Am

J Psychiatry

6. Pasquarelli

February

B, Bellak

epilepsy 139,

136:2,

and

L: A case

psychogenic

JOHN

of co-existence

convulsions.

of idiopathic

Psychosom

Med

9:137-

1947

7. Schwartz ena,

BE,

Bickford

including

RG,

Schneck

JM:

Rasmusen

hypnotically

activated

electroencephalogram. 8.

1979

J Nerv

Hypnosis

in

Modern

Charles C Thomas, 1963 9. Sumner JW, Cameron RR, ferentiation of epileptic from ogy 2:395-402, 1952

Child

Ment

Dis

Hypnotic

Medicine.

with

the

1955

Springfield,

Hypnosis seizures.

Education

F. GREDEN,

phenom-

studied

122:564-574,

Peterson DB: convulsive-like

Psychiatry

BY JOHN

WC: seizures,

Ill,

in difNeurol-

for

F.

10. Gross M: Treatment ofdissociative reaction with hypnosis. Presented at the 29th annual meeting of the American Association of Psychiatric Services for Children, Washington, DC, Nov 1620, 1977 11. Freedman AM, Kaplan HI, Sadock BJ: Comprehensive Textbook of Psychiatry. Baltimore, Williams & Wilkins, 1975, pp 2 15 1-2 155 12. Proctor JT: Hysteria in childhood. Am J Orthopsychiatry 23:394-407, 1958 13.

Stevens H: Conversion Clin Proc 43:54-64,

General

hysteria:

a neurologic

emergency.

Residents

made

WHAT CONSTITUTES an ideal child psychiatry experience for general residents? This question has perplexed generations of educators. Although child psychiatrists began their fight for recognition as a distinct professional discipline more than 50 years ago (I 2), and great strides have been ,

in some

areas,

in many

educational

impact of child psychiatry in training has been minimal. There are marked subjectively and objectively, in child

riences

among

general

give verbal support in only a few is this didactic and clinical

residencies

programs

(3). Most

for learning child actually translated emphasis.

ment,

and only

tients with by continued

then

neuroses debate,

that phase

Kubie conresidents and children

all

residents work with adolesof learning child develop-

would and

at the 130th annual meeting of the American Psychiatric Toronto, Ont. , Canada, May 2-6, 1977. Received Sept. revised April 14, 1978; accepted May 18, 1978.

Dr. Greden is with the Department of Psychiatry, University of Michigan Medical Center, Ann Arbor, Mich. 48109. At the time this work was done he was Director of Residency Education; he is now

Associate Studies

Professor Inpatient

The author participated uation, and

of Psychiatry Unit

acknowledges as a member of Deborah

and

Day

and Hospital

Medical

Director,

Clinical

Program.

the assistance of Larry Brain, of the subcommittee conducting Bland, who compiled the survey

0002-953X/79/02/02

M.D. this data.

13/04/$00.45

,

who eval-

© 1979

programs

psychiatry, but into substantial

More than a decade ago Lawrence fronted this issue by advocating that launch their training by studying infants (4). He also suggested cents after the initial

the

general residents differences, both psychiatry expe-

they

evaluate

and

psychoses. As Kubie’s proposals

treat

pa-

demonstrated did not

re-

solve the problem. Had his suggestions been widely accepted, child psychiatry experiences for general residents would certainly be longer, more intense, and more influential than they currently are. Instead, it is still child

an exceptional residency psychiatry experiences.

A program

that

has

emphasized

that

offers

extensive

child

psychiatry

training for general residents is the one at the ty of Michigan. Consequently, consideration igan’s program might provide some insights 14, 1977;

Mayo

1968

M.D.

There is continuing debate about what child psychiatry experiences should be included in a general residency. The author describes the program at the University ofMichigan in an effort to provide some insights into the interface between child psychiatry and general residency training. This program is unique in several respects: a 12-month rotation in childpsychiatry is offered, and thefaculty size and budget ofthe youth services are comparable to those ofthe adult services. A survey ofall residents and f aculty pointed up numerous disagreements as to the length ofthe rotation andpriorities in curriculum. The author discusses the influence ofthe various competitive processes on the educational program.

