Orientation in Paediatric Psychiatry
A Personal Odyssey
My topic is the development of Child Psychiatry or Paediatric Psychiatry in this country, a subject, a discipline which we never heard tell of in our undergraduate years. Indeed we wouldn’t have recognised a child psychiatrist had one come up with an enuresis alarm swinging from ear to ear. Now the first draft of this paper was quite disjointed and the limited time was only partly the reason. Essentially up to recently, the development of Child Psychiatric services here has been quite ad hoc. Indeed it was not the Department of Health, but religious organisations that initially addressed the area and provided a service. So to provide some structure I have grafted the account onto my own medical career which to an extent more or less parallels the development of Child Psychiatry Services in Ireland. Forgive the narcissism! So the revised title of the talk is Orientation in Paediatric Psychiatry, A Personal Odyssey. My practice was in the West so it should be occidentation but as you will come to see, orientation is more appropriate.
We were the pre-Belfield, the pre- Elm Park Brigade. UCD was in Earlsfort Terrace, just off Stephen’s Green and my teaching hospital, St. Vincent’s likewise straddled the corner of Lesson Street and St. Stephen’s Green. So Stephens’s Green and the surrounding area, the cafes, the pubs, the shops and the dance-halls became our campus. To an extent it was just like a small town where, over time, you came to know or half-know everybody. On one occasion, after a year’s absence, I brought my laundry into the Dry-Cleaners, Bell and Swastika, at the top of Grafton Street.; “Oh, said the assistant, I believe we have your previous lot here” and she handed me a parcel with two vests and a shirt. Students from Dublin lived at home and the rest of us, in the main, resided in digs within cycling distance of the college; Ranelagh, Rathmines, South Circular Road and adjacent areas. These were run by kind but formidable landladies originally from such far afield places as Mayo, Kerry or Cavan but now were well settled in Dublin. We too got a quick introduction to the ordinary folk of the city as our fellow residents included civil servants, bus conductors, shop assistants and the like. This stood us in good stead when relating to patients later in our clinical years.
Social life centred on the pubs and here they was some specialisation. In Lower Leeson Street, The Green Bar, run by John Lamb, was where young medical students were initiated and commenced their drinking (in those distant years, nobody but nobody in second level took a drink). Then when we matured. I’ll rephrase that, then when we started our clinical studies we graduated to Hartigan’s, just down the lane from Vincent’s A and E. Here we huddled together as in a rugby scrum but discussing our patients’ signs and symptoms. When we were interns the hospital telephone receptionists understood where to contact us when we told them that we off to the Blood Bank. O’Dwyer’s next door to Hartigan’s was patronised by students and teachers from other faculties and a wider group of the general public. Indeed Conor Cruise O’Brien from nearby Iveagh House sometimes was there playing billiards with visiting diplomats. Some of us medical students who had no prowess in rugby or who just wanted to escape for a while also slipped in.
Becoming somewhat disillusioned with clinical medicine I drifted further into town where there was a colourful and talented clientele and it was easy to join their company. In many ways this offered an alternative College which could be called the Bohemian Academy. The seminar rooms were in Sinnott’s, Neary’s, Davy Byrne’s, McDaid’s and The Bailey. Indeed just as in UCD here too there were different faculties. The writer mentors included Myles na Gopaleen, Anthony Cronin, Leland Bardwell, Pearse Hutchinson and Paddy Kavanagh, and classmates included writers James Liddy, Paul Durcan, Michael Hartnett, Eilean Ni Chuilleanain, Brian Lynch and MacDara Woods; the sculptors were Eamonn O’Doherty, Eddie Delaney and John Behan and the artists Eddie McGuire, Brian Burke, Michael Kane, Camille Souter and Charlie Cullen. There also were classes from musicians and actors. Visiting speakers came from London from such academic centres as The French bar and the Swiss in Soho, The Plough in Museum St. and The George in Portman St. They included Robert McBride, Bertie Rodgers, David Wright, and Louis McNeice and even Dominican priests from Oxford such as Herbert McCabe. The Irish Ballad and traditional music revival had just kicked off and I recall in O’Donoghues of Merion Row, Luke Kelly and Ronnie Drew being told to stop making all that noise or they’d have to leave. There were many other interesting characters and overall it was a lively stimulating environment with cliques and sub-groups forever forming and dissolving much like the academics back in College. Indeed some such as John Jordan, Earl McCarthy and David Franklin graced both Academies. Whether these experiences revealed my professional specialty or inspired it I am not sure but I decided to train in Psychiatry.
