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THE PRIVATE PRACTICE OF CHILD PSYCHIATRY BY MEMBERS OF THE AMERICAN ACADEMY OF CHILD PSYCHIATRY
THE PRIV ATE PRA CTI CE OF CHIL D PSYC HIAT RY BY ME~,rBERS OF TH E AME RICA N ACA DEM Y OF CHIL D PSYC HIAT RY
[ eann e Spi irl ock , si.n ., josept. Gree n) lVI. D .) Edw in K essler) 1U .D .) Ka th arin e H. Marti n, st.n ., j ack V. J1!all in ga) 1\'1. D .) and L ou is]. J;J1isc) iH .D . e The interest in ascerta ining som e specifics of the private practic Prion hop Works 1966 of child psychi atry was triggered during the vate Practice. Prior to the Workshop , the Private Practice Comm ittee, of th en chaired by Dr. Exie Welch , had set as its goal (1) the st udy problems exp erienc ed in th e private practice of child psychi atry , and (2 ) the exploration of all pertinent areas that were deemed impor tant by the Comm ittee. Early in the history of the Comm ittee, it had been d determ ined that the private practit ioner of child psychi atry engage diin a wide variety of activities, th at very few spent full time in the cone th led paralle ations specul rect tre atmen t of children. Our early ) clusion of th e study condu cted by Bahn, Conwell and Hurl ey (1965 pris, that " in th e provision of communit y based mental health service vate psychiatrists playa vit al role in th e array of consulta tio n, evaluaor tion, diagno sis and treatm ent service s offered to the mentally ill Medi cal Colleg e. Dr. Dr. S pu rloc k is Chairm an. Depa rtment of Psy chiatry . Meharry a Lectu rer in th e Deas ool Sch dical Me nsin Wisco of versity Uni he t with ed Green is affiliat at Geo rgeto wn Uni ry Psychiat of or Profess cal Clini a is sler Kes partmen t of Psy chiatry. Dr. artment of Psychiatry . Yal eversit y Medical Center. Dr. Martin is a Consult an t in th e Dep County Ju venile Co ur t Ne w Haven Hospital . Dr. Wallinga is Psy chiatric Con sultan t, Ramsey Californ ia as Clinical outhern S of ty Universi the with ed filiat af is Wise Dr. . olis in Minneap stitute as Instru cto r In tic choanaly Psy a Californi outhern S and Professo r in Child Psy chiatry and Superv ising A nalyst. , as several are now. A t th e time of this st udy, all wer e engaged in private practice
53
Jeanne Spurlock et al.
54
emotionally disturbed residents of the area". During the forementioned workshop, the participants expressed interest in a wide range of issues related to private practice. For example, matters pertaining to the handling of referrals and the keeping of records provoked as lively a discussion as did the topic of diagnostic and treatment methods. Responding to the enthusiasm of the Workshop participants, the Committee devised and circulated a questionnaire to the membership of the Academy in late 1967. Although the Committee gave considerable thought and time to the devising of the questionnaire, we saw, in retrospect, that a number of questions were ambiguous and that some important areas were given inadequate attention. The questionnaire was divided into two major categories: (l) direct child patient practice; and (2) salaried positions. Respondents were asked to supply additional, pertinent information (what would not be provided by responses to questions) and to evaluate the questionnaire itself. It was suggested that the respondent decide whether or not he or she wished to remain anonymous . Aware that only part of most private practitioners' professional time is scheduled for direct patient care, the first section of the questionnaire was divided into two categories: (1) Direct patient care and (2) Consultation. To determine the nature of the case load of the child psychiatrist and the methods of handling matters related to patient care, thirteen questions were listed under the heading, Direct patient care : (1) Hours/week in direct private practice (2)
Age range of children seen (pre-school ; early latency; late latency; early adolescence, 12-14; adolescence, 14 years and up)
(3)
Special areas of interest (specific age groups, specific treatment approach)
(4)
Identification of case load (number of children seen in each age range; number of adults seen as primary patients; number of adults seen as parents; practice of family or group Rx; number of cases of organically damaged, neurotic or character disorders, psychotic children; use of drugs, number of office and hospital or residential care patients)
The Private Practice of Child Psy chiatry
55
(5)
Referrals Screened by telephone or interview Number accepted for diagnosis only Acceptance of responsibility for referral for tr eatment , if treatment indicat ed Retaining of medical responsibility when /if referral made to a non-medical therapist Disciplin e of th erapist child referred to for treatment
(6)
Waiting list (kept or not kept of diagnosis and/or treatment)
(7) Scheduling (tim e for diagnostic int erview, treatment interview, drug therapy session , group th erapy, family therapy ; office hours) (8)
Fees and collections (usual fee, range of fee, different fee for different service , use of collection agency , permit running up of bill and to what limit)
(9)
Telephone use (handling of phone contact during session period , use of answering service)
(I 0) Coverage (is it provided during absence , for all or selected patients ; meetings attended/year; vacation/year ; length of time away from practice/year) (II) Professional courtesy (to whom and for what service) (12)
Records (how kept and for what services)
(13) Professional and community pressure (time given/month to community organizations and for organizational planning)
Questions about Consultation concerned ( 1) Psychiatric responsibility for children who are placed in care of agencies : (2) supervision of therapist of specific disciplines: weekly hours scheduled for same : (3) supervision provided for specific agencies and (4) pediatric hospital and consultation. Regarding salaried position , th e Committee was interested in determining the amount of time given in four areas: (I) administration ; (2) teaching and supervision; (3) direct patient care : and (4) research.
