child and adolescent psychiatry 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 psychiatric disorders and treatment responses to various interventions. child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population. 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. 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. 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. 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. 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. 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. in 1936, kanner established the first formal elective course in child psychiatry at the johns hopkins hospital. in 1944 he provided the first clinical description of early infantile autism, otherwise known as kanner syndrome. 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". 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. 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. 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. 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. 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. 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. 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. 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 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". as of 2005 there was debate in the field as to whether "neurodevelopmentalist" should be made a new speciality. 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. "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." classification of disorders not an exhaustive list developmental disorders autism spectrum disorder learning disorders disorders of attention and behaviour attention deficit hyperactivity disorder oppositional defiant disorder conduct disorder psychotic disorders childhood schizophrenia mood disorders major depressive disorder bipolar disorder persistent depressive disorder disruptive mood dysregulation disorder anxiety disorders panic disorder phobias generalized anxiety disorder eating disorders anorexia nervosa bulimia nervosa binge eating disorder avoidant/restrictive food intake disorder (arfid) rumination pica gender identity disorder gender identity disorder in children any substance use disorders alcohol use disorder substance use disorder disorders are often comorbid. for example, an adolescent can be diagnosed with both major depressive disorder and generalized anxiety disorder. the incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables. 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. 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. this assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents. 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. 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. 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-v) or the international classification of diseases (icd-11). 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. 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"). 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. 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, cognitive-behavior therapy, problem-solving therapies, psychodynamic therapy, parent training programs, family therapy, and/or the use of medication. the intervention can also include consultation with pediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organizations. 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. 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