Child Psychiatry Perspectives Professional Competence, Public Confidence, and Children's Rights

Irving N. Berlin, M.D.

Influences on Training Programs. Competence in child psychiatry is largely determined by the character of the training. Psychodynamic individual psychotherapy continues as the cornerstone of most training. However. training programs with unique approaches to diagnosis, treatment, and research provide opportunities for trainees with special interests. Although not yet well supported, research. too, is making itself felt, especially in the areas of infant and child development. earl y intervention, epidemiology, and in the neural substrates of behavior. Psychodynamic child ps ychiatry remains a very strong. fundamental inHuence because of its explanatory power, which generates many researchable hypotheses. However. research and treatment evaluation are still needed. The knowledge explosion in child development, biochemistry, genetics, psychopharmacology, and new treatment methods earlier in life has overwhelmed training programs with curriculum material to teach, not enough time to teach it. and few methods to assess what has been learned. Assessment in Supervision . Mutual assessment by supervisors with the trainees on an ongoing basis is an important tool to correct deficiencies and to learn to assess areas of competence. Unless the process is an ongoing one and we agree about the skills to be assessed, we tend, in the usual 6-month or year reports, to feel guilty for permitting shoddy or poor work to go unnoticed. By default we pass trainees along who have not learned fundamental skills. and finally we graduate them, dissatisfied with them and ourselves but caught in an episodic and inadequate evaluatory process which visits our failures in training on the community. Trainees must also assess their teachers and provide feedback about the Dr. Berlin is Professor oj Psychiatry and Pediatrics and Head of the Section of Child Psychiatry. Viet-Chairman Jor Child Mental Health at the University oj Californ ia. Davis, School of Medicine . He is also President oj the Amerkan Academy of Child Psychiatry. This pap" was modified Jrom the Presidential address at the Annllal Meeting of the Am"ican Academy of Child P.rychiatry. OctOO" 2/. /976 , Toronto, Canada . Reprints may be requested Jrom the author at the Department oj Psychiatry, Division of Mental Health . Sacramento Med ical Center, Sacrammto. CA 958/6.

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program's strengths and weaknesses as well as the quality of teaching and supervision. Thus, our trainees become our collaborators and colleagues in mutual learning. The Quest fOT Continued Education. The data in a recent survey indicate that although most child psychiatrists are in private practice, they spend about 20 percent of their time in teaching and consultation in a variety of training institutions and child-serving agencies. Teaching, supervision, and consultation encourage the clinician to keep abreast of the field. Seminars in scientific method and research methodology help trainees to examine current basic and clinical research critically, sometimes to find an area of research of particular interest to them. Good models for research productivity also help trainees learn to formulate problems, develop research protocols, and report on their work. It is abundantly clear that only in a research atmosphere is clinical research facilitated. Trainees who teach and su pervise medical students and general psychiatry residents in child psychiatry are noted by their teachers to be more involved in additional reading and learning. To ensure professional competence, it is our obligation not to permit inadequately prepared trainees to graduate until they demonstrate basic skills and knowledge. Professional Competence and Public Confidence. Can professional competence be determined by examination? As federal and state governments have expressed concerns with competence in medicine, there appears to have been precipitous action on the part of many specialty boards to impose the written examinations on their constituency, perhaps to avoid criticism, knowing that such examinations do not assess clinical competence. Further, since many child psychiatrists are not certified in the first place, reexamination cannot apply to them. The Academy and the Committee on Certification in Child Psychiatry of the Board have been involved in productive dialogue about how continuing education would serve as continuing certification in child psychiatry. Again, a critical problem is presented by the many child psychiatrists who are not certified. We need high-quality regional institutes to provide continuing education to child psychiatrists and other mental health professionals. The Academy, through its committee on the design, promotion, and running of institutes, will assist the regions in the development of regular, high-quality continuing education. Our public imagc is dctcnnincd by our visibility. Child psychiatrists arc relatively rare in community mental health centers; only 27 percent have children's services and even fewer employ child psychiatrists. We are not well known as resources in the general community or to the agencies which work with most children, the schools. We are now being used more by the courts. In part, our image is a reflection of our society's, medicine's, and psychiatry's lack of concern with children. Issues of Public Interest. In recent years we have heard a good deal about the loss of public confidence in medicine as the relationship of the medical practitioner to his or her patients becomes brief, fragmentary, and episodic rather than the needed lifelong relationship of trust and con-