56
Jeann e Spurlock et al.
Circulation and respon se Questionnaires were mailed to 26 3 members. Tw o wer e returned because of an incorrect add ress. Th ere wer e 141 responses : on e a letter of obj ection . Seven of those that resp onded wer e in retirement or semi-retireme nt. Twenty-five were in full t ime acade mic, administrative or research (o ne member) position s and did not see private pati ents. As previously implied , several qu esti ons were not answered by all respondents; this, we felt was due to the ambiguity of the question. A total of 109 respondents indicated that they wer e in full or part time private practice. Thirty eight held a half time salaried position ; 23 held full time or geographical full time salaried posit io ns (academic and/or administrat ive); 38 worked in a salari ed position less than 20 hours weekl y. It may be th at the 10 who did not ide nti fy a salaried position provide teach ing or co nsultation services witho ut rem un eration (the questionnaire failed to identi fy this possibility ; two of th e ten indi cated they were teaching in a non-salaried position ).
Privat e Practi ce and Direct Patient Care It was not possibl e t o tabul ate accurately eac h response, be cau se every question was not an swered by all resp ondents. Table 1 identifi es th e number of weekly hours spent in privat e pr act ic e: t abl e 2, the number of weekl y hours spe nt in dire ct child-patient care.
TABLE 1 Weekly Hours Spent in Privat e Practi ce
No. of Members
40 or more
33 to 40
25 to 32
17 to 24
9 to 16
8 or less
26
18
13
16
14
6
TABLE 2 Weekl y Hours Sp ent in Direct Child Patient Care 40 or more No. of Members
7
33 to 40
25 to 32
17 to 24
9 to 16
8 or less
13
10
14
33
18
57
The Private Practice of Child Psychiatry
A comparison of tables 1 and 2 indicates that the majority of respondents spend considerably more than half-time in private practice, but considerably less than half-time in direct child-patient care . This suggests that a substantial part of the most private practice time is spent in treating adult patients. Eighty respondents (a majority) indicate that this is true. Discussion among committee members confirms this. It appears , in general, that the older the child psychiatrist, the less time he spends with children and the more with adults. Perhaps this is because working with children is more time-consuming (the many contacts necessary with other significant persons in the child's world), perhaps because it is less financially rewarding (parents of younger children are less affluent and the psychiatrist can't charge for every telephone call, etc.), or perhaps just because creaky joints make it harder to get down on the floor and play . The committee's speculations about the responses prompted the question as to whether we child psychiatrists are giving too little time for that which we are best trained? Age Groups, Special Interests and Case Loads
The majority of respondents indicated that they see children in all age ranges; most indicated the upper age limit as that of late adolescence or adult. Table 3 identifies only the lower age limit.
TABLE 3 Age Groups to 4 yrs. No. of Members
62
5-8 22
9-12
12-14
14 - up
4
Areas of special interest were identified as psychotherapy (by 43), adolescence (42), psychoanalysis (25), pre-school children (13) and latency age children (10). Several kinds of psychotherapeutic models were listed: group therapy, parent guidance, marital and family treatment. Fifty-two members had families in treatment ; 17 did group therapy. The majority saw neurotic children and /or those with char-
Jeann e Spurlock et al.
58
act er disorders ; 10 had 5 - lOin their caseload . One or two psychotic children were being treat ed by 29 members ; 6 wer e treating three psychotic yo ungsters and 5 had more than three in treatment. Drug therap y is seldo m used by th e membership ; 66 seldo m prescribe medication - 20, never, and only 12 prescribe medi cation often . Eight y (8 0) resp ondents indicate d th ey see adults as primary pati ents; 55 had adults, as parents, in treatmen t. Th er e was a wid e range of the number of offi ce patients seen - 2 to 127 (the latter figure represents a number of groups seen in treatm ent). The majority (4 9 ) who responded to this question had 2 to 20 patients in their (then) current caseload. Only 21 members were seeing patients in a hospital or residential ca re setting. Noting the infrequent use o f drugs , the committee was prompted to wonder if thi s finding might re flect the child psychiatrist 's focus on basic personality cha nge rather than sym pto ma tic relief. The obs ervati on that onl y a relat ively sma ll number of respondents see patients in a hospital or residential care setting possibl y reflect s the lack o f suita ble children 's psychi atric in-patient facilities in som e communiti es. Perhaps it is also a measure of the desirability of treating children against the background of their own famil y and home, from which th e problems so often arise. Th e responses pertaining to contacts with famil y members are viewed as espec ially significant , and are reflecti ve of discussions durin g previous worksh op s. The latter relat ed to the members' concern s for the growth of the child and ado lesce nt in relation to the family .
