Introduction
A 6-month placement in child and adolescent psychiatry and/or the psychiatry of learning disability is now a mandatory part of basic specialist training in psychiatry. Although candidates may sit the MRCPsych examination before such a placement or while completing it, the MRCPsych cannot be awarded (and the candidate cannot proceed to higher specialist level training) until the placement has been satisfactorily completed.
The rationale for such a mandatory placement is that all qualified psychiatrists need to have a proper understanding of the developmental basis of psychiatric practice. To achieve this they not only need the relevant theoretical knowledge but also to have had the clinical experience of working with both children, adolescents and their families and with people with a learning disability and their families.
The main purpose of clinical placements in child and adolescent psychiatry and/or the psychiatry of learning disability is to complement trainees' theoretical learning on local MRCPsych courses. It is critical that trainers of senior house officers (SHOs) in these specialities concern themselves primarily with the learning objectives of a general psychiatrist-in-training, rather than view this as the beginning of higher training. Some trainees will take advantage of the placement to study a preferred subject in depth, but this enthusiasm should not detract from the main aims of the placement, which are to equip psychiatrists pursuing a general psychiatry career or entering another speciality with the skills necessary to recognise the need for a more specialist input, and also to consider their patients' presentation in both developmental and systemic terms.
The faculties of child and adolescent psychiatry and of learning disability have worked together to produce educational objectives for these mandatory placements (which can be in either single speciality or in a combination of the two), as well as guidelines as to how these educational objectives can best be achieved. These are summarised below.
Overall aims
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(a) To become familiar with the principles and practice of assessment, diagnosis and treatment, including therapeutic modalities, psychoactive medication and environmental manipulations of patients of all ages and their families presenting to child psychiatric or learning disability services.
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(b) To learn to consider their patients' presentations in developmental and systemic terms.
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(c) To acquire the skills necessary to differentiate between distress, disturbance and disorder, and to recognise developmental disabilities and delay.
Educational objectives
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(a) To become familiar with developmental and child psychiatric disorders.
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(b) To be able to communicate with their patients at an age or developmentally appropriate level.
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(c) To understand the influence of developmental factors on the presentation and treatment of psychiatric disorders.
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(d) To recognise the importance of interviewing other members of the family or network and to be able to carry out interviews with those involved both together with the patient and separately.
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(e) To consider the context of the presentation in terms of family life-cycle and wider systemic influences including race, ethnicity and culture.
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(f) To understand the concepts of vulnerability and resilience that lead to each individual's unique presentation, and to varying degrees of distress, disturbance and disorder.
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(g) To recognise and evaluate the interaction between genetic and environmental factors, including parental illness and developmental disability.
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(h) To understand the relationship between physical, cognitive, emotional, social and developmental factors that contribute to emotional behavioural difficulties or more serious mental illness.
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(i) To be aware of the ethical and legal issues that are applicable to children, adolescents and people with learning disabilities, including those who cannot give informed consent.
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(j) To understand the roles of other disciplines and agencies in assessment and treatment.
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(k) To become familiar with the presentations of abuse, its sequel and its management.
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(l) To be aware of the impact of labelling, and the ways in which it is utilised.
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(m) To be able to consider the significance of personal values, beliefs and assumptions in relation to one's professional role, particularly in the context of service provision for children, adolescents and people with learning disability.
The child and adolescent and learning disabilities faculties have also produced guidelines to help basic specialist training rotations to achieve these aims and objectives within existing placements and those developed specifically to meet the new mandatory requirements. These guidelines (see below) are also intended to provide a framework within which basic specialist training accreditation visitors can monitor progress and problems and advise scheme organisers accordingly.
Adult learning disability psychiatry placements
Most of the learning objectives of the curriculum can be met by having the opportunity to interview, assess and treat people with learning disabilities with a range of psychological and psychiatric disorders and by also interviewing their families. It is important that this includes patients with different degrees of learning disability and with other developmental disorders such as autism, Asperger's syndrome and hyperkinetic disorder.
In addition, there should be sufficient opportunity to relate directly to children and adolescents and their families. This can be achieved by spending approximately one session per week or equivalent, over the whole placement, in a local child development centre and/or a child and adolescent psychiatric service.
Experience of working alongside a range of other professionals is required and also the opportunity to attend case conferences or multi-disciplinary reviews during the placement. At least one case conference/review that deals with issues of child protection and abuse (looking at victim and perpetrator perspectives) should be attended.
In addition to the weekly meetings with the educational supervisor for the placement, it is suggested that regular supervision should be provided to discuss the child mental health aspects of the placement with the supervising consultant, or with other senior professional staff. This may enable the integration of the learning opportunities provided by the placement, including addressing ethical issues and self-reflection.
Supplementary experience can be gained through selected visits to special schools, training centres, nurseries, etc., to gain an understanding of the range of local resources.
Life span learning disability placements
The trainee should spend at least one session per week of the placement (or equivalent), over the whole placement, in services for children or adolescents with a learning disability and at least the equivalent of one session per week, over the whole placement, with adults with learning disabilities. There should be opportunities to undertake full assessments that include developmental and psychiatric histories taken both from and with the patient and the family.
There should be the opportunity to work as a member of a multi-disciplinary team and to attend the weekly case review meetings. Whenever issues related to the protection of children or vulnerable adults arise, these should be discussed with the trainee, who will be encouraged to attend any relevant reviews or case conferences. At least one case conference/review that deals with issues of child protection and abuse should be attended.
Depending on the nature of the experience being provided in the placement, regular supervision should be provided, with the supervising consultant or with other senior professional staff, to discuss and integrate the child mental health aspects of the placement, in addition to the weekly meetings with the educational supervisor.
Supplementary experience can be gained through selected visits to special schools, training centres, nurseries, etc., to gain an understanding of the range of local resources.
Child and adolescent psychiatry placements
Most of the learning objectives of the curriculum can be met within a child and adolescent psychiatry placement, either in a community-based or hospital-based service. Trainees will need to have the opportunity to assess and to participate in the treatment of the specific disorders highlighted in the MRCPsych curriculum for child and adolescent psychiatry. In child and adolescent psychiatry placements, trainees will usually have the opportunity to participate in inter-agency work and case conferences about specific children or young people, and in the assessment and treatment of young people individually, their parents and families.
Possible ways in which these placements can be organised to meet the agreed training objectives with regard to learning disability are suggested as follows:
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(a) Experience with children and adolescents with learning difficulties and learning disabilities can be gained by attendance with a child development team, by linking with youth offending teams for the assessment of learning disabled young offenders, or by linking with local learning disability services in relation to children and to adolescents in transition to adult services. Most child psychiatry services also see children with mild/moderate learning disability.
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(b) Experience with adults with learning disability can be gained by working with local community learning disability teams. These teams are multidiciplinary and provide the opportunity to work with adults with a range of disabilities and difficulties both in family and residential settings.
Approximately one session per week or equivalent, over the course of the 6-month placement, should be spent in working with patients with learning disabilities and their families. Selected visits to special schools (day or residential), adult training centres and voluntary sector services will provide an understanding of the range of local resources.
The educational supervisor should meet the trainee weekly and ensure that this discussion includes an integration of the learning opportunities that have been provided by the placement, in particular, with regard to their experience with patients with learning disabilities and their families and the issues that have arisen for the trainee with respect to this experience. Regular supervision with the supervisory consultant or with other senior professional staff should be provided for the learning disability component of the placement.
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