ROLES AND FUNCTIONS OF CHILD

PSYCHIATRISTS IN SOCIAL AND

COMMUNITY PSYCHIATRY: IMPLICATIONS

FOR TRAINING

Viola W. Bernard} M.D.

Current developments in the social, community, and public healthaspects of psychiatry as a whole entail growing opportunities andobligations for child psychiatrists. There are commensurate needs forappropriate training. Recognition of this is already reflected in thebroadened scope of child psychiatry training as evidenced, for exam­ple, by the inclusion within the formulations of the Committee onCertification in Child Psychiatry as well as by the A.A.P.C.C. of manyfacets of the field. Thus in the former's "Guide for Training Pro­grams in Child Psychiatry," it is pointed out that the training pro­gram should contain provision for cooperative consultative work forvarious community child care agencies, observational visits to nurs­eries and other community child care agencies. It is also recommendedthat the trainee who has selected his areas of practice in child psy­chiatry be taught in appropriate areas of administration. (The de­scription of examinations for certification in child psychiatry, as pub-

Dr. Bernard is Clinical Professor of Psychiatry; Director of the Division of Com­munity Psychiatry in the Department of Psychiatry and in the School of Public Healthand Administrative Medicine, Columbia University.

This paper was prepared as one of the background working papers for the PreparatoryCommission on Training Needs for the Conference on Training in Child Psychiatry,held in Washington, D. C., January 10-15,1963.

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166 Viola W. Bernard

lished, states that "contributions of collaborative personnel, and typesof social planning will constitute a part of the examination.")

The A.A.P.C.C. child psychiatry training prospectus indicatesthat the training should prepare a psychiatrist "for work within thebroad spectrum of emotional disturbances in children." As this con­cept is defined in more detail it is suggested that the child psychiatristreceive instruction and supervision not only in diagnostic and thera­peutic techniques with children and their parents and in the utiliza­tion of the integrated services of the psychiatric clinic team but also"in the coordination of clinic effort with the work of all health, wel­fare and educational agencies." The A.A.P.C.C. statement of Stand­ards, Policies and Procedures for Training in Child Psychiatry lists,as a part of what a child psychiatric clinic should offer the trainee,"Opportunities for cooperative consultative work with child servic­ing agencies in the community, such as social, educational, protectiveand judicial agencies. It should enable a child psychiatric trainee toenvision the field of child psychiatry in its relationship to the fieldsof child health, education and welfare." The same document stressesthe value of experience for the trainee in specialized child psychiatricsettings and asks that the training program "provide some supervisedexperience, consultative community mental health activities, in theadministration of child psychiatric facilities and in the consultantrole of the child psychiatrist." Among the topics around which didacticseminars are to be provided is included "administration in a child psy­chiatric clinic."

These excerpts are cited as indicative of the degree of acceptancein principle of certain community psychiatry functions as part of childpsychiatry. In fact, such traditional elements of child psychiatry asthe clinical team approach, collaborative treatment, case consultationto social agencies, and emphasis on prevention may be viewed to someextent as conceptual and methodological forerunners of the newlyemerging subspecialty of community psychiatry.1 While thus a spe­cial foundation within child psychiatry already exists for further

1 A confusion of terminology prevails; I use the term "community psychiatry" asinclusive of such differentiated emphases within it as social psychiatry, public healthpsychiatry, and administrative psychiatry. I also use the term to denote a psychiatricsubspecialty within the more comprehensive field of community mental health work,which calls upon the collaboration of those with more diverse competencies than theclinical team or the psychiatrist.

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development of its community psychiatry aspects, and while theseaspects have gained some official recognition within the subspecialtyof child psychiatry itself, there is still considerable need to translatesuch general acceptance of principle into actual patterns of practiceand specific training procedures, both didactic and practical.

Appropriate training cannot be considered without reference tothe roles and functions for which the training serves as preparation.It should be emphasized that the community functions appropriateto the child psychiatrist serve the same over-all goals as for all childpsychiatry, i.e., protection, furtherance, and restoring of childhoodemotional health, but are carried out at the collective level ratherthan on a one-to-one basis. The unique contribution of a child psy­chiatrist, as contrasted to many other community mental health work­ers, is his specialized clinical insight. His application of this throughsuch indirect methods of helping children as social action, adminis­tration, or consultation on social policy, as examples, should be con­ceived of as an outgrowth of his clinical training rather than in con­flict with it.

