CURRENT PERSPECTIVES

Child and Adult Psychiatry: Comparison and Contrast* PAUL

D.

STEINHAUER, M.D. I , SUSAN 1. BRADLEY, M.D. 2 AND YVON GAUTHIER, M.D. 3

at times present a consensus of expert opinions in areas in which facts are not available. Many differences between child and adult psychiatry have evolved because of the differences in the ages of the patients treated. Of course, neither child nor adult psychiatry is homogeneous. They share some tensions - between university or research-oriented psychiatrists and psychiatrists practising in the community (1,2) and among advocates of any number of different biological, psychological and social approaches. Since many child psychiatrists function within university departments of general psychiatry, it is important that each group of psychiatrists understands and appreciates the unique nature of the other. Since each area has adapted to the needs of its patients and the basic sciences it adheres to, each should be evaluated on its own terms. In this way, both groups will be free to evolve, to complement one another and to contribute to the continued development of the other as a profession. As well, medical students and residents will be exposed to two distinct models of psychiatric intervention (3).

Since its development from general psychiatry, child psychiatry has been influenced by its close involvements with the child guidance movement and pediatrics and by the age ofits patient population. This has led it to evolve in ways quite distinct from adult psychiatry, so much so that at times the understanding and relationship between the two disciplines has been somewhat strained. This paper relates the development ofchild psychiatry to its history, its tasks and its patient population, highlighting some of the major differences between child and adult psychiatry. It then looks at why research in child psychiatry has lagged behind research in adult psychiatry. It concludes by discussing tensions between the two disciplines, and why it serves the interests ofboth professions as well as those of our patients, that a better understanding and collaboration between them be established.

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ven though child psychiatry has evolved from adult psychiatry, its formative years within the child guidance movement, its close relationship to pediatrics and the patients it treats have led to marked differences between the two disciplines. As adult psychiatry orients itself more and more with biological and pharmacological concepts, thereby distancing itself from systemic and psychodynamic concepts, a greater separation between the two fields may develop. Such a separation could be mutually detrimental, since child and adult psychiatry face many similar problems and a good working relationship to promote the exchange of ideas, resources and skills is required. This paper will describe, from the perspective of child psychiatry, some of the major differences between adult psychiatry and child and adolescent psychiatry in an effort to promote respect through greater understanding. Because there are few empirical studies on some ofthe issues related to child psychiatry, this review will

Characteristics Specific to Child Psychiatry Several characteristics central to the area of child psychiatry must be understood before the gap between child and adult psychiatry can be bridged. The Role ofDevelopment in Child Psychiatry Child psychiatry is "a specialty on its own account" (4), uniquely concerned with the interplay between various developmental dimensions (physical, emotional, cognitive, social) and the influence of familial, social and cultural factors (1,2,5-7). Development is a life-long process, and general psychiatrists often treat adult patients who are dealing with unresolved developmental issues (7). However, adult development, with the exception of periodic developmental crises such as becoming a parent or losing a spouse, is generally more gradual than that of children and adolescents. This ongoing process of development considerably complicates the psychiatric evaluation of children. Some phenomena which are clearly pathological in adults are entirely normal in children and adolescents (5,8,9). Not all children of the same chronological age are at the same developmental stage; for example, one 14 year old could be prepubertal while another may be several years past puberty. To distinguish between normal development and pathology, child psychia-

*Manuscript received March 1992, revised May 1992. I Senior Staff Psychiatrist, Department of Psychiatry, Hospital for Sick Children; Professor of Psychiatry, University of Toronto, Toronto, Ontario. 2Psychiatrist-in-Chief, Department of Psychiatry, Hospital for Sick Children; Head, Division of Child Psychiatry, Department of Psychiatry, University of Toronto, Toronto, Ontario. 3Professor of Psychiatry, University of Montreal; Staff Psychiatrist, Hopital Sainte-Justine, Montreal, Quebec. Address reprint requests to: Dr. P.D. Steinhauer, Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G IX8