Presented Association,

GREDEN

Universiof Michinto the

still-nebulous interface between child psychiatry and general residency training. Several training factors seem unique to Michigan. Perhaps most important, from 1972 to 1977, almost all of the general psychiatry residents spent their entire seeond year on what is known as the youth service. The youth service at Michigan consists of child and adolescent programs. During the 12-month youth rotation, there is an emphasis on developmental theory, psyAmerican

Psychiatric

Association

213

CHILD

PSYCHIATRY

Am

TRAINING

chodynamics, inpatient and outpatient work with children and adolescents, and family therapy. The experience of the general residents is virtually identical to that of the first-year child psychiatry fellows. In essence, by the time the general resident at Michigan had completed the three-year program, he or she had also completed one-half of a child psychiatry residency. Most general residents have considered the experience educationally excellent. A second unique feature is that the youth service is proportionately larger than that found in many other programs and is geographically distinct. With more than 50 faculty and 13 child fellows, the youth service budget is comparable to that of the adult service. The child psychiatry program at Michigan clearly does not lack visibility or strength. Perhaps this explains in part why a 12-month child rotation was initially instituted. Since this program has been in operation for several years, it is now possible to assess it from a historical perspective, however brief. Soon after implementation of the program, many adult faculty members (perhaps predictably) began to criticize the length of the youth rotation. A major complaint was that with one-third of their residency being spent on youth services, general residents lacked the necessary time to learn basic primciples of adult psychiatry. The residents themselves complained of having no time for electives. Thus a seeming paradox developed. Most of the adult faculty members acknowledged that general residents should learn child psychiatry. Most also acknowledged that the general residents were mastering child psychiatry exceedingly well. However, most simultaneously found themselves advocating a reduction in this apparently worthwhile experience. The beleaguered resident group frequently appeared to be caught in the middle of this argument. To evaluate child psychiatry training for general residents, and to simultaneously collect data to assist the residency education committee in the formulation of an experiential core curriculum, a subcommittee was formed to assess this issue. A questionnaire was distributed to all faculty and residents. This paper briefly reports the subcommittee’s findings, together with my subjective impressions ofthe issue, stemming from the perspectives of having chaired the subcommittee and later directing the general residency education program.

In 1975 a 4-page questionnaire was distributed to various faculty and resident members at the University of Michigan Department of Psychiatry. Respondents

were

arbitrarily

divided

into

4 subgroups:

adult-

oriented senior faculty, general psychiatry residents, youth-oriented senior faculty, and youth fellows. The number of forms completed and the percentage of completion for each subgroup were as follows: adult senior faculty-26 (84%), youth senior faculty16

214

1979

(29%), youth try residents-21

fellows10 (91%), and general psychia(75%). A total of 73 questionnaires were returned (a completion rate of 58%). Respondents were asked to do two things: rate their attitudes about the child psychiatry rotation on a 5point Likert scale ranging from ‘strongly agree’ to strongly disagree,’ and establish priorities for 11 ‘

‘ ‘

‘

‘

psychiatric

approaches

traditionally

included

within

general residencies. These approaches included developmental theory of childhood and adolescence, inpatient treatment of adults, outpatient evaluation of children, outpatient treatment of children, outpatient treatment of adults, drug therapy of children, drug therapy of adults, crisis intervention of adults, crisis intervention of children and adolescents, treatment of adults as parents, and youth inpatient treatment. Each item was rated on a 5-point scale (1 = highest priority and 5=lowest priority). The form emphasized that ratings should be for general psychiatry child fellows. We then used mean scores sequential ranking of priorities.

residents, not to compile a

RESULTS

Q uestionnaire There child

Assessments

was

some

psychiatry

agreement

faculty

about

and

residents

priorities and

among

among

adult-

oriented a great

faculty and residents; however, there was also deal ofdisagreement. All 4 subgroups essentially agreed that the outpatient treatment of adults was of very high priority (mean rating= 1 .3). In contrast to this relative unanimity, child psychiatry faculty rated developmental theory of childhood and adolescence high enough to place it second on their listing; child psychiatry fellows ranked it first. Adult-oriented faculty and residents ranked it only fifth and sixth, respectively.

Even

ority

more

rating

it second, nificantly

striking,

adult

of 1.77 for drug

faculty

therapy

and general residents lower percentage of

had

a mean

of adults,

ranked it third. youth-oriented

pri-

ranking A sigfaculty

and fellows considered this an important item, however; they ranked it ninth and fifth, respectively. Outpatient evaluation of children was considered of much lower priority among adult-oriented psychiatrists than among child psychiatry staff and residents. Drug therapy of children and inpatient treatment of children received

METHOD

J Psychiatry 136:2, February

the

lowest

ratings

and

subsequent

rankings

among all 4 subgroups. In summary, 3 of the first 5 priority items among youth-oriented faculty pertained to child psychiatry. General residents had no youthoriented items among their first 5 items, and adultoriented theory).

