IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

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HISTORY OF CHILD PSYCHIATRY
Joseph M. Rey, Francisco B. Assumpção Jr, Carlos A. Bernad,
Füsun Çetin Çuhadaroğlu, Bonnie Evans, Daniel Fung,
Gordon Harper, Loïc Loidreau, Yoshiro Ono, Dainius Pūras,Helmut Remschmidt, Brian Robertson,
Olga A. Rusakoskaya, Kari Schleimer

Joseph M Rey MD, PhD,FRANZCP
Professor of Psychiatry, Notre
Dame University Medical
School Sydney; Honorary
Professor, University of Sydney
Medical School, Sydney,
Australia
Conflict of interest: nonereported

Francisco B Assumpção Jr
Professor, Faculdade de
Medicina da Universidadede São Paulo & Associate
Professor, Instituto dePsicologia da Universidade deSão Paulo, Brazil.
Conflict of interest: nonereported

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2015. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Rey JM, Assumpção FB, Bernad CA, Çuhadaroğlu FC, Evans B, Fung D, Harper G, Loidreau L, Ono Y, Pūras D,
Remschmidt H, Robertson B, Rusakoskaya OA, Schleimer K. History of child and adolescent psychiatry. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2015.

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IACAPAP Textbook of Child and Adolescent Mental Health

TABLE OF CONTENTS

Carlos A Bernad MD,
MPSYCHINTRODUCTION							3Buenos Aires, Argentina.

CHILD PSYCHIATRY PRIOR TO THE 20TH CENTURY 		

4

20TH CENTURY—THE CENTURY OF THE CHILD 			

5

Conflict of interest: nonereported

Measurement 							5Intelligence 					5Questionnaires 					7Diagnostic interviews 				7Developmental psychology 					8G Stanley Hall 					9Psychoanalysis 					9Piaget, Vygotsky and Bowlby 			10Nature vs nurture 				11Developmental psychopathology 			12Füsun Çetin Çuhadaroğlu
MD
Professor of Child andAdolescent Psychiatry,
Hacettepe Univ. Faculty of
Medicine, Ankara, Turkey
Conflict of interest: nonereported

Bonnie Evans PhD

Intellectual disability 						12The child guidance movement 					15Epidemiology							17Prospective studies 				17Taxonomy 							18Wellcome Trust Postdoctoral
Research Fellow, Queen Mary,
University of London
Conflict of interest: nonereported

Gordon Harper MD

The International Classification of Diseases 		
19
The Diagnostic and Statistical Manual of 						Mental Disorders				19Other classifications 				20Dimensional approaches 				20Associate Professor of
Psychiatry, Harvard Medical
School, Massachusetts, USA

Cognitive-behaviour therapy 					21Family therapy 							22Loïc Loidreau MD

Parent management training 			23Pharmacotherapy and somatic treatments 			The pharmacological revolution of the 1950s 		24Child psychiatry as a branch of medicine 					Child psychiatry and paediatrics 			
26

23
25

Conflict of interest: nonereported

Child and adolescent
psychiatrist. Centre Hospitalierde Montauban, Montauban,
France.
Conflict of interest: nonereported

		Behavioural paediatrics 				27Yoshiro Ono MD, PhD

THE HISTORY OF IACAPAP 						28Director, Wakayama Prefecture,
Mental Health & Welfare
Center, Wakayama, JapanHISTORY OF CHILD PSYCHIATRY IN DIFFERENT COUNTRIESAND REGIONS 							30Africa 								30Argentina 							31Asia 								33Brazil 								38Central and Eastern European countries 			39
France 								44Germany 							48Japan 								51Russian Federation 						53Turkey 								55United Kingdom						58United States of America					63CONCLUSIONS 							67History of child psychiatry

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Conflict of interest: nonereported

Dainius Pūras MD
Professor and Head, Centre
for Child Psychiatry & Social
Paediatrics, Vilnius University,
Lithuania.
Conflict of interest: nonereported

Helmut Remschmidt Prof Dr
med Dr phil
Klinik für Kinder-undJugendpsychiatrie,
Psychosomatik und
Psychotherapie, Fachbereich
Medizin der Philipps-Universität
Marburg, Schützenstr. Marburg,
Germany

2

IACAPAP Textbook of Child and Adolescent Mental Health“

How soon can a child go mad?” asked Henry Maudsley in his 1895 textbook
The Pathology of Mind, “Obviously not before it has got some mind to go
wrong, and then only in proportion to the quantity and quality of mind
which it has”, alluding to the widespread belief, even at the end of the 19th
century, that children’s minds were not developed and stable enough to be able toshow much psychopathology.
The history of child psychiatry—a term that can mean a collection ofservices, a body of knowledge, and a profession—is inextricably linked to thehistory of childhood; recognising childhood as a distinct period of development isa prerequisite to acknowledging child psychiatry as a discipline (a full chapter, J.9,
is dedicated to the history of childhood in this book). Thus, the history of childpsychiatry is interlocked with our understanding of development, child-rearing
practices, the place of children in society, and with non-medical fields such as
juvenile justice and education. For example, some historians date the beginningsof child psychiatry in the US to 1899 when the state of Illinois established thenation’s first juvenile court in Chicago (Schowalter, 2003).
Few references can be found about childhood psychopathology prior to the19th century. This is not restricted to children’s mental disorders; paediatrics began
to emerge as a medical specialty only by the end of the 18th century. L’Hôpitaldes Enfants-Malades founded in 1802 in Paris was the first hospital especiallyestablished for the treatment of sick children (TEC, 1981). Great Ormond Street
opened in London 50 years later. However, hospitals in the UK and elsewhere had
been providing inpatient care for substantial numbers of children long before then(Williams & Sharma, 2014).

Conflict of interest: nonereported

Brian Robertson MD
University of Cape Town, South
AfricaConflict of interest: nonereported

Olga Alekseevna
Rusakovskaya
Senior Researcher, Serbsky
National Research Centre forSocial and Forensic Psychiatry& Moscow City Psychological
Pedagogical University,
Russian Federation.
Conflict of interest: nonereported

Kari Schleimer MD, PhD
Former Senior Consultant
and Lecturer, Dept of Child &Adolescent Psychiatry, UMAS,
Malmö Hospital, University ofLund, Sweden
Conflict of interest: nonereported

The first child psychiatry shoots did not appear in the clinical tree until
as recently as the 1920s with the child guidance movement. For example, what
we now call the International Association for Child and Adolescent Psychiatryand Allied Professions (IACAPAP) started in 1937, the American Academy ofChild & Adolescent Psychiatry (AACAP) was founded in 1953. The Union ofEuropean Paedopsychiatrists, which later became the European Society for Childand Adolescent Psychiatry (ESCAP), had its first meeting in October 1954. In
many countries child psychiatry is not yet formally recognised as a subspecialty,
not taught in medical schools, and no formal training is available.
Given its short lifespan, is a history of child psychiatry justified? While
child psychiatry as a subspecialty is in its early days, it is important to chart its
development, particularly now when many of its pioneers are still alive or canbe remembered by people who learned first-hand from them. Not recording
past trends and some of the key events would be negligent since much of that
history may be forgotten and an opportunity to learn from past mistakes andsuccesses missed. It will also allow placing the current issues in a historical context.
Nevertheless, trying to summarise the history of child and adolescent psychiatry
globally—the specialty has evolved differently in different countries, e.g., Argentina,
France, Soviet Union, UK—is a large undertaking and cannot be accomplishedwith the detail it deserves in the setting of this chapter. To this end and to givean indication of the variety of practices and traditions, a large fresco is painted.
Against this background, brief summaries of the history in a few specific countries
or geographical regions are presented to highlight similarities and differences, toHistory of child psychiatry

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•
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IACAPAP Textbook of Child and Adolescent Mental Healthshow that political, economic, social and cultural factors had an impact on its
development, and that people from many countries made great contributions to
the discipline, often not recognised enough in the dominant narrative, written in
English. In this chapter the term “child psychiatry” is used to mean infant, childand adolescent psychiatry, as appropriate.

CHILD PSYCHIATRY PRIOR TO THE 20TH CENTURY
Before the 1900s little interest in child psychiatric disorders can be found.
Not a single article that made reference to children was published in the first45 years of the American Journal of Insanity (1844–1889), the forerunner of theAmerican Journal of Psychiatry (Levy, 1968a). Benjamin Rush (1812)—probably
the first American psychiatrist—made no mention of children in his influential
textbook Medical Inquiries and Observations upon the Diseases of the Mind.
Although some children in every era have shown emotional and behaviouralproblems, these were not seen as medical concerns and were dealt with in different
ways through the centuries. Behavioural disorders were largely considered moral
problems, thus deserving punishment (the result of badness rather than madness).
Failure to learn usually led to a marginalised existence, for example as a village
idiot. The scarce 18th century medical writings focused mainly on issues suchas seizures, fear in dreams, sleep disturbances, stuttering, sibling rivalry, andepilepsy. The prevailing view being that “insanity did not occur before puberty,
and it was often observed that children were not seen in public asylums or private
madhouses” (Parry-Jones, 1989). The situation changed in the 19th century whengeneral psychiatry textbooks began mentioning madness in children. For example,
Maudsley’s 1895 book dedicated a chapter to “the insanity of early life”, while
Griesinger (1867) noted that mania and melancholia did occur in children. “A
study of over 300 juveniles, aged up to 19 years, admitted to Oxfordshire asylums
in the 19th century reveals a wide range of clinical presentations including asubstantial number of mentally defective children [...] The supposed causes of
insanity fell into two broad categories. Firstly, there were psychological causes suchas fright and grief and, secondly, physical causes, including epilepsy and infectious
fevers, like typhoid and measles” (Parry-Jones, 1989). Lunatic asylums were theforerunners of psychiatric hospitals.
Towards the end of the 19th century, there was a growing understandingof the multiple factors involved in the development of childhood psychiatricdisorders, although the emphasis was on heredity: “The course of the growth anddevelopment of the brain is marked by many dangers — and no wonder—for itis the process of bringing to perfection of by far the highest evolution in Nature,
this process being constantly impeded and endangered by diseases peculiar tothe period, by parental ignorance of what the brain needs, and by unhygienic
conditions of all kinds. Above all, the process cannot be completed properly invery many cases because there is an adverse heredity—a true fate against whichknowledge, affection and will and the command of every favourable condition areoften powerless to contend […] Hereditary tendency towards insanity, howeverstrong, seldom develops into a mental disease till after the period of adolescence iswell on” (Tuke, 1892, p357).

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It was widely believed that full human development was not achieved until
around the age of 25 (confirmed recently by brain imaging techniques), and thatinsanity was rare in adolescents, becoming more common in young adults: “Thereis no period of life when uncomplicated insanity occurs more frequently thanduring the completion of the physiological era of adolescence, from twenty-one totwenty-five. As regards the two sexes our statistics seem to show that adolescencedoes not appear to be so powerful an upsetter of mental equilibrium in womenas in men.” (Tuke, 1892, p262). Puberty was recognised as a significant cause ininsanity and Durand-Fardel (1889) highlighted the existence of suicide in children.
Although juvenile insanity was thought to be rare, its existence became
widely accepted—by the end of the 19th century most textbooks included sections
on children—and juvenile insanity was differentiated from mental retardationand epilepsy (Parry-Jones, 1989). In 1887 the German psychiatrist Hermann
Emminghaus (1887) published one of the first treatises in child psychiatry (Psychic
Disturbances in Childhood). By contrast, Kraepelin’s ground-breaking psychiatrictaxonomy published in 1883 ignored children’s disorders.

Henry Maudsley(1835-1918), a British
psychiatrist, was one of thefirst to describe insanity
in children in his 1895
textbook.

20TH CENTURY
THE CENTURY OF THE CHILD
Ellen Key, a Swedish writer and suffragist best known for her 1900 book
The Century of the Child (Barnets Århundrade) proposed that the world’s children
should be the central concern of society during the 20th century, which she
named “the century of the child”. Her book became very influential as far as theunderstanding of children in society (see Chapter J.9) and child psychiatry areconcerned. Many significant advances occurred in the early 1900s that set thescene for child psychiatry to become the fully-fledged medical discipline that it istoday. These include improvements on measurement, advances on developmental
psychology, the advent of psychoanalysis, and the mental hygiene and childguidance movements.
The second half of the century, after World War II, witnessed an explosion
in research with big advances in the understanding of the nature of childhood
mental disorders, their diagnosis and classification, and in treatment—led bycognitive and behavioural approaches and psychopharmacology. It also witnessed
the definite establishment of the discipline as a medical specialty.

MEASUREMENT
The ability to reliably quantify phenomena is at the very core of scientificprogress; that is the case also in mental ill health. The development of measuring
instruments has allowed the scientific progress of the discipline and child psychiatry
to become a respected part of medicine. Further, the last century has seen a shift
from concerns about just survival to a conceptualization of health as an absenceof disease, as individuals’ ability to perform their daily activities, and in terms of
quality of life, increasingly acknowledged to be greatly influenced by a person’smental health, resilience, and ability, factors that needed to be measured reliably.

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IACAPAP Textbook of Child and Adolescent Mental Health

Click on the picture to watch a web-documentary about
Alfred Binet (in French)

Intelligence
Alfred Binet (1857-1911), one of the most influential French psychologists
and scientists, transformed the measurement of intelligence, setting the foundation
for quantitative psychology and psychiatry. In 1905, Binet together with Théodore
Simon published the first standardized scale of intelligence, the Binet-Simon Test.
The score on the scale would reveal a child’s mental age and would allow to stablish
its concordance or otherwise with physical age. The test consisted of thirty tasks ofincreasing difficulty, the product of more than 15 years of work and experimental
research with children. Binet and Simon’s test was standardized in the US shortly
after by Lewis Terman, a Stanford University psychologist. First published in the
US in1916, it was called the Stanford-Binet Intelligence Scale and soon became thecustomary intelligence test used in the US. An updated version is still in use.
Binet did not think that his test measured an inborn, crystallised cleverness;on the contrary, he believed that intelligence scores could differ with a variety offactors such as temperament and motivation. He hypothesized that intelligence
was the sum of a variety of skills and that a reliable estimate could be obtainedby sampling these skills and adding the results. The figure thus obtained is morereliable than teachers’ and parents’ estimates. Debate about what intelligence is
has raged ever since and is still far from settled. Nevertheless, the introductionof intelligence testing revolutionised clinical practice and research by allowinginterventions to be tailored to the needs and capacity of individual children.
The creation of a new instrument, which addressed some of the limitations of
the Stanford-Binet Test by David Wechsler (1896-1981), an American psychologist,
represented the next step forward in intelligence testing. In 1939 he compiled a

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IACAPAP Textbook of Child and Adolescent Mental Healthbattery of tests for adults known as the Wechsler-Bellevue Intelligence Scale. Wechsler
believed—like Binet—that intelligence involved a variety of mental abilities andstressed that factors such as personality contribute to intelligence. He rejected
the concept of an ideal mental age against which individual performance can bemeasured and defined normal intelligence as the mean test score for all the membersof an age group; the mean could then be represented by 100 on a standard scale.
The Wechsler Intelligence Scale for Children (WISC) was published in 1949.
The WISC was an adaptation to children of several of the subtests which madeup the Wechsler-Bellevue Intelligence Scale with other subtests specifically designed
for the WISC. The subtests were organized into verbal and performance scales, andprovided scores for a Verbal IQ (VIQ), a Performance IQ (PIQ), and a Full Scale
IQ (FSIQ), highlighting that abilities are not necessarily homogeneous. That is,some children may have high verbal ability but low performance skills such as
in visuospatial tasks. The WISC, which has been updated regularly since thenand normed in different countries and cultures, has become the most widely used
intelligence test in children.
Although measuring school achievement had taken place previously,
publication of the Stanford Achievement Test by Terman and colleagues in 1923,
made large scale school testing possible. Achievement tests are now widely used inclinic settings, to detect areas of educational need, and for school funding.

Questionnaires
G Stanley Hall (see below) was the major force behind questionnairedevelopment. His questionnaires covered topics as diverse as fears and dreams. Notlong after, William Healy (one of the initiators of the child guidance movement)
and Grace Fernand published in 1911 a series of tests to evaluate delinquent
children. Many other questionnaires were subsequently developed to measurespecific symptoms (e.g., depression, hyperactivity) or, from the 1960s, a wide
range of problem behaviours. The last type, pioneered by Achenbach, has evolved
into an empirical system of clinical diagnosis: ASEBA (Achenbach, 2009; see also
Chapter A.3). More recently there has been growing interest in brief questionnairesthat can be used for screening purposes, for example Goodman’s (1997) Strengths
and Difficulties Questionnaire (SDQ). Achenbach (1987) also highlighted that toachieve a more valid picture in child psychiatry, information needs to be obtained
from a variety of sources—parent, child, teacher—that often disagree. The needfor this is widely acknowledged although there is argument about how suchinformation should be integrated. Questionnaires have become an integral part ofgood everyday clinical practice mostly to measure severity of symptoms and track
response to treatment.

Diagnostic interviews
The need to improve the reliability of psychiatric diagnosis, which became
evident in the 1960s and 1970s, not only spurred the creation of better taxonomies
but also the development of structured and semi-structured diagnostic interviews,
themselves facilitated by the availability of operationalised diagnostic criteria (e.g.,
in DSM-III). One example of structured interview is the one designed by DavidHistory of child psychiatry

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Shaffer and his colleagues (1996) following a model used for adults. Structured
interviews use a set of questions that tap specific symptoms required to make adiagnosis with “yes” or “no” answers, therefore capable of being administered bylay people. These interviews have been used mainly in epidemiological studies andtheir administration has been simplified greatly by the introduction of mobile
computing.
Semi-structured interviews consist of a variety of specified symptoms(matching the diagnostic criteria for a particular disorder) that need to be rated
and have tight rules for scoring but the interviewer has freedom to ask questions
and clarification. Initially these were administered by clinicians, which wasprohibitively expensive. An example of a semi-structured interview is the KiddieSADS developed by Joaquim Puig-Antich and his colleagues.

DEVELOPMENTAL PSYCHOLOGY
Developmental psychology seeks to explain how children change overtime. Understanding development is important for the study of psychopathology.
Interest in this field grew with the acknowledgement of childhood as an importantarea of study in the 19th century (see Chapter J.9). The ongoing theme has been thetension between proponents of the roles of nature vs nurture and their interplay
in development.
The emergence of developmental psychology as a discipline is imprecise
but can be traced back to 1882 when Wilhelm Preyer, a German physiologist,
published The Mind of the Child. In this book Preyer presented his observations on
the development of his own son from birth to the age of three; work admired more

Front row, from left: Sigmund Freud, G Stanley Hall, CG Jung; back row: Abraham A Brill, Ernest Jones, Sándor
Ferenczi. Clark University, 1909.

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IACAPAP Textbook of Child and Adolescent Mental Healthfor its methodology than for the originality of its thinking. The discipline became
further established following the work of Alfred Binet on intelligence measurement
and of James Mark Baldwin (1861-1934), a US psychologist best known for the“Baldwin effect”—that epigenetic factors shape congenital endowment as muchas, or more than, natural selection.

G Stanley Hall
G Stanley Hall (1844-1924) is considered the founder of organised
psychology in the US. He started the first American journal of child psychology in1891 (Pedagogical Seminary) and the first society of child study in 1894. He wasstrongly influenced by scientists in Germany, where he spent his early professional
years. His invitation to Sigmund Freud to speak at Clark University in 1909
brought psychoanalysis to America. He also succeeded in securing the recognitionof psychology as a profession. One of Hall’s most important publications
was his two volumes dedicated to adolescence, which he conceptualised as thedevelopmental stage between 14 and 24 years of age (Hall, 1904). Apart fromdescribing adolescence as a time of “storm and stress”—a concept much maligned
in subsequent years—he already noted that adolescence was characterised by anincrease in the prevalence of depressed mood, crime rates, sensation seeking, andsusceptibility to media influences. He also highlighted the importance of peer
relationships. Likewise, Hall defined what today is often labeled as “relational
aggression”—so common in this social media age, particularly among girls. Thatis, aggression expressed through gossip, rumour, and ostracism. He supported an
evolutionary view of development, which among other consequences led him tobelieve that children should not be taught to read until the age of eight years
because literacy had happened very late in human evolutionary history (Arnett,
2006).

Click on the image toview a short biography ofJames Mark Baldwin(1861-1934), a US
psychologist who madeimportant contributions todevelopmental psychology(in Spanish; 7:31)

Psychoanalysis
One of the figures who dominated psychiatric thinking during most of the20th century was the Austrian neurologist and psychiatrist Sigmund Freud (18561939). Freud’s understanding of development grew out of his approach to humanpersonality and psychopathology based on his and his patients’ recollections.
Freud developed a model in which the libido (sexual drive) of the child focuseson different parts of the body as the child grows up (oral, anal, phallic, latency,
and genital stages). His model is an interactive one; he believed that although
the sequence and timing of these stages is biologically determined, successful
personality development depends on the experiences children have during eachstage. Freud argued that neurosis could be explained in terms of a fixation inor regression to these phases due to trauma or other experiences and could bereversed using psychoanalytic techniques. Although many details of Freud’s theoryof development have been widely discredited, his emphasis on the importance ofearly childhood experiences has had a lasting impact.
Anna Freud (1895-1982), Sigmund’s youngest daughter, and Melanie Klein(1882-1960) have been two of the most influential figures in child psychoanalysis(Anthony, 1986). Both were born in Austria and practised in England where they

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IACAPAP Textbook of Child and Adolescent Mental HealthJean Piaget (18961980) with Bärbel
Inhelder, his best known
collaborator.
Click on the image toview “Piaget on Piaget”,
a documentary about
Jean PIaget’s genetic
epistemology. It showssome of the classic
experiments about
seriation, conservationof volume and drawings.
Filmed in Switzerland
in 1977 (in French withEnglish subtitles; 41:34)

developed their own, quite different, approach to child analysis. Their influence onchild psychiatry, particularly through the child guidance movement, has been vast.
It is of note that the journal The Psychoanalytic Study of the Child, a joint AngloAmerican venture, has been in continuous publication since 1945.