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trists must constantly refer to two dimensions - phenomenological and developmental - and not just to the phenomenological dimension, as adult psychiatrists do. The extent of physical and psychological changes and the ~pee? at which they occur in the course of development will inevitably affect the manifestations of a child's disorder. Such factors will also influence the way in which the disorder affects the child, the course of the child's development the child's family, and the child's capacity to cope and adapt, Growth and development during childhood can provide strength and resilience which helps recovery. When a child's disorder or the family's reactions to it interfere with development, a self-perpetuating, cumulative developmental distortio? can occur that can permanently alter behaviour patterns, attitudes, personality structure and vulnerability to subsequent stresses (10-14). Only much more extreme developmental distortions occurring in adulthood could be expected to have comparable effects on the less adaptable adult personality. .. As we understand more about the effect of environmental and developmental factors on personality formation, we leam more about enhancing normal development to minimize or avoid developmental distortions (9). This has led to effective prevention strategies which can be applied prenatally and perinatally (15), with preschoolers (16), through schoolbased interventions (17-20) and in times of crisis (21,22).

Role of Family Assessment and Treatment Child psychiatrists cannot ignore the family. Because children are dependent on their parents for care, parents are an influential force in their lives, and it is essential to involve the parents in the treatment of children or adolescents. Treating a child from a dysfunctional family that does not support their child's therapy is unlikely to be successful until the pathological family interaction is addressed. The same applies to a lesser e~tent to the treatment of adults; their recovery may be undermined by pressures from a pathogenic family. However, t~eor~tically at least, adults can escape from the pathogenic situation whereas children, who depend on their families for survival, cannot. One could argue that some adults are so psychologically immature and dependent that they are trapped in chronically abusive situations. This should underline .the ~ecessity for all psychiatrists to consider family relationships. In fact, many adult psychiatrists treat individuals without regard for their families, while child psychiatrists cannot. Some adult psychiatrists, and most geriatric psychiatrists, consider the family of their adult patients, particularly since the literature on "expressed emotion" has provided a solid rationale for work with the families of patients with major psychiatric disorders (23). Concerns about the possible abuse of children may be pressing more adult psychiatrists to assess the families of their adult patients, especially because they may have to testify at some point regarding custody and access determinations or allegations of abuse (24-26). Prevention-minded adult psychiatrists are becoming more aware

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of the vulnerability of their patients' children and of the opportunity to intervene on their behalf.

Child Psychiatry, Pediatrics and the Allied Mental Health Professions Many children and families being treated by child psychiatrists - for disorders such as encopresis, separation anxiety disorders, or oppositional disorders - have previously been managed by pediatricians or general practitioners. It is often only after it prolonged but unsuccessful attempt at management by the primary physician that the patients are referred to a child psychiatrist (27-29). There is a chronic and severe shortage of child psychiatrists (30-35); one child in six with a diagnosable disorder receives treatment (36). Many children with disorders that have been identified are treated by social workers, psychologists. or child and youth workers based in children's inental health centres, often with little input from child psychiatrists: Child psychiatry has been criticized for passing on the management of many of the. most disturbed children and families to professionals with less training while they, especially those in private practice, provide long term psychotherapy for children who are often considerably less pathological (37). Funding patterns for psychiatric services, at least in Ontario, favour an individual treatment model over a consultative model. This model discourages indirect involvement by child psychiatrists; some of the most disturbed children or those who have already been removed from their family homes are being managed in treatment services where individual therapy is difficult. There is a constant demand for child psychiatrists to act as consultants to schools and social agencies that manage many such children. One recent survey (38) found that 64% of practising child psychiatrists provide consultation ofthis type (on an average of just less than one-half day per week), and 71 % offer consultation to social agencies or schools rather than to other physicians. While much of the consultation in child psychiatry is case-centred, there is an increasing demand for inservice training of large groups of agency staff. This strictly educational approach may have a greater overall impact by significantly improving health care professionals' awareness of advances in the field, introducing them to more systemic ways of conceptualizing cases and formulating interventions, offering guidelines for decision making and case management and demonstrating techniques of assessment and intervention (3,7,39). However, the use of educational consultation is limited, since few agencies have funding for services other than direct case consultation.

