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Children with academic problems referred for psychiatric evaluation
Publ. Hlth, Lond. (1974) 89, 5-12
Children with Academic Problems Referred for Psychiatric Evaluation H. Nichol M.B., D.P.M.
Division of Chi/d Psychiatry, Department of Psychiatry, University of British Co/umbia, Canada Some of the characteristics are described of those children under 20 years of age who received psychiatric care for academic presenting problems, Data were gathered from the 1966 records of all psychiatric facilities, including private psychiatrists, and gg/i~iT hospitals in the province; the survey is estimated as being 95'4~ complete. Of all these children 1768 (25 700 of the total) received care for academic problems (241 per 100,000); 73700 were boys. The highest prevalence rate for boys and girls combined was nearly 500 per 100,000 at the age of 10 years. Introduction Few detailed epidemiological studies of psychiatric disorders in children have been published. In order to obtain information on the nature, extent and distribution of psychiatric illness in children, and to determine the pattern of psychiatric care provided to them, a survey was undertaken of all those children under 20 years of age in a province (British Columbia) who received psychiatric care in 1966. All the psychiatric records which were made available were studied, in total 7197 cases. The estimate of unsurveyed cases was 323. Assuming this latter figure is correct, information was thus obtained on 95-5 ~o of all individuals who received psychiatric care (Nichol, 1969). The one-year prevalence rate for those receiving psychiatric care was 982 per 100,000. The incidence of individuals receiving psychiatric care for the first time in 1966 was 4438 cases giving a 1-year incidence rate of 606 per 100,000. In this paper findings are given about individuals who were recorded as receiving psychiatric care for academic presenting problems, irrespective of the year of inception of such treatment. A search of the literature has not yielded any articles specifically describing the incidence or prevalence of children with learning disabilities who received psychiatric care. Surveys exist of the utilisation of psychiatric facilities by children (Rosen, Kramer, Redick & Willner, 1968), of the epidemiology of reading retardation (Eisenberg, 1961) and of learning disorders among disadvantaged children (Kappelman, Kaplan & Ganter, 1969). The literature is replete with the detailed requirements of mental health consultation and treatment services to schools (Caplan, 1955; G.A.P., 1964; Stogdill, 1965; Tarnopol, 1969). This material provides the background for this paper but does not allow comparative comments to be made. Method Cases registered in this survey were those under 20 years of age who received care in a psychiatric facility in British Columbia in 1966. Also included were patients within the
6
H. Nichol
age range who received active in-patient care in a general hospital whether from a psychiatrist or not, for a condition for which a discharge diagnosis of Mental Disorder on the I.C.D.A. (300-329) was given. Four research assistants, who were registered nurses, reviewed all the records of those under 20 years of age who received psychiatric care during 1966 and recorded selected information on questionnaires. Basic demographic, social, diagnostic and treatment data was abstracted for all patients. For a randomly selected sample of 20 ~ , more extensive information was collected. Rather than having the research assistants visit small remote general hospitals, most of these were successfully surveyed by sending the questionnaires, together with detailed instructions on their completion, to the medical directors. All but six of the 67 psychiatrists in private practice in the province permitted their records to be surveyed. In order to determine the pattern of care given to the children coming for psychiatric evaluation with different presenting problems, the research assistants were given operational definitions of the following categories of presenting problems: somatic, p@cia~ogical, behavioural, delinquent behaviour, academic, suspicion of low intelligence, suicide attempt and other, which last category included such matters as suitability for adoption, request for therapeutic abortion, readiness for school, etc. On a non-hierarchical basis the research assistants were asked to record one, two or three of these presenting problems for each case; the majority had a single presenting problem and only a few were given three. A child was recorded as having an academic presenting problem if there was a complaint of his underachieving or failing in school. This category did not include school phobias, behaviour problems at school, the use of somatic complaints to avoid school, or truancy, but referred only to p o o r performance academically in those cases where this was not thought to be attributable to low intelligence. The data was subsequently coded, keypunched, corrected for errors and programmed for computer printout. In what follows some of the findings on children with academic presenting problems are given.
Findings A total of 1767 children received psychiatric care in 1966, giving a one-year prevalence rate of 241 per 100,000. Males preponderate in a ratio of 3 : 1. Many more boys than girls present with academic problems at an earlier age (5-9), when the ratio is 4 : 1 ; in the age group 15-19 this ratio drops to 1-5 : 1. Peak ratios of nearly 600 per 100,000 is reached for boys in the 10-14 age group, and of 893 for those aged 9 years; for girls the peak ratio was 370 at 15 years.