When

faculty

had

asked

about

services rotation for 71% ofthe adult-oriented

only

the

1 (teaching

ideal

duration

developmental

for

a youth

general residents at Michigan, faculty and 60% ofthe gener-

al residents said that the current rotation of 12 months should be shortened. None of the youth-oriented faculty expressed this sentiment; indeed, 20% felt that 1

Am

J Psychiatry /36:2, February

year

was

inadequate

and

/979

that

JOHN

the

rotation

should

be

read,

what

Subjective

Impressions

These questionnaire partial story of child residents

at

conducted

assessments psychiatry

Michigan.

in 1975,

Since

there

provide training for

this

have

simple

been

only a general

study

periodic

was

deliber-

clothing

coat),

terests

ofthe

eluded

that

tionships

where

Child

should

should

or

(5),

Goldstein

at least

the risk of oversimplifying sue, I would suggest that oriented

experiences

other

divorcing ucational decision

parents dispute maker.

ideological

versus

dispute,

biological

ment

namely,

psychiatry.

seemed

to

have

analytic

The

been

child

‘ ‘

residency

identified

dynamic education, and many adult with medical psychiatry. Whether tions were correct scarcely seemed

psychiatry with

service

segments

these

‘ ‘

to

seg-

psychoobserva-

matter

when

battle lines were drawn. A second major observation was that child psychiatrists who defended the length of their rotation were sincere in their belief that this was best for the general residents. Service considerations important. Most youth-oriented clearly believed that the best

seemed minimally faculty and fellows way to prepare for a ca-

reer in general psychiatry was to have extensive cxposure to child and adolescent psychiatry. However, I noted that adult-oriented faculty members just as fervently believed that residents should have a shorter youth-oriented rotation. Many enthusiastically pleaded for greater exposure to such topics as substance abuse, geriatric psychiatry, forensic psychiatry, neurochemistry neuroendocrinology aftercare of chronic ,

patients,

and

,

consultation

psychiatric

with

their

medical

colleagues,

research.

‘

‘

assessment general

ofthe

role ofchild

residency

psychiatry

program

at the

of Michigan perhaps demonstrates that not be resolved through simple expansion chiatry

rotations.

programs. overcome to general

The

Historically, territorial residents.

experience

child guarding In some

has

the issue will ofchild psyvalue

for

dispute

over

disputes

the child

Similarly, comes an

ther, agree

the

adultabout

in this innocent

other

psychiatrists have had to to teach their principles departments their victory

has been only partial. At Michigan, however, psychiatry segment of the department has tamed recognition, and a different explanation formulated to explain current conflicts.

I have concluded parable to a marital vorce. Unfortunately,

train-

University

the child truly atmust be

that the process is loosely cornconflict involving issues of dithe marital feud often includes a

custody

of the

is commonly educational victim.

children.

an innocent dispute To carry

the the

In

divorce victim (5). resident beanalogy fur-

and youth-oriented faculty seem such issues as what the resident

to disshould

con-

rela-

during

a divorce.

At

a complex educational isa similar need exists among

in solving

disputes

in their

intact

the ultimate

trained dency

for, it seems is not in their

about

training.

question

In my opinion, integrated

Both

which

enhance

lescents,

by

their

the

best

youth-

the child

of

their

those

adult-oriented

of child

of adults which

faculty

acceptable.

Adult

in the

psychopharmacology but emphasis

to

theory

developmental Somewhat priority

of

evaluation

and

older

items,

and

however,

per se. In laid forth survey

is

crisis

would head also be given

would

and

adoles-

resident

this would

I do not

of what important believe

may

can

have

dispute

profit

from

they pharin-

fact

that

a rotation

in time-limited must be given

inpatient

treatment

inbe

to be re-

the

knowledge, skills, at the completion

that

dren should be included If the previous analogy

curriculum

priority

no one

inter-

and would

unavailable. (As more thoroughly

child inpatient unit. Nevertheless, dencies continued consideration

ultimate question tudes are most

and crisis

therapy of children and adolescents

in a crowded

Certainly

general

in the

treatment,

childhood

would be excluded if time were macotherapy of children becomes

vestigated,

ado-

skills

present

ofchildren,

with youths. Drug treatment of children

considered.)

by the

lower on the list but still of medium would be working with adults as par-

outpatient

low-priority

resi-

psychiatry

provide

outpatient

intervention, and the list of priorities,

dency.

