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Career focus Child and adolescent psychiatry Childhood psychiatric problems are less intractable than their adult counterparts. Jonathon Goldin reviews the branch of psychiatry with development on its side Child and adolescent psychiatry is the subspecialty of psychiatry that addresses the emotional and behavioural difficulties of children from birth until school leaving age or even beyond. The child psychiatrist, working as part of a multidisciplinary team, aims to alleviate the distress of children and their families where such difficulties exist. It is a relatively young specialty, which is gaining in importance, and this is matched by a recent expansion in the number of consultant posts available. Training Child and adolescent psychiatrists are all qualified doctors. Medical students could consider doing an elective in child psychiatry to increase exposure to a specialty that does not feature prominently in the medical school curriculum. After the year as a preregistration house officer, consider gaining experience in other medical specialties, particularly paediatrics, before embarking on basic training in psychiatry. This usually lasts two to four years with attachments of six months to one year in various specialties as a senior house officer. It is worth applying for a psychiatry rotation that has good child psychiatry posts available at senior house officer level. The Royal College of Psychiatry has recently stipulated that psychiatry trainees must have a minimum of six months in child psychiatry or learning disability, or in both, before obtaining the MRCPsych. During senior house officer training the two parts of the MRCPsych examination must be passed. A trainee's time as a senior house officer in psychiatry may be shortened if he or she has other training recognised by the college. This is another reason for budding child psychiatrists to consider time as a paediatric senior house officer in a post recognised for training. After obtaining the MRCPsych, consider some time off for research or apply directly to a specialist registrar training scheme. In London up to three training schemes may conduct their interviews together under the auspices of one deanery, but outside London interviews tend to be for one scheme at a time. Once in post, the trainee then spends a minimum of three years as a specialist registrar in child and adolescent psychiatry. The Child and Adolescent Psychiatry Specialist Advisory Committee (CAPSAC) monitors the quality of specialist registrar rotations, ensuring that each one offers a suitable range of experience. Training schemes are usually structured so that the necessary range of clinical experience can be obtained (box). Two sessions a week are generally allocated to research. When the specialist registrar training has been satisfactorily completed the certificate of completion of specialist training (CCST) in child and adolescent psychiatry is awarded and consultant posts can now be applied for. The minimum period between obtaining a medical degree and obtaining the CCST in child and adolescent psychiatry is seven years, but most people take longer, allowing for a broader range of experience. Paediatric experience Training in concepts of normal development and assessment of development are essential for child and adolescent psychiatry. There is much scope for liaison between child psychiatrists and paediatricians, and many paediatric problems may have a psychosomatic component. Chronic paediatric conditions carry an increased risk of psychological problems. Experience in paediatric neurology can be particularly valuable for child psychiatrists, who often deal with children with conditions such as epilepsy or Tourette's syndrome. Obtaining the diploma of child health (DCH) while doing a paediatric attachment shows a basic knowledge of child development and paediatrics, while real high flyers may consider sitting the MRCPH before moving into psychiatric training. Experience in psychiatry Senior house officers in psychiatry are exposed to a range of psychiatric subspecialties, which helps with the decision of whether to pursue further training in child psychiatry. They become familiar with treating psychotic and affective illnesses, including the use of psychotropic drugs, skills which will be useful later in child psychiatry. Basic psychotherapeutic techniques are also learned, and in child psychiatry "psychotherapy and its applications form the basis of the majority of interventions."1 It is also worth remembering that child psychiatrists usually work closely with families. The parents of children who are referred may sometimes have mental illness, so basic psychiatric experience is also useful. Child psychiatrists place strong emphasis on the multidisciplinary approach, working closely with agencies such as social services and education departments, child protection services, and voluntary organisations. In addition to a psychiatrist, the team may comprise clinical or educational psychologists, child guidance social workers, child psychotherapists, and child psychiatric nurses. Child psychiatrists are seen as having a unique combination of knowledge and skill in the assessment and treatment