Original Article : Who Needs Child Psychiatrists ?

Who Needs Child Psychiatrists ? Robert Goodman

Do chi^^ mental health services need doctors? If so, what should their training and role be? There are persuasive reasons for child mental health services needing some doctors, though not so many that they end up being employed for tasks that could equally well be done by non-medical personnel. A t a minimum, doctors could be employed only for the purely medical aspects of assessment and treatment. Alternatively, a rather larger number of doctors could be employed as dual-trained specialists in both medical and psychological approaches. Different models of service delivery should be compared in formal trials. Without a radical shift in training, child psychiatry could become extinct, being replaced by n eurobe ha vio ural paedia trics.

Keywords: Child mental health; medical role; child psychiatry; paediatrics

Introduction

As a medical student I could never understand how an expensive medical training prepared child psychiatrists for the sort of work that occupied nearly all of their time. As an honorary consultant in child psychiatry some two decades Iater, I still cannot see much sense in the way doctors are deployed in child mental health services. Two factors have finally persuaded me to write about this issue, even though it may lay me open to accusations of disruptiveness or disloyalty to my colleagues and pro- fession. First, I think that it is an academic’s job to question the established wisdom of the day; someone needs to keep asking about the emperor’s new and old clothes--even if it is usually the questioner and not the emperor who ends up feeling foolish. I hope that ques- tioning the current organisation of children’s services will contribute to a productive debate within our disciplines that will ultimately result in more effective help for troubled children. Second, I feel increasingly guilty about training junior psychiatrists for a job that does not seem to me to have much of a future. I believe that existing child psychiatric trainings are obsolete, preparing trainees for NHS jobs that will disappear during their working lives, leaving them to retire early, retrain, move into private practice, or transfer to Social Services or Education. If trainees knowingly take this risk, that is their business; if I fail to alert them to the risk, that is mine. Before

considering what role doctors should play within child mental health services, I shall allude briefly to two issues relating to the scope of the overall service. What sorts of children should we be seeing? What sorts of treatments should we be providing?

What sorts of children should mental health services be seeing?

The remit of child mental health is currently drawn extremely widely-so widely that somewhere between 15 % and 50 % of children are identified as having mental health problems (Bird et al., 1988; Brandenburg, Fried- man & Silver, 1990), though it is only a tiny proportion of these troubled children who are seen by mental health professionals. 1 have argued elsewhere that classifying all varieties of childhood maladjustment and distress as mental health problems is inappropriate empire building, medicalising social and educational problems that need social and educational solutions (Goodman, in press). Accepting that there is no recognisable health component to most maladjustment and distress would free us up to concentrate on the minority of troubled children who do need the sort of input that mental health professionals are uniquely able to provide. At present our services haem- orrhage into general child welfare work as we vainly

Robert Goodmati

Reader in Brain and

Behavioural Medicine.

Depanment of Child

and Adolescent

Psychiatry, Institute of

Psychiatry, de

Crespigny Park, London

SE5 8AF

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Child Psvchulugl & Psychiatrj Review Volume 2, No 1. 1997 15

Original Article : Who Needs Child Psychiatrists?

attempt to plug the gaps left by Education or Social Services cuts--to the detriment of children with ’core’ mental health needs. If these arguments have any validity. the next generation of child psychiatrists may well find themselves working in a mental health service that has a more restricted focus, playing a much smaller part in the assessment and treatment of abused children and children v.ith conduct disorders. but playing a more active role in identifying and treating children with ’core‘ health prob- lems such as hyperkinesis, anorexia nervosa. autism. schizophrenia or obsessive-compulsive disorder.

What treatments should child mental health services be providing?

