CHILD PSYCHIATRY IN HONG KONG: AN OVERVIEW C.K. Wong
Hong Kong has a population of 5.5 million with 1.3 million below the age of 15. Child psychiatry has been very under-developed until recently. The brief history and development of child psychiatry in Hong Kong, and specifically that of the Child and Adolescent Psychiatric Unit at the Prince of Wales Hospital, the teaching hospital of The Chinese University of Hong Kong, are described. Traditionally psychiatric services for children in Hong Kong were heavily skewed towards neuropsychiatric and developmental conditions but in this Unit a full spectrum of child psychiatric conditions are seen. Relevant clinical statistics are used to illustrate these differences as well as to further highlight the philosophy and practice of the Unit. Other aspects, such as undergraduateand postgraduate teaching, and research are also mentioned. The magnitudeof child psychiatricmorbidity in Hong Kong is briefly illustrated with a three-stage epidemiological study done in a primary school in a lower middle social class area. It was found that 16.3% of the children were psychiatricallydisturbed. Emotional disorder, with a prevalence of 8.8 %, was the commonest condition. Finally, the future development of child psychiatry in Hong Kong is discussed, addressing the disconcerting facts of a huge population and very limited resources. Australian and New Zealand Journal of Psychiatry 1990; 24:331-338 Hong Kong has a population of 5.5 million with 1.3 million below the age of 15 [ 11. Bearing this in mind child psychiatry has been quite neglected until recently. Where, then, have all the disturbed children gone ? This will be the central theme of this paper. It will include (i) a brief historical perspective of the development of child psychiatry in Hong Kong; (ii) the experience of the Child and Adolescent Psychiatric Unit at the Prince of Wales Hospital, the teaching hospital of The Chinese University of Hong Kong; and (iii) a
Child and Adolescent Psychiatric Unit, Department of Psychiatry, The Chinese University of Hang Kong, Shatin, NT, Hong Kong C.K.Wong, MB, BS, MRC Psych, Senior Lecturer and Consultant Child Psychiatrist
brief account of a child epidemiological study in a lower middle social class area.
History ofchild psychiatry in Hong Kong Public psychiatric services in Hong Kong are provided from four quarters. The Government Mental Health Service provides the majority of services through two big mental hospitals, a hospital for chronic psychiatric patients, a psychiatric unit in a convalescent hospital, and a number of psychiatric out-patient and day-patient centres. The two universities, the University of Hong Kong and The Chinese University of Hong Kong provide psychiatric services in their respective teaching hospitals, Queen Mary Hospital and the Prince of Wales Hospital. The United
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CHILD PSYCHIATRY IN HONG KONG: AN OVERVIEW
Christian Hospital, a Government subsidized hospital, is the fourth source. As with most developing countries, when psychiatry was first established in Hong Kong about half a century ago the main concern was for acute psychotic adult patients. The development of psychiatric services understandably revolved around the treatment and rehabilitation of these adult patients. The occasional child patients were absorbed into the adult psychiatric services. Thus child psychiatry was given low priority and was no more than an offshoot of adult psychiatry. This is clearly shown by Chen [21: over an eight year period from 1977 to 1984 the mean number of new child out-patient cases presented to the whole Mental Health Service was only 324 per year (range 204 to 420). This represents a mean of 8.4 % of all new psychiatric out-patients. Now there are six child day centres in Hong Kong. These day centres, particularly those run by the Mental Health Service, almost exclusively treat pre-school children suffering from developmental or neuropsychiatric conditions, mostly infantile autism, hyperkinetic syndrome, and mental subnormality. Chen found the most common diagnoses made were infantile autism (30.1%), mental retardation (16.1%) and special symptoms or syndromes not elsewhere classified (10.4%). By contrast conduct disorder constituted only 4.7 %, neurotic disorder 3.2 % and mixed emotional and conduct disorder only 2.8%. These figures show very clearly that although attempts have been made to provide services for psychiatrically disturbed children these services are not only deficient in quantity but also very restricted in scope. There are mainly three reasons for this unfortunate state of affairs. First, the psychiatric out-patient and day-patient centres are isolated from the regional hospitals which means they fail to serve the large group of disturbed children presenting a myriad of somatic symptoms to paediatricians. Secondly, the centres are isolated from the community and rely heavily on medical sources of referrals. Disturbed children, other than those admitted to regional hospitals, are rarely picked out by doctors in the community as there is no proper primary health care in Hong Kong. Most people seek help from private practitioners on a hit-and-run basis. The poorer sector seeks help from the Government General Outpatient Departments in which each doctor sees about 20 patients per hour. Moreover, the older generation of doctors in Hong Kong have had very little training in
child psychiatry. Most disturbed children are identified by schools, the Education Department as well as statutory and voluntary social services. The lack of liaison with these professional bodies was probably one of the most important reasons for the low prevalence of emotional and conduct disorder in Chen’s study. Thirdly, the fact that there is no proper sub-specialty training in child psychiatry means that children are seen by general psychiatrists, often with questionable therapeutic results. The end result is a low referral rate with a heavy bias towards conditions with a strong medical flavour, infantile autism, mental subnormality and hyperkinetic syndrome.
