John E. Schowalter, MD

The four articles comprising this special report describe approaches to care that vary from the first session with an individual patient to the conceptualization of a mental health care delivery system for patients in primary care.

The number of child and adolescent psychiatric patients has increased greatly during the past generation. This is due to multiple reasons: better understanding of developmental psychopathology; better case-finding; and a real increase in illness. There are not enough child and adolescent psychiatrists to provide the necessary care. To this end, although the concept of training primary care clinicians to expand their provision of basic mental health care is not new, John V. Campo, M.D.'s, chronic care model, supplemented by a cadre of clinical researchers to test its effectiveness, is very exciting indeed.

I have been startled at times when, toward the end of long-term psychotherapy with an adolescent, they give a detailed and often accurate account and critique of our first session together. Richard David Brand, M.D., provides a lovely description of how one experienced clinician, with one type of practice, approaches an encounter that will set the tone for whether or not treatment begins and, if so, in what emotional atmosphere. Of course, the patient's developmental stage, type of psychopathology, support system and other variables prohibit the possibility of a cookie-cutter template for all adolescents; nonetheless, it is rare to find teachers with a fine eye for detail and the chutzpah to cite chapter and verse of specific interactions that work for them.

The article by Leo Bastiaens, M.D., focuses on the well-known problem of polypharmacy in the long-term care of treatment-resistant children. Although the issue is targeted from a residential care perspective, the excellent questions posed in the concluding paragraph are relevant for all patients who go through multiple clinicians. During my 27 years as a residency training director, I noticed that there was no end of pressures to add requirements to the curriculum, while it was almost impossible to drop a requirement. We see the same mind-set in the pressures to add, but not subtract, medications for patients who are not doing well. Because we have virtually no understanding of how multiple medications interact with one another, this practice requires change. I never maintain a previously prescribed medication unless I am willing to write a note that I am convinced of its efficacy based on personal findings or personally vetted data from others.

Finally, Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannario, Ph.D., describe a type of cognitive-behavioral therapy for sexually abused children that has been used for fewer than 10 years. Given the difficulties in treating this important population, this article provides a new approach that is being carefully studied and critiqued.

extends a warm thank you to Dr. Schowalter for his assistance in planning and reviewing this special report. Dr. Schowalter is the Albert J. Solnit Professor Emeritus and senior research scientist at the Yale University Child Study Center.

Articles

With the increase in child and adolescent patients comes an increase in challenging cases. Dr. Schowalter introduces this Child and Adolescent Psychiatry Special Report and provides perspective on articles discussing approaches to initiating care with a teen-ager, collaborating with pediatricians and other clinical topics.

Advances and Achievements

Next month in Miami, the American Academy of Child and Adolescent Psychiatry will hold its 50th anniversary meeting. In recognition of this event, the following is a brief history of the organization and of this subspecialty (Schowalter, 2000, 1994).

Most historians of child psychiatry date its beginning in this country to 1899, when Illinois established the nation's first juvenile court in Chicago. This occurrence set forth the following sequence of events. A group of influential, socially concerned women on the board of directors of Jane Addam's Hull House was shocked by juvenile delinquency. They wanted to understand its origin, prevention and treatment. These women were approximately 90 years ahead of the Centers for Disease Control and Prevention's decision to accept violence as a public health problem. In 1909, these foresighted women created the Juvenile Psychopathic Institute and hired a neurologist, William Healy, M.D., to be its first director. Although a neurologist interested in studying the delinquents' brain functioning and IQ, the perspective of the settlement house's board of directors made sure that attention also was paid to the delinquents' social factors, attitudes and motivations. To accomplish these broad evaluations and treatment strategies, Healy formed teams composed of a neuropsychiatrist, a psychologist and a social worker. This approach became the template used by most child guidance clinics for most of the 20th century. Child psychiatry's roots became implanted in the community, rather than in medical schools, and colleagues were more likely to be teachers, judges, social workers and social scientists, rather than physicians. 

Child guidance clinics blossomed in essentially all U.S. cities during the next two generations. The influence of European child psychoanalysts such as Hermine Hug-Hellmuth, Anna Freud and Melanie Klein became pervasive in this country. In the 1920s, Americans went abroad to study, and during the 1930s and 1940s, many psychoanalytically minded clinicians immigrated to the United States to escape religious persecution. Many, if not most, of these clinicians were women.

