Psychiatrie Bulletin (1990), 14,611-615
Future child and adolescent psychiatrists: a further
survey of senior registrar training
BOOLS, enior Registrar in Child & Adolescent Psychiatry, Clinical
Sciences Building, St James's University Hospital, Beckett Street, Leeds LS9 7TF
(correspondence); and DAVIDCOTTRELL, enior Lecturer in Child and Adolescent
Psychiatry, London Hospital Medical College, London El 2AD
Child and adolescent psychiatry is a growing dards. The most recent edition of the JCHPT hand
speciality. Significant increases in workload, the book (JCHPT, 1987) makes a number of changes
reasons for which have been described elsewhere from previous editions. Most striking is the substi
(Black, 1989), have led to an expansion in consultant tution of "must" for "should" throughout most of
posts across the UK. Recently the Joint Planning the child and adolescent psychiatry section. Thus,
and Advisory Committee (JPAC) reviewed senior direct experience with mentally handicapped chil
registrar numbers and recommended an increase in dren, and consultation to both a paediatric service
the establishment by 38 whole-time equivalents in and to other professionals are now mandatory rather
England and Wales, a rise of 38%, to meet the than advised. Another important change since 1979,
expected shortfall. How existing senior registrars, as is that the recommended length of training has been
well as this large number of new recruits, are trained restored to its original four years from the recent
is clearly a matter of some importance. three years.
In the United Kingdom, training in child and With the above changes in mind, a further survey
adolescent psychiatry is governed by the Joint of all senior registrars in child and adolescent psy
Committee on Higher Psychiatric Training (JCHPT) chiatry was carried out. The findings of this survey
which was formed in 1973 by the Royal College of are now reported.
Psychiatrists and the Association of University
Teachers of Psychiatry. The Committee has re
sponsibility to oversee all aspects of higher training The study
in psychiatry and is assisted in this by five specialist During the summer of 1988a modified version of the
advisory sub-committees. The Committee publishes 1979questionnaire (Garralda et al, 1983)was sent to
requirements for training which set out the types of the 123 senior registrars (67 women and 56 men)
clinical experience, supervision, formal teaching and believed to be in post in the United Kingdom and
research opportunities which should be available Ireland. A reminder letter was mailed six months
for trainees (JCHPT, 1987). The Committee also later. The original questionnaire was designed to
arranges for all training schemes to be inspected examine training as it was recommended in 1979 so
regularly to ensure that these requirements are the modifications reflected new training guidelines.
followed. The Committee has the power to remove The questionnaire consisted of five sections con
approval for training, which in turn means that cerned with:
senior registrar posts may be lost. (a) Background characteristics Personal details:
Senior registrars in child and adolescent psy length of training in; child psychiatry, general
chiatry were first surveyed in 1979. Training experi psychiatry, paediatrics, mental handicap and
ences were described and concern expressed about post-registration medicine.
the lack of adequate training facilities (Garralda (b) Theoretical orientation The available choices
et al, 1983). There are a number of reasons why a were psychodynamic-analytical, behavioural,
further survey would be valuable. Firstly, there is to social-community and biological. Respon
be a large increase in senior registrar numbers, as dents were asked to rank these in order of im
outlined above. Secondly, since its inception, the portance. It was stated that equal rankings
JCHPT through its Child and Adolescent Psychiatry could be given, so that respondents consider
Specialist Advisory Committee (CAPSAC) has ing themselves eclectic could rank the four
vigorously pursued its policy to raise training stan choices equally.
612 Boots and Cottrell
(c) Present training scheme Clinical experiences, I
workload, supervision, formal learning oc Personal characteristics of responding trainees in 1979 and
casions and the role of the clinical tutor. 1988
(d) Attitudes and availability Trainees were asked
to rate the importance and availability of a 1979(n = 74) 1988(n = 80)
range of clinical conditions, therapeutic skills, no. (%) no. (%)
clinical supervision and educational oppor
tunities. As in the previous enquiry a five point yearsMalesMarriedUK
scale was used for each item. (Importance: 1,
unnecessary; 2, optional; 3, useful; 4, import
ant; 5, indispensible. Availability: 1, not avail graduatesFull
able; 2, not on site but special arrangements time
can be made; 3, limited on site; 4, adequate; in child
5, optimal.) years2-4
(e) Representation Trainees were asked about
their knowledge of trainee representation at yearsOver4
2 years adult
the Royal College of Psychiatrists and on the 1year
JCHPT. 2 years general
Eighty completed questionnaires were returned. The papers4847525463233516702227334828(65)(59)(70)(73)(85)(31)(47)(22)(95)(30
response rate was therefore 65% compared to 69%
obtained in 1979.
