Child Psychiatry: An Observation* GEOFFREY C. FISHER, M.B., B.S.!

personality created a resistance to seeing the truth" (4). Eisenberg (5) and Lipowski (4) termed this the era of"brainlessness" or "brainless" psychiatry. However, the brain was not entirely forgotten. The finding in 1913 of treponema pallidum in the brains of general parietics (6) was a major advance. The organic basis of delirium (7) and the sequelae of wartime head trauma (8,9) were well known. The devastating epidemics of encephalitis lethargica in 1918 and 1920 prompted psychiatrists to speculate on the nature of the neuroses and psychoses (10). In the aftermath of World War II, when psychoanalysis held sway, pharmacology advanced; the calming properties of lithium (11) and the antipsychotic properties of rauwolfia alkaloids were discovered (12). Iproniazid (13) and imipramine (14) were found to have antidepressant effects. Since then, advances in pharmacological treatments have been considerable, but most of all neurobiological research was stimulated. In the last 15 years biological research, from bench biochemistry to sophisticated brain imaging, has rapidly advanced. In North America, a new species of psychiatrist has emerged - "the neuropsychiatrist." Eisenberg (5) believes that "we have been so long pilloried by our medical and surgical colleagues as witch doctors and woolly-minded thinkers that it is tempting to seek professional respectability by adhering to the reductionist model of mental disorder." We have entered a new era, that of 'mindless psychiatry' (4) or 'mindlessness' (5) - a reductionist view reminiscent of the 19th century; the loss of the human perspective is very real (15).

The quest for a coherent epistemology in psychiatry has been a challenge for academics and practitioners alike. The question from the perspective ofchild psychiatry is discussed in this observation.

'Through strife, all things arise and pass away.... War is the father and king of all: some he has made gods, and some men; some slaves and some free. ' Where there is no strife there is decay: 'the mixture which is not shaken decomposes.' Heraclitus 530-470 s.c. (1)

I

t is not uncommon for adult psychiatrists, pediatricians, psychologists and social workers to be confused occasionally about the child psychiatrist's role. Hammer (2) believes "that we as child psychiatrists have not clearly defined our varied functions to our colleagues both psychiatric and nonpsychiatric." Steinhauer (3) notes the gradual decline in the number of child psychiatrists in practice: "the great majority of child psychiatrists treat some older adolescents and adults, and as they get older, so do their caseloads, so that many child psychiatrists end up practising primarily adult psychiatry." Statements like these are only opinions; even so, they raise questions about the conceptual basis of child psychiatric practice, some of which are discussed in this paper. Brainless and Mindless Psychiatry

Psychiatry, evolving from philosophical roots, became "scientific" at the beginning of this century. Kraepelin's nosological approach separated dementia praecox from manic depression, and Wernicke worked on the boundary between neurology and psychiatry. Hughlings Jackson influenced both Wernicke and the young neurologist, Sigmund Freud; hence, the later development of the psychoanalytic movement. Like Jackson's, Freud's method was mechanistic and fashioned in the causal-deterministic thinking of the late 19th century, It was soon claimed that psychoanalysis was the basic science of psychiatry; hypotheses were presented as fact and dissenters were "given to understand that a flaw in 'Manuscript received November 1991, revised April 1992. I Assistant Professor, Departments of Psychiatry and Paediatrics, University of Calgary, Calgary, Alberta. Address reprint requests to: Dr. G.C. Fisher, The University of Calgary, Alberta Children's Hospital, 1820 Richmond Road SW, Calgary, Alberta T2T5C7

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The Evolution of Child Psychiatry

While adult psychiatry went through the "brainless/mindless" transition, child psychiatry stood aside. Although it was not deeply involved in the transformation, a nature-nurture battle was waged. The 'origins of child psychiatric practice were different from those of psychoanalysis or biological , psychiatry. Child psychiatry's origins were social, beginning with the development of child guidance clinics in the United States during the 1920s to serve the needs of families, schools and juvenile courts. Staff of these clinics were from many disciplines - social work, psychology and child psychiatry. Close links developed with educational and social work services but with relative isolation from mainstream medicine. With some notable exceptions (for example, Chess, Thomas, Birch, Ounstead, and Weiss) the biological revolution bypassed child psychiatry. Ideas were imported from general Systemstheory (16) and cybernetics (17). Theories of

