A d m i n i s t r a t i v e I s s u e s in C h i l d a n d A d u l t Psychiatry Training Programs
Jack C. Westman, MD University o f Wisconsin
Child psychiatry training programs have encountered a number of administrative problems resulting from efforts to recognize, without isolating or submerging, the unique aspects of child psychiatry within existing departments of psychiatry. This paper questions the validity of the concept of general psychiatry, which may be responsible for many of these administrative dilemmas. The thesis is advanced that adult and child psychiatry actually represent distinct fields of practice, however, training programs for each should be integrated within departments of psychiatry through both adult and child divisional administrative lines. ABSTRACT:
Much as been written about the growing pains of child psychiatry. Previous commentaries have borne the titles: Child Psychiatry: Retrospect and Prospect , Who Deserves Child Psychiatry?  and Child Psychiatry Limited? . All of these writings appear to reflect not only specific ambivalent attitudes toward child psychiatry, but also more general questions about psychiatry's place in the growing ranks of the mental health professions. Because it is caught between broad questions about who can best help the mentally ill, the emerging discipline of child psychiatry has found itself in an unusually vulnerable position. As a result of its origins in community service through which it laid the foundation for community mental health centers, child psychiatry has been publicly visible and influenced by community needs and criticisms . At the same time, because of those community roots, child psychiatry is a newcomer in medical school departments of psychiatry where it lacks an historically firm and clearly defined base. The intent of this paper Dr. Westman is Professor of Psychiatry, University of Wisconsin, 427 Lorch Street, Madison, Wisconsin 53706. Child Psychiatry and Human Development, Vol. 8(4), Fall 1978 0009-398X/78/1400-0195500.959 Human Sciences Press
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is to identify key administrative issues encountered in developing child psychiatry training programs. First, it is appropriate to note the role of child psychiatry in health care and child rearing systems. Although professionals outside of the health care system, particularly in education, have found ways of changing the behavior of children with psychological problems, child psychiatry remains the only clinical discipline that brings the knowledge of the social, behavioral and biological sciences to bear upon the mental and emotional problems of children and adolescents as they are expressed in homes, schools and communities. As a component of the health care system, child psychiatry draws upon an understanding of the individual patient and his or her relationships to others in order to offer relief from suffering and promote healthy personality development. Unlike most fields of clinical medicine, child psychiatry further depends upon the coordination of child caring systems, particularly the schools, welfare agencies, juvenile courts, family courts and child caring institutions. Conversely, the inclusion of child psychiatry programs in medical schools has enriched medical education with knowledge of personality development, family dynamics, community service networks and the psychiatric problems of children [5, 6].
Child Psychiatric Training Models Because of its multiple roots in pediatrics, psychiatry and community mental health, child psychiatry has faced unique administrative and training dilemmas. Although there is no disagreement that child psychiatrists are needed, there is much controversy regarding where, how and when they should be trained. Each of the parent fields zealously guards its stake in its offspring. The passage of time has resolved an earlier question regarding whether the child psychiatrist basically should be a pediatrician or a psychiatrist. The emergence of child psychiatry specialty certification recognized pediatric psychiatry as a part of a broader specialization in child psychiatry. American Medical Association approved residency programs in child psychiatry, therefore, must be affiliated with a psychiatry residency program, eliminating the free standing child psychiatry fellowship in a community clinic, the original training modality for child psychiatrists. The equivalent of two years of child psychiatry residency are required in addition to an adult psychiatry residency with the option of obtaining six months's training credit for one year of more of pediatric training [7, 8]. The most widely adopted administrative pattern for child psychia-
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try training has been a variously placed child psychiatry division within a department of psychiatry. The divisional organization provides a base for training child psychiatrists and contributing to the training of psychiatrists, pediatricians and allied professionals. A significant problem with this model is that the head of the child psychiatry division may have the responsibilities of a department chairman w i t h o u t commensurate administrative authority. Furthermore, the child psychiatry division tends to be regarded at the same administrative level as components of the adult training program. Because of these problems Sonis proposed another administrative model recognizing the pervasive distinctions between children and adults and placing child psychiatry within a child health center as one of the range of specialities dealing with the health problems of children [ 9]. Within that base the training of child psychiatrists would occur, and relationships would extend to pediatricians, psychiatrists and other allied health professionals. A third model for child psychiatry training is an a u t o n o m o u s department of child psychiatry, recognizing both the uniqueness of clinical services for children and the administrative advantages of departmental status within a medical school. This model is an expression of the view that the integration of psychiatry, pediatrics, child development and c o m m u n i t y mental health constitutes a new academic discipline . A fourth training model for child psychiatrists results from the continued interaction of child psychiatry programs with departments of psychiatry. In this model, adult and child psychiatrists are trained within related tracks integrated within the administrative structure of a department of psychiatry . Although the most logically conceived of all models, experience, as will be described at the University of Wisconsin, reveals that the integration of adult and child psychiatric training poses thorny administrative challenges. Within the foregoing administrative models the patterns of child psychiatry training are currently in a state of flux . Cohen and Henderson  reported a 1971 survey of child psychiatry training programs. Of 52 training programs, 48% had altered their training sequence away from the two year fellowship model, 5% were considering changing and 47% were not contemplating changes.