The personal characteristics of the trainees from
both the current survey and 1979are shown in Table Hospital out-patients
I. It can be seen that the two groups are similar in
most respects. However, in 1988a greater proportion
of trainees were female, 56% compared to 41%. Hospital in-patients
Fewer trainees had paediatric or general medical ex
perience prior to psychiatric training. More trainees Child guidance units
had published papers than in 1979.
A majority of trainees did not make an exclusive first
choice and the largest grouping of trainees (34 out of Paediatric liaison
80 = 43%) ranked all the choices equally. A further
11 trainees ranked two or three of the choices first Research
equal. Of those who did make an exclusive first
choice the most popular orientation was psychody- O 2 4 6 8 10 12 14
namic-analytical (27 trainees, 34%). This compares Mean hours per week
with 41 trainees (55%) who made this exclusive first
ES33 1979 I I 1988
choice in 1979. This left only eight trainees who
ranked either social community, behavioural or bio FIG 1.Pattern of clinical work for 74 trainees in 1979and 80
logical as exclusive first choices. trainees in 1988.
Present training scheme
The amount of time spent in various settings in 1988, senior registrars was 11.8, while for part-timers it
as compared with 1979, is shown in Figure 1. The was 7.9 per week. The ranges for these two groups
1988 figures were calculated for the 53 trainees were considerable, from 4 to 25 and from 3 to 12
who were working full time in the National Health consultations per week, respectively.
Service. Twenty-two trainees (27%) reported having less
The mean number of patient interviews and clini than one hour of individual supervision with their
cal consultations conducted per week for full-time consultant each week. Seven of these trainees
Future child and adolescent psychiatrists 613
reported having no individual supervision at all, and II
two of these did not receive supervision in a group Importance and availability of therapeutic methods by 1988
with their consultant either. Forty-three trainees rank order
(54%) received more than an hour per week of
supervision with another professional. Rated Adequate
Respondents had been asked to estimate the time
they had spent in formal learning occasions (organ 1988 1979) 1988 1979)
ised seminars or lectures on child development or
clinical child psychiatry) over the previous exact 12 Paediatric
month period. The mean amount of time spent in therapySchools
these seminars was calculated to be two hours per consultationPsychodynamicBehaviour
week in term time (assuming three ten week terms in
the year). There was a great variation in the amount therapyDrug
of time spent in this way, which ranged from 0 to 120 therapyConsultation
hours per year (mean = 17) for child development with
and from 0 to 180 (mean = 39) for child psychiatry.
Most trainees, if they reported no seminars in child therapy9089888481656049(76)(97)(78)(89)(73)(62)(54)(74)7080666043594030(50
development, did have them in child psychiatry and
vice versa; however, two trainees claimed to have had
seminars in neither child development nor psychiatry
over the preceding 12 months. in rated importance since 1979. Behaviour therapy
Trainees stated that they met with their tutor- is less available than in 1979.
coordinator a mean of 3.8 times per term. Despite the Not surprisingly, trainees rated supervision of a
fact that 84% declared satisfaction with the role of number of different therapies as important. In rank
their tutor, only 30% said that they received regular order there were; family therapy, consultation, psy-
feedback about their performance. chodynamic therapy, behaviour therapy and drug
therapy. As in 1979 there was a discrepancy between
Attitudes and availability the importance accorded to such supervision and its
perceived availability. It is of interest to note that the
Clinical problems perceived importance of supervision of drug therapy
The questionnaire listed: emotional, conduct, and has risen, and that the availability of supervision has
adolescent disorders, psychoses, disorders associated risen in all areas except behaviour therapy.
with physical illness, preschool problems, develop Opportunities to teach other psychiatrists and
mental disorders and autism, and mental handicap. medical students were considered to be important
All the above were judged to be important by most and were available to two-thirds of respondents.
respondents (rate 4 or 5). By contrast to the 1979 Only one-quarter of the trainees thought that super
survey, psychotic disorders were not ranked as low vision of their teaching of others was adequately
priority and, whereas in 1979 only one-half of available. While research time and supervision were
trainees had thought that mental handicap was im considered to be essential by over 90% of respon
portant we found that three-quarters now rated this dents, almost one-half thought supervision to be
as important. Despite this finding only one-quarter inadequate.