Piaget, Vygotsky and Bowlby
The blooming of developmental psychology occurred after World War I withJean Piaget (Switzerland), Lev Vygotsky (Russia), and John Bowlby (UK). Piaget(1896-1980) postulated that children think differently than adults, going throughfour stages of cognitive development (sensorimotor, preoperational, concrete
operational, and formal operational). For Piaget development is biologically driven
and changes as the child matures. Piaget’s ideas and methodology revolutionised
developmental psychology and had an enormous influence on education and in
future researchers. This does not mean that there were no criticisms of his theories.
For example, not everyone accepted that development occurs in stages preferring
to see it as continuous. Also, Piaget’s method was quite subjective, involved a small
group of children and thus was subject to bias, and underestimated the importanceof social and cultural influences.
Vygotsky (who died of tuberculosis in 1934 at the age of 37) believed in thefundamental role of social interaction in cognitive development. Unlike Piaget’s
notion that children’s development must precede learning, Vygotsky argued thatsocial learning comes before development. He suggested that learning occurs
through the interactions children have with their peers, teachers, and others andthat language plays a key role in this process. His theories had a great influence in
the Soviet Union but were not noticed in western countries until the 1960s; theygave impetus to considerable research on the importance of social interactions inlearning.
John Bowlby (1907-1990) was a psychiatrist trained in psychoanalysis
who became the director of the influential Tavistock Clinic in London. Bowlby
was born to an upper-middle class family who believed that too much parental
affection would spoil a child and as a result he was sent to boarding school at
the age of seven, which he later described as traumatic. He was influenced by

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IACAPAP Textbook of Child and Adolescent Mental Health

Click on the image toview a critical summary of
the theories on maternal
deprivation (The work ofRené Spitz, John Bowlby
and Michael Rutter) (6:51).

John Bowlby

ethological theories popular at the time, particularly Lorenz’s (1935) study of
imprinting. Lorenz showed that attachment in ducklings is innate and therefore
has a survival value. The thinking of psychoanalysts such as Melanie Klein also
influenced him. However, he disagreed with the psychoanalytical belief that
infants’ responses related to their internal fantasy life rather than real-life events.
His 1951 monograph on maternal deprivation, Maternal Care and Mental Health,was extremely influential, particularly his arguments about the importance ofearly attachment relationships and the damage inflicted when the parent-childrelationship is thwarted such as in institutional care or through separation. Someof these issues had already been highlighted by René Spitz through what he called“anaclitic depression” referring to partial emotional deprivation, and “hospitalism”(total deprivation). Bowlby believed that attachment behaviour is instinctive andis activated when the child separates from the mother, feels insecure, or fearful. He
suggested that a child would initially form only one attachment relationship andthat this attachment figure acts as a secure base for exploring the world, becoming
a prototype for all future relationships, so that disrupting this bond can have severe
long term consequences. Later research showed that Bowlby’s belief of a sensitive
period—between six months and three years—during which attachments can form
is too narrow. It is now widely accepted that while there is a sensitive period during
which attachments will form if possible, the time frame appears to be broader
and the consequences less fixed and irreversible. Attachment theory became an
important model for psychotherapy and, to a large extent, is the acceptable face of
today’s psychoanalysis. It influenced child care policy worldwide.

Nature vs nurture
The dictum “give me a child until he is seven and I will give you the man”
summarizes the position of those who have believed in the pre-eminence of theenvironment. This view was embraced in the second half of the 20th century by
behaviourists such as the American psychologist BF Skinner who thought thathuman behaviour was learned, e.g., the result of rewards—what he called “operant
conditioning.” However, the nature/nurture debate goes back to antiquity. For

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IACAPAP Textbook of Child and Adolescent Mental Healthexample Aristotle thought that the mind was a blank slate (tabula rasa), making
education and environment the key factors in development, while Plato believedin an innate knowledge, which is awakened by learning and experience. Aristoteles’ideas were elaborated further by Avicenna and, more recently, by thinkers such as
John Locke and Jean Jacques Rousseau.
The view that behaviour is predominantly the result of genetic endowment(breeding) was the most widely accepted belief in medical circles in the 19th and firsthalf of the 20th century—epitomised by the popularity of the eugenics movement.
It is widely accepted now that the dichotomy between nature and nurture, genetics
and environment, is simplistic, inaccurate or even misleading and that it shouldbe abandoned.
During the last four decades there has been a remarkable increase in theunderstanding of nature (genetics), nurture (environment), developmental
processes, and their interaction, which highlights that all of them are important,influence each other, and all contribute to development. For example, it is known
that a large proliferation of neurons and synapses takes place during the earlystages of development. This is followed by a selective pruning—that continues
until the mid-twenties—shaped by environmental contingencies that fine-tuneeach individual’s brain to make the best of the environment in which persons findthemselves. Some—probably many—aspects of brain development depend on
children being exposed to particular experiences at particular times (e.g., the visualcortex does not develop in individuals who are blind or reared in the dark during asensitive period). That is, genetics shape the behaviour of children by making themseek specific experiences but these experiences actually modify brain structure andfunction and influence later behaviour. These issues are well summarised by Rutter(2002), one of the scholars in this field.

Click on the image to view
an interview with Michael
Rutter discussing maternal
deprivation and geneenvironment interactions(8:21)Developmental psychopathology
Developmental psychopathology is the integrative study of the developmentof psychiatric disorders, such as schizophrenia, depression, and conduct disorder.
That is, it seeks to expose the interactions between biological, psychological andsocial aspects of normal and abnormal development across the lifespan. The earlystudies go back to the 1970s as result of prospective longitudinal studies of children
at risk for schizophrenia. Dante Cicchetti, an American psychologist, played amajor role in defining and shaping this growing field (Toth & Cicchetti, 2010).

INTELLECTUAL DISABILITY
Throughout human history societies have not been kind towards people
with disabilities, so much so that some ancient civilisations such as Rome andSparta practised infanticide of those considered to be disabled or less fit. They had
few or no rights (for example, in 13th century England guardianships were createdto take over the financial affairs of people with intellectual disabilities, considered
incapable of making decisions). Thomas Willis (1621-1675), a UK physician, wasthe first to describe intellectual disabilities as diseases of the brain. In the 18th and19th centuries, driven by the social changes ushered in by the industrial revolution,
housing and care of these individuals moved away from families and towards

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IACAPAP Textbook of Child and Adolescent Mental Health

L’Enfant Sauvage (The Wild Child) a
1970 French film directed by François Truffaut
presents a cinematic version of Itard’s reeducation work with Victor, the feral child of
Aveyron.

largely self-sufficient asylums, institutions that at best provided
for the basic needs—food, clothing, and shelter— of inmates.

From the army of 300,000
feebleminded persons in the
United States come the recruits
that swell the ranks of the
drunkards, criminals, paupers,
and other social outcasts. 25%of the girls and boys in ourreformatories are lacking inmental fibre and are unable todiscern the difference between
right and wrong or are too
weak in character to do rightwhenever there is an inducement
to do wrong. 65% of the children
have a mother or a father, orboth, who are feebleminded.
This country has so far taken
no steps to segregate theseirresponsible persons, so thenumber of them is constantly
increasing […]This army furnishes theranks of the criminals, paupers,
drunkards, the ne’er do wells,
and orders who are socially
misfits. Their incapacity
would be a priori cause of
believing that they eventuallywould become public charges
in one form or another, andinvestigation, in fact, provesthat the groups of criminals,
paupers, etc., actually do
contain large percentages ofpeople mentally irresponsible.

Implementation of universal compulsory education,
introduced in Prussia in 1763 and gradually imitated by othercountries, revealed a large number of children who were unable
to cope with schooling. Systems were progressively developed
to deal with this problem, mostly through institutional care and The New York Times, March 10,
training. The first documented program of intervention for the 1912
intellectually disabled was developed in France in 1799. Jean-Marc
Itard (1775-1838) established a skills-based program for a “feral child” discoveredin the woods near Paris, whom he named Victor. This was important because forthe first time a child with severe developmental delay was treated rather than sent
to an asylum (see also the Romanian orphans’ box in page 14). Eduoard Seguin
took Itard’s methods further and created a program to educate the “feebleminded”
at La Salpetrière in Paris. Thus, French alienists (psychiatrists) such as Edward
Seguin and Félix Voisin set the foundations for the education of intellectuallydisabled people. Seguin subsequently migrated to the US where he published an
influential book on the topic in 1866 (Harbour & Maulik, 2010). It is of note thatin France the term “idiocy” was synonymous at that time with mental illness andnot just with developmental disability.

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IACAPAP Textbook of Child and Adolescent Mental Health

The Romanian orphans
A situation with consequences not dissimilar to those found in the feral child of
Aveyron emerged in Romania in the early 1990s following the collapse of the Soviet Union.
Thousands of children suffering from extreme emotional deprivation were found in very poorly
run orphanages. Many were not orphans; they had been placed there by parents unable
to provide for them because of poverty. Parents were powerless to control the size of theirfamilies because of a ban on contraception and abortion by the communist state, legally
forcing women under 45 to have at least five children.
Children found in these orphanages showed a variety of disturbed behaviours such as
limited capacity to speak and move, rocking, difficulty giving and receiving affection, autisticlike behaviours, and indiscriminate approach to strangers. “The children had been washed in
the orphanage by being forcibly placed under a cold tap, so they had developed a terror ofwater. ‘Their skin was grey when they arrived but there was no question of just popping themin the bath. We had to start by just washing the bits that showed with a face cloth. With theyoungest one, I brought her upstairs to the bathroom when I was having a bath, and when I
saw that she was no longer petrified, asked her if she wanted to come in, too’” (Taylor, 2002).
A number of these orphans were adopted by UK and US families and some ofthem were followed up through the English and Romanian Adoptee Project. The study
has shown that children who experience extreme institutional deprivation usually show ahuge improvement in psychological functioning following successful adoption. However, asubstantial minority of those adopted after the age of sixth months continued to experiencesignificant problems.

Growing urbanization and the industrial revolution highlighted theimportance of intellectual ability to survive in that rapidly changing world.
The “feebleminded” were often blamed for the poverty, illness, and crime that
accompanied urbanization and the ghettos of disadvantage that ensued, leading
to the development of a fearful, alarmist attitude in the media toward people withintellectual disability (see box in page 13). Criminal behaviour and intellectual
disability were thought to be heritable.
Francis Galton (1822-1911) established in the UK a theoretical basis forthe heritability of intellectual disability and provided a foundation for the eugenics
movement—breeding must be managed to prevent the degeneration of the humanspecies. A drive ensued to segregate developmentally disabled people to protect
society and, even more importantly, to control their reproduction. Subsequently,
several US states enacted sterilization laws (30 states had these laws by 1944).
Between 1907 and 1944, more than 42,000 disabled people were sterilized in
the US. In Britain, the Mental Deficiency Act of 1913 emphasized segregation ofmales and females over sterilization. In Germany, the Nazi government’s adoptionof eugenics led to the 1933 compulsory sterilization law under which people
with “congenital feeblemindedness” could be forcibly sterilized—and thousands
were subsequently exterminated (Harbour & Maulik, 2010). Regrettably, some
psychiatrists and child psychiatrists were active participants in eugenic programsin Nazi Germany and elsewhere.

Some child psychiatrists
were active participants ineugenic programs in Nazi
Germany and elsewhere.

Attitudes began to change by the end of World War I and change gained
momentum after World War II. Several factors contributed to this:•Research advances began to show that intellectual disability was notnecessarily inherited; metabolic disturbances (e.g., phenylketonuria)

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IACAPAP Textbook of Child and Adolescent Mental Health••and environmental factors, such as infections and iodine deficiency werecommon, preventable or treatable causes
The Holocaust helped to discredit eugenic practices
Families of children with intellectual disability began to advocate for theirrights and demanded better education and rehabilitation services.

This attitudinal change gradually resulted in more enlightened policies—for
example, President Kennedy established the President’s Panel on Mental Retardation,
setting an agenda in the US for policy, research, prevention, education, and services(Harbour & Maulik, 2010)—and a growing emphasis on de-institutionalisation
all over the world, with the exception of Soviet countries where institutional careof childhood mental disorders was the mainstay. This seismic change crystallisedin the Convention on the Rights of Persons with Disabilities, a United Nations treaty
that seeks to protect the rights and dignity of persons with disabilities. The text
was adopted by the United Nations General Assembly on 13 December 2006. By
September 2014, there were 159 signatories, including the European Union. The
US is not yet a signatory.

THE CHILD GUIDANCE MOVEMENT
Although not formally established until the 1920s, the child guidance
movement started in Chicago in 1906, led by the neurologist William Healy, in thecontext of the international mental hygiene movement and as a result of a groupof lawyers, physicians, social workers, and philanthropists’ concern about treating
and preventing juvenile delinquency (Levy, 1968b). The child guidance movement
sought to move the focus from the juvenile justice system to the family, schooland neighbourhood. “One of its basic ideas was that even the most apparently‘normal’ child might, in the course of his or her emotional and psychologicaldevelopment, experience ‘maladjustment’. This meant that child guidance was,essentially, concerned with the whole child population, or at least that part of theHistory of child psychiatry

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William Healy (18691963) sitting, 3rd from theleft, together with colleagues
and supporters at the 25th
anniversary of the Institutefor Juvenile Research. Next
to him (2nd from left) sits
Augusta Fox Bronner, oneof his close collaborators.
She was co-director of theJudge Baker Foundation,
Boston, from 1930 to 1946.

15

IACAPAP Textbook of Child and Adolescent Mental Healthchild population which was not severely delinquent or, in the language of the time,‘mentally defective’—in other words, the overwhelming majority of children”(Stewart, 2012). Child guidance clinics had a strong multidisciplinary andpsychoanalytic ethos. Its approach represented a change from previous treatment
models, which were largely individual, toward more innovative interventions. For
the first time the mental health of children was considered an important focus
for treatment by itself. Also “child guidance sought to be a form of preventive
medicine promoting children’s mental well-being” (Stewart, 2012). In this the
movement was well ahead of its time.
The child guidance model was soon adopted in other countries (the East
London Child Guidance Clinic established in 1927 was the first in Britain) withlocal adaptations (i.e., in Scotland and Australia it had an educational bias).
Scandinavian countries also began to set up services following the child guidancemodel. In India, the first child guidance clinic was set up 1937. In 2003, there
were 164 child guidance clinics in India—a tiny number given the size and needsof a population of more than 400 million people under the age of 18. In Ireland,state-funded child guidance clinics were established quite late, in the mid-1950s.
In the UK, the child guidance movement received considerable impetus
in the 1950s because of concern for children separated from their parents as aresult of the evacuations that took place during World War II—it is of note thatvery little long term research is available on this area to guide policy; according to
one of the few long-term studies, Finnish children evacuated to Sweden during
World War II did not fare worse as adults than those who remained in Finland(Santavirta et al, 2015). The UK Education Act of 1944 placed for the first time“maladjusted” children in the same category as children with physical disabilities,
thus becoming part of the school medical service. Local education authorities
could set up child guidance clinics and for the most part it was these bodies whichbecame the providers. In the late 1920s there were two child guidance clinics in
England and Wales, by 1955 there were some 300 (Stewart, 2012).
Initially child guidance clinics represented a significant advance in service
delivery—a move from institutional to multidisciplinary community care and toprevention—however their promise faltered:
•

•
•
•

•

Child guidance clinics were often funded by non-medical organizations,such as charities or local councils, hence they often became isolated frommainstream medical, academic and research institutions
Treatment—mainly psychoanalytic in orientation—was often open-ended
and lengthy
Rather than cooperation between psychiatrists, psychologists and social
workers there was often tension
There was no interest in specific diagnosis or treatment—children with avariety of problems were lumped together as “maladjusted” and offered
non-specific treatment; andThere was an inclination to blame parents, which caused considerable
distress and alienated consumers. Particularly in the 1950s, the terms“schizophrenogenic mother” and “refrigerator mother” were widely used todescribe the hypothesized role of mothers in the aetiology of schizophrenia
and autism respectively.

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IACAPAP Textbook of Child and Adolescent Mental HealthChristchurch Health andDevelopment Study staff in2014. From left, front row:
Geri McLeod, Morwenna
Malcolm. Back row: Joseph
Boden, David Fergusson,
John Horwood.

The Los Angeles Child Guidance Clinic celebrated 100 years of continuous
operation in 2014. In recent years the child guidance model has evolved and been
updated by increasingly implementing evidence-based interventions and focussing
on prevention (e.g., parent training) and early intervention, often as an importantcomponent of “community health centres”.

EPIDEMIOLOGYChild psychiatric epidemiological research is a very recent endeavour.
Lapouse and Monk (1958) are credited with having conducted the first
epidemiological study in child psychiatry: the prevalence of parent-reported
problems in a representative sample of 482 children aged 6-12. Epidemiologicalresearch became more sophisticated with the Isle of Wight studies in which not only
parents but children themselves were interviewed (Rutter et al, 1970). To a large
extent, these studies marked the beginning of a truly scientific child psychiatry. The
introduction of new classification systems (e.g., DSM-III), which operationalised
diagnostic criteria, further facilitated and encouraged epidemiological research. By
the end of the 20th century epidemiological research had been conducted in many
countries with broadly consistent findings. These studies have uncovered a largepool of unmet need: a considerable number of children and adolescents who sufferfrom psychiatric conditions, who are significantly impaired by them, but who do
not receive treatment.

Prospective studies
A pioneer was the American sociologist Lee Robins (1922-2009) withher work on the adult outcomes of delinquent (conduct disordered) adolescents(Robins, 1966). Long-term, longitudinal studies of general population cohorts or
selected clinical samples allow hypothesis testing and have offered many insights
into clinical problems—for example showing that most psychiatric disorders havetheir onset during childhood or adolescence—and have underscored the potential
this offers for prevention. A significant methodological obstacle in the measurementof psychological problems is recall bias, which is reduced in prospective studies.
An example of this type of research is the Christchurch Health andDevelopment Study, which has followed the health, education and life progress
through infancy, childhood, adolescence and adulthood of a group of 1,265
children born in Christchurch (New Zealand) in 1977 (Fergusson & Horwood,2001). Prospective studies typically collect information from multiple sources

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IACAPAP Textbook of Child and Adolescent Mental Healthat regular intervals (e.g., every two years). Thanks to this type of research there
is a much better understanding of the continuities and discontinuities between
conditions in children and adults as well as factors that increase or decrease therisk, thus informing preventive interventions. Findings of prospective research
have had a powerful influence in changing public policy and funding of services
for children all over the world.

TAXONOMY
Taxonomy is essential for scientific progress. In psychiatry, the taxonomic
tasks are made more difficult because taxonomy varies with the purpose and context
in which classification is to be used (e.g., clinical-therapeutic, forensic, research,statistical). The early taxonomies—e.g., those of Philippe Pinel (1745-1826)—
had a clinical focus, referred only to adults, and generally classified mental illness
into insanity (including melancholia and mania), dementia and idiocy (idiotisme).
Esquirol (1772-1840) added monomania to these. The concept of moral insanity,coined by James Prichard in 1835 to describe abnormal emotions and behaviours
in individuals without intellectual impairment, delusions or hallucinations, also
became popular in the second half of the 19th century. Emil Kraepelin’s taxonomy,
which he published at the end of the 19th century, moved from focusing on
symptoms to syndromes but ignored childhood disorders altogether. However, his
categorical approach is still used today in the main classification systems. Early
diagnostic groups were based on pattern recognition, on how much an individual
patient was similar to the clinical description of a case presented by an expert orauthority.
The first modern taxonomy of childhood mental disorders was probably
the one described by Maudsley (1895) in the chapter about Insanity of Early Life
(pp259-293). He described seven different conditions:
•
•
•
•
•
•
•

Monomania or partial ideational insanity (children possessed byincontrollable impulses, for example to harm themselves, others, or steal)
Choreic delirium or choreic ideational insanity (characterised by convulsive
violence and incoherence)
Cataleptoid insanity (e.g., lying for hours or days in a sort of mysticalcontemplation, with limbs more or less rigid or fixed in strange postures)
Epileptic insanity (insanity that occurs in connexion with epilepsy)
Mania (insanity)
Melancholia (which could lead to suicide)
Affective insanity or moral insanity (a strange perversion of some fundamental
instinct or moral perversion that seems to be wilful wickedness).

In the first half of the 20th century, before the publication of DSM-III, themain classifications used were ideographic (Werry, 1985). That is, taxonomies wereanchored in a particular theory (e.g., psychoanalysis) that sought to emphasize thetotal context of the individual person and not just the symptoms. For example, thechild guidance movement largely conceptualised child psychopathology in termsof maladjustment—symptoms and behaviours were seen as the manifestation of
deeply-rooted problems, largely within the milieu of family relationships, rather
than representing different disease entities. Ideographic approaches are still widelyused in clinical practice, for example in family therapy.