Though I am unsure whether the child mental health services of the future will adopt a more restricted remit. I have no doubt that they will increasingly concentrate on treatments of proven efficacy. The new emphasis on evidence-based health provision has much to be said for it. We should not practise in a way that does more harm than good (or practise recklessly. not knowing whether we are doing more harm than good). In the past we have tacitly assumed that some treatment approaches are so ‘self- evidently‘ beneficial that the burden of proof should be on their opponents. not their proponents. The evidence that intuitively appealing social and psychological inter- ventions may turn out to be worse than nothing should force us to think again (McCord, 1992). So should the evidence that most psychotherapy for children admin- istered in everyday clinical settings is ineffective or of low efficacy (Weisz et al., 1995), or that tricyclic antidepres- sants may be ineffective for depressed children and adolescents (Hazel1 et al.. 1995). My own view is that we havc a mor:il duty to disclose to each family (and their referrer) whether the treatment we propose is of proven efficacy. and whether there is any alternative treatment approach that has been shown to be of greater efficacy. When there is no proven treatment. I believe it should be left up to the family to decide whether to accept the offer of an unproven treatment or do nothing. Other things being equal. we should strive to avoid wasting resources on treatments of low efficacy or high cost if those resources could have been diverted into more effective or less costly treatments. Though most therapy trials in child mental health have still to be done, early findings suggest that future services will be providing more by way of cognitive- behavioural therapy, medication and dietary treatment, and less by way of family therapy and psychodynamic psychotherapy.

What role should doctors pla y?

Bearing in mind these possible changes, I shall now focus on the question: What role should doctors play within child mental health services? Though there are many possible answers, 1 believe that they can be reduced to

Table 1. The role of doctors

Question: What role should doctors play in child mental health services?

Answer: 1. No role

2. A purely medical

3. A role as dual-train ialists in medical and psychological approaches

combinations and hybrids of the four ‘primary’ answers shown in Table 1. I shall discuss each in turn.

1. Docfors have no role Visitors to some community child mental health clinics might be forgiven if they concluded that doctors had no role there. On a typical day the visitors might see no medication prescribed, n o medical investigations (such as EEGs or brain scans) requested or interpreted, and no previously unrecognised physical disorders (such as epi- lepsy or a neurocutaneous syndrome) diagnosed or even discussed. Where, then, is the need for someone with a medical training? Plausible though this line of reasoning is, I d o believe that there is indeed a need for medical input; that the need would be more obvious if health provision concentrated on ‘core’ health problems rather than on propping up inadequate services for social and educational problems; and that the need is growing because of the advances in psychopharmacology, clinical neuroscience and genetics. Doctors already have essential roles to play in assessment and treatment that could not readily be taken over by any other disciplines within a child mental health team.

Physical disorders d o sometimes first present with psycho- logical symptoms. Textbooks of paediatric neurology are replete with examples of important diagnoses that are easily missed by child mental health teams. The following two quotations from one textbook are representative of many (Brett, 1991). In adrenal leucodystrophy ‘ a child- hood psychosis may be suspected and the unhappy child and his parents may be referred to a psychiatrist. Months or years of psychiatric treatment.. . may follow, until deteriorating school performance or other evidence .. . force recognition of the organic nature of the disease’ (p. 168). For several neurological disorders in childhood, psychiatric referral may lead to ‘resultant delay in the

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Original Article: Who Needs Child Psychiatrists?

correct diagnosis, since the psychiatric tabei lessens the chances of underlying organic disease being considered ’ (p. 192). At worst, delayed diagnosis may worsen the child’s prognosis or prevent the family from getting genetic counselling before the arrival of a similarly affected sibling.

Requesting and interpreting medical investigations is likely to become increasingly important as knowledge of genetic, chromosomal and brain scan abnormalities grows. This will apply not only to the sorts of neurological disorders just discussed but also to ‘primary’ psychiatric disorders such as obsessive-compulsive disorder.

Finally, doctors are needed to prescribe and monitor medication. Unfortunately, many British child psychia- trists currently seem averse to medication, perhaps on principle. This is particularly evident in the case of hyperkinesis, with most hyperkinetic children in Britain being deprived of the opportunity to see if medication could help (Taylor et al., 1991). It is no excuse that doctors elsewhere over-prescribe medication; we need to get the balance right rather than go to the opposite extreme.