The child psychiatrist is, of course, particularly aware of the sig­nificance to personality development and emotional status of thedynamic interplay between the growing child and his environment,especially the immediate social environment of the family, and, as thechild grows older, his contact with successively larger social units asat school, with peer groups, etc. The "all-purpose child psychiatrist,"if I may be permitted that term, should extend his understandingto wider ramifications of relationships between social forces, groupexperience, environmental conditions, and child mental health as abasis for appropriate interventions. For example, a customary thera­peutic function of the child psychiatrist, as a clinic team member, isto influence parental attitudes which are such a significant part ofthe child's dynamic environment; a comparable intervention at amore widely ramified level could consist of the child psychiatrist'sparticipation in framing or opposing certain types of legislation whichwould ultimately though indirectly affect child mental health by itsimpact on the life conditions of families. The community psychiatristhas much to learn from the child psychiatrist, and indeed in the train­ing of community psychiatrists particular grounding in aspects ofchild psychiatry theory and practice is essential.

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As distinguished from "the all-purpose child psychiatrist," thereare already those whose subspecialty within child psychiatry is "com­munity child psychiatry." I make this distinction because it has rele­vance to intensity of training. For the all-purpose child psychiatrist,training is enriched by a certain amount of systematically taught con­tent in such areas as consultancy, administration, community organiza­tion, program evaluation, mental health education, etc. Within thelimits of the scarce curriculum time available in relation to the totaltraining program, such content can be taught through a combinationof seminars, courses, supervised field experience, and field visits. Forthose who would in a sense subspecialize in a subspecialty, as com­munity child psychiatrists, the intensiveness and scope of trainingwould naturally be greater. In view of the manifold activities that liewithin child psychiatry, it is neither desirable nor probable that toomany would be motivated to concentrate primarily on the communitychild psychiatry subspecialty. On the other hand, it seems importantto the field as a whole that provision be made for the appropriatetraining of some such specialists in addition to orienting all childpsychiatrists to this aspect of their discipline.

The purpose of this paper is for consideration of Community andSocial Psychiatry training for child psychiatrists at the national level.The description that follows is of the training center with which Iam associated and thus most familiar. It is intended as illustrativeonly and with recognition of the many valuable alternative approachesthat are being and can be developed elsewhere.

At Columbia University, several interrelated training programs forpsychiatrists are offered by the Division of Community Psychiatryunder the joint auspices of the Department of Psychiatry and theSchool of Public Health and Administrative Medicine. The Division,as one of its several categories of training, offers a four-year combinedpsychiatric residency and training in the subspecialty of communityand social psychiatry leading to either an M.P.H. or M.S., dependingon the emphasis chosen. The first year is almost wholly devoted tobasic psychiatry; the trainee's time during the next three years isdivided between the regular residency and the training in communitypsychiatry, didactic and practical, with increasingly more time forthe latter as the total sequence progresses, so that the bulk of thefourth year is spent in supervised field placements in social and com-

Training In Child Psychiatry 169

munity psychiatry settings, with some time for carry-over of long-termsupervised psychotherapy cases.

A basic core curriculum of courses, seminars, and weekly field visitshas been developed by the Division of Community Psychiatry. Thesecourses are taken in common by the several categories of trainees incommunity and social psychiatry. Differentiation of each trainee'stotal program is assured by individual combinations of supervisedfield placements and selected elements from the full inventory oftraining resources in the Department of Psychiatry and the School ofPublic Health and Administrative Medicine.

The Division of Community Psychiatry, of which I am the Direc­tor, is working closely with the Child Psychiatry Training Programheaded by Dr. William S. Langford. Child psychiatry trainees cantake certain selected courses from the community psychiatry corecurriculum. For example, several of them are taking "Epidemiologyof Mental Disorders." They can also attend single sessions of a seminaror single field visits of the weekly field trip series when these areparticularly pertinent for the child psychiatrist. Field placements incommunity psychiatry settings, including social psychiatry researchand demonstration projects, when appropriate, are available to childpsychiatry trainees. (More detailed reference to these placementswill be made below.)