R eferrals Responses to qu estions abo ut referrals are t abulat ed in table 4. TABLE 4 Screening by telephon e Screening by int erview Accept referrals for diagno sis onl y Assume responsibility for referrals for therapy Retain medical resp on sibility wh en /if referral mad e to non-medi cal therapi st
. 37 members . 40 members . 79 members 71 members . 36 members
The Private Practice of Child Psychiatry
59
Referrals to: psychiatrists psychologists social workers psychoanalysts institutions other disciplines?
. . . . . .
68 members! 35 members 25 members 19 members 9 members 11 members
Fifty-seven (57) respondents indicated that they keep a waiting list; 30 for diagnostic evaluations, 27 for treatment. Table 6 indicates the number of new patients taken on during the year. The statistics in table 4 cause wonder about what happens to the patients and families who receive diagnostic services, but for whom the psychiatrist assumes no responsibility of referral for therapy, if indicated. We would ask whether this is the most economical use of valuable professional time and whether the diagnostic process is not much more useful to the family (and the community) if the diagnostician assumes responsibility for helping parents to find the means for carrying out his recommendations.
TABLE 5 Patients Diagnosis Treatment
1to 10 20 39
11-12
21-30
31-40
16 8
10 1
6 2
41-50
Over 50 5 5
In regard to table 5, it was startling to find that more than twothirds of the respondents take on no more than ten new patients per year for treatment, and well over one-half see less than 20 patients for diagnostic studies. The logical conclusion is that members of the Academy, though they may have an important impact on Child Psychiatry as a field, make a very small impact on the problem of meeting the individual needs of emotionally disturbed children in this country. This may be partly explained by the probability that the membership 1 34 identified discipline as child psychiatry 2 pediatricians, tutors, speech therapists
Jeanne Spurlock et al.
60
of the Academy is a much more analytically-oriented group than would be repre sentative of the child psychiatrists in this country.
Keeping the Store The time scheduled for a session period was quite varied. The majority (forty-five) scheduled 50 or 60 minutes for a diagnostic session ; thirteen scheduled 45 minutes and five set aside 90 minutes. Fifty-seven (57) memb ers identified a therapy "hour" as 50 minutes (thirty members) or45 minutes (twenty-seven members). Fifteen members scheduled therapy sessions for a period of 60 minutes. Periods for group therapy ranged from 50 to 90 minutes; family therapy from 45 minutes to two hours. Twelve members responded to the question pertaining to time for a session scheduled primarily for the prescribing of med ication ; seven scheduled 30 minutes, five set aside 50 minutes. Office hours began early and ended lat e in the day. Twenty-five members begin practice at 8 :00 or 8 :30 a.m. and end the day between 5:00 and 8 :30 p.m. ; 10 see th eir first pati ents between 7 :00 and 7 :45 a.m. and terminate with their last pati ent between 5:00 and 7 :00 p.m. Fourteen memb ers have aft ernoon and evening hours only ; 7 began at 9 :00 or 9:30 and finish between 5:00 and 9: 00 p.m. Fees and collections are identi fied in Tabl e 6. Twenty respondents use a collection agenc y ; sixty-six permit patients to run up a bill. TABLE 6 Usual fee Range of fees Diagnostic session Therapy session Drugs, prescription Individual in group Famil y therapy Agency consultation Phone consult ation .. Consultation, hospital 3 mo nthl y fee
majority, . range: $15-$75 $ 1.75...... ............ . range: $20-$30 majority, majority, . range: $15-$40 majority, . range: $10-$35 majority, . range: $ 5-$75 3 range: $25-$40 majority, range: $ 15.50-$200/day majorit y, . range: $ 5-$50 range: $20-$500 majority,
$25 $30 $30 $30 $15 $10 $25 $25 $50
The Private Practice of Child Psychiatry
61
Only 46 respondents indicated the use of any answering service ; 41 of these have a 24 hour coverage. The majority (44) of those responding seldom interrupt a session to talk with a caller; 18 never interrupt a session for this purpose. Coverage was provided by 65 members when out of th eir cities of practice. A greater number (26) of members attend three professional meetings each year ; are absent from practice (to attend meetings) for two to three days at a time. Thirtynin e members take one (21 memb ers) to two (18 members) vacations each year; a greater number total vacation time to four weeks . Professional courtesy is ext ended by 71 members to: (1) phy sicians and famili es - by 39 members (2) physicians - by 18 memb ers (3) psychologists - by 12 members (4) social workers - by 11 memb ers Several individuals give professional courtesy to one , or several, of th e following: clergy , dentists, nurses, paramedical personnel and teachers. Sixty-seven (67) of seventy-two (72) respondents charged no fee for consultation; other consultation fees listed as between 85 - 10% of the regular fee. No fee was charged for diagnostic evaluation by 62 of 68 respondents ; other diagnostic fees listed range from 85 - 50% of the regular fee. Reduction, for professional courtesy, in therapy fees ranged from 85 - 10% of the regular fee ; 3 of th e 27 respond ents charged no fee. Sixty-three (63) members indicated the keeping of th erapy notes detailed (34 members), monthly summaries (17 members) or weekly summaries (12 members). Secretarial services were used by 48 members for varying blocks of time per week (one-quarter to 40 hours). It is a somewhat humbling fact that considering our frequent discussions about medical responsibility in which we note that the discipline of medicine instills us with a responsibility toward patients that our non-medical colleagu es often do not have, onl y one-third of th e respondents have an answering service or twenty-four hour coverage, and less than one-half provide coverage of their practice when out of the city. There is little pattern to the procedures followed in regard to professional courtesy. This is not surprising since our medical colleagues, who have adhered to th e custom more strictly than psychiatrists, are also challenging its value in modern medicine.
