Development across the life cycle

O desenvolvimento ao longo do ciclo vital

A primary issue in psychiatric clinical practice is the definition of normality. Normality may be defined as utopia, as health (which is more than the absence of disease, as recommended by the World Health Organization), as average. Using a simplistic definition of normality is certainly not the best way to go, as we learn from Brazilian writer Machado de Assis in The alienist, a novel in which physician Simão Bacamarte ends up alone in the Green House asylum after having defined normality as majority.¹ It is precisely in this arena that a deep knowledge of the typical, expected human development across the life cycle acquires major relevance for child and adolescent psychiatric practice.

Beyond that: we live in an age where several trends and theoretical models have developed - and it is now necessary to bring them together. The very notion of childhood and family as we conceive them today is recent, as shown in the work of Philippe Ariès.² The study of the mind and brain has also seen an explosive growth in the 20th century, with the first half of it focusing essentially on the intrapsychic, and the second on neurobiology. At the same time, the study of social, community, and family aspects has been growing, to the point that the individual, or better, the child, is not just simply a child anymore, but rather a child and his/her circumstances, to paraphrase Ortega y Gasset.³

Leon Eisenberg, professor of Child and Adolescent Psychiatry at Harvard, deceased a few years ago, wrote a classical article entitled "Development as an unifying concept in psychiatry."⁴ The same author, a prominent critic of psychoanalysis in the 1970s, published another paper in the British Journal of Psychiatry in the 1980s, criticizing the existence of two kinds of psychiatry: one brainless and the other mindless.⁵ Eisenberg, towards the end of his life, declared that he regretted having been such a harsh critic of psychoanalysis - arguing that psychoanalysis did have a value in teaching his students to listen to their patients.

Eisenberg's major argument was that, from a developmental point of view, it is possible to integrate different areas of knowledge with the ultimate aim of understanding how, why, and why precisely a family seeks help - in addition to giving us hints of why it was not possible for that child, the adolescent, and the family to resolve the problem without resorting to a mental health professional. In this sense, an understanding that takes into consideration biological, psychological, and social aspects - i.e., a biopsychosocial understanding - is essential in psychiatric practice, especially in psychiatric practice dealing with children, adolescents, and their families.

Therefore, it is essential to have knowledge of the development of the central nervous system from as early as fertilization, with the growth of 250 thousand neurons per minute over the 9 months of pregnancy, the process of neuronal and synaptic pruning in the first years of life, and the progressive myelination of the central nervous system.⁶ Similarly, Freud's lessons about psychosexual stages (oral, anal, phallic, latency, and genital phases) is also extremely important, as are the developments of the Freudian theory with Melanie Klein and schizoparanoid and depressive positions, Bion and the mother's container function, transforming beta elements into alpha elements, Winnicott's notion that a sufficiently good mother is essential for the development of a true self.⁷

Going a bit further, understanding the family system (and its history), as well as its integration in the broader community, is also relevant. Erikson expands Freud's psychosexual stages to define different crises over the life cycle: basic trust vs. mistrust; autonomy vs. shame; initiative vs. guilt; industry vs. inferiority; identity vs. role confusion; intimacy vs. isolation; generativity vs. stagnation; integrity vs. despair.⁸ Based on all these theoretical frameworks, we can more securely get ready to treat children, adolescents and their families, always keeping in mind, as argued by Salvador Minuchin, that the map is not the territory - it only represents it.⁹

Treating infants and their parents, for example, has to take into consideration the life cycle stages that occurred before conception. As suggested by Selma Fraiberg, in every nursery there are ghosts, even when not invited.¹⁰ Therefore, a transgenerational perspective is essential for a better understanding of complaints such as insomnia, colic, and difficulties interacting. We should be attentive not only to what is reported by the mother and father, but also to how they act and interact. From a neurobiological point of view, attention to nonverbal aspects makes the most sense, as it is through nonverbal language that we may gain access to the parents' early childhood experiences - experiences that remained recorded on their procedural memory more than on their declarative one. Moreover, vital transitions and crises experienced not only by the parents (abdicating their roles as children), but also by grandparents and other members of the family, should also be considered.

Other useful areas of knowledge include the baby's organizers, according to Spitz (smiling, anxiety to strangers, the "no") and the separation and individuation processes described by Mahler.⁷ Combining this knowledge with notions of the family life cycle is also necessary. The family life cycle starts when the young adult leaves the family of origin and establishes marriage with no children (it should be noted that, in Brazil, as well as in other developing countries, leaving home can mean moving to a new house in the same property for a good portion of the population). After this adjustment period for the husband and wife, the arrival of the first child places them in another stage of the life cycle. Centripetal forces usually act at this moment, when the family tends to agglutinate because of the arrival of a new member.

