Training matters Future child and adolescent psychiatrists : a further survey of senior registrar training

Child and adolescent psychiatry is a growing speciality. Significant increases in workload, the reasons for which have been described elsewhere (Black, 1989), have led to an expansion in consultant posts across the UK. Recently the Joint Planning and Advisory Committee (JPAC) reviewed senior registrar numbers and recommended an increase in the establishment by 38 whole-time equivalents in England and Wales, a rise of 38%, to meet the expected shortfall. How existing senior registrars, as well as this large number of new recruits, are trained is clearly a matter of some importance. In the United Kingdom, training in child and adolescent psychiatry is governed by the Joint Committee on Higher Psychiatric Training (JCHPT) which was formed in 1973 by the Royal College of Psychiatrists and the Association of University Teachers of Psychiatry. The Committee has re sponsibility to oversee all aspects of higher training in psychiatry and is assisted in this by five specialist advisory sub-committees. The Committee publishes requirements for training which set out the types of clinical experience, supervision, formal teaching and research opportunities which should be available for trainees (JCHPT, 1987). The Committee also arranges for all training schemes to be inspected regularly to ensure that these requirements are followed. The Committee has the power to remove approval for training, which in turn means that senior registrar posts may be lost. Senior registrars in child and adolescent psy chiatry were first surveyed in 1979. Training experi ences were described and concern expressed about the lack of adequate training facilities (Garralda et al, 1983). There are a number of reasons why a further survey would be valuable. Firstly, there is to be a large increase in senior registrar numbers, as outlined above. Secondly, since its inception, the JCHPT through its Child and Adolescent Psychiatry Specialist Advisory Committee (CAPSAC) has vigorously pursued its policy to raise training stan dards. The most recent edition of the JCHPT hand book (JCHPT, 1987) makes a number of changes from previous editions. Most striking is the substi tution of "must" for "should" throughout most of

dards.The most recent edition of the JCHPT hand book (JCHPT, 1987) makes a number of changes from previous editions.Most striking is the substi tution of "must" for "should" throughout most of the child and adolescent psychiatry section.Thus, direct experience with mentally handicapped chil dren, and consultation to both a paediatric service and to other professionals are now mandatory rather than advised.Another important change since 1979, is that the recommended length of training has been restored to its original four years from the recent three years.
With the above changes in mind, a further survey of all senior registrars in child and adolescent psy chiatry was carried out.The findings of this survey are now reported.

The study
During the summer of 1988 a modified version of the 1979 questionnaire (Garralda et al, 1983)was sent to the 123 senior registrars (67 women and 56 men) believed to be in post in the United Kingdom and Ireland.A reminder letter was mailed six months later.The original questionnaire was designed to examine training as it was recommended in 1979 so the modifications reflected new training guidelines.The questionnaire consisted of five sections con cerned with: (a) Background characteristics Personal details: length of training in; child psychiatry, general psychiatry, paediatrics, mental handicap and post-registration medicine.(b) Theoretical orientation The available choices were psychodynamic-analytical, behavioural, social-community and biological.Respon dents were asked to rank these in order of im portance.It was stated that equal rankings could be given, so that respondents consider ing themselves eclectic could rank the four choices equally.

Findings
Eighty completed questionnaires were returned.The response rate was therefore 65% compared to 69% obtained in 1979.

Background characteristics
The personal characteristics of the trainees from both the current survey and 1979are shown in Table I.It can be seen that the two groups are similar in most respects.However, in 1988a greater proportion of trainees were female, 56% compared to 41%.Fewer trainees had paediatric or general medical ex perience prior to psychiatric training.More trainees had published papers than in 1979.

Theoretical orientation
A majority of trainees did not make an exclusive first choice and the largest grouping of trainees (34 out of 80 = 43%) ranked all the choices equally.A further 11 trainees ranked two or three of the choices first equal.Of those who did make an exclusive first choice the most popular orientation was psychodynamic-analytical (27 trainees, 34%).This compares with 41 trainees (55%) who made this exclusive first choice in 1979.This left only eight trainees who ranked either social community, behavioural or bio logical as exclusive first choices.