TABLE1. Children with academic presenting problems. Number, percentage and rates per 100,000 by age groups and sex Sex
0-4 No. Rate
M~e Female Total n %
2 1 3
---0"1
Age in groups 5-9 10-14 No. Rate No. Rate
15-19 No. Rate
505 132 637
233 149 382
516 132 322 36"1
546 199 745
585 211 407 42.2
Total
21"6
289 196 242
n 1286 481 1767
73 27
Children with academic problems Figure 1 shows the rate per 100,000 by age for both sexes at first psychiatric contact. The rate is still low at six but rises rapidly at seven. For boys and girls combined a rate of nearly 500 is reached at age 9. After a decline at ages 11-13, there is another rise at ages 14 and 15 with a steady decline in the rate after school leaving age is reached at 16. A marked effect of the location of the child's home in determining the prevalence of psychiatric care is clearly shown. The highest rates for both boys and girls aged 0-19, 586 and 542, respectively, were in the largest city (Vancouver). The lowest were for those whose homes were in the rural areas where the rate for boys was 219 and for girls only 68. The living circumstances of these children was similar in distribution to that of the total population surveyed. A majority of 65 ~ lived with their natural parents; 8 ~ lived with a step-parent, and 13 ~ lived with a single parent. Another 13 ~ lived with surrogate parents and in the remaining 1 ~ no information was available. In addition to academic presenting problems, 62 ~ of the children also were recorded as having behavioural problems, and 21 ~ with psychological problems. In on!y~3~o~ o of cases was the suspicion of low intelligence also recorded as a presenting problem. I00( o o 0 & _o 5O(
F Both
g: 0
I
I
I
2 3 4
5 6 7 8 9 I0 II 12 13 14 15 16 17 18 19 Age (years)
Figure 1. Frequency of academic presenting problems, in rate per 100,000 as a function of age and sex.
The school situation revealed that 80 ~ of these children were in regular classes, with another 10 ~ in special classes, and 2 ~ in special schools. In the remaining 8 ~ , school placement was either unknown or the children were no longer in school. Those receiving remedial education totalled 13 ~ . In addition to their having unsatisfactory achievement in school, the behaviour of 48 ~ in school was described as unsatisfactory. The mean grade placement of the children was Grade 5. At the time of the survey the Diagnostic and Statistical Manual I of the American Psychiatric Association was used in most facilities although in one large city school health service it was policy to give a symptom descriptive diagnostic categorization. Transient situational reactions accounted for 42 ~o of diagnoses, with symptom description rather than a diagnosis accounting for the next largest group of 23 ~ of children. Chronic brain syndromes were diagnosed in 6.8 ~ of children. As one would expect since there is another presenting problem category of "Suspicion of Low Intelligence," the frequency of a diagnosis of mental retardation was low. There was no great difference in the distribution of diagnoses at the community clinics or by private psychiatrists. The preponderant amount of care was given on an out-patient basis and was provided by all the various facilities in the community, private psychiatrists, general hospital clinics, community mental health centres as well as psychiatric consultation services to schools. Younger children of both sexes were seen primarily by the consultation services to schools and by community mental health centres. Older children of both sexes were seen with greater frequency by private psychiatrists. The choice of facility did not appear to vary significantly as a function of sex.
8
H. Nichol
The utilisation of facilities as a function of the location of the home of the child shows that private psychiatrists gave the highest proportion of care (44 ~ ) in the large city. In the rest of the metropolitan and in the rural areas the community health centres gave a large portion of the care provided. Information is available about the categories of individuals referring the children and the facilities to which they referred them. Physicians referred the majority of their patients to private psychiatrists; referrals from physicians accounted for 9 6 ~ of psychiatrists' cases. This high percentage was probably determined by the funding arrangements which require that a physician refer the case in order for specialist fees to be paid; the full pattern of referral is thus disguised. Schools are shown as referring a surprisingly small percentage of cases. However, although the schools referred only 11 ~ of children in the survey, they accounted for 59 ~ of referrals to the psychiatric consultation service to schools--which is no surprise. Public health nurses referred predominantly to community mental health centres. The professional providing the preponderant amount of care varied as the function of the facility. At the consultation service to schools, psychiatrists and public health nurses gave most of the care. At community mental health centres, the majority of care was provided by a combination of psychiatrist plus social worker or psychologist, or by the social worker alone; the psychiatrist working unaided gave only a small proportion of the care. In contrast, private psychiatrists were noted as providing the preponderant amount of care in virtually all instances of cases referred to them. In evaluating the children, consultation was with the child alone in only 8 ~ of cases, and then mainly with the older age group. In 78 ~ of cases, the child was seen with one or both parents, while the child and surrogate parents were seen in 4 ~o of cases. Children who were not given consultation by a psychiatrist made up the remaining percentage. The type of treatment given the children showed a preponderance of consultation and short-term psychotherapy. Care consisted of consultation only in 46 ~ of cases, while short-term psychotherapy (15 visits or less) was given in 2 7 ~ of cases and short-term psychotherapy with drugs in a further 10~. In only 3 . 6 ~ of cases was long-term psychotherapy (16 or more visits), with or without drugs, the treatment provided. Intermittent supportive treatment was given in a further 5.3 ~ of children. One or both parents were seen in treatment in addition to the child in 32 ~o of cases. The type of treatment provided varied with the facility giving it. In the consultation service to schools, consultation was used alone in 76 ~o of cases. The community mental health centres also provided consultation only in a high percentage of cases, 53 ~o. The largest percentage of children receiving long-term therapy were seen at the community mental health centres, as well as the largest percentage of those who discontinued therapy before completion. Private psychiatrists provided primarily short-term therapy, with or without drugs. The largest percentage of children receiving intermittent supportive therapy were seen by private psychiatrists. The extent of the use of additional neurological consultation or psychological testing was determined. Neither of these procedures was obtained in 47 ~ of cases. In 2 ~ of cases neurological consultation was obtained, in 46 ~ psychological testing, and in 5 ~ , both. This is a higher proportion receiving these additional consultations, than was the case with other presenting problems. The consultation service to schools provided psychological testing for 91 Yo of the children, whereas only 44 ~ at community mental health centres and 42 seeing private psychiatrists were tested. Social investigation performed by a public health nurse or social worker was done in 66 ~o of the cases; by a public health nurse in 14 ~o of the cases, by a social worker in 19 and by both it was done in 33 ~o. The type of facility determined the frequency with which
Children with academic problems
9