Jeanne Spurlock et at.
62 Consultation and Teaching
Sixty (60 ) respondents give professional servic e to community organizations for ( 24 members ) and without remuneration (36). The t ime ranged from 1 to 60 hours monthly profession al time scheduled for Consultation Servi ces is identified in Table 7. TABLE 7 Psychiatric responsibility for children in car e of agencies: 45 respondents range of number of childre n : 2 to 2000 Number of children with whom member has direct co nt act : 30 respondents rang e of number of children : 1 to 250 Supervision o f: psychiatrists" social workers psychologists other disciplines''
by , by by . . . . . . . . . . . . . . . . . . . . . .. by
71 members 3 7 members 33 members 2 1 memb ers
Hours/w eek sch edul ed for su pervisio n : range of tim e 1 to 5 hours 6 to 10 hours over 10 hours
. I to 40 hours . by 2 1 members . by 19 members . by 6 members
Supervision to agen cies: schools by 31 members social agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . by 25 members psychiatric facilities . . . . . . . . . . . . . . . . . . . . . . . by 20 members courts , polic e by 7 members da y care and group hom es by 6 members medi cal schools by 6 members 4 includ es child an alyst s, ch ild psych iatrist s, child psych iatry fell o w s, psychoanal yti c ca ndidates , ps ychiatr y resid ent s. 5these include aids , child care wor kers, dance ther api st s, gro up wo rker s, la y therapist s, ph ysicians , medical st u de nts , pe dia tr icia ns , teachers.
The Private Practice of Child Psychiatry
63
Pediatric hospital patients: 48 respondents see I to 40/month time scheduled - I to 6 hours to full time Research Research activity listed by a number of members suggests that the Academy will be privileged to hear some exciting presentations during the course of the next several years. A number of exciting projects are being conducted in public school settings; among these projects are (I) development of a reading program for mental health for elementary school teachers; (2) effect of group therapy with parents as a method of clinical intervention in working with poor academic performance in bright adolescents. "Adoption, the Effect on Development" and "Theory and Practice of Child Analysis" are two studies that are being conducted as part of the private practice of the investigators. Other research projects described were: (I) Long Term Longitudinal Study of Child Development and Motility Patterns; (2) Effects of Stelazine on Typical Children; (3) Teaching Communicative Skills to the Disadvantaged Child; (4) Riot Study; (5) Pediatric Supervision ; (6) Epidemiology of Childhood Accidents. Conclusions Throughout this communication, references have been made to a number of conclusions, as well as questions that were provoked by the information obtained from the respondents to the questionnaire. We learned of several new types of practices of child psychiatry. One respondent described the use of college students, teachers, social workers and psychologists as co-therapists in the private practice of group therapy. Respondents also raised questions and made suggestions; one requested suggestions pertaining to the financing of research; another encouraged more full time salaried comm unity involvement. A number of members called attention to the numerous hours given to professional organizations for committee work and/or as an officer. The committee was pleased, but not surprised, to establish the fact that members of the Academy devote a large amount of their professional time (often without remuneration) to community organizations. The committee's speculations, regarding
Jeanne Spurlock et al.
64
the child psychiatrist's community involvement , were confirmed. The members of the Academy are concerned and involved. Yet, as previously qu estioned, we wondered if we child psychiatrists are giving too little time to that for which we are best trained? This question, along with several others, warrants further evaluation. Of particular importance is that qu estion related to the need for modification of child psychiatry training programs. The committee advocates that a similar survey be conducted in five (5) years . In view of the expected change in the membership of the Academy, reflecting a larger cross-section of the community of child psychiatrists, it is anticipated that a subsequent survey will answer a number of questions raised in this communication, and will yield a greatly different picture of the private practice of child psychiatry.
