Australian and New Zealand Journal of Psychiatry (1978) 12: 157
THE CURRENT STATUS OF CHILD PSYCHIATRY IN AUSTRALIA WITH SPECIAL REFERENCE TO TRAINING IN GENERAL PSYCHIATRY*
by GEORGE LIPTON**
There is a widely held belief and tradition in Australia that the word ‘psychiatry’, when referring to a department or a practitioner, is synonymous with ‘general psychiatry’. The importance and task of the general psychiatrist is well emphasised in the following statement. “The capacity of such a person to integrate and to provide a fundamental level of understanding of the characteristics and needs of all age groups and ali subcultures (without having to be an outstanding expert in any of them) will be indispensable.” (Cohen 1972) Unfortunately the majority of departments of psychiatry and practitioners in the field teach or provide service predominantly to the area of adult psychiatry. Professional incursions into the problems of children, families and development may be seen as deviations, albeit necessary, from the major thrust of their activities. I t may be argued that i t is the child psychiatrist, trained initially in adult psychiatry and then in child psychiatry, who most closely shows the characteristics of a general psychiatrist. This however, is not the thesis of this paper. It would be a great loss to psychiatry indeed if the child psychiatrist of today became the general psychiatrist of tomorrow. The principal tasks of this paper are threefold. 1. To examine the relationship of child psychiatry to a truly general psychiatric training.
2. To overview the state of development of child and adult psychiatry in relationship to each other in Australia today. 3. To attempt to elucidate some of the problems which lie in the way of constructive integration.
*Received 14 April 1977 *‘*Director of Training, Joint Training Programme in Child Psychiatry, Mental Health Authority, Melbourne
Two presuppositions form the philosophical basis of this paper and underlie the arguments raised therein. 1. That’a general psychiatrist should, at the least, have training in those skills which will potentially enable him to treat any member of the population. (Currently because of the general lack of effective skills for the treatment of children many adult psychiatrists are precluded from treating up to 40% of the Australian population).
2. “Psychiatry, as all specialties in medicine, stems from developmental constructs. Psychodynamic principles have always emphasised childhood experiences as causal of later life problems. Therapies based on learning theory, family interaction, Gestalt techniques etc., also point to influences of early life involvements as determining emotional and behavioural difficulties within individuals, in families and in society. Research on pre-, peri- and postnatal factors indicate that constitutional and temperamental factors evidenced at these stages immutably determine personality characteristics t h r o u g h o u t a n individual’s life cycle.. . . . . . . . . . .Indeed the only way a qualified psychiatrist can be a generalist is if the training programmes have the stamp of child development continuously resonating throughout the formal training process.” (Schechter, 1977)
CURRENT STATE OF CHILD PSYCHIATRY IN AUSTRALIA In view of these presuppositions it is interesting to examine the current position of child psychiatry vis a vis adult psychiatry in this country. There are nearly as many children and adolescents in this country as adults. However, only approximately 5-6010 of Australian psychiatrists are trained in child psychiatry and a further 5% are recognised as child psychiatrists through extensive experience in the field. The national situation is made
158
CURRENTSTATUS OFCHILI)PSYCHIATRY I N AUSTRALIA
poorer when it is recognised that over 40% of child psychiatrists reside in Victoria. (Lipton, 1977) Compared to relatively extensive networks of adult psychiatric care facilities there are desperately few child psychiatric services. The bulk of such services are understaffed to the point of marginal viability and demonstrate an inability to meet more than the most superficial of community needs. There are no academic departments of child psychiatry in Australia and no full professors in the field. There are, in Australia, currently only two occupied Associate Chairs in Child Psychiatry within Adult Psychiatry departments. A third may soon become available. When one person recently left Australia his Associate Professorial position was downgraded to a lectureship. This person left the country to take up a full Chair in the United States. He would have remained had this been available here. While child psychiatrists can be appropriately criticised for their inadequate research efforts in this country it should also be recognised that they are not granted the opportunity for experiencing the crucible of an academic department in their own specialty from within which research traditions could ferment and develop. A rare isolated position for an individual in an adult department ddes not lead to this result. Finally, because of the lack of academic opportunities, the poor service or admiriistrative career structures available to child psychiatrists, and the additional time required to train for the specialty, recruitment to the specialty is, not surprisingly, low, even when training opportunities are available. There are currently approximately 16 or 17 persons in training in the specialty throughout the country (RANZCP 1977). While this is an advance over the situation of 5 years ago it is still very inadequate and compares very poorly with general recruitment into psychiatry which has been increasing over that period.
