Child and adolescent psychiatry

Child and adolescent psychiatry (or pediatric psychiatry) is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of these psychiatric disorders and treatment responses to various interventions.[1]

History

When psychiatrists and pediatricians first began to recognize and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era.[2] Authors like the Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn't exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and "insanity" in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualization of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the "passions" that affected the adult mind.[2]

As early as 1899, the term "child psychiatry" (in French) was used as a subtitle in Manheimer's monograph Les Troubles Mentaux de l'Enfance.[3] However, the Swiss psychiatrist Moritz Tramer (1882–1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria.[4] The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894–1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital in Baltimore.[5] Kanner was the very first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the anglophone academic community.[5] In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital.[5] In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner Syndrome.[6]

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the "Lega Nazionale per la Protezione del Fanciullo" (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the "intuition that the question of the 'mentally deficient' was more pedagogic than medical".[7] In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world's first child guidance clinic.[8] Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent's biological aspects of brain functioning and IQ, but also the delinquent's social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.[9]

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children's department.[10] Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognized medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.[11][12]

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner's students, Leon Eisenberg, the second director of the division.[5]

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by, Eva Frommer, Douglas Haldane, Michael Rutter, Robin Skynner and Sula Wolff, among others.[13] The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children's adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children's mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.[14]

It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and '70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV[15] and DSM-IVR have altered some of the parsing of psychiatric disorders into "childhood" and "adult" disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV).. The American Psychiatric Association's DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as "neurodevelopmentalists".[16][17] As of 2005 there was debate in the field as to whether "neurodevelopmentalist" should be made a new speciality.[18]

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical "Cinderella" (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.[19]


"Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors." [20]

Classification of disorders

Developmental disorders

Disorders of attention and behaviour

Psychotic disorders

Mood disorders

Anxiety disorders

Eating disorders

Gender identity disorder

Disorders can be comorbid (for example an adolescent can be diagnosed with both mood and anxiety disorders). The prevalence of psychiatric comorbidities during adolescence may vary by race and ethnicity.[21]

Clinical practice

Assessment

The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and his/her parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child's emotional or behavioral problems, the child's physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child's problems. Collateral information is usually obtained from the child's school with regards to academic performance, peer relationships, and behavior in the school environment.[22]

Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioral observation and a first-hand account of the young person's subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.[23]

The assessment may be supplemented by the use of behavior or symptom rating scales such as the Achenbach Child Behavior Checklist or CBCL, the Behavioral Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment.[24] More specialized psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child's difficulties.[25]

Diagnosis and formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behavior and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR)[26] or the International Classification of Diseases (ICD-10).[27] While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful.[28] A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarizing all the relevant factors implicated in the development of the patient's problem, including biological, psychological, social and cultural perspectives (the "biopsychosocial model").[29] The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.[30]

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behavior therapy,[31] cognitive-behavior therapy,[32] problem-solving therapies,[33] psychodynamic therapy,[34][35] parent training programs,[36] family therapy,[37] and/or the use of medication.[38] The intervention can also include consultation with pediatricians,[39] primary care physicians[40] or professionals from schools, juvenile courts, social agencies or other community organizations.[41]

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. [42]

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialized training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and continuing education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP).[43] Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.[44]

Shortage of child and adolescent psychiatrists

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced.[45] As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Center for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that "there is a dearth of child psychiatrists." Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.

Cross-cultural considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.[46][47]

Criticisms

Subjective diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack "objectivity", particularly when compared with diagnosis in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties.[48] In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".[49][50]

Traditional deficit and disease models of child psychiatry have been criticized as rooted in the medical model which conceptualizes adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterize problematic behavior as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behavior has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession (see references): it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behavior and symptoms, to promote a view of the "patient" as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behavior, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability (Boorse, 1976; Jensen, 2003; Sadler et al. 1994; Timimi, 2006).

