Responsibilities of Consultants in Child, Family and Adolescent Psychiatry: A Personal View

Abstract

psychiatry, following the College memorandum (Bulletin, September 1977, pp 4-7). In particular consideration isgiven to the implications ofconsultants working in multidisciplinary teams and attached to clinics, residential homes and schools administered by the Local Authority. Ever since 1927, when Emanuel Miller opened the East London Child Guidance Clinic, a multidisciplinary team approach has been the elected method for dealing with psy chiatric problems of children and their families. The arrangements for providing a consultant service in child psychiatry vary a great deal through out the United Kingdom, and it is possible for one consultant to be working in a variety of different ways in one health district. These variations are in part of historical origin. Hospital out-patient clinics for child and adoles cent psychiatry, and clinics in the community which are staffed from and seen as offshoots of hospitals, have expected the consultant to take the lead in developing policy to take a personal interest in orga nizing the clinic in the same way that his surgical colleague will organize his operating theatre. Each member of the team is responsible for his part of the team work, but the consultant is clearly recognized as having overall clinical responsibility for every patient referred to him. (All referrals to such a clinic will be automatically allocated to a consultant.) This system has the advantage that it clearly defines where final responsibility lies. The onus is on the consultant to see that a good service is provided. To do this he must be able to have some influence on the job description and selection of other team members, and on the policies of the clinic in relation to case notes, letters and reports (confidentiality). Since referral is to the consultant, the consultant must be in a position to control the consequences of the referral to the patients and their relatives. Traditional child guidance clinics grew from concern about children who were failing to adjust in the community, presenting difficulties in school, or appearing in the Juvenile Courts. Psychologists, psychiatric social workers, child psychiatrists and sometimes child therapists, brought their expertise together to help the child and his family as seemed appropriate. Theoretically, responsibility is shared by the team, greater responsibility being taken by those members whose expertise is most appropriate for solving the particular problem. Nevertheless, the first such clinics were all established by one strongly interested person, in most cases a doctor, who directed the proceedings. Under these circumstances, co-operation between the participants was the starting-point. During their evolution child guidance clinics have expanded their functions, so that in many areas they now provide an out-patient, diagnostic and treatment service for the full range of psychiatric disorders in childhood and adolescence. With the development of the techniques of family therapy, they are dealing with an even wider range of family disturbances. At the same time changes have occurred in the organization of the professions of social work and psychology. The new organization is more hierarchical and the individual professional is expected to be responsible to his department head and not to the child guidance team. These changes have highlighted potential difficulties present throughout the develop ment of the child guidance movement, but not previously of special importance in practice. In 1960 the Child Psychiatry Section recognized this issue in producing a document on the function and responsibility of the child psychiatrist as director of child guidance clinics, and more recently the College has published a policy statement about the responsibility of consultants in psychiatry within the NHS. In this document multidisciplinary team work is discussed fully. True multidisciplinary team work at clinical levels is recommended as probably the most effective way of staff co-operation in the treat-