PROBLEMS IN THE DEVELOPMENT OF CHILD PSYCHIATRY The major issue to examine is not so much the difficulty in developing child psychiatry but rather the difficulty in providing child psychiatry as part of general psychiatric training. I t is for this area, i f for no other, that a healthy development of the field is required. It is proposed that there are two major areas of difficulty which impede the development of child psychiatry, one in relation to psychiatry itself, and the second in relation to the society in which it finds itself.
1. IN RELATION TO PSYCHIATRY “Child psychiatry in the United States has developed a frame of reference and institutional means for achieving its main goals that are clearly advantageous to the community it serves. Yet, paradoxically, the field has been disadvantaged within its parent discipline of psychiatry.
The same attributes which are potentially so valuable for its goals of service have been handicaps within the value system of psychiatry. Child psychiatry has emerged as an honoured but low prestige sub-specialty, with problems of recruitment and support that are directly influenced by the power structure of psychiatry.” (Bloom, 1972). Solnit (1972) selects the year of 1909 as the crucial year of development for child psychiatry because in that year Freud’s Little Hans was published, Healy opened the first child guidance clinic in Chicago to treat delinquents, the first kibbutz in Israel was opened, the first kindergarten in USA was opened and President Roosevelt established the Children’s Bureau. However, it must be noted that not one of these events was in the context of orthodox medicine. Although in Australia the origins of the field were more medical with the establishment of the Child Psychiatric department by Dr. Williams at the Royal Children’s Hospital in the early twenties the major developments here have also tended to follow the lines so typical of the early American scene. These early roots have given child psychiatry its unique experience iti fields of community health programmes, team treatment approaches, conjoint family approaches, preventative psychiatry, interest in early socio-cultural effects of development and approaches to treatment which differed to the one-to-one disease oriented styles so typical of adult psychiatry of those times. It is relatively recently that child psychiatric interests have come closer to the medical fold and that adult psychiatry (as well as other branches of medicine) have come to adopt community, family, team and other approaches. This conflict between the more ‘medical’ orientation of psychiatry and the less ‘medical’ orientation of child psychiatry was recognised in the Report of the Conference on Training in Child Psychiatry of 1963 where the following statement is made: “It is a conference recommendation that where possible the names of clinics should be changed to ‘psychiatric clinic for children’ or some equivalent appellation which will clearly indicate the function of today’s services in a medical framework”. Such a statement can only be the product of the recognition of the power politics involved in being a ‘nonmedical’ discipline in the control of a ‘medical’ discipline. The generally poor practical support given to child psychiatry by adult psychiatry may reside in part in the following issues: (a) The problem of clash in philosophies of care along those axes which in the past sharply differentiated the two specialties and whose residues still remain in attitudes of many adult psychiatrists. (b) The problem of a clash in the belief of a developmental basis for viewing the human condition versus the unitary phenomenological basis more typical of classical medicine. (c) The problem of learning difficulties for trainees when child psychiatry is only a service rotation and divorced from adult psychiatry.
