the Medical Women’s Federation nationally to take an interest in domestic violence. And I said to one of our local public health doctors that I was going to take an interest in this and he said, well what does that have to do with child and adolescent mental health. So I started to think about what does it have to do with child and adolescent mental health and I think this is a process I’ve begun to think about and I am going to spend most of the time looking at a few cases so I hope there will be time for some feedback discussion.

In a sense partly to link with the issue before I think that the health professions in this country it’s just begun to dawn on them perhaps a little bit behind other agencies and other countries of the importance of recognition and awareness of domestic violence,  what can doctors do, what can health services do and I think this is stage one. For instance, the Royal College of Obstetricians and Gynaecologists has recently started to take in interest in this and they are becoming aware that pregnancy may either provoke actually the incidence of domestic violence or increase it. And here is a little snap shot from their discussion: there is increased risk to the foetus from miscarriage, premature birth, low birth weight, foetal injury, foetal death. So another reason to take a history in child psychiatry, what was going on in the pregnancy, because there may have been a direct effect on the foetus.

Now domestic violence is an ambiguous term and my looking at the literature shows that there are two schools of thought and they are not backed up by too much evidence either way. One is that it’s equal between sexes exchange of fistycuffs as it were and with equal damage appearing in A and B and on the other hand it’s about it being to do with abuse of power and very much male to female. Now I think in these issues which are largely about wife and mother abuse this is what we need to be thinking about, but I think we need to keep an open mind on the directionality.

Various definitions have been used but the incidence has been estimated as being as much as one in four women experiencing abuse from a partner. This likelihood is increased by the presence of children and pregnancy may be a precipitator. It’s of interest that 40 to 60 % of separations are estimated to have involved domestic violence. This is not obvious in the later presentation, it’s something that’s denied and glossed over. What ‘s also becoming more clear and the NSPCC is taking this up now is that there is a relationship to child abuse which is again not been fully understood before.

In cases of domestic violence in families with children, children witness the abuse in 70% of incidents. I think this is probably in contrast with presentations where certainly our experience is that the mother will say, it didn’t affect the children. Take that with pinch of salt. They have been directly physically abused in 40 to 60%, a very high percentage. Sexual and emotional abuse are also increased and conversely in child protection cases it has been found that domestic violence is probably present in about one third. The ranges of figures are rather large but that it’s a serious problem is evident. I was looking at a book by Arnon Bentovim called “Trauma Organised Systems“, this is not about domestic violence as such, his interest arose initially from child abuse work at Great Ormond Street and then sexual abuse. But what I am going to show I find has got a lot of relevance to work in this field and sheds light on the cases that we are going to look at. These are classic differentials but that does not mean they are not useful. Internalising and externalising, being more characteristic, we don’t just have to say it’s girls and boys, men and women, because it doesn’t always work out like that, but there are correspondences. Internalising you get anxiety and enmeshment, externalising - diversive, dismissive. The attribution and direction of blame, this is very important to listen out for the negative self-representation, the interjective, “It was my fault, I should not have done this, I kept blaming myself” until something finally happens to break the pattern, perhaps the abuse of the child. Externalising, negative to the other perspective, this is part of the pattern of how the cycle of violence may be produced and we will hear that in some of the examples I’ve got.

Identification this is a child, are they siding with the victim, the abused, or are they siding with the victimiser, do they become abusing and defiant themselves. And the behavioural responses, the self-destruction, we saw in a workshop this morning, this is very common presentation of young women with self-destructive behaviour, it’s common with a lot of young men too, self-mutilation, anorexia, anxiety and depression. Now we are beginning to see the symptoms which we see all the time we would have known in a sense that they derive from stress, but this is more systematic.

On the other hand aggressive, power-asserting conduct disorder, substance misuse. I think we also get substance misused very much this side as well in fact and I think that one of the sad features of our society is that sometimes the aggressors can be highly successful people not presenting as patients or seeking for help in any mode whatsoever, I am sure those of you who work within the courts will have seen for instance all this many times.

