AACAP Psychotherapy Task Force, June 1998
We are at a significant juncture, a time to reassert the scope of practice of child and adolescent psychiatry. We find this need compelling and imperative. Our field is threatened by the political and economic forces in our current environment and by tensions between the drive to understand the brain in this "decade of the brain" and the tendency in so doing to de-emphasize the psychological understanding of the mind. These tensions affect all aspects of child and adolescent psychiatry: clinical practice, training, and research. The Academy has previously delineated the responsibilities and scope of practice of the child and adolescent psychiatrist (AACAP, 1995):
In response to statements made regarding the scope of the practice of Child and Adolescent Psychiatry (Certification Committee, 1997), we must clarify that "developmental" includes the appreciation of temperament and maturational factors on each of the components delineated above (Cohen, 1993). Similarly, "emotional" involves the person's psychological makeup, including means of coping with various stressors. Children come for treatment with wide ranging symptomatology influenced by complex variables, often involving comorbidity. They are frequently involved in several social systems, including the family, school, and community agencies. We recognize that the DSM-IV does not completely describe the range of disorders experienced by children. The Classification of Child and Adolescent Mental Diagnoses in Primary Care (AAP, 1996) is more comprehensive, including risk and resiliency factors as well as the impact of the family on the child or adolescent. As such, it better approaches the scope of the differential diagnoses and therapeutic interventions that we provide.
A review of the literature finds that several authors have recently examined the roles and responsibilities of the general or child and adolescent psychiatrist (March, 1995; Beinart and Lukeman, 1997; Cottrell, 1997; Goodman, 1997; Harrison, 1997; Messent, 1997; Sledge, 1997; Weissman, 1997; Sherman, 1998; Worcester, 1998; Target and Fonagy, 1997). The changing nature of the practice of psychiatry is well recognized. In his review of the literature supporting the American Psychiatric Association's Position Statement on Medical Psychotherapy, Sledge (1997) reports:
Harrison (1997) insinuates that in the 21st Century, the psychiatrist is unlikely to have a practice in which psychotherapy is the sole treatment. However, he also reminds us that:
Many predict (Pardes, 1996; Goodman, 1997; Harrison, 1997) that eventually the primary role of the child and adolescent psychiatrist will be to coordinate the clinical team; in so far as that is true, an in-depth understanding of the psychotherapies (as with the other "tools" used in mental health) is necessary to appropriately prescribe this intervention in order that others may render it (Lieberman & Rush, 1996; Pardes, 1996; "How Large," 1997; Messent, 1997). This is also true in instances in which the psychiatrist supervises practitioners of other disciplines (Mohl, Lomax, Tasman et al 1990; Cottrell, 1997). There is indication that at times more complicated psychotherapies require performance by a psychiatrist for efficacy (Lieberman and Rush, 1997). Expectations of knowledge and competency also affect perceived efficacy of treatment (Messent, 1997), necessitating the use of different psychotherapy tools or their implementation by psychiatrists. The child and adolescent psychiatrist needs psychotherapy skills in order to recognize and integrate the cultural aspects of a patient's presentation (E. James Anthony, M.D., personal communication, 1997).
Other writers describe the efficacy of the psychiatrist providing both psychotherapy and medication management in terms of financial costs (Dewan, 1997) and pragmatism (Busch and MacKinnon, 1997; Sledge, 1997). Continual integration of pharmacotherapy and psychotherapy helps all treatment, and is not currently the norm; having one clinician well trained to integrate both nearly always has significant advantages over plural clinicians and split functions. The foundation of our profession, responsibility for meeting the needs of children from the perspective of the whole child in an integrated manner, is reiterated (Richmond and Harper, 1996). It is noted that to forget the extent of the scope of the practice of psychiatry leads one to marginalize its importance in mental health care (Weissman, 1997).
