

Saturday, August 10, 2013

Should pediatrics and child psychiatry marry for the sake of the children?

There is an interesting exchange of letters in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry between a prominent pediatrician and two psychiatrists regarding an article that recently appeared entitled "Is There a Child Psychiatrist in the House?" The pediatrician, William Carey, argues that pediatricians are well trained to manage such things as colic, sleep disturbances, toilet training and temper tantrums, perhaps more so than child psychiatrists. The authors of the original article reply that they are puzzled that Carey sees anything in the original article that threatens the role of the primary care clinician, and agree wholeheartedly with the proposed marriage.  Carey quotes a prominent British pediatrician, probably Winnicott, saying "many years ago" that "pediatrics and psychiatry have been living together long enough and its time we got married, if only for the sake of the children."

Here I would like to point out that Winnicott, a pediatrician turned psychoanalyst, practiced in a time before the explosion of psychiatric medications, and when psychoanalytic thought heavily influenced the practice of psychiatry. If that were still the case, I would agree with this marriage. However, in our current climate of mental health care, where the 15 minute "med check" is the most common type of visit, I think both fields would do well not to marry each other, but rather to marry the growing field of infant parent mental health.

I trained in both general and developmental and behavioral pediatrics, and work in a department of child psychiatry.  I know that for the most part neither discipline is exposed to the explosion of research and knowledge coming out of this new discipline, at the interface of neuroscience, genetics and developmental psychology. This knowledge has great bearing on preventive mental health care.

Here is a case in point. Prior to my own education in this new field, that came in part from my studies as a scholar with the Berkshire Psychoanalytic Institute and in part from a superb post-graduate training in infant parent mental health at U Mass Boston, I would not have known how to work effectively with mother-baby pairs in the setting of maternal mental illness.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with Jenna’s father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.
After a year of visits like this every one to two months, despite having grown up in a quite chaotic environment, Jenna is a bright, curious well-regulated toddler. The research from infant-parent mental health clearly supports devoting this kind of time and attention early on to parent-child relationships as a model of preventive mental health care.

However, in order for a marriage between the two disciplines and infant-parent mental health to be successful, both need to divorce the current climate of health care where, under the influence of a powerful health insurance industry, there is no time for listening.


  1. As an elementary school teacher married in reality to a primary care provider, I feel compelled to assert that their might be a place for educators in this marriage for the sake of the children! Childhood educators so often have insights to provide with regard to how kids and families operate over time and across settings, yet our input is rarely invoked in these mental health conversations. Conversely, the knowledge and understanding a variety of healthcare fields have to offer can be invaluable to pedagogues, yet the lines of communication are generally either closed or distorted due to outdated power dynamics. A marriage of convenience it is not, but a worthwhile one it most certainly is, particularly for the children.

  2. Hi clio
    Thanks for your comment. I agree that educators have a lot to add. However, the conversation about early intervention is often in the setting of education- as evidenced by Obama's preschool for all program. But we know that early intervention is best focused on 0-3, and this age group, particularly infants, have much more broad interface with the healthcare system than the education system.