REFERENCE BAHN, K., CONWELL, M.• & HURLEY, P. (1965) , Survey o f private psychiatric pr actice. Arch. Gen. Psychiar., 12 :295-302.
[ eann e Spi irl ock , si.n ., josept. Gree n) lVI. D .) Edw in K essler) 1U .D .) Ka th arin e H. Marti n, st.n ., j ack V. J1!all in ga) 1\'1. D .) and L ou is]. J;J1isc) iH .D . e The interest in ascerta ining som e specifics of the private practic Prion hop Works 1966 of child psychi atry was triggered during the vate Practice. Prior to the Workshop , the Private Practice Comm ittee, of th en chaired by Dr. Exie Welch , had set as its goal (1) the st udy problems exp erienc ed in th e private practice of child psychi atry , and (2 ) the exploration of all pertinent areas that were deemed impor tant by the Comm ittee. Early in the history of the Comm ittee, it had been d determ ined that the private practit ioner of child psychi atry engage diin a wide variety of activities, th at very few spent full time in the cone th led paralle ations specul rect tre atmen t of children. Our early ) clusion of th e study condu cted by Bahn, Conwell and Hurl ey (1965 pris, that " in th e provision of communit y based mental health service vate psychiatrists playa vit al role in th e array of consulta tio n, evaluaor tion, diagno sis and treatm ent service s offered to the mentally ill Medi cal Colleg e. Dr. Dr. S pu rloc k is Chairm an. Depa rtment of Psy chiatry . Meharry a Lectu rer in th e Deas ool Sch dical Me nsin Wisco of versity Uni he t with ed Green is affiliat at Geo rgeto wn Uni ry Psychiat of or Profess cal Clini a is sler Kes partmen t of Psy chiatry. Dr. artment of Psychiatry . Yal eversit y Medical Center. Dr. Martin is a Consult an t in th e Dep County Ju venile Co ur t Ne w Haven Hospital . Dr. Wallinga is Psy chiatric Con sultan t, Ramsey Californ ia as Clinical outhern S of ty Universi the with ed filiat af is Wise Dr. . olis in Minneap stitute as Instru cto r In tic choanaly Psy a Californi outhern S and Professo r in Child Psy chiatry and Superv ising A nalyst. , as several are now. A t th e time of this st udy, all wer e engaged in private practice
53
Jeanne Spurlock et al.
54
emotionally disturbed residents of the area". During the forementioned workshop, the participants expressed interest in a wide range of issues related to private practice. For example, matters pertaining to the handling of referrals and the keeping of records provoked as lively a discussion as did the topic of diagnostic and treatment methods. Responding to the enthusiasm of the Workshop participants, the Committee devised and circulated a questionnaire to the membership of the Academy in late 1967. Although the Committee gave considerable thought and time to the devising of the questionnaire, we saw, in retrospect, that a number of questions were ambiguous and that some important areas were given inadequate attention. The questionnaire was divided into two major categories: (l) direct child patient practice; and (2) salaried positions. Respondents were asked to supply additional, pertinent information (what would not be provided by responses to questions) and to evaluate the questionnaire itself. It was suggested that the respondent decide whether or not he or she wished to remain anonymous . Aware that only part of most private practitioners' professional time is scheduled for direct patient care, the first section of the questionnaire was divided into two categories: (1) Direct patient care and (2) Consultation. To determine the nature of the case load of the child psychiatrist and the methods of handling matters related to patient care, thirteen questions were listed under the heading, Direct patient care : (1) Hours/week in direct private practice (2)
Age range of children seen (pre-school ; early latency; late latency; early adolescence, 12-14; adolescence, 14 years and up)
(3)
Special areas of interest (specific age groups, specific treatment approach)
(4)
Identification of case load (number of children seen in each age range; number of adults seen as primary patients; number of adults seen as parents; practice of family or group Rx; number of cases of organically damaged, neurotic or character disorders, psychotic children; use of drugs, number of office and hospital or residential care patients)
The Private Practice of Child Psy chiatry
55
(5)
Referrals Screened by telephone or interview Number accepted for diagnosis only Acceptance of responsibility for referral for tr eatment , if treatment indicat ed Retaining of medical responsibility when /if referral made to a non-medical therapist Disciplin e of th erapist child referred to for treatment
(6)
Waiting list (kept or not kept of diagnosis and/or treatment)
(7) Scheduling (tim e for diagnostic int erview, treatment interview, drug therapy session , group th erapy, family therapy ; office hours) (8)
Fees and collections (usual fee, range of fee, different fee for different service , use of collection agency , permit running up of bill and to what limit)
(9)
Telephone use (handling of phone contact during session period , use of answering service)
(I 0) Coverage (is it provided during absence , for all or selected patients ; meetings attended/year; vacation/year ; length of time away from practice/year) (II) Professional courtesy (to whom and for what service) (12)
Records (how kept and for what services)
(13) Professional and community pressure (time given/month to community organizations and for organizational planning)
Questions about Consultation concerned ( 1) Psychiatric responsibility for children who are placed in care of agencies : (2) supervision of therapist of specific disciplines: weekly hours scheduled for same : (3) supervision provided for specific agencies and (4) pediatric hospital and consultation. Regarding salaried position , th e Committee was interested in determining the amount of time given in four areas: (I) administration ; (2) teaching and supervision; (3) direct patient care : and (4) research.