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circular causality, homeostatic systems and self-regulating mechanisms became common. The developing child came to be seen as part of a constantly shifting matrix of family and environmental relationships, variously conceptualized as modifications of general systems and cybemetic theories. Attempts at Integration According to Lipowski (4) some two million scientific articles are published annually and there are over 3,000 medical journals in existence. Keeping up with even a small part of this literature is no simple task. Training demands a detailed knowledge of not only psychopathology, but also general medicine, the neurosciences, genetics, biochemistry, sociology, epidemiology and statistics. Beyond this are the essential clinical skills. Yorke (18) argues that psychiatrists, in their efforts to synthesize these different facets, recognize the lack of an overall unifying model of psychological understanding, leading many to "uncomfortable and uneasy eclecticism." Lipowski (4) quite rightly stresses the urgent need to develop a coherent theoretical framework of our knowledge. Many believe that philosophy has a place in medical training (15,19-21) - an epistemology of psychiatry. Indeed, this would assist in developing a "weltanschauung" (a world view). The question is: whose philosophy should be followed? For many years Lipowski (4), among others, has advocated biopsychosocial models. Although they are of pragmatic value, such models do no more than summarize and speculate on the relative contributions of biological, psychological and social factors in the development of a dysfunction. Is a Freudian, Jungian, behavioural, cognitive or personal construct stance chosen for the psychological contribution? How much emphasis should be placed on any current medical condition, the intrauterine environment or genetic factors? The sociological perspective could include everything from family and work related factors to international tensions. Such a model, whether used in child or adult psychiatry, is an advance, but the ultimate boundaries are unclear. The "brainless" era taught adult psychiatrists that dogma could not be justified by clinical experience or research. From "mindless" psychiatry the limits of pure reductionist methodology are becoming clear. It is wise to be aware of the inadequacies of reductionist thinking, but care must be taken not to fall into more subtle traps. Biopsychosocial models appear to offer explanations of complex multifactorial problems, but they are no more than loose amalgamations of selected perspectives, linked to create only "illusions of integration" - artificial depictions of the human condition without solid conceptual foundations. Josiah Royce (22) warns against jumbling together "all sorts of sayings of this thinker and that, and then to declare, as makers of eclectic essays and of books of extracts love to say, 'This is all somehow great and true'."

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Discussion It could be argued that in child psychiatry the concepts of systems theory and cybernetics were imported prematurely, before the roles of such components as genetics, neurophysiology and biochemistry could be fully appreciated. The result was an over reliance on eclecticism, loose integrative models, and a lack of differentiation from related disciplines. According to Rae-Grant (23), child psychiatrists have been slow to appreciate the benefits of the biological revolution. The research challenge today is "to bring discoveries in the biological front into clinicians offices ...so that psychiatrists today and to follow possess the skills to treat...more specifically and effectively." In the same paper, he notes that "as the neurological approach becomes more successful in the research area, so the chance that neurology may take over not only the research but the practice of much of psychiatry becomes a real and alarming one." Harrington (24) speculates that psychiatrists may find themselves "an endangered species." Taylor (25) argues that child psychiatrists should be trained to "deploy physicianly skills" that are unique and different from those of social workers and psychologists. The typical graduate in medicine has been schooled in the classical scientific method. To be confronted for the first time with the shifting matrix of systems thinking can be an unsettling experience. It is possible that few specialize in child psychiatry because they retreat to the "truths" of brainless and mindless psychiatry backed up with "solid" research; for the same reasons, senior child psychiatrists "feel a pull to adult psychiatry where the techniques and research in adult psychotherapy are being actively explored in the literature and in psychotherapy study groups" (2). Whether or not this is true is debatable. However, once again questions of epistemology come to mind. Take an example from adult psychiatry - the mass of seemingly unrelated neuroanatomical, biochemical, physiological, genetic, psychological, family and sociological information that has plagued research into schizophrenia..Single factor theories have been remarkably unsuccessful in the quest for a "cause". Approaching the problem from the perspective of ~ the "dynamics of complex systems" (26), Ciompi (27) argues that an alternative conceptual basis for understanding is possible. A similar situation exists in research on boys with conduct disorder. Strauss (28) opens his paper: "To paraphrase Kant, theory without data is mere intellectual play, but data without theory are blind." Not only is further work needed to create data or "pieces of information" (biological or otherwise) in child psychiatry, new conceptualizations of integration are required. Stepping outside traditional confines and examining seemingly unrelated and sometimes contradictory and controversialareas of research, such as the mathematical modelling of ecological and weather systems and the Gaia hypothesis (29,30), may provide stimulating avenues of enquiry. Experimenting with such concepts as Rene Thom's catastrophe theory (31), chaos theory (32-34) and fractal geometry (35,36), as well as the work of Ilya Prigogine (26)

