LETTERS TO THE EDITOR Passing the Boards
examinations . T he Committee welcomes ope n discu ssio n with suggestions regardi ng the certifica tion pro cess .
To tlu: Ed itor:
Joseph Fischh off, M .D . Chairman, Co mmi ttee on Cer tification in Chi ld and Ado lesc e nt Psychi atry of the Amer ica n Board of Psychiatry and Neu rology , Inc .
I wish to e xpress concern regarding the 53 % Boa rd Exami nation pass rate reporte d by the Com mittee on Certifica tion in Child and Ado lescent Psychiatry (May, 1989 , p. 8 10). Th is is not a " sour grapes" lette r: I passed both the genera l and child psychiat ry exami nations on the first attempt. I am writing thi s lette r out of co nce rn for seve ra l of my colleagues , who, I feel cer tain, arc of equal co mpetence , and yet arc amo ng thos e who did no t pass the exa mination . Child psych iatr ists arc at the end of a lon g selection pro cess that has included graduation from medical school, resid ency, and fello wship traini ng programs which arc them selves subject to rigorous review . A prerequ isite for takin g the Child Psychiatry Board Examin ation is successful com pletion of the Ge ne ral Psychiatry Board Examination , which ave rage s a 40 % failure rate . Each child psychiatry examinee is therefore roughly in the top (,0% o f ge ne ral psychi atr y candidates (no t inc ludin g those who pass on retest) and has alread y dem on strat ed his or her ge neral skills as we ll as the abi lity to function we ll in bo th written and ora l exa m ination form ats . It is difficult to under stand , then , why on ly 53 % o f this very se lec t group of ex aminees were ab le to pass the Child Psych iatry Board Exa mination in IlJ88. Most of us know Board exam iners who arc sympatheti c to the exa m inees and feel that they give the ca ndidates ev ery opportunity to meet a min imum standa rd of competenc e. However , most of us also know ex treme ly competen t co lleagues who ha ve conditioned or failed the Child Psych iatry Examination, often in their own area of experti se , who ha ve never before faile d a major test. Ofte n, we know their work well enough to dou bt the validi ty of the tes t, rather than the competence of the indi vidu als involved . My imp ression is that , despite the ex aminers' best intenti on s, the Hoard Examination is somehow failing to ident ify a significant subgroup of candidates who arc deserving o f th is final " stamp of approva l." I have ItO easy answer s as to where the probl em lies. I trus t that the Board committee memb ers arc also struggling with the impli cations of thes e recent statis tics. I would we lcome a more open discussion in this J ournal rega rd ing our ow n certification process .
Depression in Children? To the Editor:
Compliments are du e to the authors of a series of articles inv estigating the presence of a categori cally distinct depressive syndrome in children (Sei fer et 'II., 1989) and adolescents (N urco mbe et al ., IlJ8lJ) . The authors usc an empirical analysis of data obtai ned from the Child Behav ior Che ckli st , a symptom questionnaire filled out by moth ers , to show that the presence of a categorically distin ct depressive syndromc could be supported in adole scent s , but not in children. Th e authors e loquently discuss how the ir meth od of anal ysis (a prin cipal components analysis , followed by a cluster analysis of data from an omnibus symptom chec kli st, that docs not pre-a ssum e a system of dia gnosis) avoids the circularity prese nt in man y studies of child and adole sce nt depr ession . T hese articles should be considered among the best of the year in child and ado lesce nt psyc hiatry , not so m uch for the findings, bu t for the emp irica l me thod of an alysis, whi ch has bee n rarel y used in ch ild and ado lescent psychiatry and cou ld help us in impro ving the validi ty of ou r system of cla ssifica tio n. T he findings of these studies arc far fro m de finitive; the authors poi nt out man y of their limitation s. Two major limit ati on s , however , were hard ly men tioned in the artic le rep orti ng the inabilit y to isolate a depr essive cl uster in chi ldren (Se ifer et al . , 1989). First , whereas mothers have been demonstrated to be relati vel y good reporter s of the ir chi ldren 's beha vioral sy mp toms, a number of studies have qu cstioned mothers ' abiliti es to acc urate ly repo rt man y of their chi ldre n's depressive symptoms (e. g. , Ivens and Rchm , IlJ88) . In the same issue of the Journa l, Kashani et al, ( 1989) reported that on ly 14% of parents of suicidal children wer e aware of the suicidal ideation . The reason s for this difference in repo rting arc unclear, but poss ibilities inclu de: cer tain sym ptoms in children evoke awful feelings in parents and arc thus denied; the lay conce ption tha t children do no t become depressed; and children' s lack of shari ng of their interna l worlds with thei r parent s . Seco nd, Se ifer et a!. impl y that lac k of ev idence for a " pu re" depressive disord er in children is the sa me as lack of ev ide nce for " nuclear" or major depr ession . An alternati ve ex plan atio n is that major de pression in children se ldom ex ists in a " pure" form . T he depressive disorder may requ ire the presen ce of other disorders or sy mptom cl usters (e .g., anxie ty , behavioral , de velopme nta l) in ord er to eme rge or be expres sed at a young age . Anothe r possib ility is tha t parent s tend not to recog nize depressive symptoms in the ir children , or tend no t to reco gnize them as ab norm al or req uiring of treatm ent , and only brin g the ir child to a clinic whe n non depressive symptoms eme rge . The sole usc of mo thers as inform ants and the assump tion that " pure " depression is the sa me as " nuclear" depression limit the genera lizabi lity of Seife r e t al.'s findi ng of no distinct depression cluster in chi ldren . We are surprised that these lim itations were not discussed by Seifer et a!. in an othe rwise exce llent ser ies of arti cles .