2. Doctors have a purely medical role For the reasons just discussed, no child mental health service should have to operate without any medical input. At a minimum, therefore, doctors are needed for the purely medical aspects of assessment and treatment. This is a relatively small role and even a busy clinic would probably only need a few sessions of medical time provided the psychological assessments and treatments were all carried out by non-medical personnel--clinical psychologists, psychotherapists, family therapists, etc. Though many child psychiatrists will feel horrified by this suggestion, a similarly restricted role for doctors seems to work satisfactorily in the treatment of children with cerebral palsy. Physiotherapists, speech therapists and occupational therapists provide most of the regular health service input to children with cerebral palsy. Paedi- atricians and paediatric neurologists are involved in the initial assessment and investigation; in periodic reviews ; and in the initiation and monitoring of medication if appropriate, e.g. for associated epilepsy.

Paediatricians do not seem to need to have been trained as physiotherapists in order to work successfully with physio- therapists. indeed, it is possible that reciprocal special- isation fosters mutual dependency and good team work. It seems doubtful, therefore, that the doctors working in child mental health settings need to be extensively trained in ‘ psychological ’ techniques in order to work successfully with colleagues from ‘psychological’ disciplines.

I should stress that I am not suggesting that doctors anywhere-whether in a clinic for children with cerebral palsy or a clinic for children with hyperkinesis-should behave as if they were simply biomedical technicians. Medicine is an art as well as a science, and the art of

medicine involves social and psychological skills that can and should be cultivated-but this applies to most medical specialities; learning the art of medicine is not the same as training in particular psychological treatment modalities such as psychodynamic psychotherapy.

A child mental health service that wanted to use doctors in a purely medical role would not necessarily choose to employ child psychiatrists. Community or hospital paedi- atricians would be able to take on many of the medical tasks, including advising non-medical staff about the implications of coexistent paediatric disorders, screening children for unrecognised organic disorders and initiating and monitoring medication for hyperkinesis. Tasks that were less closely allied to paediatrics-such as diagnosing and treating adolescents with schizophrenic or bipolar psychoses--could be entrusted to general psychiatrists with an interest in younger patients. Services along these lines already exist in some areas of Britain, often because it has proved impossible to recruit a suitable child psychiatrist. Such services could usefully be compared with more traditional child psychiatric services in formal trials.

3. Doctors are needed with dual medical and psychological training Relatively few doctors would be needed in the child mental health services if they restricted their activities to purely medical tasks. Do considerations of effectiveness or cost-effectiveness provide any grounds for favouring a less restricted role for doctors? I think there is indeed a strong prima facie case for doctors who are ‘dual trained’ in medicine and at least one of the psychological ap- proaches: behavioural therapy, cognitive therapy, psycho- dynamic psychotherapy or family therapy. There are likely to be advantages in having a single person who can deploy both medical and psychological expertise in the assessment and treatment of children with complex problems. In the treatment of hyperkinesis, for example, a dual-trained doctor who monitors medication and pro- vides informed behavioural advice may provide a better service (and a ‘better buy’ for the health service) than the combination of a paediatrician to monitor medication and a clinical psychologist to advise on behaviour. Having all the treatment administered by a single individual is potentially more efficient in many ways, avoiding the need to enquire twice about recent changes, and dispensing with the need for extra meetings to coordinate different treatments.

Employing dual-trained doctors could have disadvantages too. There is some risk that a dual or multiple training could generate a jack of all trades and master of none. In addition, a combined medical and psychological approach may only be needed on some occasions. To return to the previous example, if a hyperkinetic child came each month to the clinic for a review of medication and behavioural therapy, the benefit of seeing a dual-trained doctor would be present on each occasion. But what if medication only

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Origina f Articie: Who Needs Cbiid Psychiatrists?

needed reviewing every 6 months but behaviour therapy needed reviewing every month? For the 6-monthly visits. the dual-trained doctor would be combining medical and psychological roles in a cost-effective way; for the inter- vening monthly visits. however. the dual-trained doctor would be providing the same service as a clinical psy- chologist but at greater cost. Different modes of service delivery-using or avoiding dual-trained doctors-need to be compared systematically to establish what works best in which circumstances.