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may be significant steps towards developing an epistemology, not only for child psychiatry, but also for psychiatry as a whole. Consider, for example, chaos theory, which suggests that even simple deterministic systems can generate random behaviour and that randomness itself has an underlying geometric structure. This was originally the province of mathematicians and physicists who studied pendulums, dripping faucets, the weather, fluid turbulence and cosmology. These concepts have already been applied to cardiac dynamics (37-39), epidemiology (40,41), EEG mapping (42,43), genetics (44) and morphological abnormalities (45,46), pulmonology (47) and physiology (48), to mention only a few. The Newtonian and Lapacian legacy of understanding mechanisms by taking them apart and applying universal laws applies only to closed systems. Undertaking such standard research means modifying non linear processes to linear ones - ignoring small perturbations or differences in measurement and eliminating or controlling for unwanted variables and noise, so that experiments may be clean and predictable. Nature is not like this, natural processes are non linear and noisy. "Shoe-homing" non linear reality into linear pseudo-reality may make the math and statistics easier (since non linear equations are essentially unsolvable). However, children with conduct disorder and their families do not live in a closed system. Their world, internal and external, is a tapestry of shifting non linear processes. Exploring the interaction of ecology, epidemiology, family systems and biological factors in terms of the new dynamic sciences could be fruitful. . Exotic though some of these approaches may seem, child psychiatrists, because the culture is of understanding a child as part of network, may find it easier than it first may appear to apply some of these concepts. Perhaps then, Yorke's uneasy and uncomfortable eclecticism can be addressed (18). Even so, "borrowing freely from various fields" (49) must always be guarded against. The Spanish philosopher Julian Marais (50) warns: "Eclecticism is another phenomenon of eras of philosophical decline. At such times the spirit of compromise and conciliation appears, borrowing ideas from various sources and building systems that will bridge the deepest discrepancies. In general, this procedure tends to make philosophy trivial." It also trivializes the search for the "weltanschauung."

Conclusion It may appear that excursions into the area of mindless psychiatry to collect data and then integrate the pieces (from the bottom up, as it were) into a greater whole is a solution to the problem of conceptual modelling. However, using current biopsychosocial models, this would merely result in even more complex and clumsy eclectic formulations. In the scientific community at large the winds of change are blowing. The new methods of dynamic modelling suggest insights into the detailed workings of individual mechanisms (social or

biological) but simultaneously within context of the larger system. Outside the limited horizons of traditional scientific method, many believe a revolution as fundamental as Newtonian classical physics, relativity and quantum mechanics is underway (33) - "a paradigm shift" in the words of Thomas Kuhn (51). Others are less certain; chaos, for instance, is fashionable. Intriguing and exciting though these new approaches are, probably the greatest challenge facing child psychiatry today, if not all of psychiatry, is to create such frameworks within a coherent and practical philosophy (15). Many, I suspect, will disagree with this formulation, but that does not really matter, only a "mixture which is not shaken decomposes."

