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RAD-SPENDER-11-0304-C000-V1.indd ii 29/06/11 8:39 AM
Primary Child and Adolescent
Mental Health
A practical guide
VOLUME I
Second Edition
Dr Quentin Spender
Consultant in Child and Adolescent Psychiatry
Wolverhampton City Primary Care Trust
Wolverhampton, UK
Dr Judith Barnsley
Consultant in Child and Adolescent Psychiatry
Dorset Healthcare University NHS Foundation Trust
Poole, UK
Alison Davies
Primary Mental Health Worker
Sussex Partnership NHS Foundation Trust
Chichester, UK
and
Dr Jenny Murphy
Clinical Psychologist
Dorset Healthcare University NHS Foundation Trust
Poole, UK
Boca Raton London New York
CRC Press is an imprint of the

Taylor & Francis Group, an informa business
RAD-SPENDER-11-0304-C000-V1.indd iii 29/06/11 8:39 AM

First published 2011 by Radcliffe Publishing
Published 2016 by CRC Press

Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2011 Quentin Spender, Judith Barnsley, Alison Davies and Jenny Murphy
CRC Press is an imprint of Taylor & Francis Group, an Informa business
First Edition 2001
No claim to original U.S. Government works
ISBN-13: 978-1-84619-542-6 (pbk)
Quentin Spender, Judith Barnsley, Alison Davies and Jenny Murphy have asserted their right
under the Copyright, Designs and Patents Act 1998 to be identified as the author of this work.
This book contains information obtained from authentic and highly regarded sources.
Reasonable efforts have been made to publish reliable data and information, but the author
and publisher cannot assume responsibility for the validity of all materials or the
consequences of their use. The authors and publishers have attempted to trace the copyright
holders of all material reproduced in this publication and apologize to copyright holders if
permission to publish in this form has not been obtained. If any copyright material has not
been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted,
reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other
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Visit the Taylor & Francis Web site at

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and the CRC Press Web site at

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RAD-SPENDER-11-0304-C000-V1.indd iv 29/06/11 8:39 AM

Contents
Preface to the second edition vi

About the authors xiii
Acknowledgements xiv
Part 1: Overview 1
1 The context for provision of Child and Adolescent Mental

Health Services 3
2 Preschool 19
3 Middle childhood 34
4 Adolescence 68
Part 2: General issues 87
5 Temperament 89
6 Resilience and risk 93
7 Attachment theory and looked-after children 102
8 Family issues 115
9 Separation, divorce and reconstituted families 140
10 Death, dying and bereavement 153
11 Effects of parental mental illness (including substance misuse)
on children and families 168
12 Child abuse and safeguarding 176
13 Behaviour management 201
Index 237
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Preface to the second edition
In the decade since the first edition of this book, the way in which mental health
services in the United Kingdom are provided to children and adolescents has
changed in a number of ways. Although geographical uniformity has proved dif-
ficult to achieve, frontline services have been extensively developed to improve the
mental health of the under-18 population.
The aim of this book is to give those working at the frontline – the first profes-
sionals that a child or parent may meet when asking for help – a practical guide
about what to do. The chapters are structured to enable relevant theoretical issues
to be summarised simply, followed by detailed suggestions about how to gather
relevant information and how to help, leaving referral to specialised services as a
last resort.
Our vision is that a whole variety of professionals to whom children or parents
may turn for help will have at their fingertips a means of understanding the prob-
lems presented, and will be able to offer straightforward ways of helping. Profes-
sionals at the frontline need training and advice from more experienced and highly
trained colleagues; but we hope this book will also play a role in their professional
development and provide an additional source of support, either as a component
of learning or as a resource for teaching.
It would be foolhardy not to acknowledge some of the difficulties inherent in
providing a universal Child and Adolescent Mental Health Service (CAMHS) that
can meet everyone’s needs. These barriers include the following.
➤ Agency cooperation – Using the broadest definition of CAMHS, services are
provided and professionals employed by not only the National Health Service
but also by Educational and Social Care organisations; others play a role, such
as the youth criminal justice system, substance misuse services and counselling
charities. A single child may have contact with a bewildering array of different
organisations and individuals, making effective cooperation between them a
significant challenge.
➤ Management issues – The joint management of Education and Social Care, and
the appointment of jointly funded Commissioners, has been introduced to help
coordinate the main involved agencies. There remains tremendous variation in
management structures. Considering now the narrow definition of CAMHS,
specialised services may be part of Mental Health Trusts, Primary Care Trusts
vi
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PREFACE TO THE SECOND EDITION vii
or Trusts providing hospital paediatric care. Within these Trusts, specialised

CAMHS may be in a directorate with a variety of bedfellows, for instance: adult
mental health; adult learning difficulty; community paediatrics; hospital pae-
diatrics; health visiting; school nursing; and many others. Some Trusts favour
medics in managerial roles such as that of CAMHS Clinical Director; some
Trusts prefer non-clinicians for service management roles; others prefer clini-
cians such as nurses, psychologists or social workers for both clinical and ser-
vice management roles.
➤ This variation in management structures is part of the ‘postcode lottery’, mean-
ing that services may be available in one area but not another, and that where
the child and family live may be as much a factor in determining what help is
available as the skill-mix of professionals. Another component of this is that
areas of deprivation have higher per capita funding, but in relatively affluent
areas, a higher proportion of the population in need may present for help, with
the result that services may paradoxically be more stretched in more affluent
areas. This can be exacerbated by the cost of housing contributing to difficulties
in recruiting staff. The independent sector is just as patchy in its provision (per-
haps more). Added to all this is the variation in the four countries of the UK:
England, Scotland, Wales and Northern Ireland. We have not attempted in this
book to do justice to this, but have stuck to what we know, which is our own
practice within three different regions of England: we cannot claim with our
limited joint experience to understand the range of service provision within
even one country.
➤ Service lacunae (gaps in what is provided) have persisted, despite a variety of
attempts to make services more uniform, such as the National Service Frame-
work1 and the establishment of a peer-reviewing system.2 An example is the
service received by children with learning difficulties and their families, which
is still extremely patchy and highly variable.
➤ Funding issues – It is beyond the scope of this book to present the arguments
about the inequitable share of the funding cake allocated to under-18s com-
pared to other age groups, or mental health problems compared to other cat-
egories of ill health. Killers such as cancer, heart disease or premature birth are
more likely to get the sort of publicity that mobilises political will. Some have
described CAMHS as the ‘Cinderella of Cinderellas’. Periods of investment tend
to be followed by periods of renewed financial stringency. Joint commission-
ing arrangements may not be able to prevent huge sums being spent on highly
specialised provision for a small number of individuals, thus stifling investment
in small-scale outpatient teams: a larger scale preventative approach may be
necessary for this.
➤ Customer confusion – All of this variation may leave parents very confused
about how best to access help for their child. Professionals may also be con-
fused about who is best placed to deliver the best help at the best time: the
professional who first sees the child may be chosen more by accident than by
any logical process. Some acronyms (abbreviations) may add to the overall con-
fusion. We give here a selection:
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viii PREFACE TO THE SECOND EDITION
— ABE Achieving Best Evidence

— ASBO Antisocial Behaviour Order
— ASSIST Asylum Seeker Support Initiative Short Term
— BESD Behavioural, Educational and Social Difficulties
— BEST Behavioural and Educational Support Team
— BOSS Business Opportunity Sourcing Service
— BPD Borderline Personality Disorder
— BPD Bipolar Disorder
— BPD Broncho-Pulmonary Dysplasia
— BPS British Psychological Society
— CAF Common Assessment Framework
— CAFE Child and Adolescent Faculty Executive
— CAP Child and Adolescent Psychiatry
— CORC CAMHS Outcome Research Consortium
— CPD Continuing Professional Development
— CPD Continuous Peritoneal Dialysis
— CPS Crown Prosecution Service
— CRB Criminal Records Bureau
— DAT Drug and Alcohol Team
— DAT Drug Action Team
— DCSF Department for Children, Schools and Families
— DNA Did Not Arrive
— DNA Deoxyribonucleic acid
— DoH Department of Health
— DTO Detention and Training Order
— EBD Educational and Behavioural Difficulties
— EBPD Emerging Borderline Personality Disorder
— E2E Entry to Employment
— FAST Family Advice and Support Team
— FIP Family Intervention Project
— FRT Family Resource Team
— GAP Guideline Appraisal Panel
— HAVOC Having an Alternative View of Crime
— HMYOI Her Majesty’s Young Offender Institution
— IRS worker Integrated Resettlement Support worker
— ISP Initial Supervision Plan
— ISSP Intensive Supervision and Surveillance Programme
— JAR Joint Area Review
— KYPE Keeping Young People Engaged
— LAC Looked-After Children
— LD Learning Difficulty
— MAPPA Multi-Agency Public Protection Arrangements
— MAST Multi-Agency Support Team
— MHPW Mental Health and Psychological Wellbeing
— MLD Moderate Learning Difficulty
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PREFACE TO THE SECOND EDITION ix
— NEET Not in Education, Employment or Training