Over-prescription of psychoactive drugs

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the U.S. Food and Drug Administration (FDA) issued the Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in pediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.[51]

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioral issues other than a psychotic disorder, which is not the ideal treatment approach for these drugs.[52] In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families.[52] More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in pediatric populations. Because of the risk of weight gain, metabolic syndrome, and cardiovascular changes with antipsychotic use, the use of the drugs in pediatric populations is highly scrutinized and their use recommended only in combination with effective parent-training interventions.[52]

Electroconvulsive therapy

In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments.[53] This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy.[54] In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated.[55] Commenting on his experience as part of Bender's therapeutic program, Ted Chabasinski said that, "It really made a mess of me ... I went from being a shy kid who read a lot to a terrified kid who cried all the time."[56] Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Center.[57]

See also

Notes
  1. Sadock, Benjamin J; Sadock, Virginia A; Kaplan, Harold I (2009), Kaplan and Sadock's Concise Textbook of Child and Adolescent Psychiatry, Lippincott Williams & Wilkins, ISBN 9780781793872
  2. Shuttleworth, Sally (January 2012), "Victorian visions of child development", The Lancet, 379 (9812): 212–213, doi:10.1016/s0140-6736(12)60091-9, PMID 22272394, S2CID 35218208
  3. Manheimer, Marcel (1900), "Les troubles mentaux de l'enfance (review)", Journal of Mental Science, 46 (193): 342–343, doi:10.1192/bjp.46.193.342.
  4. Eliasberg, WG (July 1964), "In memoriam: Moritz Tramer M.D.(1882-1963)", American Journal of Psychiatry, 121: 103–4, doi:10.1176/ajp.121.1.103, PMID 14154770
  5. Child and Adolescent Psychiatry at the Johns Hopkins Hospital
  6. Neumärker, K.-J. (2003), "Leo Kanner: His Years in Berlin, 1906–24. The Roots of Autistic Disorder", History of Psychiatry, 14 (2): 205–208, doi:10.1177/0957154X030142005, PMID 14518490, S2CID 2513608
  7. Caffo, E. (1999), "Child and adolescent psychiatry in Italy", in Remschmidt, H.; van Engeland, H. (eds.), Child and Adolescent Psychiatry in Europe, Steinkopff, pp. 187–196, doi:10.1007/978-3-642-96003-1_15, ISBN 978-3-642-96005-5
  8. Beuttler, Fred and Bell, Carl (2010). For the Welfare of Every Child – A Brief History of the Institute for Juvenile Research, 1909 – 2010. University of Illinois: Chicago
  9. Schowalter, John E. (2000). Child and Adolescent Psychiatry Comes of Age, 1944-1994. In Menninger RW and Nemiah JC (Eds). American Psychiatry After World War II – 1944 – 1994. Washington, D.C.: American Psychiatric Press, p. 461 – 480
  10. Evans, Bonnie; Rahman, Shahina; Jones, Edgar (2008-12-01), "Managing the 'unmanageable': interwar child psychiatry at the Maudsley Hospital, London", History of Psychiatry, 19 (4): 454–475, doi:10.1177/0957154X08089619, PMC 2801544, PMID 19397089
  11. "About Us". AACAP. Archived from the original on 21 April 2011. Retrieved 25 March 2011.
  12. Kutchins, Herb; Kirk, Stuart A. (1992). The selling of DSM: the rhetoric of science in psychiatry. New York: A. de Gruyter. ISBN 978-0-202-30431-1.
  13. Green, Jonathan; Yule, William (2001), "Foreword", in Jonathan Green and William Yule (ed.), Research and Innovation on the Road to Modern Child Psychiatry: Festschrift for Professor Sir Michael Rutter, London, p. vii; Stevenson, Jim (2001), "The Significance of Genetic Variation for Abnormal Behavioural Development", in Jonathan Green and William Yule (ed.), Research and Innovation on the Road to Modern Child Psychiatry: Festschrift for Professor Sir Michael Rutter, London, p. 20
