It would appear at first glance that pediatricians and child psychiatrists would be natural collaborators, bringing their distinct areas of expertise together to provide comprehensive clinical care for children. Pediatricians and child psychiatrists are among the few medical specialties that focus entirely on children and adolescents. They both tend to be more politically liberal than most other physician groups and they both have adapted to live at the bottom of the medical pay scale.
Despite the 4 years shared in medical school, the same fundamental desire to help children, and some similar sociopolitical characteristics, pediatricians and child psychiatrists have had their difficulties working together over die years. At least once a decade for the past 70 years, influential pediatricians and child psychiatrists have written thoughtfully on the state of the relationship between the disciplines; examples are listed in the sidebar on page 388. A range of problems have been identified and solutions proposed, but working together effectively for die benefit of children remains a challenge. In my view, four factors contribute to the challenge: (1) distinct developmental histories of each specialty; (2) characterlogic differences between child psychiatrists and pediatricians; (3) significant differences in models of practice; and (4) unrealistic expectations that each discipline may have of the other. This article compares pediatrics and child psychiatry in each of these areas and concludes with some suggestions to improve collaboration.
The evolution of pediatrics and child psychiatry has been a gradual process of increasing interaction. In an excellent review of the early years of pediatrics, Julius Richmond (1967) described the Golden Age of Curative Pediatrics, between 1920 and 1950.1 During this exciting period, major advances in immunizations, nutrition, intravenous therapy, antibiotics, and hormone replacement (eg, insulin) dramatically reduced childhood morbidity and mortality. Pediatricians established the controlled empirical investigation as the gold standard during this period and they were absorbed in the purely biologic sphere of illness.
Overlapping Development of Pediatrics & Child Psychiatry
Despite subsequent changes in practice and a more comprehensive approach that includes interest in behavioral and developmental problems, the expectation of cures and a strong biological emphasis remain in pediatrics as important residua of the Golden Age.
In contrast, child psychiatry evolved from the social welfare system and has yet to have the experience of readily available, simply applied cures. In the 1920s, child psychiatry had its birth in child guidance clinics affiliated with the juvenile justice system. As offshoots of medicine and general psychiatry, pediatrics and child psychiatry were pushed together by an influential report in 1932 mat decried the loss of humanistic values in an increasingly technologically-based medical system, the overuse of laboratory tests witib. too little consideration of psychological issues, and a deficient emphasis on prevention.2 Liaison psychiatry programs in general hospitals and children's hospitals were established to broaden physician's skills and to improve total patient care. Child psychiatry fellowships for pediatricians were established and a small cadre of retooled pediatricians, led by Leo Kauner at Johns Hopkins, began to assert their influence. Currently, a mandated component of child psychiatric training is consultation liaison experience in the pediatric setting. Although there was a brief period in the 1970's when psychiatry was moving away from medicine (to the extent that an internship was not even required before psychiatry residency), overall the advances in psychiatry and child psychiatry in the past 2 decades have dramatically enhanced the biological basis of the field to balance the psychosocial underpinning.
The increasing overlap between child psychiatry and pediatrics, as depicted in the Figure, provides common ground for me two disciplines and smooth collaboration. However, the influence of distinct roots for each discipline and the residual impact of the Golden Age of curative pediatrics (or lack of the same in child psychiatry) are still influential.
Pediatricians and child psychiatrists are different people. Of course, neimer group of physicians is homogeneous and describing typical characteristics of tfiose in either discipline could be construed as stereotyping. However, consideration of ways mat the worldviews, styles, and interests of pediatricians and child psychiatrists differ may shed light on collaboration issues.
Enzer et al. (1986)3 sought to assess how beliefs about the nature of childhood differed between pediatricians and child psychiatrists before and after training. Using descriptions of childhood gleaned from poetry and classic literature in a standard format, they asked pediatricians f and psychiatrists at various points in meir training to agree or disagree with the sentiments expressed in a series of quotations. Pediatricians revealed an optimistic, upbeat attitude and childhood was seen as idyllic, carefree, and pleasurable. In contrast, child psychiatrists endorsed a view of childhood that included significant struggle, conflict, and powerlessness. These attitudinal differences were present at the outset of training and were reinforced during residency. The differences, while not consuming or absolute, are informally acknowledged by fully trained pediatricians and child psychiatrists currently in practice.