At the edges of the dominant psychodynamic and psychosocial viewpoints were organic psychiatry and behaviorism. Organic, or biologic, psychiatry was widely considered a failed pathway espoused by forgotten old men near retirement age. Behaviorism became popular in academic psychology, with John Watson and B.F. Skinner being articulate advocates. However, translations of strict academic behavioral paradigms to clinical use mainly failed. The majority of clinicians believed the behaviorists were so narrow and dogmatic that the "whole child" was lost. Anna Freud's 

, first published in German in 1936 and in English in 1946, and the first edition of 

 by Leo Kanner, M.D., in 1935 were very influential. Kanner took the name from the German term 

While it might seem curious, World War II helped child psychiatry in a number of ways. Because of the huge military draft, background histories were available for hundreds of thousands of late adolescents and young adults with varied backgrounds and socioeconomic levels--rich, poor, white, African-American, educated, uneducated, urbanite and farmer. By the end of the war, it was obvious that soldiers who had behavior problems as children were much more likely to be prematurely discharged, disciplined, wounded or killed. It was a statistic that could not be ignored. 

On July 3, 1946, President Harry Truman declared war on mental illness when he signed the National Mental Health Act. Three years later, the National Institute of Mental Health was born. Prevention was an important goal and the quality of mothering was considered key. Women's magazines cropped up like mushrooms. If mothers failed, professionals were needed to be available to intervene. A cadre of experts was building. Increasing numbers of trained psychiatrists spilled over into a greater number of child psychiatrists. At the same time, many pediatricians found that the new antibiotics made their specialty consist largely of well child care. Some found this boring. Federal training funding became available to convert pediatricians into pediatric psychiatrists.

The American Academy of Child Psychiatry was founded in 1953. It was preceded by two organizations interested in children's mental health. One such organization, the American Orthopsychiatric Association (AOA), was formed in 1924. It was multidisciplinary, and its main focus was prevention. Politically, members often leaned to the left and tended to view diagnoses as hurtful labels. In 1948, 54 child guidance clinics created an organization of clinics. The foci of this group, the American Association of Psychiatric Clinics for Children (AAPCC), were to develop standards for clinical care and for training. Before child psychiatry residencies, the gold standard credential for child psychiatry was an AAPCC certificate of training.

The movement toward subspecialization picked up speed in 1943 when the American Psychiatric Association converted its section on Mental Deficiency to the Section on Child Psychiatry. Six years later, the Section was elevated in status to the Standing Committee on Child Psychiatry. In 1947, the Group for the Advancement of Psychiatry appointed a Committee on Child Psychiatry. In 1951, the presidents of AAPCC and AOA--George Gardner, M.D., and James Cunningham, M.D.--called together 17 psychiatrists who worked with children to discuss the formation of a separate organization for child psychiatrists. The following year, 96 psychiatrists met in Atlantic City, N.J. They agreed to form the American Academy of Child Psychiatry (AACP) and have membership by invitation only. There were 107 charter members. Subsequent members were required to have three member sponsors and American Board of Psychiatry and Neurology (ABPN) certification. Members applying were also required to have made an "outstanding contribution to the field of child psychiatry," as reflected by unanimous approval by the AACP Council and a two-thirds majority of the members. (The requirements have changed; for more information, please visit <www.aacap.org/membership/joinaacap.htm>.)

In 1948, Frederick Allen, M.D., proposed that child psychiatry be recognized by the ABPN; however, nothing came of his proposal. Although some child psychiatrists favored an autonomous specialty, similar to pediatrics' break from internal medicine, this did not seem feasible. There was some debate as to whether the new specialty would be pediatric psychiatry or child psychiatry, but a vote by AAPCC clinic directors overwhelming favored a link to psychiatry rather than to pediatrics. 

In 1958, six child psychiatrists met with the ABPN's president and secretary to discuss the possible particulars for a new psychiatric discipline. There was agreement on a two-year child psychiatry residency, with the option to replace the third year of general psychiatry residency with the first year of child psychiatry training. The subspecialty was approved in February 1959. As a result, a six-person ABPN Committee on Certification in Child Psychiatry was formed. The American Board of Pediatrics (ABP), through the American Board of Medical Specialties, demanded that there always be an ABP non-voting observer on the committee to ensure that the ABPN treated child psychiatry right, and an ABP observer remains today. About 160 clinicians were grandfathered into the subspecialty. 