The evaluation and treatment of preschoolers also requires knowledge of the characteristics of normal development. Understanding cognitive development (for example, as suggested by Piaget, divided into [1] sensorimotor, [2] preoperational, [3] concrete operational, and [4] formal operational)¹¹ is important not only for evaluation, but also when offering the patient's and his/her family's feedback and psychoeducation - not to mention treatment. Using either more clinical/psychopharmacological or more psychotherapeutic approaches, entering the child's fantasy and playing world is essential. This is true both from the point of view of identifying symptoms for the establishment of a formal diagnosis (trauma, for example, may be re-enacted in play, as recognized by the new operational criteria for post-traumatic stress disorder in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5]); and for an understanding of play as free association, as illustrated by Freud - an 18-month old child that plays with a spool may be symbolizing distancing and approximating.¹²

Integrating knowledge in the treatment of school-age children is also paramount. Being alert to aspects of the oedipal conflict and its repercussions in latency is extremely important while evaluating symptoms in this age group. Understanding the meaning of fears, anxiety, obsessions, or compulsions may help us distinguish between the normal and the pathological. At the same time, knowing that disorders such as attention-deficit/hyperactivity disorder (ADHD) are characterized by a maturation delay in cortical thickness (about 3 years of delay, especially in the prefrontal cortex, in relation to controls with typical development, according to a cohort study conducted by the U.S. National Institute of Mental Health) is also important when evaluating a preschooler.¹³ There is also evidence that children born in the beginning of the academic year have a higher likelihood of being diagnosed with ADHD after controlling for all other variables, only because they are less "mature."¹⁴ Families with small children have to face the start of school and other community activities. At this point, tension related to comparisons between families may emerge. The use of psychopharmacological drugs by a child, for example, has an impact on how parents see themselves in relation to other parents in the same school.

The treatment of adolescents should also take into consideration biopsychosocial aspects of this stage of the life cycle. In addition to maturation of the nervous system, at this stage hormonal changes take place that will culminate in puberty. Body changes urge the adolescent to deal with this strange, disturbing phenomenon - and indeed, he/she will be experiencing a strangeness, not only for him/herself, but also for the people living with him/her. As suggested by Blos, this is the stage when a second individuation process takes place, i.e., when the adolescent has to disidentify from childhood and from his/her parents.¹⁵ Meltzer argues that the adolescent inhabits four worlds: family (in which he/she remains as in latency); adults (in which he/she is a pseudo-adult); other adolescents (groups of the same sex at first, then couples); and his/her own world (a refuge for reflection).¹⁶ In these oscillations, families with adolescents have to prepare for some comings and goings. Parents have to be ready to welcome the adolescent back after they have been discarded and depreciated - they have to survive the adolescent, as argued by Winnicott.¹⁷ And the same principle is valid for us, therapists: we have to be ready for no shows and acting outs, even though always attentive to the meaning of these communicative actions.

When children are in adolescence, parents are reaching middle age, and grandparents, old age. The "maturescence" stage has been referred to as a way back from adolescence.¹⁸ It is important to be attentive to this when we see a father or mother who may, at the same time, idealize and envy aspects of their adolescent child. The Australian model of mental health of young people suggests that the cutoff for child/adult services should be at around 25 years of age.¹⁹ This makes sense not only from the point of view of the incidence/first episode of mental disorders, but also because of the invasion of adolescence into young adulthood. The so-called "adultescence" is characterized by economic independence with fewer advances in emotional aspects. Moreover, it is increasingly common, as a result of marketplace demands, that young adults will stay longer at their parents' homes.

The moment when children leave home is another landmark. The so-called empty nest syndrome may cause parents to get ahead and develop mechanisms that will make their children stay longer, e.g., a mother who renovates the daughter's room when the latter is ready to leave home. Approaches that carry this understanding - e.g., individual systemic psychotherapy - have more and more shown to be promising and necessary when treating children, adolescents, and young adults (but not only these age groups).²⁰

Knowing aspects of the individual life cycle of each family member and of the family system as a unit is extremely important. The death of a family member, for example, has a tremendous impact on all others. Whether death is the result of a slow process (with stages such as denial, anger, bargaining, depression, and acceptance, as suggested by Kübler-Ross)²¹ or an unexpected, acute event, it will certainly have repercussions in the whole family system, and perhaps beyond it. Thus, having knowledge of vital crises also helps us understand accidental crises of the life cycle, as it provides us with elements to understand how a child, adolescent, and their families deal with stressors. Therefore, as suggested by Carter & McGoldrick,²² we can outline the family life cycle using vertical elements (transgenerational, not only family, but also community elements) and horizontal elements (vital and accidental crises) (Figure 1).

Figure 1
Vertical and horizontal stressors of the family life cycle.22

In sum, integrating knowledge and seeing children and adolescents as individuals undergoing major transformation allows us to conceptualize cases thinking of their diagnosis always in the gerund form, as taught by Prego e Silva.²³ Moreover, it helps us achieve a broader understanding of the integration of children and adolescents in their family and social contexts. All this with the objective of engaging patients, family members, and the broader community (school, neighbors) in effective treatment strategies to reduce suffering and promote the full development of those who are starting their journey across the life cycle.

Acknowledgements

Christian Kieling receives research support from Brazilian governmental agencies Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS); he also receives royalties from Artmed and Manole. The author is grateful to all those who presented him to the authors here cited, especially Professor Maria Lucrécia Scherer Zavaschi, for introducing him to the work of Leon Eisenberg. He also thanks medical student Lucas Battel for transcribing the original manuscript.

References

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• Financial support: none.
• This paper was developed for the written test of the competition examination for the position of locum tenens Professor of Child and Adolescent Psychiatry at the Department of Psychiatry and Legal Medicine of Universidade Federal do Rio Grande do Sul, held on July 17, 2013 (the original, handwritten draft is available as online supplementary material)

Supplementary

Publication Dates

• Publication in this collection
  Apr-Jun 2014