When child psychiatry was more theoretically than empirically based, those who were drawn to the profession were interested in developmental and psychoanalytic theory. Although the psychiatric knowledge base is now broader and empirically grounded, many child psychiatrists still enjoy theoretical discussions and see themselves as fairly reflective in nature. Pediatricians, on the other hand, tend to describe themselves as activists and extremely practical. These characteristics lend themselves to public advocacy and pediatricians are perhaps the most tireless and effective advocates among physicians, both individually and as a discipline.
Pediatricians' optimistic, positive view of childhood is associated with another important characteristic: the ability to reassure effectively and to reduce anxiety in their patients and their parents. Reassurance is a staple of pediatric practice and generally it constitutes a useful, efficient intervention. In contrast, child psychiatrists need to develop the ability to tolerate anxiety and sometimes even provoke it as a motivator of change. Overall, pediatricians are less comfortable than child psychiatrists in directly confronting anxiety and other strong emotions and better at reassuring or minimizing the affect.
Child Psychiatry and Pediatrics: 6 Decades of the Relationship
The day-to-day practice of pediatrics is remarkably different from child psychiatry in a number of ways that impact ease of collaboration. Historically, pediatricians have had a public health focus and feel a responsibility to help large numbers of children. Pediatric practice is geared toward high volume and brief interactions; in depth knowledge of die patient is aggregated over many such visits throughout childhood. Child psychiatrists' modal interaction with patients has been die 50-minute hour, with 10 minutes allocated for paperwork, phone calls, and other duties, before seeing the next patient. Even with managed care mandating more brief interactions, the practice of child psychiatry is still a low volume, high intensity endeavor compared to pediatrics.
Pediatricians' need to be practical and oriented to immediate concerns is associated with a focus on direct symptom management and brief interventions. Child psychiatrists' long-term orientation can appear impractical or unresponsive when viewed in this light.
Pediatricians typically rely on history garnered from the parents, their own physical examination, and die laboratory for diagnostic data. The child is frequently only a passive participant in the evaluation and treatment process. In contrast, die child psychiatry patient is usually an active contributor of diagnostic information and is a central, independent participant in the therapy. Thus, a child psychiatrist may be dismayed with die pediatrician when a child reveals seemingly basic information in a psychiatric interview that was not known to die pediatrician.
Pediatricians expect to treat all the children in a family to acquire a good knowledge of and relationship with mem over time and to see the children regularly in times of health and illness. In contrast, child psychiatrists' contracts with families are more urne limited, rarely include all me children in a family, and are tied to periods of maladjustment or psychopamology. The impact of managed care on me practice of child psychiatry has been more pronounced than on pediatrics in terms of limiting bom the length of a specific contact and the duration of treatment, as an endpoint is typically demanded and authorization must be sought for continued or renewed contact. Lack of understanding of mese practice differences can lead to frustration when me disciplines interact.
Too often, differences between the disciplines are seen by one as deficiencies in me other. Expliciüy or implicitly, child psychiatrists may seek to remake pediatricians in their own image or vice versa. It is worthwhile to examine some of me specific unrealistic expectations each discipline may have of the other.
Child psychiatrists may expect pediatricians to be mental healm professionals, eg, to monitor psychotropic medications after discharge, to implement a behavioral contingency program, to make assessments about an adolescent's suicidal potential, to summarize parental psychopamology. Although a minority of pediatricians embrace this job description and a large number reluctantly assume those duties for lack of an alternative, it is unrealistic for child psychiatrists to expect it. Pedicatricians' training generally does not support it, meir comfort level is low, and mental health issues are not what drew mem to pediatrics.
Related to this is child psychiatrists' unrealistic expectation mat pediatricians understand psychotherapy, eg, what the process is, the curative factors, how to respond to patients' or parents' questions or dissatisfactions. Pediatricians don't usually regard their own responses to a patient as useful diagnostic data and they rarely have a background in family systems theory. It is more effective and appreciated for a child psychiatrist to provide mis kind of background information before the situation arises than to label a pediatrician as unpsychologically-minded afterward.