Fifty years ago there was no organised Psychiatric training in this country but a couple of years as Registrar in St. John of God Hospital Stillorgan gave me a good start. Here the psychiatric treatment was bang up-to-date and the care was of high standard but the experience, though valuable, was somewhat limited. We had no female patients. Perhaps in the Ireland of those years women didn’t develop psychiatric illness. Whatever, the St. John of God Brothers’ Hospital treated only men. This was something that intrigued the interview board at my next appointment; the Postgraduate Psychiatric Training scheme at Cambridge University, the original Cambridge, the one in England. It attracted many eminent speakers and for example I recall attending a fascinating lecture by Anna Freud. We also attended The Tavistock Centre in London, where the staff included research psychiatrists such as John Bowlby, whose Attachment Theory made a lot of sense to me.
The effective psychotherapeutic drugs had just become available, and mental illness was becoming treatable and even curable. These medications certainly enabled the patients to become accessible to other psychotherapeutic methods. Many patients were being discharged from the Lunatic Asylums and followed -up at newly established Outpatient Clinics. Later Psychiatric Units were located in general hospitals.
After a few more years training, I had a brilliant insight. Surely if we focussed on the patients at the beginning of their illnesses, indeed if we treated psychiatrically ill children, then they wouldn’t have to be admitted to these hospitals in the first place. Prevention and early intervention was the logical course and an economical one.
I started my Child Psychiatry training in London and then moved to a Senior Registrar Training post in Exeter, in Devonshire, which included a placement in a day and small residential unit. I had discovered that in childhood there is very little actual psychiatric illness as we know it, well serious psychosis at any rate. Some Bipolar disorders did begin in adolescence and schizophrenia, but there were very, very few children who suffered from hallucinations and delusions. It was around this time that it was established that autism was a separate clinical developmental condition and not a childhood form of schizophrenia as previously believed.
There were other conditions and syndromes such as Tourette’s syndrome, with tics and habit spasms and of course teenagers with anorexia nervosa and others with crippling obsessions and compulsions. However the vast majority of our child patients had what were termed emotional disorders, habit disorders and behavioural / conduct disorders.
By and large this was a new constituency involving much more involvement with the patient’s family, something I welcomed. The presenting problems usually were multi-factorial in origin, possibly having features from within the child, from the family and from the school and/or community. Therefore the diagnostic and treatment approach was through the multi-disciplinary team; Child Psychiatrist, Educational/Clinical Psychologist and Family Social Worker. Each professional contributed to the multi-axial diagnostic formulation and to the treatment, which again could include the patient’s family and usually his/her school. Working through play therapy with an individual child is a fascinating and a highly creative experience.
In the NHS there were blue-prints for everything, every possible clinic and service had centrally laid down staff-patient ratios and norms. Hospital and clinic architectural designs for different demographics were already drawn up. Everything was decided by the Department of Health in London and only minor modifications were permitted to meet local circumstances. Therefore committee meetings with management dealt with minor matters and were extremely boring. I acquired virtually no management or administrative experience.
Having spent eight years in England, on that auspicious day, April the First 1975, with my wife Rachel, herself also a psychiatrist, and our baby son, Eoin, I took up office as Clinical Director in Child and Adolescent Psychiatry to the Western Health Board in Ireland. My appointment was to the Teaching hospital, then the Regional Hospital Galway, and my task was to do Child Psychiatry for the community with about 105,000 school-children dispersed across the three counties, Galway, Mayo and Roscommon. I was Clinical Director but there was no one to direct, indeed there was no office and no budget. But there was plenty of good will. I was lodged temporarily in the new unopened general adult psychiatry unit in the Regional Hospital. The new Professor there had refused to accept nursing staff assigned by the union officials from the local mental hospital. A stalemate ensued so my temporary lodgings could extend until that was resolved.
In the hospital I was made most welcome by the other consultants. They told me that there was a great need for a Child Psychiatrist, a crying need in fact. The CEO of the Board was delighted with my appointment and assured me that the service requirements would be fully met.