The first certifying exam was in the form of essay questions. The committee found them impossible to grade, so it announced there would be a follow-up oral examination. There are those today who are still hot with anger about first missing the cut to be grandfathered, then taking the essay exam, and then being forced to take a not previously announced oral exam. Nonetheless, in April 1960, 101 candidates passed the first child psychiatry boards. Also in 1960, the Accreditation Council for Graduate Medical Education's Residency Review Committee (RRC) in Psychiatry approved 11 child psychiatry residency programs. The stipulation that child psychiatry residencies must be linked to psychiatry residencies and that these must be linked to medical centers was an occurrence of extreme importance. It forced child psychiatry, sometimes kicking and screaming, from community child guidance centers to hospitals and medical schools. In my opinion, this saved child psychiatry from being marginalized. If it had not been pulled into medicine, it would have been replaced by a new iteration born in medicine.

During the 1960s, the AACP struggled with its identity. 

The Journal of the American Academy of Child Psychiatry

 was launched in 1962, granting the field its own publication. However, as more and more clinicians were trained and certified, they wanted to have an organization of their own. Regional organizations formed, and there was the beginning of a push for an open, not invitation-only, national association. The AACP, after much debate and a 176-11 vote, opened its organization in 1969 to include members on the basis of their practice and training in child psychiatry (Bemman, 1970). That year, its membership tripled from 218 to 688.

Although leadership of the American Psychiatric Association was ambivalent about this somewhat unexpected "child," in 1969, then Medical Director Walter Barton, M.D., offered rental space in the APA building, and eight file drawers of records were moved in. In 1973, Virginia Anthony was hired and she remains the academy's executive director. In 1983, the academy published 

Child Psychiatry: A Plan for the Coming Decades

. It was the summary of five years' work by 100 consultants to, and members of, six task forces. These were not only child psychiatrists, but also included nationally known general psychiatrists; pediatricians; deans; professors of epidemiology, nursing, psychology and law; leaders of the NIMH; and various child advocates. Recommendations were made for man power, clinical service delivery and training; the most important recommendation, however, was the challenge to develop research strategies that would allow data-based understanding and treatment of the mental illnesses of children. While child psychiatry had long gathered anecdotal data, particularly about social and psychodynamic influences, it was 10 years behind general psychiatry in biological and epidemiological research. Indeed, this document changed the field.

In the past 20 years, there has been a steady increase in residents who choose child psychiatry, and academy membership now numbers almost 7,000. In 1986, the academy voted to expand its name to the American Academy of Child and Adolescent Psychiatry and within a few years, this expansion was approved by the ABPN and the Psychiatry RRC.

Besides its journal, the AACAP has published books, both for professionals and the laity, approximately 50 policy statements and over 200 "Facts for Families." The latter are available to families and are printed in English, French, Spanish, German, Polish and Icelandic. The AACAP collaborates closely with the APA, the American Academy of Pediatrics and other organizations in regard to clinical, policy and research issues. During the past decade, the academy was awarded funding from both the NIMH and the National Institute on Drug Abuse to oversee five-year K-12 training grants for young investigators in child and adolescent psychiatry.

During the past 50 years, evolving interest in and understanding of developmental psychopathology have shown how intertwined developmental stages are for patients' diagnosis and treatment. In the decades to come, genetics, neuroimaging and other new techniques will not only affect our work with children, but also determine the type and number of professional organizations that will be needed to treat children and adolescents with mental illnesses.

AACP (1983), Child Psychiatry: A Plan for the Coming Decades. Washington, D.C.: American Academy of Child Psychiatry.
 

Bemman S (1970), Epilogue and a new beginning. J Am Acad Child Psychiatry 9(2):193-201.
 

Freud A (1946), The Ego and the Mechanisms of Defense. New York: International Universities Press Inc.
 

Kanner L (1935), Child Psychiatry. Springfield, Ill.: C. C. Thomas.
 

Schowalter JE (1994), The History of Child and Adolescent Psychiatry. In: Psychiatry, vol. 2, Michels R, Cooper A, Guze S et al., eds. Philadelphia: JB Lippincott, pp1-13.
 

Schowalter JE (2000), Child and Adolescent Psychiatry Comes of Age. In: American Psychiatry After World War II (1944-1994), Menninger R, Nemiah J, eds. Washington, D.C.: American Psychiatric Press, pp461-480.

The American Academy of Child & Adolescent Psychiatry will hold its 50th anniversary meeting in October, but the field can trace its U.S. origins to Chicago in 1899. Learn how the specialty has developed over the years in this historical essay.

A History of Child and Adolescent Psychiatry in the United States

Clinicians who work with children face particular ethical issues, but they are not exempted from the general ethical considerations that face all mental health clinicians.

