Where should s/he be?

Where should such an adolescent be who is mainly truant from school and a threatening bully when present, acts violently, runs away, uses alcohol and whatever substances, has sex with adult partners? Add that this kid self-mutilates and overdoses? Threatens with suicide but belittles the threats when offered treatment? Steals, participates in fights, is suspected of drug trafficking?

Add that the kid has a history of witnessing family violence, parental alcoholism, being victim of physical and sexual abuse?  Add that the parents of this kid don’t feel they can, or that they should in the first place, set any limits to this kid. Add that the kid claims that there is nothing wrong, and that all interventions, not to mention limits are bullying.

Child welfare, health care, education, youth work and NGO experts in Finland are currently busy thinking about how to completely renovate the services for children, youth and their families, in the context of one of the government’s priority projects in the field of health and welfare http://valtioneuvosto.fi/hallitusohjelman-toteutus/hyvinvointi. This effort should result in a new order of health and welfare services to children/ adolescents and their families. There will be a primary level integrated health and welfare service with a very low threshold. The primary level will hopefully prevent a major share of conditions that require the second level, specialized integrated welfare and health services (centralized to regional level), not to mention the tertiary level, integrated services for challenging needs (still further centralized). It is the last where we come to the young person I presented in the beginning.

There are challenging needs in somatic illnesses alone – let’s mention surgery of rare malformations, or the treatment of rare hereditary metabolic conditions. There are challenging needs in psychiatry –let’s mention early onset schizophrenia. Severe anorexia nervosa is certainly challenging for both psychiatry and somatic medicine. But when we discuss the “challenging” tertiary level care, we are actually only discussing the case of the rule-breaking adolescent, or a child developing to that direction.

Such behavior sets requirements for child welfare, health care, school and youth work. Extremely rule-breaking kids tend to end up in locked up care. But where should this take place? Child welfare service often argue that psychiatry should provide this care, as the young person has clearly suffered traumata and thus needs psychotherapy (within log term inpatient care), and psychiatry again argues that child welfare should provide appropriate living conditions before results can be expected from psychotherapeutic interventions.

The ideal services will also be child centered, and help people in the way they want to be helped. We all believe that rule breaking up to harming others and oneself is a “cry for help” and indicates an underlying distress/disorder that needs cure. Is it child centered to respond to this nonverbal cry or to the verbalized leave me alone?

As a chief adolescent psychiatrist I often face hopes that adolescent psychiatry could be the safe haven from where an adolescent cannot runaway to use substances, have sex with adults and commit crimes. But recent legal developments actually point to the direction that psychiatric wards will become hotels where people can check in and out as they desire, and when in, come and go freely, refuse therapeutic activities, welcome visitors such as gang members, keep their personal guns, knives and drug supplies at hand. I have heard similar concerns from child welfare settings.

Appropriate limit-setting is a part of therapeutic management of the case of an adolescent developing towards antisocial personality and addiction. If all limit-setting is seen as wrongful wielding of power, we can as well not intervene.