Geri Fox, M .D . Univers ity of Illi nois
The Hoard replies: For ma ny ycars , the pass rate has been in the (,0% ra nge . Th e candidates who do not pass either co nd ition or fail. For many years , the Committee on Certifica tio n on Child and Adole scen t Psych iatry of the Americ an Board of Psychiatr y and Neurolo gy has evaluated each exam ination in dep th , c.g . , the wr itten ex am ination, the individua l sections of the ora l examination, the candidate gro up , and the exam iners,
Dr. Fox is co rrec t in stating that there arc no casy answer s as the Com mittee assesses thc resul ts of eac h e xamination , often with the expertise of co nsulta nts and also w ith informat ion obtained from other board s coping w ith the same issues co nce rning their exa mination s. I would note that since the exa mi natio n in child psych iatr y or igina ted , no mailer the for mat, the pass rate has becn in the (,0% rangc. Th e Co mmittee takes its charge serio usly and will co ntinue to evalu ate the
Benjamin Shain , M .D . , Ph . D. Michael Naylor , M .D . The University of Mi chi gan
484
examinations . T he Committee welcomes ope n discu ssio n with suggestions regardi ng the certifica tion pro cess .
To tlu: Ed itor:
Joseph Fischh off, M .D . Chairman, Co mmi ttee on Cer tification in Chi ld and Ado lesc e nt Psychi atry of the Amer ica n Board of Psychiatry and Neu rology , Inc .
I wish to e xpress concern regarding the 53 % Boa rd Exami nation pass rate reporte d by the Com mittee on Certifica tion in Child and Ado lescent Psychiatry (May, 1989 , p. 8 10). Th is is not a " sour grapes" lette r: I passed both the genera l and child psychiat ry exami nations on the first attempt. I am writing thi s lette r out of co nce rn for seve ra l of my colleagues , who, I feel cer tain, arc of equal co mpetence , and yet arc amo ng thos e who did no t pass the exa mination . Child psych iatr ists arc at the end of a lon g selection pro cess that has included graduation from medical school, resid ency, and fello wship traini ng programs which arc them selves subject to rigorous review . A prerequ isite for takin g the Child Psychiatry Board Examin ation is successful com pletion of the Ge ne ral Psychiatry Board Examination , which ave rage s a 40 % failure rate . Each child psychiatry examinee is therefore roughly in the top (,0% o f ge ne ral psychi atr y candidates (no t inc ludin g those who pass on retest) and has alread y dem on strat ed his or her ge neral skills as we ll as the abi lity to function we ll in bo th written and ora l exa m ination form ats . It is difficult to under stand , then , why on ly 53 % o f this very se lec t group of ex aminees were ab le to pass the Child Psych iatry Board Exa mination in IlJ88. Most of us know Board exam iners who arc sympatheti c to the exa m inees and feel that they give the ca ndidates ev ery opportunity to meet a min imum standa rd of competenc e. However , most of us also know ex treme ly competen t co lleagues who ha ve conditioned or failed the Child Psych iatry Examination, often in their own area of experti se , who ha ve never before faile d a major test. Ofte n, we know their work well enough to dou bt the validi ty of the tes t, rather than the competence of the indi vidu als involved . My imp ression is that , despite the ex aminers' best intenti on s, the Hoard Examination is somehow failing to ident ify a significant subgroup of candidates who arc deserving o f th is final " stamp of approva l." I have ItO easy answer s as to where the probl em lies. I trus t that the Board committee memb ers arc also struggling with the impli cations of thes e recent statis tics. I would we lcome a more open discussion in this J ournal rega rd ing our ow n certification process .