GEORGE LIPTON
(d) Power politics in terms of territorial jealousy and the threat to generally precarious financial supports. An attempt, to appear forward looking by employing a token child psychiatrist in an ineffective and junior position with few prospects is a very poor disguise for this. (e) Problems to general psychiatric departments when there is a possibility gf training truly general psychiatrists and many of the teachers are limited to a narrower adultomorphic view of the field. This problem is often represented at psychiatric conferences where amongst several dozen topics such as schizophrenia, REM sleep, lithium etc., there is one section ‘Child Psychiatry’. It is this relegation of child psychiatry to the level of a biochemical or disease specific interest that shows the lack of recognition of the pervasive influence of the knowledge and attitudes which may be contributed to general psychiatry in all areas. This attitude in the view of the author is currently the most dangerous threat to the success of the new Royal Australian and New Zealand College of Psychiatrists training regulations.
2. IN RELATION TO SOCIETY This second area of difficulty will be touched on only briefly. I t lies in the paradoxical attitude of the society in which we live. Australians have always prided themselves on being child oriented but in fact allow the grossest forms of child neglect, abuse and maltreatment to be perpetrated with an apparent denial of what is happening. This can be seen in the relative lack of legislation granting rights to children, the paucity of funding to provide care of many sorts, the ineffective concern for supporting families at risk and the poor support for those who wish to d o so. I t finds expression in the design and management of many children’s wards and hospitals and in all the pressures which lead mothers to leave their children. It is interesting that in Victoria many more people contact the RSPCA to report maltreatment of animals than call the Children’s Protection Society regarding the maltreatment of children. The Children’s Protection Society can evidence many instances where serious child maltreatment was known to the neighbourhood who felt i t “none of their business to interfere with what someone else did to their kids”. (Sittlington, 1977). The lack of priority for child psychiatric facilities is a small part of this. That children in difficulties or at risk are a major problem in our community is supported by the most conservative figures which suggests that the prevalence of childhood disturbance requiring psychiatric care may be 10% or more. (Rutter, 1970; Rutter, 1973; Leslie, 1974; Krupinski, 1971). I . By age 1 I one in nine children have lost one or both parents. 2. 10u/oof children are born to single mothers. 3. Approximately 14°10 of families live below the poverty line.
159
4. 7-10% of children have serious chronic illness of
primarily physical origin. 5. 7 % of 3 year olds, show moderate to severe behaviour disturbances.
6 . The point prevalence of physical illness in adults is between 23-33070.
7. 10% of all persons spend some time during their life as a patient in a psychiatric hospital. (Eisen, 1977). In view of the major prevalence of children a t risk for emotional disturbance which may effect the rest of their lives it is amazing how little attention is given by the community to developing services directed to primary prophylactic emotionai care for children and their families. To the present day this is still reflected in medical school curricula where child development and emotional needs of children still rank far behind anatomy and physiology in their teaching priorities. While this is improving slowly there are few medical schools currently teaching who effectively inculcate a developmental attitude and a child perspective in their students. I t is therefore not surprising that these community attitudes are also to be seen in the general medical field, adult psychiatrists, administrators and politicians.
ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS AND GENERAL PSYCHIATRIC TRAINING Despite these criticisms important changes have taken place in this country in the last five years. The Royal Australian and New Zealand College of Psychiatrists has given a major lead and provided a unique opportunity for rapid development of training programmes to teach truly general psychiatry. By grasping the nettle and‘ increasing the training to five years, (RANZCP 1975) a step that both the USA and Canada are reluctant to do, it has made it possible to make time available to add an important developmental component to the training. I t had preceded this by establishing standards and certification for training in Child Psychiatry in order to ensure the production of specialists who will carry the brunt of this form of teaching in the early years.