additional investigations by these professionals were undertaken. The consultation service to schools used these professionals most frequently, the public health nurse even more than both the nurse and the social worker. At the community mental health centres both investigations were used most frequently, followed by use of the social worker; the public health nurse was not used alone with any frequency. Private psychiatrists seldom used social investigation by these professionals. Care was provided for the first time in 1966 to 1170 (66 ~ ) of the children. This gives a 1-year incidence rate of 160 per 100,000. Of those re-admitted to care from previous years, 27 700 had been treated in more than one group of psychiatric facilities. The nature of the previous care was consultation only in 28 % of cases, short-term psychotherapy in 32 70, and long-term psychotherapy in 19 70. The nature of the previous care was unknown in the remainder of cases. The material recorded on the chart was insufficient to provide any estimate of outcome in 46%00of cases. Improvement was noted in 35% of cases, no change in 16700 and in 370 of cases was deemed to be worse at the end of treatment. Of the cases seen for the kfi)~ime in 1966, 62 70 were terminated during the course of the year. Another 26 7o were continued in care into 1967, and in 12 % the situation was unknown. Discussion
For the presenting problem of academic difficulties, boys preponderated over girls, especially in the earlier years, to about the same extent as they did with the presenting problem of delinquent behaviour, although in this latter situation, they were an older age group. The frequency with which children were referred for psychiatric evaluation at 6 years of age was low, despite the fact that the children had already entered school. The marked increase in referral for psychiatric evaluation occurred at the age of 7, with the peak rate for both sexes occurring at the age of 9. Admittedly, it is difficult to recognise which among the children who are having difficulty in learning in the earliest grades, are doing so because of some immaturity which will be self-correcting. Nevertheless, the need for the early identification of children with emotional, reading or learning handicaps is clearly recognised, so that preventive intervention with remedial education or treatment may be instituted promptly (Bower, 1969; De Hirsch, Jansky & Langford, 1966; Johnson & Myldebust, 1967). The rise in the rate of referral at the ages of 14 and 15 presumably represented the added learning problems experienced by many children who enter high school. After school leaving age there was a marked diminution in referral for academic difficulties. While this is no surprise, it should not be forgotten that many of the individuals who were identified earlier will continue to have difficulty throughout life in acquiring new information with all the attendant problems which that will engender for many of them; they are no longer "statistics" but they retain limitations which make some of them unduly subject to stress in situations demanding learning. The ready availability of psychiatric consultation services in the province was seen to be confined largely to the one large metropolitan area. It is of particular interest that even within this area, there was a higher frequency of psychiatric evaluation undertaken for residents of the inner city. Most psychiatrists had their offices in this inner city, and it would thus appear that living even a few miles away was sufficient, for one reason or another, to decrease the likelihood of a child receiving psychiatric care. A deficit in the availability of psychiatric care was particularly evident for those living in the rural areas. Although it may have been that the records of the psychiatric facilities did not show the full extent of remedial education being provided, it is disconcerting to note that only 13 ~o of those referred for academic problems were noted as being provided with remedial
10
H. Nichol
instruction in school. Regrettably, this low figure was probably fairly accurate, since remedial reading and remedial educational services were generally not readily available in 1966. As Eisenberg (1966) has shown, it was not only in the schools that there was a lack of awareness of the prevalence of reading disabilities in children. This diagnosis was virtually never made by those working in psychiatric facilities although the symptom category of Learning Disability could have been used. This study illustrates, as have those of Lapouse (1965), Rutter, Tizard & Whitmore (1970), and Wishik (1964), the need to survey all the facilities providing care to a total community, or to a cohort in a designated community, in order to get an idea of the incidence and prevalence of recognised disability. If the psychiatric services to schools alone had been surveyed, then only 13"47o of the cases would have been recognised. In addition, the study of care given by all facilities indicates a difference in the pattern of care they provide because of policy and priority decisions. For example, the consultation service to schools evaluated a much younger age group than did the private psychiatrists; this represented a definitive policy on the part of the former to provide preventive intervention, and priority was given to the evaluation of younger children. The professional providing the preponderant amount of care is clearly a function of who is employed in the particular facility. It should not be unnoticed that for the same presenting problems a psychiatrist, a nurse, a social worker, a psychologist, or a teacher may be the professional giving the majority of care. For the community mental health centres and for the private psychiatrists, there was no great difference in the proportion of children with various diagnoses. Werry (1965) has emphasised that this should give us pause to look to our Trade Union type of professional posturing more carefully; we need to clarify our thinking about the qualifications required for those who give treatment. Particularly noteworthy is the extent to which the private psychiatrists are obliged t o - - o r are inclined t o - - w o r k alone in providing care to children and their families. The existing medical insurance arrangements then, and the current ones under Medicare, legislate for this pattern of practice; its desirability requires to be evaluated. It may be deemed appropriate to have many more psychological, community liaison and remedial teaching services available on a more flexible basis to co-operate with psychiatrists in private practice; or the latter may be encouraged to affiliate more closely by giving sessions for consultation purposes to schools on a regional basis, and to seek to limit their referrals to a defined catchment area. One change that can be recommended immediately to improve consultation services by private psychiatrists to educational agencies--as well as to welfare and forensic ones-is that several direct meetings with school personnel (and with welfare and forensic staff) per child per annum, should be a funded item under Medicare. Eisenberg (1961) suggests that such arrangements would lead to a better utilisation of psychiatrists' services and to the more satisfactory collaboration with other professional colleagues, which is currently receiving such emphasis (C.E.L.D.I.C., 1970). The type of consultation performed was almost universally (over 90 ~ ) one which involved one or both parents which indicates that children with academic problems are probably not being evaluated without attention to familial factors. By contrast, less than 50 ~o of children seen in all groups of facilities other than the consultation service to schools received psychological testing. When one considers that these children were being evaluated for academic presenting problems this apparent disregard for the need for a detailed appraisal of their cognitive functioning is disconcerting. Is it only that there is shortage of clinical psychologists' services, or does this reveal an over-emphasis on "dynamics"?