child

are served

parts

treatment

than

is being

ofa

of children or young adolescents this, it appears that the program

the most

any

a resident

interests

of those

rather

treatment considering

of what

that a mini-version best interests.

learning

vention patient

in the

parent

associates

the child’s

‘

ents,

This

and

and the psychiatry resident in an edshould be able to identify one major For general residents, the role of parent’ should be filled by general psychiatrists. It is clear that the advice and consent of child psychiatry staffis needed to compile the best program. We cannot return to the days of resistance to child psychiatry training for general residents. Nevertheless, if we keep

cence. to high

DISCUSSION

ing

residents

‘

to protect

one

ations about changing the rotation. As I observed and participated in these debates, I was struck by several factors. First, the issue ofchild psychiatry training for general residents often became confounded with an-

psychiatry

she

important

it was

with

he or she

he

GREDEN

wear (such as a ‘go to school,” what ideology should be professed, and where the resident should spend the majority of his or her time. In their influential publication Beyond the Best Inwhite

lengthened.

F.

on a resito the

and attiof resiof chil-

on this list. can be continued

for one fi‘parental disagreement’ cease. For this to occur, agreement will have to be reached in some fundamental areas. Since ideological differences inevitably will continue, we need to intensify our assessment of what residents ultimately do or should be doing in the treatment of panal

step,

my

ultimate

wish

is that

the

‘

‘

tients

(6, 7).

cannot

agree

If adult-

on what

and

youth-oriented

psychiatric

residents

psychiatrists

should

do 215

CHILD

PSYCHIATRY

Am

TRAINING

after training, has the highest

they certainly will not agree about what priority during residency. If reasonable agreement were reached, the next question would be whether residents have the knowledge, skills, and attitudes to do what is required. Using such information, an irreducible experiential core curriculum could be devised to stipulate the educational experiences in child psychiatry that every resident should have to practice answer

need

to

be

evaluated?

What

too. If this is to be prevented, we must remind ourselves what the educational end product of our efforts should be, namely, a competent general psychiatrist with a thorough understanding of developmental theory and family dynamics, with fundamental skills for child evaluation and diagnosis, and with adequate time to master the multitude of other areas now proven to be relevant to the treatment of adult patients.

chiatry

generations

could

the

be the case.

ther-

be developing

country. (8)

is the

role

ofdrug

given

it is amazing

noted

to child that

in certain

Nevertheless,

In his extensive

Kubie

be? nor-

of attention

ago,

actually

throughout

ages should they be done? Should

REFERENCES 1. Crutcher

this

dissertation

that

once

psy-

programs

becomes

‘ ‘

216

for that have

assuming

general

Child

psychiatry-history

its

rightful

residents.

the opposite the potential

can to

place

Data also occur. become

in educational

from

this

study

Child psychitraditionalists,

GE: History of Psychiatry, HI, Sadock BJ.

L: A Survey

dency

of

112,

child psychiatry, 2nd ed. Edited Baltimore, Williams

Washington,

1973 LS: Reflections

its

development.

J

Resources DC,

on training.

5, Solnit

A, Freud

Child. New York, Free Hammett VBO, Spivack Sharfman

MA,

Grad

training during the past 435, 1976 8. Kubie L: Traditionalism 19,

in Psychiatric

American

Psychoanalytic

AM, 1975

Resi-

Psychiatric

A: Beyond

Asso-

Forum

1964

the Best

Press, 1973 0: What residents

Arch Gen Psychiatry 33:415-416, 7.

in Comprehensive by Freedman & Wilkins Co,

1:95-

1966

5. Goldstein 6.

of

of Academic

Training.

ciation, 4. Kubie

‘

from

Gardner Textbook Kaplan

3. Gurel

to

appears

on tradition-

a program

2.

a custody

operational it is difficult to modify. He attributed this resistance to ‘the hold on seniority rights which no one ever gives up willingly. At one point in psychiatrid history, this pattern probably prevented child psychiatry programs suggest atrists

R:

Biol Psychiatry 6:191-196, 1943

apy for children? Considering the lack

alism,

1979

general psychiatry. One could then attempt to such difficult questions as How many children

When should these evaluations mal families be followed? What

battle

J Psychiatry 136:2, February

CJ:

after

of the

graduation.

1976

Outcomes decade. Arch

in psychiatry.

do

Interests

of

psychiatric

Gen J Nerv

Psychiatry Ment

residency

33:431Dis 139:6-