of respondents considered that mental handicap
experience was adequately available. In addition Representation
an adequate experience of developmental disorders Most respondents (94%) claimed to know about the
(including autism) was only reported by 42% of functions of CAPSAC, and most (80%) were aware
trainees, even though it was considered by most of comments from the last visiting team. Only 5 of
trainees to be important. the 17 part-timers knew that informal advice about
part-time training is available from a member of
Therapeutic methods CAPSAC. A majority of trainees did not know who
Attitudes towards therapeutic methods are shown in their representatives were on the Collegiate Trainees
Table II. As in 1979 family therapy remained very Committee.
popular, but by contrast to 1979, consultation to
both paediatricians and to schools was considered
important by nine out of ten trainees. It can be seen Comment
that the therapeutic approach was eclectic with a This is an incomplete survey as the response rate was
high level of interest in a range of therapeutic only 65%. The fact that senior registrars regularly
methods. Marital therapy has suffered a reduction move post on the rotation and leave to take up
614 Boots and Cottrell
consultant appointments is a partial explanation of satisfaction with tutors was reported to be good, most
this figure, which is nevertheless comparable with the trainees did not receive regular feedback. It would
earlier study of Garralda et al (1983). The questions seem to be uncertain whether tutors have taken on
asked were about the training scheme, not the this possibly useful, but certainly difficult role.
trainee's particular post, and it is therefore likely that
In the last nine years, it is notable that there has been
our replies refer to the majority, if not all training a change in attitude towards psychosis, mental handi
schemes. However, with anonymous replies this cap and other developmental disorders. That these are
remains uncertain. now seen as more important and that nothing is seen
The proportion of female trainees has increased as less important, suggests trainees have a broader
and this is only partly accounted for by part-time view today of what constitutes child psychiatry. Un
training recommendations introduced by the DHSS fortunately, as nine years ago, availability of experi
in circular PM(79)3 which have been implemented in ence does not match up to interest. This is particularly
most regions (Collegiate Trainees Committee, 1987; so with respect to mental handicap where only one-
Gath, 1988). Almost all trainees taking up this quarter of trainees feelthey have adequate experience.
scheme are women and because training is part-time As CAPSAC now states that experience of working
it takes longer than four years. with children with mental handicap is a mandatory
It is surprising that the number of trainees with a training requirement, this suggests either that come
year's paediatric experience has dropped by one- schemes do not meet these requirements or that ex
third, especially in light of the importance attached perience acceptable to CAPSAC seems inadequate to
by trainees to paediatric liaison. This fall has not trainees. There are clearly problems with providing
been matched by an increase in trainees with a brief training in this area - if an under-developed service
paediatric experience, only a further six trainees had exists (as is often the case for children with mental
completed six months in paediatrics. Registrar and handicap and psychiatric disorder) who is to train the
SHO posts are increasingly linked to specialist train trainee? A Joint Working Party has recently made
ing rotations and it is becoming more difficult for recommendations concerning this important area
future child psychiatrists to find posts where they can (Joint Working Party, 1989).
do 6-12 months of paediatrics. One of the benefits The major change in therapeutic activity, aside
of Achieving a Balance (DHSS, 1986) may be that from the generally more eclectic approach men
trainees can obtain a more varied experience at tioned earlier, is the growth in perceived importance
senior house officer level. It is encouraging that more of consultation. The decrease in rated importance of
trainees have published papers. marital therapy is interesting - this may now be seen
There have been considerable changes since 1979 as part and parcel of family therapy, or it is possible
concerning where the trainees spend the bulk of their that there are greater opportunities for child psy
time. The move from child guidance clinics to hospi chiatrists to refer on couples with marital difficulties,
tal out-patient departments probably reflects chang leaving the child psychiatrist to concentrate on the
ing clinical practice. The move out of in-patient units child and/or family. Behaviour therapy continues to
most likely results from the view that, although in- be seen as relatively unavailable. Given the proven
patient units have many resources, they are not the relevance of this therapeutic modality to certain child
best places for trainees to receive the bulk of their and adolescent disorders, this is an area which needs
training, since most will go on to provide mostly urgent attention.
out-patient services at consultant level. The mean Availability of specific supervision has generally
number of clinical contracts might seem low, at 12 improved since 1979 although there are still signifi
per week, but it must be remembered that trainees cant numbers of trainees who feel inadequately
only have seven sessions for clinical work and that a supervised in a number of therapies. Availability for
good proportion of this time is spent in consultation supervision in behavioural therapy has actually
and other forms of indirect contact. Nevertheless, dropped.