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IACAPAP Textbook of Child and Adolescent Mental Health

The international Classification of Diseases (ICD)
During the 19th century the need to have a classification of diseases thatprovided information about causes of death became increasingly clear. In 1853a uniform classification of causes of death that could be used internationally wascommissioned and adopted by several countries. Subsequently this classification
was reviewed regularly and updated. The need for a morbidity classification was
also recognised soon after; a list of diseases to meet the requirements of a variety oforganizations, such as health insurers, administrators and clinicians. In the wordsof William Farr (1807-1883), the first medical statistician of England and Wales,a “system of nomenclature to diseases which, though not fatal, cause disability inthe population” (Registrar General of England and Wales, 1856). In 1910, theInternational Classification of Causes of Sickness and Death was published in the
US. However, there was no international uniformity; different countries often
used their own classification. The Sixth Revision of the now called International
Classification of Diseases, Injuries, and Causes of Death (ICD-6) was published in
1949; it included for the first time a section on mental disorders. ICD-7 and ICD8 listed some childhood psychiatric disorders (e.g., mental deficiency). ICD-9,
published in 1977, added “behaviour disorders of childhood”. Nevertheless, theclassification of childhood disorders in ICD-9 was clearly inadequate. A significant
improvement occurred with the publication of ICD-10 (endorsed in May 1990)
where a multiaxial approach was introduced, similar but not identical to that in
DSM-III. ICD-10 also included a description of the main categories and diagnostic
criteria for research. ICD-10 is currently being revised.

Click on the image toaccess the DSM-I

According to Rutter (2011) multiaxial systems of classification have many
advantages in child psychiatry because they:
•
•
•
•

•

Avoid false dichotomies resulting from having to choose between two
diagnoses that do not constitute alternatives in a meaningful sense
Require a coding on each and every axis
Avoid the unreliability resulting from different theoretical assumptions
Provide a means not only to record the main clinical picture, but also makes
it possible to include dimensional features (e.g., intellectual level and degreeof functional impairment).
Represent a style of thinking closer to most clinicians’ preferred style ofworking than a traditional categorical system.

The Diagnostic and Statistical Manual of Mental Disorders(DSM)“The American Psychiatric Association Committee on Nomenclature andStatistics developed a variant of the ICD-6 that was published in 1952 as thefirst edition of Diagnostic and Statistical Manual: Mental Disorders (DSM-I).
DSM-I contained a glossary of descriptions of the diagnostic categories and was
the first official manual of mental disorders to focus on clinical utility. The use of
the term ‘reaction’ throughout DSM-I reflected the influence of Adolf Meyer’s
psychobiological view that mental disorders represented reactions of the personality
to psychological, social, and biological factors” (APA). However, DSM-I did not
specifically mention childhood disorders apart from “mental deficiency”. DSM-II

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IACAPAP Textbook of Child and Adolescent Mental Health(published in 1968) included a section on the behavioural disorders of childhood
and adolescence listing a variety of “reactions” such as withdrawing, overanxious,
runaway, unsocialised aggressive, group delinquent, and hyperkinetic.
DSM-III (published in 1980) revolutionised the approach to the diagnosisof childhood (and adult) disorders because (Rutter & Shaffer, 1980):
•
•
•
•
•
•
•

It used a phenomenological approach
Recognized that disorders rather than individuals should be classified
Introduced a multiaxial framework
Provided a more comprehensive listing of child psychiatric disorders
Improved diagnostic criteria
Added codings for psychosocial stressors, andRecognised that disorders may persist into adult life.

DSM-IV, an updated version of DSM-III, was published in 1994 andDSM-5 in 2013. DSM-5 has abandoned the multiaxial model (for more details
about changes in DSM-5, please go to Chapter A.9).

Other classifications
Not all countries use ICD-10 or DSM-5; the latter has been the classification
more often used in research studies. A few use their own classification or modified
versions. For example, because of perceptions that the main classifications did nottake into account individual differences enough, were reductionist, and overly
focused on operationalised diagnostic criteria, French child psychiatrists chose todevelop their own classification, the French Classification for Child and Adolescent
Mental Disorders (CFTMEA), initially published in 1983. CFTMEA is bi-axial:
one axis lists the basic clinical categories while the other includes associated andpossibly etiological factors (Mises et al, 2002).

Dimensional approaches
Dimensional classifications assume that psychiatric symptoms and illnesses
cannot be simply defined by a “present/absent” dichotomy since they vary inseverity, like blood pressure. Thus, depression can be severe, moderate, mild,
subclinical etc. representing different degrees in a depression dimension and thisvariation has implications for treatment and outcome. There has been muchargument over the last 50 years about the merits of categorical vs dimensional
approaches, with the dimensional view being often preferred by psychologists andresearchers due to its higher statistical power, while categories are favoured by healthinsurance companies and clinicians because they set thresholds for treatment moreclearly. In practice both categorical and dimensional approaches have advantages
and disadvantages and there have been moves to incorporate dimensional features
into the categorical classifications (e.g., in DSM-5) and vice versa. The empirical
ASEBA system of diagnosis is one example (Achenbach, 2009); it has the advantagethat it incorporates ratings from multiple informants, takes into account cultural
aspects, and can generate diagnoses consistent with DSM-5 (see Chapter A.3).
Dimensional classifications are more problematic when dealing with uncommon
conditions.

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IACAPAP Textbook of Child and Adolescent Mental HealthAaron Beck (left) and Albert Ellis at the American Psychological Association Convention in Washington DC in 2000
(Photo: Fenichel)

COGNITIVE-BEHAVIOUR THERAPY (CBT)The origin of CBT goes back to the Russian physiologist Ivan Pavlov’s(1849-1936) famous experiments in classical conditioning (conditioned reflexes).
One example of the therapeutic usefulness of Pavlov’s findings is the enuresis alarm(bell and pad), although it appears that its discovery by the German paediatrician
von Pfaundler in 1904 was accidental and not the result of his application of
Pavlov’s theories. The bell and pad alarm is still the most effective treatment for
nocturnal enuresis.
A variety of therapeutic approaches based on behavioural principles (not onlyclassical conditioning but also operant conditioning) became increasingly popularparticularly in the US, delivered mainly by psychologists. Operant conditioning
was popularised by the US psychologist BF Skinner (1904-1990) who showed thatbehaviour can be modified by its antecedents and consequences, called reinforcers.
The next important discovery occurred in the 1960s, the so-called second
wave of CBT; the finding that thoughts (cognitions) can influence behaviour andfeelings and vice versa. For example, Aaron Beck, a US psychiatrist, showed that
depressed patients experienced negative thoughts about themselves, the world or
the future that seemed to arise spontaneously (automatic thoughts). When thesenegative thoughts were recognised and challenged rationally, patients’ thinking
became more realistic and they felt better. This was called cognitive therapy.
Nowadays what is called CBT consists of a heterogeneous array oftechniques both behavioural and cognitive that are structured, short-term, andpresent-oriented, loosely based on the above theories. CBT techniques are used

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IACAPAP Textbook of Child and Adolescent Mental Healthin the treatment and prevention of most mental disorder in youth and theireffectiveness is supported by a rapidly growing body of research. CBT practitioners
have emphasized all along the importance of measurement and of empirical testingof its effectiveness.
Currently there is a trend to focus not only on what people think but on
how they think (third wave). These new approaches include Marsha Linehan’s
dialectical behaviour therapy, mindfulness-based cognitive therapies, and schema
therapy, among others (Kahl et al, 2012).

FAMILY THERAPYFamily therapy is an umbrella term that covers a variety of clinicalapproaches that seek to treat child psychiatric disorders within the family systemrather than focusing on the individual patient. They assume that family interactions
play a key role in the causation and maintenance of children’s maladjustment,
thus interventions are designed to effect change in family relationships with the
expectation this would lessen symptoms in the identified child.
The roots of family therapy can be found in the late 19th century: theindustrial revolution, the rapid migration of peasants from the countryside to
the cities, and the stress these changes caused in families and communities. The
modernist’s and the so-called progressives’ view of society in the US was that, asa result of these vicissitudes, many families became victims of the quick socialchange and were in need of sustained help. Professional social work emerged inthis context, mostly in the UK and in the US, largely to deal with the resulting
poverty and homelessness. Another precursor of family therapy was the marriage
counselling movement in the 1920s, which sought to provide troubled couples
with information, support, counselling, and guidance by an assortment of marriage
counsellors—clergy, lawyers, gynaecologists, social workers—not specially trained
as such.

Jane Addams (1860–
1935) was a founder of
the US Settlement House
movement and is considered
one of the early influenceson professional social work.
The settlement movement
focused on the causes ofpoverty through the “threeRs” (Research, Reform, andResidence). They provided avariety of services including
educational, legal, andhealth to needy families.
These programs also
advocated for changes insocial policy. Workers inthe settlement movement
immersed themselves in theculture of those they were
helping.

The formal development of family therapy, which did not take place until
the late 1940s, was facilitated by the emergence of systems theory and social
psychiatry. The former shifts the focus from the individual to the system (thefamily) while the latter emphasizes the importance of cultural differences and social
settings in the causation of psychiatric disorder. Family therapy was promoted also
by dissatisfaction with the traditional practice of individual child psychotherapy.
By the mid-1960s, several schools of family therapy had emerged suchas Salvador Minuchin’s structural family therapy, the Milan systems model, theexperiential approaches of Virginia Satir, and intergenerational therapies, toname just a few. Structural family therapy was initially developed to work withchildren who showed significant behaviour problems or eating disorders. Its key
concept is that of boundary: “functional” families are characterised by clear andflexible boundaries, “enmeshed” families are those whose members are excessively
intrusive, “disengaged” families are those whose members are not available to one
another. Structural family interventions seek, among other goals, to re-establish
boundaries that are clear and flexible.
Systemic therapies, of which many variations exist, have their origin in the
Milan School of Mara Selvini Palazzoli, an Italian psychiatrist, but also derive

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IACAPAP Textbook of Child and Adolescent Mental Healthfrom the work of Minuchin. “Systemic therapy neither attempts a ‘treatment ofcauses’ nor of symptoms, rather it gives living systems nudges that help them todevelop new patterns together, taking on a new organizational structure that allows
growth”(von Schlippe & Schweitzer, 1998).

Parent management training
Arguably the most significant therapeutic advance in this domain
has been the development of CBT-based family interventions, collectively
known as “parent management training” or “parent effectiveness training”,
grounded on social learning theory and stemming largely from the workin the 1950s and 1960s of Gerald Patterson, a US psychologist. Patterson(1982) proposed a model of how parental conduct may exacerbate children’s
negative behaviour and result in what he designated as “coercive family
processes”. His work showed that parents of disruptive children are more
likely to be inconsistent in how they apply rules, and give commands thatare either unclear or the result of their own current emotional state rather
than contingent upon the child’s behaviour (Quy & Stringaris, 2012).
Parent management training focuses on parents as principal agents ofchange because they are their children’s best teachers, their advocates, andare responsible for managing many social environments. The goal of parent
management training is to teach positive parenting skills and discourage
coercive tactics. Parent management training programs—there are many
available—have been shown to be effective in reducing troublesome childbehaviour and to prevent the development of, or lessen a variety of disruptive
and emotional disorders in children (Sanders et al, 2014).

PHARMACOTHERAPY AND SOMATIC TREATMENTS
No advance has revolutionised clinical child psychiatric practice as muchas the introduction of psychotropic drugs. Opiates, bromides and chloral hydrate

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Rivendell Paediatric
Psychopharmacology
Conference 1999, Sydney,
Australia. From left, backrow: Robert Redwin, Stanley
Rapoport, John Werry, Susan
MK Tan. Front row: Garry
Walter, Felicity Waters, Jean
Starling, Judith Rapoport,
Joseph M Rey.

23

IACAPAP Textbook of Child and Adolescent Mental Healthwere widely used in the 19th century to treat agitation and epilepsy. Barbital, also
known as barbitone, was the first commercially available barbiturate. It was used asa hypnotic from 1903 to the mid-1950s, becoming popular in psychiatry for thetreatment of schizophrenia through “prolonged sleep therapy” in the 1920s—thistreatment was subsequently abandoned because it was ineffective and dangerous
to patients. There were few reports of the use of these treatments in children except
for barbiturates in epilepsy.
Georges Heuyer was the first to use electroconvulsive therapy (ECT)—asomatic treatment—in young people in the early 1940s. He achieved a dramatic
improvement in some cases at a time when effective treatments were practically
non-existent. Lauretta Bender became a strong advocate of ECT in the US.
Subsequently, in spite of its effectiveness and safety in mood disorders, ECT has
become a controversial treatment—of last resort in the young—and its use inyouth banned in some countries (Rey & Walter, 1997).
Charles Bradley reported in 1937 that a group of children with behaviouralproblems improved when treated with benzedrine (dl-amphetamine), a
psychostimulant drug. However, this finding went unnoticed. The approval of
methylphenidate (Ritalin®) by the FDA in 1955 and the growing awareness ofchildren suffering from hyperkinetic disorder—diagnosis introduced in DSM-II
in 1968 as “hyperkinetic impulse disorder”—were catalysts in the increasing useof stimulants for ADHD, which peaked at the end of the 20th century (see box inpage 25). Stimulant drugs are the best studied in child psychiatry.

The pharmacological revolution of the 1950s
The Australian psychiatrist John Cade discovered in 1949 the effectivenessof lithium salts in treating mania. However, the psychiatric world was slow to adopt
this treatment largely because of deaths resulting from relatively minor overdosing.
Subsequent research by Mogens Schou and Paul Baastrup in Denmark and of
Samuel Gershon and Baron Shopsin in the US helped to overcome resistance tothe use of lithium and its prescription was approved by the FDA in 1970.
The potential role of chlorpromazine in psychiatry was first recognized byHenri Laborit, a surgeon and physiologist in the French army. Pierre Deniker andJean Delay conducted in 1952 the first systematic studies of this drug showing
its effectiveness in psychotic patients. The discovery of chlorpromazine ushered
in real advances in the treatment of schizophrenia and the synthesis later on ofseveral other dopamine antagonists. A new generation of antipsychotics (second
generation) emerged in the 1980s. The second generation antipsychotics showedsimilar effectiveness but fewer extrapyramidal effects, although they have significant
unwanted metabolic effects causing weight gain and diabetes. The first second
generation antipsychotic, clozapine, was introduced in Europe in 1971. It waswithdrawn by the manufacturer in 1975 because it could cause agranulocytosis.
Its use, with the appropriate monitoring, was approved again in1989 after having
been shown to be effective in treatment-resistant schizophrenia.
Evidence of the antidepressant activity of iproniazid, a monoamine oxidase
inhibitor and a well-known treatment for tuberculosis, was presented in 1957
by two US psychiatrists, George Crane and Frank Ayd. The initial report of theHistory of child psychiatry

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IACAPAP Textbook of Child and Adolescent Mental Healtheffectiveness of imipramine (Tofranil®) for depression also occurred in 1957.
This was the first of the tricyclic antidepressants. A new class of antidepressants,
selective serotonin reuptake inhibitors (SSRIs), led by fluoxetine (Prozac®), became
available in 1987. The SSRIs were subsequently found to be effective in the young
not only for depression but also for anxiety disorders and had fewer side effects
than the tricyclics.
Chlordiazepoxide (Librium®) was the first of another new class of drugs, thebenzodiazepines, introduced in clinical care in 1960. Many others followed andtheir prescription for a variety of conditions boomed, so much so that by mid-tolate 1970s, benzodiazepines topped the “most frequently prescribed” lists. By the
1980s a more sober realization of their effectiveness began to dawn, together withgrowing concern about the risk of abuse and dependence. Thankfully, prescriptionof benzodiazepines for children has been much more restrained than for adults
largely due to the lack of evidence of effectiveness in childhood mental disorders.
All these new classes of drugs, although tested in adults, were used widely inchildren without their safety and effectiveness having been examined fully in thisage group, an ongoing problem that has plagued paediatric psychopharmacology.
For example, it was found that tricyclic antidepressants are not, or are only
marginally more effective than placebo in the young while they have serious side
effects, particularly on overdose.
The data from the National Centre for Health Statistics reported in the sidebox highlight the impact of medication in clinical practice, which has been immense.
Medication prescribing has become the largest component of the work of many
child psychiatrists. The availability of psychotropic medications has facilitated theestablishment of behavioural paediatricians as a subspecialty (see below), resulted
in a decline in the use of talking therapies—increasingly provided by non-medical
professionals—and, according to some, a de-skilling of the profession.
The growth in medication prescribing—often without an appropriate
evaluation of the patient by professionals trained in child psychiatry—and
polypharmacy, even in pre-school children, has raised concerns in the larger
community about unnecessary prescribing and about an over-reliance on
medication to the detriment of other therapy forms. Critics also worry about thelong-term effects of psychotropic drugs on the developing brain, although noreliable data are available suggesting this might be a problem.

“The latest estimate fromthe National Centre for
Health Statistics reportsthat 7.5% of US children
between ages 6 and 17
were taking medication for‘emotional or behaviouraldifficulties’ in 2011-2012.
The CDC [Centres for
Disease Control andPrevention] reports afive-fold increase in thenumber of children under
18 on psychostimulantsfrom 1988-1994 to
2007–2010, with the mostrecent rate of 4.2%. The
same report estimatesthat 1.3% of children
are on antidepressants.
The rate of antipsychotic
prescriptions for children
has increased six-fold overthis same period, according
to a study of office visits
within the National
Ambulatory Medical
Care Survey. In children
under age 5, psychotropic
prescription rates peaked
at 1.45% in 2002-2005 anddeclined to 1.00% from2006-2009.” (NIMH)

CHILD PSYCHIATRY AS A BRANCH OF MEDICINE
The term “child psychiatry” was coined only recently, in the later part of the
19 century. Hermann Emminghaus pioneered child and adolescent psychiatrywith the publication in 1887 of his book Die Psychischen Störungen des Kindesalters(Mental Disorders of Childhood), the first textbook in German dealing withemotional problems in children and considered by some as the dawn of childpsychiatry. The Swiss psychiatrist Moritz Tramer (1882–1963) was probably the
first to define the parameters of the discipline in terms of diagnosis, treatment, andprognosis; he also described the syndrome of elective mutism. In 1934, Tramer
founded the Journal of Child Psychiatry (Zeitschrift für Kinderpsychiatrie), which
later became Acta Paedopsychiatrica, IACAPAP’s official journal from the 1960s tothHistory of child psychiatry

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IACAPAP Textbook of Child and Adolescent Mental Healththe 1990s, when it ceased publication because of financial problems (Schleimer,2012).
The epidemic of encephalitis lethargica that spread around the globe afterWorld War I—the precise cause of this illness is still unknown—resulted in many
children subsequently developing behavioural problems and increased the needfor services for them. As a result, some specialist units were created such as thechildren’s unit at Bellevue Hospital in New York City in 1920 (Chess & Hassibi,1978).
The first chair of child psychiatry was created in 1923 in Rosario, Argentina,
held by an Italian neuropsychiatrist and psychoanalyst, Lanfranco Ciampi. This waswell before the first academic child psychiatry department in the US, set up by Leo
Kanner in 1930 at Baltimore’s Johns Hopkins Hospital. Kanner is considered thefirst physician to be identified as a child psychiatrist in the US; his textbook, Child
Psychiatry (1935), is credited with introducing both the specialty and the term to
the English speaking world. Lauretta Bender (1897-1987) was also an influential
figure not only for her work in language disorders, childhood schizophrenia, andfor developing the Bender Visual-Motor Gestalt Test but particularly because she was
the director of the children’s unit at Bellevue Hospital in New York City where she
began training child psychiatrists in 1934, Stella Chess among then.
In a few countries (e.g., Germany, US) child psychiatry has evolved as anindependent discipline, in others as a sub-specialty within psychiatry (e.g., Australia,
New Zealand, UK), yet in others, particularly low and middle income countries, it
is not yet recognised as a separate specialty from psychiatry or paediatrics.

Child psychiatry and paediatrics
The relationship between paediatrics and child psychiatry has been an uneasy
one and has varied considerably according to institution, country and time. In theUK, for example, Aubrey Lewis (1900-1975) believed that “child psychiatry has thesame relation to psychiatry as paediatrics does to medicine” (Graham et al 1999,
p19). Aubrey Lewis was the first chair of psychiatry at the newly created London’sInstitute of Psychiatry; he became a catalyst for the flourishing of psychiatry in
Encephalitis lethargica
Half a million to a million people were affected between 1916 and 1927, one-third of whom died. Only sporadic cases
have been described since then. Patients who survived encephalitis lethargica often developed incapacitating neuropsychiatricsequelae (e.g., post-encephalitic Parkinson’s disease, catatonia, obsessive compulsive disorder, mutism, and severe conduct
problems in children). “Younger children, between 5 and 10 years old, might merely irritate with their clinginess; their impaired
concentration; their incessant restlessness and need for noise; and their lack of consideration for others—not unlike current
attention deficit disorders. But as they grew in strength, their incorrigible impulsiveness escalated in violence and they poseda danger to themselves and others. Errant behaviours included cruelty to anyone who crossed them; destructiveness; lying;and self-mutilation including, in one example, removal of eyes. When they reached adolescence, these patients manifested
inappropriate and excessive sexuality, including sexual assault without regard for age or gender. Bizarrely, these children were
driven by impulsiveness, not self-interest. Thefts, for example, were not undertaken for personal benefit and stolen goods were
often immediately forgotten, or given away” (Foley, 2011).
The cause has not been established. Some speculate that it might have been a post viral syndrome related to the1918 influenza pandemic, although this seems unlikely. More recent work suggests it is an immunological disorder triggered bya streptococcal infection. What in recent years has been termed PANDAS (paediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections) may be a manifestation of the same disease.