— NHS National Health Service
— NICE National Institute for Health and Clinical
Excellence
— OFSTED Office for Standards in Education
— OoH Out of Hours
— PAYP Positive Activities for Young People
— PCAMHW Primary Child and Adolescent Mental Health Worker
— PCSO Police Community Service Officer
— PCT Primary Care Trust
— PDP Personal Development Plan
— PHEW Psychological Health and Emotional Wellbeing
— PMHW Primary Mental Health Worker
— PREMs Patient-Reported Experience Measures
— PROMs Patient-Reported Outcome Measures
— PRU Pupil Referral Unit
— PTSD Post Traumatic Stress Disorder
— PSA Parenting Support Adviser
— PSR Pre-Sentence Report
— RAP Recurrent Abdominal Pain
— RAP Resource Allocation Panel
— RAP Resettlement and Aftercare Provision
— RoH Risk of Harm
— SENCo Special Educational Needs Coordinator
— SIG Special Interest Group
— SIPS Social Inclusion and Pupil Support
— SLA Service Level Agreement
— SLD Severe Learning Difficulty
— SMART Specific, Measurable, Achievable, Realistic and
Time-bounded
— SPP Senior Parenting Practitioner
— SSIW Social Services Inspectorate for Wales
— TAC Team Around the Child
— TaMHS Targeted Mental Health in Schools
— TPU Teenage Pregnancy Unit
— VLO Victim Liaison Officer
— WPI Wales Programme for Improvement
— YADAS Young Adults’ Drug and Alcohol Service
— YIP Youth Inclusion Programme
— YISP Youth Inclusion Support Panel
— YJB Youth Justice Board
— YOI Young Offender’s Institution
— YOIS Youth Offending Information System
— YOT Youth Offending Team
— … and many others.
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x PREFACE TO THE SECOND EDITION
Another change since the first edition of this book is the increasing availability
of protocols and guidelines developed to reduce the risks inherent in any dab-
bling with other people’s mental health – and the variability of clinical approach
inevitable in a multidisciplinary field. Some are local, others are national, in
particular the Scottish Intercollegiate Guideline Network (SIGN)3 guidelines in
Scotland and the National Institute for Health and Clinical Excellence (NICE)4
guidelines for the whole UK. These aim to make clinical practice more evidence-
based and uniform, and should in theory reduce the postcode lottery.
Other developments such as leaflets,5 information sheets,6 websites7 and chari-
ties8 have aimed at reducing the confusion for families of knowing which profes-
sion they should go to when, and the confusion for professionals about whether
they are duplicating others’ work, or alternatively allowing families to fall into the
gaps between services. Various ways of combining professionals from different
disciplines into teams who are more coordinated, or more convenient for fami-
lies, or more convenient for agencies, have been devised (see some of the acro-
nyms above), but there seems to be a remarkable lack of uniformity. The Common
Assessment Framework9 is an attempt to save professionals in different agencies
from carrying out repeated initial assessments that ask all the same questions:
once done by one agency, it should be shared electronically with others who need
to be involved. The use of Electronic Health Records is already common in Health
Centres, and is due to spread to specialist CAMHS as we write this edition. We
anticipate some difficulties including all the information gathered by specialist
CAMHS in electronic form – not least because of concerns about who will access
the information.
Just as the expectations placed on professionals working in all levels of CAMHS
have changed in a decade, so have the lives of young people been transformed by
readily available internet access. Social contact can now take place without any-
one leaving their rooms. Cyber-bullying and internet grooming (leading to sexual
abuse) have added new dimensions to the hazards of adolescent relationships.
Whereas previously we might have worried whether we should allow a parent to
show us her daughter’s diary without permission, we may now be worried about
whether to look at a personal blog, and how we should respond to what we may
find there. Similarly, whilst there is much helpful information on the Internet,
young people can also access unhelpful sites such as pro-anorexia and pro-suicide
websites that compound their despair and undermine the help they may be offered
or at least need.
One change that has particularly affected the target audience for this book is
the advent, at least in some areas, of the Primary Child and Adolescent Mental
Health Worker, variously abbreviated as PCAMHW or PMHW. This specialism
was just being developed as the first edition was being published. The initial
idea for the book (which we must credit to Professor Peter Hill) was as a source
of practical information for those working in primary care – the case exam-
ples were written with General Practitioners in mind – but GPs may have been
only a small proportion of the book’s readership. Professor Hill was also part
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PREFACE TO THE SECOND EDITION xi
of the group that developed10 the idea of the Four Tier system and the Primary
Child and Adolescent Mental Health Worker (for further details see Chapter 1:
Context).
The first edition seems to have been devoured by a variety of professionals
doing Tier 1 and Tier 2 work, and we hope this edition will cater more overtly
for these groups. We have shifted the emphasis to make the book suitable for any
profession to whom the Primary Child and Adolescent Mental Health Worker
consults. We hope the book will enable frontline practitioners (Tier 1 or uni-
versal services) to catch child mental health conditions at an early stage so that
interventions can be provided without having to wait for specialised services
(Tier 3 or targeted services) to become involved. The authorship, instead of being
a mixture of Child and Adolescent Psychiatrists and GPs, is now a mixture of
Child and Adolescent Psychiatrists and Primary Child and Adolescent Mental
Health Workers.
Rather than tinker with the first edition, we have rewritten the whole book,
reorganising some of the chapter structure, but keeping the more successful chap-
ters while updating them. We have persisted in our strategy of breaking-up the
text by liberal use of bullet points, tables, case examples, summary boxes (includ-
ing ‘Practice Points’ and ‘Alarm Bells’) and figures. The most striking change is
perhaps the first main section of the book (Chapters 2 to 4), which emphasises our
developmental approach by describing the differences between three important
development stages: pre-school, middle childhood and adolescence. In particular,
the chapter on middle childhood contains much of the content of the first chapter
in the first edition, which was entitled ‘Assessment’. We have also changed the title,
to reflect the change in emphasis.
A note on terminology: We have alternated the female and male pronoun when
talking about an unspecified child (or parent). We are aware there are various
definitions of ‘children’ (for instance: under-13, Gillick incompetent, under-16
or under-18); ‘adolescents’ (12–25 being perhaps the most inclusive); and ‘young
people’ (for instance, 16- and 17-year-olds, 11–19 or seven to 25). But we have
used these terms colloquially, without attempting to stick to one definition. We
have also used the terms ‘parent’ and ‘carer’ interchangeably (so as to avoid the
cumbersome phrase ‘parent or carer’). We have tried to keep abbreviations to a
minimum, but have allowed ourselves to use a few, such as: ‘CAMHS’ for Child
and Adolescent Mental Health Services; ‘ADHD’ for Attention-Deficit/Hyperac-
tivity Disorder; GCSEs for General Certificate of Secondary Education exams; and
‘DVDs’ for Digital Versatile Discs.
A note on case examples: We have pursued a policy of peppering the text liber-
ally with these, in order to break up the text, maintain clinical relevance and keep
things interesting. The case examples vary in their origins: some are based on a
single case, with enough details altered to make the identity unrecognisable to
anyone but the child and family; some incorporate details of more than one case;
and some are fictionalised on the basis of our clinical experience (so effectively
incorporating the details of many cases).
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xii PREFACE TO THE SECOND EDITION
We hope that our labours will enable our readers to improve the mental health
and emotional well-being of children throughout the United Kingdom, and pos-
sibly elsewhere.
Quentin Spender
Judith Barnsley
Alison Davies
Jenny Murphy
April 2011
REFERENCES
1 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_4089114
2 www.rcpsych.ac.uk/crtu/centreforqualityimprovement/qinmaccamhs.aspx
3 www.sign.ac.uk
4 www.nice.org.uk
5 www.rcpsych.ac.uk
6 CAMHS Evidence Based Practice Unit. Choosing What’s Best For You: what scientists have
found helps children and young people who are sad, worried or troubled. London: CAMHS
publications; July 2007. Available at: www.annafreud.org/ebpu (accessed 20 March 2011).
7 www.mentalhealth.org.uk
8 www.youngminds.org.uk
9 www.education.gov.uk/childrenandyoungpeople/strategy/integratedworking/caf/
a0068957/the-caf-process
10 Health Advisory Service. Together We Stand: the commissioning, role and management of
child and adolescent mental health services. London: HMSO; 1995.
RAD-SPENDER-11-0304-C000-V1.indd xii 29/06/11 8:39 AM

About the authors
Dr Quentin Spender, Consultant in Child and Adolescent Psychiatry, Wolver-

hampton City Primary Care Trust, Wolverhampton, UK
Dr Judith Barnsley, Consultant in Child and Adolescent Psychiatry, Dorset
Healthcare University NHS Foundation Trust, Poole, UK
Alison Davies, Primary Mental Health Worker, Sussex Partnership NHS Founda-
tion Trust, Chichester, UK
Dr Jenny Murphy, Clinical Psychologist, Dorset Healthcare University NHS
Foundation Trust, Poole, UK
xiii
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Acknowledgements
This book germinated from an idea that we must credit to Professor Emeritus Peter
Hill, who wanted to fashion a companion volume to the same publisher’s The Child
Surveillance Handbook,1 of which he was an initial co-author. Along with our own
changing co-authorship, we have benefited from the direct or indirect input of
the following: Rosemarie Berry, Chrissy Boardman, Teri Boutwood, Nina Bunce,
Anna Calver, Esther Crawley, David Candy, Steve Clarke, David Rex, Moira Doo-
lan, Danya Glaser, Gill Goodwillie, Sue Horobin, Amelia Kerswell, Karen King,
Sebastian Kraemer, Karen Majors, Rebecca Park, Joanna Pearse, Nigel Speight,
Anne Stewart and Wendy Woodhouse. We would also like to thank the children
and families whom we have all seen in our clinical work: they have taught us so
much, and many of them have provided us with the stories for our case examples.
Note
1 First edition published in 1990, second edition published in 1994 and third edi-
tion published in 2009. Hall D, Williams J, Elliman D. The Child Surveillance
Handbook. 3rd ed. London and New York: Radcliffe Publishing; 2009.
xiv
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PART 1
Overview
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CHAPTER 1
The context for provision of

Child and Adolescent
Mental Health Services
A DEFINITION OF CHILD MENTAL HEALTH

Mental health in children and young people has been defined as having the follow-
ing components:1
➤ a capacity to enter into and sustain mutually satisfying personal relationships
➤ a continuing progression of psychological development
➤ an ability to play and to learn so that attainments are appropriate for age and
intellectual level
➤ a developing moral sense of right and wrong
➤ the degree of psychological distress and maladaptive behaviour is within nor-
mal limits for the child’s age and context.
Additional aspects of emotional well-being include the following:

➤ a capacity to use and enjoy solitude
➤ empathy and awareness of others’ feelings
➤ continuing emotional, intellectual and spiritual development
➤ becoming able to learn and benefit from setbacks or problems.
In the words of one young person reporting to the 2008 UK Child and Adolescent
Mental Health Services (CAMHS) review panel, which will be quoted extensively
in this chapter: ‘It doesn’t mean being happy all the time but it does mean being
able to cope with things’.2
Child mental health problems are therefore difficulties or disabilities in these
areas that may arise from any number of congenital, constitutional, environmen-
tal, family or illness factors. Such problems have two components: firstly, the pre-
senting features are outside the normal range for the child’s developmental age,
intellectual level and culture (‘deviance’ – with a statistical more than a sociologi-
cal meaning); and secondly, the child or others are suffering from the dysfunction
(‘impairment’). Or to put it in a nutshell:
Disorder = deviance plus impairment.
There is no mental health disorder unless both aspects are present.

