Australian and New Zealand Journal of Psychiatry (1979) 13191-192
CHILD PSYCHIATRY IN THE INTERNATIONAL YEAR OF THE CHILD J. S . WERRY
There are compelling reasons apart from the International Year of the Child to examine the current status of child psychiatry. One is clear evidence of public resistance to the mushrooming cost of health services which put the onus on all branches of medicine to do some close self examination. The second is the conspicuous inability to date, of child psychiatry to provide sufficient manpower to serve the child population of Australasia adequately. The reasons for the shortages of child psychiatrists in Australasia are complex. Probably, some of them lie in the low status of and support for child psychiatry within departments of psychiatry and paediatric hospitals evident in such things as the scarcity of senior academic appointments especially Chairs in Child Psychiatry, insufficient curriculum time and grossly inadequate and even unsalubrious clinical facilities. However, some must lie in a degree of unattractiveness of child psychiatry as a career, such as the lack of relevance so far, of much of the glamorous psychopharmacological and other neuroscience developments in adult psychiatry and the paucity of nice, clear cut diseases like schizophrenia and affective disorders. Child psychiatry is now part of psychiatry but it was not always so. Much of its development occurred in community clinics tied to courts, in child welfare agencies or in schools, and paediatricians as much as psychiatrists figured prominently in its early development. The move to within psychiatry in the post war period has meant a disruption of much of its sense of identity and very often, its geographical separation of working site from the locus of academic control and from research facilities. Further, the glamorous developments in psychopharmacology and the neurosciences relevant to psychiatry have as yet, and for
the foreseeable future, will have only limited relevance to child psychiatry. The historical roots of child psychiatry have given it certain strengths most of which have only recently appeared in adult psychiatry and presented there as if they were new discoveries! Included here would be a community orientation, the multidisciplinary team, a multifaceted rehabilitation approach to management and an awareness of the importance in diagnosis and management of the total social ecology including the family. But, it has created problems too. Child psychiatrists often seem to lose sight of their medical training and, perhaps as a result, of their scientific rigour, too. They are seen by paediatricians at times as foolishly psychogenically-oriented in their approach to conditions like enuresis, encopresis, autism or ulcerative colitis, naive in their ‘mass equivalent’ approach to brain function embodied in such concepts as minimal brain dysfunction and unacceptably unwilling to take emergency calls. Sometimes too, the intellectual vigour and energy of child psychiatry seems to be diverted from hardnosed scientific enquiry which is the essence of medicine, to fads and proselytising of social issues founded on mawkish sentimentality about children and naivety about political, economic and social realities. Certainly the amount of good research in child psychiatry in Australasia is abysmally low though some of this is no doubt a reflection of the inequitable allocation of resources by academic departments of psychiatry. What should child psychiatrists spend their time doing then? It is sometimes difficult to distinguish the activities of child psychiatrists from others who work with children such as social workers, educational psychologists, occupational therapists and so on except that child psychiatrists usually hold
Downloaded from anp.sagepub.com at UNIVERSITE DE MONTREAL on June 8, 2015
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CHILDPSYCHIATRY I N THE INTERNATIONAL YEAROF THE CHILD
positions of authority and get paid more. The attitude that child psychiatrists deserve this higher status by virtue of being doctors and ips0 fucto are smarter, clinically more competent and better administrators is disputable since many of the innovators and leaders in abnormal child behaviour were or are not medically trained, for example, Anna Freud, Bettelheim, Redl, Satir, to quote a few idols. Surely, the indisputable attribute of the child psychiatrist lies in his medical training, the relevance of which can be seen most clearly in such activities as the differential diagnosis of children with obscure somatic complaints or conditions which might have an organic aetiology, the management of children with psychological and behavioural problems associated with physical illness and the administration of psychotropic drugs and other medical treatments. On the other hand, much of the knowledge relevant to behaviour disorders, child development, learning difficulties, psychotherapy, behaviour therapy, family therapy, access and custody disputes requires no such medical training and it is not easy to dismiss the claim that such activities are often a waste of a doctor’s time particularly since less expensive more available persons can do them just as well. Further, child psychiatrists lack the necessary theoretical and methodological knowledge to undertake the kind of research in these areas so that despite good ideas their efforts are often characterized by lack of sophistication and scientific acceptability. Obviously, some training, experience and limited practice in these non-medical areas is necessary for a child psychiatrist but this should be seen as subordinate to the real role which, as in medicine in general, is largely diagnostic and therapeutic only to a limited degree. It also means that ordinarily child psychiatrists should practise in paediatric medical facilities leaving the work in courts, welfare homes, schools and child guidance clinics to those who are or shouId be properly trained for it, performing occasional ‘medical’ consultations to such agencies when requested. Since primary prevention in child psychiatry is largely a matter of applied common sense and humanitarianism coupled to social engineering, the responsibility for it should be the