At a more intensive level of collaborative training, there are al­ready two candidates enrolled, and one is under consideration, whoare preparing themselves to be what was referred to above as sub­specialists, i.e., community child psychiatrists. They will undertakecombined training whereby over a five-year period (or less if theycome in with advanced standing) they can fulfill requirements forcertification by the Boards in both General Psychiatry and Child Psy­chiatry as well as for the degree of either M.P.H. or M.S. (in Com­munity Psychiatry) .

As we know, in the four-year training for career child psychiatriststhe first of the two child psychiatry years is in lieu of the third yearof the general residency. The combined residency and degree coursesfor community psychiatry also take four years. By adding one addi­tional year, we are devising an integrated program for those who wantto become community child psychiatrists. The five-year programwould make them eligible for American Board Examinations in

170 Viola W. Bernard

General Psychiatry and in Child Psychiatry (after the required yearsof experience) and eligible for a degree, M.P.H. or M.S. (in Com­munity and Social Psychiatry). Although this is still in process ofbeing worked out, the general plan for the five years is as follows,with appropriate modifications for those entering with advancedstanding from either Public Health or Psychiatric Residency:First Year: General Psychiatric Residency.Second Year: General Psychiatric Residency and Community Psy­

chiatry; about half time each. The Community Psychiatry frac­tion includes courses, seminars, and field visits.

Third Year: General Psychiatry Residency and Community Psy­chiatry; about half time each. The Community Psychiatry frac­tion includes courses, seminars, and some field placements.

Fourth Year: First year of basic Child Psychiatry residency.Fifth Year: Second year of Child Psychiatry. Community Psychiatry

field placements in various types of child-focused settings. Thesemay involve child psychiatric consultation in child care andeducational agencies, for example, as well as such functions asprogram planning and evaluation and continuation of super­vised long-term therapy cases in child psychiatry, as well as con­ferences and seminars. Since the second year of child psychiatrygives opportunities for assignments in areas of the candidates'major future activities, it may be suitably combined with theCommunity Psychiatry training for selected trainees.

Such a joint program entails flexibility and cooperation by itsleadership in the interpretation of essentials rather than on theirforms per se, lest rigidities or rivalries as to respective requirementsand schedules defeat the purposes of optimal comprehensive train­ing. The division of trainee time for each of the five years should notbe so hard and fast as to preclude some carry-over of certain activitiesinto a succeeding year if this serves objectives of the training as awhole. For example, while the course, seminar, and field visits cur­riculum in community psychiatry would be mainly concentrated with­in the second and third years as outlined above, more time for ex­perience with long-term supervised psychotherapy, extending overseveral years, may be gained if the community psychiatry course workis also spread, so that one course or so each semester could be takenin the first child psychiatry year, especially if courses are among those

Training In Child Psychiatry 171

appropriate to the all-purpose child psychiatrist, such as "Epidemiol­ogy of Mental Disorder," "Principles of Administration." "LegalAspects of Psychiatry," or "Psychiatric Consultancy of Various Kinds."In order for the fifth year to serve simultaneously as training in childpsychiatry and community and social psychiatry, a considerable periodof time would be devoted to supervised field experience in a settingor settings where practical experience in functions and roles of thecommunity child psychiatrist could be gained. Such assignments wouldbe made, however, in such a way that ongoing activities in the specificchild psychiatry training center could be maintained.

Among the field training settings which are affiliated with the Di­vision of Community Psychiatry that can be selected for the childpsychiatry trainees in particular are:

(1) The Bank Street College of Education. (This placement maybe supplemented by work at the Fieldston Schools and theNew York City Board of Education.)

(2) Louise Wise Services. (Adoption and Unmarried MotherServices.)

(3) Wiltwyck School for Boys, Inc.(4) Henry Ittleson Center for Child Research.(5) Northside Center for Child Development.(6) Psychiatric Services for the newly consolidated State-Wide

Family Court in New York City.In addition to these affiliated settings, several research projects with­in the Division's Community Psychiatry Research Unit which arealready under way or contemplated, are appropriate for participationof community child psychiatry trainees.