4 PRIMARY CHILD AND ADOLESCENT MENTAL HEALTH
THE ORGANISATION OF SERVICES

Children’s mental health needs, in the broadest sense, are met by a multitude of
people: firstly, and most obviously, by their parents (or carers), other relatives and
friends; but also by a variety of professionals, from those who look after the baby
in hospital, the toddler in nursery, the child in school and the adolescent in youth
clubs to the various professionals working in multidisciplinary teams that we will
call ‘specialist CAMHS’.
The Four-Tier model

This broad approach to service delivery was the basis for the Health Advisory
Service Report ‘Together We Stand’,3 which provided a new way of thinking about
how CAMHS can be organised. The authors of the report4 proposed two new con-
cepts: the Four-Tier system and the primary mental health worker (PMHW or
PCAMHW). These concepts can still give rise to endless confusion and debate,
although their description in the original document is fairly clear. Part of the
reason for the confusion is that services have developed in very different ways
in different parts of the United Kingdom, so that people whose job titles are the
same may do very different things, and the same service may be provided in dif-
ferent areas by people with different training or job titles. Teams of people working
together to help children, young people and their families may have a variety of
different names. Examples include:
➤ ‘Team Around the Child’
➤ ‘Behavioural and Educational Support Team’
➤ ‘Multi-Agency Support Team’
➤ ‘Social Inclusion Team’
➤ ‘Integrated Service Delivery Areas’
➤ ‘Primary Care Behaviour Service’
➤ ‘Children’s Emotional Health and Wellbeing Service’
➤ ‘Targeted Mental Health in Schools’ team
➤ and many others.
Our attempts in this book to explain these concepts will inevitably fall foul of such
geographical variability in the way that services and teams are named – as well as
the frequent major changes that are made to the ways in which services are deliv-
ered, particularly with each new government.
Figure 1.1 attempts to clarify the Four-Tier model, but with the strong caveat
that the exact placement within the diagram of each profession may seem appro-
priate only in some areas.
The traditional threefold division of services was into primary care (who refer
onto) secondary or specialist care (who refer onto) tertiary care – even more spe-
cialist care – traditionally in the local teaching hospital.
In the fourfold model, Tier 1 practitioners are those working in universal serv-
ices, such as primary care, schools or youth clubs. These professionals are not
primarily trained as mental health specialists – but mental health and emotional

THE CONTEXT FOR PROVISION OF CHILD AND ADOLESCENT MENTAL HEALTH SERVICES 5
Recipients of a service Children and young people Parents and carers
Professionals not primarily employed to deal with child mental health
Social Inclusion Voluntary organisations General Practitioners

Pupil Support Workers
Tier 1 Social Workers Paediatricians
Community in safeguarding teams
School staff
School Nurses Health Visitors
Youth Workers
Educational
Welfare Officers Youth Offending Connexions Family
Team workers Resource
Centres
Child mental
Child
health
Educational Psychologists Psychologists
Tier 2 professionals
working in
isolation Paediatricians Primary Child Community Learning
Mental Health Workers Disability Nurses
Child Child mental health

Psycho- Social Workers
Child therapists
Psychiatrists Family
Clinical Nurse
Specialists therapy
Assessment teams
Tier 3 teams
Counselling Clinical
Multi- Psychologists Psychologists
disciplinary
teams
Day unit
Substance teams
misuse
services
Special units ‘Tertiary’ clinics Services for young

for the deaf for specialist perpetrators of
Tier 4 assessment sexual abuse
Specialist Inpatient
clinics units Forensic adolescent mental health services
FIGURE 1.1 The four tier model of child and adolescent mental health provision. The
oval represents specialist CAMHS

well-being is increasingly seen as everyone’s business. Their role includes: promot-

ing mental health; providing general advice, support and treatment for less severe
problems; helping to identify problems early; and referring on to more specialised
services.5 An example of this sort of work is given in Box 1.1.
BOX 1.1 Case Example
Sandra, aged four years, is referred to her health visitor by her nursery school
because she is having episodes of rage during which she goes blue and appears
to stop breathing. The health visitor checks that Sandra’s mother, Janet, has given
consent to the referral and then visits her at home, while Sandra is there, to discuss
the concerns. She then visits the nursery school to talk to the staff and following this
she reviews the situation with a local primary mental health worker.
The health visitor and primary mental health worker have little difficulty establish-
ing that these episodes, which happen at home as well as at the nursery school,
are blue breath-holding attacks. Although there are no concerning features in the
history, Janet remains anxious about the breath-holding attacks and so the health
visitor arranges for a general practitioner’s appointment, where a thorough history,
examination and explanation provides Janet with some reassurance.
The health visitor then gives Janet the behavioural management advice contained
in Chapter 18 of this book on Breath-holding. She reinforces this advice with further
telephone support and a home visit six weeks later.
At this follow-up, the attacks have substantially reduced and Janet is much more
confident about managing the behaviour.
Tiers 2 and 3 include the traditional narrowly defined ‘specialist CAMHS’ service
in the oval, which is part of secondary care. A referral from Tier 1 is usually neces-
sary to allow a child or family to have access to it. Tier 2 is uni-disciplinary and
Tier 3 multi-disciplinary. Tier 2 professionals have specific mental health training.
They may support service delivery at Tier 1 by carrying out assessment, treatment,
consultation or training. Tier 3 teams usually offer a specialised service to those
with more severe, complex and persistent disorders. Confusion sometimes arises
with this model because the same professional may work in Tier 2 and Tier 3 in
the same day: she may be working in isolation in the morning, but in collaboration
with others in the afternoon. The nature of multidisciplinary working is also a lit-
tle ambiguous: does it require the young person or family to be seen by more than
one professional, or is it sufficient for the case referred to be discussed by several
professionals for the approach to be considered multidisciplinary?
Tier 4 services are more highly specialised, are roughly equivalent to tertiary
care, and usually require a referral from Tiers 2 or 3. Most serve a larger area than
the referring Tier 2/3 services.
It is debatable whether there are any other professionals in Tiers 2 or 3 who
work outside the oval: educational psychologists used to work regularly in

specialist CAMHS teams, but now seldom do; however, many are now part of
separate multidisciplinary teams centred around a school or group of schools.
Day units may be staffed by the same professionals who work for part of their
week in specialist CAMHS teams. Individuals within the oval may work partly in
conjunction with other team members (Tier 3) and partly on their own (Tier 2),
so may effectively be part of both tiers. Some Tier 4 teams may work in relative
isolation, so seem more like services at Tier 2 or Tier 3 level: for instance, sub-
stance misuse teams.
A development of this Four-Tier model has been an extra tier (not included
on our diagram) between specialist outpatient (Tier 3) and inpatient (Tier 4)
services, often referred to as Tier 3+ or Tier 3½. These sub-teams may take vari-
ous forms, including crisis intervention teams managed by a Tier 3 service or
outreach teams managed by a Tier 4 service. They are thought to lessen the
number and duration of costly inpatient admissions, and therefore more than
save what they cost.
One of the underlying principles of this model is that children’s mental health
needs should be met at the lowest tier possible. This book can be seen as part of this
general trend to empower a wider range of professionals in fulfilling the maxim
that child mental health and emotional well-being is everybody’s business.6
Uni-disciplinary versus multidisciplinary working

There is no research evidence we are aware of to prove that multidisciplinary
working has a better (or worse) outcome than uni-disciplinary working, but
clinical experience suggests that straightforward cases can be helped effectively
by a skilled worker from almost any relevant background, whereas more com-
plex cases require the input of more than one discipline. To insist that all cases
referred for help should have multidisciplinary input, or worse still multi-agency
input, is unnecessarily expensive. A more flexible approach that is needs-led
by the individual child or family may be more cost-effective.7 Some would go
further and point out a potential risk that the more professionals involved with
a child, the less effective they are all likely to be in helping the child and fam-
ily: but it may be simply that the child has complex needs of a sort that are not
easy to remedy by one professional, but which draw in a large number of differ-
ent professionals. In this case, cooperation is essential, as opposed to duplica-
tion or working in contrary directions, and may require the agreed appointment
of a lead professional, a key worker or a care-coordinator, as well as regular
(and very costly) multi-professional meetings (called in some places the Team
Around the Child). A Common Assessment Framework meeting may kick-start
this process.8
Paediatric mental health

The provision of mental health services is not confined to mental health prac-
titioners: paediatricians, both in hospital and even more so in the community,
manage a great many mental health problems, often without much support from

overstretched specialist CAMHS services (Tier 2/3). These may include mental
health problems experienced by:
➤ children with disability, particularly neurological disability or sensory impairment
➤ children who have been abused
➤ looked-after children
➤ children who present primarily with physical symptoms that are subsequently
found to be indicators of an underlying mental health problem
➤ autistic spectrum disorders
➤ ADHD.
Some families may prefer to see a paediatrician for such problems, as they per-
ceive this as less stigmatising than attending a mental health service. In Figure
1.1, we have placed paediatricians in both Tier 1 and Tier 2, but some may soon
be within Tier 3, due to a training programme in paediatric mental health that
has been developed while we wrote this edition; and some paediatric neurologists
may be involved in Tier 4 neuro-psychiatric assessment teams. This illustrates
that arguments about which tier a particular person is working at are likely to be
unhelpful. Another pitfall of the Four-Tier model is the professional snobbery
that sometimes develops between the tiers, on the assumption that the higher a
tier in which a professional works, the more skilled she must be. So staff in inpa-
tient units may look down on outpatient teams, whose members may in turn look
down upon uni-disciplinary working – which may in fact be the most challenging
of all and require the most skill – not least because a sole professional is doing it.
The Four-Tier model is simply one way of understanding how services are
organised; an alternative model, which some may see as more user-friendly, is
described below.
The concept of the primary mental health worker