The Wisconsin Experience The University of Wisconsin Department of Psychiatry has had the opportunity to try various psychiatric training models. The department's manageable size and c o m m i t m e n t to training innovations has
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provided a framework, unhampered by inflexible administrative lines, for innovations in both the curriculum and clinical experiences of psychiatric training. Because administrative structures can arise from considerations unrelated to training objectives, such as the nature of physical facilities, the expediences of meeting funding requirements and the theoretical biases of the faculty, the Wisconsin department of psychiatry elected to let the administrative structure of the child psychiatry training program float to find its level in relationship to achieving training objectives. The intent was to ferret out the ingredients of child psychiatry training needed to develop knowledge and clinical skills within the context of university graduate education. Rather than fitting training to administration, we wished to mold administrative structure to training objectives. In 1970 the department made a commitment to provide training in child psychiatry for all psychiatric residents. The initial plan was that all residents would receive the equivalent of one year of training in child psychiatry during a three year period with those electing full training in child psychiatry devoting an additional year to child psychiatry training. One of the expectations was that graduates of the Wisconsin program would be prepared as general psychiatrists at the end of three years of residency. This goal was stimulated in part by the need in c o m m u n i t y mental health centers for psychiatrists prepared to deal with the problems of all age groups. Another intent was to improve the quality of psychiatric training through exposure to the theory and clinical practice of child psychiatry as an ingredient of training for adult psychiatrists. Because the integrated program coincided with the institution of an experimental program which permitted the completion of psychiatric training six years after entering medical school, the possibility also existed that an additional year of training in child psychiatry might be more readily sought by psychiatric residents.
Is General Psychiatry A Valid Concept? The Wisconsin experience mobilized a range of fundamental issues, providing tentative answers to some and calling attention to others. From 1970 to 1975, when child psychiatry training was available to all residents, approximately 30% elected full training in child psychiatty. Although a higher proportion than was reported by most training programs, this trend confirmed Cohen's  experience that recruitment for child psychiatry was facilitated by beginning work with
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children during the first year of residency. We found, also, that full exposure to training in child psychiatry identified two groups of residents: those who wish to specialize in child psychiatry and those who find that they do n o t have interest in work with children. We can validate the existence of a group of psychiatric residents, previously described b y Work , with interests in human development, social systems, early therapeutic intervention and collaborative t e a m w o r k that attract them to child psychiatry. Conversely, there is a larger number of trainees who do not show these interests and elect adult psychiatric practice. The 1970 American Psychiatric Association Survey of American Psychiatrists  confirms in later practice our observation of two groups of trainees, those who become adult psychiatrists and those who become child psychiatrists. The survey revealed that 69% of American psychiatrists do not see children and 35% do n o t see adolescents. These findings indicate that general psychiatrists are in fact adult psychiatrists. If there is a general psychiatrist, it probably is the child psychiatrist, a finding also confirmed both b y the 1970 APA survey and a 1971 American Academy of Child Psychiatry report  which disclosed that most child psychiatrists work with adults. It is a misconception that child psychiatrists are interested only in children. Actually intellectual and clinical stimulation for the child psychiatrist springs from desires to be involved in the early detection, treatment, and prevention of mental illness, in addition to an interest in child caring systems. All of these activities require familiarity with both children and adults. Child psychiatrists are deeply involved in the diagnosis and treatment of adults in the family and c o m m u n i t y systems of the children t h e y serve. In addition to differences in trainee interests and actual clinical practice the concept of the general psychiatrist is further challenged by the content and duration of general psychiatry residencies. Although one can say that a graduate of a three year psychiatric residency is a general psychiatrist it is unlikely that such a psychiatrist, in fact, is prepared to deal with all psychiatric problems. Actually, at least three years of residency are required to prepare an individual for the practice of adult psychiatry and at least four years for child psychiatry. Another source of misunderstanding has been the blurring of the differences between adult and child psychiatry by the appearance of family oriented diagnosis and treatment. There has been a tendency to regard family psychiatry as a field of practice in itself and as the unifying vehicle for adult and child psychiatry . Malone 