  14. Rutter, Michael (1990), Chapter 7, Isle of Wight Revisited, Twenty-five years of child psychiatric epidemiology. In Annual Progress in Child Psychiatry and Child Development. Chess, Stella and Herzig, Margaret (eds), Psychology Press, ISBN 978-0-87630-602-4
  15. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington DC: American Psychiatric Association, 1994
  16. Shea, SE; Gordon, K; Hawkins, A; Kawchuk, J; Smith, D (12 December 2000). "Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on A.A. Milne". Canadian Medical Association Journal. 163 (12): 1557–9. PMC 80580. PMID 11153486.
  17. "International Child Neurology Association Newsletter: Excerpts". Pediatric Neurology. 17 (1): 92–93. July 1997. doi:10.1016/S0887-8994(97)90006-0.
  18. ALARCÓN, RENATO D. (June 2005). "Psychiatry, 2nd ed". American Journal of Psychiatry. 162 (6): 1234–1236. doi:10.1176/appi.ajp.162.6.1234.
  19. Barrett, Susan (2019). "From Adult Asylums to CAMHS Community Care: the Evolution of Specialist Mental Health Care for Children and Adolescents 1948-2018". Revue Française de Civilisation Britannique, XXIV-3. XXIV (3). doi:10.4000/rfcb.4138.
  20. Child Adolesc Psychiatric Clin N Am 26 (2017) 611–624
  21. Weller, Bridget E.; Blanford, Kathryn L.; Butler, Ashley M. (2018). "Estimated Prevalence of Psychiatric Comorbidities in U.S. Adolescents With Depression by Race/Ethnicity, 2011-2012". The Journal of Adolescent Health. 62 (6): 716–721. doi:10.1016/j.jadohealth.2017.12.020. ISSN 1879-1972. PMID 29784115.
  22. Rutter, Michael and Taylor, Eric. Chapter 2, Clinical assessment and diagnostic formulation. In Rutter and Taylor (2002)
  23. Angold, Adrian. Chapter 3, Diagnostic interviews with parents and children. In Rutter and Taylor (2002)
  24. Verhulst, Frank and Van der Ende, Jan. Chapter 5, Rating scales. In Rutter and Taylor (2002)
  25. Sergeant, Joseph and Taylor, Eric. Chapter 6, Psychological testing and observation. In Rutter and Taylor (2002)
  26. American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition, American Psychiatric Publishing, ISBN 978-0-89042-025-6
  27. International Classification of Diseases (ICD), World Health Organisation, retrieved 2008-07-02
  28. Rousseau, Cécile; Measham, Toby; Bathiche-Suidan, Marie (2008), "DSM IV, Culture and Child Psychiatry", Canadian Academy of Child and Adolescent Psychiatry, 17 (2): 69–75, PMC 2387108, PMID 18516309
  29. Winters, Nancy; Hanson, Graeme; Stoyanova, Veneta (January 2007), "The Case Formulation in Child and Adolescent Psychiatry", Child and Adolescent Psychiatric Clinics of North America, 16 (1): 111–132, doi:10.1016/j.chc.2006.07.010, PMID 17141121
  30. Egger, Helen (July 2009), "Psychiatric assessment of young children", Child and Adolescent Psychiatric Clinics of North America, 18 (3): 559–580, doi:10.1016/j.chc.2009.02.004, PMID 19486838
  31. Herbert, Martin. Chapter 53, Behavioural therapies, in Rutter and Taylor (2002)
  32. Brent, David, Gaynor, Scott and Weersing, Robin. Chapter 54, Cognitive-behavioural approaches to the treatment of depression and anxiety. In Rutter and Taylor (2002)
  33. Compas, Bruce, Benson, Molly et al. Chapter 55, Problem-solving and problem-solving therapies, in Rutter and Taylor (2002)
  34. Lieberman A.F.; Van Horn P.; Ippen C.G. (2005). "Towards evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence". Journal of the American Academy of Child and Adolescent Psychiatry. 44 (12): 1241–1248. doi:10.1097/01.chi.0000181047.59702.58. PMID 16292115.