of psychiatric disorder in children and adolescents. Effective leadership and managerial skills are also required. Subspecialties Many consultants work in child guidance clinics or child and family consultation services in the community, but in the broad field of child psychiatry there is a range of subspecialties to pursue or develop an interest in. Some consultants work in inpatient or day patient units. Some specialise in the treatment of adolescents, developing special expertise and treating conditions such as eating disorders, psychosis, self harming behaviour, and substance misuse. Some may be particularly interested in forensic work, for which there has been a steady increase in demand over the past 20 years. This work includes becoming involved in child protection issues and addressing antisocial behaviour in children and teenagers. Individual psychotherapy (psycho-dynamic or cognitive behavioural), family therapy, or group therapy are further options. Some psychiatrists prefer neuropsychiatry and the treatment of conditions that have a clearer organic basis. Learning disability is another subspecialty. Finally, the development of child psychiatry has emphasised the need for academics and an increasingly research and evidence based approach to clinical practice. Clinical benefits The importance of child mental health is being increasingly understood. Much of the work of a child psychiatrist is preventive, aiming to intervene before psychological problems become too entrenched or chronic. One also has "development on one's side": children are still developing individuals, which hopefully means that problems are less likely than in adults to become chronic. The pace of the work is probably less hectic than in most adult psychiatric jobs, and there tends to be less on-call or emergency work. The daily work can be extremely varied, typically involving face to face contact with individual children or families, team meetings, consultation with other agencies, liaison with local schools or paediatric wards, and a management meeting. Trainee schemes are usually quite humane. There is an emphasis on good postgraduate training, and part time posts are widespread. There is usually time to talk to patients, getting to know both the children and their families, and good therapeutic outcomes can be deeply satisfying. Drawbacks If glamour and status are what you seek then child psychiatry may not be for you. The work can be emotionally stressful and may, for example, expose you to extremely distressing cases of child abuse. Socioeconomic problems often contribute substantially to morbidity in child psychiatric populations, and at times psychiatrists may feel they have little power to address such deficits. Personal attributes Child psychiatrists need to be able to communicate effectively with children and their parents. They need to be able to empathise with patients and convey an understanding of their difficulties. They often deal with complex problems that do not have easy solutions, and they need to be able to tolerate a degree of uncertainty and anxiety. At the same time, researchers in child psychiatry attempt to answer complex questions and need to think clearly and logically? Child psychiatrists also need to be able to think broadly and draw on a range of treatment approaches, which encompass psychotherapy and pharmacotherapy. Many trainees have experience of personal psychotherapy, which can help them cope with the emotional demands of child psychiatry and offer a valuable insight into the problems of patients. Personal psychotherapy is not, however, a compulsory part of the training. The number of consultant posts in child and adolescent psychiatry has increased recently, so, unlike in specialties such as obstetrics and gynaecology, finding a consultant post should not be a problem. Many child psychiatrists work part time so it is a good specialty to combine with family commitments. Most child psychiatrists work predominantly within the NHS, but there is some limited scope for private practice, including the provision of court reports. Future developments The recent emphasis on evidence based practice has led child psychiatrists, like other specialists, to evaluate the effectiveness of their treatment. Understanding of some of the biological and genetic factors underlying certain child psychiatric conditions has increased and will continue to increase in the future. The increasing tendency to use more drugs--for example, in the treatment of attention deficit hyperactivity disorder--is not without controversy, but there is a recognition that the use of drugs forms only part of an integrated treatment plan. Child psychiatry is a specialty that requires a flexible and thoughtful approach. Child psychiatrists aim to improve the mental health of future generations, and, although the work is often demanding, it is also enormously rewarding.
Jonathon Goldin, specialist registrar in child and adolescent psychiatry, Tavistock and Portman NHS Trust, London NW3 5BA
Further reading Advisory Paper. Child and Adolescent Psychiatry Specialist Advisory Sub-Committee, Royal College of Psychiatrists. London: Royal College of Psychiatrists, 1995.
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