H. Remschmidt . H. van Engeland (Eds.) Child and Adolescent Psychiatry in Europe

H. Remschmidt H. van Engeland Editors

Child and Adolescent Psychiatry in Europe Historical Development Current Situation Future Perspectives

fI) STEINKOPFF , Springer

Editors' addresses:

Prof. Dr. Dr. H. Remschmidt Univ.-Klinik ffir Psychiatrie und Psychotherapie des Kindes- und Jugendalters Klinikum der Philipps-Universitat D-35033 Marburg Germany

Prof. Dr. H. van Engeland Department of Child & Adolescent Psychiatry University Hospital Utrecht P.O. Box 85500 NL-3508 GA Utrecht The Netherlands

Die Deutsche Bibliothek - CIP-Einheitsaufnahme

Child and adolescent psychiatry in Europe I H. Remschmidt ; H. van Engeland ed. - Darmstadt: Steinkopff; New York: Springer, 1999 ISBN-13: 978-3-642-96005-5 e-ISBN-13: 978-3-642-96003-1 001: 10.1007/978-3-642-96003-1 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broad­casting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from SteinkopffVeriag. Violations are liable for prosecution under the German Copyright Law.

© by Dr. Dietrich SteinkopffVeriag GmbH & Co. KG, Darmstadt 1999

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Preface

The intention of this book is to provide an overview of child and adolescent psychiatry in Europe, focusing on the historical development, current situation, and future perspectives of the specialty.

Child and adolescent psychiatry is now acknowledged as a medical specialty or subspecialty in almost all European countries. Also, the number of child psychia­trists has increased dramatically over the last decade. However, there are still enormous differences from country to country, not only with regard to the num­ber of specialists, but also with regard to the extent and nature of services provided and their diagnostic and therapeutic orientation. Furthermore, important differ­ences exist in the training curricula for child and adolescent psychiatry within medicine and other professional fields, both inside and outside the universities, and in the image and importance of this discipline to the public.

This diversity is also reflected in the reports on the historical development, current situation and future perspectives of child and adolescent psychiatry in 31 European countries, all following the same structure in order to facilitate compa­rability. This structure comprises (1) the historical development and the current situation, (2) classification systems and diagnostic and therapeutic methods, (3) structure and organization of services, (4) cooperation with other medical and non-medical disciplines, (5) training and continuing medical education, (6) research, and (7) future perspectives.

After the fall of the iron curtain, the situation of states in Eastern Europe has changed remarkably. This has also influenced the development and structure of child and adolescent psychiatry in Eastern European countries. We have tried to include as many of these countries as possible.

We hope that this volume whose publication date coincides with the 11 th Inter­national Congress of the European Society for Child and Adolescent Psychiatry (ESCAP) will support the aims of this society laid down in the ESCAP constitution:

~ to foster the European tradition of child and adolescent psychiatry, ~ to facilitate and extend the bonds between physicians practising child and

adolescent psychiatry in European countries, ~ to spread the results of research and experience in this branch of medicine by

publishing reports and organizing scientific conferences and meetings, and ~ to collaborate with international organizations with the same or related aims.

Accordingly, we hope that this volume will make a substantial contribution to the development of an empirically based child and adolescent psychiatry in Europe and facilitate cooperation between countries.

Our thanks and appreciation go to our colleagues for their enthusiasm in writing about their countries, to the staff of Steinkopff Publishers and -last but not

VI Preface

least - to Dipl.-Psych. Johanna Schneider, Dr. Peter M. Wehmeier, Dipl.-Psych. Monika Becker, and Dr. Helen Crimlisk, who carried out the editorial work with great prudence.