56
Jeann e Spurlock et al.
Circulation and respon se Questionnaires were mailed to 26 3 members. Tw o wer e returned because of an incorrect add ress. Th ere wer e 141 responses : on e a letter of obj ection . Seven of those that resp onded wer e in retirement or semi-retireme nt. Twenty-five were in full t ime acade mic, administrative or research (o ne member) position s and did not see private pati ents. As previously implied , several qu esti ons were not answered by all respondents; this, we felt was due to the ambiguity of the question. A total of 109 respondents indicated that they wer e in full or part time private practice. Thirty eight held a half time salaried position ; 23 held full time or geographical full time salaried posit io ns (academic and/or administrat ive); 38 worked in a salari ed position less than 20 hours weekl y. It may be th at the 10 who did not ide nti fy a salaried position provide teach ing or co nsultation services witho ut rem un eration (the questionnaire failed to identi fy this possibility ; two of th e ten indi cated they were teaching in a non-salaried position ).
Privat e Practi ce and Direct Patient Care It was not possibl e t o tabul ate accurately eac h response, be cau se every question was not an swered by all resp ondents. Table 1 identifi es th e number of weekly hours spent in privat e pr act ic e: t abl e 2, the number of weekl y hours spe nt in dire ct child-patient care.
TABLE 1 Weekly Hours Spent in Privat e Practi ce
No. of Members
40 or more
33 to 40
25 to 32
17 to 24
9 to 16
8 or less
26
18
13
16
14
6
TABLE 2 Weekl y Hours Sp ent in Direct Child Patient Care 40 or more No. of Members
7
33 to 40
25 to 32
17 to 24
9 to 16
8 or less
13
10
14
33
18
57
The Private Practice of Child Psychiatry
A comparison of tables 1 and 2 indicates that the majority of respondents spend considerably more than half-time in private practice, but considerably less than half-time in direct child-patient care . This suggests that a substantial part of the most private practice time is spent in treating adult patients. Eighty respondents (a majority) indicate that this is true. Discussion among committee members confirms this. It appears , in general, that the older the child psychiatrist, the less time he spends with children and the more with adults. Perhaps this is because working with children is more time-consuming (the many contacts necessary with other significant persons in the child's world), perhaps because it is less financially rewarding (parents of younger children are less affluent and the psychiatrist can't charge for every telephone call, etc.), or perhaps just because creaky joints make it harder to get down on the floor and play . The committee's speculations about the responses prompted the question as to whether we child psychiatrists are giving too little time for that which we are best trained? Age Groups, Special Interests and Case Loads
The majority of respondents indicated that they see children in all age ranges; most indicated the upper age limit as that of late adolescence or adult. Table 3 identifies only the lower age limit.
TABLE 3 Age Groups to 4 yrs. No. of Members
62
5-8 22
9-12
12-14
14 - up
4
Areas of special interest were identified as psychotherapy (by 43), adolescence (42), psychoanalysis (25), pre-school children (13) and latency age children (10). Several kinds of psychotherapeutic models were listed: group therapy, parent guidance, marital and family treatment. Fifty-two members had families in treatment ; 17 did group therapy. The majority saw neurotic children and /or those with char-
Jeann e Spurlock et al.
58
act er disorders ; 10 had 5 - lOin their caseload . One or two psychotic children were being treat ed by 29 members ; 6 wer e treating three psychotic yo ungsters and 5 had more than three in treatment. Drug therap y is seldo m used by th e membership ; 66 seldo m prescribe medication - 20, never, and only 12 prescribe medi cation often . Eight y (8 0) resp ondents indicate d th ey see adults as primary pati ents; 55 had adults, as parents, in treatmen t. Th er e was a wid e range of the number of offi ce patients seen - 2 to 127 (the latter figure represents a number of groups seen in treatm ent). The majority (4 9 ) who responded to this question had 2 to 20 patients in their (then) current caseload. Only 21 members were seeing patients in a hospital or residential ca re setting. Noting the infrequent use o f drugs , the committee was prompted to wonder if thi s finding might re flect the child psychiatrist 's focus on basic personality cha nge rather than sym pto ma tic relief. The obs ervati on that onl y a relat ively sma ll number of respondents see patients in a hospital or residential care setting possibl y reflect s the lack o f suita ble children 's psychi atric in-patient facilities in som e communiti es. Perhaps it is also a measure of the desirability of treating children against the background of their own famil y and home, from which th e problems so often arise. Th e responses pertaining to contacts with famil y members are viewed as espec ially significant , and are reflecti ve of discussions durin g previous worksh op s. The latter relat ed to the members' concern s for the growth of the child and ado lesce nt in relation to the family .