To reinforce the development of child mental health provision in Tier 1 settings
and link this to existing Tier 2 and 3 provisions, the Health Advisory Service
proposed the new job title of ‘primary mental health worker’, who works in Tier
2. This would not be a new discipline, but merely a new role. Professionals filling
this role could include clinical nurse specialists, social workers, child psycholo-
gists or any other child mental health professional with sufficient training to work
as a generalist in a variety of settings. It was assumed their role would include:
➤ direct assessment and treatment for mild to moderate difficulties
➤ consultation and advice to members of Tier 1 services
➤ referral when necessary to the local specialist CAMHS (Tier 2/3 service)
➤ providing child mental health training to Tier 1 service providers.
And so it has turned out (roughly), with the inevitable large geographical variation
in management structures and job descriptions.
An alternative model
The Four-Tier model is merely a way of looking at existing services and helping
to organise them, so it is not susceptible to randomised controlled trials, as some

TABLE 1.1 Universal, targeted and specialist services
Universal services Work with all children and young people. They promote and
support mental health and psychological well-being through the
environment they create and the relationships they have with
children and young people. They include early years providers
and settings such as childminders and nurseries, schools,
colleges, youth services and primary healthcare services such as
GPs, midwives and health visitors.
Targeted services Are engaged to work with children and young people who have
specific needs – for example, learning difficulties or disabilities,
school attendance problems, family difficulties, physical illness
or behaviour difficulties. Within this group of services we also
include CAMHS delivered to targeted groups of children, such as
those in care.
Specialist services Work with children and young people with complex, severe and/
or persistent needs, reflecting the needs rather than necessarily
the ‘specialist’ skills required to meet those needs. This includes
CAMHS at Tiers 3 and 4 of the conceptual framework (though
there is overlap here as some Tier 3 services could also be
included in the ‘targeted’ category). It also includes services
across education, social care and youth offending that work with
children and young people with the highest levels of need – for
example, in pupil referral units (PRUs), special schools, children’s
homes, intensive foster care and other residential or secure
settings.
have suggested. While very helpful in guiding thinking about the development
of CAMHS in the broadest sense, it has led to frequent misunderstandings and
unproductive debates about who fits into what tier at which time of day.
A more recent model is shown in Table 1.1.9 This divides services into univer-
sal, targeted and specialist, thereby in some ways reverting to the old primary/
secondary/tertiary model, but extending it well beyond health. It overcomes some
of the definitional conflicts inherent in the Four-Tier model. It remains to be seen
whether this model will increase clarity and reduce confusion (as intended) – or
will in time become susceptible to the same drift in meaning and inter-professional
rivalry that has sabotaged the clarity of the Four-Tier model. One potential confu-
sion is that so-called ‘specialist’ services are not necessarily the most specialised
in terms of professional training but are specialised in terms of the multiple needs
of the children they select to treat. It might make more sense to call them ‘multi-
needs services’ or ‘multi-professional services’.
What children, young people and families want

‘What children, young people and their families and carers want is often quite sim-
ple. They told us they want consistent relationships with people who can help and
to be treated with dignity and respect.’10 This is expanded in Table 1.2:11

TABLE 1.2 How to make services more effective: themes defined by children and carers
Awareness There should be more awareness in children’s centres, schools,

colleges and primary care health centres about:
● mental health
● how to promote it
● how to deal sensitively with issues that arise.
Trust There should be opportunities to build a trusting relationship with a

known member of staff in schools, so that problems can be shared
and discussed.
There should be regular contact with the same staff in targeted and
specialist services.
There should be clarity over confidentiality arrangements.
Accessibility Services should be in convenient places.
Information and advice should be available in a range of relevant
formats and media.
There should be a single point of entry to specialist mental health
services.
Services should be age-appropriate.
Communication Whichever service you are dealing with, it is important to feel listened
to and given individual attention.
The language used by staff should be straightforward, with no
technical jargon.
Involvement You should be valued for the insight and experience you bring.
There should be opportunities to discuss what services and
interventions are available.
Support when it’s Services should be available when the need first arises, not just when
needed things reach crisis point.
Services should stay in touch after support or treatment has finished
and follow up any problems.
Holistic approach Services should think about you as an individual – for example,
providing help with practical issues and addressing your physical
health as well as your mental health
It’s not all up to health

The old threefold model of primary, secondary and tertiary care assumed that eve-
rything is provided by health, which may still be the case in the specialities of sur-
gery, but is no longer the case for children’s mental health. Youth offending teams,
for instance, may include only one health employee (or in some cases none); while
specialist teams for assessing and treating young perpetrators of sexual abuse may
be financed and staffed by a charity such as the National Society for the Preven-
tion of Cruelty to Children. Youth workers can provide valuable input for young
people who may not feel comfortable with the nature of other helping services.

Connexions was set up as an extension of the Careers Advisory Service, but its
expanded remit can include sorting out many mental health issues, especially for
young people with learning difficulties, or those who, for other reasons, do not fit
into readily available educational or employment opportunities. There are many
other examples of organisations that contribute to children’s emotional health
and well-being: steps have been taken to ensure that all have a ‘common core’ of
training.12 In particular, education and social care contribute a large component of
overall mental health provision.
Education
In schools, support for individual children is invaluable, either in the form of
someone a child can talk to if she needs, or special needs help. Group or class-
room initiatives are also important, either as part of lessons in personal, social
and health education, or preferably as part of a whole school prioritisation of
pastoral care. Teaching staff and learning support assistants within the school
may be supported by local partnership teams centred on a cluster of schools.
These teams may have a variety of names (see the bullet-point list on page 4).
They can include a variety of professionals: educational psychologists; special-
ist advisory teachers; social workers; school nurses; mental health workers with
links to Tier 3 CAMHS; educational welfare officers; social inclusion workers;
and representatives from youth services, children’s centres, the police or volun-
tary organisations. These may form a ‘virtual team’, with members who are based
in different teams on different sites, or a real team, with co-located offices. Coor-
dination of input from different agencies may be a challenge, and may require
different sorts of solutions in different localities. Special schools may need more
specialist input. Meeting the mental health needs of 14–19 year olds may result in
particular difficulties for sixth-form colleges and Connexions, not least because
of the variable age cut-offs of different agencies.
BOX 1.2 Case Example
Robert, aged 14 years, is having difficulty managing in school due to his behav-
iour. He has been to his local specialist CAMHS service for assessment of possible
ADHD, but has refused a trial of medication, and says he does not want to return for
any more appointments.
His father left home when he was three years old after a period of domestic
violence. His mother has two younger children by a different father, who has also
left the family home. She had a difficult relationship with her own mother, but Robert
has always got on well with his maternal grandfather and one of his maternal uncles.
At school, he gets into frequent fights and is often sent out of the classroom for
being disruptive. He responds well to small-group or individual tuition in the Learning
Support Unit (Special Needs Department), but is getting low grades for most sub-
jects, especially those involving literacy skills. He is however good at physical educa-
tion and craft, design and technology. He has recently been given three short-term

exclusions, for a combination of fighting with other pupils and swearing at teachers.
His mother is concerned that most of Robert’s friends seem to be involved in minor
criminal activities and possibly drug use (which Robert denies).
The special needs coordinator is concerned that Robert will be permanently
excluded, so, with his mother’s permission, seeks advice from the primary mental
health worker. Together, they agree that the special needs coordinator will approach
her local partnership team for further advice and in particular the social inclusion
worker. The social inclusion worker meets with Robert and his mother: he tries
to focus on Robert’s strengths rather than his problems. He gets Robert onto a
local activity scheme, which involves Robert in after-school and Saturday morning
activities, including a martial arts class, skateboarding, a drama group and a guitar
workshop. Robert makes a good relationship with a particular youth worker, who
manages to encourage Robert to establish a more pro-social group of friends, so
that he keeps out of trouble with the police. The special needs coordinator enrols
Robert at the beginning of Year 10 into college courses, each for one day per week,
in motor mechanics and carpentry, both of which he enjoys. He is allowed to reduce
the number of GCSEs he is enrolled for.
Over the next two years, Robert narrowly manages to avoid permanent school
exclusion, although he still has difficulties managing classroom situations with
particular teachers, and has to spend about half of his remaining three days in
school in the Learning Support Unit. He gets a D grade in Maths GCSE, and with
support from his Connexions worker, continues at college on a carpentry course
while taking his English GCSE re-sit. He has some difficulty getting an appren-
ticeship, but eventually finds one with a relative. Although he still clashes with his
mother about his late bedtimes and untidy room, she is pleased about the friends
he has made.
Higher levels of organisation

The work of different agencies needs coordination. In England, this can be pro-
vided locally by children’s trusts or strategic partnerships, but there seems to be
ample scope for confusion about which of many intermediate management struc-
tures is responsible for what, perhaps partly because there are two government
ministries mainly responsible (the Department of Health and the Department
for Education – previously the Department of Children, Schools and Families).
Variations in commissioning arrangements and funding streams, both geographi-
cally and in time cycles, can make it difficult at times to implement the hard-won
agreements made at strategic planning meetings. More effective coordination at a
national level may be provided by the National Advisory Council, which aims to
hold government, children’s trusts and commissioners to account in implementing
the conclusions of the National CAMHS review.
Wales, Scotland and Northern Ireland have different structures for coordinat-
ing provision.

