Interpretation of the child's state

First we need to wed the various concepts used to describe poorly children to the developmental processes substantiating their developmental pathways. Let us identify first with the parents who are keen to assess their child's state of distress accurately and decide how poorly the child is. They have skills in minding their child, knowing the child's usual ways of responding in their shared semiotic niche (Hoffmeyer Reference Hoffmeyer2008), their shared language (in its widest sense) for coping and complaining (Wilkinson Reference Wilkinson2003). What do their quirks mean? Initially they only have the infant's change in current level of functioning to go by, combined with the history of how their child's functioning has changed over time, in which circumstances and with which associated physical signs. Is the child behaving as usual? A hand on the forehead – flushed face? The sign in the child becomes a signal for the VIPs, based on their interpretation of what is making a difference to the child's state. The VIPs respond in the light of their interpretation and provide the child with an experience that a collection of signs functions as a symptom of a state that requires intervention (Wilkinson Reference Wilkinson1988). This process leads to error if the natural noise in the child's behaviour and complaining is given significance due to the interpretative biases and sensitivities of the caregiver – and what are culturally acceptable interpretations. These might be linked to the VIPs’ own experiences of illness or trauma – for example, somatoform disorders are associated with greater bodily preoccupations in children whose parents have similar health beliefs (Marshall Reference Marshall, Jones and Ramchandani2007) – part of their shared semiotic niche. In the language of the disco, it can produce the screech of feedback, as when the microphone and the loudspeaker are too close and the amplifier is turned up high. Clinical practice needs to know what turns up the VIPs’ sensitivities about the need for action and how the family regulates interpersonal intimacy – being mindful of their needs. The VIP response can also give illness-type symptoms leverage outside the dis-ease paradigm within which they were initially interpreted.

Symbols and signs: coding duality

Symbols, as in culturally accepted symptom aggregations and diagnoses, and signs, as in the bodily expression of state, are of different logical types (Bateson Reference Bateson1979: pp. 127–143; Harré Reference Harré1991). To borrow from the language of biosemiotics, it is as if the analogue information of the continually varying state of the child (consistent with a dimensional approach to diagnosis) gets transformed into a digital code – and this two-sided quality, as in code duality (Hoffmeyer Reference Hoffmeyer2008: pp. 71–109), is repeated in the observations of clinicians to determine the diagnosis (the child has a diagnosis or does not). The critical challenge in child psychiatry concerns this code duality and how the analogue and digital information transformations affect how parents and clinicians respond to graded subjective states of discomfort and talk about them as things with identity. This is dramatically revealed in the code duality of sex and gender. Nevertheless, subjective states of discomfort can suddenly reach a crisis point, as in ‘feedback’ (for other rapid shifts in behaviour and affect, these can best be modelled mathematically using catastrophe theory (Woodcock Reference Woodcock and Davis1978)). Mindful medicine includes and addresses the constantly evolving subjective states of the VIPs and child and the way they interact, whereas industrialised medicine is more closely aligned with having a diagnosis or not, the digital approach, rather than the dimensions of subjective distress, the analogue experience.

The utility of diagnoses

The utility of diagnoses is in their implication of guiding towards a helpful response, within the overarching paradigm of ensuring survival and minimising discomfort. But there is another paradigm of secondary importance that helps ensure survival: if the stress level is kept within bounds, an allostatic process, there is optimal integration of information from all memory systems, the implicit and explicit systems with their own underlying subsystems, to inform action. If not, then implicit learning will force through impulsive responses without reflection on the potential consequences (Wilkinson Reference Wilkinson2022). The goal for the RDoC (Cuthbert Reference Cuthbert2014) is to increase the utility of diagnoses; searching for validity is no longer the issue for the National Institute of Mental Health in the USA. Such utility, which is person centred rather than diagnosis dependent, is the lodestone of precision medicine. Mindful medicine has the same potential.

An example: ADHD and complex systems

The diagnosis of attention-deficit hyperactivity disorder (ADHD) is currently seen as a category of neurodevelopmental disorder, analogous to a biomedical condition. The dimensional range of ADHD symptoms has been packaged to fit the prevailing diagnostic systems, albeit with modifications to diagnostic criteria over the years along the journey from hyperkinesis to ADHD. But ADHD should definitively not to be regarded as a category (Coghill Reference Coghill and Sonuga-Barke2012). The symptoms do not constitute something a person has or does not have, but reflect dimensions of function in specific contexts. The world at large has yet to drop this misunderstanding. There are many vested interests in encouraging us to think about ADHD as a condition that primarily requires working with an individual patient and where medication is usually required – and that absolves everyone of personal responsibilities for enabling these young people to work towards more balanced ways of living with their predispositions. Not least schools are absolved from considering why it is often the youngest boys in the class who display most symptoms. Why does the prescription of medication for ADHD differ by a factor of 20 between the Nordic countries? There is no question that genetic and neurological factors can play a role, as well as the form of early care and, as with school expectations and structure, other environmental factors. The issue becomes how the child has adapted to the demands of his developmental niche given his initial resources, with a more or less mindful approach from those supporting the child.