Each of these settings lends itself to a variety of different field train­ing experiences to be planned for each trainee in terms of individualbackgrounds, interests, and career plans. Some might profit morefrom the administrative, policy-making, and organizational aspectsof a setting's program, and others from its various types of consultancywork, program evaluation, action research or program planning, andpractice. Whichever the specific area chosen for concentration, how­ever, it is approached from the over-all perspective of community andsocial psychiatry, with stress on the larger context within which it isan integrated component.

An attitude of community-mindedness and an integrative way of

172 Viola W. Bernard

seeing relevant connections between what is seemingly disparate areamong the basic attributes of the community child psychiatrist. Theseare expressed through many different types of activity. As psychiatryand the provision of mental health services grows more complex, theneed for subspecialization within psychiatry increases, as evidencedby the development of child psychiatry itself, with its many sub­divisions. But the drawbacks of specialization increase corresponding­ly, so that the resulting isolation and compartmentalization requirenew modes of reintegration and intercommunication.

The report Young Children of Mentally III Parents (April, 1962) ,prepared by the Mental Health Section of the Citizens' Committeefor Children of New York, Inc.,2 is illustrative of the assumptionby child psychiatrists of pertinent responsibility for identifying andattacking a significant problem, and of coordination and integrationat the community level. In this particular example of social action,the Mental Health Section which was comprised of child psychiatrists,psychologists, and social workers, convened two meetings, severalmonths apart, with policy-making representatives of state and local,public and private, health, education, and welfare agencies in orderto focus community attention on the needs of these particular childrenand their families. The first meeting gave rise to participation by thetotal group in preparing illustrative case material. Between the twocommunity meetings, the Mental Health Section members workedtogether in jointly refining and clarifying the thinking for the reportwhich was prepared. At the second meeting, ongoing concerted com­munity activity was assured by arranging for its continuance underthe official aegis of the New York City Community Mental HealthBoard.

This description indicates in this particular instance of child psy­chiatry activity various ingredients such as group process, communityorganization, and collaborative patterns between child psychiatristsand others that differ from clinical team work both as to the enlargedcomposition of the partnership and in the nature of its work. Thetext of the report demonstrates a number of other functions of com­munity and social child psychiatrists, among others: those of con­ceptual integration; of identification with both parents and childrenas interacting members of a family unit; of viewing both mental

2 Unpublished. Some mimeographed copies available at Citizens' Committee for Chilodren of New York, Inc., 112 East 19 Street, New York 3, N. Y.

Training In Child Psychiatry 173

hospital services and community-based services as functional com­ponents of a continuum of services to people as members of familiesboth in and out of their own homes; of the use of public health ap­proaches to data gathering and prevention; of techniques of com­munication; of providing clinically informed consultation on adminis­trative policies and procedures; of stimulating appropriate demonstra­tion projects; of the building of hypotheses and in designing researchto test them as basic to the planning of improved kinds of service.

I am currently engaged in two other illustrative instances of childpsychiatrists functioning in community and social psychiatry. Oneconcerns referral and screening policies of psychiatric services forchildren in municipal hospitals, the other planning and setting upappropriate psychiatric services for the newly consolidated state-wideFamily Court in New York City. The Commissioner of Hospitals withthe support of the Mayor has appointed a committee, co-chaired by twocommunity child psychiatrists, composed of representatives from thepublic and private psychiatric, health, and social agencies that aresignificant to child mental health. Since referral, screening, and intakeprocedures occur at the interchange point between community andhospital-based mental health services for children, they are criticallystrategic for coordinated interprofessional and interagency effort toimprove the total network of mental health services for children atthe collective level. This committee typifies another important rolefor community and social child psychiatrists, i.e., that of implement­ing clinically sound changes in patterns of public care by workingwith governmental officials and involvement in governmental process.

The second committee referred to above for planning child psychia­try services for the Family Court in New York City includes judges,city officials, child psychiatrists, psychologists, social workers, and childcare experts. Here again, we see the child psychiatrist's function in agroup made up of people with different kinds of specialized knowl­edge, in different positions of responsibility and authority, and in ajoint effort to effect creative synthesis with respect to a vital and multi­faceted community mental health issue.