The ChiM and Adolescent Psychiatric Unit at the Prince of Wales Hospital Since the opening of its teaching hospital in April, 1984, the Department of Psychiatry of The Chinese University of Hong Kong has aimed to develop child psychiatry as a recognizable and independent subspecialty in all three major aspects: (i) clinical service; (ii) undergraduate and postgraduate teaching; and (iii) research. The task has not been an easy one. The reason is simple. In the planning of the Hospital, long before any member of the Department took up office, child psychiatry was almost totally forgotten. The only reference to children in the design of the Hospital was a room designated “Playroom” and an area designated “Children’s Waiting Area” in the psychiatric outpatient clinic of the Hospital. Despite this we are determined to achieve our goals. Our experience of introducing and developing this sub-specialty may appear insignificant to people from well-established child psychiatry departments. But the history of how we established this sub-specialty from scratch within the boundaries of a general psychiatry department may still be of interest. Since there were no designated staff or other provisions the Department started its Child and Adolescent Psychiatric Unit by giving away one Lectureship post for general psychiatry to child psychiatry. As to staff from other professional disciplines the Unit had to share them with the rest of the Department. But over the years the Unit has acquired the following designated staff: one senior lecturer who is also the consultant child psychiatrist of the Unit; one full-time senior registrar or registrar level trainee; one part-time senior registrar from the British Military Hospital in Hong Kong; four psychiatric nurses (one each for the out- patient clinic,
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C.K. WONG
f l
Table I . The primary psychiatric diagnoses (n=298)
'Diagnosis Emotional disorder Conduct disorder Hyperkinetic syndrome Infantile autism Adjustment reaction (ICD-9309) Mixed disturbance of conduct and emotions Hysteria Schizophrenia Tourette's syndrome Other neurotic conditions Enuresis Specific disorders of sleep Manic-depressivepsychosis Frontal lobe syndrome Encopresis
Table 2 . Abnormal psycho-social situations of the clinical samples (n=298)
n
(%I
54 34 30 27 25 19 14 10 10 8 8 7 3 2 1
18.1 11.4 10.1 9.1 8.4 6.4 4.7 3.4 3.4 2.7 2.7 2.3 1.0 0.7 0.3
'The total number of diagnoses is not equal to the total number of cases since some children are not given any Axis 1 diagnosis
day hospital, and male and female wards); four teachers; one occupational therapist; and a visiting educational psychologist from the Education Department. But in addition to the designated staff the Unit still shares the man-power provided for the whole Department: 45 nurses (excluding the four designated nurses); two psychiatric social workers; three occupational therapists; and two full-time equivalent clinical psychologists. Since the Unit takes up about 25% of the in-patient beds and day-patient places of the Department it takes up an equivalent percentage of man-power from this general pool of staff. The Unit also has very limited inputs from some other services which are based outside the Department: community psychiatric nursing; physiotherapy and speech therapy. The Unit is expanding constantly. It is hoped that in the near future the number of full-time trainees will increase from one to three: one senior registrar and two registrars. Within a year or two the following additional designated staff may become a reality: two speech therapists; one or two additional occupational therapists; one or two more teachers; and one full-time clinical psychologist. To illustrate how we actually coped with such meagre staffing and to illustrate our philosophy and
2 Abnormal psycho-social situation
n
%
Discordant family relationship Lack of warmth in family Anomalous family Lack of or inadequate communication in family Excess or abnormal parental control Inadequate or inconsistent parentalcontrol Other intrafamily stress Mental disturbance and illness in other family member Stress trom school
103 63 59
34.6 21.4 19.8
50
16.8
46
15.4
44 42
14.8 14.1
40 39
13.4 13.1
practice two clinical samples will be summarized.The first is a retrospective sample of 93 patients seen in our first year of service [3,4]. The second is a prospective sample of 205 patients seen during 1987 using The Child Psychiatric Patient Database System of The Chinese University of Hong Kong [ 5 ] . The two samples are combined in the subsequent presentation (n=298).
The philosophy of our clinical practice We set out to provide the full spectrum of child psychiatric services, i.e. for the full range of age and diagnostic categories. Table 1 shows the ICD-9 Axis 1 diagnoses. Emotional disorder, conduct disorder, mixed disturbance of conduct and emotions, neurotic conditions, and adjustment reaction added up to 5 1.7 % of all cases. There are still a substantial proportion of patients suffering from hyperkinetic syndrome and infantile autism, constituting 19.2 % of all cases. New referrals increased from 100 in 1984 to 300 in 1988. The estimated number for 1989 is 400. We aim to provide the full range of treatment methods. As mentioned previously the other child psychiatric day centres or units in Hong Kong mainly look after pre-school children suffering from infantile autism, mental handicap and other neuropsychiatric and developmental conditions. As might be expected, many of our patients come from very abnormal psychosocial backgrounds, as shown in Table 2. Clear-
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CHILD PSYCHIATRY IN HONG KONG: AN OVERVIEW
334
Table 3. Modes of treatment of the clinical samples (n=298)
Mode of treatment.
n
YO
Family therapy
128
43.0
Individualchild psychotherapy
50
16.8
Medication
41
13.8
Hospitalisation
16
5.4
Individual parent psychotherapy
14
4.7
Paramedical staff including psychiatric nurses, occupational therapists, medical social workers and clinical psychologistswere involved theapeutically in 105 cases (35.2%). The figures in this table include their inputs.
ly the successful management of such patients depends on a full therapeutic repertoire. The treatment offered is shown in Table 3 . Various forms of psychotherapy, in particular family therapy and individual child psychotherapy were among the most commonly used methods of treatment. As indicated in Table 3 we are the first psychiatric unit (whether adult or child) in Hong Kong in which psychiatric nurses and other paramedical staff are heavily involved in psychotherapeutic work under close supervisionof the consultant. As the Unit continues to grow the repertoire of our treatment methods is also enlarging. In particular, group therapy for different kinds of patients and parents has become an important mode of treatment. We have also helped organize a strong parents’ group for parents of children suffering from various conditions such as infantile autism and hyperkinetic syndrome. We try not to admit child patients but if necessary they are admitted to the two general psychiatric wards of the Department (one male and one female ward). The mixing of child and adult in-patients is not by design but simply because the Hospital has no provision for child psychiatric wards. The child patients occupy about 16 to 20 out of a total of 72 in-patient beds. Likewise, child day patients occupy about 8 to 13 out of a total of 50 places. We were worried initially about mixing children and adult
patients. However, it is over 5 years now since we started and despite our misgivings this somewhat unusual arrangement has worked much better than expected. We put very strong emphasis on liaison with other departments within the teaching Hospital and with professional bodies outside the Hospital. This liaison is vitally important for two reasons. The first is the identificationof disturbed children. Table 4 shows the source of referral of our patients. The teaching hospital itself is the commonest source of referral and the Education Department second. Almost without exception they are appropriate referrals. The two sources combined accounted for nearly two-thirds of our cases. Referrals from the Hospital consisted mainly of emotionally disturbed children presenting with somatic symptoms and children suffering from psychiatric complications of a primary physical condition such as cerebral palsy, epilepsy, head injury or leukaemia. Referrals from the Education Department include mainly behaviourally disturbed children. We have also established a very good liaison with a major child assessmentcentre in Hong Kong, from which we have a constant supply of younger children suffering from various developmental conditions (Table 1). Most of our patients actually suffer from multiple problems which traverse the boundaries of child psychiatry, education, medical social work and various other medical and para-medical professional disciplines. This is the second reason for emphasizing liaison: therapeutic success depends on a genuine multi-disciplinaryapproach. Besides keeping a good relationship we actively reach out to these professional bodies. Since 1984, we have been invited to the fortnightly case conference of the Special Education Section of the Education Department. In each of these conferences 3 to 6 new cases are presented and an equal number of old cases are reviewed. A majority of these children are ultimately referred formally to our Unit. To promote cross-fertilizationwe actively welcome staff from other professional bodies to come to our academic and clinical activities. Over the last few years a large number of social workers, educational psychologists and counsellors, principals and teachers, and even the Juvenile Protection Section of the police have come to these activities. We are also frequently invited to give lectures or run workshops for the staff of these agencies.
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Special Education Section. Students are actively involved in the new case session as well as in the child case conferences and the psychosocial seminars. We rely heavily on audio-visual systems to maximize the effectiveness of teaching.