The challenge is related to the way people develop, how nature, nurture and environment interact. People are complex systems of nested complex systems, living in complex social networks influencing the biology of the interacting and recursive complex bodily systems – and just as confusing! Just saying one uses a biopsychosocial model, and so implying these complex system effects, is not enough alone to advance clinical practice. In Popper's terminology, the World 1 elements are in a complex relationship to World 2 elements (Popper Reference Popper and Eccles1977: p. 36) (Box 1). Yet diagnoses are built on a biomedical premise founded in World 1 understanding. Complex systems, as entertained in the biopsychosocial model, give rise to non-linear results with emergent properties, such as psychological suffering. To give an example from another field, predicting the results of climate change from all the complex recursively interacting systems that from moment to moment give us our weather depends on understanding the non-linear results of complex system interactions. Using diagnoses is like using the weather forecast, whereas treatment entails addressing the interacting systems giving rise to the storm of ADHD, and the precipitating and maintaining factors leaving the patient in a state of dis-ease.Footnote ^b

Towards an ecobiopsychosocial model

Ecological processes have to be included in conceptualising what is going on with subjective dis-ease, currently packaged into diagnostic categories. Symptoms overlap between different diagnoses, blurring the boundaries between categories (Kendell Reference Kendell and Jablensky2003). Bronfenbrenner (Reference Bronfenbrenner1979) made an excellent start in providing us with a conceptualisation of the ecology of human development (Fig. 1). But we need to acknowledge that this is a gross simplification, something he tried to address subsequently with his ‘PPCT’ modification, i.e. including process–person–context–time (Bronfenbrenner Reference Bronfenbrenner, Moen, Elder and Lüscher1995), which importantly includes the developmental processes over time. I suggest that the way forward is to convert child psychiatry to the tenets of developmental psychopathology, and place adaptation and the understanding of complex systems at the core of its practice. The biomedical model appears to be maintained because child psychiatry has built its clinical ‘house’ on the sands of this model. It has invited industry to make use of these unreliable categories, as if they were individual personal failings, rather than the subjective dis-ease of patients who have adapted to their context given their resources, some of which will be associated with predisposing biomedical diagnoses and the processes moulding their behaviour in their developmental niche. What started as a useful adaptation can prove singularly unhelpful in new contexts. This brings us back to including attachment strategies as adaptation to context (Crittenden Reference Crittenden, Landini and Spieker2021) in clinical formulations and the importance of retaining a multiaxial classification system with the transition to ICD-11, as recommended by Rutter (Reference Rutter2011), so that context and the patient's differential susceptibility to that context receive the attention they deserve.Footnote ^c We need to move to an ecologically informed biopsychosocial model (Bolton Reference Bolton and Gillett2019).

When attachment strategies fail to adapt

Each attachment strategy has its advantages and disadvantages depending on context. Type B results in the ideal victim for a psychopath, and is not necessarily ‘secure’, as in one label given to type B; type A can be the ideal self-sufficient survival strategy in a civil war; type C can be ideal for different circumstances, such as forcing yourself to the front of the queue in a stretched health service or, for a manipulative politician, avoiding taking personal blame (Box 3). But in new contexts, a strategy that was advantageous to maximise available care and survival at home can prove to be a liability or, if lucky, an opportunity for further development – changing school, moving house, long-term relationships, a pregnancy, among others. However, if the opportunity is missed, then behaviour that ensured the available care at home can either escalate, according to the practice of ‘maybe more of the same will force a response’, or enable a more extreme form of self-sufficiency. This can bring the child to the attention of others as ‘disordered’. Symptoms have communicative force and are not equivalent to signs of disease. Their origins have to be understood in terms of their history of interpersonal effectiveness.

Sameroff's (Reference Sameroff2009) transactional psychology has provided us with an approach that links attachment theory and adaptation. Through acknowledging the importance of the transacting genetic, constitutional, neurobiological, biochemical, psychological and sociological factors in the determination of behaviour, he has assisted with building a bridge to an alternative to diagnoses to inform the treatment formulation. Remembering the way complex systems function, he has pointed out that each of these factors changes the others through their dynamic transactions. Gene expression is changed in different environments; the care of the infant shapes brain development, etc. And potentially states get transformed into traits.