On paper the provision of 20% of training time to developmental psychiatry, which must include experience in a child psychiatric department and also a special experience in general psychiatric departments, looks excellent. It would seem to meet the criteria described above. The aim of these innovations is to establish a developmental framework to all psychiatry and to teach skills which will allow the trainee to manage all patients from the general population. The major question for the next decade is ‘will it happen as intended?’. In the favour of the changes are the enthusiastic support of the College
I60
CURRENTSTATUSOF CHILD PSYCHIATRY IN AUSTRALIA
council, despite some minority dissenting voices in the College membership. Against this however is the shortage of child psychiatrists and the shortage of adequate teaching settings in terms of staff and space. The double bind, of course, is that without these teachers a developmental perspective will not be established for the general psychiatrist and recruitment to child psychiatry will remain low.
may be the insidious institutional resistance to change. Lip service can be paid to the regulations but their spirit may be lost. I f a term in child psychiatry is equated to an equivalent term on a chronic schizophrenic ward and there is no effective overflow of developmental attitudes to general psychiatry the place of child psychiatry will be institutionalised as a marginally relevant subspecialty and the College philosophy will fail to take hold.
4. Administration of specialised
children’s psychiatric
services. Thus, from a secure and fertile base, with scientific and medical credibility, the child psychiatrist will be able to collaborate with departments of adult or general psychiatry to contribute to the development of the truly general psychiatrist of the future.
A more subtle problem however
Finally, how will trainees deal with those conflicts which
may occur i f their gradually developing attitudes subtly conflict with those of their major teachers and the consultants with whom they might normally identify. In view of the past and recent history of child psychiatry, its general lack of progress in this country and its recurrent experiences with unfulfilled promises it behoves of all of us to maintain a close watching brief over the new initiative of the College to ensure its appropriate implementation.
THE FUTURE OF CHILD PSYCHIATRY A brief comment is required on the need to maintain the
discipline of child psychiatry as a specialist entity in itself. Solnit (1972) states “the co-ordination and collaboration necessary to foster the integration of child psychiatry’s contribution to the training of the general psychiatrist is more assured by the sound and balanced development of child psychiatry as a unique discipline than it is by being ensconced in a department of psychiatry”. This view is strongly endorsed by the author. The most urgent priority in the field of psychiatry in Australia is the establishment of independent University departments of child psychiatry. While the base of child psychiatry will always remain clinical and community oriented I foresee the particular role of the specialist child psychiatrist of the future to be I . Research 2. Teaching 3 . Primary, secondary and tertiary consultation
Reprint requests to: Dr. George Lipton Director of Training Joint Training Programme in Child Psychiatry 14 Powletr Street Heidelberg \’ictoria 3084
REFERENCES Bloom, S.W. (1972). The power politics of psychiatry and resistance to change, in The Integration o f Child Psychiatry into the Basic Residency Programme (Eds. Madow, Leo and Malone, Charles A . ) Townhouse Press Inc., Hillsdale, New Jersey. Cohen, R.L. (1972). Toward a redefinition of general psychiatry, in The Integration o f Child Psychiatry into the Basic Residericy Programme. (Eds. Madow, Leo and Malone, Charles A.) Townhouse Press Inc., Hillsdale, New Jersey. Eisen, P. (1977). Stress on f h e Family. Paper presented to Reproduction and Family Health (Standing) Committee of National Health and Medical Research Committee. Krupinski, J . , and Stoller, A. (1977). Health of a Metropolis. Halstead Press, Sydney. Lipton, G.L. (1977). Unpublished preliminary study of child psychiatry manpower in Australia. Revised Examination Bylaws (1976). Royal Australian and New Zealand College of Psychiatrists, Melbourne. Rutter, M., Tizard, J., and Whitmore, K . (1970). Educatioii, Health and Behaviour. Longman, London. Ruttcr, M. (1973). Why are London children so disturbed? Proceedings o f the Royal Society o f Medicine, 66: 122 1, Schechter, M. (1977). Child and General Psychiarry: A Canadian-American View. Paper presented at A.P.A. Congress, Toronto. Sittlington, W. (1977). Personal communication. Solnit, A . (1972). Integration from a position of strength, in The Integration of Child Psychiatry into the Basic Residency Programme. (Eds. Madow, Leo and Malone, Charles A.) Townhouse Press Inc., Hillsdale, New Jersey .