Table 4 . Source of referral of the clinical samples (n=298) ~
n
Paediatrics 3rthopaedic and traumatic surgery 3eneral psychiatry kcident and emergency Medicine Surgery 3bstetrics and gynaecology
%
Postgraduatetraining and training of other professionaldisciplines
80 7 6 6 5 4 1 -
rota1 other departments
109
36.6
special education section
63
21.1
'rivate medical institutions and irivate practitioners
48
16.1
Ither Government and subsidised ion-psychiatric medicationinstituions
37
12.4
Ither psychiatric departments
23
7.7
;elf referral
11
3.7
7
2.3
social agencies and the legal iepartment
335
Undergraduateteaching The aims of our teaching are two fold: (i) to equip our students with a reasonable knowledge of child psychiatry; and (ii) to help them appreciate the psychiatric aspects of the practice of medicine, irrespective of specialty [6]. The second is a common goal of the teaching programme of the Department of Psychiatry. We believe that the most effective way to promote psychiatry is to let our students appreciate the important contributions of psychiatry to medicine in general rather than to try t o turn them into psychiatrists. Child psychiatry occupies 25 % of the 10- week full-time psychiatry clerkship. The teaching methods include: (i) the clinical new case session; (ii) the child case conference; (iii) the lecture series; (iv) the psychosocial seminar Cjoint teaching with the Department of Paediatrics during the Paediatrics Module); and (v) the joint case conference with the
We are still the only child psychiatric unit in Hong Kong which offers full-time postgraduate training in child psychiatry. The Unit takes up one full-time trainee of the senior registrar or registrar level who is rotated to the Unit for 6 months. As mentioned we hope in the near future the number of full-time trainees will be increased to three. Again we rely heavily on our audio-visual systems to make supervision much more effective and efficient. We also run a part-time senior registrar programme for the British Military Hospital in Hong Kong. The army psychiatrist spends 2 to 3 sessions per week in the Unit. He takes part in the ward round, the child case conference as well as running a clinical session with simultaneous interpretation. In addition the Unit offers placements to students of other professional disciplines including social work, clinical psychology and occupational therapy. Their supervisors also contribute to the care of patients.
Research We believe that research is one of the most important ways to establish and promote our specialty. A computerized clinical register forms the basis of our ongoing clinical research. This is based on the patient database system designed by Wong [5] which consists of (i) a semi-structured interview schedule; and (ii) a computerized patient information system. We are about to launch the third version of this system, the main features are total computerisation of the patient records, including information about in-patient and day-patient treatment, and out-patient follow-up sessions. This system solves the dilemma of coping with a heavy clinical load while at the same time ensuring the clinical materials are researchable. Other research includes the translation, validation and standardization of well established instruments such as the Rutter Scales A2 and B2 [7 - 101, the Family Environment Scale [ 111 and the Junior Eysenck Personality Questionnaire [12,13]. The Unit also makes use of
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some well-known adult instruments in its clinical research involving the parents of our patients. These include the General Health Questionnaire [ 14 - 161and the adult Eysenck Personality Questionnaire [ 12, 131. The third major area of research is epidemiology which will be further elaborated below.
what is the magnitude of child psychiatric morbidity in Hong Kong 3 Though it is not possible to give a complete answer to this question some estimate can be made based on one research project. 7 18 primary pupils of a primary school in a lower middle social class area were studied in a three stage epidemiological project [ 17,181. All the 7 18 pupils were screened using a multiple criterion screening procedure resembling the studies of Kolvin et a1 [19] and Macmillan et a1 [20] with additional specific questions. In the second stage, all potential cases and a I-in-10 random sample of the potential non-cases were interviewed jointly by the child psychiatrist and the principal of the school. School records were also studied and a number of questionnaires administered. In the third stage medical students interviewed the parents again to obtain a developmental and psychosocial history. The results on the screening procedure and prevalence have been presented in detail in two papers [ 17,181. In summary, it was found that the overall prevalence of definite cases was 16.3% with 95% confidence limits of 11.7% to 20.9% (after adjusting for sampling errors in the false negatives). The mean duration of morbidity of all definite cases was 42 months. The most common diagnostic category was emotional disorder, 8.8% (95% confidence limits 5.0% to 12.6%).The prevalence of other diagnoses were: conduct disorder, 2.0% (no confidence limits since no sampled false negative cases); mixed disturbance, 3.0% (95% confidence limits 0.3% to 5.7%); hyperkinetic syndrome, 1%; hyperkinetic conduct disorder, 1%; and Gilles de la Tourette’s syndrome, 0.4%. There were also a number of children who had few overt behavioural symptoms and yet they had unequivocally been beset with long-standing and severe emotional conflicts, usually the results of long-standing family psychopathology. For example one Primary Four girl revealed that for many years she had to look after herself and her younger siblings, including shopping for food and cooking, seven days a week, since her parents were out early in the morning until 10 or
11 p.m. She admitted in tears that for many years she had felt persistently very unhappy, lonely and dissatisfied. But she never had any problems with conduct, school work or peers. We used the term “subclinical cases”and the prevalence was 19.5% (95% confidence limits 10.8% to 28.2%). They could also be construed as mild or high risk cases. From the perspective of preventive child psychiatry these children should be identified and helped. Although the study was only done in one school but because of a uniform policy of city planning and because the allocation of a significant proportion of primary school places are randomized according to address our findings at least give a rough idea of the psychiatric morbidity among lower middle social class children in Hong Kong.
Implicationsfor the future development of child psychiatry in Hong Kong As a psychiatric sub-specialty the task of child psychiatry is to integrate the biological, psychological and environmental perspectives and to see things from a developmental perspective. The history of child psychiatry is a short and emotionally charged one, reflecting how society perceives and values children [21]. Most would agree that child psychiatry has come to a crucial stage of evolution [22 - 251. Parry-Jones [23] suggested that the late 1980s may well be a turning point for either the “advancement or decline” of the sub-specialty. Chess [26] summarized this history in her succinct article and concluded that child psychiatry “has come of age”. This is also reflected in child psychiatry being recognized as a specialty or sub-specialty in many parts of the world. For example the Royal College of Psychiatrists has a Section of Child and Adolescent Psychiatry, established as early as 1946 as a Section of the then Royal MedicoPsychological Association [22]. The Royal Australian and New Zealand College of Psychiatrists established its Faculty of Child Psychiatry in May, 1987 [27]. Prior to that there was a Section of Child Psychiatry within the College from 1968. Wiener [28] in his president’s plenary address to the American Academy of Child and Adolescent Psychiatry talked about good news and bad news for child psychiatry. The bad news includes: (i) child psychiatry will have to continue “cost containment and cost reduction”; (ii) child psychiatry survives in a “consumer-oriented marketplace environment”; and
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(iii) competition [from all quarters] will increase. The good news includes: (i) child psychiatrists will remain in short supply; (ii) child psychiatry will increasingly establish itself as an important academic discipline; (iii) training will become progressively more rigorous as standards continue to increase; and (iv) the commitment to develop a scientific data base will earn increasing respect and attention from professionals as well as the public. In this international scenario what about child psychiatry for Hong Kong ? With 1.3 million children below the age of 15, how much child psychiatry is available ? Currently our Unit can see at most about 400 new cases per year. It is clearly very important for Hong Kong to further develop this sub-specialty. In our clinical practice we regularly come across patients with a long history of morbidity who have often been unrecognized, misdiagnosed and mismanaged by other professionals or doctors of other specialties or even by general psychiatrists [3,4]. It is long overdue for Hong Kong to realize, as other advanced countries have done for decades, that the scope, training and practice of child psychiatry are fundamentally different from that of adult psychiatry. We need a recognizable and independent sub-specialty of child psychiatry, by which we mean (i) clinical and administrative autonomy; (ii) recognizable professional expertise; and (iii) recognition by professional bodies and administrators alike. This sub-specialty should serve (i) to promote awareness of child psychiatric morbidity thereby contributing to prompt case identification; (ii) to provide consultation to other disciplines dealing with children; (iii) to train not only future child psychiatrists but also to take part in the training of other related professional disciplines; (iv) to provide front- line work in the treatment of psychiatrically disturbed children; and (v) to promote and contribute to relevant research. For a long time to come Hong Kong will still be in great shortage of child psychiatrists. Careful planning and deployment of man-power is crucial. First, we believe the base of this sub-specialty should preferably be in the general hospitals. This preserves the medical identity of the sub-specialty and through close collaboration with other specialties in the hospitals very important liaison work can be established. This is shown by the fact that referrals from within our teaching hospital is the most common source of ourpatients. Secondly, child psychiatry should establish a good working relationship with professional bodies in the
337
community, such as shown by the fact that the Education Department is our second commonest source of referrals. Thirdly, even one step further, child psychiatry should seek to help disturbed children indirectly through providing consultation and support to other professional bodies. Child psychiatry in Hong Kong until very recently has been a hybridized amorphous variant of general psychiatry. It is very easy to recognize this strange creature: it treats children like miniature adults with a strong tendency to make things worse rather than better. If the experience of so many countries and if 1.3 million children are insufficient to convince authorities that Hong Kong needs child psychiatry as an independent sub-specialty, then psychiatry in Hong Kong is very sick indeed.