4 T h e is CI need,for doctors retrained in ps~~chological

Some doctors are happy to leave practically all of their medical training behind them and concentrate almost exclusively on psychological approaches to assessment and treatment. In effect. these doctors are retrained rather than dual trained. 1 would consider a child psychiatrist to haLe retrained as a family therapist, for example, if he or she subsequently looked after a very similar clinical load to a non-medical family therapist and never (or almost never) made use of specifically medical expertise in assessment or treatment. This does not necessarily render the medical training entirely valueless: simply by virtue of being a doctor. the therapist may be invested with greater authority or healing power by patients. fellow doctors and other agencies. Despite these possible benefits. however. retraining will often be an unattractive option from the health economist's point of view: not only has money been spent on a medical training that was largely or entirely unnecessary but the doctor who has rttrained is on a substantially higher salary scale than non-medical family therapists providing a comparable service. Similar arguments apply to doctors who have retrained as psychodynamic. behavioural or cognitive therapists. Aithough I would be totally opposed to trying to prevent doctors from retraining as psychological therapists if they found that medicine was not for them. a time may come within the working lifetime of the current generation of trainees when retrained doctors take on the salary scale of their new profession.

i lJ )I )V(I(I rhP.5

The distinction that 1 am drawing between dual training and retraining may be clarified by an analog). Maxillo- facial surgeons are dual trained in medicine and dentistry. The rationale for this lengthy dual training is that i t enables the specialist to do things that neither a 'pure' dentist nor a 'pure' doctor could do. Naturally enough. niauillofacial surgeons do not spend their timc crowning teeth or replacing fillings: if they spent all or nearly all of their time on ordinary dental work, there would be good reason to pay them as dentists and little reabon to pay theni as doctors even though they had completed a medical training,

Does child psychiatry have a future?

For the reasons given earlier. I think we should reject two of the four 'primary' answers to the question: What role should doctors play in child mental health services? At

one extreme, it would be a mistake to have no medical involvement a t all : important physical diagnoses would be missed ; the aetiological role of neurological and other biological factors would be harder to evaluate; and children would be deprived of effective medical treat- ments.

At the other extreme, a poorly resourced service can ill afford to employ doctors who have been retrained in psychological approaches and hardly ever employ a medical approach; the same job could be done more economically by non-medical personnel. Considerations of equity are also relevant: when the child mental health services in some areas are unable to fill their medical posts because of a national shortage of suitable candidates, it is surely inequitable for the child mental health services in other areas to be employing more doctors than they need (even if they can afford it). Nor can this shortage of suitable doctors easily be solved by increasing the number of training posts since, anecdotally a t least, there is widespread difficulty in recruiting trainees of a suitable calibre.

The remaining two 'primary' answers could both form the basis for effective and cost-effective services. If doctors within child mental health services restricted themselves to purely medical activities, relatively few such doctors would be needed-and some or all of them could potentially be drawn from paediatrics or general psychiatry rather than from child psychiatry. More doctors would be needed if they were dual trained and deployed a combination of psychological and medical techniques in assessment and treatment. Child psychiatrists are the obvious candidates for this extended role, though behavioural paediatricians also need to be considered.

My guess is that child mental health services could work well with either purely medical doctors or dual-trained doctors. Perhaps one model would work better for some disorders but not for others. Guesswork can only take us so far, however, and we badly need relevant empirical evidence to guide decisions that could affect the lives of tens of thousands of children as well as hundreds of professionals-and cost o r save millions of pounds per year. I would like to see head-to-head comparisons of different models of service delivery, including different ways of using doctors, with multiple outcome measures covering effectiveness, patient satisfaction, professional satisfaction and cost.

If we d o not reflect on our effectiveness and costliness, others will. Pretending that all is well and continuing with our traditional ways of working will only succeed in wasting our last chance to put our own house in order before changes are imposed on us from the outside. The coming crisis will not go away just because we refuse to facc it but if we d o facc it now, wc may yet bc ablc to turn the impending crisis into an opportunity. Until recently there has been little genuinely medical information bearing on the assessment and treatment of troubled children.