THE CURRENT STATUS OF CHILD PSYCHIATRY IN AUSTRALIA WITH SPECIAL REFERENCE TO TRAINING IN GENERAL PSYCHIATRY*
by GEORGE LIPTON**
There is a widely held belief and tradition in Australia that the word ‘psychiatry’, when referring to a department or a practitioner, is synonymous with ‘general psychiatry’. The importance and task of the general psychiatrist is well emphasised in the following statement. “The capacity of such a person to integrate and to provide a fundamental level of understanding of the characteristics and needs of all age groups and ali subcultures (without having to be an outstanding expert in any of them) will be indispensable.” (Cohen 1972) Unfortunately the majority of departments of psychiatry and practitioners in the field teach or provide service predominantly to the area of adult psychiatry. Professional incursions into the problems of children, families and development may be seen as deviations, albeit necessary, from the major thrust of their activities. I t may be argued that i t is the child psychiatrist, trained initially in adult psychiatry and then in child psychiatry, who most closely shows the characteristics of a general psychiatrist. This however, is not the thesis of this paper. It would be a great loss to psychiatry indeed if the child psychiatrist of today became the general psychiatrist of tomorrow. The principal tasks of this paper are threefold. 1. To examine the relationship of child psychiatry to a truly general psychiatric training.
2. To overview the state of development of child and adult psychiatry in relationship to each other in Australia today. 3. To attempt to elucidate some of the problems which lie in the way of constructive integration.
*Received 14 April 1977 *‘*Director of Training, Joint Training Programme in Child Psychiatry, Mental Health Authority, Melbourne
Two presuppositions form the philosophical basis of this paper and underlie the arguments raised therein. 1. That’a general psychiatrist should, at the least, have training in those skills which will potentially enable him to treat any member of the population. (Currently because of the general lack of effective skills for the treatment of children many adult psychiatrists are precluded from treating up to 40% of the Australian population).
2. “Psychiatry, as all specialties in medicine, stems from developmental constructs. Psychodynamic principles have always emphasised childhood experiences as causal of later life problems. Therapies based on learning theory, family interaction, Gestalt techniques etc., also point to influences of early life involvements as determining emotional and behavioural difficulties within individuals, in families and in society. Research on pre-, peri- and postnatal factors indicate that constitutional and temperamental factors evidenced at these stages immutably determine personality characteristics t h r o u g h o u t a n individual’s life cycle.. . . . . . . . . . .Indeed the only way a qualified psychiatrist can be a generalist is if the training programmes have the stamp of child development continuously resonating throughout the formal training process.” (Schechter, 1977)
CURRENT STATE OF CHILD PSYCHIATRY IN AUSTRALIA In view of these presuppositions it is interesting to examine the current position of child psychiatry vis a vis adult psychiatry in this country. There are nearly as many children and adolescents in this country as adults. However, only approximately 5-6010 of Australian psychiatrists are trained in child psychiatry and a further 5% are recognised as child psychiatrists through extensive experience in the field. The national situation is made
158
CURRENTSTATUS OFCHILI)PSYCHIATRY I N AUSTRALIA
poorer when it is recognised that over 40% of child psychiatrists reside in Victoria. (Lipton, 1977) Compared to relatively extensive networks of adult psychiatric care facilities there are desperately few child psychiatric services. The bulk of such services are understaffed to the point of marginal viability and demonstrate an inability to meet more than the most superficial of community needs. There are no academic departments of child psychiatry in Australia and no full professors in the field. There are, in Australia, currently only two occupied Associate Chairs in Child Psychiatry within Adult Psychiatry departments. A third may soon become available. When one person recently left Australia his Associate Professorial position was downgraded to a lectureship. This person left the country to take up a full Chair in the United States. He would have remained had this been available here. While child psychiatrists can be appropriately criticised for their inadequate research efforts in this country it should also be recognised that they are not granted the opportunity for experiencing the crucible of an academic department in their own specialty from within which research traditions could ferment and develop. A rare isolated position for an individual in an adult department ddes not lead to this result. Finally, because of the lack of academic opportunities, the poor service or admiriistrative career structures available to child psychiatrists, and the additional time required to train for the specialty, recruitment to the specialty is, not surprisingly, low, even when training opportunities are available. There are currently approximately 16 or 17 persons in training in the specialty throughout the country (RANZCP 1977). While this is an advance over the situation of 5 years ago it is still very inadequate and compares very poorly with general recruitment into psychiatry which has been increasing over that period.