Emphasis in Child Psychiatry The emphasis on the contribution of familial and social factors to psychopathology in children has been so strong that, until the work of Thomas and Chess on temperament (40), biological influences were largely unappreciated in child psychiatry. Since then, most child psychiatrists have favoured a multifactorial approach to formulation that exam-

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ines biological, developmental, familial, social and psychological factors in an effort to understand personality development and psychopathogenesis. While this approach is difficult to study empirically, it has allowed researchers to clinically capture the unique qualities of individual children and their interaction with their families and environment (2,41). The continued emphasis on the contributions of developmental, familial, social and biological factors has made the adoption of a systemic approach to formulation in child psychiatry almost inevitable. A number of researchers (3,5,7) maintain that child psychiatry deals more comprehensively with the person in his or her environment than almost any other profession. In child psychiatry, the child's family background may become the major focus of intervention, and child psychiatrists are much more likely than adult psychiatrists to work toward changing adverse environmental influences, such as those existing within the school, families, foster care families and juvenile court systems (3,7,9). One poorly appreciated side-effect of the involvement with the social environment is the considerable time spent consulting and collaborating with other professionals - teachers, social workers, day care workers, probation officers - who affect children's lives to such a great extent, for better or worse. Child psychiatrists who are willing to work with the team can be of more help to children by consulting with other professionals on an ongoing basis than by treating them directly. Child psychiatrists are best qualified to contribute to agencies their familiarity with and strength in all levels of the biopsychosocial model, their ability to integrate these through systemic formulation and, as a result, their ability to enhance treatment planning of some of the most difficult cases (39,42). The importance and effectiveness of such collaborative activities, referred to as the "multiplier effect," are often poorly understood both by adult psychiatrists and administrators of health insurance plans. Health insurance plans refuse to fund them, with the exception of conferences with the caseworker of children in foster care. The Child Psychiatrist as a Generalist

Since child psychiatrists formulate and intervene systemically to address problems at various levels of the biopsychosocial model, it is not surprising that most practising child and adolescent psychiatrists are truly generalists. The need to encourage parents to become involved in their child's therapy - through conjoint family therapy, concurrent parent counseling or collaboration with a colleague who treats the parents or family of the child - is central to the effective practice of child psychiatry (43). A child psychiatrist's ability to deal with parents' individual and marital pathology by helping them with their parenting skills is often crucial to keeping children in treatment and to the effectiveness of the therapy. Most child psychiatrists work with younger children, adolescents and university students, some of whom they follow through into adulthood. Since marital problems are associated