Acknowledgement The author is deeply grateful to Professor Robert Adler of the Department. of Child and Family Psychiatry, Royal Children’s Hospital, Melbourne, for his invaluable support and suggestions in the preparation of this paper. He is also deeply grateful to Professor C.N.Chen of the Department for his vision and unfailing support throughout the years and to colleagues of the Department and the Unit for their steadfast devotion to their patients; without them the accomplishment described in this paper would have never become a reality.
1. Hong Kong Government. Hong Kong Annual Digest of Statistics.
Hong Kong: Census and Statistics Department, 1987. 2. Chen SCL. Child psychiatric cases attending a government psychiatric out-patient clinic over six years. In T.P. Khoo, ed. Mental Health in Hong Kong 1986. Hong Kong: Mental Health Association of Hong Kong, 1986. 3. Wong CK. Child psychiatry in Hong Kong: I. a retrospective study. Journal of Hong Kong Medical Association 1988; 4 0 4049. 4. Wong CK. Child psychiatry in Hong Kong: 11. understanding psychiatrically disturbed children. Journal of the Hong Kong Medical Association 1988; 40: 50-54. 5. Wong CK. The Child Psychiatric Patient Database System of the Chinese University of Hong Kong. Methods of Information in Medicine 1987; 26: 195-200. 6. Wong CK. Child psychiatry in a new medical school in Hong Kong: the way we teach medical students. Psychiatric Bulletin of the Royal College of Psychiatrists 1989; 13: 67- 69. 7. Rutter M. A children’s behaviour questionnaire for completion by teachers: preliminary findings. Journal of Child Psychology and Psychiatry 1967; 8: 1-1 1.
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8. Rutter M, Tizard J, Whitmore K. Education, Health and Behaviour. London: Longman Press, 1970. (Reprinted 1981. New York: Robert Krieber Publishing Company.) 9. Wong CK. The Rutter parent scale A2 and teacher scale 8 2 in Chinese: I. translation study. Acta Psychiatrica Scandinavica 1988; 77: 724-728. 10. Wong CK. The Rutter parent scale A2 and teacher scale 8 2 in Chinese: 11. clinical validity among Chinese children. Acta Psychiatrica Scandinavica 1988; 78: 11-17. 1 1 , Moos RH, Moos BS. Family Environment Scale: Manual 2nd ed. California: Consulting Psychologists Press, 1986. 12. Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Questionnaire. London: Hodder & Stoughton, 1975. 13. Eysenck SBG, Chan J. A comparative study of personality in adults and children: Hong Kong versus England. Personality and Individual Differences 1982; 3: 153-160. 14. Goldberg DP. Manual of the General Health Questionnaire. London: NFER Publishing Company, 1978. 15. Chan DW, Chan TSC. Reliability, validity and the structure of the General Health Questionnaire in a Chinese context. Psychological Medicine 1983; 13: 363-371. 16. Chan DW. The Chinese version of the General Health Questionnaire: does language make a difference’?Psychological Medicine 1985; 15: 147.155. 17. Wong CK, Lau JTF, Chan SC. A psychiatric epidemiological study on 7 18 Chinese children in Hong Kong: I. designing a multiple criterion screening procedure. 18. Wong CK, Lau JTF, Chan SC. A psychiatric epidemiological study on 7 I8 Chinese children in Hong Kong: 11. prevalence of morbidity.
19. Kolvin I, Carside RF, Nicol AR, Leitch I., Macmillan A. Screening schoolchildren for high risk of emotional and educational disorder. British Journal of Psychiatry 1977; 131: 192-206. 20. Macmillan A, Kolvin I, Garside RF, Nicol AR, Leitch, 1M. A multiple criterion screen for identifying secondary school children with psychiatric disorder. Psychological Medicine, 1980: 1 0 265-276. 21. von Gontard A. The development of child psychiatry in 19th century Britain. Journal of Child Psychology and Psychiatry 1988; 29569-588. 22. Hersov L. Child psychiatry in Britain - the last 30 years. Journal of Child Psychology and Psychiatry 1986; 27: 781- 801. 23. Parry-Jones WL. The hisiory of child and adolescent psychiatry: its present day relevance. Journal of Child Psychology and Psychiatry 1989; 30: 1:3-1 I. 24. Rae-Grant Q. Child psychiatrists in the 90’s: who will want us, who will need us? Canadian Journal of Psychiatry 1986; 3 1 : 493498. 25. Rutter M. Child psychiatry: looking 30 years ahead. Journal of Child Psychology and Psychiatry 1986; 27: 803- 840. 26. Chess S. Child and adolescent psychiatry come of age: a fifty year perspective. Journal of the American Academy of Child and Adolescent Psychiatry 1988: 27: 1: 1-7. 27. Methven RJ. Faculty of Child Psychiatry. Australian and New Zealand Journal of Psychiatry 1988; 22:238-239. 28. Wiener JM. The future of child and adolescent psychiatry: if not now, when? Journal of the American Academy of Child and Adolescent Psychiatry 1988; 27: 12-10.