The psychotherapies alone are an effective remedy for many psychiatric disorders (Mohl, Lomax, Tasman et al., 1990; March, 1995; Sledge, 1997; Worcester, 1998) including large numbers of the mild and moderately disordered (who are far more numerous than the severely disordered); these include many depressions and anxiety disorders as well as many character disorders and family disorders and children who have been physically or sexually abused or neglected. This population comprises a significant portion of the patient population of the child and adolescent psychiatrist. The psychiatrist often serves a coordinating role in the multidisciplinary treatment of these children and adolescents. The use of the psychotherapies is also a mainstay in work with children and adolescents who have developmental disabilities or are mentally retarded (Feinstein, 1997).
Children's play was recently proven statistically to be an effective predictor of psychopathology (Warren, 1996); this is a confirmation of the very large literature and even larger clinical experience of those who have used play therapy techniques for most of this century (Lewis, 1997). In combination with pharmacotherapy, the psychotherapies are effective in numerous other disorders (March, 1995; O'Brien and Perlmutter, 1997; Sledge, 1997; Worcester, 1998).
Further, the use of the psychotherapies increases compliance with pharmacotherapy (O'Brien and Perlmutter, 1997). To eliminate or even significantly diminish the psychotherapies from the arsenal of the child and adolescent psychiatrist would be severely to decrease the ability to provide the highest level, or even an ethical and professional level, of clinical care.
Submitted by the AACAP Psychotherapy Task Force: Rachel Ritvo, M.D., Chair, Cheryl Al-mateen, M.D., Lee Ascherman, M.D., William Beardslee, M.D., Lawrence Hartmann, M.D., Owen Lewis, M.D., Shirley Papilsky, M.D., John Sargent, M.D., Eva Sperling, M.D., Gregory Stiener, M.D., and Eva Szigethy, M.D.
References
American Academy of Child and Adolescent Psychiatry (1995), The Child and Adolescent Psychiatrist. Washington, DC: American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics (1996), The Classification ofChild and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary care (DSM-PC) Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics
Beinart H and Lukeman D (1997), Who needs child psychiatrists? A response by two clinical child psychologists. Child Psychology and Psychiatry Review 2:22-23
Busch FN and MacKinnon RA (1997), Psychotherapy's role in psychiatry. American Journal of Psychiatry 154:1481-2
Cohen DJ (1993), Evaluation of contemporary treatment models: concepts and issues in the mental health system for children and adolescents. Presented at the Latin American Society of Child and Adolescent Psychiatry, September, Chile
Cottrell D (1997), Who needs child psychiatrists?: A response by a child psychiatrist. Child Psychology and Psychiatry Review 2:24-25
Dewan MJ (1997), Cost of care by psychiatrist versus split treatment. Presented at American Psychiatric Association Annual Meeting, May 14-21, 1997, San Diego
Feinstein C (1997), Study Section on Mental Retardation and Developmental Disabilities, personal communication
Goodman R (1997) Who needs child psychiatrists? Child Psychology and Psychiatry Review 2:15-19
Hartmann L (1992), Reflections on Humane Values and Biopsychosocial Intergration. American Journal of Psychiatry 149:1135-1141
Harrison X (1997), How large a part should psychotherapy get in training? Psychiatric News 32:4, 22
Lewis O (1997), Integrated psychodynamic psychotherapy with children. Child and Adolescent Psychiatric Clinics of North America 6:53-68
Lieberman JA and Rush AJ (1996), Redefining the role of psychiatry in medicine. American Journal of Psychiatry 153:1388-97
Lieberman JA and Rush AJ (1997), Redefining the role of psychiatry in medicine: Reply. American Journal of Psychiatry 154:1482
March JS (1995), Cognitive-behavioral psychotherapy for children and adolescents with OCD: a review and recommendations for treatment. Journal of the American Academy of Child and Adolescent Psychiatry 34:7-18
Messent P (1997), Who needs child psychiatrists?: A response by a social worker. Child Psychology and Psychiatry Review 2:20-21
Mohl PC, Lomax J, Tasman A, Chan C, Sledge W, Summergrad P, and Notman M (1990), Psychotherapy training for the psychiatrist of the future. American Journal of Psychiatry 147:7-13