Children with academic problems
11
A complaint frequently made by school personnel about psychiatric services is that there is a great shortage of treatment provided to those referred. This survey does nothing to refute that observation for this area, in 1966--and the lack persists.
Conclusions (1) Boys preponderate over girls (3 : l); the ratio in the 5-9 age group was 4 : 1, and in the 15-19 age group, it was 1"5 : 1. (2) A highest prevalence rate of 581 per 100,000 occurred in boys in the 10-14 age group referred for academic presenting problems, and 893 for boys aged 9 years. (3) There was a major deficiency in the availability of psychiatric consultation and treatment services in the province except in the metropolitan area. (4) There appeared to be a definite need for increased remedial education services. (5) There was little recognition of the extensive prevalence of reading disability as a contributing factor in children presenting with academic difficulties. (6) There was a major deficiency of psychological services. (7) There was evidence of a need to diminish the professional isolation of the private psychiatrist. Then, as now, under Medicare, the remuneration of psychiatrists did not fund the provision of consultation to professionals other than the referring physician; this should be remedied immediately so as to facilitate direct communication with school personnel.
Acknowledgement This study was assisted by funds provided by the Public Health Research Grant Project No. 609-7-161 of the National Health Grants Programme, Canada. It was concluded at the Vancouver General Hospital.
References Bower, E. M. (1969). Early Identification of Emotionally Handicapped Children in School. Second Edition. Springfield, Illinois: C. C. Thomas. Caplan, G. (1955). Mental health consultation to schools. In The Elements of a Community Mental Health Programme. New York: Milbank Memorial Fund. Commission on Emotional and Learning Disorders in Children (1970). One Million Children. L. Crainford: Toronto, for the Commission on Emotional and Learning Disorders in Children. De Hirsch, K., Jansky, J. J. & Langford, W. S. (1966). Predicting Reading Disability. New York: Harper and Row. Committee on Nomenclature and Statistics of the American Psychiatric Association (1952). Diagnostic and Statistical Manual: Mental Disorders. Washington: American Psychiatric Association. Eisenberg, L. (1961). Journal of Child Psychology and Psychiatry 2, 229. Eisenberg, L. (1966). Pediatrics 37, 352. Group for the Advancement of Psychiatry (1964). The Psychiatrist As a Consultant to the School Washington: American Psychiatric Association. Johnson, D. J. & Myklebust, H. R. (1967). Learning Disabilities. New York: Grune and Stratton. Kappelman, M. M., Kaplan, E. & Ganter, R. L. (1969). Journal of Learning Disabilities 2, 262. Lapouse, R. (1965). American Journal of Public Health 55, 1130. Nichol, H. (1969). Children Receiving Psychiatric Care in British Columbia in 1966. Presented at Western Regional Conference of Canadian Psychiatric Association. Rosen, B. M., Kramer, M., Redick, R. W. & Willner, S. G. (1968). Utilization of PsychiatricFacilities by Children. Washington: Public Health Service Publication No. 1868. U.S. Government Printing Office. Rutter, M., Tizards, J. & Whitmore, K. (1970). Education, Health andBehaviour. London: Longman.
12
H. Nickol
Stogdill, C. G. (1965). Canada's Mental Health 13 (Sup.), 48. Tarnopol, L. (Ed.). (1969). Learning Disabilities: Introduction to Educational and Medical Management. Springfield, Illinois: C. C. Thomas. Werry, J. (1965). Canada's Mental Health 13, (1). Wishik, S. M. (1964). Georgia Study of Handicapped Children. Atlanta: The Georgia D e p a r t m e n t o f Public Health. This article gives a good insight into many of the problems encountered with children with academic difficulties, but our referee points out that conditions in the U.K. are very different in certain aspects. For example, here the School Psychological Service and School Medical Officers are the main source of referral to Child Guidance Clinics; private psychiatrists have a limited function in this field; we have extensive help from lay child psychiatrists working from C.G.C.s; long term psychotherapy--a year or more--including a parent, with the help of a social worker, is the usual recommendation; the social worker attempts to assess at first each family. In the U.K. there are a limited number of inpatient units for children under 13 years, where full neurological, blood, urine and chromosome counts are carried out, and some therapy, the average leng~.o_g stay being 6-9 months. Here the whole emphasis is on the team approach, together with Social Service, Education, Probation Departments, local G.P.s, consultant paediatricians and District and Area Health Authorities. However, with Professor Nichol we can only agree about our mutual lack of resources. The same clinical problems beset us both, but we approach them differently; in particular private child psychiatry is extremely limited in the U.K. Ed.
