Child and adolescent psychiatry

Overview
A branch of psychiatry that specialises in work with children, teenagers, and their families.

History
An important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with the neonate and eventually extending through adolescence. As early as 1899, the term 'child psychiatry' (in French) was used as a subtitle in Manheimer's monograph Les Troubles Mentaux de L'Enfance. However, the Swiss Moritz Tramer (1882-1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first use in English of the term "child psychiatry" occurred when Leo Kanner published his textbook under that name in the USA in 1935.

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children.

Academic divisions of child psychiatry began to develop, particularly in the USA, in the 1930s. The first 'pediatric psychiatry clinic' was established in 1930 in Baltimore, headed by Leo Kanner. In 1933, The Maudsley Hospital in London opened a children's department under Mildred Creak, and research in child psychiatry began to increase. Similar overall early developments took place in many other countries.

The era since the 1980s flourished, in large part, because of contributions made in the 1970s, a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by Michael Rutter. The first comprehensive population survey of 9-to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children's adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time in their subsequent re-evaluation of the original cohort of children (unsurprisingly since the environments that nurtured their emotional and developmental difficulties remained largely unchanged). It was paralleled by similarly work on the epidemiology of autism that was to enormously increase the number of children labeled as autistic in future years. Although attention had been given in the 1960s and 1970s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability.

Criticisms
Traditional deficit and disease models of child psychiatry have been criticised as rooted in the medical model which conceptualises adjustment problems in terms of disease states. That is, they explicitly characterise problematic behavior as representing a disorder within the child or young person. It has become increasingly apparent, since the early 1990s, that the role of environmental influences on behaviour has become increasingly neglected, leading to a decrease in popularity of, for example, family therapy. There are increasing criticisms of the medical model approach: it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behaviour and symptoms, it promotes a view of the "patient" as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behaviour, it also promotes a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and is based on the shakey foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability (Boorse, 1976; Sadler et al. 1994; Timimi, 2006). It is well known that diagnostic validity and reliability is questionable in the case of adults and these difficulties are even more acute in the case of child and adolescent emotional and developmental difficulties (Ash, 1949; Bean, 1983; Costello, 1986; Mehlman, 1952, Wakefield, 1994).

General references

 * Ash, P. The Reliability of Psychiatric Diagnosis. Journal of Abnormal Social Psychology v. 44 (1949), pp. 272-276. A study focussing on three psychiatrists and the degree to which they disagreed on diagnosis of the same patients. Study focussed on a number of variables including the seriousness of pathology and the interaction between these variables and consistency. Results show a very low percentage of consistent diagnoses for all three doctors.
 * Barbour and Allen B. Caring for Patients: a Critique of the Medical Model. Stanford, Ca.: Stanford University Press, 1995. This book relegates the medical model of illness to at least a less primary role in the conceptualisation and treatment of problems. The author argues that "when applied without perspective" the medical model and discrete diagnostics are invalid, and that "a better understanding of the relation of the illness to the life of the patient" can obviate many of the problems the model otherwise incurs.
 * Bean, Philip. Mental Illness: Changes and Trends. New York: John Wiley and Sons, 1983. A collection of interdisciplinary articles discussing various and varied issues in mental health, including the difficulty of a "scientific" psychiatry, and the effects of diagnosis on patients, and a fleshing out of the difficulties implied by finding a definition for normality.
 * Barker, Philip (2004). Basic Child Psychiatry. Blackwell.
 * Beck, A.T. et al. Reliability of Psychiatric Diagnosis. American Journal of Psychiatry v. 119 (October), pp. 351-357. A research study assessing the degree of diagnostic agreement among 4 psychiatrists diagnosing patients in an inpatient facility. Results showed a level of concordance of 54%, high enough to be clearly non-random, but low enough to raise questions about the utility of diagnostics as a treatment or research tool.
 * Boorse, Christopher. "What a Theory of Mental Health Should Be." Journal of the Theory of Social Behavior, 6 (1976): 61-84.
 * Costello, Anthony J. (1986). Assessment And Diagnosis Of Affective Disorders In Children Journal of Child Psychology and Psychiatry 27 (5), 565–574.
 * Farber, Seth. Transcending Medicalism. Journal of Mind and Behaviour, v. 8(1) (1987) pp. 105-132. An argument that psychiatric diagnostics are internally flawed and anti-therapeutic. The author argues for a more culturally informed conception of mental problems beginning from an understanding of these entities not as an epidemic but as a sign of human change and evolution.
 * Mehlman, B. "The Reliability of Psychiatric Diagnosis." Journal of Abnormal and Social Psychology v. 47 (1952), pp. 577-578. A study showing that individual psychiatrists have individualised patterns of diagnosis which vary from psychiatrist to psychiatrist. This indicates the degree to which subjectivity enters into diagnosis even at the level of implementation, much less formulation.
 * Rutter, Michael and Taylor, Eric. (2005). Child and Adolescent Psychiatry. Blackwell Science.
 * Sadler, John. Z., Osborne P. Wiggins, and Michael. A. Schwartz, (editors). Philosophical Perspectives on Psychiatric Classification. (Baltimore: Johns Hopkins University Press, 1994).
 * Timimi, Sami (2002). Pathological Child Psychiatry and the Medicalization of Childhood. Brunner-Routledge.
 * Timimi, Sami (2005). Naughty Boys: Anti-social Behaviour, ADHD and the Role of Culture. Palgrave Macmillan.
 * Timimi, Sami (2006). Critical Voices in Child and Adolescent Mental Health. Free Association Books.
 * Wakefield, Jerome C. "The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values." American Psychologist 47, no. 3. (1992): 373-88.