I have been a grandfather for only 13 years, but for 37 years I have lived a grandparent's
dream: people pay me to tell them how to raise their children. This is only one of
the many rewards child and adolescent psychiatry has offered me. Table 1 lists some
more of them.
Table 1
Why I Like Being a Child and Adolescent Psychiatrist
• Growth and development heal many things that the doctor can take credit for
• Patients seldom die
• Privilege of seeing children improve and watching young success
• Acceptance into the family's emotional life
• Wide options for specialization; lots of ways to make yourself useful, which is
good for the doctor's self-esteem
• Chance to be a role model, which is also good for doctor's self-esteem
• Chance to be confronted by precocious sages, which is good for doctor's humility
• Chance to witness parental heroism, which is also good for doctor's humility
• Interesting cocktail-party observations of new acquaintances when they ask your
occupation (also good for the doctor's humility)
• Continual learning, whether you want it or not
Probably the greatest satisfaction in child psychiatry is the wide selection of options
for specialization: psychotherapy, psychopharmacology, nutrition, biochemistry, genetics,
family therapy, parent guidance, custody and visitation advice, epidemiology, disorder
specialization, research, consultation, public education and best of all, the chance
to integrate it all and play at being a comprehensive physician. The myriad challenges
provoke learning and continued development that keep one young at heart and mind.
Sometimes I think I should pay to practice child psychiatry.
It should be obvious by now to even the casual reader that I enjoy the privilege of
being a child and adolescent psychiatrist and that enjoyment manifests in a playful
attitude. That playful attitude includes not taking myself too seriously. In fact,
I'm proud of my humility! It was earned at the expense of repeated humbling experiences
in two ways:
Confronting tragic situations that I could not help, where all my education, training,
experience and brilliant diagnostic insight seemed useless; and
Witnessing real heroism by some parents who struggle with sick children's difficult
problems without complaining and with indefatigable hope. They outshine any professional
pretensions of mine. By showing me my limitations and forcing me to compare myself
to patients and parents (and occasional colleagues) of superior moral caliber, child
psychiatry has made a better, more honest person of me and for this I'm grateful.
On the other hand, there is the mind-blowing exhilaration of watching a child improve
after some prescription, potion or psychotherapeutic intervention and being allowed
to believe that I had something to do with the improvement. The healing power of nature
is truly a marvel to behold. Even more marvelous is being allowed to be a party to
it, to enjoy the privilege of assisting that mysterious healing power. The experience
is doubly gratifying, because in child psychiatry we have the privilege of helping
two (or more) people in tandem: the child and the parent who was suffering with his/her
child. It is almost as much pleasure to watch the parents’ spirits soar as the child
improves, as it is to watch the child improve. I have often said that in stimulant
studies of attention-deficit/hyperactivity disorder, I can break the blind by looking
at the mother's face at a return appointment:…” if she looks tired and discouraged,
it's placebo; if she smiles and looks happy, it's active drug.
Child psychiatry has offered a constant learning experience, not only from the rapid
expansion of knowledge in the field, but from contact with children, parents, students,
residents, colleagues, interdisciplinary clinical teams, multi-site research teams
and most recently, from email questions from the public about an article I had not
previously seen.
However, I soon learned that there are many useful things no one will teach me because
no one yet knows. In trying to find new answers to unanswered questions, I was seduced
into research and now enjoy child psychiatry even more. In clinical treatment research,
I can enjoy all the advantages of clinical practice (without the need for insurance
paperwork) and in addition experience the thrill of data analysis. Analyzing the data
is like opening a surprise package, like unwrapping a Christmas present: you don't
know what you're getting; you may be hoping for a certain thing, but have no assurance
that's what you will get. Sometimes it's a lump of coal, but even that you can use
to light the fire for the next study.
The fact that we are dealing with growing, developing organisms should direct our
attention to the building blocks for that growth/development: nutrients. One of my
pleasures has been to participate in research on nutritional aspects of child psychiatry.
Equally gratifying is to participate in efforts to make such interest and research
respectable. The implicit double standard about drugs and psychosocial treatments
on the one hand and nutrition and other complementary considerations on the other
seems to make many intelligent colleagues reluctant to acknowledge any interest in
this area. The discovery of closet nutritionists after boldly speaking out on the
subject has been a repeated joy.
The experience of observing nature's healing power, coupled with the interest in research,
has led me to a great interest in placebo/Hawthorne effect. I'm fascinated by the
fact that this no-risk treatment can produce an improvement, depending on the disorder,
that is a tenth to twice as much as active medication. For example, if an antidepressant
has a 60% response rate and placebo 40% response rate, then the pharmacological effect
is 20% response, the difference. In this case, the placebo effect is twice as strong
as the pharmacological effect and when you give an antidepressant, 2/3 of the effect
is placebo. This is why witch doctors, shamans and charlatans thrive: in the example
given, they can be 2/3 as effective as the most expert allopathic psychiatrist. We
need to understand this effect better: how much of it is real improvement, how much
statistical regression to the mean, how much rater expectation, etc.? Mastery of placebo
effect for the good of our patients is particularly important in child psychiatry
because children are subject to two sets of expectations: their own and their parents’
and they are probably more sensitive to the expectation matrix than adults are. We
should strive to be good witch doctors as well as good psychotherapy technicians,
pharmacologists and nutrition experts. I can proudly (and humbly) say that I've become
the best witch doctor I can be.
And that's what child and adolescent psychiatry means to me.
About the Author
L. Eugene Arnold, M.Ed, M.D. is Professor Emeritus of Psychiatry at Ohio State University,
where he was formerly director of the division of child and adolescent psychiatry
and vice-chair of psychiatry. He graduated from Ohio State University College of Medicine
magna cum laude, interned at University of Oregon, took residencies at Johns Hopkins,
where he earned the M.Ed. and served in the U.S. Public Health Service. He is a co-investigator
in the OSU Research Unit on Pediatric Psychopharmacology. He has over 37 years’ experience
in child psychiatric research, including the multi-site NIMH Multimodal Treatment
Study of Children with ADHD (“the MTA”), for which he continues as executive secretary
and current chair of the steering committee. A particular interest is alternative
and complementary treatments for ADHD. His publications include 9 books, 55+ chapters
and 150+ articles.