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Original Article: Who Needs Child Psychiatrists?

Advances in neurobiology, genetics and psychopharma- cology are just beginning to change that-and the pace is hotting up. There will be a growing need for doctors who can harness this new knowledge to the assessment and treatment of children with mental health problems. Having been a medical lightweight for so many decades, it would be a shame if child psychiatry foundered just at the point when it could have come into its own.

Implications for training

If my predictions are accurate, child psychiatry will only survive if the next generation of trainees have a very different training from their predecessors. The emphasis of the new training would need to be on organic disorders, biological determinants of behaviour and psychopharma- cology. Some paediatric experience, including exposure to paediatric neurology, should probably be mandatory. Most trainees would need to acquire some expertise in a range of psychological therapies, partly to use them in conjunction with medical therapies if working single- handed, and partly to gain a better appreciation of what non-medical therapists can and cannot do. General child welfare work should no longer be emphasised. Though the child psychiatrists of the future would concentrate on assessing and treating ‘core’ mental health problems, they would still need to know about the whole range of childhood maladjustment and distress, including conduct disorder and child abuse, in order to be prepared for situations where medical, social and educational factors interact, mimic one another or need to be treated in conjunction.

Without a radical shift in training, I predict that child psychiatrists will become extinct as their old niches disappear and a new breed of neurobehavioural paedi- atricians proves better adapted to the new niches. Opin- ions will differ as to whether this would be a change for the better or the worse. Personally, 1 hope for a discipline that is equally paediatric and psychiatric rather than exclus- ively paediatric or psychiatric.

Conclusion

At present, doctors are often employed in child mental health services for tasks that do not require a medical training. This is undesirable for three reasons. First, there are many children who really would benefit from medical assessment or treatment of their mental health problems,

but who do not get that help because child psychiatrists have been diverted into non-medical tasks. Second, there is a national shortage of child psychiatrists, plus wide- spread difficulty in recruiting trainees of a suitable calibre; the shortfall might disappear if child psychiatrists could be used more sparingly by employing them only for tasks that needed a medical training (as well as, or instead of, a psychological training). Third, since doctors are par- ticularly expensive to train and employ, it is a waste of scarce resources to employ a doctor to do tasks that could equally well be done by non-medical personnel. Child psychiatric training and deployment need to change radically if child psychiatry is to survive in a health service demanding effectiveness and value for money.

References

Bird, H.B., Canino, G., Rubio-Stipec, M., Gould, M.S., Ribera, J., Sesman, M., Woodbury, M., Huertas-Goldman, S., Pagan, A., Sanchez-Lacay, A. & Moscosco, M. (1988). Esti- mates of the prevalence of childhood maladjustment in a com- munity survey in Puerto Rico. Archives of General Psychiatry, 45, 112&1126.

Brandenburg, N.A., Friedman, R.M. & Silver, S.E. (1990). The epidemiology of childhood psychiatric disorders : Preva- lence findings from recent studies. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 7 6 8 3 .

Brett, E.M. (1991). Paediatric neurology (2nd edn.). Edinburgh: Churchill Livingstone.

Goodman, R. (in press). Child mental health: An overextended

Hazell, P., O’Connell, D., Heathcote, D., Robertson, J. & Henry, D. (1995). Efficacy of tricyclic drugs in treating child and adolescent depression : A meta-analysis. British Medical Journal, 310, 897-90 1.

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Taylor, E., Sandberg, S., Thorley, G. & Giles, S. (1991). The epidemiology of childhood hyperactivity. Institute of Psychi- atry: Maudsley Monographs, 33. Oxford : Oxford University Press.

Weisz, J.R. , Donenberg, G.R., Han, S.S. & Kauneckis, D. (1 995). Child and adolescent psychotherapy outcomes in experiments versus clinics: Why the disparity? Journal of

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