PROBLEMS IN THE DEVELOPMENT OF CHILD PSYCHIATRY The major issue to examine is not so much the difficulty in developing child psychiatry but rather the difficulty in providing child psychiatry as part of general psychiatric training. I t is for this area, i f for no other, that a healthy development of the field is required. It is proposed that there are two major areas of difficulty which impede the development of child psychiatry, one in relation to psychiatry itself, and the second in relation to the society in which it finds itself.
1. IN RELATION TO PSYCHIATRY “Child psychiatry in the United States has developed a frame of reference and institutional means for achieving its main goals that are clearly advantageous to the community it serves. Yet, paradoxically, the field has been disadvantaged within its parent discipline of psychiatry.
The same attributes which are potentially so valuable for its goals of service have been handicaps within the value system of psychiatry. Child psychiatry has emerged as an honoured but low prestige sub-specialty, with problems of recruitment and support that are directly influenced by the power structure of psychiatry.” (Bloom, 1972). Solnit (1972) selects the year of 1909 as the crucial year of development for child psychiatry because in that year Freud’s Little Hans was published, Healy opened the first child guidance clinic in Chicago to treat delinquents, the first kibbutz in Israel was opened, the first kindergarten in USA was opened and President Roosevelt established the Children’s Bureau. However, it must be noted that not one of these events was in the context of orthodox medicine. Although in Australia the origins of the field were more medical with the establishment of the Child Psychiatric department by Dr. Williams at the Royal Children’s Hospital in the early twenties the major developments here have also tended to follow the lines so typical of the early American scene. These early roots have given child psychiatry its unique experience iti fields of community health programmes, team treatment approaches, conjoint family approaches, preventative psychiatry, interest in early socio-cultural effects of development and approaches to treatment which differed to the one-to-one disease oriented styles so typical of adult psychiatry of those times. It is relatively recently that child psychiatric interests have come closer to the medical fold and that adult psychiatry (as well as other branches of medicine) have come to adopt community, family, team and other approaches. This conflict between the more ‘medical’ orientation of psychiatry and the less ‘medical’ orientation of child psychiatry was recognised in the Report of the Conference on Training in Child Psychiatry of 1963 where the following statement is made: “It is a conference recommendation that where possible the names of clinics should be changed to ‘psychiatric clinic for children’ or some equivalent appellation which will clearly indicate the function of today’s services in a medical framework”. Such a statement can only be the product of the recognition of the power politics involved in being a ‘nonmedical’ discipline in the control of a ‘medical’ discipline. The generally poor practical support given to child psychiatry by adult psychiatry may reside in part in the following issues: (a) The problem of clash in philosophies of care along those axes which in the past sharply differentiated the two specialties and whose residues still remain in attitudes of many adult psychiatrists. (b) The problem of a clash in the belief of a developmental basis for viewing the human condition versus the unitary phenomenological basis more typical of classical medicine. (c) The problem of learning difficulties for trainees when child psychiatry is only a service rotation and divorced from adult psychiatry.