I diligently sat in my office from 9.00 am to 5.00 pm each day, pouring over the map, reading health board reports and journals and twiddling my thumbs. Apart from having no staff to direct, I had no patients to treat. After a month or so, this started becoming stressful. By now I had a secretary, so two of us were idle. I wrote to all and sundry about my presence with the clinic times. Then I visited the other Child Psychiatric services in the Country which in the main were run by voluntary services. There were eight Consultants in Dublin and one in Cork. The St. John of God order in Dublin had a comprehensive Child Psychiatric Service and the Mater Hospital and the Eastern Health Board had residential services for Childhood Autism.
The Development status of the services was as follows:
- 1950s St John of God, Orwell Road, Dublin
- 1960s EHB St. Loman’s Hospital (ASD)
- 1960s Mater Hospital CGC; St. Paul’s Beaumont (ASD)
- 1970 CUH Temple St. Dublin
- 1970s St. John of God Stillorgan (Adolescents )
- 1970s Brothers of Charity, CGC Lota, Cork.
- 1970s SHB. In-patient unit, St. Stephen’s Hospital, Cork.
- 1970s EHB . St. James’s Hospital; Warrenstown House; Court Hall
The CEO appointed me to a variety of committees such as the Child Care Policy Committee and invited me to the Health Board Meetings where the members were told that ours was the only Health Board outside Dublin with a Child Psychiatrist. Indeed this was something of a mantra of his. The fact that I was not actually treating patients didn’t seem to matter at all. Gradually it dawned on me that I was a Trophy Consultant. One day, perhaps feeling triumphant, the CEO asked me whether I would like to cover the North-West Health Board as well; he would fly me to Letterkenny by Helicopter. I formed the image of myself as St. Patrick blessing communities.
I certainly had a task ahead of me: Locating patients. I set about outlining the potential of the Child Psychiatry profession, its community orientation, the range and nature of problems addressed and its therapeutic approach; Firstly to the referral agents.
At the annual Hospital seminar day for GPs, I thought that the new Family Therapy approach to childhood problems would resonate with these Family doctors, one which they could adapt for their own practice. I showed how the child’s problem could have a part to play within the family relationship system and might in fact be a symptom of its dysfunction. I gave what I considered were neat case vignettes illustrating where the relationship inter-actions within some families, viewed as a system, were maintaining the child’s problem behaviours. Alas the only question this elicited was:
“Dr. Carroll why doesn’t the Health Board issue free clothes for Mentally Handicapped children, the way the County Medical Officer used to?”
As I have said, I certainly had a task ahead of me. Having realised that in the Regional Teaching Hospital we could not compete for resources with shroud-waving surgeons, we moved to the Community Care programme. Here my lack of administrative training proved to be an advantage. Instead of drawing up three-year and five-year development plans and presenting them to the Board’s committees, I went straight up to the Department of Health in Dublin and made my case. I knew no better. Luckily there was a Keynesian Minister of Finance at the time, who believed that full employment was the right policy. The administration delivered and a nuclear Child Guidance team was recruited and we were set up in a detached dwelling in the Community, suitably modified: Lyradoon Family Centre. In the meantime that Minister, having nearly bankrupted the country, his Government collapsed and he had been appointed as a Professor of Economics.
The sociological movement which would result in the re-labelling, in the categorising or diagnosing children, with identifying various syndromes hadn’t reached the West of Ireland yet. We did what we could to appraise people of our therapeutic potential. We had started regular meetings with Community Care Staff and Teachers, as well as Family Doctors to outline our service. Eventually this missionary work resulted in a steady stream of referrals. And my now not so naive approach towards acquiring staff continued. I came to realise that my success had to do with national politics and each change of Government resulted in a wave of new appointments. Within a few years all our needs were met: we had four post-graduate trainees, six psychologists, social workers, occupational therapists, nurses, speech and language therapists and child-care workers. At one stage we were so embarrassed with staff numbers and I had to lend two trainee doctors to adult psychiatry to fulfil their training needs.
The positive feature was that we never had a waiting-list. Our philosophy was to deliver a community-orientated service so we started Clinics in Health Centres in major towns. We also were involved in training the Medical students and provided placements for student nurses, social worker and occupational therapists.