THE BROADER CONTEXT: INEQUALITY

Any textbook such as this is in danger of giving the impression that children’s
mental health is remediable only by the measures described herein. It is therefore
worth emphasising, as others have done,13 that measures of a different nature may
be equally – or perhaps more – important. These are concerned with remedy-
ing the social and economic context in which mental health issues arise. Indeed,
some argue14 that these are the main determinants of international differences
in mental health, such as those highlighted in a 2007 UNICEF report.15 A recent
British report was commissioned to review the evidence and make recommen-
dations.16 A selection of issues raised may serve to illustrate how much more is
relevant to children’s mental health and well-being than we could hope to cover
in this book.
➤ Children from disadvantaged backgrounds are more likely to begin primary
school with lower personal, social and emotional development and communi-
cation, language and literacy skills than their peers.17 These children are also at
significantly increased risk of developing conduct disorders that could lead to
difficulties in all areas of their lives, including educational attainment, relation-
ships and longer-term mental health. There are clear socioeconomic gradients
in all these factors.
➤ Even the best primary schools struggle with an intake of children who lack
‘school readiness’, that is, those whose behaviour stops them from learning
or who lack the necessary communication and social interaction skills. Cost-
effectiveness analysis of early literacy interventions shows a significant return
on investment: for instance, the ‘Every Child a Reader’ programme could offer
a return of more than £17 in the next 31 years for every £1 spent now, based on
the estimated costs of problems associated with continuing poor literacy such
as truancy and poor employment prospects.
➤ Early intervention through intensive home visiting programmes during and
after pregnancy can be effective in improving the health, well-being and self-
sufficiency of low-income, young first-time parents and their children. An
example of this being successfully applied in the UK is the Family Nurse Part-
nership programme18 in Tower Hamlets, East London.19 Proven benefits from
home visiting, to both mother and child, include:
— improvements in the mother’s prenatal health
— improved parenting skills
— greater involvement of fathers
— improved child development
— reduced behavioural problems
— fewer injuries to children
— a reduction in child maltreatment20
— improvements in school readiness
— fewer arrests of children when they reach adolescence
— fewer subsequent pregnancies (in the mother)
— increased maternal employment
— improved maternal mental health and social functioning.

➤ High-quality preschool programmes (nursery schooling) can improve chil-

dren’s self-esteem and behaviour. Better outcomes include:
— a higher rate of subsequent adult employment
— fewer crimes committed
— being more likely to complete school
— having higher earnings.
➤ Bad housing conditions: including homelessness, temporary accommodation,
overcrowding, insecurity, and housing in poor physical condition – constitute
a risk to health, including mental health: children in bad housing conditions
are more likely to have mental health problems such as anxiety and depression,
experience long-term disability and have delayed cognitive development. These
adverse outcomes reflect both the direct impact of the housing and the associ-
ated material deprivation.
➤ Living close to areas of green space – parks, woodland and other open spaces –
can improve health, regardless of social class.
— Green spaces have been associated with improved mental health and
reduced stress levels, plus an increased ability to face problems.
— The presence of green space near the home encourages social contact and
integration.
— Exercising outside can have more positive mental health benefits than exer-
cise of other kinds.
— Marking school playgrounds with designs that stimulate active games is
associated with a 20% long-term improvement in physical activity.
— A natural play environment at school also helps to reduce bullying, increase
creative play, improve concentration and increase self-esteem.
➤ Availability of healthy food, and in particular fresh produce, is often worse
in deprived areas due to the mix of shops that tend to locate in these neigh-
bourhoods. For instance, McDonald’s outlets in England and Scotland are four
times more concentrated in the most deprived areas than in the least deprived
areas. Low-income groups are more likely to consume fat spreads, non-diet soft
drinks, meat dishes, pizzas, processed meats, whole milk and table sugar than
the better-off.
We have included a chapter on diet and exercise, but have not included chapters on
how to help children who start school with socio-economic disadvantage to catch
up; town planning; or how to lobby politicians.
Young people who are disengaged21

A proportion of secondary school pupils may not find what is taught in the class-
room of much interest, thinking they will not succeed even if they try; they may
have few if any aspirations for the future; they may see antisocial behaviour as a
way of keeping in with peers, which is more important than approval from – or
respect for – teachers. Some of these young people can be helped by providing
some sort of vocational training, but many will not engage even in this. Almost

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evident that the strategic value of its position is very high. Such again
is, and to a greater degree was, the position of England. The trade of
Holland, Sweden, Russia, Denmark, and that which went up the
great rivers to the interior of Germany, had to pass through the
Channel close by her doors; for sailing-ships hugged the English
coast. This northern trade had, moreover, a peculiar bearing upon
sea power; for naval stores, as they are commonly called, were
mainly drawn from the Baltic countries.
But for the loss of Gibraltar, the position of Spain would have been
closely analogous to that of England. Looking at once upon the
Atlantic and the Mediterranean, with Cadiz on the one side and
Cartagena on the other, the trade to the Levant must have passed
under her hands, and that round the Cape of Good Hope not far from
her doors. But Gibraltar not only deprived her of the control of the
Straits, it also imposed an obstacle to the easy junction of the two
divisions of her fleet.
At the present day, looking only at the geographical position of
Italy, and not at the other conditions affecting her sea power, it
would seem that with her extensive sea-coast and good ports she is
very well placed for exerting a decisive influence on the trade route to
the Levant and by the Isthmus of Suez. This is true in a degree, and
would be much more so did Italy now hold all the islands naturally
Italian; but with Malta in the hands of England, and Corsica in those
of France, the advantages of her geographical position are largely
neutralized. From race affinities and situation those two islands are
as legitimately objects of desire to Italy as Gibraltar is to Spain. If the
Adriatic were a great highway of commerce, Italy’s position would be
still more influential. These defects in her geographical
completeness, combined with other causes injurious to a full and
secure development of sea power, make it more than doubtful
whether Italy can for some time be in the front rank among the sea
nations.
As the aim here is not an exhaustive discussion, but merely an
attempt to show, by illustration, how vitally the situation of a country
may affect its career upon the sea, this division of the subject may be
dismissed for the present; the more so as instances which will further
bring out its importance will continually recur in the historical
treatment. Two remarks, however, are here appropriate.
Circumstances have caused the Mediterranean Sea to play a
greater part in the history of the world, both in a commercial and a
military point of view, than any other sheet of water of the same size.
Nation after nation has striven to control it, and the strife still goes
on. Therefore a study of the conditions upon which preponderance in
its waters has rested, and now rests, and of the relative military
values of different points upon its coasts, will be more instructive
than the same amount of effort expended in another field.
Furthermore, it has at the present time a very marked analogy in
many respects to the Caribbean Sea,—an analogy which will be still
closer if a Panama canal route ever be completed. A study of the
strategic conditions of the Mediterranean, which have received
ample illustration, will be an excellent prelude to a similar study of
the Caribbean, which has comparatively little history.
The second remark bears upon the geographical position of the
United States relatively to a Central-American canal. If one be made,
and fulfil the hopes of its builders, the Caribbean will be changed
from a terminus, and place of local traffic, or at best a broken and
imperfect line of travel, as it now is, into one of the great highways of
the world. Along this path a great commerce will travel, bringing the
interests of the other great nations, the European nations, close
along our shores, as they have never been before. With this it will not
be so easy as heretofore to stand aloof from international
complications. The position of the United States with reference to
this route will resemble that of England to the Channel, and of the
Mediterranean countries to the Suez route. As regards influence and
control over it, depending upon geographical position, it is of course
plain that the center of the national power, the permanent base,[19] is
much nearer than that of other great nations. The positions now or
hereafter occupied by them on island or mainland, however strong,
will be but outposts of their power; while in all the raw materials of
military strength no nation is superior to the United States. She is,
however, weak in a confessed unpreparedness for war; and her
geographical nearness to the point of contention loses some of its
value by the character of the Gulf coast, which is deficient in ports
combining security from an enemy with facility for repairing
warships of the first class, without which ships no country can
pretend to control any part of the sea. In case of a contest for
supremacy in the Caribbean, it seems evident from the depth of the
South Pass of the Mississippi, the nearness of New Orleans, and the
advantages of the Mississippi Valley for water transit, that the main
effort of the country must pour down that valley, and its permanent
base of operations be found there. The defense of the entrance to the
Mississippi, however, presents peculiar difficulties; while the only
two rival ports, Key West and Pensacola, have too little depth of
water, and are much less advantageously placed with reference to the
resources of the country. To get the full benefit of superior
geographical position, these defects must be overcome. Furthermore,
as her distance from the Isthmus, though relatively less, is still
considerable, the United States will have to obtain in the Caribbean
stations fit for contingent, or secondary, bases of operations; which
by their natural advantages, susceptibility of defense, and nearness
to the central strategic issue, will enable her fleets to remain as near
the scene as any opponent. With ingress and egress from the
Mississippi sufficiently protected, with such outposts in her hands,
and with the communications between them and the home base
secured, in short, with proper military preparation, for which she has
all necessary means, the preponderance of the United States on this
field follows, from her geographical position and her power, with
mathematical certainty.
II. Physical Conformation.—The peculiar features of the Gulf