R eferrals Responses to qu estions abo ut referrals are t abulat ed in table 4. TABLE 4 Screening by telephon e Screening by int erview Accept referrals for diagno sis onl y Assume responsibility for referrals for therapy Retain medical resp on sibility wh en /if referral mad e to non-medi cal therapi st
. 37 members . 40 members . 79 members 71 members . 36 members
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Referrals to: psychiatrists psychologists social workers psychoanalysts institutions other disciplines?
. . . . . .
68 members! 35 members 25 members 19 members 9 members 11 members
Fifty-seven (57) respondents indicated that they keep a waiting list; 30 for diagnostic evaluations, 27 for treatment. Table 6 indicates the number of new patients taken on during the year. The statistics in table 4 cause wonder about what happens to the patients and families who receive diagnostic services, but for whom the psychiatrist assumes no responsibility of referral for therapy, if indicated. We would ask whether this is the most economical use of valuable professional time and whether the diagnostic process is not much more useful to the family (and the community) if the diagnostician assumes responsibility for helping parents to find the means for carrying out his recommendations.
TABLE 5 Patients Diagnosis Treatment
1to 10 20 39
11-12
21-30
31-40
16 8
10 1
6 2
41-50
Over 50 5 5
In regard to table 5, it was startling to find that more than twothirds of the respondents take on no more than ten new patients per year for treatment, and well over one-half see less than 20 patients for diagnostic studies. The logical conclusion is that members of the Academy, though they may have an important impact on Child Psychiatry as a field, make a very small impact on the problem of meeting the individual needs of emotionally disturbed children in this country. This may be partly explained by the probability that the membership 1 34 identified discipline as child psychiatry 2 pediatricians, tutors, speech therapists
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of the Academy is a much more analytically-oriented group than would be repre sentative of the child psychiatrists in this country.
Keeping the Store The time scheduled for a session period was quite varied. The majority (forty-five) scheduled 50 or 60 minutes for a diagnostic session ; thirteen scheduled 45 minutes and five set aside 90 minutes. Fifty-seven (57) memb ers identified a therapy "hour" as 50 minutes (thirty members) or45 minutes (twenty-seven members). Fifteen members scheduled therapy sessions for a period of 60 minutes. Periods for group therapy ranged from 50 to 90 minutes; family therapy from 45 minutes to two hours. Twelve members responded to the question pertaining to time for a session scheduled primarily for the prescribing of med ication ; seven scheduled 30 minutes, five set aside 50 minutes. Office hours began early and ended lat e in the day. Twenty-five members begin practice at 8 :00 or 8 :30 a.m. and end the day between 5:00 and 8 :30 p.m. ; 10 see th eir first pati ents between 7 :00 and 7 :45 a.m. and terminate with their last pati ent between 5:00 and 7 :00 p.m. Fourteen memb ers have aft ernoon and evening hours only ; 7 began at 9 :00 or 9:30 and finish between 5:00 and 9: 00 p.m. Fees and collections are identi fied in Tabl e 6. Twenty respondents use a collection agenc y ; sixty-six permit patients to run up a bill. TABLE 6 Usual fee Range of fees Diagnostic session Therapy session Drugs, prescription Individual in group Famil y therapy Agency consultation Phone consult ation .. Consultation, hospital 3 mo nthl y fee
majority, . range: $15-$75 $ 1.75...... ............ . range: $20-$30 majority, majority, . range: $15-$40 majority, . range: $10-$35 majority, . range: $ 5-$75 3 range: $25-$40 majority, range: $ 15.50-$200/day majorit y, . range: $ 5-$50 range: $20-$500 majority,
$25 $30 $30 $30 $15 $10 $25 $25 $50
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Only 46 respondents indicated the use of any answering service ; 41 of these have a 24 hour coverage. The majority (44) of those responding seldom interrupt a session to talk with a caller; 18 never interrupt a session for this purpose. Coverage was provided by 65 members when out of th eir cities of practice. A greater number (26) of members attend three professional meetings each year ; are absent from practice (to attend meetings) for two to three days at a time. Thirtynin e members take one (21 memb ers) to two (18 members) vacations each year; a greater number total vacation time to four weeks . Professional courtesy is ext ended by 71 members to: (1) phy sicians and famili es - by 39 members (2) physicians - by 18 memb ers (3) psychologists - by 12 members (4) social workers - by 11 memb ers Several individuals give professional courtesy to one , or several, of th e following: clergy , dentists, nurses, paramedical personnel and teachers. Sixty-seven (67) of seventy-two (72) respondents charged no fee for consultation; other consultation fees listed as between 85 - 10% of the regular fee. No fee was charged for diagnostic evaluation by 62 of 68 respondents ; other diagnostic fees listed range from 85 - 50% of the regular fee. Reduction, for professional courtesy, in therapy fees ranged from 85 - 10% of the regular fee ; 3 of th e 27 respond ents charged no fee. Sixty-three (63) members indicated the keeping of th erapy notes detailed (34 members), monthly summaries (17 members) or weekly summaries (12 members). Secretarial services were used by 48 members for varying blocks of time per week (one-quarter to 40 hours). It is a somewhat humbling fact that considering our frequent discussions about medical responsibility in which we note that the discipline of medicine instills us with a responsibility toward patients that our non-medical colleagu es often do not have, onl y one-third of th e respondents have an answering service or twenty-four hour coverage, and less than one-half provide coverage of their practice when out of the city. There is little pattern to the procedures followed in regard to professional courtesy. This is not surprising since our medical colleagues, who have adhered to th e custom more strictly than psychiatrists, are also challenging its value in modern medicine.