I am starting off with what you might call a typical school-phobic. Although she was 11 Mary was in fact pubertal and I think that’s important because of the degree of her distress, she was terrified of going to school. She’d only been for 3 half days, many struggles and tantrums with her mother and stepfather. Disliked school and as many of these children do she feared failure and criticism. She worried so much about school, she couldn’t sleep, she had anxious dreams and was even sick in the morning under pressure. So we got some somatic symptoms there and certainly her grandmother thought she might have something abdominally wrong. She never liked school and was always clingy, but it got worse at starting at secondary school. That’s another fairly classic sort of timing. Friends there, she’s worried when she was away from her family, she never liked school. She admitted to worrying about not being at home to look after other members of her family, especially her mother. That’s again something one often gets with school phobics, it’s not so much the school that they are phobic about although that’s an element, it’s that when they are at school these young people are anxiously brooding about what will happen to their parents some of which is based on reality. She was also quite clearly depressed, loss of appetite and weight, restless, didn’t think life was worth living, loss of interest, not wanting to go out. Now the history was that there was domestic violence from the pregnancy, I don’t have full data of any of these, it’s like an incident, but was it important? - yes, it’s a kind of organising feature, the pattern of this life. Mother decided to leave father after three months after a violent row and returned to live with her parents. Normal development except some clingyness but she became very insecure when her father reappeared and fought through court for staying access.

When these battles continue through court they are quite damaging for children. Different court systems take very different approaches to access rulings and domestic violence. My understanding is that English courts tend to go more for it’s good for children to see their fathers than Scottish courts and Danish courts, it varies in different parts of the world they are sometimes use court battle as a method to control the mother. He continued to appear at the house bang at the door and so forth. He would have not abused the child but all of this had a deal of effect on her and in particular when he suddenly gave up when the money issue came up and said she wasn’t his daughter anyway. This was all very much still alive to her and on her mind. However the precipitating incident was that mother had developed cancer and that’s what finally tipped her over. But issue about her father was very relevant. So that was an internaliser and a girl. But it’s 50:50 with school phobics.

Here is a girl who is an externaliser. Very argumentative, outbursts, exclusions, truancy. She had been rowing with her mother but that had begun to improve. A very lovely girl extremely tall conspicuous and I think when she squared up to her teachers they found it rather alarming. Indeed they burst into tears. Now, where was this coming from, the only thing we essentially got out of it was the background for domestic violence which was the reason the parents have broken up and one felt as one often does that the child blamed the mother and was angry and to some extent it was coming out at home in terms of rows with authoritative figures at school.

Little boy we saw recently lacking in self-confidence, maybe aggressive, very poor history. School failure. The oldest of four children often very helpful. Suggestion that he is becoming the father and indeed he sort of sat in the father’s chair in the assessment, we don’t have a specific father’s chair but if we did he was sitting in it. Stormy relationship with frequent violence, mother had certainly gone for father with the knife and recounted this with great enthusiasm. On the other hand the children were certainly involved and it was frightening for them, they had been the ones who’d had to call the police on several occasions. A disconcerting thing Terry remarked that his mother’s sister is now pregnant by his father, this was disgusting to have a cousin who is also a half brother and how could we help - kill my aunt. Well, in terms of problem solving solutions this doesn’t go well for his future relationships.