Present training scheme
The amount of time spent in various settings in 1988, as compared with 1979, is shown in Figure 1.The 1988 figures were calculated for the 53 trainees who were working full time in the National Health Service.
The mean number of patient interviews and clini cal consultations conducted per week for full-time senior registrars was 11.8, while for part-timers it was 7.9 per week.The ranges for these two groups were considerable, from 4 to 25 and from 3 to 12 consultations per week, respectively.Twenty-two trainees (27%) reported having less than one hour of individual supervision with their consultant each week.Seven of these trainees reported having no individual supervision at all, and two of these did not receive supervision in a group with their consultant either.Forty-three trainees (54%) received more than an hour per week of supervision with another professional.
Respondents had been asked to estimate the time they had spent in formal learning occasions (organ ised seminars or lectures on child development or clinical child psychiatry) over the previous exact 12 month period.The mean amount of time spent in these seminars was calculated to be two hours per week in term time (assuming three ten week terms in the year).There was a great variation in the amount of time spent in this way, which ranged from 0 to 120 hours per year (mean = 17) for child development and from 0 to 180 (mean = 39) for child psychiatry.Most trainees, if they reported no seminars in child development, did have them in child psychiatry and vice versa; however, two trainees claimed to have had seminars in neither child development nor psychiatry over the preceding 12 months.
Trainees stated that they met with their tutorcoordinator a mean of 3.8 times per term.Despite the fact that 84% declared satisfaction with the role of their tutor, only 30% said that they received regular feedback about their performance.

Clinical problems
The questionnaire listed: emotional, conduct, and adolescent disorders, psychoses, disorders associated with physical illness, preschool problems, develop mental disorders and autism, and mental handicap.All the above were judged to be important by most respondents (rate 4 or 5).By contrast to the 1979 survey, psychotic disorders were not ranked as low priority and, whereas in 1979 only one-half of trainees had thought that mental handicap was im portant we found that three-quarters now rated this as important.Despite this finding only one-quarter of respondents considered that mental handicap experience was adequately available.In addition an adequate experience of developmental disorders (including autism) was only reported by 42% of trainees, even though it was considered by most trainees to be important.

Therapeutic methods
Attitudes towards therapeutic methods are shown in Table II.As in 1979 family therapy remained very popular, but by contrast to 1979, consultation to both paediatricians and to schools was considered important by nine out of ten trainees.It can be seen that the therapeutic approach was eclectic with a high level of interest in a range of therapeutic methods.Marital therapy has suffered a reduction 613 Not surprisingly, trainees rated supervision of a number of different therapies as important.In rank order there were; family therapy, consultation, psychodynamic therapy, behaviour therapy and drug therapy.As in 1979 there was a discrepancy between the importance accorded to such supervision and its perceived availability.It is of interest to note that the perceived importance of supervision of drug therapy has risen, and that the availability of supervision has risen in all areas except behaviour therapy.
Opportunities to teach other psychiatrists and medical students were considered to be important and were available to two-thirds of respondents.Only one-quarter of the trainees thought that super vision of their teaching of others was adequately available.While research time and supervision were considered to be essential by over 90% of respon dents, almost one-half thought supervision to be inadequate.

Representation
Most respondents (94%) claimed to know about the functions of CAPSAC, and most (80%) were aware of comments from the last visiting team.Only 5 of the 17 part-timers knew that informal advice about part-time training is available from a member of CAPSAC.A majority of trainees did not know who their representatives were on the Collegiate Trainees Committee.