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IACAPAP Textbook of Child and Adolescent Mental Healththe UK after World War II and was instrumental in Michael Rutter’s decision to
become a child psychiatrist. Lewis was a supporter of the independence of childpsychiatry and the need for specialist training. Winnicott, on the contrary, believedthat paediatricians should be trained as child psychiatrists mainly by doing childpsychoanalysis (Graham et al 1999, p20). Donald Winnicott (1896-1971) was a
British paediatrician who trained in psychoanalysis and became a very influential
figure in the British Psychoanalytical Society and in child psychiatry in the 1950s
and 1960s with his concepts of holding, the good enough mother, transitional
objects, and the true and false self.
The uneasiness of this relationship is exemplified by the experience in theUS—which has parallels in other countries—where the bulk of child psychiatryin the 1920s and 1930s was practised in the community-based child guidance andjuvenile justice systems, far from mainstream medical centres. Paediatricians rarely
worked in child guidance clinics, did not speak the same (psychoanalytic) language
and had different priorities than psychiatrists. Paediatricians were more concernedwith acute, short term care while child psychiatrists and psychologists focused
mostly on long term therapy and chronic problems. That is, child psychiatric care
was seen as irrelevant to the needs of the children looked after by paediatricians.
Some influential paediatricians argued that they should be in control of thetreatment, with the assistance of psychiatrists, social workers and psychologists
when dealing with chronic, complex problems. As a result, for example, no childpsychiatrist was appointed to the Boston Children’s Hospital until after World War
II. From the 1960s onwards, consultation-liaison services began to be set up with
mixed success. Yet, the model of paediatricians being trained by child psychiatrists
continued to be not acceptable to many paediatricians who preferred to be taught
by their own colleagues (Haggerty & Friedman, 2003).
In 1984, several US institutions sought to integrate psychiatry and paediatrics
by setting up a 5-year training program in paediatrics, general psychiatry and childand adolescent psychiatry (“triple board certification”), which continues today andhas been modestly successful, although the number of people completing training
has been relatively small. Physicians completing the triple board program are able
to practice any of the three specialties alone or in combination. Australia has asimilar program with comparable outcomes.

Behavioural paediatrics
Developmental-behavioural paediatricians seek to evaluate, treat andmanage infants, children, and adolescents with a wide range of developmental andbehavioural conditions and physical complaints (The Society for Developmental
and Behavioral Pediatrics). Behavioural paediatrics as a paediatric subspecialty
began to develop in the US in the 1970s in the context of a variety of circumstances,some of them already alluded to, namely the scarcity and limited availability ofchild psychiatrists; the introduction of psychotropic drugs, which made the timeconsuming talking therapies less relevant for some disorders; the perceived increaseof behavioural and psychosocial problems in children and adolescents coupledwith a decrease in the incidence of traditional medical illnesses; and parents’ andschools’ increased expectations of treatment. It was also alleged that paediatricians,
who had ongoing contact with children from infancy to adulthood, were in the

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IACAPAP Textbook of Child and Adolescent Mental Healthbest position to prevent, detect and treat many of these problems (Haggerty &Friedman, 2003). The Society for Developmental and Behavioral Pediatrics(initially called the Society for Behavioral Pediatrics) was formed in 1982. Stanford
B Friedman and Robert J Heggarty played a key role in its development. The
Society began sponsoring the Journal of Developmental and Behavioral Pediatrics
in 1985.

THE HISTORY OF IACAPAPThe history of child and adolescent psychiatry is best understood in terms ofthe development and progress of the international organizations that work for theestablishment and expansion of child mental health activities all over the world,
in developed as well as in less developed countries. The International Association
for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) is theprofessional umbrella organization for child and adolescent mental healthassociations and their individual members. IACAPAP advocates for the needs oftroubled children and their families at a national and international level through its
member associations and via links with the World Health Organization (WHO)and World Psychiatric Association (WPA), among others.
In 1935 a group of European psychiatrists started work to establish andexpand contacts between psychiatrists working in the new field of child psychiatry.
These pioneers were Georges Heuyer (France), Moritz Tramer (Switzerland), Paul
Schröder (Germany), Carlos de Sanctis (Italy), Nic Waal (Norway), and EmanuelMiller (UK). What we call IACAPAP today started in 1937 as The International
Committee for Child Psychiatry. This committee aimed at organizing a scientificcongress and at promoting and supporting a scientific approach to the mentally ill
child. Georges Heuyer, head of the Clinique Annexe de Neuropsychiatrie Infantile inParis, was to be the organiser and chairman of the first congress in Paris in 1937—
officially called The First International Conference on Child Psychiatry. Moritz
Tramer was also involved in the organization of this congress, where delegates from
26, mostly European, countries participated.
Because of World War II, the second international congress was postponed
until 1948 and took place in London. During this meeting The International
Committee was renamed The International Association for Child Psychiatry(IACP). About 30 national societies were members at that time. All countries were

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IACAPAP Executive
Committee, Beijing, 201028

IACAPAP Textbook of Child and Adolescent Mental Healthto have access to IACP, however a credentials committee was set up to verify thequalifications of each applicant. The name of the association was changed once
more in 1958 to The International Association for Child Psychiatry and Allied
Professions (IACP&AP) and again in 1978 to the name it has today—IACAPAP.
At last, adolescents were incorporated in the official name. However, years later
separate international organizations were created for adolescent psychiatry (ISAPin 1984 and ISAPP today) and for infant psychiatry (WAIMH in 1992).
Thus, the movement towards international child mental health began inEurope among medical specialists in child psychiatry. Expedited by the migrationof child mental health professionals to the US before and during World War II,
North American professionals became involved in this international association
at an early stage. Also, from the 1970s, professionals from other parts of theworld began to be elected as officers of the Executive Committee of IACAPAP—
from South America, Africa, Asia, the Middle East, and Oceania. The IACAPAP
constitution says that officers of the Executive Committee shall be drawn withregard to gender, professional background and age, as well as taking into accountthe principal cultural and geographic regions of the world. Today all parts of the
globe are represented through national societies as full members: 58 in 2014.

More details about
IACAPAP’s history can befound in the booklet by Kari
Schleimer 75 Years with
IACAPAP.
kari.schleimer@bredband.net

In 1954 IACAPAP was officially incorporated in Massachusetts, UnitedStates of America, as a tax-exempt organization. Currently it is registered in Geneva,
Switzerland, as a non-government organization, structured as a corporation, andempowered as a juridical entity.
If networking with likeminded professionals was the initial driving force for
IACAPAP, the emphasis soon evolved “to advocate for the promotion of mental
health and development of children and adolescents through policy, practice andresearch. To promote the study, treatment, care and prevention of mental andemotional disorders and disabilities involving children, adolescents and theirfamilies through collaboration among the professions of child and adolescent
psychiatry, psychology, social work, paediatrics, public health, nursing, education,social sciences and other relevant disciplines”.
To achieve these purposes, one of the main activities of IACAPAP has been
the organization of international congresses—to meet with colleagues, to learn
from each other, and to promote ethical child and adolescent mental health services
and practices. At the beginning, the constitution stipulated that congresses were to
be held every four years. In 2008, it was decided that world congresses should beorganized every two to four years. Besides congresses, regional conferences devoted
to specific topics have been organized regularly. Furthermore, so-called study
groups (or seminars) have been conducted since 1954; in recent years especiallyin low income countries to stimulate the recognition and development of thediscipline in these countries. Since 1998 research seminars for young scientists (theHelmut Remschmidt Seminars) and since 2004 the Donald J Cohen Fellowship
Programme have been regular events to help younger child mental healthprofessionals, especially from less developed countries, to promote their careerdevelopment. Publications like the Bulletin since 1994, the IACAPAP Book Series
since 1970, the e-Textbook of Child and Adolescent Mental Health since 2012, andthe IACAPAP Declarations, mostly published in connection with congresses, haveall broadened the services that are offered to mental health professionals. Child andHistory of child psychiatry

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IACAPAP Textbook of Child and Adolescent Mental Health

Adolescent Psychiatry and Mental Health (CAPMH), an open access online journal
became the official scientific journal of IACAPAP in 2013. The IACAPAP website
is the portal to access most of this material.

HISTORY OF CHILD PSYCHIATRY IN DIFFERENTCOUNTRIES AND REGIONSAFRICA
Historically, psychiatric disorders of children and adolescents were slow to
be recognized in Africa, with those of infants being last of all. As a general rule,child and adolescent psychiatry developed in Africa only in the second half of the20th century. Invariably, medical professionals established the kind of psychiatricservices they were familiar with in the English-speaking countries of the northernhemisphere or in France, Portugal, and Spain. Other than francophone countries inNorth Africa, this brief history covers Anglophone countries only. The informationin this report is largely based on the paper by Robertson et al (2010).
In North Africa, until the year 2000, most child and adolescent psychiatry
services were provided by general psychiatrists with an interest in child psychiatry.
In countries formerly colonized by France, the French psychodynamic model
was predominant, as in day hospital programmes for psychosis or autism. Egypt
developed a more eclectic approach. Over the last decade, the situation has changed
rapidly, with moves towards formal child and adolescent psychiatry training andservices. Tunisia has developed child and adolescent psychiatry as a specialty,
independent from general psychiatry, training three to four new specialists per
year. Morocco is also following this option.
By 2015, in Anglophone sub-Saharan Africa, outside of Nigeria and South
Africa, possibly twenty to thirty psychiatrists would have had some formal training
in child and adolescent psychiatry, but only a few would have had more than one
year of supervised training in a recognized training programme. In the last twenty
years interest in child and adolescent psychiatry in Nigeria has grown significantly,
IACAPAP Study Group, Abuja, Nigeria, 2009

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IACAPAP Textbook of Child and Adolescent Mental Healthaided by regular updates organised by the West African College of Physicians.
Since 1999 many child and adolescent psychiatry services have opened aroundthe country including some with inpatient facilities. The graduation in 2014 of
the first class from the newly established Master of Science programme in Childand Adolescent Mental Health at the University of Ibadan will more than double
the number of Nigerian psychiatrists with a child and adolescent qualification, as
well as increase the numbers of child and adolescent mental health professionals inother parts of the region.
South Africa has provided a complete two-year postgraduate training inchild and adolescent psychiatry for general psychiatrists since 1983. There are
currently over 30 child and adolescent psychiatrists in the country. Child andadolescent psychiatry services are generally tertiary level outpatient clinics, withsome centres providing day and inpatient services. Programs in infant psychiatry
are developing strongly in one or two centres. The South African Association forChild and Adolescent Psychiatry established the peer-reviewed Journal of Childand Adolescent Mental Health in 1989.
The above-named achievements by child and adolescent psychiatry in Africa
represent only a small inroad into the challenges posed by the largely unmet childand adolescent mental health needs on the continent. Neuropsychiatric conditions
constitute a significant proportion of these and include the impact of ongoing
major environmental hazards like HIV/AIDS and other epidemics, as well as war,among the many difficult circumstances in which children grow up on the African
continent. The optimal development of child and adolescent psychiatry services
is made more difficult by a steady and debilitating brain drain, a relative lack ofgood research programmes, and under-resourcing by governments. In the absenceof formal psychiatric services, children and adolescents with psychiatric disorders
may receive interventions from professionals in other sectors, or from traditional
healers or non-governmental organisations. Child and adolescent psychiatry
services will not be able to develop adequately until national child and adolescentmental health policies and plans are adopted with dedicated funding and suitably
qualified personnel to implement them.

ARGENTINA
Early in the 20th century Argentina was an intellectual powerhouse for childpsychiatry. Those were times of affluence and of a thriving cultural life in the
country. The first child psychiatry chair in the world (Cátedra de Neuropsiquiatría
Infantil) was created in 1923 in Rosario for Lanfranco Ciampi, an Italian psychiatrist
who had trained in Rome with Sante De Sanctis. This is currently the only chairof child psychiatry in Argentina. Ciampi also created in Rosario an enlightenedschool for the intellectually disabled using a multidisciplinary approach.

Mahfoud Boucebci(1937-1993) was one of
the founders of Algerian
psychiatry. He authorednumerous books andarticles and was particularly
concerned about helping
the intellectually disabled.
He was president of
the Algerian Society ofPsychiatry and vicepresident of IACAPAP.
He campaigned for asecular democracy andwas a founding member
in 1985 of the first league
for human rights in Algeria.
During the Algerian civil
war—an armed conflict
between the Algerian
government and various
Islamist groups that began
in 1991 and during which
many intellectuals wereassassinated—Boucebci
was stabbed to deathat the age of 56 outside
L’Hopital Drid-Hocine,
Algiers, where he was the
director. A foundation wasestablished in his name in1994 to continue his work.

To meet the needs of children, particularly those with intellectual disabilities,
a number of Medico Pedagogical Institutes (Institutos Médico Pedagógicos) werecreated following the lead of Carlos Bernad Morales. These were institutions withmultidisciplinary staff that sought to address the specific needs of each child.
This model is still followed in other South American countries and in Spain.
Relationships between health professionals and schools were also developed to deal
with children’s specific learning disorders such as dyslexia.

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IACAPAP Textbook of Child and Adolescent Mental HealthTelma Reca, who had returned to Argentina in 1934 after a period of
specialization in the US, was influential in introducing the child guidance model
popular in the US at the time. She began working in the old Hospital de Clinicas
de Buenos Aires treating children with developmental disabilities, motor skills
difficulties and behaviour problems. The Hospital Carolina Tobar García, which
opened in 1968, was the first hospital in Argentina that specifically addressed childand adolescent psychiatric care.
The introduction of concepts such as “minimal brain dysfunction” in the
1960s led to an interaction between psychiatrists, neurologists, teachers and speechtherapists. Developmental problems with affective or behaviour symptoms weretreated as near-neurosis or adaptation syndromes. Mood and anxiety disorders
were not a focus of clinical attention as much as they are today. There was also
a great interest in high functioning autistic children, which led to the creationof special classrooms for them, with only a few pupils and staffed by teachers,
psychologists and speech therapists.

Lanfranco Ciampi(1885-1962), held the firstchair of child psychiatry in
the world, established in
Rosario, Argentina, in 1922.

Psychoanalysis had a very large impact in the evolution of child psychiatry inArgentina. While psychoanalytic ideas had reached South America much earlier—Freud’s works were translated into Spanish in the 1930s—the Spanish civil war,
the rise of Nazism, and World War II resulted in several trained psychoanalysts
migrating to, or seeking refuge in Argentina, such as Ángel Garma. The creationof the Argentinean Psychoanalytic Association (Asociación Psicoanalítica Argentina)
in 1942 was an important milestone. The subsequent popularity of psychoanalysis
led to many professionals, particularly psychologists, training in the discipline andan overcrowded field. The dominant influences in the 1970s and 1980s were
continental European—exemplified by Ajuriaguerra’s 1973 textbook Tratado dePsiquiatría Infantil—and Freudian or Kleinian-style psychoanalysis.
The publication of DSM-III in 1980 and subsequent editions, thenewfound eclectic approach of North American psychiatry, the evidence-based
treatment movement, and globalization have had a growing impact on clinicalpractice in the last 30 years and there has been a dramatic increase in the useof psychotropic medications. This was compounded in Argentina by economic
problems and social strife that created a difficult environment for the practice ofthe specialty. Nevertheless services for children and adolescents are increasing.
The child psychiatry paradigm—and the name of services—has been changing
over the years to reflect the ideas prevalent at the time: from mental hygiene,
to developmental psychology, to psychopathology, and finally to mental health,although child psychiatry is still used.
The AAPI (Asociación Argentina de Psiquiatría Infanto Juvenil y Profesionales
Afines), created in 1969, is the main child and adolescent mental health associationin the country and a member of IACAPAP. Uruguay, Chile and other SouthAmerican countries have their own associations. They are all part of FLAPIA(Federación Latinoamericana de Psiquiatría de la Infancia y Adolescencia), theSouth American child and adolescent mental health umbrella organization. BothAAPI and FLAPIA conduct congresses, training courses and advocate for better
education of professionals and better services.

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IACAPAP Textbook of Child and Adolescent Mental Health

Melanie Klein was very
influential in South American
child psychiatry.

ASIA
Asia is a conglomerate of very diverse countries, regions and cultures, uniquein the sense that mental health was not in the domain of health until very recently.
Emotional concerns were seen as the domain of families and communities. It is not
as if mental health needs were not met prior to the formal development of childmental health services; they were often provided by existing social and community
resources. This could include village elders, medical practitioners who took careof children and social services. In China, the earliest account of mental healthrelated literature was not in medical accounts by physicians but rather in a volume
on dreams as early as the late Ming Dynasty (around 1636) (Vance, 2014). The
combination of biologic and psychological approaches was emphasised as earlyas the 18th century (Chen, 2014). In countries that were part of the former
British Empire, such as India and Singapore, British-style services gained strong
foothold from the 1960s and 1970s. There were child guidance clinics that were

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IACAPAP Textbook of Child and Adolescent Mental Healthsmall and poorly staffed. Specific child psychiatric training was not available
and most practitioners were trained in Britain. Most of the child psychiatricwork was undertaken by general psychiatrists, which often resulted in children
being treated like mini adults. Indonesia, Japan, Philippines, South Korea andThailand were influenced by US practitioners, who promoted the development oflocal training programs. Most of such services drew from influential individuals
who sponsored such development, for example Kusumanto Setyonegoro (1924–
2008) in Indonesia. His influence brought South East Asian child psychiatry into
the forefront in the region. Most Asian countries had child psychiatry services
concentrated in urban centres such as Jakarta, Tokyo, Seoul, Manila, Bangkok andBangalore.
Formal services in Asian countries started in several ways. One wasthrough the formation of professional associations with prominent individuals
who advocated for the establishment of services or by influencing national policy
development. For example, in China, Tao Guo Tai singlehandedly set up childpsychiatric services in 1930 in Nanjing. Through his influence and patronage,
the entire country was galvanised to develop this type of services (Hong et al,2004). Another way was through the development of mental health policies. In
Singapore, the government started child mental health services in 1970; children
were seen as important in the new country and their physical and emotional health
had to be addressed. In 2005, the government moved to improve existing services
in response to the tragic suicide of an 11 year old. This resulted in the formationof a National Committee on developing child psychiatric services and subsequentplans (Fung et al, 2012).

Textbook by Tao Guo
Tai, the first Chinese childpsychiatrist

Regional review
Because of the diverse nature of the Asian continent, a sample of several
regions and countries is provided in Table J.10.1, incorporating data from several
sources (e.g., Guerrero et al, 2013; Hirota et al, 2014, Hong et al, 2004; Tan et al,2008). Most child psychiatry services started between the 1960s and 1980s largely
following Western models (Mcclure & Shirataki 1989; Woon, 1981; Fung et al,2012). Formation of national and, eventually, regional associations resulted in amore rapid growth of services. IACAPAP held its international congress in Kyoto,
Japan in 1990 and the idea of an Asian association was seeded at that meeting.
The Asian Society for Child and Adolescent Psychiatry and Allied Professions(ASCAPAP) was formed in 1996 and its membership has grown steadily sincethen. Because Asia is a mix of high, middle and low income regions and countries,
development has been uneven. Even when resources are available, developmentof services may depend on how well professionals (for example psychiatrists andpaediatricians) collaborate in defining the basis for child psychiatric practice. For
example, in Japan, child guidance clinics were set up in 1974 but were run bypaediatricians with psychiatrists performing a visiting role (McClure & Shirataki,1989).

International collaborations
Concerns about the mental health of children in Asia only started in the
1970s. The WHO set up an expert committee for third world countries in 1976,

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IACAPAP Textbook of Child and Adolescent Mental Healthwhich produced a technical report the following year. The findings were consistent
but loosely based on a survey of only four countries: India, Thailand, Sri Lanka,
and Indonesia (Bartlett, 1980). The finding was that all four countries did nothave significant services but were developing them following Western lines, so thatin Indonesia and Thailand American influences were prominent. An interesting
point in India and Sri Lanka was that although adult mental health was considered
to be the domain of clinics and hospitals, child mental health was seen as a matterfor the family. Influential paediatric texts did not include child mental healthissues. The 1977 report concluded by suggesting the following developments:•

Services should be planned and coordinated because mental health needed
multidisciplinary input. In fact, based on the WHO report, the need forcross-sectorial national plans was emphasised•

Development of child mental health centres was needed and models in
Jakarta and Bangalore were lauded as examples•

Need for training child psychiatrists, who were divided into two groups,
general psychiatrists who do some work with children and families, andspecialised child psychiatrists who work only with children. The need forcross cultural training in influential western centres for professionals fromcountries without local training programs was emphasised. This was thecase for many Asian countries in which child psychiatrists were rare or nonexisting•Child psychiatry and paediatrics were seen as complementary and the needfor cross training was emphasised. Many paediatricians had little training inmanaging mental health issues and did not work closely with child mental
health services•

Teachers should be trained in areas such as child abuse, mental retardation,
learning difficulties and epilepsy. This was akin to suggesting using
educational settings as potential primary mental health care delivery points•

Culturally appropriate health education should be used, with proper
evaluation before being embraced•

The number of educational psychologists should be increased as they could
be the link between mental health care and education.