coast, alluded to, come properly under the head of Physical
Conformation of a country, which is placed second for discussion
among the conditions which affect the development of sea power.
The seaboard of a country is one of its frontiers; and the easier the
access offered by the frontier to the region beyond, in this case the
sea, the greater will be the tendency of a people toward intercourse
with the rest of the world by it. If a country be imagined having a
long seaboard, but entirely without a harbor, such a country can have
no sea trade of its own, no shipping, no navy. This was practically the
case with Belgium when it was a Spanish and an Austrian province.
The Dutch, in 1648, as a condition of peace after a successful war,
exacted that the Scheldt should be closed to sea commerce. This
closed the harbor of Antwerp and transferred the sea trade of
Belgium to Holland. The Spanish Netherlands ceased to be a sea
power.
Numerous and deep harbors are a source of strength and wealth,
and doubly so if they are the outlets of navigable streams, which
facilitate the concentration in them of a country’s internal trade; but
by their very accessibility they become a source of weakness in war, if
not properly defended. The Dutch in 1667 found little difficulty in
ascending the Thames and burning a large fraction of the English
navy within sight of London; whereas a few years later the combined
fleets of England and France, when attempting a landing in Holland,
were foiled by the difficulties of the coast as much as by the valor of
the Dutch fleet. In 1778 the harbor of New York, and with it
undisputed control of the Hudson River, would have been lost to the
English, who were caught at disadvantage, but for the hesitancy of
the French admiral. With that control, New England would have
been restored to close and safe communication with New York, New
Jersey, and Pennsylvania; and this blow, following so closely on
Burgoyne’s disaster of the year before, would probably have led the
English to make an earlier peace. The Mississippi is a mighty source
of wealth and strength to the United States; but the feeble defenses
of its mouth and the number of its subsidiary streams penetrating
the country made it a weakness and source of disaster to the
Southern Confederacy. And lastly, in 1814, the occupation of the
Chesapeake and the destruction of Washington gave a sharp lesson
of the dangers incurred through the noblest water-ways, if their
approaches be undefended; a lesson recent enough to be easily
recalled, but which, from the present appearance of the coast
defenses, seems to be yet more easily forgotten. Nor should it be
thought that conditions have changed; circumstances and details of
offense and defense have been modified, in these days as before, but
the great conditions remain the same.
Before and during the great Napoleonic wars, France had no port
for ships-of-the-line east of Brest. How great the advantage to
England, which in the same stretch has two great arsenals, at
Plymouth and at Portsmouth, besides other harbors of refuge and
supply. This defect of conformation has since been remedied by the
works at Cherbourg.
Besides the contour of the coast, involving easy access to the sea,
there are other physical conditions which lead people to the sea or
turn them from it. Although France was deficient in military ports on
the Channel, she had both there and on the ocean, as well as in the
Mediterranean, excellent harbors, favorably situated for trade
abroad, and at the outlet of large rivers, which would foster internal
traffic. But when Richelieu had put an end to civil war, Frenchmen
did not take to the sea with the eagerness and success of the English
and Dutch. A principal reason for this has been plausibly found in
the physical conditions which have made France a pleasant land,
with a delightful climate, producing within itself more than its people
needed. England, on the other hand, received from Nature but little,
and, until her manufactures were developed, had little to export.
Their many wants, combined with their restless activity and other
conditions that favored maritime enterprise, led her people abroad;
and they there found lands more pleasant and richer than their own.
Their needs and genius made them merchants and colonists, then
manufacturers and producers; and between products and colonies
shipping is the inevitable link. So their sea power grew. But if
England was drawn to the sea, Holland was driven to it; without the
sea England languished, but Holland died. In the height of her
greatness, when she was one of the chief factors in European politics,
a competent native authority estimated that the soil of Holland could
not support more than one eighth of her inhabitants. The
manufactures of the country were then numerous and important, but
they had been much later in their growth than the shipping interest.
The poverty of the soil and the exposed nature of the coast drove the
Dutch first to fishing. Then the discovery of the process of curing the
fish gave them material for export as well as home consumption, and
so laid the corner-stone of their wealth. Thus they had become
traders at the time that the Italian republics, under the pressure of
Turkish power and the discovery of the passage round the Cape of
Good Hope, were beginning to decline, and they fell heirs to the great
Italian trade of the Levant. Further favored by their geographical
position, intermediate between the Baltic, France, and the
Mediterranean, and at the mouth of the German rivers, they quickly
absorbed nearly all the carrying-trade of Europe. The wheat and
naval stores of the Baltic, the trade of Spain with her colonies in the
New World, the wines of France, and the French coasting-trade were,
little more than two hundred years ago, transported in Dutch
shipping. Much of the carrying-trade of England, even, was then
done in Dutch bottoms. It will not be pretended that all this
prosperity proceeded only from the poverty of Holland’s natural
resources. Something does not grow from nothing. What is true, is,
that by the necessitous condition of her people they were driven to
the sea, and were, from their mastery of the shipping business and
the size of their fleets, in a position to profit by the sudden expansion
of commerce and the spirit of exploration which followed on the
discovery of America and of the passage round the Cape. Other
causes concurred, but their whole prosperity stood on the sea power
to which their poverty gave birth. Their food, their clothing, the raw
material for their manufactures, the very timber and hemp with
which they built and rigged their ships (and they built nearly as
many as all Europe besides), were imported; and when a disastrous
war with England in 1653 and 1654 had lasted eighteen months, and
their shipping business was stopped, it is said “the sources of
revenue which had always maintained the riches of the State, such as
fisheries and commerce, were almost dry. Workshops were closed,
work was suspended. The Zuyder Zee became a forest of masts; the
country was full of beggars; grass grew in the streets, and in
Amsterdam fifteen hundred houses were untenanted.” A humiliating
peace alone saved them from ruin.
This sorrowful result shows the weakness of a country depending
wholly upon sources external to itself for the part it is playing in the
world. With large deductions, owing to differences of conditions
which need not here be spoken of, the case of Holland then has
strong points of resemblance to that of Great Britain now; and they
are true prophets, though they seem to be having small honor in
their own country, who warn her that the continuance of her
prosperity at home depends primarily upon maintaining her power
abroad. Men may be discontented at the lack of political privilege;
they will be yet more uneasy if they come to lack bread. It is of more
interest to Americans to note that the result to France, regarded as a
power of the sea, caused by the extent, delightfulness, and richness
of the land, has been reproduced in the United States. In the
beginning, their forefathers held a narrow strip of land upon the sea,
fertile in parts though little developed, abounding in harbors and
near rich fishing grounds. These physical conditions combined with
an inborn love of the sea, the pulse of that English blood which still
beat in their veins, to keep alive all those tendencies and pursuits
upon which a healthy sea power depends. Almost every one of the
original colonies was on the sea or on one of its great tributaries. All
export and import tended toward one coast. Interest in the sea and
an intelligent appreciation of the part it played in the public welfare
were easily and widely spread; and a motive more influential than
care for the public interest was also active, for the abundance of ship-
building materials and a relative fewness of other investments made
shipping a profitable private interest. How changed the present
condition is, all know. The center of power is no longer on the
seaboard. Books and newspapers vie with one another in describing
the wonderful growth, and the still undeveloped riches, of the
interior. Capital there finds its best investments, labor its largest
opportunities. The frontiers are neglected and politically weak; the
Gulf and Pacific coasts actually so, the Atlantic coast relatively to the
central Mississippi Valley. When the day comes that shipping again
pays, when the three sea frontiers find that they are not only
militarily weak, but poorer for lack of national shipping, their united
efforts may avail to lay again the foundations of our sea power. Till
then, those who follow the limitations which lack of sea power placed
upon the career of France may mourn that their own country is being
led, by a like redundancy of home wealth, into the same neglect of
that great instrument.
Among modifying physical conditions may be noted a form like
that of Italy,—a long peninsula, with a central range of mountains
dividing it into two narrow strips, along which the roads connecting
the different ports necessarily run. Only an absolute control of the
sea can wholly secure such communications, since it is impossible to
know at what point an enemy coming from beyond the visible
horizon may strike; but still, with an adequate naval force centrally
posted, there will be good hope of attacking his fleet, which is at once
his base and line of communications, before serious damage has
been done. The long, narrow peninsula of Florida, with Key West at
its extremity, though flat and thinly populated, presents at first sight
conditions like those of Italy. The resemblance may be only
superficial, but it seems probable that if the chief scene of a naval
war were the Gulf of Mexico, the communications by land to the end
of the peninsula might be a matter of consequence, and open to
attack.
When the sea not only borders, or surrounds, but also separates a
country into two or more parts, the control of it becomes not only
desirable, but vitally necessary. Such a physical condition either gives
birth and strength to sea power, or makes the country powerless.
Such is the condition of the present kingdom of Italy, with its islands
of Sardinia and Sicily; and hence in its youth and still existing
financial weakness it is seen to put forth such vigorous and
intelligent efforts to create a military navy. It has even been argued
that, with a navy decidedly superior to her enemy’s, Italy could better
base her power upon her islands than upon her mainland; for the
insecurity of the lines of communication in the peninsula, already
pointed out, would most seriously embarrass an invading army
surrounded by a hostile people and threatened from the sea.
The Irish Sea, separating the British Islands, rather resembles an
estuary than an actual division; but history has shown the danger
from it to the United Kingdom. In the days of Louis XIV, when the
French navy nearly equalled the combined English and Dutch, the
gravest complications existed in Ireland, which passed almost wholly
under the control of the natives and the French. Nevertheless, the
Irish Sea was rather a danger to the English—a weak point in their
communications—than an advantage to the French. The latter did
not venture their ships-of-the-line in its narrow waters, and
expeditions intending to land were directed upon the ocean ports in
the south and west. At the supreme moment the great French fleet
was sent upon the south coast of England, where it decisively
defeated the allies, and at the same time twenty-five frigates were
sent to St. George’s Channel, against the English communications. In
the midst of a hostile people, the English army in Ireland was
seriously imperiled, but was saved by the battle of the Boyne and
flight of James II. This movement against the enemy’s
communications was strictly strategic, and would be as dangerous to
England now as in 1690.
Spain, in the same century, afforded an impressive lesson of the
weakness caused by such separation when the parts are not knit
together by a strong sea power. She then still retained, as remnants
of her past greatness, the Netherlands (now Belgium), Sicily, and
other Italian possessions, not to speak of her vast colonies in the New
World. Yet so low had the Spanish sea power fallen, that a well-
informed and sober-minded Hollander of the day could claim that
“in Spain all the coast is navigated by a few Dutch ships; and since
the peace of 1648 their ships and seamen are so few that they have
publicly begun to hire our ships to sail to the Indies, whereas they
were formerly careful to exclude all foreigners from there.... It is
manifest,” he goes on, “that the West Indies, being as the stomach to
Spain (for from it nearly all the revenue is drawn), must be joined to
the Spanish head by a sea force; and that Naples and the
Netherlands, being like two arms, they cannot lay out their strength
for Spain, nor receive anything thence but by shipping,—all which
may easily be done by our shipping in peace, and by it obstructed in
war.” Half a century before, Sully, the great minister of Henry IV,
had characterized Spain “as one of those States whose legs and arms
are strong and powerful, but the heart infinitely weak and feeble.”
Since his day the Spanish navy had suffered not only disaster, but
annihilation; not only humiliation, but degradation. The
consequences briefly were that shipping was destroyed;
manufactures perished with it. The government depended for its
support, not upon a widespread healthy commerce and industry that
could survive many a staggering blow, but upon a narrow stream of
silver trickling through a few treasure-ships from America, easily and
frequently intercepted by an enemy’s cruisers. The loss of half a
dozen galleons more than once paralyzed its movements for a year.
While the war in the Netherlands lasted, the Dutch control of the sea
forced Spain to send her troops by a long and costly journey overland
instead of by sea; and the same cause reduced her to such straits for
necessaries that, by a mutual arrangement which seems very odd to
modern ideas, her wants were supplied by Dutch ships, which thus
maintained the enemies of their country, but received in return
specie which was welcome in the Amsterdam exchange. In America,
the Spanish protected themselves as best they might behind
masonry, unaided from home; while in the Mediterranean they
escaped insult and injury mainly through the indifference of the
Dutch, for the French and English had not yet begun to contend for
mastery there. In the course of history the Netherlands, Naples,
Sicily, Minorca, Havana, Manila, and Jamaica were wrenched away,
at one time or another, from this empire without a shipping. In
short, while Spain’s maritime impotence may have been primarily a
symptom of her general decay, it became a marked factor in
precipitating her into the abyss from which she has not yet wholly
emerged.
Except Alaska, the United States has no outlying possession,—no
foot of ground inaccessible by land. Its contour is such as to present
few points specially weak from their saliency, and all important parts
of the frontiers can be readily attained,—cheaply by water, rapidly by
rail. The weakest frontier, the Pacific, is far removed from the most
dangerous of possible enemies. The internal resources are boundless
as compared with present needs; we can live off ourselves
indefinitely in “our little corner,” to use the expression of a French
officer to the author. Yet should that little corner be invaded by a
new commercial route through the Isthmus, the United States in her
turn may have the rude awakening of those who have abandoned
their share in the common birthright of all people, the sea.
III. Extent of Territory.—The last of the conditions affecting the