The most frightening one in some ways was the story of least violence and think this is why individual cases are so important to look at. Ryan was brought by his mum and said if it’s anything stupid I am walking out, that’s threatening us, I am happy. Mother downplayed everything, we want to communicate better, she was upset, Ryan had got physical with her. She was blamed by an older sister and Ryan blamed her. So they were blaming and victimising the mother. Ryan is an able boy despite dyslexia, he was communicative, mature bossy. What was going on here. Mother had had three major partners: the father of the oldest girl who had died and I think that’s very important, her next partner who was the father of the next two, they had a baby who had died so we had two deaths. He used to drink, freak out and smash the place up, but he wasn’t violent. This is the account from the daughter, it may or may not have been true and it was interesting that it came from the daughter, the mother didn’t dare say anything so direct. They were supposed to be on friendly terms, he remains unwell, that means alcohol. The more recent relationship with the partner had broken up because the daughter said, he wanted things to be clean and tidy, i.e. mother wasn’t getting them clean and tidy and that again was blaming the mother, sort of abusive control. We are worried about this boy, he does not see that as a problem and the mother is finding it’s difficult to control. Many other cases suddenly come to light when you wonder about domestic violence and it isn’t just direct child abuse but involves children in abusive family system.

Gail Slap: Thank you. Our third speaker is Aggrey Burke who is a consulting psychiatrist with St. George’s Hospital and Medical Centre  is London, The title of the presentation is “Youth and the Family with Respect to Deprivation and Cultural Issues”.

Youth and the Family with Respect to Deprivation and Cultural Issues  Aggrey Burke

I am Jamaican by background and I wanted to look today at an area of interest and aspects of work that I am researching in and working actively clinically as well which concerns black people in Britain. I am kind of worried that in America, in France, in Holland, in Britain, in Germany - in the Western world the real problems about deprivation and disadvantage and these are often shelved within the context of findings among more privileged persons in these societies. But there are some generalised findings and they are relevant to all groups. Parental acceptance and rejection. There was some work done in which they tried to look at what happens to children who are rejected, self-esteem is very much affected in that population and how such individuals have a hostility and feelings of aggression. And indeed here in London for those of you who don’t come from here or here in Britain if you have an ethnic minority population living in a town and you go to any locked facilties, locked facilities for the mentally handicapped, locked facilities for disturbed adolescents, locked facilities for children who children who are out of control, locked facilities for mental patients, you find about 70% of black meaning people like me persons even though we make up only about 5 or 6% of the population. So it’s round about always 10 times. And one wonders, is it the society which is leading to greater rejection or is it simply parental rejection or acceptance.

Now I want to look today at the whole business of a sample of adolescent mothers who became pregnant for the first time when they were under 18 and want to reflect a little bit on what sort of interaction might there be between the mother and the child and is age a factor in that. Well in fact the critical thing which might affect mother/child interaction might be disadvantage, that they are the group of mothers who live on welfare are really up against it. And here in Britain is the same thing. Now, we should wish to reflect on the fact that even in 1982 in America there were black excesses for children in institutions, that makes sense with their high levels of black poverty there, the same is true here and we suspect in Holland  and in France we suspect the same is true that we don’t only have children in institutions but young people who get arrested by the police and are locked up are going to be more often black. So we want to know whether this issue is simply an issue which will go away or an issues which we need to reflect on a bit more.

Now Charleston and others looked at about a thousand children who are placed between 1980 and 1984 and the followed up. And they looked at mixed race groups and white groups and black groups and what they found was that a tendency to placement breakdown seemed to be greater among children placed transracially. You know there is a debate here about this transracial placement, the black workers like myself believe that transracial placements should not happen. The government thinks that it should happen. So there we are. And the reasons for the two sides are worthy of debate but we don’t have time today. Now Ravinda Barn looked at a number of children in one borough and found that the black cases in care came from families where their mothers had mental health problem, whereas white cases came into care more frequently because the children were disturbed. Now that’s interesting from many points of view because the mother’s mental health is something that we often subsume under the categories schizophrenia and voices coming through light, whereas mental health has something to do with self-esteem, feeling good about oneself and all those kinds of things.