there is a wide range of clinical contacts per week, The supervision of teaching and research were
suggesting that some trainees are underworked and both considered to be grossly inadequate. This has
others overworked. It is encouraging that all trainees serious implications for the way the profession is
said they were able to take two sessions a week for presented to others and for the future development
research as per JCHPT requirements. of practice. Although over the past nine years
It is of concern that one-quarter of trainees received CAPSAC's standards have risen, it would seem that
less than one hour of supervision per week. This is trainees' expectations have risen even higher. The
unacceptable by CAPSAC standards and of itself question arises, as to what, or who makes a good
should warrent removal of accreditation from the supervisor; should trainees be getting more training
training scheme, unless rectified. Also of concern is techniques of supervision so that they will be better
the reported wide range of formal teaching provided, equipped as trainers of the future? Who trains the
with some trainees receiving very little. Although trainer?
Future child and adolescent psychiatrists 615
One possible explanation for trainees' high expec questionnaire and Dr Peter Hill for commenting on
tation is the widespread knowledge of the role and an earlier draft. Dr Garralda kindly supplied us with
function of CAPSAC and of the higher training re an original copy of the 1979 questionnaire.
quirements. It was disappointing however, that given
the College's encouragement of junior doctor rep Further tabulated results are available from Dr Boots.
resentation at all levels, so few trainees were aware of
their representatives on the Collegiate Trainees
In conclusion, it would seem that today's trainees BLACK,D. (1989) Consultant manpower in child psy
are more eclectic, more research orientated and more chiatry. Psychiatric Bulletin, 13, 32-55.
COLLEGIATE TRAINEES' COMMITTEE (1987) Part-time train
community based. They are willing to see a larger
range of clinical problems but lack training oppor ing in psychiatry. A brief guide to the options available.
Bulletin of the Royal Collegeof Psychiatrists, 11,137-142.
tunities in some of these areas. They do not yet feel DHSS (1986) Hospital Medical Staffing - Achieving a
adequately supervised, although this has improved Balance. London: DHSS.
over nine years. We suggest that another similar sur GATH,A. (1988) Part-time senior registrar training in child
vey is carried out in about five years to indicate and adolescent psychiatry. Bulletin of the Royal College
changes over that period. We also hope that a par of Psychiatrists, 12, 368-370.
allel survey of the trainers for each scheme will be M. M.
GARRALDA, E., WIESELBERG, & MRAZEK,D. A.
carried out in the near future. (1983) A survey of training in child and adolescent
psychiatry. British Journal of Psychiatry, 143,498-504.
JOINT COMMITTEE ONHIGHER PSYCHIATRIC (
Acknowledgements Handbook. London: Royal College of Psychiatrists.
JOINTWORKING PARTY (1989) the training required to pro
The authors would like to thank Miss Suzanna vide a psychiatric service for children and adolescents
Goodwyn for ensuring that all trainees received the with mental handicaps. Psychiatric Bulletin, 13,326-328.
Psychiatric Bulletin (1990), 14,615-617
Child and adolescent psychiatry training schemes: recent
PETERREDER,Consultant; and CLARELUCEY, enior Registrar, Department of Child &
Family Psychiatry, Charing Cross Hospital, 2 Wolverton Gardens, London W6
Child and adolescent psychiatry training has pro senior registrars, lecturers, and part-time senior
gressed considerably in recent years. Additional registrars currently training, how long they spend in
training posts have been created, as well as senior each leg of the rotation, and how many consultants
academic appointments, and some pre-existing are available to offer training placements.
rotations have coalesced, allowing innovative We also asked more open-ended questions about
schemes of high quality to evolve. CAPSAC (Child specific aspects of the schemes, including experience
and Adolescent Psychiatry Specialist Advisory Sub- of child guidance, in-patients, day-patients, mental
Committee) has continued to oversee established handicap, paediatric liaison, management skills, the
standards and encourage these changes. psychological therapies, and the organisation of
We were interested to review the present position research and academic components. Finally, we
in order to discover the number of schemes and train asked the tutors to comment on what they considered
ing posts in existence and the developments that have the special features of their scheme, significant
occurred. This report is based on a questionnaire sent changes that have occurred in the past two years, and
to all post-graduate tutors in child and adolescent changes they anticipated over the next two years.
psychiatry listed by CAPSAC. We asked each tutor All tutors responded, and we are very grateful to
to record the name of the scheme, the number of them for their co-operation.