Varieties of ‘dis-ease’ and the goal-corrected partnership

One of the key ideas from attachment theory was to frame treatment in terms of developing goal-corrected partnerships, rather than a goal-directed partnership determined by one or other party to the treatment relationship. This originated from observations of the way in which cooperation between infant and parent developed (Marvin Reference Marvin, Britner, Cassidy and PR1999). To advance cooperation in addressing ‘dis-ease’ we need to differentiate between the concepts of (a) illness, for our subjective discomfort, (b) disease as delineated by identifiable pathognomonic processes, and (c) disorders which are collections of symptoms occurring regularly together, albeit without identifiable pathognomonic processes. Disorders are of symbolic significance, not to be confused with the signs of disease. And then there are also (d) sickness, to describe the state attributed by VIPs based on their interpretative codes, and (e) predicaments, the challenges resulting from the state (Box 4) (Wilkinson Reference Wilkinson1988: pp. 37–38). Again these are different logical types, potentially leading to confusing health/dis-ease dialogue depending on perspective if one mistakenly believes them to be necessarily coherent.

Each of these states is related to activation of different memory systems to guide the predictive brain (Clark Reference Clark2016) towards a helpful activity pattern, so that compassionate empathy trumps emotional empathy and establishes trust through responses that assuage the child's distress, the child's need, the essence of intelligent kindness (Ballatt Reference Ballatt, Campling and Maloney2020). The greater the mobilised fear in the VIP, child or doctor, the greater the chance that implicit learning, the procedural memory guiding the motor response or perceptuo-affective memory guiding the emotional reaction, will precipitate more impulsive practice. Reflection requires that the doctor is calm enough to integrate information from all memory systems. How a doctor's tertiary intersubjectivity (Box 2) has formed their anticipatory responses to the needs of others sets them on to one or other sort of alliance with the patient. Using the term ‘client’ is detrimental to this process of achieving a goal-corrected partnership, which instead needs to be built around the subjective discomfort of the patient (etymologically from the Latin for ‘I suffer’), their illness and how the patient's function is affected, their predicament.

Mindful medicine: reading attachment strategies

Different attachment strategies and their modified effectiveness in the light of trauma, loss and learned helplessness when trying to settle can only be here described with a rather coarse outline. Suffice it to say that there is a major challenge for mindful practice in child psychiatry to avoid overlooking those patients using a type A strategy because their needs are not ‘flagged’ effectively. The caregiving contingencies they experienced led to them becoming as self-sufficient as possible. They often appear to find it a challenge to share their discomforts with strangers, or even have an effective language for doing so. This can result in premature discharge, the classic flight into apparent health. This contrasts with the exaggerated rather flamboyant style of those with a type C strategy in their meeting with health services. For them suffering may be emphasised to ensure a response that they have otherwise found insufficient or unpredictably available in their developmental niche. This group of patients needs predictability of a finite response and the avoidance of interminable treatment, the symptoms nevertheless often returning when discharge is imminent (Wilkinson Reference Wilkinson2022). The difference between type A and type C patients who cut themselves may show itself by the first group always keeping their cutting hidden and often denied, whereas the second would prefer to use short-sleeved T-shirts and make their bleeding as visible as possible. To develop the practice of more mindful medicine the nuances in these attachment distinctions need to be fully developed in the context of clinicians being aware of their own attachment strategies when under stress. And we must not forget that administrators in the health service, in order to facilitate mindful practice, must also be aware of these interpersonal dynamics and the parts they play indirectly in the treatment dynamic.

The case formulation

In clinical practice these varying strategies for optimal adaptation need to be integrated in clinical formulations to guide treatment. Using a combination of Sameroff's insights and research into personality (Wilkinson Reference Wilkinson2022) we can conceptualise the clinician's case formulation in mindful terms as the transacting genetic, constitutional, neurobiological and biochemical factors in infancy in interaction with the infant's attachment behaviour and subsequent attachment strategies (Box 5). In true complex system processes, these early attachment patterns feed into the developing brain's structure, to modify the infant's dispositions, given their differential susceptibility, and maintain or resolve what could come mistakenly to be regarded as inborn vulnerabilities. Into these interactions with the attachment strategies of children, we still need to add experience of trauma and loss, and learned helplessness, which have major effects on the execution of attachment strategies, as well as affecting biomedical processes associated with higher mortality and morbidity (see for example Wang Reference Wang, Sun and Missmer2023 and its commentary, Segal Reference Segal2023, which provides ideas for clinical responses).

A clinical vignette