  35. Schechter DS, Willheim E (2009). "When parenting becomes unthinkable: Intervening with traumatized parents and their toddlers". Journal of the American Academy of Child & Adolescent Psychiatry. 48 (3): 249–254. doi:10.1097/chi.0b013e3181948ff1. PMID 19242290.
  36. Scott, Stephen. Chapter 56, Parent training programmes, in Rutter and Taylor (2002)
  37. Jacobs, Brian and Peaarse, Joanna.Chapter 57, Family therapy, in Rutter and Taylor (2002)
  38. Heyman, Isobel and Santosh, Paramala. Chapter 59, Pharmacological and other physical treatments, in Rutter and Taylor (2002)
  39. Rauch, Paula and Jellinek, Michael. Chapter 62, Paediatric consultation, in Rutter and Taylor (2002)
  40. Garralda, Elena. Chapter 65, Primary health care psychiatry, in Rutter and Taylor (2002)
  41. Nicol, Rory. Chapter 64, Practice in non-medical settings, in Rutter and Taylor (2002)
  42. Bachmann M, Bachmann CJ, John K, Heinzel-Gutenbrunner M, Remschmidt H, Mattejat F. The effectiveness of child and adolescent psychiatric treatments in a naturalistic outpatient setting. World Psychiatry. 2010;9(2):111–117. doi:10.1002/j.2051-5545.2010.tb00288.x, Z Kinder Jugendpsychiatr Psychother. 2008 Sep;36(5):321-33. doi: 10.1024/1422-4917.36.5.321
  43. "Specialties & Subspecialties". American Osteopathic Association. Archived from the original on 2015-08-13. Retrieved 18 September 2012.
  44. AACAP Archived 2007-09-29 at the Wayback Machine
  45. Thomas, Christopher; Holzer, Charles (2006), "The continuing shortage of child and adolescent psychiatrists", Journal of the American Academy of Child and Adolescent Psychiatry, 45 (9): 1023–31, doi:10.1097/01.chi.0000225353.16831.5d, PMID 16840879, S2CID 17187044
  46. Wintrob R. Cross-cultural psychiatry. Psychiatric Times. 2010;27:27.
  47. Measham T, Guzder J, Rousseau C, Nadeau L. Cultural considerations in child and adolescent psychiatry. Psychiatric Times. 2010;27:38-40.
  48. Ronald Pies (October 2007). "How "Objective" Are Psychiatric Diagnoses?". Psychiatry (Edgmont). 4 (10): 18–22. PMC 2860522. PMID 20428307.
  49. Frances, Allen (6 August 2013). "The new crisis of confidence in psychiatric diagnosis". Annals of Internal Medicine. 159 (2): 221–222. doi:10.7326/0003-4819-159-3-201308060-00655. PMID 23685989.
  50. Frances, Allen (January 2013). "The past, present and future of psychiatric diagnosis". World Psychiatry. 12 (2): 111–112. doi:10.1002/wps.20027. PMC 3683254. PMID 23737411.
  51. Webber, Jo., Plotts, Cynthia A. Emotional and Behavioral Disorders Theory and Practice 5th Edition. 2008. Pearson Education: New York, NY. p. 98.
  52. American Psychiatric Association (September 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Psychiatric Association, retrieved 30 December 2013, which cites
  53. Rey, Joseph M., and Walter, Gary (May 1997). "Half a century of ECT use in young people". The American Journal of Psychiatry. 154 (5): 595–602. doi:10.1176/ajp.154.5.595. PMID 9137112.
  54. Shorter, Edward, and Healy, David (2007). Shock therapy : a history of electroconvulsive treatment in mental illness (1. publ. ed.). New Brunswick, N.J.: Rutgers University Press. p. 137. ISBN 978-0-8135-4169-3.
  55. Boodman, Sandra G. (24 September 1996). "Shock therapy: it's back". Washington Post.
  56. Sullivan, Valerie (30 October 1982). "General news: Berkeley, California". United Press International.
  57. Hill, Gladwin (31 October 1982). "Now therapy by the ballot". The New York Times. Retrieved 23 March 2011.

References
  • Rutter, Michael; Bishop, Dorothy; Pine, Daniel; =Scott, Steven; Stevenson, Jim S.; Taylor, Eric A.; Thapar, Anita (2010), Rutter's Child and Adolescent Psychiatry (5th ed.), Wiley-Blackwell, ISBN 978-1-4051-4593-0
  • Goodman, Robert; Scott, Steven (2012), Child and Adolescent Psychiatry, Wiley-Blackwell, ISBN 978-1-119-97968-5
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