concern of all members of the community not just child psychiatrists or even in child psychiatrists in particular. There is good reason to ponder whether child psychiatry would be better placed within psychiatry or within paediatrics. Most of the true child psychiatric need (that is tied to medicine) lies within the context of paediatrics and because of greater numbers, most ‘child psychiatry’ is in fact carried out by paediatricians. Recognition of this can be seen in the new development of behavioural paediatrics as a subspeciality and the increasing tendency for paediatric journals to publish child psychiatry type articles, amateurish though they may be. It looks like the full turn of the wheelpaediatricians started child psychiatry, they lost it to psychiatry and now they are recapturing it by default and sheer weight of numbers. An argument could be made for the divorce of child psychiatry from psychiatry with the former joining behavioural paediatrics. The new behavioural paediatrician would then rotate through psychiatry rather than being seen as a trainee in psychiatry itself. This suggestion has the merit of lack of stigma for child patients, reduction in irrelevant or replaceable activities, improved recruitment prospects, more science and less sentiment and better communication with paediatric and family practitioner colleagues. The big risk of course is too much dilution of the psychological component in training. This could be overcome by subspeciality status within paediatrics and different training requirements. If on the other hand child psychiatry is to remain within psychiatry it requires to be accorded a top priority in terms of allocation of academic posts, research and allied facilities. To achieve this it may in some instances be necessary for medical schools from different universities to pool their resources to create one viable, academically strong institute of child psychiatry in a given city such as Sydney or Melbourne. The views expressed here are unlikely to prove popular but they are something to ponder in 1979, the International Year of the Child.
J. S. WERRY, Professor of Psychiatry, School of Medicine, University of Auckland P.B., Auckland, New Zealand.
Downloaded from anp.sagepub.com at UNIVERSITE DE MONTREAL on June 8, 2015
CHILD PSYCHIATRY IN THE INTERNATIONAL YEAR OF THE CHILD J. S . WERRY
There are compelling reasons apart from the International Year of the Child to examine the current status of child psychiatry. One is clear evidence of public resistance to the mushrooming cost of health services which put the onus on all branches of medicine to do some close self examination. The second is the conspicuous inability to date, of child psychiatry to provide sufficient manpower to serve the child population of Australasia adequately. The reasons for the shortages of child psychiatrists in Australasia are complex. Probably, some of them lie in the low status of and support for child psychiatry within departments of psychiatry and paediatric hospitals evident in such things as the scarcity of senior academic appointments especially Chairs in Child Psychiatry, insufficient curriculum time and grossly inadequate and even unsalubrious clinical facilities. However, some must lie in a degree of unattractiveness of child psychiatry as a career, such as the lack of relevance so far, of much of the glamorous psychopharmacological and other neuroscience developments in adult psychiatry and the paucity of nice, clear cut diseases like schizophrenia and affective disorders. Child psychiatry is now part of psychiatry but it was not always so. Much of its development occurred in community clinics tied to courts, in child welfare agencies or in schools, and paediatricians as much as psychiatrists figured prominently in its early development. The move to within psychiatry in the post war period has meant a disruption of much of its sense of identity and very often, its geographical separation of working site from the locus of academic control and from research facilities. Further, the glamorous developments in psychopharmacology and the neurosciences relevant to psychiatry have as yet, and for
the foreseeable future, will have only limited relevance to child psychiatry. The historical roots of child psychiatry have given it certain strengths most of which have only recently appeared in adult psychiatry and presented there as if they were new discoveries! Included here would be a community orientation, the multidisciplinary team, a multifaceted rehabilitation approach to management and an awareness of the importance in diagnosis and management of the total social ecology including the family. But, it has created problems too. Child psychiatrists often seem to lose sight of their medical training and, perhaps as a result, of their scientific rigour, too. They are seen by paediatricians at times as foolishly psychogenically-oriented in their approach to conditions like enuresis, encopresis, autism or ulcerative colitis, naive in their ‘mass equivalent’ approach to brain