Child psychiatrists often unrealistically expect pediatricians to have a high level of interest in psychiatric patients' physical problems, eg, ear infections, constipation, enuresis. Whether it is caused by a lack of appreciation that there are plenty of opportunities to treat these problems in routine pediatric practice or that psychiatric disorders complicate their management, child psychiatrists often summarily turf these problems to pediatricians with little thought or communication. Even more problematic are occasions when child psychiatrists attribute to pediatricians similar disinterest in psychiatric problems and fail to communicate after a referral.
Pediatricians are equally prone to unrealistic expectations, but in different areas. Because pediatricians' patient appointments are brief and they often move from one examining room to another, it is usually easy for another physician to speak quickly with a pediatrician; phone calls are often taken immediately or returned a few minutes later. Child psychiatrists, in contrast, have few or no office staff, longer appointments, and a high level of patient affect that most are loath to interrupt. If pediatricians expect of child psychiatrists availability similar to other pediatricians, they are certain to be disappointed.
Most pediatricians are unaware of the fact that managed care impacts psychiatric treatment much more pervasively than me rest of medicine. Unrealistic rates, authorization hurdles, retroactive disallowance, and required submission of detailed case descriptions and treatment plans increasingly are causing many child psychiatrists to resign from managed care plans. Pediatricians' expectation that child psychiatrists should see patients regardless of insurance issues is unrealistic. A related expectation, experienced by many psychiatrists, is that a child psychiatrist should somehow make heroic efforts to fix the shortcomings of the mental health system so that a pediatrician's particular patient can get needed but unavailable service.
Finally, pediatricians often expect that child psychiatrists have a degree of comfort and expertise in doing medical work-ups that is beyond most child psychiatrists - the counterpoint to child psychiatrists' expectations that pediatricians should be mental health professionals. No matter what should be the case (we all went to medical school), such an expectation strains the relationship between the disciplines.
SUGGESTIONS TO IMPROVE COLLABORATION
The most important thing that pediatricians and child psychiatrists can do to improve collaboration is to recognize that the differences they perceive are real, permanent, and even desirable. Children are best served when they have access to a full range of medical expertise even with the associated personality and practice characteristics. A missionary approach, in which each discipline attempts to bring religion to the heathen in the other discipline, is doomed from the start. Few physicians are eager to be converted. Conscious recognition of the differences allows us to replace negative prejudice with interdisciplinary respect, an essential component of effective collaboration.
Just as all politics are local, all relationships are personal. Practitioners in each discipline need to develop strong individual relationships with counterparts in the other discipline. Establishing most-favored-nation status with at least one cross-disciplinary colleague has many benefits. It can result in smoother referrals, better communication, and useful informal consultations. In addition, such working relationships serve to model effective collaboration to observers in both disciplines.
Collaboration is fostered in academic centers through interdisciplinary research projects. In addition to being the proper scientific approach to complex biopsychosocial issues, sharing a research project requires respectful collaboration. The resulting increased understanding of disciplinary strengths, approaches, and values, as well as the personal relationships that are forged in solving research problems together, are reinforced with the successful completion of a project of mutual interest. Similar advantages are derived from joint advocacy efforts.
Pediatricians' history of advocacy, the organizational expertise, and large numbers are much appreciated when added to child psychiatrists' efforts to improve access to quality behavioral health services. Ultimately, children are the beneficiaries of strong collaboration on every level between pediatricians and child psychiatrists.
1. Fritz, GK. Consultation-liaison in child psychiatry and the evolution of pediatric psychiatry. Psychosomatics. 1990;31:85-90.
2. Fritz, GK. The hospital: an approach to consultation. In: Fritz GK, Mattison RE, Nurcombe B, Spirito A (eds). Child and Adolescent Mental Health Consultation in Hospitals, Schools and Courts. Washington D.C. American Psychiatric Press Inc., 1993, pp. 7-25.
3. Richmond JB. Child development: a basic science for pediatrics. Pediatrics. 1967; 39:649-658.
4. Work H. The "menace of psychiatry revisited": the evolving relationship between pediatrics and child psychiatry. Psychosomatics. 1989; 30:86-93
5. Enzer NB, Singleton DS, Snellman LA, et al. Interferences in collaboration between child psychiatrists and pediatricians: a fundamental difference in attitudes toward childhood. J Dev Behav Pediatr. 1986;7:186-193.
Child Psychiatry and Pediatrics: 6 Decades of the Relationship