Children with Academic Problems Referred for Psychiatric Evaluation H. Nichol M.B., D.P.M.
Division of Chi/d Psychiatry, Department of Psychiatry, University of British Co/umbia, Canada Some of the characteristics are described of those children under 20 years of age who received psychiatric care for academic presenting problems, Data were gathered from the 1966 records of all psychiatric facilities, including private psychiatrists, and gg/i~iT hospitals in the province; the survey is estimated as being 95'4~ complete. Of all these children 1768 (25 700 of the total) received care for academic problems (241 per 100,000); 73700 were boys. The highest prevalence rate for boys and girls combined was nearly 500 per 100,000 at the age of 10 years. Introduction Few detailed epidemiological studies of psychiatric disorders in children have been published. In order to obtain information on the nature, extent and distribution of psychiatric illness in children, and to determine the pattern of psychiatric care provided to them, a survey was undertaken of all those children under 20 years of age in a province (British Columbia) who received psychiatric care in 1966. All the psychiatric records which were made available were studied, in total 7197 cases. The estimate of unsurveyed cases was 323. Assuming this latter figure is correct, information was thus obtained on 95-5 ~o of all individuals who received psychiatric care (Nichol, 1969). The one-year prevalence rate for those receiving psychiatric care was 982 per 100,000. The incidence of individuals receiving psychiatric care for the first time in 1966 was 4438 cases giving a 1-year incidence rate of 606 per 100,000. In this paper findings are given about individuals who were recorded as receiving psychiatric care for academic presenting problems, irrespective of the year of inception of such treatment. A search of the literature has not yielded any articles specifically describing the incidence or prevalence of children with learning disabilities who received psychiatric care. Surveys exist of the utilisation of psychiatric facilities by children (Rosen, Kramer, Redick & Willner, 1968), of the epidemiology of reading retardation (Eisenberg, 1961) and of learning disorders among disadvantaged children (Kappelman, Kaplan & Ganter, 1969). The literature is replete with the detailed requirements of mental health consultation and treatment services to schools (Caplan, 1955; G.A.P., 1964; Stogdill, 1965; Tarnopol, 1969). This material provides the background for this paper but does not allow comparative comments to be made. Method Cases registered in this survey were those under 20 years of age who received care in a psychiatric facility in British Columbia in 1966. Also included were patients within the
6
H. Nichol
age range who received active in-patient care in a general hospital whether from a psychiatrist or not, for a condition for which a discharge diagnosis of Mental Disorder on the I.C.D.A. (300-329) was given. Four research assistants, who were registered nurses, reviewed all the records of those under 20 years of age who received psychiatric care during 1966 and recorded selected information on questionnaires. Basic demographic, social, diagnostic and treatment data was abstracted for all patients. For a randomly selected sample of 20 ~ , more extensive information was collected. Rather than having the research assistants visit small remote general hospitals, most of these were successfully surveyed by sending the questionnaires, together with detailed instructions on their completion, to the medical directors. All but six of the 67 psychiatrists in private practice in the province permitted their records to be surveyed. In order to determine the pattern of care given to the children coming for psychiatric evaluation with different presenting problems, the research assistants were given operational definitions of the following categories of presenting problems: somatic, p@cia~ogical, behavioural, delinquent behaviour, academic, suspicion of low intelligence, suicide attempt and other, which last category included such matters as suitability for adoption, request for therapeutic abortion, readiness for school, etc. On a non-hierarchical basis the research assistants were asked to record one, two or three of these presenting problems for each case; the majority had a single presenting problem and only a few were given three. A child was recorded as having an academic presenting problem if there was a complaint of his underachieving or failing in school. This category did not include school phobias, behaviour problems at school, the use of somatic complaints to avoid school, or truancy, but referred only to p o o r performance academically in those cases where this was not thought to be attributable to low intelligence. The data was subsequently coded, keypunched, corrected for errors and programmed for computer printout. In what follows some of the findings on children with academic presenting problems are given.
Findings A total of 1767 children received psychiatric care in 1966, giving a one-year prevalence rate of 241 per 100,000. Males preponderate in a ratio of 3 : 1. Many more boys than girls present with academic problems at an earlier age (5-9), when the ratio is 4 : 1 ; in the age group 15-19 this ratio drops to 1-5 : 1. Peak ratios of nearly 600 per 100,000 is reached for boys in the 10-14 age group, and of 893 for those aged 9 years; for girls the peak ratio was 370 at 15 years.