Although high-quality clinical training and experience are basicprerequisites, they are often not enough to qualify child psychiatriststo function effectively in such situations. Without supplementarytraining or experience along the lines suggested earlier, excellent

174 Viola W. Bernard

clinicians have failed in necessary intergroup communication, in fa­cility with group process, and in awareness of social realities.

Reference was made earlier to the social contribution child psy­chiatrists can make in advising legislators or those who in turn usepolitical process to effect legislation with respect to laws, either di­rectly or indirectly affecting child mental health. For example, ifchild psychiatrists understand adoption as a form of preventive psy­chiatry and thus within their scope, they can recognize their share ofresponsibility for legislation toward insuring procedures and safe­guards for adoptive placement of children in the kinds of familiesthat are psychologically health-promoting.

In connection with adoption another recent example of a somewhatdifferent form of community child psychiatry functioning comes tomind. This concerned standards for agency practice in advising adop­tive parents about how to tell the children of their adoption. This af­fected considerable numbers of children. The question centered onthe optimal age, psychologically, at which adopted children should betold about their adoption. In this instance, theoretical considerationsof personality development and child-parent relationships enteredinto such issues as the respective advantages and hazards of being in­formed at the oedipal or latency phases. A meeting was called ofchild psychiatrists and analysts and adoption agency administratorsand supervisors. The child psychiatrists who could integrate theirpsychotherapeutic experience with disturbed adoptive children andparents with broader knowledge about pertinent variables in adop­tive practice and general community handling of dependent and neg­lected children could offer more realistic and meaningful consulta­tion than those who relied on psychotherapeutic experience alone.

Case consultation to social agencies and educational institutionsby child psychiatrists is accepted and familiar practice. As we are calledupon, however, for consultation on issues of administration and pro­gram and in addition on matters of broad social policy, it becomesdesirable to supplement clinical training for adequate fulfillment ofthis role. To illustrate by way of some current examples, child psy­chiatrists are being consulted by educators about the psychologicalimplications of policies and procedures for conducting nuclear airraid drills, about school segregation-desegregation issues, and aboutspecial classes for autistic children in public schools. All of these

Training In Child Psychiatry 175

questions, and the many more that might be cited, are directly re­lated to mental health and illness of children; all of them can bedealt with more effectively when the child psychiatrist's clinical in­sight is augmented by knowledge of the social and educational con­texts, and principles and techniques of consultation.

Child psychiatrists are also called upon by health, welfare, andcorrectional agencies, and should sometimes take the initiative whennot called upon, in relation to community approaches to such com­plex psychosocial problems as teenage drug addiction, juvenile de­linquency, multi-problem families, and illegitimacy. No single dis­cipline can plan or implement the total concerted remedial measuresthat such problems require; child psychiatrists can playa significantrole, and should assume their distinctive share of responsibility.

A community child psychiatrist gives high priority to developinginnovations and improvements for therapeutic access to the largenumbers of children who have been relatively untreatable by tradi­tional methods. Among these many are underprivileged and sufferfrom combinations of serious social pathology and psychopathology.Furthermore, because the community child psychiatrist is in a specialposition to discern the pathogenic elements for children in varioussocial conditions, he has a special role in mobilizing community con­cern for rectifying them. In general, greater sensitivity and sophistica­tion as to dynamic interactions and relationships between social andintrapsychic processes, achievable during training, helps child psy­chiatrists, in cooperation with many other community mental healthworkers, to extend their sphere of therapeutic effectiveness at thecommunity level.

In the foregoing pages some of the educational implications forchild psychiatry of current trends in social and community psychiatryhave been discussed. Similarly, distinctive contributions which childpsychiatry can make to the developing subspecialty of social and com­munity psychiatry have been stressed. Differing intensities of ap­propriate training for the latter have been suggested, respectively,for "all-purpose" career child psychiatrists and those who would pre­pare themselves for a new kind of subspecialty within a subspecialty,i.e., "community child psychiatry." Ambiguities and differing opin­ions prevail, during the present evolving stage, as to what is meant byCommunity, Social and Public Health, both theoretically and prac-

176 Viola W. Bernard

tically. For the sake of darity, therefore, the training implications inthese areas for child psychiatrists have been presented here in termsof specific roles and functions, with illustrative examples of these, aswell as of a pilot training program for "community child psychia­trists."