Child and adolescent psychiatry: The need for training and development

In the last few decades, it has been continuously stressed that the significance that mental disorders have for patients and society should be acknowledged. This is due to both the elevated frequency of such disorders and the social and economic burden they represent.^1,2 Generalised acceptance of the fact that there are elevated pre-adult rates of these pathologies has been especially slow. Children and adolescents represent approximately 1/3 of the global population, and 20% of them are considered to require psychiatric care.³ Consequently, these pathologies are becoming more and more important among public health priorities.^4,5 Evidence shows that a very significant portion of adult psychiatric disorders have their start in infancy or adolescence.⁶ In this issue, Catalá-López et al.⁷ showed that disability-adjusted life years lost, in adolescents and youth, are in large part related to psychiatric disorders such as depression, alcohol abuse, drug addiction, schizophrenia or bipolar disorder. Early care for the different disorders in the first stages of life can prevent negative consequences derived from the disorder, as in the case of children with autism⁸ or those at risk of conduct disorder.⁹ Some of these preventative programmes, which can be costly at first, have demonstrated that they can later reduce the overall cost of treatment, special education services and patient dependency.¹⁰ In addition to the elevated frequency of disorders in children and adolescents and the influence on functioning at these ages, the long-term repercussions (years after the onset of problems) are also very important. Engqvist and Rydelius,¹¹ using a registry of 1400 cases, analysed mortality in adult subjects that had been treated for a psychiatric disorder during their childhood or adolescence. The mortality rate was determined when these children were adults and the rate found was significantly higher than that of the general population. Thirty-two deaths were due to suicide, intoxication, overdose or an accident, 1 was due to complications from alcohol dependence syndrome and 5 were due to natural causes. The mortality predictors were conduct problems, problems in school, substance abuse and criminality. All of this emphasises the importance of appropriate treatment at early ages. However, there is still a wide gap between real healthcare needs at these ages and the development, and thus the availability, of healthcare resources in many countries.¹²

Changes in child and adolescent psychiatry from the 50s have been considerable. The first classifications from the WHO¹³ had very few defined diagnoses for child mental disorders, such as conduct disorder in children. Likewise, the first child and adolescent psychiatry associations did not originate until the 50s. On the other hand, the approach was similar for any pathology and included, as a rule, general play therapy and parent counselling. Currently, things have changed considerably. There has been advancement in the definition and diagnostic criteria of several disorders that can present themselves in children and adolescents.¹⁴ Differential diagnosis is given more value and not only is environmental influence important, but also whether the child's own characteristics are genetic, temperamental or personality-related, in both clinical and research fields.¹⁵ Compared to adults, there are notable differences at these ages in manifesting disorders due to different factors. Among them, it should be emphasised that the brain is still developing and highly plastic, that the environment greatly influences the state of the child or adolescent and that limits between normal and pathological are also determined by age. Therefore, we need experienced clinical centres that assess using instruments appropriate for the ages of patients that attend. Furthermore, these centres should use different sources of information. In these centres, specific and differentiated treatments also need to be available for disorders, both in the psychotherapeutic approach (attention to problems in cognitive processing, experiences, coping strategies and problem-solving, behaviour contingencies) and the pharmacological approach, with different ages being taken into consideration. The evolutionary stages from birth to adolescence have specificities that require different interventions and strategies that cater to each stage. Family involvement, not only in diagnosis but also in the patient's treatment, is absolutely necessary for better results. All this implies that different expertise and abilities are required from those needed to attend to consultations in general psychiatry.

In addition, at these ages, it is even more necessary to approach disorders in an interdisciplinary manner and with participation from different professionals such as psychiatrists, psychologists, nurses or social workers, in addition to collaboration from teachers and school psychologists. In the case of children at risk for different reasons, such as not depending on an appropriate environment, family problems, learning problems, chronic illnesses, etc., preventative work can be carried out that also includes support and attention from the adults in charge of their care. Interaction is necessary between the institutions responsible for taking care of children and adolescents (child protection services, prosecutor's office and juvenile courts). Although collaboration between different disciplines and agencies is very necessary, it can also present difficulties¹² as many times they do not use the same language, programmes for approaching the problems are not in sufficient agreement and coordination is costly because it involves more dedication from professionals.

Therefore, it is essential that speciality training in child and adolescent psychiatry be carried out appropriately and under good quality control. This way, professionals that work with children and adolescents will not be trained using only personal initiatives that are unorganised or uncontrolled by official training plans. It is important to achieve homogenous and complete training. If not, it is difficult to address the childhood pathology with the quality necessary, to make treatment homogenous and to correctly follow international guides. On the other hand, if training in the early ages is not optimal, their specificities will not be taken into consideration and there will be difficulties in detecting and treating disorders poorly understood in general psychiatry. With respect to healthcare resources, there has been less development of these resources in many countries in comparison to adult psychiatry. This makes access to treatment difficult for children or adolescents with disorders, or, in many cases, care is not performed in the most appropriate place.¹² Other benefits that can be obtained from good training are greater professional identity, as professionals will have decided to dedicate themselves to this specialty from the beginning, and they will voluntarily prioritise their own healthcare network and they will belong to specific associations, consequently advancing the knowledge in this area. It is important that professionals collaborate to diminish the stigma and improve the public perception of child mental health, its treatments (especially drug treatment) and research.¹⁶

Regarding research, there has also been progressive international recognition of the importance of these ages, given that they make it possible to study the different disorders without influence from years of evolution or successive treatments. Research also contributes knowledge about first symptoms, which may be fundamental for prevention. However, the problem previously mentioned regarding professionals’ lack of specific training and the issue of fewer resources have also contributed to research in child and adolescent psychiatry developing more slowly. Therefore, despite the big differences between different countries, it can be said that child and adolescent psychiatry is generally still behind adult psychiatry and other specialties. Furthermore, there is a wide gap between habitual practice and research.^12,17 Obviously, the final objective of research in child and adolescent psychology is to improve clinical practice, and that requires increasing the relationship between these 2 perspectives to both optimise daily practice and prioritise research that answers relevant questions for improving diagnoses and treatments. Therefore, research that incorporates different disciplines (both basic and clinical) should be promoted. Developmental neuropsychology, genetics, neuroimaging, neurobiology, therapy, epidemiology and prevention would be of major importance.¹⁵ Some of the studies related to child and adolescent mental health that should be promoted with the help of public funds would be those that involve prevalence rates and long-term follow-up of disorders, as well as quality clinical trials and cost-effective treatment analyses.^12,17 To facilitate the work of researchers dedicating themselves to child and adolescent disorders, more specific regulations are also required for these ages (e.g., consents for procedures or recruitment). The ethical aspects of research with children are especially important, but researchers have to have ethics committees, project evaluators and regulating agencies with sufficient expertise that can collaborate and help researchers in planning and carrying out relevant studies.