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and McDermott  appropriately point out that family diagnosis and therapy are techniques of value in both adult and child psychiatry and that they provide c o m m o n conceptual and clinical grounds b u t do not in themselves erase the distinctions between the unique fields of clinical practice in adult and child psychiatry. Supervening all of these considerations is the greater need for child than adult psychiatrists in both academic areas and in health care delivery systems by more than double the number. Although precise figures cannot be assembled to establish h o w many child psychiatrists are required, there is no disagreement that all children should have access to child psychiatric services when needed. According to AMA and NIMH data [19, 20] there were 2,600 child psychiatrists in the nation in 1976 and 8,400 more are needed (a quadrupling to one to 20,000 population). The comparable figures for adult psychiatrists were 24,000 in 1976 and a need for 22,000 more (a doubling to one to 5,000 population).
Administrative Issues in Child and Adult Psychiatry Training The need of the child psychiatrist for training in adult psychiatry argues strongly against separate training programs for adult and child psychiatrists. Not only do separate training programs overlook the need of the adult psychiatrist for a developmental point of view both in didactic and clinical experiences, but they run the risk of training child psychiatrists without competence in dealing with adults in child caring systems. An outgrowth of the idea of separate training programs is the model of a three year block of adult and a two year block of child psychiatric training. Not only does that separation deprive the child trainee of long term continuity with the clinical problems of children and the opportunity to follow adult patients for more than two years, bu~ separate adult and child psychiatry training blocks deprive the adult resident of correlations between children and adult patients. Perhaps the most compelling argument against separate training for adult and child psychiatrists is the fact that both are based upon the same basic and clinical sciences. The conceptual bases of both adult and child psychiatry are identical, making it redundant to plan separate training curricula and impossible to separate off aspects of the behavioral and biological sciences that pertain either to adult or child psychiatry. All of these points highlight the issues facing medical school administrations t o d a y in responding to the need for trained child psy-
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chiatrists and the provision of child psychiatry input for psychiatrists, pediatricians, family medicine practitioners and medical students. It, therefore, is necessary for medical schools to make a commitment to training in child psychiatry and to provide the administrative mechanisms to support it. Administrative recognition for child psychiatry within a department of psychiatry is indicated, not only because of the need to coordinate child psychiatric programs, but also to overcome several levels of misunderstanding. For example, one of the major stumbling blocks in integrated training programs for adult and child psychiatrists is the general tendency to regard the field of child psychiatry as one aspect of psychiatry on the same categorical level as group therapy, drug therapy, community psychiatry or administrative psychiatry. In fact adult and child psychiatry each contain aspects of group therapy, drug therapy, community psychiatry  and administrative psychiatry. Because of this kind of system level confusion, child psychiatry training programs find themselves competing with components of adult psychiatry training programs, such as an adult inpatient service, for budget and faculty recruitment. Without clear administrative lines, the director of a child psychiatry training program may be on the same administrative level as the director of an adult clinioal service. Another practical problem resulting from the lack of administrative clarity for child psychiatry programs is the tendency to place the child psychiatrist in competition with other department faculty members for promotion and merit purposes without recognizing the need for child psychiatrists to develop areas of specialized expertise. The child psychiatrist may be expected simply to carry the responsibility for teaching child psychiatry, ignoring the fact that academic adult psychiatrists are not expected to handle all aspects of adult psychiatry. Unrecognized, yet vital for the advancement of child psychiatry, is the need for child psychiatrists to specialize in liaison, psychopharmocology, behavior therapy, inpatient treatment and other areas of teaching and research activity. The heavy demands placed upon academic child psychiatrists for teaching, administration and service have handicapped the scientific development of the field .