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with children's difficulties, child psychiatrists frequently perform marital therapy, often as a sequel to family therapy, once the triangulation in which the child had been trapped has been undone. Child psychiatrists also treat individual adults, either to diversify their practices or to continue working with a parent with whom a therapeutic alliance formed during family or marital therapy. Identifying and serving those families who require only time-limited and primarily educational intervention is also an important component of child psychiatric practice. The treatments provided by both adult psychiatrists and child psychiatrists vary considerably. While some offer only a narrow range of interventions - such as psychoanalysis or psychopharmacology or family therapy - most are more pluralistic, blending psychodynamic and/or cognitive behaviour and/or behaviour therapies to fit the needs of the patient. Some, but not all, also treat groups. Because of the nature of their work, most child psychiatrists become involved in some aspects of forensic child psychiatry, either by reporting suspicions or allegations of abuse, involvement in litigation surrounding custody and access, or following a patient charged as a young offender. A general bias against the use of medication in child psychiatric practice is decreasing. Except for the use of psychostimulants to treat hyperactivity, medications are not used as often by child psychiatrists as by adult psychiatrists. One reason is that psychopharmacology research in children lags behind that in adults. Second, some of the medications most useful for treating adults (for example, the tricyclic antidepressants) are less effective and have a lower margin of safety in children than in adults. Third, prescribing medication for a child is a far more complex undertaking, given the need to obtain informed consent from the parents and child, the different effect of medication on children of different ages, and our society's negative attitudes toward "drugging" children. Medication is used more selectively in child psychiatry as an adjunct to psychotherapy than it was ten years ago (44). Some authors (13,45), concerned with what they consider to be the residual effect of the child guidance clinic model (i.e., child psychiatry's tendency to diffuse itself through excessive involvement with the allied professions) applaud the recent trend towards the increased use of medication by child psychiatrists. Others (1,2), however, while welcoming advances in psychopharmacology and the development of a research base for child psychiatry, warn against allowing the pendulum to swing so far that, to paraphrase Eisenberg (46), we move from a psychiatry that ignored the brain to one that loses sight of the mind. There is considerable concern that, because of the trend toward greater subspecialization in psychiatry, fewer and fewer psychiatrists are remaining generalists (7,8,47). We suggest that of all psychiatrists, except perhaps geriatric psychiatrists, those who work with children are most likely to be generalists. Adult psychiatrists usually treat adults only, mostly one-to-one, or adults and older adolescents (48-51). Since they rarely take on patients whom they will follow through all the stages of life, it is probably more appropriate

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to consider them specialists in adult psychiatry than true generalists (3,7,8,31). Differences in Assessment Children, and many adolescents, like forensic patients, often cannot or will not provide the basic information on their history needed for assessment. Often they do not see themselves as having a problem and are frequently brought for assessment only because others (primarily parents and teachers) are concerned about their behaviour. Denial and a tendency to blame others for their own difficulties are normal defenses until the end of latency. Therefore, the history obtained from a child must always be corroborated by parents and teachers. This increases the scope of assessments and interventions involving children. The DSM-III-R or the ICD-9 criteria frequently prove unsatisfactory when diagnosing disorders in children since both of these systems assume that a single individual has the disorder. Since, in child psychiatry, one is dealing with interpersonal problems most of the time, it is hard to fit the individual child successfully into either ofthese unidimensional approaches to diagnosis. Steinhauer (52) suggests that one needs to understand the interaction of six separate dimensions of individual and family functioning for adequate formulation in child psychiatry. As a result, a consultation which, in adult psychiatry, may require one and one-half hours, may well, in child psychiatry, take four and one-half hours or more (10). If, as a result of a marital separation, the child has two families, the assessment may be even more complicated and time-consuming. Meijer (5) and Rae-Grant (9) have pointed out that assessments.'of children frequently depend less on auditory and verbal interactions and more on visual factors, such as observations of play and behaviour and the interpretation of drawings. Sessions are typically less formal and involve a greater orientation towards activity. Those unfamiliar with children's cognitive and behavioural expressions at different ages and levels of development may find it hard to understand and adjust to children's feelings and fantasies expressed through play rather than verbalization. This may make it more difficult for some psychiatrists to think or respond therapeutically when interviewing children (53). Those who need to be in control in order to feel comfortable may feel a loss of control and/or adult status just talking or playing with young children. For some adult psychiatrists, this constitutes a barrier to interviewing children. Particularly when there is conflict between children or adolescents and their parents, both the conscious values and the infantile conflicts of the therapist may make it extremely difficult to remain objective (5). Countertransference can lead to overidentification with the child or the parents, making it difficult to remain impartial (54). Child psychiatrists are generally prone to overidentifying with the child, while adult psychiatrists are more likely to identify with the parents who are caught in a struggle with defiant and omnipotent adolescents (54,55).