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Hong Kong has a population of 5.5 million with 1.3 million below the age of 15. Child psychiatry has been very under-developed until recently. The brief history and development of child psychiatry in Hong Kong, and specifically that of the Child and Adolescent Psychiatric Unit at the Prince of Wales Hospital, the teaching hospital of The Chinese University of Hong Kong, are described. Traditionally psychiatric services for children in Hong Kong were heavily skewed towards neuropsychiatric and developmental conditions but in this Unit a full spectrum of child psychiatric conditions are seen. Relevant clinical statistics are used to illustrate these differences as well as to further highlight the philosophy and practice of the Unit. Other aspects, such as undergraduateand postgraduate teaching, and research are also mentioned. The magnitudeof child psychiatricmorbidity in Hong Kong is briefly illustrated with a three-stage epidemiological study done in a primary school in a lower middle social class area. It was found that 16.3% of the children were psychiatricallydisturbed. Emotional disorder, with a prevalence of 8.8 %, was the commonest condition. Finally, the future development of child psychiatry in Hong Kong is discussed, addressing the disconcerting facts of a huge population and very limited resources. Australian and New Zealand Journal of Psychiatry 1990; 24:331-338 Hong Kong has a population of 5.5 million with 1.3 million below the age of 15 [ 11. Bearing this in mind child psychiatry has been quite neglected until recently. Where, then, have all the disturbed children gone ? This will be the central theme of this paper. It will include (i) a brief historical perspective of the development of child psychiatry in Hong Kong; (ii) the experience of the Child and Adolescent Psychiatric Unit at the Prince of Wales Hospital, the teaching hospital of The Chinese University of Hong Kong; and (iii) a
Child and Adolescent Psychiatric Unit, Department of Psychiatry, The Chinese University of Hang Kong, Shatin, NT, Hong Kong C.K.Wong, MB, BS, MRC Psych, Senior Lecturer and Consultant Child Psychiatrist
brief account of a child epidemiological study in a lower middle social class area.
History ofchild psychiatry in Hong Kong Public psychiatric services in Hong Kong are provided from four quarters. The Government Mental Health Service provides the majority of services through two big mental hospitals, a hospital for chronic psychiatric patients, a psychiatric unit in a convalescent hospital, and a number of psychiatric out-patient and day-patient centres. The two universities, the University of Hong Kong and The Chinese University of Hong Kong provide psychiatric services in their respective teaching hospitals, Queen Mary Hospital and the Prince of Wales Hospital. The United
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Christian Hospital, a Government subsidized hospital, is the fourth source. As with most developing countries, when psychiatry was first established in Hong Kong about half a century ago the main concern was for acute psychotic adult patients. The development of psychiatric services understandably revolved around the treatment and rehabilitation of these adult patients. The occasional child patients were absorbed into the adult psychiatric services. Thus child psychiatry was given low priority and was no more than an offshoot of adult psychiatry. This is clearly shown by Chen [21: over an eight year period from 1977 to 1984 the mean number of new child out-patient cases presented to the whole Mental Health Service was only 324 per year (range 204 to 420). This represents a mean of 8.4 % of all new psychiatric out-patients. Now there are six child day centres in Hong Kong. These day centres, particularly those run by the Mental Health Service, almost exclusively treat pre-school children suffering from developmental or neuropsychiatric conditions, mostly infantile autism, hyperkinetic syndrome, and mental subnormality. Chen found the most common diagnoses made were infantile autism (30.1%), mental retardation (16.1%) and special symptoms or syndromes not elsewhere classified (10.4%). By contrast conduct disorder constituted only 4.7 %, neurotic disorder 3.2 % and mixed emotional and conduct disorder only 2.8%. These figures show very clearly that although attempts have been made to provide services for psychiatrically disturbed children these services are not only deficient in quantity but also very restricted in scope. There are mainly three reasons for this unfortunate state of affairs. First, the psychiatric out-patient and day-patient centres are isolated from the regional hospitals which means they fail to serve the large group of disturbed children presenting a myriad of somatic symptoms to paediatricians. Secondly, the centres are isolated from the community and rely heavily on medical sources of referrals. Disturbed children, other than those admitted to regional hospitals, are rarely picked out by doctors in the community as there is no proper primary health care in Hong Kong. Most people seek help from private practitioners on a hit-and-run basis. The poorer sector seeks help from the Government General Outpatient Departments in which each doctor sees about 20 patients per hour. Moreover, the older generation of doctors in Hong Kong have had very little training in
child psychiatry. Most disturbed children are identified by schools, the Education Department as well as statutory and voluntary social services. The lack of liaison with these professional bodies was probably one of the most important reasons for the low prevalence of emotional and conduct disorder in Chen’s study. Thirdly, the fact that there is no proper sub-specialty training in child psychiatry means that children are seen by general psychiatrists, often with questionable therapeutic results. The end result is a low referral rate with a heavy bias towards conditions with a strong medical flavour, infantile autism, mental subnormality and hyperkinetic syndrome.
The ChiM and Adolescent Psychiatric Unit at the Prince of Wales Hospital Since the opening of its teaching hospital in April, 1984, the Department of Psychiatry of The Chinese University of Hong Kong has aimed to develop child psychiatry as a recognizable and independent subspecialty in all three major aspects: (i) clinical service; (ii) undergraduate and postgraduate teaching; and (iii) research. The task has not been an easy one. The reason is simple. In the planning of the Hospital, long before any member of the Department took up office, child psychiatry was almost totally forgotten. The only reference to children in the design of the Hospital was a room designated “Playroom” and an area designated “Children’s Waiting Area” in the psychiatric outpatient clinic of the Hospital. Despite this we are determined to achieve our goals. Our experience of introducing and developing this sub-specialty may appear insignificant to people from well-established child psychiatry departments. But the history of how we established this sub-specialty from scratch within the boundaries of a general psychiatry department may still be of interest. Since there were no designated staff or other provisions the Department started its Child and Adolescent Psychiatric Unit by giving away one Lectureship post for general psychiatry to child psychiatry. As to staff from other professional disciplines the Unit had to share them with the rest of the Department. But over the years the Unit has acquired the following designated staff: one senior lecturer who is also the consultant child psychiatrist of the Unit; one full-time senior registrar or registrar level trainee; one part-time senior registrar from the British Military Hospital in Hong Kong; four psychiatric nurses (one each for the out- patient clinic,
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C.K. WONG
f l
Table I . The primary psychiatric diagnoses (n=298)
'Diagnosis Emotional disorder Conduct disorder Hyperkinetic syndrome Infantile autism Adjustment reaction (ICD-9309) Mixed disturbance of conduct and emotions Hysteria Schizophrenia Tourette's syndrome Other neurotic conditions Enuresis Specific disorders of sleep Manic-depressivepsychosis Frontal lobe syndrome Encopresis
Table 2 . Abnormal psycho-social situations of the clinical samples (n=298)
n
(%I
54 34 30 27 25 19 14 10 10 8 8 7 3 2 1
18.1 11.4 10.1 9.1 8.4 6.4 4.7 3.4 3.4 2.7 2.7 2.3 1.0 0.7 0.3
'The total number of diagnoses is not equal to the total number of cases since some children are not given any Axis 1 diagnosis
day hospital, and male and female wards); four teachers; one occupational therapist; and a visiting educational psychologist from the Education Department. But in addition to the designated staff the Unit still shares the man-power provided for the whole Department: 45 nurses (excluding the four designated nurses); two psychiatric social workers; three occupational therapists; and two full-time equivalent clinical psychologists. Since the Unit takes up about 25% of the in-patient beds and day-patient places of the Department it takes up an equivalent percentage of man-power from this general pool of staff. The Unit also has very limited inputs from some other services which are based outside the Department: community psychiatric nursing; physiotherapy and speech therapy. The Unit is expanding constantly. It is hoped that in the near future the number of full-time trainees will increase from one to three: one senior registrar and two registrars. Within a year or two the following additional designated staff may become a reality: two speech therapists; one or two additional occupational therapists; one or two more teachers; and one full-time clinical psychologist. To illustrate how we actually coped with such meagre staffing and to illustrate our philosophy and
2 Abnormal psycho-social situation
n
%
Discordant family relationship Lack of warmth in family Anomalous family Lack of or inadequate communication in family Excess or abnormal parental control Inadequate or inconsistent parentalcontrol Other intrafamily stress Mental disturbance and illness in other family member Stress trom school
103 63 59
34.6 21.4 19.8
50
16.8
46
15.4
44 42
14.8 14.1
40 39
13.4 13.1
practice two clinical samples will be summarized.The first is a retrospective sample of 93 patients seen in our first year of service [3,4]. The second is a prospective sample of 205 patients seen during 1987 using The Child Psychiatric Patient Database System of The Chinese University of Hong Kong [ 5 ] . The two samples are combined in the subsequent presentation (n=298).