Helmut Remschmidt President of ESCAP

Herman van Engeland Past President of ESCAP

Contents

Preface.......................................................................... V

Introduction ..................................................................... XIII

Child and adolescent psychiatry in Austria ...................................... . M. H. Friedrich

Child and adolescent psychiatry in Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 J.-p. Matot, B. Verbeeck,J.-Y. Hayez

Child and adolescent psychiatry in Bulgaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 M. Achkova, N. Polnareva

Child and adolescent psychiatry in Croatia ....................................... 41 S. NikoliC, V. Rudan, V. Vidovic

Child and adolescent psychiatry in the Czech Republic ........................... 55 E.Mala

Child and adolescent psychiatry in Denmark. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 P. H. Thomsen

Child and adolescent psychiatry in Estonia....................................... 81 J. Liivamagi

Child and adolescent psychiatry in Finland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 J. Piha, F. Almqvist

Child and adolescent psychiatry in France. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 P.Jeammet

Child and adolescent psychiatry in Germany ..................................... 117 H. Remschmidt

Child and adolescent psychiatry in Greece ....................................... 137 J. Tsiantis, S. Beratis, E. Tsanira, G. Karantanos

Child and adolescent psychiatry in Hungary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 A. Vetr6

Child and adolescent psychiatry in Iceland ....................................... 165 H. Hannesd6ttir

Child and adolescent psychiatry in Ireland ....................................... 175 P. McCarthy

Child and adolescent psychiatry in Italy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 E. Caffo

VIII Contents

Child and adolescent psychiatry in Latvia ........................................ 197 A. Kishuro

Child and adolescent psychiatry in Lithuania. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 D. Puras

Child and adolescent psychiatry in Luxembourg ................................. 213 C. Frisch-Desmarez

Child and adolescent psychiatry in the Netherlands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 H. van Engeland

Child and adolescent psychiatry in Norway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Ingrid Spurkland, Inger Helene Vandvik

Child and adolescent psychiatry in Portugal M. J. Vidigal, C. Marques, A. Matos

249

Child and adolescent psychiatry in Romania ..................................... 261 T. Mircea

Child and adolescent psychiatry in Russia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 A. A. Severny, Y. S. Shevchenko, B. A. Kazakovtsev, L. V. Kim

Child and adolescent psychiatry in Serbia .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 V.lspanovic-Radojkovic. N. Tadic

Child and adolescent psychiatry in Slovakia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 J. Pecenak

Child and adolescent psychiatry in Slovenia . ........... : . . . . . . . . . . . . . . . . . . . . . . . . . 313 M.Tomori

Child and adolescent psychiatry in Spain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 J. L. Pedreira-Massa, J. L. Alcazar, J. T. i Vilaltella

Child and adolescent psychiatry in Sweden ...................................... 351 K. Schleimer

Child and adolescent psychiatry in Switzerland .................................. 363 D. BUrgin, W. Bettschart

Child and adolescent psychiatry in Ukraine ...................................... 381 M. Levinsky, S. Aksentyev

Child and adolescent psychiatry in the United Kingdom. . . . . . . . . . . . . . . . . . . . . . . . . . 395 P. Hill

Authors' addresses

Prof. Dr. Dr. Meglena Achkova Alexandrovska University Hospital 1 Georgi Sofiisky Str. BG-1431 Sofia Bulgaria

Prof. Dr. Dieter Burgin Kinder- und jugendpsychiatrische Universitatsklinik u. -poliklinik Schaffheuserrheinweg 55 CH-4058 Basel Switzerland

Prof. Dr. Ernesto Caffo Clinica Psichiatrica Cattedra di Neuropsichiatria Infantile Via del Pozzo 71 1-41100 Modena Italy

Prof. Dr. Herman van Engeland Dept. of Child and Adolescent Psychiatry University Hospital Utrecht P.o. Box 85500, NL-3508 GA Utrecht The Netherlands

Prof. Dr. Max H. Friedrich Universitatsklinik filr N europsychiatrie des Kindes- und Jugendalters Wahringer Gurtel18-20 A-1090 Wien Austria

Dr. Christine Frisch-Desmarez Psychiatrie pour Enfants et Adolescents 36 rue Tony Neumann L-2241 Luxembourg Luxembourg

Dr. Helga Hannesd6ttir Dept. Child and Adol. Psychiatry Skipholti 50 IS-lOS Reykjavik Iceland

Prof. Dr. Peter Hill Department of Psychological Medicine Great Ormond Street Hospital for Children UK-London WC1N 3JH United Kingdom