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The Executive Council ofthe Bangladesh Association
for Child and Adolescent
Mental Health (BACAMH)
at the 2012 Annual General
Meeting

35

IACAPAP Textbook of Child and Adolescent Mental Health

Table J.10.1 Overview of the status of child psychiatry in several Asian regions andcountries*

COUNTRY

Bangladesh
Brunei
Darussalam
Cambodia

China

Hong Kong

India

POPULATION(millions)% AGED 0-15
YEARS
166
30%

Japan

Lao PDR

Malaysia

Mongolia

Myanmar(YEAR STARTED)

15

18%
7
12%
1,300

253
29%
127
13%

Professional Committee on
Mental Health In Children(1986)

1930

Hong Kong College of
Psychiatrists (1948)

1960s

Indian Association for Childand Adolescent Mental
Health (1990)

1937

Association of Child And
Adolescent Mental Health,Indonesia

1978

Japanese Society for Child
Psychiatry (1960). Became
Japanese Society for Childand Adolescent Psychiatry

1920s

1
(4)
0
(41)
500
(20,500)
30
(300)
100
(4,000)
40
(600)
1,677
(13,534)

7

2

35%

(2)

31
26%
3
27%

Malaysian Associationof Child and Adolescent
Psychiatry (MYCAPS)(2014)
Recognised subspecialty
1978

CHILD
PSYCHIATRY
TRAINING
PROGRAM(814)*

1996

31%

NUMBEROF CHILDPSYCHIATRISTS(TOTAL N OF
PSYCHIATRISTS)
2

2005

25%

1,400

YEAR CHILDPSYCHIATRYSERVICES
STARTED

Bangladesh Association
for Child and Adolescent
Mental Health (2008)

0.4

28%
Indonesia

CHILD PSYCHIATRY
ORGANISATION

1968

25
(289)
2
(135)

56

0

25%

(80)

3-year
6 year training
program in general
psychiatry. No
specific childpsychiatry training.
3-year training
program
2 years in addition
to 3 years ingeneral psychiatry
3 year of a 5 year
training program forpsychiatrists

4 years of training
to be psychiatrists
followed by 3 years
for child psychiatry
I year, general
psychiatry training
2 years training in
general psychiatry*Some of the data are not available. These are best estimates obtained from a variety of sources.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.10.1 Overview of the status of child psychiatry in several Asian regions andcountries (continuation)*

COUNTRY

Pakistan

POPULATION(millions)% AGED 0-15
YEARS

CHILD PSYCHIATRY
ORGANISATION(YEAR STARTED)YEAR CHILDPSYCHIATRYSERVICES
STARTEDNUMBEROF CHILDPSYCHIATRISTS(TOTAL N OF
PSYCHIATRISTS)

188

2

34%

(342)

CHILD
PSYCHIATRY
TRAINING
PROGRAM

Philippines Mental Health
Association (PMHA) (1950)
Philippines

100
34%

Child and Adolescent
Psychiatrists of Philippines(CAPPI) (1993)

1950s

20
(400)

The Philippine Societyof Child and Adolescent
Psychiatry (1996)

Singapore

South Korea

Sri Lanka

TaiwanThailand

Vietnam

5
16%

51
14%

Section of Child Psychiatry,
College of Psychiatrists,
Academy of Medicine
Singapore (2014)
Korean Academy of Childand Adolescent Psychiatry(1983)

1970

1958

3-4 years of general
psychiatry and2 years of childpsychiatry

25
(208)

4 years of general
psychiatry
residency and1 year of childpsychiatry

400

4 years general
psychiatry and2 years of childpsychiatry training

20
25%

14%

Taiwanese Society forChild and Adolescent
Psychiatry (TSCAP) (1998)

68

Royal College of
Psychiatrists of Thailand

23

18%

Psychiatric Association ofThailand (1950s)

1953

1960s

195
(1,480)

120
(520)

93

10

23%

(700)

3.5 years of general
psychiatry. 1 yearof child psychiatry
training
3 years of general
psychiatry. 4 yearsof child psychiatry
training
2 years of general
psychiatry training*Some of the data are not available. These are best estimates obtained from a variety of sources.

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IACAPAP Textbook of Child and Adolescent Mental Health

These ideas were consistent across the various reports that emerged in the last
three decades (Belfer 2008; Hong KM 1982; McClure & Shirataki 1989; Woon,
1981). Some of these ideas can be best promoted through regional organisations.
ASCAPAP since its inception in 1996 is an example of collaboration between
different countries within the region by sharing knowledge and experiences, by
the development of training programmes, professional development, and researchcollaboration.

Asia in comparison with the rest of the world
The WHO Mental Health Atlas gives a good summary of the extent of
mental health services globally (WHO, 2005; 2011). Ten countries in the South
East Asian WHO region (Bangladesh, Bhutan, India, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka, Thailand and, Timor Leste) were evaluated. The
atlas provides information on six domains: governance, financing, services,human resources, medications, and information systems. The key finding was that
resources for mental health were insufficient, poorly distributed, and inefficient,with a general trend of reduction in institutional care. For the South East Asian
region, the pertinent points were:
•

•

•

•

Although mental health is considered in general health policies in 80% ofcountries and dedicated mental health policies exist in 70% of them (second
only to the European region), population coverage was only 30%. Mental
health plans were present in 80% of countries in Asia compared with theworldwide average of 70%.
Asia allocates to mental health the lowest amount of funds, in terms ofpercentage of the health budget. Even with such a low allocation, most of
the mental health budgets in Asia were spent on inpatient care.
Asia has the highest availability of mental health resource manuals inprimary care at 50%. Facilities for mental health delivery (outpatient, day
treatment and inpatient) were the lowest in the world
Mental health workforce is amongst the smallest in the world—second only
to Africa—with an average of 0.23 psychiatrists per 100,000 population(world average was more than five times higher at 1.27/100,000). A similar
pattern exists for the rest of the mental health workforce.

In 2005, WHO also developed a mental health atlas for child and adolescentmental health (Belfer 2008; WHO 2005) but only three South East Asian
countries completed the survey (India, Sri Lanka and Thailand). In comparison
with general mental health policies, specific child and adolescent policies were lesscommon (50%). Like in their adult counterparts, the mental health workforce wassignificantly smaller than in Europe and the Americas.

BRAZIL
Until the mid-19th century, Brazilian medicine was completely dependent
on Portuguese medicine as Brazil was not allowed to have its own universities.
Those interested in becoming physicians were forced to study in Europe (e.g.,
Lisbon or Paris). By 1808, with the arrival of the Portuguese court in Brazil (theBraganza royal family and its court of nearly 15,000 people) fleeing from the
Napoleonic invasion of Portugal, two pioneer medical schools were establishedin Rio de Janeiro and Salvador (Bahia). Even so, there was no teaching on mental

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IACAPAP Textbook of Child and Adolescent Mental Healthillness care, which was only established in 1822. By 1824 the mentally ill had been
deprived of political rights and the Santas Casas (“Holy Houses of Mercy”, religious
institutions of Portuguese origin scattered around the country that ran charity
hospitals) assumed their care. Three psychiatric nuclei grew in Rio de Janeiro (ledby Juliano Moreira), São Paulo (coordinated by Francisco Franco da Rocha), andRecife (Pernambuco), represented by Ulysses Pernambucano. In relation to childand adolescent psychiatry, the first nucleus developed a special school linked to
Hospital Juliano Moreira. The second nucleus originated an “abnormal children´s”
section in Hospital do Juquery in 1929, run by Vicente Batista. The third conducteda series of studies on mental retardation and evaluation tests. In 1932 the Russian
psychologist and pedagogue Helena Antipoff founded the Sociedade Pestalozzi in
Belo Horizonte (Minas Gerais), focusing on the multidisciplinary care of children
disabled or mentally disordered.
By the mid-1950s, some child psychiatry facilities were set up in association
with general hospitals. One of them was headquartered in the Universidade do
Brasil (Rio de Janeiro) in 1953 and in 1955 another in the Universidade de São
Paulo. The latter was headed by Stanislau Krynski, arguably the most influential
child psychiatrist in Brazil until the mid-1980s. By the mid-1960s, Krynski linked
with the Associação de Pais e Amigos dos Excepcionais (Association of Parents andFriends of Exceptional Children, APAE, an association that, in addition to parents
and friends of the “special”, sought to prevent and treat disabilities and to promote
the welfare and development of people with intellectual disability). He trained
several disciples and conducted many studies on mental retardation.

Salvador Célia (19402009) was a leading
Brazilian child psychiatrist.
He was secretary and vicepresident of IACAPAP.

During the mid-1970s child psychiatry in Brazil underwent significant
changes under the influence of Argentinian psychoanalysts who migrated toBrazil during Argentina’s military dictatorship, resulting in Brazil losing most ofits distinct clinical traditions. This situation remained until the mid-1990s whena new generation of Brazilian child psychiatrists, influenced by North American
psychiatry, changed the profile of the specialty, losing the continental European
flavour to adopt an Anglo-American empirical-pragmatic approach (Assumpção,1995).
Even after this shift, child psychiatry in Brazil is currently in difficulties.
Whether this is due to the low number of trained professionals (presently under
300 and badly distributed geographically), to the dearth of training programs, orto the absence of child mental health teaching in most Brazilian medical schools’
curricula, is unclear. Moreover, this crisis is exacerbated by a lack of youth mental
health policies and of specialist health services for this age group, creating a vicious
cycle of lack of services and professional interest. Thus child psychiatry in Brazil is
stepping unsteadily into the 21st century.

CENTRAL AND EASTERN EUROPEAN COUNTRIES(CEECs)
The situation in the field of child and adolescent mental health in Central
and Eastern Europe deserves special attention. This is a huge region covering 30
new democracies, which emerged after the collapse of the Soviet Union and its
then satellites, with a population of around 400 million. These countries have very
different cultural backgrounds. Geographically, not all are even located in Central

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IACAPAP Textbook of Child and Adolescent Mental Healthand Eastern Europe—the countries of the Balkan region are in South-Eastern
Europe. However, they all have a similar context because, after having been undercommunism for 50 to 70 years, they have faced a transition from totalitarianregimes to democratic ones. The period from 1990 —when socio-political changes
started— has been marked by an impressive combination of successes, challenges
and failures in many areas, including in child and adolescent mental health.
Under Soviet rule, CEECs developed a unique system of mental healthcare for both children and adults different from that in developed and developing
countries. Contrary to what occurred in most of the rest of the world, this system
was driven by Soviet ideology, which supported health policy and social security
with relatively large amounts of financial and human resources. However, compared
to western countries, resources were predominantly invested in residential
institutions. State policy was based on a model of social exclusion of vulnerable
groups. The usual solution was to institutionalise children in cases where families
were in crisis or children developed problems. The official indicator of the system’s
good performance was a high percentage of “organized children” (which meant
institutionalised children) with any type of developmental or psychosocial problem.
Community-based services were prevented from developing by the very fact that
Soviet ideology held that psychosocial problems had been successful solved by thepolitical system, resulting in a lack of development of the psychosocial components
of care, and the child and adolescent mental health field being dominated byconcepts such as “defectology” and “child psycho-neurology”.
Child psychiatry was initially part of child psycho-neurology and evolvedon the basis of a narrow biomedical model represented by the clinical neurology ofthe mid-20th century. In the 1970s, child and adolescent psychiatry was recognized
as a specialty, becoming independent from child neurology throughout the Soviet
Union. Since then the specialty has been struggling for independence from adultpsychiatry with varying degrees of success in different countries. While adultpsychiatry in the Soviet Union was known for its extremely broad criteria forschizophrenia —resulting in psychiatrically-justified political abuses— child andadolescent mental health was looking for other ways of interpreting the possible
causes of emotional and behavioural disorders. As a result, diagnoses different fromthe widely accepted classifications (ICD, DSM) were often used, reflecting theformer links with child neurology (such as organic brain syndrome or organictype consequences of hypothetical mild brain damage during pregnancy, labour or
early infancy). It is important to remember that these trends were the outcome ofideological statements by a totalitarian state, according to which the psychosocial
causes for disorders had been eliminated. Thus, pharmacological treatment
was used extensively in both outpatient and inpatient child psychiatry services.
Professional groups of clinical psychologists started to slowly grow only from the
1980s. Social work as a specialty was non-existent until 1990 when the sociopolitical changes in the region started.
The services for children with developmental disabilities grew under theconcept of “defectology”, which was a Soviet equivalent of special education. The
level of defect was assessed in each disabled child to decide whether it was costeffective to invest in his or her education as future cheap labour force. As a result
mildly intellectually disabled children were usually referred to special schools, while
those with moderate and severe intellectual disability were assessed as uneducable.

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IACAPAP Textbook of Child and Adolescent Mental HealthChildren in a Romanianorphanage in the early
1990s (Photo: Mike Carroll)

Professionals gave parents the strong advice of abandoning these children, placing
them in state institutions for the rest of their lives. Tragically, a large group ofchildren suffering from social and emotional deprivation were also placed in
special boarding schools by labelling them as mildly intellectually disabled. In
this way the Soviet system was hiding social problems and presenting them asproblems emerging in the brain of the child. The Romanian orphanages are an
extreme and heartbreaking example of this. Under Nicolae Ceauşescu, abortionand contraception were forbidden in Romania. This resulted in many children
being abandoned and placed in orphanages with disabled and mentally ill ones.
These vulnerable children were subjected to institutionalised neglect and abuse,including physical and sexual abuse and given drugs to control their behaviour.

Child psychiatry in Lithuania after the collapse of the Soviet
Union
Following the collapse of the Soviet Union in 1991 there were dramatic
political changes in the CEECs and opportunities for developing modern
approaches to child and adolescent mental health. Child psychiatry in thesecountries emerged in this context. The successes, challenges and failures of the
Lithuanian child development model are described as an example. The situationand development in other CEECs may be quite different.
In 1991, a Child Development Centre was established in Vilnius as ademonstration clinic for the implementation of contemporary child and adolescentmental health policies and practices. The centre was affiliated with Vilnius
University. Since then, considerable progress has been made in restoring a balance
within the biopsychosocial paradigm. However, after 25 years of attempting tochange service delivery there is a sobering acknowledgement that the influenceof the former ideology is still vast and contemporary approaches to treatment areoften losing the battle for funding to traditional services, which still rely on theconcept of social exclusion, stigma and institutionalization.

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IACAPAP Textbook of Child and Adolescent Mental HealthWith the help of the international community, more than 50 diagnostic
and therapeutic methods have been introduced into clinical practice in Lithuania.
The attitude has been to accept all the evidence-based approaches and not tobecome dependent on one or another school of thought or clinical practice. As
there is ideological control no longer, the mass media has begun to highlight the
problems that had been hidden from the public during the Soviet era and theChild Development Centre took advantage of this to urge politicians to initiatechanges within the system.
The first problem brought to people’s attention was the plight of children
with developmental disabilities, including intellectual disability and autism. A
strong coalition of professionals, parents’ organizations, and reform-minded
politicians was successful in convincing the national authorities to develop a
network of community based services for these children—as an alternative to the
traditional system of large residential institutions. The Child Development Centre
has been driving this process with professional education and skills, emphasizing
early intervention for infants and preschool children with developmental problems
and disabilities. This field has grown as developmental (social) paediatrics, witha network of community-based teams throughout the country. Thus, a goodfoundation has been built for the reintegration of disabled children into theeducation system and society in general.
The specialty of child and adolescent psychiatry has become well establishedin Lithuania, with a four-year postgraduate (residency) training program. In 2015
there are 80 specialists in child psychiatry working in outpatient and inpatient
services. After long debates with the compulsory health insurance fund, relatively
good agreements have been achieved, so that funding of inpatient and day careservices allows having teams of professionals working with children in need. A pilot
service for an intensive one-week crisis intervention program has been opened, also
covered by health insurance despite referred cases not necessarily having a medical
diagnosis. It was an important victory to convince national authorities that healthinsurance funds should be used for the effective and flexible management of urgent
psychosocially challenging cases (e.g., suicide attempts, physical or sexual abuse).
Outpatient services are staffed by child psychiatrists, psychologists and social
workers, who are employed by municipal mental health centres, funded by healthinsurance on a capitation basis. However, these so-called primary care mental
health centres are too weak to perform the mission expected of them since they
have an extremely small number of non-medical staff (such as one professional per
30,000 population). Currently, negotiations with government are taking place todevelop regional child and adolescent mental health centres with larger catchment
areas, which would have a higher number of psychologists and social workers in
the team and will be able to better fill this gap.

Click on the image to accessChild and Adolescent
Mental Health in Europe:
Infrastructures, Policy andProgrammes. Luxembourg:
European Communities.

The ongoing debate indicates that there are many challenges and obstacles
for the development of child and adolescent mental health services in Lithuania,
which seems to follow the path of what happened in Western Europe 50 years ago.
Opponents of change argue that most of the population (and especially families
at risk) are not motivated to receive psychosocial interventions, that there is nota large enough workforce (health professionals are not eager to move to work in
the provinces; they often chose to migrate to other countries because of better
salaries). Further, most child psychiatrists working in existing services are reluctant

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IACAPAP Textbook of Child and Adolescent Mental Healthto support the development of new services and there is a popular view among
health authorities that the compulsory health insurance fund (the only way tofund healthcare services in Lithuania) should not be used to pay for interventions
provided by professionals who are not medical practitioners. It will be known in
the future if a breakthrough in the development of child and adolescent mental
health services is possible in Lithuania. The outcome of this debate could be
important in the broader European and global context as it raises importantquestions about priorities when developing healthcare systems.
Despite the achievements, 25 years of change have not managed to eliminate
fully the Soviet legacy in mental health and social policy. The state of the child andadolescent mental health field is a good reflection of the level of democracy andcivil society in a country. While the physical health of children (such as preventionof infant mortality and morbidity, vaccination, prevention of infectious diseases)
were already adequately addressed during the Soviet era—and developed further
as a priority during the transition period—there is still a lack of political will tomanage comprehensively many child and adolescent mental health problems.
From 2007 to 2009, a project funded by the European Commission andled by Lithuania (Puras et al, 2010), examined challenges and opportunities forthe development of effective and evidence-based child mental health policies in
the context of the European Union (EU) enlargement. The large number ofcountries (16) and organizations (35) from old and new EU member states thatparticipated allowed comparisons between countries and regions. There was a clear
difference in the quality, quantity and direction of child and adolescent mental
health services. While Northern, Western and Southern European countries (oldEU member states) had well established services with a large number of allied
mental health professionals supporting child psychiatrists in teams, in many newer
EU countries (Bulgaria, Romania, Baltic countries) a large proportion of humanand financial resources was still employed in ineffective residential settings (such as
infant homes and large residential institutions for older children with and without
disabilities). The situation in the Baltic countries was significantly better than in
Eastern non-EU countries (such as the Russian Federation or Ukraine). The childand adolescent mental health field in Central European countries (such as Czech
Republic and Poland) and the former Yugoslavian states has developed more
effective community-based services compared with countries that had been partof the Soviet Union. This difference could mean that Eastern European countries
had a heavier legacy of the totalitarian mentality than Central European countries,
Baltic countries being in the middle. As an example, the project studied thesituation of children born to parents with intellectual disability. While countries
such as Finland have developed services for such families, Lithuania, Bulgaria andRomania still—as a rule and not as an exception—institutionalise both motherand child.
One of the systemic gaps in many CEECs is the lack of a culture ofevaluation and monitoring of policies and services. The Soviet tradition was tofocus on statistics that reflected processes and not outcomes. This gap has not been
filled thus far; research and evaluation activities in child and adolescent mental
health are not funded by governments.

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IACAPAP Textbook of Child and Adolescent Mental Health

FRANCE
After a long period during which the specific nature of children’s mental
disorders had been ignored, French psychiatrists became interested in the conceptof “idiocy” through the works of Itard about the Sauvage de l’Aveyron, a feral child.
Jean Marc Gaspard Itard, a student of Pinel—the father of asylum psychiatry—isknown for his work on access to language. Until then, only educationalists hadstudied children and then only from the teaching point of view. Even when general
hospitals were created in every major French city by the 1662 Royal Edict, children
did not receive special attention. Forsaken with beggars and convicts, children had
only one specific feature: abandonment—a widespread practice throughout the
middle ages.

“Idiocy”
In 1800, Itard developed the first medico-educational therapy. The result,in addition to an extensive observation on what looked like childhood autism, wasa debate about whether mental disorders were inborn or acquired, psychologicalor organic in nature, a debate that would haunt the 19th century and hindered
psychiatric care in the first half of the 20th century.
Idiocy in French was synonymous with mental illness or lunacy, and theonly application of asylum medicine concerning children. Edouard Seguin—
who worked as a teacher in an asylum—developed a type of care for the idiots.
He considered that idiots had “an infirmity of the nervous system” and needed
educative and sensory treatments based on physical activities. Seguin thought that

With the appointment of Bourneville in 1890, and later on, in 1957, of Roger Misès, La Fondation Vallée has been at the centre
of innovation and care for children and adolescents in France.

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IACAPAP Textbook of Child and Adolescent Mental Healthidiots had a preserved intelligence behind their disease. The work of Seguin was
not well received by the alienists (physicians working in asylums); half a century
and the work of Bourneville must come to pass for real advances in the treatmentof idiocy to occur. Désiré-Magloire Bourneville, an alienist, recommended themethods of Seguin and led the Fondation Vallée. He fought for early treatment andfor consistency in punishment in his teaching. He is known for his activism against
the deplorable conditions in asylums for the mentally ill. He focused above all on
the development of education.
These approaches had the advantage of thinking about treatment despite
the ongoing debate on aetiology, which became complicated further with thetheory of degeneration proposed by Benedict Morel. According to Morel, idiocy
and imbecility (intellectual disability) were the legacy of madness over several
generations. This reflected the eugenic interpretation of man and his destiny
popular at the time and reflected in literary works such as Zola’s. Idiocy started tobe considered an incurable condition and not a progressive disease.

Roger Misès (19242013) had a major impact
on the development of childmental health services inFrance.