I am doing a large sample of consecutive cases of mothers referred to me because of family proceedings here in Britain and I am an adult psychiatrist that sees myself as a psychotherapist as well. And this is a sample from this large sample and these are 58 mothers born here in Britain, the reasons that one is taking the ones born in Britain is that one finds that those who come here when they are children are very very different from those who are born here. And those who come here as adults whether from Africa or wherever are very very different from those who come here as migrants as children. So there are 3 very very different groups. Now this sample of  mothers is youngsters who are 17 years old or less at the time of birth of the first child. OK, there are lots of individual issues about this sample but the group issues are much more commanding in terms of interest. The great majority of them came from a background of disadvantage and many times very profound disadvantage, and one has a sense that this teenage group can be distinguished from the other bit of the sample that 18 years old at the time of the first pregnancy. What kind of home did they come from and is it really important to be able to look at the background of these people in terms of their homes.

We divided the sample, into 3 groups: those who have 2 parents who are black, those who have 1 parent who is black and 1 parent who is white and that’s called a mixed race parental sample and those who have 2 parents who are white. And so you have these 3 groups and one would want to know are there differences in the backgrounds of these groups of adolescents, mothers at the time of the birth of the first child. Well, mental illness is equally distributed among the 3 groups in terms of mental illness in a parent. And 55% of these youngsters came from households in which their parents committed violence against each other usually the man against the woman, the father against the mother, but sometimes the other way around as well, women are not taking it any more in the same way. And that seems to be true for white mothers, mixed-race mothers and black mothers, they seem to be muscling up and saying, We are not going to take it any more.

Now, the youngsters, these mothers came from abusive backgrounds, 60% complained of physical abuse when they were growing up, 60% complained of sexual abuse and a lot of them it was the same person getting these two things and more than that complained of rejection and emotional abuse. So just to picture this, the youngsters who had children before 18 and come to the courts here in  Britain under the Children Act come from very abusive backgrounds. 55% domestic violence, 60% - physical abuse and 50% - sexual abuse, it’s a big tragedy. To begin to estimate the extent of a tragedy is to be working with these youngster and the previous speaker was very helpful in looking at couple of cases. Now, surprisingly parental alcoholism seems to be the stronghold of the mixed race and white mothers, so people who come from white homes, usually a mother white seem to booze much more. And the black mothers in this sample have a lower rate. Now I was very impressed with that because there are sort of reasons to believe that this kind of thing among deprived groups might not be that different.

In terms of disturbance, what kind of youngsters were they? Three fifths of these youngster mothers suffered conduct disorder in childhood and upbringing, so they were disturbed people. And a half of them were aggressive people. So we are looking at not an easy population, it’s a population that somehow had a lot of difficulties. The non-white mothers, the mixed race and the black ones were more likely to be expelled from school. Now we know in Britain that there is a selective factor at how people are locked up and how people are dealt with, we don’t know the extent of a selective factor but here we have some little bit of evidence that in terms of what was happening to these youngsters earlier in life they were having the same amount of abuse but they were more likely to be expelled from school if they were black. And you can imagine what happens to these mixed race group, they are growing up in a white household and then they notice that the teachers are doing the same to them as the black children, can you imagine? The non-white mothers were more likely to be locked up in secure facilities, in special homes, in prisons, they were more likely to be locked up than the white ones. So we are beginning to sort of see the social workers, people like myself psychiatrists and all that and not all that fair sometimes.

A worry in this sample is that half of the adolescent mothers have spent time in care so they have been already put into the care system and they were coming back to the family proceedings courts with a kind of statement, hey, I’ve been there, I’ve come back with my child, and you say to yourself, what’s that about? Is it a cycle of abuse, is it a cycle of care, is it a make belief care system, what is it about? Well, almost all of the mothers in this sample admitted to feeling angry, depressed and confused from early adolescence, you could say, not surprising, and you could say, well, is it a statement, getting pregnant before they are 18  s statement of their anger with the world or it is a statement of seeking another home? These are very powerful issues and one would certainly wish to be able to work with it. And of course we all worked with it and one want to know these feelings of anger and depression and confusion, what are they about?