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Sixty (60 ) respondents give professional servic e to community organizations for ( 24 members ) and without remuneration (36). The t ime ranged from 1 to 60 hours monthly profession al time scheduled for Consultation Servi ces is identified in Table 7. TABLE 7 Psychiatric responsibility for children in car e of agencies: 45 respondents range of number of childre n : 2 to 2000 Number of children with whom member has direct co nt act : 30 respondents rang e of number of children : 1 to 250 Supervision o f: psychiatrists" social workers psychologists other disciplines''
by , by by . . . . . . . . . . . . . . . . . . . . . .. by
71 members 3 7 members 33 members 2 1 memb ers
Hours/w eek sch edul ed for su pervisio n : range of tim e 1 to 5 hours 6 to 10 hours over 10 hours
. I to 40 hours . by 2 1 members . by 19 members . by 6 members
Supervision to agen cies: schools by 31 members social agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . by 25 members psychiatric facilities . . . . . . . . . . . . . . . . . . . . . . . by 20 members courts , polic e by 7 members da y care and group hom es by 6 members medi cal schools by 6 members 4 includ es child an alyst s, ch ild psych iatrist s, child psych iatry fell o w s, psychoanal yti c ca ndidates , ps ychiatr y resid ent s. 5these include aids , child care wor kers, dance ther api st s, gro up wo rker s, la y therapist s, ph ysicians , medical st u de nts , pe dia tr icia ns , teachers.
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Pediatric hospital patients: 48 respondents see I to 40/month time scheduled - I to 6 hours to full time Research Research activity listed by a number of members suggests that the Academy will be privileged to hear some exciting presentations during the course of the next several years. A number of exciting projects are being conducted in public school settings; among these projects are (I) development of a reading program for mental health for elementary school teachers; (2) effect of group therapy with parents as a method of clinical intervention in working with poor academic performance in bright adolescents. "Adoption, the Effect on Development" and "Theory and Practice of Child Analysis" are two studies that are being conducted as part of the private practice of the investigators. Other research projects described were: (I) Long Term Longitudinal Study of Child Development and Motility Patterns; (2) Effects of Stelazine on Typical Children; (3) Teaching Communicative Skills to the Disadvantaged Child; (4) Riot Study; (5) Pediatric Supervision ; (6) Epidemiology of Childhood Accidents. Conclusions Throughout this communication, references have been made to a number of conclusions, as well as questions that were provoked by the information obtained from the respondents to the questionnaire. We learned of several new types of practices of child psychiatry. One respondent described the use of college students, teachers, social workers and psychologists as co-therapists in the private practice of group therapy. Respondents also raised questions and made suggestions; one requested suggestions pertaining to the financing of research; another encouraged more full time salaried comm unity involvement. A number of members called attention to the numerous hours given to professional organizations for committee work and/or as an officer. The committee was pleased, but not surprised, to establish the fact that members of the Academy devote a large amount of their professional time (often without remuneration) to community organizations. The committee's speculations, regarding
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the child psychiatrist's community involvement , were confirmed. The members of the Academy are concerned and involved. Yet, as previously qu estioned, we wondered if we child psychiatrists are giving too little time to that for which we are best trained? This question, along with several others, warrants further evaluation. Of particular importance is that qu estion related to the need for modification of child psychiatry training programs. The committee advocates that a similar survey be conducted in five (5) years . In view of the expected change in the membership of the Academy, reflecting a larger cross-section of the community of child psychiatrists, it is anticipated that a subsequent survey will answer a number of questions raised in this communication, and will yield a greatly different picture of the private practice of child psychiatry.
REFERENCE BAHN, K., CONWELL, M.• & HURLEY, P. (1965) , Survey o f private psychiatric pr actice. Arch. Gen. Psychiar., 12 :295-302.