An international perspective on training in child and adolescent psychiatry

European Child & Adolescent Psychiatry -     

The case formulation in child and adolescent psychiatry

This article reviews the various definitions of case formulation, differences between diagnosis and case formulation, how case formulation for the child patient differs from the adult patient, and case formulation in the context of residency training, including challenges for residents transitioning from adult psychiatry. It presents a suggested structure for constructing a biopsychosocial formulation that can be applied in a training setting. Several specialized types of psychotherapy formulation are reviewed in more detail. The article concludes with a case example of a child psychiatry resident's case formulation before and after discussion in supervision.     

The psychodynamic formulation in child and adolescent psychiatry

DSM-III and DSM-III-R aid diagnostic clarity but do not help clinicians plan for common therapies available. A psychodynamic formulation has been described for adults to complement diagnosis and guide management. Child and adolescent psychiatrists would benefit if such a scheme were available for their use. Psychodynamic formulations based on current models are offered and their elements are described. Case vignettes and therapeutic plans are presented to show the practical value of a formal psychodynamic formulation, regardless of the treatment employed.     

Neuroimaging in child and adolescent psychiatry

Although less well studied in child and adolescent psychiatry than in adult psychiatry, brain imaging has significantly altered psychiatric research and practice. This review focuses on the modalities that are used to image the brain. These include structural imaging techniques of computer tomography (CT) and magnetic resonance imaging (MRI), as well as functional imaging techniques of computed electroencephalography (CEEG), positron emission tomography (PET), and single photon emission computed tomography (SPECT). The technologies are reviewed, strengths and weaknesses of modalities discussed, and research progress reported.     

Malpractice in child and adolescent psychiatry

Over the past 40 years, malpractice suits in child and adolescent psychiatry have gone from almost nonexistent to a source of major concern. Suits that involve child and adolescent patients remain fairly uncommon, and no damages are paid in six out of seven cases. The two cardinal principles for the clinician in avoiding and defending malpractice suits are to practice in accordance with his or her best clinical judgment and to document care, particularly in areas in which an unexpected adverse result may lead to a lawsuit. The most common areas that give rise to suit are failure to protect a child inpatient from assault or sexual interaction with another inpatient, adolescent suicide, medication errors, and issues related to child abuse. Evolving areas of malpractice law derive from incipient patient's rights legislation, development of the "direct victim" test in cases brought by third-party parents against therapists who have diagnosed children as sexually abused, implementation of new federal rules regarding privacy of records, and provision of medical information or treatment over the Internet.     

Training general psychiatry residents in child and adolescent psychiatry

The authors describe the nature of current social and economic forces impacting on the education and future practice of general psychiatry residents in child and adolescent psychiatry. They review theoretical and practical reasons for training in child and adolescent psychiatry, analyze the form and content of what is currently taught based on a national survey of general training programs, and suggest guidelines for the training and postgraduate practice of general psychiatrists in evaluating and treating children and adolescents. The authors conclude that while social and economic changes necessitate general psychiatrists' clinical involvement with children and adolescents, insufficient general training may necessitate postgraduate education and supervision. They pose ethical and professional dilemmas for the field in meeting the national shortage of child and adolescent psychiatrists and propose strategies to enhance recruitment into child and adolescent residency training.     

The pitfalls of universalism in child and adolescent psychiatry

European Child & Adolescent Psychiatry -     

The dexamethasone suppression test in child and adolescent psychiatry

The dexamethasone suppression test was performed on 67 children and adolescents who were hospitalized in the child psychopathology unit of Herold Hospital (Paris). We used the DSM-III diagnostic criteria. After 10 preliminary trials using 2 mg/1.73 m2 of dexamethasone, 63 trials were conducted with a dosage of 1 mg/1.73 m2. In 19 cases of anorexia nervosa, non-suppression was associated with the weight reduction, with no other significance attached to the results. In 30 pubertal cases, 11 out of the 20 depressed patients escaped from dexamethasone suppression while none of the 10 non-depressed patients did. Those 5 adolescents who were categorized as depressed with psychotic features all escaped suppression. Criteria of specificity and more specifically the role of weight loss, are discussed. In 8 prepubertal patients (under Thirteen) the 4 depressed cases showed no escape response but this response was noted in 2 out of the 4 other children. These results suggest the presence of neuroendocrinological alterations in depressed pubertal children similar to those observed in some depressed adults. We could not find similar alterations in our small sample of non pubertal children.     

Political lobbying for child and adolescent psychiatry.

Lobbying for child and adolescent psychiatry works best when association members team with staff to communicate with members of Congress. Communication comes in many forms, some more effective than others, but without it, no opportunities for policy changes are generated. Legislators want to know what their constituents are interested in, and child and adolescent psychiatrists serve themselves and their profession by knowing the legislative agenda, using the tools available for reaching out to legislators, and using every opportunity available to move the agenda.     

A core curriculum for child and adolescent psychiatry

 This paper suggests that it will be increasingly necessary to have a core curriculum for training in child and adolescent psychiatry. The reasons include the growth of knowledge, need for selection of information, the influence of evidence-based practice and accountability, and recognition of training across the European community. The principles for organising a curriculum are coherence, accessibility, and the context of professional development. Implementation of these principles is illustrated by the St Mary’s training programme in London. Important components are the reading seminars in developmental psychopathology and the psychological treatments course. Implementing a core curriculum nationally and internationally would have difficulties, which could be overcome by a compromise of central control and local interests and initiatives.