An Administrative Proposal for Child and Adult Psychiatry Training It is timely to consider an administrative model that would integrate child psychiatry with adult psychiatry in a department of psy-
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chiatry in such a way that the training of both adult and child psychiatrists is furthered. A model that could achieve this aim and maintaln administrative lines that would protect both adult and child psychiatric training programs is to place the chairperson of a department of psychiatry over two clearcut administrative divisional lines, one under the responsibility of a coordinator of a child psychiatry division and the other under a coordinator of an adult psychiatry division. Not only would this free the chairperson from immediate responsibility for both adult and child programs and permit concentration upon the broader issues facing psychiatry, but it would insure that the divisional coordinators responsible for training programs were both interested in and trained for their areas of responsibility. The details of service, training and research activities would vary widely depending upon the setting, however, there would be overall recognition that child and adult programs differ in their styles of operation. Perhaps the most persuasive argument for discrete adult and child divisions within departments of psychiatry is the fact that the different styles of adult and child practice are n o t clearly reflected in training institutions. Trainees need personal models in the form of both adult and child psychiatric practitioners. The lack of visible models and administrative support for them has contributed to the myth of the general psychiatrist and has clouded the real distinctions between adult and child psychiatric practice. Conclusion
In making the transition from c o m m u n i t y clinics to university health science centers, child psychiatry training programs have encountered a number of administrative issues. Problems have resulted from efforts to recognize, without isolating or submerging, the unique aspects of child psychiatry within existing departmental organizational structures. This paper questions the validity of the concept of general psychiatry, which may be responsible for many of these administrative dilemmas. The thesis is advanced that adult and child psychiatry actually represent distinct fields of practice, however, training programs for each should be integrated within departments of psychiatry through both adult and child divisional administrative lines. References 1. Kanner L: Child psychiatry: Retrospect and prospect. Am J Psychiatry 117: 15-22, 1960.
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2. Solnit AJ: Who deserves child psychiatry?: A study of priorities. J Child Psychiatry 5:1-34, 1965. 3. Nuffield EJA: Child psychiatry limited? J Child Psychiatry 7:210-222, 1968. 4. Berlin IN: A history of challenges in child psychiatry training. MH 48: 558565, 1964. 5. Lewis M: Child psychiatry and medical education. J Child Psychiatry 12: 407-424, 1973. 6. Werkman SL: The Role of Psychiatry in Medical Education. Cambridge, Massachusetts: Harvard University Press, 1966. 7. American Board of Psychiatry and Neurology. Information for Applicants for Certification in Child Psychiatry. Evanston, Illinois, 1978. 8. Krug OM: Career Training in Child Psychiatry. Washington, D.C.: American Psychiatric Association, 1964. 9. Sonis M: The administrative place of child psychiatry within a department of psychiatry of a school of medicine. In P Adams, H Work, J Kramer, Academic Child Psychiatry, GainesviUe, Florida, Society of Professors of Child Psychiatry, 1969. 10. Rubin SE, Enser NB: An approach to the integration of child psychiatry in the basic residency. Presented at the annual meeting of the American Academy of Child Psychiatry, 1972. 11. Silver LB et al: Governmental peer review of training programs in child psychiatry. Am J Psychiatry 134 Supplement:11-14, March, 1977. 12. Cohen RL, Henderson PB: Experiences m the alteration of sequence inchild psychiatric training. J Child Psychiatry 12:441-460, 1973. 13. Work HH: Career choice in the training of the child psychiatrist. J Child Psychiatry 7:442-453, 1967. 14. Arnhoff FN, Kumbar AH: The Nation's Psychiatrists--1970 Survey. Washington, D.C.: American Psychiatric Association, 1973. 15. Spurlock J, et ah The private practice of child psychiatry by members of the American Academy of Child Psychiatry. J Child Psychiatry 1 O:53-64, 1971. 16. Westman JC: Child psychiatry: An introduction. Mich Med 63:485-487, 1964. 17. Malone CA: Observations on the role of family therapy in child psychiatry training. J Child Psychiatry 13:437-458, 1973. 18. McDermott JF, Char WF: The undeclared war between child and family therapy. J Child Psychiatry 13:422-436, 1974. 19. Center for Health Services Research and Development. Distribution of Physicians in the United States, 1976. Chicago: American Medical Association, 1977. 20. Kramer M: Some perspectives on the role of biostatistics and epidemiology in the prevention and control of mental disorders. Health and Society Summer, 1975. 21. Brunstetter RW: Community child psychiatry: Description of a training program and comments. J Child Psychiatry 9:445-461, 1970.