Depression in Children? To the Editor:
Compliments are du e to the authors of a series of articles inv estigating the presence of a categori cally distinct depressive syndrome in children (Sei fer et 'II., 1989) and adolescents (N urco mbe et al ., IlJ8lJ) . The authors usc an empirical analysis of data obtai ned from the Child Behav ior Che ckli st , a symptom questionnaire filled out by moth ers , to show that the presence of a categorically distin ct depressive syndromc could be supported in adole scent s , but not in children. Th e authors e loquently discuss how the ir meth od of anal ysis (a prin cipal components analysis , followed by a cluster analysis of data from an omnibus symptom chec kli st, that docs not pre-a ssum e a system of dia gnosis) avoids the circularity prese nt in man y studies of child and adole sce nt depr ession . T hese articles should be considered among the best of the year in child and ado lesce nt psyc hiatry , not so m uch for the findings, bu t for the emp irica l me thod of an alysis, whi ch has bee n rarel y used in ch ild and ado lescent psychiatry and cou ld help us in impro ving the validi ty of ou r system of cla ssifica tio n. T he findings of these studies arc far fro m de finitive; the authors poi nt out man y of their limitation s. Two major limit ati on s , however , were hard ly men tioned in the artic le rep orti ng the inabilit y to isolate a depr essive cl uster in chi ldren (Se ifer et al . , 1989). First , whereas mothers have been demonstrated to be relati vel y good reporter s of the ir chi ldren 's beha vioral sy mp toms, a number of studies have qu cstioned mothers ' abiliti es to acc urate ly repo rt man y of their chi ldre n's depressive symptoms (e. g. , Ivens and Rchm , IlJ88) . In the same issue of the Journa l, Kashani et al, ( 1989) reported that on ly 14% of parents of suicidal children wer e aware of the suicidal ideation . The reason s for this difference in repo rting arc unclear, but poss ibilities inclu de: cer tain sym ptoms in children evoke awful feelings in parents and arc thus denied; the lay conce ption tha t children do no t become depressed; and children' s lack of shari ng of their interna l worlds with thei r parent s . Seco nd, Se ifer et a!. impl y that lac k of ev idence for a " pu re" depressive disord er in children is the sa me as lack of ev ide nce for " nuclear" or major depr ession . An alternati ve ex plan atio n is that major de pression in children se ldom ex ists in a " pure" form . T he depressive disorder may requ ire the presen ce of other disorders or sy mptom cl usters (e .g., anxie ty , behavioral , de velopme nta l) in ord er to eme rge or be expres sed at a young age . Anothe r possib ility is tha t parent s tend not to recog nize depressive symptoms in the ir children , or tend no t to reco gnize them as ab norm al or req uiring of treatm ent , and only brin g the ir child to a clinic whe n non depressive symptoms eme rge . The sole usc of mo thers as inform ants and the assump tion that " pure " depression is the sa me as " nuclear" depression limit the genera lizabi lity of Seife r e t al.'s findi ng of no distinct depression cluster in chi ldren . We are surprised that these lim itations were not discussed by Seifer et a!. in an othe rwise exce llent ser ies of arti cles .
Geri Fox, M .D . Univers ity of Illi nois
The Hoard replies: For ma ny ycars , the pass rate has been in the (,0% ra nge . Th e candidates who do not pass either co nd ition or fail. For many years , the Committee on Certifica tio n on Child and Adole scen t Psych iatry of the Americ an Board of Psychiatr y and Neurolo gy has evaluated each exam ination in dep th , c.g . , the wr itten ex am ination, the individua l sections of the ora l examination, the candidate gro up , and the exam iners,
Dr. Fox is co rrec t in stating that there arc no casy answer s as the Com mittee assesses thc resul ts of eac h e xamination , often with the expertise of co nsulta nts and also w ith informat ion obtained from other board s coping w ith the same issues co nce rning their exa mination s. I would note that since the exa mi natio n in child psych iatr y or igina ted , no mailer the for mat, the pass rate has becn in the (,0% rangc. Th e Co mmittee takes its charge serio usly and will co ntinue to evalu ate the
Benjamin Shain , M .D . , Ph . D. Michael Naylor , M .D . The University of Mi chi gan
484