The organisation of care: From maladjusted childhood todivision into psychiatric sectors
At the beginning of the 20th century, Bourneville saw his work and hisdesire to create genuine asylum schools somewhat hampered by the work of
Binet and Simon, the creators of psychometrics. Alfred Binet, who was directorof the psychology laboratory at the Sorbonne, defined the idiot as a child unable
to communicate with language. He wrote in 1908, with the psychiatrist Théodore
Simon, Abnormal Children. The advent of psychometric testing allowed thedevelopment of specialised classes in France, where school had become compulsory
by the Ferry Act of 1884. Classification led, on the one hand, to a great improvementin the support provided by state-funded schools to children considered “curable”,
but maintained segregation for children considered “incurable”, who were directed
towards asylums without any real treatment.
The 20th century thus began with a split between the support offered
to some children by schools and the confinement of others in asylums, whichbecame psychiatric hospitals in 1938. Conditions became increasingly precarious
in asylums as the theory of degeneration reached its zenith. Debate then became
about abnormal childhood—with a distinction between “the abnormal child in
asylums” and “the abnormal child in schools”.
Besides this, French child psychiatry became increasingly interested in avariety of other issues such as juvenile delinquency, psychoanalysis, the work ofdevelopmentalists such as Piaget and Wallon, not to mention the emergence ofphenomenology—the study of psychopathology, broadly defined, including signs,
symptoms, and their underlying thoughts and emotions. Outpatient consultation
services began to appear in the 1920s. The discipline started to change its concern
from the dichotomy educable/not educable, to open up a different perspective on
developmental and behavioural disorders in children. The term “child-psychiatry”(pédopsychiatrie in French) appeared for the first time in 1912.
Upon the arrival of the Popular Front (an alliance of left-wing groups) topower in 1936, significant work was undertaken to coordinate clinical services. In

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IACAPAP Textbook of Child and Adolescent Mental Health1937 Henri Wallon, a psychologist and politician, began to develop a nationwide
network providing psychological care and protection for children. Some hospital
services were enhanced, such as Georges Heuyer’s at la Salpêtrière, in collaboration
with the first French psychoanalyst, Eugenie Sokolnicka, and later with Sophie
Morgenstern. Meanwhile, universities supported the gradual institutionalisation of
French child psychiatry. The creation of the first child psychiatry outpatient clinic
by Collin in 1912, the holding of the first international congress of psychiatry in1937 in Paris, the creation of the first French chair of child psychiatry in 1948
(for George Heuyer in Paris) and the holding of the “Psychiatry White Paper
Days” organised by L’Evolution Psychiatrique (a journal of phenomenology andpsychoanalysis) in 1965, 1966 and 1967, were important milestones.
The clinical care system relied on institutions for “maladjusted” children.
This term first appeared during the Vichy regime but it followed work that
had started before the capitulation of France to Nazi Germany. The definitionof maladjusted children first appeared in 1944 in the Lagache Report (Daniel
Lagache was a psychiatrist and professor of psychology at the Sorbonne): “A childis maladjusted who has insufficient abilities or defects in his/her character putting
him/her in extended conflict with reality and the demands of his/her surroundings,
according to his/her age and social environment”. The provision of a more orless intensive treatment depended on the severity of the disorder: “Overall, we
can distinguish between the recoverable, semi-recoverable and non-recoverable”.
The non-recoverable were placed in institutions. These views, at the height of
the German “final solution”, reflected the ideology of the Vichy regime. It is still
the subject of historical research whether physicians and administrators actuallyknew the fate reserved for the mentally ill in psychiatric hospitals. The reality isthat about 40,000 mentally ill patients died of starvation or neglect in French
psychiatric hospitals during the Nazi occupation.
After the liberation, awareness of this carnage stimulated a more humane
attitude, to think differently about the provision of psychiatric care. Largely
influenced by the Anglo-Saxon and Italian anti-psychiatry ideas (echoed in
France by Michel Foucault) and especially by institutional psychotherapy (createdby Francois Tosquelles) “psychiatry sectors” were created in the 1960s—eachsector catering for a designated population, aiming at ensuring equal access tocare whatever the place of residence. His process was, on the one hand part ofa democratic regional organisation of mental health care, and on the other thefoundation for a better understanding of mental disorders. Psychiatric sectors
were put in place in 1960, initially affecting both adults and children. In 1972,
sectors specific to child psychiatry were created. The Government Circular of 1972
(Circulaire Misès) supported a new organisation of clinical services, more democratic
and less rejecting of the severe forms of disease. Roger Misès can be considered thefather of child psychiatry sectorisation. He was confronted by an asylum systemthat in his view made patients worse. Thus, he developed the “new psychiatricclinic” based on multidisciplinary teamwork with educators, psychologists,
pedagogues, psychiatrists, and psychiatric nurses working side by side using thetheoretical contributions of psychoanalysis and other schools. He drafted thecircular of 14 March 1972 that created the child and adolescent psychiatry sectors.
This movement occurred in the aftermath of the May 1968 events in France—a
period of great civil turmoil punctuated by demonstrations, general strikes, andHistory of child psychiatry

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Serge Lebovici (19152000) was an influential
French psychiatrist andpsychoanalyst who waspresident and honorarypresident of IACAPAP.
In 1958, he set up theCentre Alfred Binet,
an outpatient service inthe 13th arrondissementof Paris. In 1978, he wasappointed Professor at the
Université Paris Nord at
Bobigny.

46

IACAPAP Textbook of Child and Adolescent Mental Healththe occupation of universities and factories. The same year, psychiatry split fromneurology becoming both empowered and emancipated. Day hospitals became
the alternative institutional structure for inpatient care to prevent segregation. The
CMPs (centres médico-psychologiques or mental health centres) became the gateway
for the provision of care. Psychoanalytic thinking and institutional psychotherapy
played a large role in this reorganisation.
Over time this system has become the victim of its own success. According
to some this success has, in places, crystallised treatment around psychoanalytic
ideology rather than on a medical model. Recently, child psychiatry services haveundergone significant changes in their organisation and therapeutic methods. Since
the 1990s, and especially since the beginning of the 21st century, the contributionof the neurosciences and cognitive science has improved clinical practice.
The territorial organisation gave a real impetus to training. No formalchild psychiatry education existed until the 1970s. The first training program
was started by the “four colonels” (Lebovici, Diatkine, Soulé and Misès) in Paris,
which progressively disseminated to the entire country. In the last two decades ofthe 20th century almost all universities offered PhD degrees in child psychiatry,both for teaching and research. The census of 2014 reported that there were 743
child psychiatrists, more than 14,000 adult psychiatrists and more than 100,000
family physicians (for a population of about 70 million). The number of childpsychiatrists does not include psychiatrists without a specific diploma who treat
children. Indeed, there is no big difference between adult and child psychiatrists.
Unlike in some other European countries, French training does not separate childand adult psychiatry; child psychiatrists must be adult psychiatrists first.

Click on the image toview Marcel Manheimer’smonograph Les Troubles
Mentaux de l’Enfance,

The development of psychopathological understanding
In the first half of the 20th century, the issue of child psychosis helped tooffset the influence of psychometrics, which had become ubiquitous. In addition
to psychoanalytic concepts, other contributions enriched the understanding of
mental disorders in children: developmental psychology with Jean Piaget andHenri Wallon and phenomenology.
After the 1950s, clinical descriptions became more refined: “there are two
types of maladjusted children: those deficient in intelligence and those unbalanced
by character or behaviour”, Heuyer wrote. More and more children received
outpatient assessment with psychological tests, rehabilitation and psychotherapy.
Drug treatments were emerging, such as the use of phenobarbital for behaviouraldisorders with violence. Nevertheless, the tradition of institutionalising maladjusted
children in boarding schools persisted.
At the International Congress of Paris in 1937, continental European
clinicians became aware of the US literature on childhood schizophrenia througha communication by Despert. Subsequently, childhood psychosis began totake a special place in French child psychiatry, whose practitioners rejected thedichotomies between psychogenesis and organogenesis, curability and incurability.
The notion of handicap was also considered by child psychiatrists as alienating,perceiving the term as synonymous with loss of hope.

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IACAPAP Textbook of Child and Adolescent Mental Health“The French Classification for Child and Adolescent Mental Disorders(CFTMEA) was created in 1983 by a task force led by Professor Roger Misèswith one major goal: to offer French child psychiatrists an alternative to DSMIII. French child psychiatrists worried that DSM-III was quite different fromthe clinical process that most of them were using for diagnosis decision making.
They also worried that the DSM-III could drastically change clinical practices byfocusing all of the clinical and therapeutic attention on isolated symptoms rather
than taking into account structural psychopathological configurations” (Mises etal, 2002).
French language publications in child psychiatry have had a significant
impact in other European countries, French-speaking African countries, and in
Spain and Latin America—mostly through translations into Spanish of influential
textbooks (e.g., by Serge Levovici and by De Ajuriaguerra). This influence has been
gradually waning (Maldonado-Duran & Helmig, 2001).

GERMANYThe field of child and adolescent psychiatry and psychotherapy in Germany
is defined by the German Medical Association as comprising “the diagnosis, nonoperative treatment, prevention and rehabilitation of psychiatric, psychosomatic,
developmental and neurological diseases or disorders as well as psychological andsocial behaviour disturbances during childhood and adolescence”. This definition
has been modified several times and was first used in 1968, when child andadolescent psychiatry became an independent specialty. At that time, the specialty
was called “child and adolescent psychiatry”. Psychotherapy was added to thetitle in 1993, taking into account the importance of psychotherapeutic treatment
methods. This section is a revised version of a chapter in Child and Adolescent
Psychiatry in Europe, edited by Helmut Remschmidt and Herman van Engeland(Heidelberg: Springer, 1999).
The postgraduate training schedule to become a child and adolescent
psychiatrist and psychotherapist requires five years, out of which one year can becompleted either in paediatrics or in general psychiatry. Training can be undertaken
in all the 16 states of the Federal Republic of Germany and ends with an oral
examination at the office of the medical association (Landesärztekammer) of eachstate.

Historical development
German child psychiatry is very closely connected to European andinternational developments. Its roots go back to several other disciplines, especiallypaediatrics and psychiatry, but also clinical psychology, pedagogy (therapeuticeducation) and also, with regard to many regulations, to social sciences and law.
These influences, however, did not lead child psychiatry to become a mixture ofheterogeneous disciplines but to be an independent specialty that integrates allthese influences in order to give psychiatrically ill and disturbed children and andtheir families the best possible support.
An important milestone in the history of German child psychiatry was
the textbook by Hermann Emminghaus (1887) entitled Psychic Disturbances in

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Hermann
Emminghaus (18451904) was Director of the
Department of Psychiatryat the University of Freiburg
from 1886 to 1902 andauthor of the first textbook
in child- and adolescent
psychiatry.

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IACAPAP Textbook of Child and Adolescent Mental HealthChildhood, which has been called the “cradle” of child psychiatry (Harms, 1960).
In 1899, the term “child psychiatry” was first used by the French psychiatrist M
Manheimer who subtitled his book Les Troubles Mentaux de l’Enfance as Précisde Psychiatrie Infantile (Stutte, 1974). The books by Wilhelm Strohmayer (1910)
Psychopathology of Childhood, Theodor Ziehen’s (1915) Mental Disorders inChildhood, August Homburger’s (1926) Lectures on Childhood Psychopathology, andMoritz Tramer’s (1942) Textbook of General Child Psychiatry further contributed tothe development of the discipline. After World War II, the handbook article byHermann Stutte (1960), the textbook by Jakob Lutz (1961), and the Textbook ofSpecial Child and Adolescent Psychiatry by Harbauer et al (1971) were influential
also. These textbooks were followed by several others and by the three-volume
Child Psychiatry in Clinic and Practice, edited by Helmut Remschmidt and Martin
Schmidt (1985, 1988).
As far as journals in German are concerned, three developments were
important:•••

In 1898, the journal Children’s Faults (Die Kinderfehler) was founded. It
became later the Journal for Child Research (Kinderforschung), which ceased
publication in 1944, during World War II, after the 50th volume. After thewar, this journal continued as the Yearbook for Youth Psychiatry (founded in
1956) and has been running since 1973 under the title Journal of Child andAdolescent Psychiatry (Zeitschrift für Kinder-und Jugendpsychiatrie). Following
the change in the name of the specialty, the title was changed to Journal ofChild and Adolescent Psychiatry and Psychotherapy in 1996.
In 1934, Moritz Tramer founded the Journal of Child Psychiatry (Zeitschrift
für Kinderpsychiatrie) which continued until 1984 as Acta Paedopsychiatrica
and ceased publication in 1994.
A third journal—initially with a more psychoanalytic and, later, moreinterdisciplinary orientation—Practice of Child Psychology and Psychiatry
was founded in 1951 by Annemarie Dührssen and Werner Schwidder. It
continues to be published today and has a large readership.

Heinrich Hofmann(1809-1894) was director of
the “Hospital for Epileptics
and Mentally Sick Patients”
and started one of thefirst departments for childpsychiatry. He also becamefamous as a writer ofchildren’s books, especially
Der Struwwelpeter(Shockheaded Peter),considered the firstdescription of a child withADHD.

The establishment of a new discipline, however, is only possible if it has ascientific base and if it is supported by professional organizations that drive thediscipline forward. The official foundation of a German association for child andadolescent psychiatry took place on September 5, 1940, in Vienna as the German
Society for Child Psychiatry and Therapeutic Education. Its first president was
Paul Schröder, head of the department of psychiatry at the University of Leipzig.
During World War II, under the Nazi regime, some German child psychiatrists
were involved in the euthanasia program through which thousands of mentallyhandicapped and psychiatrically ill children were murdered with their cooperation.
In 1950, the German Association for Youth Psychiatry was re-established asa medical association, with close links with other disciplines such as therapeuticeducation, law, clinical psychology, psychiatry, and paediatrics.
German child psychiatry has evolved from four traditions:
1. The neuropsychiatric tradition, going back to its roots in neurology
and psychiatry, from which child psychiatry has evolved in several
places. This tradition was prominent in the former German
Democratic Republic where the specialty was called “child

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IACAPAP Textbook of Child and Adolescent Mental Healthand adolescent neuropsychiatry”. It continues nowadays in theneuropsychological approaches dominant in several fields of childpsychiatry
2. A tradition in therapeutic education, which developed mainly
in paediatric settings and can be considered a precursor of thedepartments of psychosomatics in paediatric hospitals
3. The psychodynamic-psychoanalytic tradition, which goes back tothe beginning of psychoanalysis. This tradition was responsible forthe inclusion of psychodynamic psychotherapy in the curriculum forchild psychiatrists as well as for the establishment of “psychagogues”(who later changed their name to “psychoanalytic child andadolescent psychiatrists”)
4. The empirical-epidemiological tradition. This orientation wasestablished in the 1960s and 1970s and was influenced to a great
extent by empirical research from the UK and the US.
After the German reunification, a Society for Neuropsychiatry of Childhoodand Adolescence was founded in February 1990 in the former East-Germany,
which was later integrated into the German Society for Child and Adolescent
Psychiatry that in 1994 became the Society for Child and Adolescent Psychiatry
and Psychotherapy. This society holds an official meeting every second year indifferent cities in Germany.
There are two other organizations of child and adolescent psychiatry inGermany: a “professional organization” (Berufsverband) which was founded in1978 and represents child and adolescent psychiatrists and psychotherapists inprivate practice (with 907 members in 2013), and the Conference of Directors ofChild and Adolescent Psychiatric Hospitals, founded in 1990 (in 2014 it had 142
members).
These organizations have established a close cooperation and have joint
working groups for quality assurance, training, and research. They have publishedguidelines for the optimal practice of child and adolescent psychiatry and amemorandum on the current status of child and adolescent psychiatry in Germany(edited by Andreas Warnke and Gerd Lehmkuhl in 2011).

Recent developments
The treatment of psychiatrically disturbed children and adolescents inGermany is funded by (a) the insurance for acute disorders, (b) by the youth
welfare organization and (c) after the acute phase of the illness, by the social
security system for rehabilitation and reintegration. The social security system is
responsible only for physically handicapped and severely intellectually disabledchildren and adolescents, whereas the youth welfare organization is responsible forpsychiatrically disabled children up to the age of 18.
With regard to the progress of child and adolescent psychiatry in Germany
in general, four developments during the last forty years have been critical:••

The Psychiatry Enquête of the Federal Government (report 1975)
The model program, Psychiatry, of the Federal Government (1980-1985)

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Hermann Stutte (19091982) was appointed to
the first independent chairof child and adolescent
psychiatry in West
Germany in 1954. He wasthe child psychiatry pioneerin Germany after WorldWar II and president of theEuropean Union of Child
Psychiatrists.

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IACAPAP Textbook of Child and Adolescent Mental Health••

The Psychiatry Personnel Equipment Act (introduced stepwise between 1991
and 1995), and
The inclusion in 1992 of psychotherapy into the training curriculum and in
the name of the specialty.

These four developments have influenced current child and adolescent
psychiatry and psychotherapy in a remarkable way. The Psychiatry Enquête, initiatedby two members of parliament, opened the door for a broad inquiry about thesituation of psychiatry and child and adolescent psychiatry across West Germany.
After the report of the commission (1975), a model program, Psychiatry, wascreated which was implemented in 14 regions of the Federal Republic, evaluateddifferent types of services and created new ones. One region (Marburg) was devoted
exclusively to the evaluation and establishment of child and adolescent psychiatricservices. Many newly created services could be continued. The Psychiatry Personnel
Equipment Act was responsible for more satisfactory staffing of psychiatrichospitals and services, which led to a remarkable improvement in everyday work.
The inclusion of psychotherapy into the curriculum for child psychiatrists andfor general psychiatrists was not only important for the training of each childand adolescent psychiatrist but also improved the status of child and adolescent
psychiatry.

Current situation
The population of Germany in 2014 was around 80 million, among them
13 million were children aged less than 19 years—about 16% of the population.
In 2014, child and adolescent psychiatry and psychotherapy was represented
in 142 child psychiatric hospitals and departments, among them, 25 university
departments. Out of the 1,965 specialists in child and adolescent psychiatry andpsychotherapy (more than half are women), 907 are working in private practice,i.e., covered by insurance. There is one child and adolescent psychiatrist per
40,979 inhabitants or per 6,644 children less than 19 years of age. The parallel
figures for child and adolescent psychiatrists in private practice are 1:88,780 and
1:14,394 respectively. The German Society for Child and Adolescent Psychiatry
and Psychotherapy had 1,164 members in 2014; in 1975, there were only 200,
among them 34 women. This growth is a remarkable achievement.
Challenges remain. Though the Federal Government of Germany has
accepted the proposal of the Expert Commission for the Model Programme
Psychiatry to establish a department of child and adolescent psychiatry in every
university, these are lacking in nine of of 36 universities. There are not enoughchild and adolescent psychiatrists in private practice and there is an enormous needfor research in many areas.

JAPAN
Efforts to raise public awareness regarding childhood mental disorders
and delinquency were already starting to be seen in Japan at the turn of the 20th
century along with the rapid social modernization. Psychiatrists and psychologists
interested in children had been involved in research and treatment of young people
with behaviour problems and developmental delay at some public and private
child study institutes (there were 33 institutes in 1922). Influenced by the mental

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IACAPAP Textbook of Child and Adolescent Mental Healthhygiene and the child guidance movements in the US, child guidance clinics were
established in Nagoya and Tokyo in 1936, where some 80% of children referred
were intellectually disabled. After the interruption caused by World War II, several
university hospitals resumed outpatient services and child psychiatric wards were
established in the National Kohnodai Hospital and Tokyo Metropolitan Umegaoka
Hospital in the late 1940s.

Fom left: Kosuke Yamazaki,
Shigeta Saito, Reimer
Jensen, Koichiro Shirahashi,
Kiyoshi Ogura at the
IACAPAP Kyoto Congressof 1990.

In the wake of the first report of infantile autism at the 49th annual meetingof the Japanese Society of Psychiatry and Neurology in 1952, psychiatrists
interested in childhood mental disorders organized a study group from which
the Japanese Society for Child Psychiatry was established in 1960 (renamed theJapanese Society for Child and Adolescent Psychiatry [JSCAP] in1983). JSCAP isa multidisciplinary organization with a membership of 3,592 in 2014—of whom
1,677 are psychiatrists and 322 are paediatricians—making it one of the largestof its type in the world. JSCAP has been a member of IACAPAP since 1962 andhosted the 12th international congress of IACAPAP in Kyoto in July 1990—
the first IACAPAP congress in Asia. Furthermore, JSCAP was instrumental inestablishing the Asian Society for Child and Adolescent Psychiatry and Allied
Professions (ASCAPAP), which held its 1st congress in Tokyo in April 1996.
The focus of research and practice had been on autism spectrum disorders
from the very beginning of JSCAP—Hans Asperger gave the keynote address
at the 6th meeting of the society in 1966. In the 1970s, school refusal became
another major clinical focus, which led to the development of school-based mental
health services. Today, school psychologists are available at most public schools.
Experience of mental health care for children affected by massive disasters suchas the Hanshin-Awaji earthquake of 1997 and the East-Japan earthquake andHistory of child psychiatry

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IACAPAP Textbook of Child and Adolescent Mental Healthtsunami of 2011 made necessary the development of a more systematic mental
health support system for victims of disaster. Also, with the surge in reports ofchild abuse and neglect in the 1990s, childhood trauma has become a focus ofchild psychiatry and child mental health in Japan.
In spite of the mental health care needs of children and adolescents, educationand training of professionals in this field has been far from ideal. Although JSCAP
launched an accreditation program of specialist child psychiatrists in 1991, as ofMarch 2014 there were only 206 members accredited. Also, only 16 out of 80
university hospitals have a division of child psychiatry, resulting in a shortage of
specialist child mental health professionals. To increase the number of professionals
in this discipline the Ministry of Health, Labour and Welfare began to develop a
training program in 2005.