O'Brien JD and Perlmutter I (1997), The effect of medication on the process of psychotherapy. Child and Adolescent Psychiatric Clinics of North America 6:185-196
Pardes H (1996), A changing psychiatry for the future. American Journal of Psychiatry 153:1383-6
Richmond JB and Harper G (1996), Child and adolescent psychiatry: Toward the twenty-first century. Harvard Review of Psychiatry 4:61-66
Sherman (1998) Child's play can be a clue to psychophathology. Clinical Psychiatry News
Sledge WH (1997), Resource Document on Medical Psychotherapy. Journal of Psychotherapy Practice and Research 6:123-129
Society for Developmental and Behavioral Pediatrics, Certification Committee (1997), Petition for subspecialty boards in Developmental-Behavioral Pediatrics. Elk Grove, IL: Society for Developmental and Behavioral Pediatrics
Target M and Fonagy P (1997), Research on intensive psychotherapy with children and adolescents. Child and Adolescent Psychiatric Clinics of North America 6:39-51
Warren S (1996), Can emotions and themes in childen's play predict behavior problems? Journal of the American Academy of Child and Adolescent Psychiatry 35:1331-1337
Weissman S (1997), Psychiatrists: Shortage or Surplus? Psychiatric Times 14:50
Worcester S. (1998), Psychotherapy still relevant in anxiety disorders Clinical Psychiatry News 26(1):30
We are at a significant juncture, a time to reassert the scope of practice of child and adolescent psychiatry. We find this need compelling and imperative. Our field is threatened by the political and economic forces in our current environment and by tensions between the drive to understand the brain in this "decade of the brain" and the tendency in so doing to de-emphasize the psychological understanding of the mind. These tensions affect all aspects of child and adolescent psychiatry: clinical practice, training, and research. The Academy has previously delineated the responsibilities and scope of practice of the child and adolescent psychiatrist (AACAP, 1995):
The child and adolescent psychiatrist...specializes in the diagnosis and treatment of disorders of thinking, feeling or behavior....[After] a comprehensive diagnostic examination...with attention to [the] physical, genetic, developmental, emotional, cognitive, educational, family, peer and social components, arriving at a diagnosis and diagnostic formulation....The child and adolescent psychiatrist then designs a treatment plan which considers all the components....An integrated approach may involve...psychotherapy; medication; or consultation with other physicians or professionals from schools, juvenile courts, social agencies or other community organizations....
In response to statements made regarding the scope of the practice of Child and Adolescent Psychiatry (Certification Committee, 1997), we must clarify that "developmental" includes the appreciation of temperament and maturational factors on each of the components delineated above (Cohen, 1993). Similarly, "emotional" involves the person's psychological makeup, including means of coping with various stressors. Children come for treatment with wide ranging symptomatology influenced by complex variables, often involving comorbidity. They are frequently involved in several social systems, including the family, school, and community agencies. We recognize that the DSM-IV does not completely describe the range of disorders experienced by children. The Classification of Child and Adolescent Mental Diagnoses in Primary Care (AAP, 1996) is more comprehensive, including risk and resiliency factors as well as the impact of the family on the child or adolescent. As such, it better approaches the scope of the differential diagnoses and therapeutic interventions that we provide.
A review of the literature finds that several authors have recently examined the roles and responsibilities of the general or child and adolescent psychiatrist (March, 1995; Beinart and Lukeman, 1997; Cottrell, 1997; Goodman, 1997; Harrison, 1997; Messent, 1997; Sledge, 1997; Weissman, 1997; Sherman, 1998; Worcester, 1998; Target and Fonagy, 1997). The changing nature of the practice of psychiatry is well recognized. In his review of the literature supporting the American Psychiatric Association's Position Statement on Medical Psychotherapy, Sledge (1997) reports:
The psychiatrist brings to the psychotherapeutic work specialized knowledge, techniques, and clinical experience grounded in the physician's medical expertise and guarded by professional standards. (p. 124).