Almost always, psychiatric treatment for minors is initiated not by the patient, but through the pressure of others. In most instances, the pressure is from parents, physicians, school personnel and/or legal authorities. Since child psychiatric patients are especially vulnerable to coercion by others, their clinicians must be particularly careful to know their own ethical responsibilities and their patients' rights.

Many practitioners remember the Accreditation Council for Graduate Medical Education residents' required lectures and seminars on ethics as dull, irrelevant or skipped. Learned physicians (Brewin, 1993) have questioned the usefulness of teaching ethics, at least of an "academic" type, rather than the more clinically based type. I agree, but I believe the quite common negative response of residents' exposure to ethics is not due mainly to poor teaching. I believe it is because ethics, once acknowledged, demand complicated, uncomfortable thinking. It is much easier to only think of other peoples' ethics, not our own.

Most ethical issues are complex and subject to multiple interpretations, perspectives and reactions. Seldom are there obvious, easy solutions. Ethical considerations are often a balance between gray concepts. Unethical decisions can occur when one "good" impinges too much on or denies another "good." For example, a young teen-age patient smokes marijuana. You believe she is not using it in a way that puts her in immediate physical danger, but it is against the law. You discuss with the patient the fact that she seems to recklessly put herself in danger of being arrested. She does not change her behavior. Circumstances should dictate whether informing the parents would help or hurt the best interests of the child. The impact of the decision on the patient-doctor relationship may be crucial.

The American Academy of Child and Adolescent Psychiatry (AACAP)  published a Code of Ethics with 17 ethical principles in 1980. Highlights are in the Table. A handful of points made in the code and several ethical aspects of research are covered elsewhere in this section.

The clinician's overriding commitment must be to the patient. More often than with adults, fees are not paid by the patient. The primary commitment cannot be to the payer, parents, authorities or oneself. The clinician's task is to not only avoid harming the child, but to also effect the best or ultimate good for the patient, all things considered. No one would disagree with this seemingly simple precept, but the devil then comes in the details. Both "ultimate good" and "all things considered" are cotton candy terms--luscious looking, but mainly air. 

The issues of consent, confidentiality, professional responsibility, authority, and behavior must be viewed within the context of development and the overlapping and potentially conflicting rights of the child or adolescent, of the parents, and of society.

While the child's welfare is paramount, this should optimally be assessed in the context of family and community. At the same time, it is our duty to protect the child as much as we can from deleterious actions by family and community. Balancing the above two sentences often demands careful thinking. For example, an adolescent patient may terrorize family members to the point of substantial suffering, but not break a law. A residential school may be indicated in your opinion, but the patient refuses to leave home or stop exerting control over siblings and parents. In addition, you believe the patient's sadistic machinations are psychologically self-destructive as well. The ethical concerns here may be difficult to sort out.

Clinicians must be aware of their own views of child rearing, values and behaviors. It is our task, as long as they do no harm or stunt the child's development, to support the individual qualities of our patients and their parents. Individual value preferences vary greatly, and it is unethical for the therapist to base decisions on what is actually personal bias.

Including the patient as much as possible in therapeutic decisions is much more difficult with children and adolescents than it is for adults. Since the patient is a minor--with few exceptions--the parents have the legal right to approve or disapprove of the clinician's medical recommendations. However, the wise clinician is aware that a treatment's course, except for our youngest patients, is determined mostly by the quality of the clinician-patient relationship. It is the clinician's ethical duty, in providing information to the patient, to judge the amount of information and mode of communication that provides "as thorough an understanding as can usefully be grasped and therapeutically utilized in the care of the child" (AACAP, 1980).

When discussing treatment options, it is important to realize that developmental stage, not age, is the more important variable on which to base children's cognitive abilities. At times, there will be a difference of opinion between parent and patient in regard to the clinician's recommendation. When this happens, the therapist's role is to work toward a decision or compromise that is best for the child. This, of course, may not always be the choice of the child. In these cases, much careful therapeutic work is required to, if possible, help the patient understand that it is because of their best interests that you support the decision. Patients will often be convinced by health reasons for a decision, rather than by what they perceive as parental or societal reasons based on tradition or morality.