RUSSIAN FEDERATIONChild and adolescent psychiatry in Russia started at the beginning of the
20 century as a division of general psychiatry. Long before, from the second half ofthe 19th century, the first steps were taken toward the organization of medico-social
services, asylums and special schools for underachieving children with intellectual
disability and epilepsy. K Ushinskij, F Erisman, and Andrian S Griboedov wereamong the physicians who worked with children with mental disorders at thattime. In 1887, the problem of the medical care and education of intellectuallydisabled children was broadly discussed by psychiatrists such as Korsakov, Serbskij,
Yakovenko, and Rossolimo at the 1st Congress of Psychiatrists in Moscow. Fromthe end of 19th century several scientific clinico-psychopathological and pathoanatomical works in child psychiatry were published by Lesgaft, Merzheevskij, S
Danilo and others.
th

At the beginning of the 20th century, several institutes were created to study
normal and abnormal child development, such as the Institute of Child Neurology
and Psychology of Rossolimo (1911), the Pedological Institute set up in 1907 by
V Behterev to study human beings as a subject of upbringing, and the Children’s
Investigation Institution (1918) headed by A Griboedov.
After the October 1917 Revolution more institutes, departments and clinics
for children with special needs and mental disorders were set up, as well as special
schools to look after orphans, homeless and mentally ill children. The EducationalClinical Institution (Воспитательно-Клинический институт) with a boarding
school for 100 children, psychotherapy and physiotherapy rooms, psychology
laboratory, and workshops was opened in 1919 to examine diseases of the nervous
system in childhood and psychoneuroses. The Institution for the Defective Child,
which consisted of several schools and sanatoriums, was developed to explore
educational and therapeutic interventions for children with abnormal behaviour.
In 1921 the Pedagogic Institutes headed by P Kaschenko to train specialists in the
education of “defective” children was opened. A department “not for defective
children and neurotics, but for mentally ill children” was set up in 1919 within
the Psychoneurologic Institute of St Petersburg (now named after V Behterev)
under the leadership of R Golant and Mnuchina. In Moscow in 1920 there were
three services for children attached to psychiatric hospitals. A system of psychoneurological centres (dispensaries) was set up in the 1920s for case detection,

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IACAPAP Textbook of Child and Adolescent Mental Healthambulatory treatment, evaluation for hospitalization, consultation at schools, toprovide health education for parents, teachers and paediatricians, and to collectstatistics about child mental illnesses. This system was in place until the 1990s.
There are efforts in some areas to bring this structure back to life.
The beginning of the 20th century was the golden age of Russian psychology,
neurology and psychiatry, with important contributions, among others, from VM
Behterev (1857-1927) in neurology and objective psychology (which states thatbehavior can be studied through observable traits), LS Vygotsky (1896-1934)
who developed an influential theory of cultural and biosocial development andon the connections between mind and speech, G I Chelpanov (1862-1936),
who developed social psychology, and AF Lazurskij (1874-1917) who developed
a classification of personalities. At the same time three child psychiatry schools
developed, in Moscow (with VA Gilyarovsky, MO Gurevich, TP Simson, and GE
Suchareva), Leningrad (NI Ozeretskii and SS Mnuchin) and Ukraine (TI Udin
and GE Suchareva).
T P Simpson and her co-workers focused on disorders starting in infancy andearly childhood. In her monograph The Schizophrenia of Early Infancy (1948) she
described in details 73 cases of early childhood schizophrenia with catatonia andoligophrenia-like symptoms. In Moscow and Leningrad the clinical picture andcourse of organic disorders in connection with infections, trauma and intoxication
were explored.
After World War II interest in behaviour disorders, neuroses, and thedevelopment of personality disorders increased in the USSR and interest in
schizophrenia and autistic disorders continued. Unfortunately, because of
the political situation, ideology began to interfere with science. Contact withinternational psychological and psychiatric specialists was discouraged from the late
1930s and as result international exchanges diminished significantly or stopped.
In 1950 the Pavlovian Session (Павловская сессия) was organized (a joint
session of the Academy of Sciences and the Academy of Medical Sciences of theUSSR) in order to counter Western ideas, giving a monopoly over psychiatry andpsychology to the Pavlovian school. As a result, Soviet child psychiatry repudiatedfor a long period the achievements of science outside of the USSR and became
isolated. It worked as a system of active case finding, medical treatment, andinstitutionalization. Children with mental retardation or mental disorders wereplaced in special schools; those with more severe conditions who were considered
uneducable were placed in special asylums. This situation began to change in the
1990s when treatment became more humane, with greater respect for humanrights, deinstitutionalization began and international contacts resumed.

“The relation of thought
to word is not a thing but
a process, a continual
movement back and forthfrom thought to word andfrom word to thought. In
that process, the relation ofthought to word undergoeschanges that themselves
may be regarded as
developmental . . . Thought
is not merely expressedin words; it comes into
existence through them.”
Lev Vygotsky

Lev Vygotsky (18961934) highlighted theimportance of social
environment in thedevelopment of higher
cognitive functions. His
research was preserved(and sometimes distorted)by a group of his students
and colleagues, theVygotsky Circle.

In 2015, there are some state-run institutions and many more private ones
where psychiatrists, psychologists, educational specialists are working together.
The children’s right to live in a family and to education and social interaction havebecome national policy.
At the time of publication there is no officially recognised speciality of childpsychiatry (although it existed until 1995). Once students complete their 6-year
medical degree, they may choose to train in psychiatry (for 1 or 2 years) in adultor in paediatric units; further qualifications are not required to work as a childpsychiatrist. There is a Russian Association of Child Psychiatrists and Psychologists

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IACAPAP Textbook of Child and Adolescent Mental Health

GE Suchareva in 1968 with a patient and a group of her pupils.
Grunya Efimovna Suchareva (Груня Ефимовна Сухарева; 1891-1981) graduatedfrom Kiev’s Women’s Medical University. In 1919, she was appointed head of the Departmentof Defective Children and lecturer in Kiev’s Medical Pedagogic Institute. Subsequently she
combined clinical work in several psychiatric clinics in Moscow and in Kharkov, Ukraine.
She published a variety of articles on “schizoid psychopathy” but her main interest was onschizophrenia. In 1937 appeared the first volume of her influential monograph Клиника
шизофрении у детей и подростков (течение, прогноз, систематика) [The Clinical Pictureof Schizophrenia in Children and Adolescents (Course, Prognosis, Classification)].
Suchareva’s clinical activities and research were summarised in the three volumes of “ClinicalLectures on the Psychiatry of Childhood” (published in 1940, 1959, and 1965). In 1996
one of her papers originally published in German was translated into English by Sula Wolff
with the title “The first account of the syndrome Asperger described?” It would appear that
Suchareva’s had been the first depiction of Asperger’s disorder about 10 years before Hans
Asperger’s (Wolff, 1996).

(ACPP) that was created in 1992. In 2007 it was estimated that there were 1,400
child psychiatrists for a population of about 32 million children and adolescents(Grebchenko & Koren, 2007).

TURKEYChild and adolescent psychiatry in Turkey began as a division of paediatrics
and, in the late 1950s, of general psychiatry. Before then, there had been only childwelfare units within the Ministry of Social Support working in the field of childdevelopment. The first child psychiatrists started working with child welfare units
to incorporate mental health within these services. The child psychiatry pioneers in
Turkey were people working voluntarily with children and adolescents in general
psychiatry clinics. Later on, upon the return to Turkey of a very small group of
professionals trained in the US, Germany and the UK, the two groups worked
together to establish child and adolescent psychiatry units within the paediatrics
and psychiatry departments and were finally included formally within psychiatry.
They also attracted to their units psychologists and social workers interested
in working with children. However, up to the late 1980s there were child andadolescent psychiatry units and clinics only in the three largest cities (Istanbul,
Ankara and Izmir), at university hospitals.

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IACAPAP Textbook of Child and Adolescent Mental HealthChild psychiatry training was accepted as subspecialty training (following
four years of general psychiatry training) in the late 1970s. Because of lack ofawareness of the importance of child mental health, there were no policies
about the issue and thus there was much reluctance to fund positions for childmental health training. Through the efforts of a group of pioneers (such as Atalay
Yörükoğlu, Mualla Öztürk, Ridvan Cebiroğlu) the number of formally trained
child psychiatrists grew to 25 by 1990.
The Turkish Association for Child and Adolescent Psychiatry (TACAP) wasestablished by this small group in 1991. The first president was Atalay Yörükoğlu.
The establishment of TACAP had enormous implications for the development ofchild psychiatry, of child and adolescent mental health policies, and in increasing
the Turkish public’s awareness of child and adolescent mental health issues. Alongwith its focus on professional development, TACAP worked with the Ministryof Health to develop child mental health policy in connection with the national
mental health policy program. The Association has always been the core body
advocating for child and adolescent mental health and for the development ofchild psychiatry as a separate medical branch (officially recognised in 1996). As
a result of these efforts child and adolescent psychiatry has also been included in
medical schools’ curricula at the preclinical and clinical levels.
The board of TACAP has seven members: president, vice-president,
secretary general, treasurer, and three other members. Within the association,
there are 16 committees working on various subjects: infant and adolescentmental health, consultation-liaison, ADHD and learning disorders, autism andother pervasive developmental disorders, mood disorders, inpatient psychiatry,disabilities, ethics, trauma, psychopharmacology, psychotherapy, children’s rights,
international affairs, public education, and forensic psychiatry. Developmentof research projects, increasing public awareness and advocating for child andadolescent mental health, publishing books and booklets for professionals and the
public, organizing meetings and training courses, and establishing a code of ethics
are some of the activities performed by these committees.
The Board for Training in Child and Adolescent Psychiatry, established
Atalay Yörükoğlu
was one of the pioneers ofchild psychiatry and mental
health (known in Turkey
as “the Dr Spock of mental
health”). After receiving his
medical degree from the
University of Istanbul in
1953, he trained in the US
and returned to Turkey in1964 to assume a full-time
faculty appointment at the
University of Hacettepe inAnkara. He was an ardentadvocate of children’s rights
and the first president of
the Turkish Association
for Child and Adolescent
Psychiatry.

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IACAPAP Textbook of Child and Adolescent Mental Healthwithin the association, coordinates training programs, sets standards—inconjunction with the Union of European Medical Specialties—conducts the board
exams for qualification, and establishes continuing medical education programs.
The child psychiatry training program consists of a separate curriculum of four
years after finishing medical school. Medical graduates enter the program via acentralised examination. Child psychiatry is currently one of the most highly rated
specialties in Turkey. The training program has theoretical, clinical and researchcomponents that run in an integrated way. Both the biological and psychodynamic
aspects of child psychiatry are covered in the curriculum and basic psychotherapy
courses are also provided. Since some of the child psychiatry departments have few
academic staff, TACAP runs complementary courses three times a year.
TACAP has organized a national child and adolescent psychiatry congress
every year since 1990, an adolescent psychiatry symposium since 1996, and a childand adolescent mental health policy workshop since 2004. The Turkish Journal ofChild and Adolescent Mental Health, published quarterly, is the official journal of
the association. During the last few years, eight books have been published, one
being a child psychiatry textbook, along with other handbooks and booklets.
Child and adolescent psychiatrists played an active role lobbying thegovernment to include a separate child and adolescent mental health section in the2003 National Mental Health Policy Program. This resulted in the establishmentof the Child and Adolescent Mental Health Division (under the Departmentof Mental Health, within the Ministry of Health), and the Advisory Council forthis division—the primary body for child and adolescent mental health policy
development—composed of mental health professionals working with children
and adolescents.
Though child and adolescent mental health professionals are working very
hard to implement the aims of the profession, inevitably there are obstacles toovercome at times. One of the important issues in Turkey is the small numberof child psychiatrists (around 600—the number actually doubled in the past
six years) for the number of people aged under 18 (approximately 20 million).
There are also difficulties implementing programs, the result not only of politicalissues but also of a lack of resources. There is a need for more psychologists, social
workers, counsellors and other mental health professionals working in the field aswell as child and adolescent psychiatrists. Currently, paediatricians, psychologists,social workers, counsellors and psychiatric nurses have their own professionalorganizations. TACAP is working in collaboration with these organizations toincrease the number of professionals working in the field. On the positive side,
nowadays financial sources to run projects can be obtained more easily frominternational bodies or nongovernment organizations, such as the European Union,
UNICEF and Turkish Institute for Science and Technology but sustainability ofthe programs is still a problem.
In 2014, there were 40 university clinics and 35 state hospital clinics forchild and adolescent psychiatry in the country. However, only six of the clinics
have an inpatient unit and most of the time young patients have to be admitted toeither paediatric or adult psychiatric wards. The most frequently treated psychiatricconditions are anxiety, mood disorders and developmental problems. Conduct andsubstance use disorders are still relatively infrequent.

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IACAPAP Textbook of Child and Adolescent Mental HealthChild and adolescent psychiatrists in Turkey, although a small group, arehighly committed. TACAP is enthusiastic about international collaborations, isa member of the European Union of Medical Specialists, ESCAP and IACAPAP
and was the local organiser of the 18th World Congress of IACAPAP in Istanbul
in 2008, and the Regional Congress of the International Society for Adolescent
Psychiatry and Psychology in 2013.

UNITED KINGDOM (UK)The history of the research and treatment of children with mental healthproblems in the UK has been characterized by three historical waves that have had
influence and ramifications internationally. Firstly, work in child psychology andchild guidance in the 1920s and 1930s established the principle of early intervention
in child mental health and collaboration with schools and other health services.
Secondly, the work of psychoanalytically-oriented researchers at the Tavistock
Clinic in the post-World War II period encouraged greater collaboration withfamilies as well as propagating internationally influential theoretical approaches
such as John Bowlby’s attachment theory. Finally, the work of researchers andclinicians based at the Maudsley Hospital from the 1960s onwards has influenced
the observation and study of clinical syndromes, encouraging epidemiological,
statistical and genetic research, and multimodal treatment.

Child psychology, child guidance and the interwar period
In 1913, Cyril Burt was appointed as the first official psychologist in theworld, working for the London County Council in overseeing the testing andtreatment of all children in that city (Sutherland, 1984). Education was madecompulsory in the UK in 1880 and Burt’s appointment encouraged the practicalimplementation of psychological sciences in Britain via the education system.
His work was supported by the experimental approaches of Susan Isaacs wholater became head of the Department of Child Development at the Institute ofHistory of child psychiatry

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Participants in a “Witness
Seminar” hosted by theCentre for the History ofMedicine at the Universityof Glasgow in May 2009.
“Witnesses” were selectedon the basis of theircontributions to different
spheres of child psychiatryin the UK, particularly
from 1960 to 1990. Fromleft, front row: Ian Berg,Dora Black, Lionel Hersov,
Bryan Lask, Philip Graham.
Second row: Arnon
Bentovim, William Yule,Sebastian Kraemer. Backrow: Bob Jezzard, Michael
Rutter, Malcolm Nicolson,
Hugh Morton (photo:
University of Glasgow).

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IACAPAP Textbook of Child and Adolescent Mental Health

Education. Burt, Isaacs and other educational psychologists lay the foundations
for the development of both child psychology and psychiatry in Britain. After
Burt’s death (1971) it was alleged that he had falsified results on his studies on theinheritability of intelligence but this has not been proven conclusively.
Early treatments for childhood mental illness and psychopathology went
through a major growth period in Britain in the late 1920s following a generous
donation from the Commonwealth Fund, a US-born charitable venture, toestablish child guidance clinics across the UK. These funds encouraged the growthof psychological disciplines and promoted interdisciplinary work by teaming
up physicians with psychologists and social workers (Evans et al, 2008). Child
guidance clinics gave medical authority to the psychological sciences and also
encouraged the development of child psychiatry as a niche discipline.
In 1927, Emmanuel Miller, a formidable figure in the field, established thefirst child guidance clinic in East London. In 1928, William Moodie establisheda demonstration child guidance clinic in North London, which taught childguidance techniques to others, and Margaret Lowenfeld founded a clinic for thetreatment and study of nervous and difficult children in Central London. These
clinics pioneered new techniques such as Lowenfeld’s “World Technique” thatencouraged children to use toy figures in sand to depict their inner world, andthus to enable therapists to engage with them in thinking through their difficulties(Lowenfeld et al, 1988). Isaacs also worked on the significance of children’s playin understanding their motivations, thoughts and dreams. Their work was highly
influential to the development of child psychotherapy techniques in Britain andabroad. However, during the interwar period, child guidance clinics did not treat
children classed with “mental deficiency” as this section of the population was still
held in institutional care under the 1913 Mental Deficiency Act (Stewart, 2013).
This meant that the techniques developed within the child guidance clinics were
not designed to include the treatment of children who rated poorly on intelligence

Objects used in Lowenfeld’s“World Technique”.
Photo: Science Museum,LondonHistory of child psychiatry

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IACAPAP Textbook of Child and Adolescent Mental Healthtests and therefore were somewhat limited in their applicability to the whole
population.
The late 1920s and the growth of the child guidance movement also saw
increasing numbers of child patients being referred to major centres for thetreatment of both adult and child mental illness, in particular the Tavistock Clinic,
established in 1921, and the Maudsley Hospital, established in 1923. Whilst theformer worked primarily in developing psychoanalytic theory and techniques forchildren, the latter began to work on behaviour management and collaboration
with other social agencies such as children’s care committees. The Maudsley
became known as an institution where very severe cases of child mental illness could
be referred. The hospital set up large outpatient and inpatient units for detailed
observation and treatment of child psychopathology in the late 1930s, althoughthese were made redundant during the war because of the threat of bombing.

The post-World War II era and the growth of psychotherapeutic
approaches
World War II stimulated the development of child psychotherapeutictechniques by providing a lamentable testing ground for psychological theory as
many children were separated from their families or experienced other traumas dueto the air raids. Isaacs, Anna Freud, Dorothy Burlingham and John Bowlby wereamongst a group of psychologists and psychoanalysts who studied the responsesof children to these difficult circumstances and the impact that it had on theirmental health, culminating in the Cambridge Evacuation Survey—paradoxically,
the survey emphasized the distress suffered by adults and downplayed that sufferedby children. John Bolwby later went on to develop his theory of “maternal
deprivation” in a 1951 report for the World Health Organization that had
international impact, making his “attachment theory” renowned across the globe.
The late 1940s and early 1950s saw growing interest in treating wholefamilies rather than individual children. The evacuation surveys had encouraged
the enactment of the 1948 Children’s Act in Britain, which established a centralized
structure to child care. Local authority children’s officers oversaw children’s
psychological development and sought to intervene where they saw necessary. At
the Tavistock Clinic, the Children’s Department was renamed the Departmentof Children and Parents in 1953 and psychotherapists aimed to integrate wholefamilies into the treatment process. Melanie Klein’s theories of infantile phantasy
and Donald Winnicott’s work on transitional objects helped to establish British“object relations theory” as a dominant discourse within both psychologicaland political circles and helped to establish the Tavi [Tavistock] model of childpsychotherapy, in which clinicians employed play therapy and transference models
to elicit and expel pathological memories (Rose, 1999).
Throughout the 1960s and 1970s, Tavistock-inspired psychoanalytic modelsof child development and the management of trauma continued to thrive throughthe work of the Association of Child Psychotherapists and the Journal of Child
Psychotherapy. Esther Bick established the Tavistock model of infant observation in
the early 1960s, which was later developed by Martha Harris and Margaret Rustin
as an essential component in child psychotherapy training. These methods were
propagated by Harris and others who went on international lecturing tours as wellas publishing widely (Williams et al, 2012).
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The Maudsley Hospitalchild outpatient department,
1938.
Photo: London Metropolitan
Archives.

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At institutions such as the Maudsley, instead of focusing on family
treatment and the observation of “normal” infants, clinicians placed increased
emphasis on observing individual psychopathology in great detail and this led tosome rifts between the Tavi and Maudsley approaches. In 1953 Kenneth Cameronand Elwyn James Anthony established a clinic at the Maudsley Hospital for the
rigorous observations of children then diagnosed with schizophrenia and psychosis.
They also encouraged a comprehensive vision of the work of child psychiatrists
to include intellectual disability, thereby challenging the exclusivity of approach.
Their work also challenged psychoanalytic assumptions about thought patterns inearly infancy (Evans, 2014).
At the celebrated Great Ormond Street Children’s Hospital in London,
Mildred Creak sought to anchor child psychiatry in the field of paediatrics and thus
to ward off widespread theoretical divisions. Creak’s method was very practicaland she aimed to treat children’s problems with play, speech therapy, discussion,and collaboration with social and educational services. Both Creak and EmanuelMiller, in particular, saw child psychiatry as a discipline that could draw frommultiple theoretical models but whose primary aim was to witness improvementsin children’s health. They were practice-driven, rather than research-driven, andtheir work provided a model for practical engagement as the primary object of theprofession. Emmanuel Miller established the Association for Child Psychology andPsychiatry in 1966 (renamed Association for Child and Adolescent Mental Healthin 2005), a leading British organization later responsible for publishing the journalChild and Adolescent Psychology and Psychiatry. Miller later went on to edit thefirst key British textbook in child psychiatry that covered language development,
early experiences, parent-child relations, social factors, psychotherapy, behavioural
methods, drug therapy, community services, and crisis intervention (Miller, 1968).
Their work provided a blueprint for non-dogmatic and open-minded approaches
that drew from the best practices of all workers.