Harrison (1997) insinuates that in the 21st Century, the psychiatrist is unlikely to have a practice in which psychotherapy is the sole treatment. However, he also reminds us that:
It should not be forgotten that supervised psychotherapy in residency education has and continues to nurture and hone clinicians' skills in [clinical assessment/intervention strategy planning] interviewing....there is no better educational methodology than supervised psychotherapy for learning how to relate in a clinical interview with children and to gather meaning from what the child says and does, or does not say and does not do (p.33).
Many predict (Pardes, 1996; Goodman, 1997; Harrison, 1997) that eventually the primary role of the child and adolescent psychiatrist will be to coordinate the clinical team; in so far as that is true, an in-depth understanding of the psychotherapies (as with the other "tools" used in mental health) is necessary to appropriately prescribe this intervention in order that others may render it (Lieberman & Rush, 1996; Pardes, 1996; "How Large," 1997; Messent, 1997). This is also true in instances in which the psychiatrist supervises practitioners of other disciplines (Mohl, Lomax, Tasman et al 1990; Cottrell, 1997). There is indication that at times more complicated psychotherapies require performance by a psychiatrist for efficacy (Lieberman and Rush, 1997). Expectations of knowledge and competency also affect perceived efficacy of treatment (Messent, 1997), necessitating the use of different psychotherapy tools or their implementation by psychiatrists. The child and adolescent psychiatrist needs psychotherapy skills in order to recognize and integrate the cultural aspects of a patient's presentation (E. James Anthony, M.D., personal communication, 1997).
Other writers describe the efficacy of the psychiatrist providing both psychotherapy and medication management in terms of financial costs (Dewan, 1997) and pragmatism (Busch and MacKinnon, 1997; Sledge, 1997). Continual integration of pharmacotherapy and psychotherapy helps all treatment, and is not currently the norm; having one clinician well trained to integrate both nearly always has significant advantages over plural clinicians and split functions. The foundation of our profession, responsibility for meeting the needs of children from the perspective of the whole child in an integrated manner, is reiterated (Richmond and Harper, 1996). It is noted that to forget the extent of the scope of the practice of psychiatry leads one to marginalize its importance in mental health care (Weissman, 1997).
The psychotherapies alone are an effective remedy for many psychiatric disorders (Mohl, Lomax, Tasman et al., 1990; March, 1995; Sledge, 1997; Worcester, 1998) including large numbers of the mild and moderately disordered (who are far more numerous than the severely disordered); these include many depressions and anxiety disorders as well as many character disorders and family disorders and children who have been physically or sexually abused or neglected. This population comprises a significant portion of the patient population of the child and adolescent psychiatrist. The psychiatrist often serves a coordinating role in the multidisciplinary treatment of these children and adolescents. The use of the psychotherapies is also a mainstay in work with children and adolescents who have developmental disabilities or are mentally retarded (Feinstein, 1997).
Children's play was recently proven statistically to be an effective predictor of psychopathology (Warren, 1996); this is a confirmation of the very large literature and even larger clinical experience of those who have used play therapy techniques for most of this century (Lewis, 1997). In combination with pharmacotherapy, the psychotherapies are effective in numerous other disorders (March, 1995; O'Brien and Perlmutter, 1997; Sledge, 1997; Worcester, 1998).
Further, the use of the psychotherapies increases compliance with pharmacotherapy (O'Brien and Perlmutter, 1997). To eliminate or even significantly diminish the psychotherapies from the arsenal of the child and adolescent psychiatrist would be severely to decrease the ability to provide the highest level, or even an ethical and professional level, of clinical care.
Submitted by the AACAP Psychotherapy Task Force: Rachel Ritvo, M.D., Chair, Cheryl Al-mateen, M.D., Lee Ascherman, M.D., William Beardslee, M.D., Lawrence Hartmann, M.D., Owen Lewis, M.D., Shirley Papilsky, M.D., John Sargent, M.D., Eva Sperling, M.D., Gregory Stiener, M.D., and Eva Szigethy, M.D.