function embodied in such concepts as minimal brain dysfunction and unacceptably unwilling to take emergency calls. Sometimes too, the intellectual vigour and energy of child psychiatry seems to be diverted from hardnosed scientific enquiry which is the essence of medicine, to fads and proselytising of social issues founded on mawkish sentimentality about children and naivety about political, economic and social realities. Certainly the amount of good research in child psychiatry in Australasia is abysmally low though some of this is no doubt a reflection of the inequitable allocation of resources by academic departments of psychiatry. What should child psychiatrists spend their time doing then? It is sometimes difficult to distinguish the activities of child psychiatrists from others who work with children such as social workers, educational psychologists, occupational therapists and so on except that child psychiatrists usually hold
Downloaded from anp.sagepub.com at UNIVERSITE DE MONTREAL on June 8, 2015
192
CHILDPSYCHIATRY I N THE INTERNATIONAL YEAROF THE CHILD
positions of authority and get paid more. The attitude that child psychiatrists deserve this higher status by virtue of being doctors and ips0 fucto are smarter, clinically more competent and better administrators is disputable since many of the innovators and leaders in abnormal child behaviour were or are not medically trained, for example, Anna Freud, Bettelheim, Redl, Satir, to quote a few idols. Surely, the indisputable attribute of the child psychiatrist lies in his medical training, the relevance of which can be seen most clearly in such activities as the differential diagnosis of children with obscure somatic complaints or conditions which might have an organic aetiology, the management of children with psychological and behavioural problems associated with physical illness and the administration of psychotropic drugs and other medical treatments. On the other hand, much of the knowledge relevant to behaviour disorders, child development, learning difficulties, psychotherapy, behaviour therapy, family therapy, access and custody disputes requires no such medical training and it is not easy to dismiss the claim that such activities are often a waste of a doctor’s time particularly since less expensive more available persons can do them just as well. Further, child psychiatrists lack the necessary theoretical and methodological knowledge to undertake the kind of research in these areas so that despite good ideas their efforts are often characterized by lack of sophistication and scientific acceptability. Obviously, some training, experience and limited practice in these non-medical areas is necessary for a child psychiatrist but this should be seen as subordinate to the real role which, as in medicine in general, is largely diagnostic and therapeutic only to a limited degree. It also means that ordinarily child psychiatrists should practise in paediatric medical facilities leaving the work in courts, welfare homes, schools and child guidance clinics to those who are or shouId be properly trained for it, performing occasional ‘medical’ consultations to such agencies when requested. Since primary prevention in child psychiatry is largely a matter of applied common sense and humanitarianism coupled to social engineering, the responsibility for it should be the
concern of all members of the community not just child psychiatrists or even in child psychiatrists in particular. There is good reason to ponder whether child psychiatry would be better placed within psychiatry or within paediatrics. Most of the true child psychiatric need (that is tied to medicine) lies within the context of paediatrics and because of greater numbers, most ‘child psychiatry’ is in fact carried out by paediatricians. Recognition of this can be seen in the new development of behavioural paediatrics as a subspeciality and the increasing tendency for paediatric journals to publish child psychiatry type articles, amateurish though they may be. It looks like the full turn of the wheelpaediatricians started child psychiatry, they lost it to psychiatry and now they are recapturing it by default and sheer weight of numbers. An argument could be made for the divorce of child psychiatry from psychiatry with the former joining behavioural paediatrics. The new behavioural paediatrician would then rotate through psychiatry rather than being seen as a trainee in psychiatry itself. This suggestion has the merit of lack of stigma for child patients, reduction in irrelevant or replaceable activities, improved recruitment prospects, more science and less sentiment and better communication with paediatric and family practitioner colleagues. The big risk of course is too much dilution of the psychological component in training. This could be overcome by subspeciality status within paediatrics and different training requirements. If on the other hand child psychiatry is to remain within psychiatry it requires to be accorded a top priority in terms of allocation of academic posts, research and allied facilities. To achieve this it may in some instances be necessary for medical schools from different universities to pool their resources to create one viable, academically strong institute of child psychiatry in a given city such as Sydney or Melbourne. The views expressed here are unlikely to prove popular but they are something to ponder in 1979, the International Year of the Child.
J. S. WERRY, Professor of Psychiatry, School of Medicine, University of Auckland P.B., Auckland, New Zealand.
Downloaded from anp.sagepub.com at UNIVERSITE DE MONTREAL on June 8, 2015