There was a clinical ethical dilemma. Were we justified in pathologising behaviour which the community wasn’t concerned about? For example with something as innocuous as bed-wetting, I would say to a mother, Well, I’m glad to be able to tell you, Mrs. O’Flaherty, that there is nothing wrong with Eamonn’s kidneys or bladder; “ O thanks be to God! Dr. that’s great news entirely thanks very much, we’re most grateful to you” and off they would go. But, the Bed-wetting Mrs. O’Flaherty. “Never mind the wet beds Dr. we can manage them all right.”
Likewise there was no ADHD, no hyper kinesis, just ‘buachailli dana, bionn se an- busy, an-gnothach’ Was I to say, no, this is an organic cerebral condition which results in his inattention and hyper-activity. Well to get methyl-phenidate for my ADHD patients then was quite an elaborate chore. We had to arrange with a compliant pharmacist, notify the Central Pharmacy in Dublin to deliver the prescription for the named patient. None of this was reassuring to the family or indeed the GP.
The Stolen Child by W. B. Yeats
Away with us he’s going,
He’ll hear no more the lowing
Of the calves on the warm hillside
Or the kettle on the hob
Sing peace into his breast,
Or see the brown mice bob
Round and round the oatmeal chest.
For he comes, the human child,
To the waters and the wild
With a faery, hand in hand,
For the world’s more full of weeping than he can understand.
[Now I refer to ‘A Stolen Child’ by William Butler Yeats and its relevance to Child Psychiatry. Autism makes sense of the changelings of traditional belief that the fairies stole a human child, usually male and left behind a fairy child, a leanbh siofrach. Indeed, given the gender predominance of autism in boys the practice of dressing all children as girls as a preventive also fits this notion. I don’t say that this belief was current when I pioneered the Child Psychiatric service but we had no cases of autism. The Health Board told me that three had been sent to Dublin but I was unable to locate them.
The Department of Education didn’t acknowledge Autism at all so there was no special provision in schools, and certainly no special care assistants. So as with everything else, we had to set about developing that specialised service. And again, what is the right approach to delivering a diagnosis to a parent? Your son has childhood autism, but I’m afraid that there is no service available for him]
The Health Board continued to deliver on its promise so within a few years we had our own residential and day treatment unit with an attached special school. This was located in a fine old stately home, Lenaboy Castle in its own grounds which had been the Black and Tans Barracks and more recently a children’s residential home. Whilst it was a somewhat institutional building our child patients loved it, its nooks and crannies and more recently took to calling it Hogworths. Apart from some occasional hassle from the ghosts, it served us very well.
WHB. UCHG 1975;
Lyradoon Family Centre; 1976
St. Anne’s Children’s Centre, Galway 1978
Child Psychiatric Services were developing steadily throughout the country.
In 1984, A Department Policy Committee delivered a report called
“Planning for the Future”
This title indicated that a new approach to Health Planning was being adopted ea\lthin Ireland. Whilst essentially dealing with Adult psychiatry and recommending the phased closure of the Mental Hospitals with the development of Community based services, Chapter 12 focussed on Child Psychiatry. It recommended the establishment of two Child Psychiatric Teams in each Health Board Area, one specialising in Adolescents.
In 2003 a Working Group Report recommended a number of in-patient units throughout the country.
The Most Recent report “Vision For Change” 2006, is quite enlightened and for example recommends:
Composition of the Child and Adolescent Community Teams Two child and adolescent CMHTs should be established for each sector of 100,000 population.
Individual teams should comprise the following:
- One consultant psychiatrist.
- One doctor in training.
- Two psychiatric nurses.
- Two clinical psychologists.
- Two social workers.
- One occupational therapist.
- One speech and language therapist.
- One child care worker.
- Two administrative staff.
On January 1st 2009 the College of Psychiatry of Ireland was launched
So to conclude, The Current National position is that the HSE has approximately 63 CAMHS teams consisting of 512 staff members.
There are 32 Senior Registrars in Higher Training. There are three University Chairs of Child and Adolescent Psychiatry Nationwide there are six residential units, the slides illustrate one in Dublin, Cork and Dublin.
The State of Play in the Western Region is that the three counties now have six Consultant led CAMHS teams and the purpose-built Residential Unit, approved under Mental Health Legislation with two consultants and a staff of fifty covering twenty beds.
Nunc Dimittis.Anthony Carroll FRCPsych