TABLE1. Children with academic presenting problems. Number, percentage and rates per 100,000 by age groups and sex Sex
0-4 No. Rate
M~e Female Total n %
2 1 3
---0"1
Age in groups 5-9 10-14 No. Rate No. Rate
15-19 No. Rate
505 132 637
233 149 382
516 132 322 36"1
546 199 745
585 211 407 42.2
Total
21"6
289 196 242
n 1286 481 1767
73 27
Children with academic problems Figure 1 shows the rate per 100,000 by age for both sexes at first psychiatric contact. The rate is still low at six but rises rapidly at seven. For boys and girls combined a rate of nearly 500 is reached at age 9. After a decline at ages 11-13, there is another rise at ages 14 and 15 with a steady decline in the rate after school leaving age is reached at 16. A marked effect of the location of the child's home in determining the prevalence of psychiatric care is clearly shown. The highest rates for both boys and girls aged 0-19, 586 and 542, respectively, were in the largest city (Vancouver). The lowest were for those whose homes were in the rural areas where the rate for boys was 219 and for girls only 68. The living circumstances of these children was similar in distribution to that of the total population surveyed. A majority of 65 ~ lived with their natural parents; 8 ~ lived with a step-parent, and 13 ~ lived with a single parent. Another 13 ~ lived with surrogate parents and in the remaining 1 ~ no information was available. In addition to academic presenting problems, 62 ~ of the children also were recorded as having behavioural problems, and 21 ~ with psychological problems. In on!y~3~o~ o of cases was the suspicion of low intelligence also recorded as a presenting problem. I00( o o 0 & _o 5O(
F Both
g: 0
I
I
I
2 3 4
5 6 7 8 9 I0 II 12 13 14 15 16 17 18 19 Age (years)
Figure 1. Frequency of academic presenting problems, in rate per 100,000 as a function of age and sex.
The school situation revealed that 80 ~ of these children were in regular classes, with another 10 ~ in special classes, and 2 ~ in special schools. In the remaining 8 ~ , school placement was either unknown or the children were no longer in school. Those receiving remedial education totalled 13 ~ . In addition to their having unsatisfactory achievement in school, the behaviour of 48 ~ in school was described as unsatisfactory. The mean grade placement of the children was Grade 5. At the time of the survey the Diagnostic and Statistical Manual I of the American Psychiatric Association was used in most facilities although in one large city school health service it was policy to give a symptom descriptive diagnostic categorization. Transient situational reactions accounted for 42 ~o of diagnoses, with symptom description rather than a diagnosis accounting for the next largest group of 23 ~ of children. Chronic brain syndromes were diagnosed in 6.8 ~ of children. As one would expect since there is another presenting problem category of "Suspicion of Low Intelligence," the frequency of a diagnosis of mental retardation was low. There was no great difference in the distribution of diagnoses at the community clinics or by private psychiatrists. The preponderant amount of care was given on an out-patient basis and was provided by all the various facilities in the community, private psychiatrists, general hospital clinics, community mental health centres as well as psychiatric consultation services to schools. Younger children of both sexes were seen primarily by the consultation services to schools and by community mental health centres. Older children of both sexes were seen with greater frequency by private psychiatrists. The choice of facility did not appear to vary significantly as a function of sex.
8
H. Nichol
The utilisation of facilities as a function of the location of the home of the child shows that private psychiatrists gave the highest proportion of care (44 ~ ) in the large city. In the rest of the metropolitan and in the rural areas the community health centres gave a large portion of the care provided. Information is available about the categories of individuals referring the children and the facilities to which they referred them. Physicians referred the majority of their patients to private psychiatrists; referrals from physicians accounted for 9 6 ~ of psychiatrists' cases. This high percentage was probably determined by the funding arrangements which require that a physician refer the case in order for specialist fees to be paid; the full pattern of referral is thus disguised. Schools are shown as referring a surprisingly small percentage of cases. However, although the schools referred only 11 ~ of children in the survey, they accounted for 59 ~ of referrals to the psychiatric consultation service to schools--which is no surprise. Public health nurses referred predominantly to community mental health centres. The professional providing the preponderant amount of care varied as the function of the facility. At the consultation service to schools, psychiatrists and public health nurses gave most of the care. At community mental health centres, the majority of care was provided by a combination of psychiatrist plus social worker or psychologist, or by the social worker alone; the psychiatrist working unaided gave only a small proportion of the care. In contrast, private psychiatrists were noted as providing the preponderant amount of care in virtually all instances of cases referred to them. In evaluating the children, consultation was with the child alone in only 8 ~ of cases, and then mainly with the older age group. In 78 ~ of cases, the child was seen with one or both parents, while the child and surrogate parents were seen in 4 ~o of cases. Children who were not given consultation by a psychiatrist made up the remaining percentage. The type of treatment given the children showed a preponderance of consultation and short-term psychotherapy. Care consisted of consultation only in 46 ~ of cases, while short-term psychotherapy (15 visits or less) was given in 2 7 ~ of cases and short-term psychotherapy with drugs in a further 10~. In only 3 . 6 ~ of cases was long-term psychotherapy (16 or more visits), with or without drugs, the treatment provided. Intermittent supportive treatment was given in a further 5.3 ~ of children. One or both parents were seen in treatment in addition to the child in 32 ~o of cases. The type of treatment provided varied with the facility giving it. In the consultation service to schools, consultation was used alone in 76 ~o of cases. The community mental health centres also provided consultation only in a high percentage of cases, 53 ~o. The largest percentage of children receiving long-term therapy were seen at the community mental health centres, as well as the largest percentage of those who discontinued therapy before completion. Private psychiatrists provided primarily short-term therapy, with or without drugs. The largest percentage of children receiving intermittent supportive therapy were seen by private psychiatrists. The extent of the use of additional neurological consultation or psychological testing was determined. Neither of these procedures was obtained in 47 ~ of cases. In 2 ~ of cases neurological consultation was obtained, in 46 ~ psychological testing, and in 5 ~ , both. This is a higher proportion receiving these additional consultations, than was the case with other presenting problems. The consultation service to schools provided psychological testing for 91 Yo of the children, whereas only 44 ~ at community mental health centres and 42 seeing private psychiatrists were tested. Social investigation performed by a public health nurse or social worker was done in 66 ~o of the cases; by a public health nurse in 14 ~o of the cases, by a social worker in 19 and by both it was done in 33 ~o. The type of facility determined the frequency with which
Children with academic problems
9