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fidence. Simultaneously, the cost of fewer personal medical services has risen enormously. The provision of continuity of care for children and families seems illusory as few physicians or other medical personnel are trained for such a function, and funding for such care, for most people, seems unlikely. Psychiatry has oversold. in general. its capacity to heal all mental illness and provide respite for severe emotional disorders. In child psychiatry, too. a similar oversell has occurred. We often fail to find the time and the entry to the school system. Thus. we find ourselves not included in many special education programs for hyperactive children. those with severe behavior problems or even in instances of childhood autism or psychosis. Other physicians are used to provide prescriptions for drugs that educators feel will help manage the child in the regular and special classroom. Our input into these systems. which care for most of the children. must be greater and we need to train for such roles. Those of us involved in training and teaching child psychiatry in community mental health centers find that children do not have high priority and those mental health professionals who are given the mandate to treat children and consult with day care centers and schools are not well trained in therapeutic work or in mental health consultation. Those who are well trained arc often used primarily to follow children being treated with drugs and to treat directly those children and families others feel they cannot treat. In only a few centers are child psychiatrists used to provide inservice training and consultation with those professionals and paraprofessionals who do treat children. Although many child psychiatrists in private practice are involved as consultants to mental health centers, to child-serving agencies and 111 teaching, their community visibility is not great. The Integrating Role of the Child Psychiatrist. As physicians, we have begun to differentiate a special role which includes an understanding of neurophysiological development and its interweaving with psychosocial and cognitive development, permitting more precise assessment of the total developmental status of the child. Involved also in the physician/child psychiatrist role is the integration of developmental data and biochemical research on mental disorders which permit more effective and rational use of psychopharmacological agents to help in the treatment of certain disorders. The prevention of abuse of drugs in the treatment of disorders of childhood and adolescence is an important function of child psychiatry. In severe disorders of childhood, knowledge of development, psychopharmacology. and methods of intensive interpersonal treatment helps develop a treatment plan and epitomizes the unique role of the child psychiatrist. Professional Conscience and Child Care. Academy members have become involved with JACH, the OCHAMPUS reviews, etc. Their reviews indicate that treatment and living conditions in residential care facilities for children are often poor. It is important that we as a profession not only

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work toward improved care in state institutions, but that we take responsibility as consultants for the general treatment and specific therapeutic programs to which we lend our name. While we may not practice behavior modification, special education methods, or milieu therapy, we usually can evaluate whether it is used in appropriate ways for certain children. More important, if we fail to assess the quality of care in such efforts, we risk our credibility as professionals concerned with the mental health of children. The Child Psychiatrist as Child Advocate. In our country, poverty keeps increasing, inner cities are constantly expanding, families are under continued great pressures socioeconomically, and the increased divorce and child abuse rates in all socioeconomic classes bespeak greater troubles for parents and their children. Under these conditions, child psychiatrists have a new obligation-to become aware of the psychosocial needs of children and to become their advocates with legislative bodies, local, state, and federal administrations and courts. Training programs in child psychiatry should include experience in early intervention programs. We need to learn about early treatment modalities that can be effective. We also must become aware of how helping parents early in the child's life can reduce and alleviate emotional and psychological disorders. As we understand more about mother-infant bonding, we will be able to intervene and be helpful with disturbances that may begin in early infancy. At a recent mini-White House conference on Early Intervention, such agencies as N.I.M.H., O.e.O. and N.I.H.C.O. described some of their very effective research and demonstration projects. One of these illustrated some of the early awareness infants have of parents' emotional state, as reflected in a friendly smiling face and the infant's distress reactions when the face was immobile. Early intervention studies were described with unwed, depressed mothers and many others. Several investigators and executives from large foundations asked, "Why do these elegant research studies; why provide effective demonstrations in early intervention if no programmatic implementation was to follow?" This is an issue which we, as an Academy of child psychiatrists, must focus on. We must mobilize our regional councils and concentrate our efforts in Washington to make sure that this nation begins to focus on children as a high priorit y.

We need to design programs where child psychiatrists can learn how to have impact on public policy. Without constant efforts to face legislators and administrations with the needs of children and the ways in which the lives of children can be protected and enriched, programs for children are rarely considered in the face of other needs in our society. Thus, the recent revisions of the community mental health legislation make children's services a priority, but there is no money to make these services a reality. Recent N.I.M.H. manpower projections almost entirely ignore the needs of children. Childrens' Rights, Child Psychiatry, and Developmental Concerns. Research in

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child development and its disorders reveals that many children can be identified as being at high risk in infancy and early childhood. We know a good deal about the background of parents who abuse their children and who usually have been beaten and neglected themselves. We can often identify the factors in both family life and in the environment which lead to family disorganization and problem children, as well as parents with problems. Many of these are societal problems. We note an increase in violence in childhood and early adolescence both in murder and suicide. We need to turn part of our focus on how our society affects our children. Traditionally, we have tended our professional business with the knowledge that we cannot eliminate poverty or reform society's priorities. However, as child psychiatrists, we are charged with a concern and with an obligation to act on those issues which influence the mental health of children. Therefore, as an Academy we have begun to take positions on the American Indian child, the needs of orphans from foreign lands, and the issues of concern in health insurance for mental health of children. The critical requirements of disturbed children for adequate diagnosis and treatment and the protection of their rights are reflected in the Academy's pioneering development of P.S.R.O criteria for children in residential care. Our concern with adequate training and manpower to help prevent, intervene early, and treat mental disorder in children has led to involvement with various private and governmental agencies to focus on these concerns. A primary function of child psychiatrists both as individuals and as members of various organizations should be to use the data which come from ever-increasing basic, epidemiologic, and clinical research, as well as from demonstration projects. Such information must be used to influence key individuals in legislative, administrative, and legal arms of government, so that they can take advantage of our expanding knowledge as they devise social policy and implement programs for children and adolescents.

Child psychiatry perspectives. Professional competence, public confidence, and children's rights.

Child Psychiatry Perspectives Professional Competence, Public Confidence, and Children's Rights Irving N. Berlin, M.D. Influences on Training Progra...
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