References 1. Durant W. The story of philosophy. New York: Simon and Shuster, 1961. 2. Hamer ES. The third special edition on child psychiatry: an overview (letter). Can J Psychiatry 1989; 34(1): 75. 3. Steinhauer P. Editorial. The third special edition on child psychiatry: an overview. Can J Psychiatry 1988; 33(6): 429-430. 4. Lipowski ZJ. Psychiatry: mindless or brainless, both orneither? Can J Psychiatry 1989; 34(3): 249-254. 5. Eisenberg L. Mindlessness and brainlessness in psychiatry. Br J Psychiatry 1986; 148: 497-508. 6. Noguchi H, Moore JW. A demonstration of treponema pallidum in the brain in cases of general paralysis. Med 1913; 17: 232-238. 7. Bonhoeffer K. Exogenous psychoses. Zentralblatt fur Nervenheilkunde 1909; 32: 499-505. Translated by Marshall H. In: Shepherd M, eds. Themes and variations in European psychiatry. Hirsch SR, Shepherd M, eds. Bristol: John Wright, 1974. 8. Roper E. Zur Prognose der Himschusse. Meunchener Medizinische Wochenschrift 1917; 64(1): 121-125. 9. Forster E. Die psychen Storungen der Himverletzen. Monatsschrift fur Psychiatrie und Neurologie, 1919; 46: 61. 10. Hendrick L Encephalitis lethargica and the interpretation of mental disease. Am J Psychiatry 1928; 7: 989-1014. II. Cade JFJ. Lithium salts in treatment of psychotic excitement. Med J Aust 1949; 2: 349. 12. Kline NS. Use of rauwolfia serpentina benth. Neuropsychiatric Conditions 1954; 59(1): 107-132. 13. Crane GE. Psychiatric side-effects of iproniazid. Am J Psychiatry 1956; 112: 494-501. 14. Kuhn R. Treatment of depressive states with G-12-355 (imipramine hydrocloride). Am J Psychiatry 1958; 115(5): 459-464. 15. Fisher Gc. Biopsychosocial models and the human condition. (in preparation). 16. von Bertalanaffy L. General systems theory. New York: George Braziller, 1968. 17. Weiner N. Cybernetics, or control and communication in the animal and machine, second edition. New York: M.LT. Press, 1948. 18. Yorke C. A defect in training. Br J Psychiatry 1988; 152: 159-163. 19. Yonge KA. Reflections on the epistimology of psychiatry. Can J Psychiatry 1988; 33(8): 686-690. 20. Benjamin J. The mind-body problem: another defect in training (letter). Br J Psychiatry 1988; 153: 123-124.

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38. Savino GV, Romanelli L, Gonzalez DL, et al. Evidence for chaotic behavior in driven ventricles. Biophys J 1989; 56(2): 273-280. 39. Pool R. Is it healthy to be chaotic? Science 1989; 243: 604-607. 40. Pool R. Is it chaos, or is it just noise? Science 1989; 243: 25-28. 41. Olsen LF, Truty GL, Schaffer WM. Oscillations and chaos in epidemics: a nonlineardynamic study of six childhood diseases. Theor Popul Bioi 1988; 33(3): 344-370. 42. Watt RC, Hameroff SR. Phase space electroencephalography (EEG): a new mode of intraoperative EEG analysis. Int J Clin MonitComput 1988; 5(1): 3-13. 43. Arle JE, Simon RH. An application of fractal dimension to the detection of transients in the electroencephalogram. Electroencephalogr Clin Neurophysiol 1990; 75(4): 296-305. 44. Jeffrey HJ. Chaos game representation of gene structure. Nucleic Acids Res 1990; 18(8): 2163-70. 45. Sleeman BD. Period-doubling bifurcations leading to chaos in discrete models of biology. IMA J Math Appl Med BioI 1988; 5(1): 21-31. 46. Nainar SM. Fractals: the key to craniofacial growth dynamics? Am J Orthod Dentofacial Orthop 1990; 97(1): 87. 47. Nelson TR, West BJ, Goldberger AL. The fractal lung: universal species-related scaling patterns. Experientia 1990; 46(3): 251254. 48. Goldberger AL, Rigney DR, West B1. Chaos and fractals in human physiology. Sci Am 1990; 262(2): 42-49. 49. The concise Oxford English dictionary. Oxford: Oxford University Press, 1977. 50. Marais J. History of philosophy. Translated by Appelbaum S, Strowbridge CC. New York: Dover Publications, Inc., 1967. 51. Kuhn, TS. The structure of scientific revolutions. second edition. Chicago IL: University of Chicago Press, 1970.

Resume La recherche d' une epistemologie logique en psychiatrie a ere un defi pour les universitaires et les praticiens. Cette question, approchee selon fa perspective de la psychiatrie de l' enfant, sera abordee dans cette «observation».

Child psychiatry: an observation.

Child Psychiatry: An Observation* GEOFFREY C. FISHER, M.B., B.S.! personality created a resistance to seeing the truth" (4). Eisenberg (5) and Lipows...
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