additional investigations by these professionals were undertaken. The consultation service to schools used these professionals most frequently, the public health nurse even more than both the nurse and the social worker. At the community mental health centres both investigations were used most frequently, followed by use of the social worker; the public health nurse was not used alone with any frequency. Private psychiatrists seldom used social investigation by these professionals. Care was provided for the first time in 1966 to 1170 (66 ~ ) of the children. This gives a 1-year incidence rate of 160 per 100,000. Of those re-admitted to care from previous years, 27 700 had been treated in more than one group of psychiatric facilities. The nature of the previous care was consultation only in 28 % of cases, short-term psychotherapy in 32 70, and long-term psychotherapy in 19 70. The nature of the previous care was unknown in the remainder of cases. The material recorded on the chart was insufficient to provide any estimate of outcome in 46%00of cases. Improvement was noted in 35% of cases, no change in 16700 and in 370 of cases was deemed to be worse at the end of treatment. Of the cases seen for the kfi)~ime in 1966, 62 70 were terminated during the course of the year. Another 26 7o were continued in care into 1967, and in 12 % the situation was unknown. Discussion
For the presenting problem of academic difficulties, boys preponderated over girls, especially in the earlier years, to about the same extent as they did with the presenting problem of delinquent behaviour, although in this latter situation, they were an older age group. The frequency with which children were referred for psychiatric evaluation at 6 years of age was low, despite the fact that the children had already entered school. The marked increase in referral for psychiatric evaluation occurred at the age of 7, with the peak rate for both sexes occurring at the age of 9. Admittedly, it is difficult to recognise which among the children who are having difficulty in learning in the earliest grades, are doing so because of some immaturity which will be self-correcting. Nevertheless, the need for the early identification of children with emotional, reading or learning handicaps is clearly recognised, so that preventive intervention with remedial education or treatment may be instituted promptly (Bower, 1969; De Hirsch, Jansky & Langford, 1966; Johnson & Myldebust, 1967). The rise in the rate of referral at the ages of 14 and 15 presumably represented the added learning problems experienced by many children who enter high school. After school leaving age there was a marked diminution in referral for academic difficulties. While this is no surprise, it should not be forgotten that many of the individuals who were identified earlier will continue to have difficulty throughout life in acquiring new information with all the attendant problems which that will engender for many of them; they are no longer "statistics" but they retain limitations which make some of them unduly subject to stress in situations demanding learning. The ready availability of psychiatric consultation services in the province was seen to be confined largely to the one large metropolitan area. It is of particular interest that even within this area, there was a higher frequency of psychiatric evaluation undertaken for residents of the inner city. Most psychiatrists had their offices in this inner city, and it would thus appear that living even a few miles away was sufficient, for one reason or another, to decrease the likelihood of a child receiving psychiatric care. A deficit in the availability of psychiatric care was particularly evident for those living in the rural areas. Although it may have been that the records of the psychiatric facilities did not show the full extent of remedial education being provided, it is disconcerting to note that only 13 ~o of those referred for academic problems were noted as being provided with remedial
10
H. Nichol
instruction in school. Regrettably, this low figure was probably fairly accurate, since remedial reading and remedial educational services were generally not readily available in 1966. As Eisenberg (1966) has shown, it was not only in the schools that there was a lack of awareness of the prevalence of reading disabilities in children. This diagnosis was virtually never made by those working in psychiatric facilities although the symptom category of Learning Disability could have been used. This study illustrates, as have those of Lapouse (1965), Rutter, Tizard & Whitmore (1970), and Wishik (1964), the need to survey all the facilities providing care to a total community, or to a cohort in a designated community, in order to get an idea of the incidence and prevalence of recognised disability. If the psychiatric services to schools alone had been surveyed, then only 13"47o of the cases would have been recognised. In addition, the study of care given by all facilities indicates a difference in the pattern of care they provide because of policy and priority decisions. For example, the consultation service to schools evaluated a much younger age group than did the private psychiatrists; this represented a definitive policy on the part of the former to provide preventive intervention, and priority was given to the evaluation of younger children. The professional providing the preponderant amount of care is clearly a function of who is employed in the particular facility. It should not be unnoticed that for the same presenting problems a psychiatrist, a nurse, a social worker, a psychologist, or a teacher may be the professional giving the majority of care. For the community mental health centres and for the private psychiatrists, there was no great difference in the proportion of children with various diagnoses. Werry (1965) has emphasised that this should give us pause to look to our Trade Union type of professional posturing more carefully; we need to clarify our thinking about the qualifications required for those who give treatment. Particularly noteworthy is the extent to which the private psychiatrists are obliged t o - - o r are inclined t o - - w o r k alone in providing care to children and their families. The existing medical insurance arrangements then, and the current ones under Medicare, legislate for this pattern of practice; its desirability requires to be evaluated. It may be deemed appropriate to have many more psychological, community liaison and remedial teaching services available on a more flexible basis to co-operate with psychiatrists in private practice; or the latter may be encouraged to affiliate more closely by giving sessions for consultation purposes to schools on a regional basis, and to seek to limit their referrals to a defined catchment area. One change that can be recommended immediately to improve consultation services by private psychiatrists to educational agencies--as well as to welfare and forensic ones-is that several direct meetings with school personnel (and with welfare and forensic staff) per child per annum, should be a funded item under Medicare. Eisenberg (1961) suggests that such arrangements would lead to a better utilisation of psychiatrists' services and to the more satisfactory collaboration with other professional colleagues, which is currently receiving such emphasis (C.E.L.D.I.C., 1970). The type of consultation performed was almost universally (over 90 ~ ) one which involved one or both parents which indicates that children with academic problems are probably not being evaluated without attention to familial factors. By contrast, less than 50 ~o of children seen in all groups of facilities other than the consultation service to schools received psychological testing. When one considers that these children were being evaluated for academic presenting problems this apparent disregard for the need for a detailed appraisal of their cognitive functioning is disconcerting. Is it only that there is shortage of clinical psychologists' services, or does this reveal an over-emphasis on "dynamics"?