The Social Psychiatry Research Unit and statistical methods
The 1960s saw a flood of innovative methods and approaches to intellectual
disability and mental illness in children at the Maudsley Hospital. These werelargely stimulated by the termination of the Mental Deficiency Legislation in
1959. The Maudsley’s Social Psychiatry Research Unit, funded by the British
Medical Research Council, produced important studies such as Jack Tizard’s workon the significance of quality of care to the cognitive development of children withlearning disabilities. This highlighted the importance of intellectual stimulation
and a supportive environment to children, no matter what their intellectual level.
Michael Rutter is one of the most influential figures to emerge from this historicalmoment and he went on to systematically rewrite the rules for research in childpsychiatry.
In 1970, Michael Rutter, Jack Tizard and Kingsley Whitmore publishedan epidemiological study of the entire population of children resident on the Isleof Wight, a small island in the English Channel. This report—Education, Healthand Behaviour—highlighted the multiple environmental factors that could impact
on children’s mental growth, including social inequalities, and argued for new
approaches to treatment that were based on the findings of epidemiological studies
and clinical research trials. In 1975, Rutter and colleagues published a report for theHistory of child psychiatry

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Click on the image toaccess several video clips
reflecting an interview withMichael Rutter, his careerand contributions

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IACAPAP Textbook of Child and Adolescent Mental HealthWorld Health Organization that pioneered the multi-axial model of child diagnosis
that took into account intellectual level and associated etiological environmental
factors as well as the child’s clinical presentation. This multi-axial model was later
introduced into the third edition of the US Diagnostic and Statistical Manual of
Mental Disorders. Rutter, the first professor of child psychiatry in Great Britain,
has since gone on to develop new approaches to treatment, for example supportinga multimodal management designed to treat the different aspect of a child’s specificclinical syndrome. This treatment is rooted in empirical evidence, that is, having
been shown to be effective in that particular clinical population (Rutter et al,2008).
Growth in the Maudsley’s statistical methods was coupled with an upsurgeof behaviouristic and cognitive approaches to treatment. Operant conditioning
therapies, where children were systematically rewarded for socially desirable
behaviour, began to have an impact on the treatment of intellectual disabilities
in the 1960s and 1970s. This was in parallel with a growing emphasis on
cognitive treatments, which inspired a new understanding of intelligence andmental abilities via the work of Beate Hermelin, Neil O’Connor, and Uta Frith.
Maudsley researchers conducted detailed investigations of the specific cognitive
impairments experienced by children who displayed overt clinical symptoms of
psychopathology and helped forge a space for the developing field of cognitive
neuroscience. Hermelin, O’Connor, and Frith encouraged new methods to enable
children with psychological difficulties to learn more adaptive behaviour throughspeech therapy as well as behavioural techniques. Encouraged by Hans Eysenck(1964), they conducted, along with other Maudsley researchers, trials that proved
the effectiveness of structured behavioural methods in generating clinical results.
Maudsley researchers have played a particularly influential role in autism
research since the 1970s. In 1977, Rutter published the first genetic study ofautism and his definition formed the basis for the description employed in DSM
III. Lorna Wing delineated Asperger’s syndrome, drawing from the work of theAustrian paediatrician Hans Asperger, subsequently recognized worldwide as avariant of autism—now considered part of the autism spectrum. Other influential
autism researchers include Frith and Simon Baron-Cohen, who originated theconcepts of executive functions and theory of mind to explain autism (Evans,2013).

The Faculty of Child and Adolescent Psychiatry
The Faculty of Child and Adolescent Psychiatry of the Royal Collegeof Psychiatrists (RCP) had its beginnings in 1942 when The Royal MedicoPsychological Association (the forerunner of the RCP) set up a Child Guidance
Sub-Committee. It was renamed the Child Psychiatry Sub-Committee in March
1943 and became a Section in 1946. It was called the Child and Adolescent
Psychiatry Section from the early 1980s until 1997 when it was renamed theFaculty of Child and Adolescent Psychiatry (Bewley, 2008).
Any member of the RCP may apply to be a member of the Faculty ofChild and Adolescent Psychiatry. In effect most practising child and adolescent
psychiatrists in the UK are members but other RCP members with a special
interest in the specialty are also affiliated. The fact that a college member belongs
to the faculty does not necessarily mean that they are working in child psychiatry.

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IACAPAP Textbook of Child and Adolescent Mental Health

Most practising child and adolescent psychiatrists in the UK are consultants or“higher trainees” and the faculty has a major role in supporting specialist training.
Child and adolescent psychiatry is a recognised specialty in the UK, and training
in an approved training scheme leads to a certificate of completion of training fromthe General Medical Council and to access to consultant posts in the specialty.
The faculty runs a strong academic programme with a specific day in the College’s
annual general meeting, a teaching day in the winter, and a three-day residential
conference each autumn.

Conclusion
British child psychiatry and mental health research has produced a wealth ofinnovative theories, methods and approaches that have had worldwide influence.
From Lowenfeld’s “world technique” and Bowlby’s attachment theory to Rutter’s
multi-axial model of diagnosis and Frith and Baron-Cohen’s work on autism andtheory of mind, British research has had a major impact on global understandingsof atypical development and mental illness and the use of psychotherapies to treat
it. It is perhaps because of the dynamic clashes between the Tavi and the Maudsley
models in Britain that researchers have been so productive in generating evidence
to support their theories and thinking about new ways to put these into practice.
Since the 1980s, clinicians have focused on the treatment of particular disorders
based on DSM and ICD categories. This is a testament to the work of childpsychiatrists such as Rutter and Wing who sought to base treatment methods
directly on epidemiological and statistical studies.

UNITED STATES OF AMERICA (US)Child Psychiatry in the United States, as in other countries, represents anarray of services, a body of knowledge, and a profession. The growing field has
had to balance challenges encountered elsewhere—whether to evolve as a medical
subspecialty or as a multidisciplinary field; whether to focus on the most impaired
or on children with varying degrees of impairment; and whether to treat those
whose parents seek and can afford psychiatric services or whether to serve a whole
population. This section will specifically review the field’s history in the US, bothto understand the place of child psychiatry in the US and to anticipate its future
evolution.
Services later called child psychiatric began when social workers and otheradvocates, calling attention to children in the criminal justice system, argued forspecial courts. Under William Healy, a neurologist, these gave rise to the Juvenile
Psychopathic Institute (later the Institute for Juvenile Research) in 1899, then theJudge Baker Guidance Center in Boston. Healy, who spoke of eliciting the “child’s
own story”, became one of the first US child psychiatrists (Richmond & Harper,
1996). Years later, child clinicians including psychoanalysts were credited withteaching all physicians to “listen to the patient” (Eisenberg, 2001). The resulting
child guidance clinics gave rise to two multidisciplinary associations: the American
Orthopsychiatric Association, formed in 1924, and the American Association of
Psychiatric Clinics for Children, established in 1948 (Schowalter, 2003). These
predated the American Academy of Child Psychiatry, founded in 1953.

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IACAPAP Textbook of Child and Adolescent Mental Health

While child guidance clinics treated troubled individual children, theirwork also addressed factors in the family and community. Study of these factors,
along with adversities such as poverty, racism, homelessness and refugee status(Eisenberg & Belfer, 2009), was advanced in three fields influential in US childpsychiatry: cultural anthropology, family treatment, and epidemiology.
The impact of culture on child development and mental health was studied
by Margaret Mead, Ruth Benedict and their colleagues. Erik Erikson (1902-1994)
attempted a synthesis of psychoanalysis, history, and culture in his 1950 book
Childhood and Society. Relevant hypotheses were tested empirically by Whiting
and Child (1953). “Transcultural psychiatry” developed as a field with laterparticipation by child psychiatrists (Minde, 2005; Joshi & Pumariega, 2010).

Past presidents of
IACAPAP at the IACAPAPSan Francisco Congress,
1994. Forefront: Al Solnit.
Middle row, from left: Mary
Philips (widow of the late
Irving Philips), Colette
Chiland, E. James Antony.
Back row: Lionel Hersov,
Reimer Jensen, Donald J.
Cohen.

Families were addressed in several ways. Early parent-blaming—by using
derogatory terms such as “refrigerator mother” and “parentectomy” (Eisenberg,
2001)—gave way to creative ways of joining with families. Family therapy wasdeveloped, among others, by Salvador Minuchin and Jay Haley, physicians andnon-physicians (Minuchin, 1974). Parent education and family training sought toteach parenting skills and empower parents, including using the Triple P program
created in Australia (Sanders et al, 2014). More recently, services have beendeveloped that are designed to create family-driven care and to support parents
with peers with lived experience (“parent partners”; see below).
A third approach to examine the child-in-context has been through childpsychiatric epidemiology. Extending the work in the UK of Rutter and hiscolleagues, community studies by Felton Earls and others quantified the effects
of neighbourhood cohesion on child development and mental health. Theydeveloped and measured the role of individual and collective efficacy in mitigatingrisk and promoting resilience (Carlson et al, 2014).

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IACAPAP Textbook of Child and Adolescent Mental Health

Clinical services for troubled children in the US until the 1980s werepredominantly community-based. In addition, US children benefited from
hospital-based consultation, where child psychiatrists recognized opportunities tohelp children that went beyond the presenting medical illness (Prugh, 1983), andresidential services that offered treatment for troubled young people. Residential
services were often long-term, provided far from home and with little family
participation (Whittaker & Trieschman, 1972; Redl & Wineman, 1957). In these
services the child psychiatrist worked with a team, at times as a consultant, attimes prescribing medications, but less often as the team leader, in contrast to
adult psychiatric services. The services were also predominantly psychodynamic inorientation. While the first academic department was founded by Kanner at Johns
Hopkins in the 1930s, most medical centres did not have such departments until
the later part of the century.
In the last three decades of the 20th century, US child psychiatry joined
other countries in applying approaches to assessment, treatment and evaluation
already established in general psychiatry. Eisenberg’s study of the use of stimulants
in attention-deficient children pioneered the use of the randomized controlled
clinical trial (Eisenberg, 2007). With support from governments, foundations,and the pharmaceutical industry, such investigations flourished, introducing new
medications to psychiatry and more rigorous approaches to assessment. Many
endorsed a new standard of care—evidence-based treatment—with findings basedon the results of randomised controlled trials, though often short-term when mostpsychiatric conditions are chronic or recurrent.
The increasing role of pharmacotherapy reflected an important change insociety, a readiness among parents and other professionals, little seen previously,
to define children’s needs in biological terms (the so-called chemical imbalance),
and to look at medications for help. Many were not only willing but eager touse pharmacotherapy. For child psychiatrists, such definition of children’s needs
offered an advantage vis-à-vis other mental health professionals but also a risk.
The risk was that the role of the child psychiatrist would be limited to assessment
for and prescribing psychoactive medications, the child psychiatrist becoming the“meds-doc”.
US child psychiatry became a subspecialty of general psychiatry with its
establishment in 1959 as a subspecialty of the American Board of Psychiatry
and Neurology. As a result, the base of American child psychiatry moved fromthe community (outpatient clinics, courts, community centres, and residential
treatment) into departments in academic medical centres.
Part of this move was the establishment of the American Academy ofChild Psychiatry (ACAP) in 1953. Founded by child psychoanalysts and a few
psychiatrically oriented paediatricians, the ACAP, initially a club restricted toinvited members, later expanded to include a new generation of child psychiatrists.
Full membership continues to be limited to physicians, excluding allied healthprofessionals. In 1986 ACAP changed its name to American Academy of Childand Adolescent Psychiatry (AACAP), at least in part due to the perceived clinicaland economic threat from adolescent psychiatrists whose training did not include
child psychiatry. Currently, the AACAP has approximately 8,000 members and 58
affiliated regional organizations. Reflecting the influential role of American child

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Leon Eisenberg (19222009) was the chairmanof the department ofchild psychiatry at Johns
Hopkins Hospital after Leo
Kanner. Subsequently he
was appointed professorof psychiatry at Harvard
Medical School. He
conducted some of the first
rigorous studies of autism,attention deficit disorder,
randomised controlled
trials and learning delays
and became a prominentadvocate for children
struggling with disabilities.
He was described as beinga pivotal person in 20th
century US child psychiatry.

65IACAPAP Textbook of Child and Adolescent Mental Healthpsychiatry worldwide, the AACAP has established a membership category for
non-US physicians, who have increasingly looked to the Journal of the American
Academy of Child and Adolescent Psychiatry and to AACAP’s annual meetings forcontinuing education.
US government support for child psychiatry grew, but slowly, in the same
period. Recognizing the extent of disability due to mental health problems in
World War II soldiers, the National Mental Health Act was enacted in 1946,
leading to the creation of the National Institutes of Mental Health (NIMH)
in 1949. The NIMH remains the dominant funding agency of mental healthresearch, though its support for research in children became important only in the
1970s. The US Federal government has also supported training for paediatriciansin child psychiatry.
Since the 1970s there has been increased interest in the objective descriptionof disorders and empirical science in child psychiatry. In 1983, the AACAP’s
Child Psychiatry: A Plan for the Coming Decades, written with participation frommany disciplines and the NIMH, concluded that child psychiatry was 10 years
behind adult psychiatry in biological and epidemiological research. The document
supported initiatives in those fields and in the genetics of childhood disorders.
There were several consequences of this for child psychiatrists. For one, those inacademic settings now grounded their work in the peer-reviewed literature, not justin clinical experience, an emphasis that created a divide between the biologicallyoriented academic child psychiatrists and those providing clinical services in thecommunity. At the same time, in community-based child psychiatry/child mental
health programs, child psychiatrists’ roles diversified, with the child psychiatrist
serving as school consultant, program consultant, or manager. For another, theincreasing emphasis on psychopharmacology—supported by the pharmaceuticalindustry—influenced child psychiatrists’ training and practice. Unquestioning
pharmacotherapy is been replaced by discernment and limits on promotion frompharmaceutical companies.
As mentioned, political support for child psychiatric research and training
increased with the recognition of mental disability in military recruits and of
the disparities between research support for child psychiatry and other medical
specialties. The government, acknowledging that the majority of children withclinically significant mental disorders receive no mental health services (Knitzer,
1982), has created a network of systems of care to provide services closer to home,with a positive role for parents (supported by parent partners—community partners
with lived experience similar to the youths’ parents), and better coordination ofmental health, education, and social services. The role of the child psychiatrist inthese innovative services is evolving (Pumariega & Winters, 2003).

Yale Child Study
CentreArnold Gesell (18801961), a psychologist andpediatrician establishedthe Yale Child Study
Centre in 1911 and was thefirst director. The Centre
subsequently became aleading research hub forchild mental disorders, suchas autism and obsessive
compulsive disorder, andchild development.
An intersection with
IACAPAP happened
early and has been very
productive. Al Solnit, thecenter’s third director,
was the 10th president of
IACAPAP (1974-1978).
During his tenure, Solnit
oversaw the 9th congressof IACAPAP in 1978,
the first of two held in
Melbourne, Australia. A
year later Solnit organizeda study group in Senegal,
in close collaboration with
IACAPAP stalwarts E
James Anthony, Collette
Chiland, Gerald Kaplan,and Serge Lebovici. Also in
attendance at the Senegal
meeting was Donald J.
Cohen who subsequently
became deeply immersed
in IACAPAP’s activities andwas President from 1992
to 1998.

In 2015, child psychiatrists in the US remain the diagnosticians but withthe expectation of a biological explanation. Psychotherapy with children, once a
primary area of endeavour for them, is now often carried out by other professionals.
The child psychiatrist may be seen increasingly as the purveyor of medications
and their scope of practice is changing as many leave the public sector for private
practice. Today’s academic child psychiatrist may lack the comprehensive
understanding that leaders of an earlier era had, a particularly striking change,in view of the voice given by child psychiatrists in previous decades to the “child’s

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IACAPAP Textbook of Child and Adolescent Mental Healthown story.”
US child psychiatrists, having seen much innovation in the field, now face
the challenges of:•

Seeing children’s troubles in terms of development or in terms of (relatively
fixed) categorical diagnoses•

Seeing children’s troubles in terms of processes located solely within thechild or in terms also of the context /ecology and relationships in which thechild lives and grows•

Seeing children as the object of intervention or as an agent, with a sensethat they can shape their lives•

Promoting or neglecting the narratives of acknowledgement and meaningmaking that support growth and recovery•

Embracing a comprehensive range of ways to help children and families as
opposed to limiting their interventions to pharmacology.

Child psychiatrists may beseen increasingly as thepurveyors of medications

CONCLUSIONSAs shown in this brief historical review, although gestation was slow, progressat the level of clinical services—particularly in developed countries— researchand policy in a broadly defined child psychiatry has been outstanding since its
inception about 100 years ago. More than in any other developmental stage,
psychiatric disturbance in children occurs in the setting of dramatic biological,
cognitive and emotional changes and impacts on individuals, families, schools,
neighbourhoods, and judicial and education systems. That is, optimal treatment
usually requires medical and allied professionals with expertise in all these domains
working together, a difficult undertaking that explains some of the tensions andchallenges that child psychiatry has experienced over the years, and still faces.
There are also dark pages in child psychiatry’s short history, which should
not be glossed over because they may hold the key to avoid making the same
mistakes in the future. The darkest one has been the participation of somechild psychiatrists in eugenic practices during the first half of the 20th century,
particularly—but not exclusively—in Nazi Germany. Unnecessarily blaming
parents (e.g., “schizophrenogenic mother”), punitive attitudes towards patients
under the guise of therapy, and failure to protect children, particularly those ininstitutions, have been or still are areas of concern. More recently, prescribing
unnecessary medications and polypharmacy, particularly for very young children,
and administering treatments which are known to be ineffective or on the bases ofideology and not on the grounds of empirical evidence or sound clinical reasoning,suggest that many ethical issues are still far from resolved.
Child mental health research by psychiatrists, psychologists, paediatricians,social workers, mental health nurses and other allied professionals has blossomed,
particularly after the end of Wold War II, so much so that childhood and adolescencehas become the most vibrant area of mental health research largely due to therecognition that most mental disorders have their onset during this developmental
period. Advances have led to a much better understanding of normal development,
its disorders, the nature of psychiatric illnesses in children, and their treatment.

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Progress is likely to continue at an increasing pace due to technological innovations,for example in imaging and genetics. Yet, while societies are becoming healthier(in terms of life expectancy) and wealthier, psychosocial problems in children andadolescents appear to have been increasing in the last 50 years: depression, selfharm, autism spectrum disorders, ADHD, eating disorders, etc. Perhaps the mostimportant challenge that we face is to understand why (Rutter, 2002). The impact
on children of significant social changes (such as high divorce rates, increasing
number of single parent and blended families, same-sex marriages, children left
behind in China’s quest for development etc.) are still not well understood.

Societies are becoming
healthier and wealthier
while psychosocial
problems in children andadolescents appear to beon the increase.

In spite of the successes, child psychiatry as a medical subspecialty isundergoing dramatic changes, facing new opportunities and challenges as a resultof globalisation, the evidence-based movement, the advent of the Internet, and theworldwide political and economic climate. Globalisation is lessening differences inknowledge and clinical practice between western and non-western, developed anddeveloping countries, making it more difficult for ideology-driven or idiosyncratic
practices to take hold. However, some lament that globalization may lead to
unwarranted homogenisation, to the loss of important cultural nuances, or toforsake ethnic or other differences that could be used to enhance diagnosis andtreatment.
The Internet is facilitating the dissemination of up-to-date clinicalinformation and training (this eBook is an example). While an emphasis on evidencebased clinical decision making is increasing the quality of that information, oftraining and of clinical practice, critics argue that lack of evidence is not necessarily
the same as lack of effectiveness— the usefulness of many interventions has notbeen studied yet—and that most randomised controlled studies examine shortterm efficacy while many childhood mental disorders are chronic or recurrent.
Conversely, the Internet can rapidly spread erroneous or even harmful practices(e.g., the case about the MMR vaccine and autism) while youths’ easy access toand reliance on social media is creating its own new challenges (see Chapter H.6).

The impact on childrenof social changes (highdivorce rates, increasing
number of single parent
and blended families,
same-sex marriages etc)
are still not well understood.

The sky is bright but some clouds are appearing on the horizon. In spite of
the fact that youth mental health problems seem to be on the increase and of theexistence of a large pool of unmet need—huge in low income countries—there is
growing competition between specialties and professional groups. The demand forchild psychiatrists far outstrips supply worldwide. This is compounded by a serious
maldistribution, especially acute in rural areas and in low income countries, wheremost of the children of the world actually live.
The proliferation of associations—country-based, specialty-based,theoretical orientation-based, and illness-based—each with their own agenda andinterests is making it more difficult for child mental health professionals to present
a unified front and to have as strong a voice as possible in advocating for childmental health policy in global fora such as the WHO, or at country level.
The rapid expansion in the use of medication risks making childpsychiatrists glorified pill-dispensers with shrinking skills in other key areas (e.g.,
psychotherapy, CBT), which are increasingly delivered by other professionals.
This can result also in several experts dealing with a single child’s problems—apsychiatrist prescribing medication, a psychologist administering CBT, a social
worker doing family therapy, etc. While this could be considered optimal care in

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IACAPAP Textbook of Child and Adolescent Mental Healthsome contexts, the consequent increase in costs, the risk of families being given
conflicting advice or of falling through the cracks, the increased time demands
on patients, and the impact on the therapeutic relationship may be more harmful
than the benefit obtained.
Political and economic problems are resulting in stagnating, if not
dwindling, government expenditure in healthcare in many parts of the world—child psychiatry services often an easy target—and threatening to undermine thevery foundations of the welfare state, which has served children well. While theneed for more services is almost universally acknowledged, child mental healthcare is often given low priority by health administrators and policy makers. Lackof funds and the worldwide dearth of professionals with adequate training makethe commissioning of new services difficult. These problems are made even worse
by ongoing military conflict and terrorism in many regions—with children being
some of the main victims—and by the so far unbridled climate change, theconsequences of which we can hardly fathom.

Child psychiatry is still
looking for its place in thesun in many parts of theworldChild psychiatry is still looking for its place in the sun in many parts of
the world, either because the number of professionals is very small or for theirinability to persuade authorities of the value for training and quality of care of
its recognition as a specialty. For example, after many years of lobbying, childpsychiatry has been recognised as a subspecialty in Spain in 2014. Conversely, theRussian Federation ceased to recognise the subspecialty of child psychiatry in 1995
(the specialty had previously been recognised in Russia from the 1970s).
Child psychiatrists in the 21st century will need to take a proactive role
in reshaping their role and showing their worth in a very competitive andrapidly changing environment. Should child psychiatrists continue to evolve
predominantly as a medical specialty narrowly focusing on biological treatments?
As therapists? As coordinators or managers of the various professionals involved incare, integrating biological, psychological and social aspects of treatment…?

••

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