Comment
This is an incomplete survey as the response rate was only 65%.The fact that senior registrars regularly move post on the rotation and leave to take up consultant appointments is a partial explanation of this figure, which is nevertheless comparable with the earlier study of Garralda et al (1983).The questions asked were about the training scheme, not the trainee's particular post, and it is therefore likely that our replies refer to the majority, if not all training schemes.However, with anonymous replies this remains uncertain.
The proportion of female trainees has increased and this is only partly accounted for by part-time training recommendations introduced by the DHSS in circular PM(79)3 which have been implemented in most regions (Collegiate Trainees Committee, 1987;Gath, 1988).Almost all trainees taking up this scheme are women and because training is part-time it takes longer than four years.
It is surprising that the number of trainees with a year's paediatric experience has dropped by onethird, especially in light of the importance attached by trainees to paediatric liaison.This fall has not been matched by an increase in trainees with a brief paediatric experience, only a further six trainees had completed six months in paediatrics.Registrar and SHO posts are increasingly linked to specialist train ing rotations and it is becoming more difficult for future child psychiatrists to find posts where they can do 6-12 months of paediatrics.One of the benefits of Achieving a Balance (DHSS, 1986) may be that trainees can obtain a more varied experience at senior house officer level.It is encouraging that more trainees have published papers.
There have been considerable changes since 1979 concerning where the trainees spend the bulk of their time.The move from child guidance clinics to hospi tal out-patient departments probably reflects chang ing clinical practice.The move out of in-patient units most likely results from the view that, although inpatient units have many resources, they are not the best places for trainees to receive the bulk of their training, since most will go on to provide mostly out-patient services at consultant level.The mean number of clinical contracts might seem low, at 12 per week, but it must be remembered that trainees only have seven sessions for clinical work and that a good proportion of this time is spent in consultation and other forms of indirect contact.Nevertheless, there is a wide range of clinical contacts per week, suggesting that some trainees are underworked and others overworked.It is encouraging that all trainees said they were able to take two sessions a week for research as per JCHPT requirements.
It is of concern that one-quarter of trainees received less than one hour of supervision per week.This is unacceptable by CAPSAC standards and of itself should warrent removal of accreditation from the training scheme, unless rectified.Also of concern is the reported wide range of formal teaching provided, with some trainees receiving very little.Although

Boots and Cottrell
satisfaction with tutors was reported to be good, most trainees did not receive regular feedback.It would seem to be uncertain whether tutors have taken on this possibly useful, but certainly difficult role.
In the last nine years, it is notable that there has been a change in attitude towards psychosis, mental handi cap and other developmental disorders.That these are now seen as more important and that nothing is seen as less important, suggests trainees have a broader view today of what constitutes child psychiatry.Un fortunately, as nine years ago, availability of experi ence does not match up to interest.This is particularly so with respect to mental handicap where only onequarter of trainees feelthey have adequate experience.
As CAPSAC now states that experience of working with children with mental handicap is a mandatory training requirement, this suggests either that come schemes do not meet these requirements or that ex perience acceptable to CAPSAC seems inadequate to trainees.There are clearly problems with providing training in this area -if an under-developed service exists (as is often the case for children with mental handicap and psychiatric disorder) who is to train the trainee?A Joint Working Party has recently made recommendations concerning this important area (Joint Working Party, 1989).
The major change in therapeutic activity, aside from the generally more eclectic approach men tioned earlier, is the growth in perceived importance of consultation.The decrease in rated importance of marital therapy is interesting -this may now be seen as part and parcel of family therapy, or it is possible that there are greater opportunities for child psy chiatrists to refer on couples with marital difficulties, leaving the child psychiatrist to concentrate on the child and/or family.Behaviour therapy continues to be seen as relatively unavailable.Given the proven relevance of this therapeutic modality to certain child and adolescent disorders, this is an area which needs urgent attention.
Availability of specific supervision has generally improved since 1979 although there are still signifi cant numbers of trainees who feel inadequately supervised in a number of therapies.Availability for supervision in behavioural therapy has actually dropped.
The supervision of teaching and research were both considered to be grossly inadequate.This has serious implications for the way the profession is presented to others and for the future development of practice.Although over the past nine years CAPSAC's standards have risen, it would seem that trainees' expectations have risen even higher.The question arises, as to what, or who makes a good supervisor; should trainees be getting more training techniques of supervision so that they will be better equipped as trainers of the future?Who trains the trainer?One possible explanation for trainees' high expec tation is the widespread knowledge of the role and function of CAPSAC and of the higher training re quirements.It was disappointing however, that given the College's encouragement of junior doctor rep resentation at all levels, so few trainees were aware of their representatives on the Collegiate Trainees Committee.
In conclusion, it would seem that today's trainees are more eclectic, more research orientated and more community based.They are willing to see a larger range of clinical problems but lack training oppor tunities in some of these areas.They do not yet feel adequately supervised, although this has improved over nine years.We suggest that another similar sur vey is carried out in about five years to indicate changes over that period.We also hope that a par allel survey of the trainers for each scheme will be carried out in the near future.