Children with academic problems
11
A complaint frequently made by school personnel about psychiatric services is that there is a great shortage of treatment provided to those referred. This survey does nothing to refute that observation for this area, in 1966--and the lack persists.
Conclusions (1) Boys preponderate over girls (3 : l); the ratio in the 5-9 age group was 4 : 1, and in the 15-19 age group, it was 1"5 : 1. (2) A highest prevalence rate of 581 per 100,000 occurred in boys in the 10-14 age group referred for academic presenting problems, and 893 for boys aged 9 years. (3) There was a major deficiency in the availability of psychiatric consultation and treatment services in the province except in the metropolitan area. (4) There appeared to be a definite need for increased remedial education services. (5) There was little recognition of the extensive prevalence of reading disability as a contributing factor in children presenting with academic difficulties. (6) There was a major deficiency of psychological services. (7) There was evidence of a need to diminish the professional isolation of the private psychiatrist. Then, as now, under Medicare, the remuneration of psychiatrists did not fund the provision of consultation to professionals other than the referring physician; this should be remedied immediately so as to facilitate direct communication with school personnel.
Acknowledgement This study was assisted by funds provided by the Public Health Research Grant Project No. 609-7-161 of the National Health Grants Programme, Canada. It was concluded at the Vancouver General Hospital.
References Bower, E. M. (1969). Early Identification of Emotionally Handicapped Children in School. Second Edition. Springfield, Illinois: C. C. Thomas. Caplan, G. (1955). Mental health consultation to schools. In The Elements of a Community Mental Health Programme. New York: Milbank Memorial Fund. Commission on Emotional and Learning Disorders in Children (1970). One Million Children. L. Crainford: Toronto, for the Commission on Emotional and Learning Disorders in Children. De Hirsch, K., Jansky, J. J. & Langford, W. S. (1966). Predicting Reading Disability. New York: Harper and Row. Committee on Nomenclature and Statistics of the American Psychiatric Association (1952). Diagnostic and Statistical Manual: Mental Disorders. Washington: American Psychiatric Association. Eisenberg, L. (1961). Journal of Child Psychology and Psychiatry 2, 229. Eisenberg, L. (1966). Pediatrics 37, 352. Group for the Advancement of Psychiatry (1964). The Psychiatrist As a Consultant to the School Washington: American Psychiatric Association. Johnson, D. J. & Myklebust, H. R. (1967). Learning Disabilities. New York: Grune and Stratton. Kappelman, M. M., Kaplan, E. & Ganter, R. L. (1969). Journal of Learning Disabilities 2, 262. Lapouse, R. (1965). American Journal of Public Health 55, 1130. Nichol, H. (1969). Children Receiving Psychiatric Care in British Columbia in 1966. Presented at Western Regional Conference of Canadian Psychiatric Association. Rosen, B. M., Kramer, M., Redick, R. W. & Willner, S. G. (1968). Utilization of PsychiatricFacilities by Children. Washington: Public Health Service Publication No. 1868. U.S. Government Printing Office. Rutter, M., Tizards, J. & Whitmore, K. (1970). Education, Health andBehaviour. London: Longman.
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Stogdill, C. G. (1965). Canada's Mental Health 13 (Sup.), 48. Tarnopol, L. (Ed.). (1969). Learning Disabilities: Introduction to Educational and Medical Management. Springfield, Illinois: C. C. Thomas. Werry, J. (1965). Canada's Mental Health 13, (1). Wishik, S. M. (1964). Georgia Study of Handicapped Children. Atlanta: The Georgia D e p a r t m e n t o f Public Health. This article gives a good insight into many of the problems encountered with children with academic difficulties, but our referee points out that conditions in the U.K. are very different in certain aspects. For example, here the School Psychological Service and School Medical Officers are the main source of referral to Child Guidance Clinics; private psychiatrists have a limited function in this field; we have extensive help from lay child psychiatrists working from C.G.C.s; long term psychotherapy--a year or more--including a parent, with the help of a social worker, is the usual recommendation; the social worker attempts to assess at first each family. In the U.K. there are a limited number of inpatient units for children under 13 years, where full neurological, blood, urine and chromosome counts are carried out, and some therapy, the average leng~.o_g stay being 6-9 months. Here the whole emphasis is on the team approach, together with Social Service, Education, Probation Departments, local G.P.s, consultant paediatricians and District and Area Health Authorities. However, with Professor Nichol we can only agree about our mutual lack of resources. The same clinical problems beset us both, but we approach them differently; in particular private child psychiatry is extremely limited in the U.K. Ed.