Differences in Personal Characteristics Studies have compared first year residents (56) and medical students (57) who are pursuing careers in either child or adult psychiatry. They have identified two main groups of prospective child psychiatrists: those with a previous interest in pediatrics, and those already leaning toward psychoanalysis. Those who had completed an elective or clerkship in pediatrics - by 1985, this constituted nearly 75% of the future child psychiatrists - more closely resembled pediatricians in their profiles than they resembled other psychiatrists. At the beginning of their residency, the prospective child psychiatrists who were not interested in pediatrics were virtually indistinguishable from their peers who became adult psychiatrists (56). The prospective child psychiatrists interested in psychoanalysis resembled their peers who focused on the psychoanalysis of adults more than they resembled the non analytically oriented child psychiatrists. Senior medical students interested in either child or adult psychiatry differed from each other on only four of 17 variables on the AAMC Graduation Questionnaire (57). This work is summarized in Table I. While confirming Weissman and Bashook's findings that more women and students interested in pediatrics were interested in child psychiatry, this data also suggests that graduates of medical schools oriented towards either research or primary practice were more likely to become adult psychiatrists than child psychiatrists. It also begins to explain some of the attitudinal differences between the two groups that will be discussed in the next section of this paper. Research Issues Child psychiatrists have much to learn from their colleagues in adult psychiatry in the area of research design and methodology even though child psychiatrists in research face different challenges. The interaction of the developmental, familial and intrapsychic factors makes the study of children's psychiatric disorders far more complex than that of comparable adult populations. Also, since children are typically involved in either a clinic referral or a research study dependent on their parents' decision, the researcher must work with the parents, who may be less interested in becoming involved in research if they are not suffering personally and if they fail to underTable I Predictors Distinguishing between Future Adult and Child Psychiatrtsts" Standard Predictor of being in the Canonical Child Psychiatry Subgroup Coefficient Pediatric elective/clerkship 0.84 Research orientation of medical school - 0.32 Being a woman 0.31 Primary care orientation of medical school - 0.19 *reprinted with permission from Haviland, Dial and Pincus (27)

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stand the need to provide information about themselves and their backgrounds in studies of their children. Measurement issues arise from these population differences. Since it is very difficult to obtain reliable information on young children, it is necessary to rely on several informants, such as parents and teachers, who often disagree in their reporting of the symptoms (36). This requires one informant to be chosen to provide information on the particular issue under study and strategies to deal with differences, thereby increasing the complexity of data analysis (58). Furthermore, particularly in longitudinal studies, measurement tools may change with the child's age, since very few have been adapted to apply from early childhood to late adolescence. Researchers seek reasonably comparable instruments but must consider whether or not differences over time are real or a function of differences in the instruments used. One strategy to address some of these measurement issues has been direct observation. Although this is often a more acceptable way of obtaining reliable information, it is a complex undertaking that can only be carried out in certain defined situations and does not purport to be an observation of the total experience. Furthermore, direct observation is expensive because of the cost of salaries connected with such studies. As indicated previously, child psychiatrists may be less oriented to research than adult psychiatrists. Thus, the number of researchers in anyone child psychiatry centre is small, limiting the number of mentors available to new researchers. The current biological orientation of research may direct individuals interested in empirical research toward adult psychiatry, while others who are more clinically oriented will move to specialties such as child psychiatry. This may be particularly true for women, who have always been more numerous in child psychiatry. For women who choose academic careers, research demands may seem impossible, since they often coincide with their major childbearing years, and these conflicting demands mean that academic activities may have to be put on hold. Research on children imposes legal and ethical constraints which are often more complicated than they are with adults because of issue of third-party consent. Generally, it is considered unethical to use any intrusive measure unless clinical benefit can be demonstrated. Therefore, relatively simple procedures, such as taking blood samples for endocrine or genetic studies, are not justified unless there is a clear clinical benefit. Measures such as nuclear magnetic resonance imaging or positron emission tomography may not be acceptable for children under the age of 16, who cannot freely consent to the procedure. These constraints limit the number of ways a young population can be studied. As the science of psychiatry is now proceeding through such technologies, child psychiatry may be at a disadvantage unless less intrusive ways of studying similar functions are developed. Generally, interventions that are considered acceptable for children and adolescents differ from those for adults. The discomfort felt by many clinicians and parents about drug interventions for children makes it difficult for anyone re-