References
American Academy of Child and Adolescent Psychiatry (1995), The Child and Adolescent Psychiatrist. Washington, DC: American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics (1996), The Classification ofChild and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary care (DSM-PC) Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics
Beinart H and Lukeman D (1997), Who needs child psychiatrists? A response by two clinical child psychologists. Child Psychology and Psychiatry Review 2:22-23
Busch FN and MacKinnon RA (1997), Psychotherapy's role in psychiatry. American Journal of Psychiatry 154:1481-2
Cohen DJ (1993), Evaluation of contemporary treatment models: concepts and issues in the mental health system for children and adolescents. Presented at the Latin American Society of Child and Adolescent Psychiatry, September, Chile
Cottrell D (1997), Who needs child psychiatrists?: A response by a child psychiatrist. Child Psychology and Psychiatry Review 2:24-25
Dewan MJ (1997), Cost of care by psychiatrist versus split treatment. Presented at American Psychiatric Association Annual Meeting, May 14-21, 1997, San Diego
Feinstein C (1997), Study Section on Mental Retardation and Developmental Disabilities, personal communication
Goodman R (1997) Who needs child psychiatrists? Child Psychology and Psychiatry Review 2:15-19
Hartmann L (1992), Reflections on Humane Values and Biopsychosocial Intergration. American Journal of Psychiatry 149:1135-1141
Harrison X (1997), How large a part should psychotherapy get in training? Psychiatric News 32:4, 22
Lewis O (1997), Integrated psychodynamic psychotherapy with children. Child and Adolescent Psychiatric Clinics of North America 6:53-68
Lieberman JA and Rush AJ (1996), Redefining the role of psychiatry in medicine. American Journal of Psychiatry 153:1388-97
Lieberman JA and Rush AJ (1997), Redefining the role of psychiatry in medicine: Reply. American Journal of Psychiatry 154:1482
March JS (1995), Cognitive-behavioral psychotherapy for children and adolescents with OCD: a review and recommendations for treatment. Journal of the American Academy of Child and Adolescent Psychiatry 34:7-18
Messent P (1997), Who needs child psychiatrists?: A response by a social worker. Child Psychology and Psychiatry Review 2:20-21
Mohl PC, Lomax J, Tasman A, Chan C, Sledge W, Summergrad P, and Notman M (1990), Psychotherapy training for the psychiatrist of the future. American Journal of Psychiatry 147:7-13
O'Brien JD and Perlmutter I (1997), The effect of medication on the process of psychotherapy. Child and Adolescent Psychiatric Clinics of North America 6:185-196
Pardes H (1996), A changing psychiatry for the future. American Journal of Psychiatry 153:1383-6
Richmond JB and Harper G (1996), Child and adolescent psychiatry: Toward the twenty-first century. Harvard Review of Psychiatry 4:61-66
Sherman (1998) Child's play can be a clue to psychophathology. Clinical Psychiatry News
Sledge WH (1997), Resource Document on Medical Psychotherapy. Journal of Psychotherapy Practice and Research 6:123-129
Society for Developmental and Behavioral Pediatrics, Certification Committee (1997), Petition for subspecialty boards in Developmental-Behavioral Pediatrics. Elk Grove, IL: Society for Developmental and Behavioral Pediatrics
Target M and Fonagy P (1997), Research on intensive psychotherapy with children and adolescents. Child and Adolescent Psychiatric Clinics of North America 6:39-51
Warren S (1996), Can emotions and themes in childen's play predict behavior problems? Journal of the American Academy of Child and Adolescent Psychiatry 35:1331-1337
Weissman S (1997), Psychiatrists: Shortage or Surplus? Psychiatric Times 14:50
Worcester S. (1998), Psychotherapy still relevant in anxiety disorders Clinical Psychiatry News 26(1):30