development of a nation as a sea power, and touching the country
itself as distinguished from the people who dwell there, is Extent of
Territory. This may be dismissed with comparatively few words.
As regards the development of sea power, it is not the total number
of square miles which a country contains, but the length of its coast-
line and the character of its harbors that are to be considered. As to
these it is to be said that, the geographical and physical conditions
being the same, extent of sea-coast is a source of strength or
weakness according as the population is large or small. A country is
in this like a fortress; the garrison must be proportioned to the
enceinte. A recent familiar instance is found in the American War of
Secession. Had the South had a people as numerous as it was
warlike, and a navy commensurate to its other resources as a sea
power, the great extent of its sea-coast and its numerous inlets would
have been elements of great strength. The people of the United States
and the Government of that day justly prided themselves on the
effectiveness of the blockade of the whole Southern coast. It was a
great feat, a very great feat; but it would have been an impossible feat
had the Southerners been more numerous, and a nation of seamen.
What was there shown was not, as has been said, how such a
blockade can be maintained, but that such a blockade is possible in
the face of a population not only unused to the sea, but also scanty in
numbers. Those who recall how the blockade was maintained, and
the class of ships that blockaded during great part of the war, know
that the plan, correct under the circumstances, could not have been
carried out in the face of a real navy. Scattered unsupported along
the coast, the United States ships kept their places, singly or in small
detachments, in face of an extensive network of inland water
communications which favored secret concentration of the enemy.
Behind the first line of water communications were long estuaries,
and here and there strong fortresses, upon either of which the
enemy’s ships could always fall back to elude pursuit or to receive
protection. Had there been a Southern navy to profit by such
advantages, or by the scattered condition of the United States ships,
the latter could not have been distributed as they were; and being
forced to concentrate for mutual support, many small but useful
approaches would have been left open to commerce. But as the
Southern coast, from its extent and many inlets, might have been a
source of strength, so, from those very characteristics, it became a
fruitful source of injury. The great story of the opening of the
Mississippi is but the most striking illustration of an action that was
going on incessantly all over the South. At every breach of the sea
frontier, warships were entering. The streams that had carried the
wealth and supported the trade of the seceding States turned against
them, and admitted their enemies to their hearts. Dismay, insecurity,
paralysis, prevailed in regions that might, under happier auspices,
have kept a nation alive through the most exhausting war. Never did
sea power play a greater or a more decisive part than in the contest
which determined that the course of the world’s history would be
modified by the existence of one great nation, instead of several rival
States, in the North American continent. But while just pride is felt
in the well-earned glory of those days, and the greatness of the
results due to naval preponderance is admitted, Americans who
understand the facts should never fail to remind the overconfidence
of their countrymen that the South not only had no navy, not only
was not a seafaring people, but that also its population was not
proportioned to the extent of the sea-coast which it had to defend.
IV. Number of Population.—After the consideration of the natural
conditions of a country should follow an examination of the
characteristics of its population as affecting the development of sea
power; and first among these will be taken, because of its relations to
the extent of the territory, which has just been discussed, the number
of the people who live in it. It has been said that in respect of
dimensions it is not merely the number of square miles, but the
extent and character of the sea-coast that is to be considered with
reference to sea power; and so, in point of population, it is not only
the grand total, but the number following the sea, or at least readily
available for employment on shipboard and for the creation of naval
material, that must be counted.
For example, formerly and up to the end of the great wars
following the French Revolution, the population of France was much
greater than that of England; but in respect of sea power in general,
peaceful commerce as well as military efficiency, France was much
inferior to England. In the matter of military efficiency this fact is the
more remarkable because at times, in point of military preparation at
the outbreak of war, France had the advantage; but she was not able
to keep it. Thus in 1778, when war broke out, France, through her
maritime inscription, was able to man at once fifty ships-of-the-line.
England, on the contrary, by reason of the dispersal over the globe of
that very shipping on which her naval strength so securely rested,
had much trouble in manning forty at home; but in 1782 she had one
hundred and twenty in commission or ready for commission, while
France had never been able to exceed seventy-one.
[The need is further shown, not only of a large seafaring
population, but of skilled mechanics and artisans to facilitate ship
construction and repair and supply capable recruits for the navy.—
Editor.]
... That our own country is open to the same reproach is patent to
all the world. The United States has not that shield of defensive
power behind which time can be gained to develop its reserve of
strength. As for a seafaring population adequate to her possible
needs, where is it? Such a resource, proportionate to her coast-line
and population, is to be found only in a national merchant shipping
and its related industries, which at present scarcely exist. It will
matter little whether the crews of such ships are native or foreign
born, provided they are attached to the flag, and her power at sea is
sufficient to enable the most of them to get back in case of war. When
foreigners by thousands are admitted to the ballot, it is of little
moment that they are given fighting-room on board ship.
Though the treatment of the subject has been somewhat
discursive, it may be admitted that a great population following
callings related to the sea is, now as formerly, a great element of sea
power; that the United States is deficient in that element; and that its
foundations can be laid only in a large commerce under her own flag.
V. National Character.—The effect of national character and
aptitudes upon the development of sea power will next be
considered.
If sea power be really based upon a peaceful and extensive
commerce, aptitude for commercial pursuits must be a
distinguishing feature of the nations that have at one time or another
been great upon the sea. History almost without exception affirms
that this is true. Save the Romans, there is no marked instance to the
contrary.
[Here follows a survey, covering several pages, of the commercial
history and colonial policies of Spain, Holland, and Great Britain.—
Editor.]
... The fact of England’s unique and wonderful success as a great
colonizing nation is too evident to be dwelt upon; and the reason for
it appears to lie chiefly in two traits of the national character. The
English colonist naturally and readily settles down in his new
country, identifies his interest with it, and though keeping an
affectionate remembrance of the home from which he came, has no
restless eagerness to return. In the second place, the Englishman at
once and instinctively seeks to develop the resources of the new
country in the broadest sense. In the former particular he differs
from the French, who were ever longingly looking back to the
delights of their pleasant land; in the latter, from the Spaniards,
whose range of interest and ambition was too narrow for the full
evolution of the possibilities of a new country.
The character and the necessities of the Dutch led them naturally
to plant colonies; and by the year 1650 they had in the East Indies, in
Africa, and in America a large number, only to name which would be
tedious. They were then far ahead of England in this matter. But
though the origin of these colonies, purely commercial in its
character, was natural, there seems to have been lacking to them a
principle of growth. “In planting them they never sought an
extension of empire, but merely an acquisition of trade and
commerce. They attempted conquest only when forced by the
pressure of circumstances. Generally they were content to trade
under the protection of the sovereign of the country.” This placid
satisfaction with gain alone, unaccompanied by political ambition,
tended, like the despotism of France and Spain, to keep the colonies
mere commercial dependencies upon the mother-country, and so
killed the natural principle of growth.
Before quitting this head of the inquiry, it is well to ask how far the
national character of Americans is fitted to develop a great sea
power, should other circumstances become favorable.
It seems scarcely necessary, however, to do more than appeal to a
not very distant past to prove that, if legislative hindrances be
removed, and more remunerative fields of enterprise filled up, the
sea power will not long delay its appearance. The instinct for
commerce, bold enterprise in pursuit of gain, and a keen scent for
trails that lead to it, all exist; and if there be in the future any fields
calling for colonization, it cannot be doubted that Americans will
carry to them all their inherited aptitude for self-government and
independent growth.
VI. Character of the Government.—In discussing the effects upon
the development of a nation’s sea power exerted by its government
and institutions, it will be necessary to avoid a tendency to over-
philosophizing, to confine attention to obvious and immediate causes
and their plain results, without prying too far beneath the surface for
remote and ultimate influences.
Nevertheless, it must be noted that particular forms of government
with their accompanying institutions, and the character of rulers at
one time or another, have exercised a very marked influence upon
the development of sea power. The various traits of a country and its
people which have so far been considered constitute the natural
characteristics with which a nation, like a man, begins its career; the
conduct of the government in turn corresponds to the exercise of the
intelligent will-power, which, according as it is wise, energetic and
persevering, or the reverse, causes success or failure in a man’s life or
a nation’s history.
It would seem probable that a government in full accord with the
natural bias of its people would most successfully advance its growth
in every respect; and, in the matter of sea power, the most brilliant
successes have followed where there has been intelligent direction by
a government fully imbued with the spirit of the people and
conscious of its true general bent. Such a government is most
certainly secured when the will of the people, or of their best natural
exponents, has some large share in making it; but such free
governments have sometimes fallen short, while on the other hand
despotic power, wielded with judgment and consistency, has created
at times a great sea commerce and a brilliant navy with greater
directness than can be reached by the slower processes of a free
people. The difficulty in the latter case is to insure perseverance after
the death of a particular despot.
England having undoubtedly reached the greatest height of sea
power of any modern nation, the action of her government first
claims attention. In general direction this action has been consistent,
though often far from praiseworthy. It has aimed steadily at the
control of the sea.
[The remainder of the chapter, quoted in part on pp. 141–146,
outlines the extension of Great Britain’s trade and sea power during
the seventeenth and eighteenth centuries.—Editor.]
4. Definition of Terms[20]
Strategy, Tactics, Logistics
“Strategy,” says Jomini, speaking of the art of war on land, “is the art
of making war upon the map, and comprehends the whole theater of
warlike operations. Grand tactics is the art of posting troops upon
the battlefield, according to the accidents of the ground; of bringing
them into action; and the art of fighting upon the ground in
contradistinction to planning upon a map. Its operations may extend
over a field of ten or twelve miles in extent. Strategy decides where to
act. Grand tactics decides the manner of execution and the
employment of troops,” when, by the combinations of strategy, they
have been assembled at the point of action.
... Between Strategy and Grand Tactics comes logically Logistics.
Strategy decides where to act; Logistics is the act of moving armies; it
brings the troops to the point of action and controls questions of
supply; Grand Tactics decides the methods of giving battle.
5. Fundamental Principles[21]
Central Position, Interior Lines, Communications
The situation here used in illustration is taken from the Thirty Years’
War, 1618–1648, in which the French House of Bourbon opposed the
House of Austria, the latter controlling Spain, Austria, and parts of
Germany. France lay between Spain and Austria; but if Spain
commanded the sea, her forces could reach the field of conflict in
central Europe either by way of Belgium or by way of the Duchy of
Milan in northern Italy, both of which were under her rule.
[The upper course of the Danube between Ulm and Ratisbon is
also employed to illustrate central position, dominating the great
European theater of war north of the Alps and east of the Rhine.—
Editor.]
The situation of France relatively to her two opponents of this
period—Spain and Austria—illustrates three elements of strategy, of
frequent mention, which it is well here to name and to define, as well
as to illustrate by the instance before you.
1. There is central position, illustrated by France; her national
power and control interposing by land between her enemies. Yet not
by land only, provided the coast supports an adequate navy; for, if
that be the case, the French fleet also interposes between Spanish
and Italian ports. The Danube is similarly an instance of central
position.
2. Interior lines. The characteristic of interior lines is that of the
central position prolonged in one or more directions, thus favoring
sustained interposition between separate bodies of an enemy; with
the consequent power to concentrate against either, while holding
the other in check with a force possibly distinctly inferior. An interior
line may be conceived as the extension of a central position, or as a
series of central positions connected with one another, as a
geometrical line is a continuous series of geometrical points. The
expression “Interior Lines” conveys the meaning that from a central
position one can assemble more rapidly on either of two opposite
fronts than the enemy can, and therefore can utilize force more
effectively. Particular examples of maritime interior lines are found
in the route by Suez as compared with that by the Cape of Good
Hope, and in Panama contrasted with Magellan. The Kiel Canal
similarly affords an interior line between the Baltic and North Sea, as
against the natural channels passing round Denmark, or between the
Danish Islands,—the Sound and the two Belts.[22] These instances of
“Interior” will recall one of your boyhood’s geometrical theorems,
demonstrating that, from a point interior to a triangle, lines drawn to
two angles are shorter than the corresponding sides of the triangle
itself. Briefly, interior lines are lines shorter in time than those the
enemy can use. France, for instance, in the case before us, could
march twenty thousand men to the Rhine, or to the Pyrenees, or
could send necessary supplies to either, sooner than Spain could
send the same number to the Rhine, or Austria to the Pyrenees,
granting even that the sea were open to their ships.
3. The position of France relatively to Germany and Spain
illustrates also the question of communications. “Communications”
is a general term, designating the lines of movement by which a
military body, army or fleet, is kept in living connection with the
national power. This being the leading characteristic of
communications, they may be considered essentially lines of
defensive action; while interior lines are rather offensive in
character, enabling the belligerent favored by them to attack in force
one part of the hostile line sooner than the enemy can reinforce it,
because the assailant is nearer than the friend. As a concrete
instance, the disastrous attempt already mentioned, of Spain in 1639
to send reinforcements by the Channel, followed the route from
Corunna to the Straits of Dover. It did so because at that particular
moment the successes of France had given her control of part of the
valley of the Rhine, closing it to the Spaniards from Milan; while the
more eastern route through Germany was barred by the Swedes, who
in the Thirty Years’ War were allies of France. The Channel therefore
at that moment remained the only road open from Spain to the
Netherlands, between which it became the line of communications.
Granting the attempt had been successful, the line followed is
exterior; for, assuming equal rapidity of movement, ten thousand
men starting from central France should reach the field sooner.
The central position of France, therefore, gave both defensive and
offensive advantage. In consequence of the position she had interior
lines, shorter lines, by which to attack, and also her communications
to either front lay behind the front, were covered by the army at the
front; in other words, had good defense, besides being shorter than
those by which the enemy on one front could send help to the other
front. Further, by virtue of her position, the French ports on the
Atlantic and Channel flanked the Spanish sea communications.
At the present moment, Germany and Austria-Hungary, as
members of the Triple Alliance, have the same advantage of central
and concentrated position against the Triple Entente, Russia, France,
and Great Britain.
Transfer now your attention back to the Danube when the scene of
war is in that region; as it was in 1796, and also frequently was
during the period of which we are now speaking.... You have seen
before, that, if there be war between Austria and France, as there so
often was, the one who held the Danube had a central position in the
region. Holding means possession by military power, which power
can be used to the full against the North or against the South—
offensive power—far more easily than the South and North can
combine against him; because he is nearer to each than either is to
the other. (See map.) Should North wish to send a big reinforcement
to South, it cannot march across the part of the Danube held, but
must march around it above or below; exactly as, in 1640,
reinforcements from Spain to the Rhine had, so to say, to march
around France. In such a march, on land, the reinforcement making
it is necessarily in a long column, because roads do not allow a great
many men to walk abreast. The road followed designates in fact the
alignment of the reinforcement from day to day; and because its
advance continually turns the side to the enemy, around whom it is
moving, the enemy’s position is said to flank the movement,
constituting a recognized danger. It makes no difference whether the
line of march is straight or curved; it is extension upon it that
constitutes the danger, because the line itself, being thin, is
everywhere weak, liable to an attack in force upon a relatively small
part of its whole. Communications are exposed, and the enemy has
the interior line....
This is an illustration of the force of Napoleon’s saying, that “War
is a business of positions.” All this discussion turns on position; the
ordinary, semi-permanent, positions of Center, North, and South; or
the succession of positions occupied by the detachment on that line
of communications along which it moves. This illustrates the
importance of positions in a single instance, but is by no means
exhaustive of that importance. Fully to comprehend, it is necessary
to study military and naval history; bearing steadily in mind
Napoleon’s saying, and the definitions of central position, interior
lines, and communications.
Take, for example, an instance so recent as to have been
contemporary with men not yet old,—the Turkish position at Plevna
in 1877. This stopped the Russian advance on Constantinople for
almost five months. Why? Because, if they had gone on, Plevna
would have been close to their line of communications, and in a
central position relatively to their forces at the front and those in the
rear, or behind the Danube. It was also so near, that, if the enemy
advanced far, the garrison of Plevna could reach the only bridge
across the Danube, at Sistova, and might destroy it, before help could
come; that is, Plevna possessed an interior line towards a point of the
utmost importance. Under these circumstances, Plevna alone