Now, I started off by talking about disadvantaged and one of the really bad things about modern urban life is the council house, the local authority residence in a society where to own your house makes sense. And 90% the sample of people coming from the family proceedings court come from the deprived, they come from housing estates, social workers strive on rescuing children in housing estates, I don’t know if there are any children to be rescued in other estates but they strive on housing estate. And it’s important to know because it’s a law, the Children Act which is almost entirely designed to deal with the disadvantaged though it was not written in that way. And they are on housing estates, they are on income support, they are on the welfare that we were talking of before. Black mothers were less like likely to be married than mixed race and white mothers. That’s an incidental finding, there are lots of ways you can look at it but there we are. When I examined these cases I had some surprising findings: 40% were suffering from a diagnosable condition in which they are abusing some illicit substance, so I wasn’t examining them when they got their first baby I examined them later on sometimes, sometimes when they got their first baby. And when I examined them 40% were abusing in a diagnosable way addiction way for many of them some illicit substance, crack cocaine, heroin, marihuana in vast amounts is also alcohol. Almost all of them were suffering from personality disorders.

So in a way they were coming to because they were messed up people and you see here low self-esteem, messed up feeling, impulsive behaviour and fears of abandonment that makes them the way they are and really any programme of retrieval or treatment which ever you want to seek, you have to dwell on the problem that they were messed up people, I am not saying everybody who gets a child before they are 18 I am talking about those who were coming for family proceedings courts. And that’s very important to kind of distinguish them from the main body of the population.

Parasuicide was something that black mothers did less. In fact three times less. The mixed race and the white mothers three quarters of them were involved in cutting or overdosing or something, but the black mothers is was about a quarter. And you wonder well, is pregnancy part of this sort of impulsive behaviour for some of them and what is it about, because many of them of course go on to have many more children. Now, there is some lot of business, little things which might be important in explaining some of these findings. One of them is a stepfather. A stepfather has all kinds of implications in a disadvantaged group and one wonders here whether the stepfather might have been important in the mixed race and white group. It was more prevalent than in the black group. And then the business of race and what are we. Do we want to be all white in this society and are we proud to be black or proud to be Asian or Turkish or something. Racial identity confusion was found to have been present in upbringing in three quarters of the mixed race mothers, three quarters, three out of four are those mothers who came to the family proceedings courts were brought up mainly by white mothers were messed up in terms of who am I, in terms of race. It’s very powerful I think. Because I would not for a moment want to pass comments on the generalisable, how much this can be generalised I think white mothers and people being brought up by white mothers it’s fine. A quarter of black mothers, remember a lot of them were brought up in care by white children’s home’s people you know, a quarter of the black mothers here were also racially confused. So it’s not just a mixed race thing, it’s a black thing. As they grow through and become adults about half of them started to say, hey, I am black, I am OK, I accept that. But about a half of those who were confused in growing up remain confused in adulthood. You can imagine what that can give rise to.

Something interesting is how we start to think about working with this population, can we really say it doesn’t matter who is working with what. Racial experience of mixed race and black mothers may be important factors in placement decisions and in management. In a place like London more than half the children in care may be black, so we would want to have a sense of a how we go about it.

In terms of making sense of deprivation one would wish to reflect a little on what happens to children in single parent households. These households tend to be more deprived, there is a higher rate of accidents, there are higher rates of illnesses and abusive violence to children. What I want to say today and  to leave you with is, is there a violence as well coming from how we in society and that’s professionals are dishing out knowledge and does the violence leave this very very vulnerable group of youngsters on the rocks for life or do we have a way to start reallocating resources, start rethinking the model so that we don’t leave them on the rock. My work with this population is problematic. No less so than your work. I thought the material might have been useful today in terms of offering a possibility of thinking through something that may be almost impossible. The background factors of the black mothers in this sample were somewhat different from the background factors of the mixed race and white. But the reaction to the background factors of the mixed race mothers was like the black. That’s something we’ve got to bear in mind.