Dr. Veronika ISpanovic-Radojkovic Institute for Mental Health Palmoticeva 37 YU-11000 Beograd Serbia

Prof. Dr. Philippe Jeammet Institut Mutualiste Montsouris 42, Bd. Jourdan F-75014 Paris France

Dr. Aigars Kishuro State Mental Health Care Centre Raina bulvaris 27 LV-1359 Riga Latvia

X Authors' addresses

Dr. Michael Levinsky Rehabilitation Center for Children with Disability 51, Pushkinskaya str. UA-2700l Odessa Ukraine

Dr. Juri Liivamagi University of Tartu Dept. of Cild & Adolescent Psychiatry 31 Raja Street EE 2400 Tartu Estonia

Dr. Eva Mala Psychiatric Clinic University Hospital Vlivalu84 CZ-Praha 5 - Motol, 150 05 Czech Republic

Prof. Dr. Jean-Paul Matot Universite libre de Bruxelles Service de Sante Mentale PsyCampus 50 avo F.-D. Roosevelt CP 184 B-1050 Bruxelles Belgium

Prof. Dr. Paul McCarthy Dept. of Child and Adolescent Psychiatry, St. James Hospital James Street IRL-Dublin 8 Ireland

Prof. Dr. Dr.Tiberili Mircea University of Medicine and Pharmacy Timisoara Str. Tarnava no. 2 RO-1900 Timisoara Romania

Prof. Dr. Dr. Stanisa Nikolic Clinic for Psychological Medicine Kispaticeva 12 Rebro-KBC RH -10000 Zagreb Croatia

Dr. Dr. Jan PeceMk Department of Psychiatry University Hospital Mickiewiczova 13 SK-81369 Bratislava Slovakia

Prof. Dr. Jose-Luis Pedreira-Massa Child and Adolescent Psychiatry Unit (SESPA) E-33400 Aviles (Asturias) Spain

Prof. Dr. Jorma Piha University of Turku Dept. of Child Psychiatry SF-20520 Turku Finland

Dr. Dr. Dainius Puras National University Hospital Child Development Center Vytauto 15 2004 Vilnius Lithuania

Prof. Dr. Dr. Helmut Remschmidt Univ.-Klinik fur Psychiatrie und Psychotherapie des Kindes- und Jugendalters Klinikum der Philipps-Universitat D-35033 Marburg Germany

Dr. Kari Schleimer Dept. Child & Adol. Psychiatry Malmo University Hospital S-20502 Malmo Sweden

Prof. Dr. Anatoly A. Severny 23,18/15 Grusinskyval. RUS-123056 Moscow Russia

Dr. Ingrid Spurkland National Center for Child and Adolescent Psychiatry Sognsvannsvn. 53-67 Postbox 26 Vinderen N-0319 Oslo Norway

Dr. Per Hove Thomsen Child & Adolescent Psychiatric Hospital Dept. of Research Harald Selmersvej 66 DK-8240 Risskov Denmark

Prof. Dr. Dr. Martina Tomori University of Ljubljana Zaloska C. 29 SLO-l105 Ljubljana Slovenia

Authors' addresses XI

Prof. Dr. John Tsiantis Athens University Medical School Department of Child Psychiatry Aghia Sophia Children's Hospital Dept. of Psycholog. Pediatrics Thivon and Levathiasstr. GR-11527 Athens Greece

Prof. Dr. Agnes Vetro Szent-Gyorgyi Albert Med. University Szemmelweisz u. 6 H-6721 Szeged Hungary

Dr. Maria Jose Vidigal Clinica Infantil Pavilhao 25 P-1700 Lisboa Portugal

Introduction

H. Remschmidt, H. van Engeland, J. Piha

1. Historical development

The discipline of Child and Adolescent Psychiatry is now acknowledged as a medical specialty or subspecialty in almost all European countries and throughout the world. It has its roots in the neighbouring disciplines of neurology, psychiatry, pediatrics, and psychology among others. Those working in the field have learned in recent decades that interdisciplinary co-operation is an absolute necessity for scientific and clinical progress.