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searcher to obtain an adequate sample and establish the efficacy of medications in child and adolescent populations. Furthermore, rarely can an intervention study of a child and adolescent population be considered adequate ifthe intervention is aimed only at children or adolescents and not their families. This makes intervention studies with these populations complex, because interventions are aimed at different parts of an interacting system. Current areas of emphasis in child psychiatry such as early intervention, prevention, and consultation pose a problem because of the long follow-up periods required to assess outcome and the inability to control for the diluting effect of many intervening variables. Obviously, measurement of such interactions is not easy. Competition for research dollars has become more and more rigorous. In part, because of the methodological complexities described earlier and in part, because of a lack of research training, proposals by child psychiatrists often do not fare well in a competitive market. Although many university settings are promoting research training through fellowship programs as entry criteria for staff appointments, there are generally few trainees in child psychiatry in such programs. The difficulty in encouraging training in research in child psychiatry has led to a proposal for dramatically increased funding in the United States. Leckman (59) has published a more detailed discussion of the issues in child psychiatry research. Despite the difficulties in child psychiatric research, it is critical that research be supported and promoted. Most disorders begin in childhood and adolescence, and our ability to intervene effectively is dependent on our ability to better identify disorders at their onset or to prevent them entirely. Relationship Between Child and Adult Psychiatry

The relationship between child and adult psychiatry was considered problematic by Winnicott (4) as early as 1963. Westman (3) noted that child and adult psychiatry are distinct fields of practice that differ significantly in their operation and that both lose when the differences between their separate models become blurred. He noted that a common problem with the model of divisions of child psychiatry within departments of general psychiatry is that the heads of the divisions may have the responsibility of a department chair without commensurate administrative authority. Westman also suggested that academic child psychiatrists are often compared unfairly with other faculty members when it comes to promotions and merit. This is because the chairs of the departments and the adult psychiatrists who form the majority of promotion committees often fail to appreciate the unique nature and demands of child psychiatry, the differences in knowledge, developmental expertise, specialized diagnostic and therapeutic techniques, the unique consultative and collaborative activities which, while time-consuming, are a critical part of child psychiatric practice, and the additional problems in child psychiatric research caused by the inevitably complicating effects of developmental and family influences. Westman reviewed a number of administrative models (60-62)

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before suggesting yet another: two divisions - one adult and one child - reporting to a single chair of a department of general psychiatry. This model, he suggested, would appropriately recognize the differences between adult and child psychiatry while ensuring that a coordinator trained in and committed to each discipline would allow that subspecialty to develop independently. As recently as 1988, Solnit and Michels (7) debated whether the relationship between child and general (adult) psychiatry had kept child and adolescent psychiatry from reaching its potential. Solnit suggested that child psychiatry lacked the courage, imagination and initiative to seize control of its own destiny, but added that general psychiatry encouraged this dependent attitude by subordinating child psychiatry to its own priorities, including "a bewitchment with drugs, with community health centres as well as with frantic attempts to find short cuts...[in response to the] staggering tasks and a tendency to make promises that can't be kept." He criticized child psychiatry's failure to "question, study and teach about the destructive impact that the revolving door policy of state hospitals...lubricated by the widespread use of medication in high dosages ...which has released adult patients from the hospitals without regard for the impact on their children and other family members" (II). Solnit was not alone in his concern about the detrimental effects of adult psychiatry on child psychiatry, Winnicott (4) and Philips (I) had expressed the same concern earlier. Michels, an adult psychiatrist, conceded the uniqueness of child psychiatry, but suggested that few child psychiatric programs have enough practitioners, teachers, and, especially, researchers to function independently of departments of general psychiatry. He believed that because of the long period of training necessary for clinical competence in child psychiatry and the discipline's roots in psychoanalysis and in non medical child guidance clinics, child psychiatry has become separated from its base in science and research, so that there are few child psychiatrists with primary research interests. While Solnit agreed that the priority of child psychiatry is the development of an academic base, the two disagreed on how to achieve this. Michels warned that the establishment of separate departments would separate leading academic child psychiatrists from adult psychiatrists, hindering the development of an academic base. Solnit countered that far too often the academic leaders in child psychiatry have moved away from the goals of child psychiatry to serve the priorities of departments of general psychiatry. . When we review this debate from the vantage point of child psychiatry in Canada, we see that there are still few divisions of child psychiatry with enough practitioners, teachers and researchers, and those that have reached this level are already functioning autonomously within their respective departments of general psychiatry. What concerns us more than separate departments of child psychiatry is whether or not the unique goals, techniques, problems and priorities of child psychiatry are sufficiently appreciated by adult psychiatrists. Can general psychiatrists who fail to grasp the essential differences between adult and child psychiatry be