GEORGE LIPTON
(d) Power politics in terms of territorial jealousy and the threat to generally precarious financial supports. An attempt, to appear forward looking by employing a token child psychiatrist in an ineffective and junior position with few prospects is a very poor disguise for this. (e) Problems to general psychiatric departments when there is a possibility gf training truly general psychiatrists and many of the teachers are limited to a narrower adultomorphic view of the field. This problem is often represented at psychiatric conferences where amongst several dozen topics such as schizophrenia, REM sleep, lithium etc., there is one section ‘Child Psychiatry’. It is this relegation of child psychiatry to the level of a biochemical or disease specific interest that shows the lack of recognition of the pervasive influence of the knowledge and attitudes which may be contributed to general psychiatry in all areas. This attitude in the view of the author is currently the most dangerous threat to the success of the new Royal Australian and New Zealand College of Psychiatrists training regulations.
2. IN RELATION TO SOCIETY This second area of difficulty will be touched on only briefly. I t lies in the paradoxical attitude of the society in which we live. Australians have always prided themselves on being child oriented but in fact allow the grossest forms of child neglect, abuse and maltreatment to be perpetrated with an apparent denial of what is happening. This can be seen in the relative lack of legislation granting rights to children, the paucity of funding to provide care of many sorts, the ineffective concern for supporting families at risk and the poor support for those who wish to d o so. I t finds expression in the design and management of many children’s wards and hospitals and in all the pressures which lead mothers to leave their children. It is interesting that in Victoria many more people contact the RSPCA to report maltreatment of animals than call the Children’s Protection Society regarding the maltreatment of children. The Children’s Protection Society can evidence many instances where serious child maltreatment was known to the neighbourhood who felt i t “none of their business to interfere with what someone else did to their kids”. (Sittlington, 1977). The lack of priority for child psychiatric facilities is a small part of this. That children in difficulties or at risk are a major problem in our community is supported by the most conservative figures which suggests that the prevalence of childhood disturbance requiring psychiatric care may be 10% or more. (Rutter, 1970; Rutter, 1973; Leslie, 1974; Krupinski, 1971). I . By age 1 I one in nine children have lost one or both parents. 2. 10u/oof children are born to single mothers. 3. Approximately 14°10 of families live below the poverty line.
159
4. 7-10% of children have serious chronic illness of
primarily physical origin. 5. 7 % of 3 year olds, show moderate to severe behaviour disturbances.
6 . The point prevalence of physical illness in adults is between 23-33070.
7. 10% of all persons spend some time during their life as a patient in a psychiatric hospital. (Eisen, 1977). In view of the major prevalence of children a t risk for emotional disturbance which may effect the rest of their lives it is amazing how little attention is given by the community to developing services directed to primary prophylactic emotionai care for children and their families. To the present day this is still reflected in medical school curricula where child development and emotional needs of children still rank far behind anatomy and physiology in their teaching priorities. While this is improving slowly there are few medical schools currently teaching who effectively inculcate a developmental attitude and a child perspective in their students. I t is therefore not surprising that these community attitudes are also to be seen in the general medical field, adult psychiatrists, administrators and politicians.
ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS AND GENERAL PSYCHIATRIC TRAINING Despite these criticisms important changes have taken place in this country in the last five years. The Royal Australian and New Zealand College of Psychiatrists has given a major lead and provided a unique opportunity for rapid development of training programmes to teach truly general psychiatry. By grasping the nettle and‘ increasing the training to five years, (RANZCP 1975) a step that both the USA and Canada are reluctant to do, it has made it possible to make time available to add an important developmental component to the training. I t had preceded this by establishing standards and certification for training in Child Psychiatry in order to ensure the production of specialists who will carry the brunt of this form of teaching in the early years.