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Textbook Primary Child and Adolescent Mental Health A Practical Guide Volume 1 Quentin Spender Ebook All Chapter PDF

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Primary Child and Adolescent Mental

Health A Practical Guide Volume 1

Child Adolescent and Family Refugee Mental Health A

DSM 5 Pocket Guide for Child and Adolescent Mental

A Practical Approach to Adolescent Bone Health A Guide

Disease Control Priorities Volume 8 Child and

Adolescent Mental Health Prevention and Intervention

Pediatric Mental Health for Primary Care Providers A

Neinstein s Adolescent and Young Adult Health Care A

CDEV 2: Child and Adolescent Development Spencer A

RAD-SPENDER-11-0304-C000-V1.indd i 29/06/11 8:39 AM

Boca Raton London New York

CRC Press is an imprint of the

RAD-SPENDER-11-0304-C000-V1.indd iii 29/06/11 8:39 AM

Published 2016 by CRC Press

First Edition 2001

No claim to original U.S. Government works

ISBN-13: 978-1-84619-542-6 (pbk)

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

British Library Cataloguing in Publication Data

Typeset by KnowledgeWorks Global Ltd, Chennai, India

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Preface to the second edition vi

1 The context for provision of Child and Adolescent Mental

Part 2: General issues 87

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or Trusts providing hospital paediatric care. Within these Trusts, specialised

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— ABE Achieving Best Evidence

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— NEET Not in Education, Employment or Training

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Dr Quentin Spender, Consultant in Child and Adolescent Psychiatry, Wolver-

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The context for provision of

A DEFINITION OF CHILD MENTAL HEALTH

Additional aspects of emotional well-being include the following:

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THE ORGANISATION OF SERVICES

The Four-Tier model

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Recipients of a service Children and young people Parents and carers

Professionals not primarily employed to deal with child mental health

Social Inclusion Voluntary organisations General Practitioners

Child Child mental health

Special units ‘Tertiary’ clinics Services for young

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well-being is increasingly seen as everyone’s business. Their role includes: promot-

BOX 1.1 Case Example

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Uni-disciplinary versus multidisciplinary working

Paediatric mental health

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The concept of the primary mental health worker

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TABLE 1.1 Universal, targeted and specialist services