expected to represent child psychiatry's needs fairly at a planning level, or are they more likely to evaluate child psychiatrists and their goals according to adult psychiatric values and priorities (4)? Child psychiatrists must learn to point out the distinctions between our separate goals and priorities - and adult psychiatrists must be more prepared to listen and support them - if child psychiatry is to achieve both autonomy and its full potential. Comment

Why is it important to consider differences in practice and in the challenges facing child and adult psychiatry? As mental health professionals; we are facing economic constraints and the growing realization that the current pattern of services is not adequate to address the needs of the mentally ill, be they children or adults. As we work to develop more comprehensive, cost-efficient systems of care, prevention and early intervention become integral parts of services provided by both child and adult psychiatrists (63). This means supporting individuals within communities, and places a greater emphasis on families, their functioning and their capacity to support mental health and ongoing development. Developing these will require greater collaboration between child and adult psychiatrists, both for the study and evaluation of patients within university settings and for practice within the community. There is now data available which suggest that children of parents with psychiatric disorders are at risk of developing a variety of disorders themselves (14,38,64-68). We therefore need to understand the pathogenesis of the children's disorders and to explore more effective ways of intervening, both with children and their parents, who already suffer from a psychiatric disorder. Clearly, such collaboration cannot be undertaken by either child or adult psychiatrists in isolation; they require a close working relationship based on mutual respect. Youth are poorly cared for in our current health system (69). This arises partly because of different patterns of practice in mental health care for children and adults. The morbidity connected with youth who have psychiatric disorders can be prevented to some extent through coordination, but this will require an improved understanding and mutual respect of the caregivers on both sides of this divide. Ultimately, we are all interested in improving the care of patients. The need to explore ways of collaborating and to reduce the differences that may interfere with our ability to respect each other and to work together are of great importance.If we can achieve this, both our science and our patients will benefit. References 1. Philips I. The decay of optimism: the opportunity for change. J Am Acad Child Psychiatry 1986; 25(2): 151-157. 2. Chess S. Child and adolescent psychiatry come of age: a fifty year perspective. J Am Acad Child Adolesc Psychiatry 1988; 27(lj: 1-7.

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Resume Le developpement de La pedopsychiatrie en tant que sousspecialite de la psychiatrie generale a eee influence des le debut par une interaction profonde avec Le mouvement de guidance infantile et La pediatrie, ainsi que par l' age des maLades concernes. La pedopsychiatrie a done evolue differemment de La psychiatrie de l' aduLte, au point, parfois, de susciter des tensions entre Les deux disciplines. Les auteurs brossent le tabLeau de l' evolution de La pedopsychiatrie a La lumiere du contexte historique, des taches et de La population de maLades, en soulignant certaines distinctions importantes entre La psychiatrie de l' enfantetde l'aduLte. Puis, ils examinent Les raisons pour Lesquelles Les travaux de recherche ne sont pas aussi avances dans le domaine de La pedopsychiatrie que dans celui de La psychiatrie de l'aduLte. Pour conclure, Us discutent des tensions entre les deux disciplines et des raisons pour Lesquelles une meilleure comprehension et une pLus grande collaboration beneficieraient tant aux membres des deux professions qu' a Leurs maLades.