On paper the provision of 20% of training time to developmental psychiatry, which must include experience in a child psychiatric department and also a special experience in general psychiatric departments, looks excellent. It would seem to meet the criteria described above. The aim of these innovations is to establish a developmental framework to all psychiatry and to teach skills which will allow the trainee to manage all patients from the general population. The major question for the next decade is ‘will it happen as intended?’. In the favour of the changes are the enthusiastic support of the College
I60
CURRENTSTATUSOF CHILD PSYCHIATRY IN AUSTRALIA
council, despite some minority dissenting voices in the College membership. Against this however is the shortage of child psychiatrists and the shortage of adequate teaching settings in terms of staff and space. The double bind, of course, is that without these teachers a developmental perspective will not be established for the general psychiatrist and recruitment to child psychiatry will remain low.
may be the insidious institutional resistance to change. Lip service can be paid to the regulations but their spirit may be lost. I f a term in child psychiatry is equated to an equivalent term on a chronic schizophrenic ward and there is no effective overflow of developmental attitudes to general psychiatry the place of child psychiatry will be institutionalised as a marginally relevant subspecialty and the College philosophy will fail to take hold.
4. Administration of specialised
children’s psychiatric
services. Thus, from a secure and fertile base, with scientific and medical credibility, the child psychiatrist will be able to collaborate with departments of adult or general psychiatry to contribute to the development of the truly general psychiatrist of the future.
A more subtle problem however
Finally, how will trainees deal with those conflicts which
may occur i f their gradually developing attitudes subtly conflict with those of their major teachers and the consultants with whom they might normally identify. In view of the past and recent history of child psychiatry, its general lack of progress in this country and its recurrent experiences with unfulfilled promises it behoves of all of us to maintain a close watching brief over the new initiative of the College to ensure its appropriate implementation.
THE FUTURE OF CHILD PSYCHIATRY A brief comment is required on the need to maintain the
discipline of child psychiatry as a specialist entity in itself. Solnit (1972) states “the co-ordination and collaboration necessary to foster the integration of child psychiatry’s contribution to the training of the general psychiatrist is more assured by the sound and balanced development of child psychiatry as a unique discipline than it is by being ensconced in a department of psychiatry”. This view is strongly endorsed by the author. The most urgent priority in the field of psychiatry in Australia is the establishment of independent University departments of child psychiatry. While the base of child psychiatry will always remain clinical and community oriented I foresee the particular role of the specialist child psychiatrist of the future to be I . Research 2. Teaching 3 . Primary, secondary and tertiary consultation
Reprint requests to: Dr. George Lipton Director of Training Joint Training Programme in Child Psychiatry 14 Powletr Street Heidelberg \’ictoria 3084
REFERENCES Bloom, S.W. (1972). The power politics of psychiatry and resistance to change, in The Integration o f Child Psychiatry into the Basic Residency Programme (Eds. Madow, Leo and Malone, Charles A . ) Townhouse Press Inc., Hillsdale, New Jersey. Cohen, R.L. (1972). Toward a redefinition of general psychiatry, in The Integration o f Child Psychiatry into the Basic Residericy Programme. (Eds. Madow, Leo and Malone, Charles A.) Townhouse Press Inc., Hillsdale, New Jersey. Eisen, P. (1977). Stress on f h e Family. Paper presented to Reproduction and Family Health (Standing) Committee of National Health and Medical Research Committee. Krupinski, J . , and Stoller, A. (1977). Health of a Metropolis. Halstead Press, Sydney. Lipton, G.L. (1977). Unpublished preliminary study of child psychiatry manpower in Australia. Revised Examination Bylaws (1976). Royal Australian and New Zealand College of Psychiatrists, Melbourne. Rutter, M., Tizard, J., and Whitmore, K . (1970). Educatioii, Health and Behaviour. Longman, London. Ruttcr, M. (1973). Why are London children so disturbed? Proceedings o f the Royal Society o f Medicine, 66: 122 1, Schechter, M. (1977). Child and General Psychiarry: A Canadian-American View. Paper presented at A.P.A. Congress, Toronto. Sittlington, W. (1977). Personal communication. Solnit, A . (1972). Integration from a position of strength, in The Integration of Child Psychiatry into the Basic Residency Programme. (Eds. Madow, Leo and Malone, Charles A.) Townhouse Press Inc., Hillsdale, New Jersey .