The philosophy of our clinical practice We set out to provide the full spectrum of child psychiatric services, i.e. for the full range of age and diagnostic categories. Table 1 shows the ICD-9 Axis 1 diagnoses. Emotional disorder, conduct disorder, mixed disturbance of conduct and emotions, neurotic conditions, and adjustment reaction added up to 5 1.7 % of all cases. There are still a substantial proportion of patients suffering from hyperkinetic syndrome and infantile autism, constituting 19.2 % of all cases. New referrals increased from 100 in 1984 to 300 in 1988. The estimated number for 1989 is 400. We aim to provide the full range of treatment methods. As mentioned previously the other child psychiatric day centres or units in Hong Kong mainly look after pre-school children suffering from infantile autism, mental handicap and other neuropsychiatric and developmental conditions. As might be expected, many of our patients come from very abnormal psychosocial backgrounds, as shown in Table 2. Clear-
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CHILD PSYCHIATRY IN HONG KONG: AN OVERVIEW
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Table 3. Modes of treatment of the clinical samples (n=298)
Mode of treatment.
n
YO
Family therapy
128
43.0
Individualchild psychotherapy
50
16.8
Medication
41
13.8
Hospitalisation
16
5.4
Individual parent psychotherapy
14
4.7
Paramedical staff including psychiatric nurses, occupational therapists, medical social workers and clinical psychologistswere involved theapeutically in 105 cases (35.2%). The figures in this table include their inputs.
ly the successful management of such patients depends on a full therapeutic repertoire. The treatment offered is shown in Table 3 . Various forms of psychotherapy, in particular family therapy and individual child psychotherapy were among the most commonly used methods of treatment. As indicated in Table 3 we are the first psychiatric unit (whether adult or child) in Hong Kong in which psychiatric nurses and other paramedical staff are heavily involved in psychotherapeutic work under close supervisionof the consultant. As the Unit continues to grow the repertoire of our treatment methods is also enlarging. In particular, group therapy for different kinds of patients and parents has become an important mode of treatment. We have also helped organize a strong parents’ group for parents of children suffering from various conditions such as infantile autism and hyperkinetic syndrome. We try not to admit child patients but if necessary they are admitted to the two general psychiatric wards of the Department (one male and one female ward). The mixing of child and adult in-patients is not by design but simply because the Hospital has no provision for child psychiatric wards. The child patients occupy about 16 to 20 out of a total of 72 in-patient beds. Likewise, child day patients occupy about 8 to 13 out of a total of 50 places. We were worried initially about mixing children and adult
patients. However, it is over 5 years now since we started and despite our misgivings this somewhat unusual arrangement has worked much better than expected. We put very strong emphasis on liaison with other departments within the teaching Hospital and with professional bodies outside the Hospital. This liaison is vitally important for two reasons. The first is the identificationof disturbed children. Table 4 shows the source of referral of our patients. The teaching hospital itself is the commonest source of referral and the Education Department second. Almost without exception they are appropriate referrals. The two sources combined accounted for nearly two-thirds of our cases. Referrals from the Hospital consisted mainly of emotionally disturbed children presenting with somatic symptoms and children suffering from psychiatric complications of a primary physical condition such as cerebral palsy, epilepsy, head injury or leukaemia. Referrals from the Education Department include mainly behaviourally disturbed children. We have also established a very good liaison with a major child assessmentcentre in Hong Kong, from which we have a constant supply of younger children suffering from various developmental conditions (Table 1). Most of our patients actually suffer from multiple problems which traverse the boundaries of child psychiatry, education, medical social work and various other medical and para-medical professional disciplines. This is the second reason for emphasizing liaison: therapeutic success depends on a genuine multi-disciplinaryapproach. Besides keeping a good relationship we actively reach out to these professional bodies. Since 1984, we have been invited to the fortnightly case conference of the Special Education Section of the Education Department. In each of these conferences 3 to 6 new cases are presented and an equal number of old cases are reviewed. A majority of these children are ultimately referred formally to our Unit. To promote cross-fertilizationwe actively welcome staff from other professional bodies to come to our academic and clinical activities. Over the last few years a large number of social workers, educational psychologists and counsellors, principals and teachers, and even the Juvenile Protection Section of the police have come to these activities. We are also frequently invited to give lectures or run workshops for the staff of these agencies.
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Special Education Section. Students are actively involved in the new case session as well as in the child case conferences and the psychosocial seminars. We rely heavily on audio-visual systems to maximize the effectiveness of teaching.
Table 4 . Source of referral of the clinical samples (n=298) ~
n
Paediatrics 3rthopaedic and traumatic surgery 3eneral psychiatry kcident and emergency Medicine Surgery 3bstetrics and gynaecology
%
Postgraduatetraining and training of other professionaldisciplines
80 7 6 6 5 4 1 -
rota1 other departments
109
36.6
special education section
63
21.1
'rivate medical institutions and irivate practitioners
48
16.1
Ither Government and subsidised ion-psychiatric medicationinstituions
37
12.4
Ither psychiatric departments
23
7.7
;elf referral
11
3.7
7
2.3
social agencies and the legal iepartment
335
Undergraduateteaching The aims of our teaching are two fold: (i) to equip our students with a reasonable knowledge of child psychiatry; and (ii) to help them appreciate the psychiatric aspects of the practice of medicine, irrespective of specialty [6]. The second is a common goal of the teaching programme of the Department of Psychiatry. We believe that the most effective way to promote psychiatry is to let our students appreciate the important contributions of psychiatry to medicine in general rather than to try t o turn them into psychiatrists. Child psychiatry occupies 25 % of the 10- week full-time psychiatry clerkship. The teaching methods include: (i) the clinical new case session; (ii) the child case conference; (iii) the lecture series; (iv) the psychosocial seminar Cjoint teaching with the Department of Paediatrics during the Paediatrics Module); and (v) the joint case conference with the
We are still the only child psychiatric unit in Hong Kong which offers full-time postgraduate training in child psychiatry. The Unit takes up one full-time trainee of the senior registrar or registrar level who is rotated to the Unit for 6 months. As mentioned we hope in the near future the number of full-time trainees will be increased to three. Again we rely heavily on our audio-visual systems to make supervision much more effective and efficient. We also run a part-time senior registrar programme for the British Military Hospital in Hong Kong. The army psychiatrist spends 2 to 3 sessions per week in the Unit. He takes part in the ward round, the child case conference as well as running a clinical session with simultaneous interpretation. In addition the Unit offers placements to students of other professional disciplines including social work, clinical psychology and occupational therapy. Their supervisors also contribute to the care of patients.
