“Avoid the ideologies that seek to avoid the use of empirical evidence.” Sir Michael Rutter

Opening of the ESCAP 2009 Budapest Congress by Sir Michael Rutter

Child and adolescent psychiatry: past and future in a new Europe

ESCAP 2009 Congress in Budapest, Hungary: opening lecture by Sir Michael Rutter (UK) – “Child and Adolescent Psychiatry: past and future in a new Europe”. Chaired by P.A. Rydelius (Sweden), 22 August 2009, 19:00 at the Budapest Congress & World Trade Center.

The origins of child guidance clinics in the first half of the 20th Century will be noted with respect to their multi-disciplinary emphasis, their child welfare approach and their focus on environmental causes. Thereafter, the history of research into, and services to deal with, child and adolescent psychopathology will be reviewed under several different headings. These will include diagnostic distinctions; the use of epidemiology to plan services and to study risk factors; establishment of value of longitudinal studies; the development of systematic training programmes; the establishment of the value of developmental psychopathology; the development of focused psychological therapies using problem-solving strategies; the use of pharmacological treatments; the use of randomized controlled trials; the recognition of the importance of genetic influences and of gene-environment interdependence; understanding of the role of cognitive processes in social functioning; the recognition of the influence of social contexts; the development of ‘natural’ experiments as a way of testing hypotheses on environmental causes; the damaging effects of antiscience ideologies; and the misleading claims of biological determinism.

Against this historical background, a selective overview will be undertaken of some of the key opportunities and challenges, and some of the hazards and concerns. With respect to research, clearly a range of strategies need to be employed to tackle a diverse variety of issues, but there are several especially promising areas that warrant priority. Psychosocial researchers need to take seriously the challenge of testing for environmental mediation; in that connection the use of ‘natural experiments’ is particularly important.

Psychosocial research also needs to determine the biological basis of effects that persist beyond the exposure to stress/adversity; that is the question of how environments ‘get under the skin’. Epigenetic and biological programming effects are likely to be crucial but mental models must also be examined.

There is also the parallel issue of how genes’ get outside the skin’ through genetic effects on environmental exposure and environmental susceptibility.

Experimental studies, combining structural and functional brain imaging with genomics, in order to determine the biological pathways involved, carries the rich potential of showing how both genes and environments bring about their effects. Animal models are also an essential part of the research agenda. Both human and animal research needs to use intermediate phenotypes in order to study neural effects. Longitudinal studies of high risk groups should enable identification of the processes involved in the transition across developmental changes in psychopathology (such as from the broader phenotype of autism to the traditional handicapping condition, or from the prodromata of schizophrenia to a schizophrenic psychosis). Studies of treatments (both psychological and pharmacological) will need to test for the mediators of efficacy and the causes of individual differences in response. Age differences in response to drugs and to major hazards were shown some thirty years ago, but the mechanisms involved remain to be established.

With respect to problems and concerns, there is the need to avoid the ideologies that seek to avoid the use of empirical evidence. That applies as much to pharmacological evangelism and biological determinism as to psychoanalysis, family therapy and attachment theory. As Eisenberg put it, there are the twin dangers of brainless psychiatry and mindless psychiatry. We need to welcome the role of industry in scientific progress but we have to guard against the biases and control (as well as the secret greed) that may come in with the tide. Training based on a single treatment method is undesirable and this applies now to the unthinking extension of CBT as it did in the past to psychoanalytic individual psychotherapy. Finally, attention needs to be drawn to the fact that with some very notable exceptions, child and adolescent psychiatrists, particularly in Europe, have played a rather minor role in the major areas of innovative research. Adult psychiatrists and developmental psychologists have increasingly taken leadership. There is much that is good in both child/adolescent psychiatry research and clinical services, but there are important weaknesses that require remedial action.