Principles X through XIII deal with the complicated issues of confidentiality with minors (AACAP, 1980). The first anecdote touches on this issue. It is very helpful to discuss confidentiality during the first minutes of the first patient meeting. Particularly with adolescents, most clinicians prefer to meet initially with parents or guardians in order to obtain a full history. After the first meeting with the adolescent, meetings with such family members must be done carefully. Typically, the patient is told that confidentiality can be breached in situations when the clinician fears imminent danger to or by the patient, or when the patient gives permission. Younger, and sometimes older, patients give standing permission to provide information to parents. Nonetheless, it is usual to tell patients what you will communicate or, based on developmental considerations, have them present. Most practitioners welcome parental input, but a confidentiality pact must then be made with the parent as to whether or not you will share with the patient their information and its source. Here, too, the ethics must be based primarily on what is in the patient's best interests. There are circumstances, such as court evaluations, when there is no confidentiality, and this reality must be communicated at the onset. Patients cannot be used for teaching purposes without their understanding, permission and parental consent.

The burgeoning of managed care and other reimbursement systems followed a shift in public opinion whereby there was an increased acceptance that patient privacy be reduced in order to reduce medical costs. The AACAP's annotations (1996) reiterated the primacy of the patient's best interests. The clinician must help parents and patients understand the trade-off between divulging information to a payer and obtaining reimbursement. Increasingly, child and adolescent psychiatrists are dropping out of reimbursement plans. Some base this on intolerable invasions of patient privacy by insurers. This ethical stand, however, raises the ethical question of diminishing the already insufficient number of practitioners available to treat mentally ill minors.

The recent surge in prescription psychopharmaceuticals for minors is probably the largest area for ethical questions. It is unethical not to use medications when they are the best treatment available, but even the thoroughly documented success of stimulants for the treatment of attentional problems is disputed by some. There has been much published about the ethical questions of direct-to-consumer advertising (Rosenthal et al., 2002); pharmaceutical firms' marketing to patients whose names were made available by pharmacists (Zimmerman and Armstrong, 2002) and their tracking of physicians' prescribing patterns (Kaiser Family Foundation, 2002); and physicians' acceptance of gifts, trips and money from these firms (Wazana, 2000). The ethics of rushing to use new drugs was raised in a survey that found on average 20% of newly approved drugs are either withdrawn or later must carry a "black box" warning of serious side effects (Lasser et al., 2002). A counterbalancing ethic is that when using new drugs, clinicians can be a positive force. Efficacy demonstrated in strict research settings must be demonstrated to be effective in clinical settings, and it then must be disseminated successfully to all clinicians (Hoagwood and Olin, 2002). The AACAP is strenuously recruiting members into child and adolescent psychiatry trial networks to aid the transition of efficacy to effectiveness findings. A case can be made that if one uses medications, it is unethical to refuse to help assess their safety and effectiveness.

The topic of ethics is usually not thought about, because it is difficult. On the other hand, practitioners who do think about ethics are better clinicians. Less important, but worthwhile, is that those who think about ethics are less likely to be called before ethics committees. If one never thinks about ethical issues, one never will see them, until it is too late. A useful and probably necessary step is to consult with trusted colleagues when unsure of your conduct. No one is value-free, and ethics requires value balancing. If you do not wish to discuss a troubling issue with a friendly colleague, it is best to re-think your position. Acknowledging and wrestling with ethical issues can lead to greater clinical wisdom.

AACAP (1980), Code of Ethics. Washington, D.C.: AACAP.
 

AACAP (1996), Annotations to AACAP ethical code. AACAP News, pp17-20.
 

Brewin TB (1993), How much ethics is needed to make a good doctor? Lancet 341(3):161-163.
 

Hoagwood K, Olin SS (2002), The NIMH blueprint for change report: research priorities in child and adolescent mental health. J Am Acad Child Adolesc Psychiatry 41(7):760-767.
 

Kaiser Family Foundation (2002), National Survey of Physicians Part II: Doctors and Prescription Drugs. Menlo Park, Calif.: The Kaiser Family Foundation.
 

Lasser KE, Allen PD, Woolhandler SJ et al. (2002), Timing of new black box warnings and withdrawals for prescription medications. JAMA 287(17):2215-2220.
 

Rosenthal MB, Berndt ER, Donohue JM et al. (2002), Promotion of prescription drugs to consumers. N Engl J Med 346(7):498-505.
 

Wazana A (2000), Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 283(3):373-380.
 

Zimmerman A, Armstrong D (2002), Useof pharmacies by drug makers to pushpills raises privacy issues. The Wall Street Journal. May 1, p1.

Mental health care professionals must be aware of the responsibilities and conflicts that present when patients are children and adolescents. Prescribing medications to minors and working with the child's guardian in treatment decisions are discussed.

John E. Schowalter, MD

Articles

Advances and Achievements

A History of Child and Adolescent Psychiatry in the United States

Minding the Children