Research We believe that research is one of the most important ways to establish and promote our specialty. A computerized clinical register forms the basis of our ongoing clinical research. This is based on the patient database system designed by Wong [5] which consists of (i) a semi-structured interview schedule; and (ii) a computerized patient information system. We are about to launch the third version of this system, the main features are total computerisation of the patient records, including information about in-patient and day-patient treatment, and out-patient follow-up sessions. This system solves the dilemma of coping with a heavy clinical load while at the same time ensuring the clinical materials are researchable. Other research includes the translation, validation and standardization of well established instruments such as the Rutter Scales A2 and B2 [7 - 101, the Family Environment Scale [ 111 and the Junior Eysenck Personality Questionnaire [12,13]. The Unit also makes use of
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CHILD PSYCHIATRY IN HONG KONG: AN OVERVIEW
some well-known adult instruments in its clinical research involving the parents of our patients. These include the General Health Questionnaire [ 14 - 161and the adult Eysenck Personality Questionnaire [ 12, 131. The third major area of research is epidemiology which will be further elaborated below.
what is the magnitude of child psychiatric morbidity in Hong Kong 3 Though it is not possible to give a complete answer to this question some estimate can be made based on one research project. 7 18 primary pupils of a primary school in a lower middle social class area were studied in a three stage epidemiological project [ 17,181. All the 7 18 pupils were screened using a multiple criterion screening procedure resembling the studies of Kolvin et a1 [19] and Macmillan et a1 [20] with additional specific questions. In the second stage, all potential cases and a I-in-10 random sample of the potential non-cases were interviewed jointly by the child psychiatrist and the principal of the school. School records were also studied and a number of questionnaires administered. In the third stage medical students interviewed the parents again to obtain a developmental and psychosocial history. The results on the screening procedure and prevalence have been presented in detail in two papers [ 17,181. In summary, it was found that the overall prevalence of definite cases was 16.3% with 95% confidence limits of 11.7% to 20.9% (after adjusting for sampling errors in the false negatives). The mean duration of morbidity of all definite cases was 42 months. The most common diagnostic category was emotional disorder, 8.8% (95% confidence limits 5.0% to 12.6%).The prevalence of other diagnoses were: conduct disorder, 2.0% (no confidence limits since no sampled false negative cases); mixed disturbance, 3.0% (95% confidence limits 0.3% to 5.7%); hyperkinetic syndrome, 1%; hyperkinetic conduct disorder, 1%; and Gilles de la Tourette’s syndrome, 0.4%. There were also a number of children who had few overt behavioural symptoms and yet they had unequivocally been beset with long-standing and severe emotional conflicts, usually the results of long-standing family psychopathology. For example one Primary Four girl revealed that for many years she had to look after herself and her younger siblings, including shopping for food and cooking, seven days a week, since her parents were out early in the morning until 10 or
11 p.m. She admitted in tears that for many years she had felt persistently very unhappy, lonely and dissatisfied. But she never had any problems with conduct, school work or peers. We used the term “subclinical cases”and the prevalence was 19.5% (95% confidence limits 10.8% to 28.2%). They could also be construed as mild or high risk cases. From the perspective of preventive child psychiatry these children should be identified and helped. Although the study was only done in one school but because of a uniform policy of city planning and because the allocation of a significant proportion of primary school places are randomized according to address our findings at least give a rough idea of the psychiatric morbidity among lower middle social class children in Hong Kong.
Implicationsfor the future development of child psychiatry in Hong Kong As a psychiatric sub-specialty the task of child psychiatry is to integrate the biological, psychological and environmental perspectives and to see things from a developmental perspective. The history of child psychiatry is a short and emotionally charged one, reflecting how society perceives and values children [21]. Most would agree that child psychiatry has come to a crucial stage of evolution [22 - 251. Parry-Jones [23] suggested that the late 1980s may well be a turning point for either the “advancement or decline” of the sub-specialty. Chess [26] summarized this history in her succinct article and concluded that child psychiatry “has come of age”. This is also reflected in child psychiatry being recognized as a specialty or sub-specialty in many parts of the world. For example the Royal College of Psychiatrists has a Section of Child and Adolescent Psychiatry, established as early as 1946 as a Section of the then Royal MedicoPsychological Association [22]. The Royal Australian and New Zealand College of Psychiatrists established its Faculty of Child Psychiatry in May, 1987 [27]. Prior to that there was a Section of Child Psychiatry within the College from 1968. Wiener [28] in his president’s plenary address to the American Academy of Child and Adolescent Psychiatry talked about good news and bad news for child psychiatry. The bad news includes: (i) child psychiatry will have to continue “cost containment and cost reduction”; (ii) child psychiatry survives in a “consumer-oriented marketplace environment”; and
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(iii) competition [from all quarters] will increase. The good news includes: (i) child psychiatrists will remain in short supply; (ii) child psychiatry will increasingly establish itself as an important academic discipline; (iii) training will become progressively more rigorous as standards continue to increase; and (iv) the commitment to develop a scientific data base will earn increasing respect and attention from professionals as well as the public. In this international scenario what about child psychiatry for Hong Kong ? With 1.3 million children below the age of 15, how much child psychiatry is available ? Currently our Unit can see at most about 400 new cases per year. It is clearly very important for Hong Kong to further develop this sub-specialty. In our clinical practice we regularly come across patients with a long history of morbidity who have often been unrecognized, misdiagnosed and mismanaged by other professionals or doctors of other specialties or even by general psychiatrists [3,4]. It is long overdue for Hong Kong to realize, as other advanced countries have done for decades, that the scope, training and practice of child psychiatry are fundamentally different from that of adult psychiatry. We need a recognizable and independent sub-specialty of child psychiatry, by which we mean (i) clinical and administrative autonomy; (ii) recognizable professional expertise; and (iii) recognition by professional bodies and administrators alike. This sub-specialty should serve (i) to promote awareness of child psychiatric morbidity thereby contributing to prompt case identification; (ii) to provide consultation to other disciplines dealing with children; (iii) to train not only future child psychiatrists but also to take part in the training of other related professional disciplines; (iv) to provide front- line work in the treatment of psychiatrically disturbed children; and (v) to promote and contribute to relevant research. For a long time to come Hong Kong will still be in great shortage of child psychiatrists. Careful planning and deployment of man-power is crucial. First, we believe the base of this sub-specialty should preferably be in the general hospitals. This preserves the medical identity of the sub-specialty and through close collaboration with other specialties in the hospitals very important liaison work can be established. This is shown by the fact that referrals from within our teaching hospital is the most common source of ourpatients. Secondly, child psychiatry should establish a good working relationship with professional bodies in the
337
community, such as shown by the fact that the Education Department is our second commonest source of referrals. Thirdly, even one step further, child psychiatry should seek to help disturbed children indirectly through providing consultation and support to other professional bodies. Child psychiatry in Hong Kong until very recently has been a hybridized amorphous variant of general psychiatry. It is very easy to recognize this strange creature: it treats children like miniature adults with a strong tendency to make things worse rather than better. If the experience of so many countries and if 1.3 million children are insufficient to convince authorities that Hong Kong needs child psychiatry as an independent sub-specialty, then psychiatry in Hong Kong is very sick indeed.
Acknowledgement The author is deeply grateful to Professor Robert Adler of the Department. of Child and Family Psychiatry, Royal Children’s Hospital, Melbourne, for his invaluable support and suggestions in the preparation of this paper. He is also deeply grateful to Professor C.N.Chen of the Department for his vision and unfailing support throughout the years and to colleagues of the Department and the Unit for their steadfast devotion to their patients; without them the accomplishment described in this paper would have never become a reality.
1. Hong Kong Government. Hong Kong Annual Digest of Statistics.
Hong Kong: Census and Statistics Department, 1987. 2. Chen SCL. Child psychiatric cases attending a government psychiatric out-patient clinic over six years. In T.P. Khoo, ed. Mental Health in Hong Kong 1986. Hong Kong: Mental Health Association of Hong Kong, 1986. 3. Wong CK. Child psychiatry in Hong Kong: I. a retrospective study. Journal of Hong Kong Medical Association 1988; 4 0 4049. 4. Wong CK. Child psychiatry in Hong Kong: 11. understanding psychiatrically disturbed children. Journal of the Hong Kong Medical Association 1988; 40: 50-54. 5. Wong CK. The Child Psychiatric Patient Database System of the Chinese University of Hong Kong. Methods of Information in Medicine 1987; 26: 195-200. 6. Wong CK. Child psychiatry in a new medical school in Hong Kong: the way we teach medical students. Psychiatric Bulletin of the Royal College of Psychiatrists 1989; 13: 67- 69. 7. Rutter M. A children’s behaviour questionnaire for completion by teachers: preliminary findings. Journal of Child Psychology and Psychiatry 1967; 8: 1-1 1.
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8. Rutter M, Tizard J, Whitmore K. Education, Health and Behaviour. London: Longman Press, 1970. (Reprinted 1981. New York: Robert Krieber Publishing Company.) 9. Wong CK. The Rutter parent scale A2 and teacher scale 8 2 in Chinese: I. translation study. Acta Psychiatrica Scandinavica 1988; 77: 724-728. 10. Wong CK. The Rutter parent scale A2 and teacher scale 8 2 in Chinese: 11. clinical validity among Chinese children. Acta Psychiatrica Scandinavica 1988; 78: 11-17. 1 1 , Moos RH, Moos BS. Family Environment Scale: Manual 2nd ed. California: Consulting Psychologists Press, 1986. 12. Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Questionnaire. London: Hodder & Stoughton, 1975. 13. Eysenck SBG, Chan J. A comparative study of personality in adults and children: Hong Kong versus England. Personality and Individual Differences 1982; 3: 153-160. 14. Goldberg DP. Manual of the General Health Questionnaire. London: NFER Publishing Company, 1978. 15. Chan DW, Chan TSC. Reliability, validity and the structure of the General Health Questionnaire in a Chinese context. Psychological Medicine 1983; 13: 363-371. 16. Chan DW. The Chinese version of the General Health Questionnaire: does language make a difference’?Psychological Medicine 1985; 15: 147.155. 17. Wong CK, Lau JTF, Chan SC. A psychiatric epidemiological study on 7 18 Chinese children in Hong Kong: I. designing a multiple criterion screening procedure. 18. Wong CK, Lau JTF, Chan SC. A psychiatric epidemiological study on 7 I8 Chinese children in Hong Kong: 11. prevalence of morbidity.
19. Kolvin I, Carside RF, Nicol AR, Leitch I., Macmillan A. Screening schoolchildren for high risk of emotional and educational disorder. British Journal of Psychiatry 1977; 131: 192-206. 20. Macmillan A, Kolvin I, Garside RF, Nicol AR, Leitch, 1M. A multiple criterion screen for identifying secondary school children with psychiatric disorder. Psychological Medicine, 1980: 1 0 265-276. 21. von Gontard A. The development of child psychiatry in 19th century Britain. Journal of Child Psychology and Psychiatry 1988; 29569-588. 22. Hersov L. Child psychiatry in Britain - the last 30 years. Journal of Child Psychology and Psychiatry 1986; 27: 781- 801. 23. Parry-Jones WL. The hisiory of child and adolescent psychiatry: its present day relevance. Journal of Child Psychology and Psychiatry 1989; 30: 1:3-1 I. 24. Rae-Grant Q. Child psychiatrists in the 90’s: who will want us, who will need us? Canadian Journal of Psychiatry 1986; 3 1 : 493498. 25. Rutter M. Child psychiatry: looking 30 years ahead. Journal of Child Psychology and Psychiatry 1986; 27: 803- 840. 26. Chess S. Child and adolescent psychiatry come of age: a fifty year perspective. Journal of the American Academy of Child and Adolescent Psychiatry 1988: 27: 1: 1-7. 27. Methven RJ. Faculty of Child Psychiatry. Australian and New Zealand Journal of Psychiatry 1988; 22:238-239. 28. Wiener JM. The future of child and adolescent psychiatry: if not now, when? Journal of the American Academy of Child and Adolescent Psychiatry 1988; 27: 12-10.
MOUNTS BAY CLINIC Are you a young, energetic and enthusiastic psychiatrist? Come and join the Mounts Bay Clinic, a dynamic private psychiatric unit in Perth. A pleasant working environment overlooking the Swan River and the city of Perth awaits you, together with an established and motivated team of professionals committed to excellence and specialising in service delivery, GP education, research and professional development. Your practice will constitute the group’s sixth outpatient practice and your patients will have access to the full range of services offered by Mounts Bay Clinic. The Clinic comprises a nine bed Inpatient Unit and a Day Therapy Unit, with a full-time staff of 3 clinical psychologists, 2 occupational therapists, clinical nurse supervisor and ward nurses. The staff provides group therapy programmes based on cognitive behavioural and systems theory to manage a wide variety of adult psychiatric disorders. Sessions are fully covered by the major health funds. A package in the range of $80-105,000 will be negotiated, depending on experience. For further information please contact Gillian Hewitson at Mounts Bay Clinic, 35 RichardsonStreet, West Perth, WA, 6005. Telephone (09) 481 2992, Fax (09) 481 4454.
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