The historical development of the discipline of Child and Adolescent Psychiatry varies across Europe. Since the beginning of the century, however, four traditions have made substantial contributions to the current body of knowledge, as well as to the orientation of child psychiatric institutions. These traditions are still evident and influential today.

... The neuropsychiatric tradition. This goes back to the formerly unified disci­plines of psychiatry and neurology. This tradition remains influential in Ger­many, and was also a significant feature in France, Italy, and in many Eastern European countries. Several scientific associations still include reference to neu­rology, such as the Association of Child and Adolescent Neuropsychiatry (Aus­tria), Neuropsichiatria Infantile (Italy), and the Developmental Age Neurology and Psychiatry (Serbia). This tradition has more recently been extended in some countries to embrace substantial contributions from neuropsychology.

... The remedial clinical tradition (heilpadagogisch-klinische Tradition). This movement started in Austria and Switzerland, promoted by Hans Asperger in Austria and Paul Moor in Switzerland. The approach was later continued as the so-called psychosomatic tradition in pediatrics and still plays a major role in childrens' hospitals with departments of child psychosomatics.

... The psychodynamic-psychoanalytic tradition. This tradition evolved mainly in Western Europe and was developed from the work of Sigmund Freud, Anna Freud, Alfred Adler, Melanie Klein, Rene Spitz, and other pioneers of psycho­analytic work with children.

... The empirical, epidemiological, and statistical tradition. This has emerged over recent years in a number of European countries, with a strong focus in England, Scandinavia, Germany, and Switzerland. It has been strongly influenced by Michael Rutter's work in England and also from research impulses from the United States.

It is important to realize that these traditions of research and clinical practice did not evolve successively, but rather, simultaneously. There has, however, been a

XIV Introduction

swing in recent years toward the empirical approach, particularly focusing on the biological aspects of child and adolescent psychiatry.

All countries in Europe have set up national organizations, although these have different orientations and functions. In most countries, those working with children and adolescents are represented by one body. An exception is Finland, where the associations for adolescent psychiatry and child psychiatry exist as separate entities.

The first symposium of European child psychiatrists took place October 30-31, 1954 in Magglingen/Switzerland. At this meeting, the first attempts were made to establish a unifying scientific association. The official foundation of the Union of European Pedopsychiatrists occurred in 1960 at the first European congress in Paris. Further congresses were held in Rome (1963), Wiesbaden (1967), Stockholm (197l), Vienna (1975), Madrid (1979), Lausanne (1983), Varna (1987), London (1991), Utrecht (1995), and Hamburg (1999). The name of the society was changed following a decision at the congress in Madrid from the Union of European Pedo­psychiatrists (UEP) to the European Society for Child and Adolescent Psychiatry (ESCAP).

The history of Child and Adolescent Psychiatry in the different countries is described in the following chapters, all of which start with a historical perspective.

2. Current situation

The number of child psychiatrists has dramatically increased over the last decade in nearly all European countries. The current situation in the 31 European countries described is shown in Table I, which shows data on the professional and scientific organizations, the departments of child psychiatry, the number of child psychia­trists, and population data for each country. It can be seen that there is a long tradition of Child and Adolescent Psychiatry beginning in France (1937) and Germany (1940). As far as the number of university departments is concerned, France also holds the top position (n = 33), followed by Germany (n = 26) and Italy (n = 24).

Provision of services varies widely across Europe. This is also demonstrated in Table I, which shows the ratio of child and adolescent psychiatrists to the popula­tion under the age of 20 years. Using this as a measure of services, the best provi­sion is to be found in Switzerland (1: 5,300), followed by Finland (1: 6,600), France (1: 7,500), and Sweden (1: 7,700). It is also interesting to note that the proportion of the population under 20 also varies widely across Europe, the lowest rate being found in Italy (20 %) and Germany (21 %), and the highest rate in Ireland and Iceland (both 31 %), Slovakia (29 %), and Serbia (28 %).

The data in this table must be considered approximate and provisional. It has proved difficult to obtain reliable, comparable information about services and departments. Despite some reservations about the quality of the data, we still felt it was important and illuminating to include it here, as it reveals large differences in service organization and provision. Further details, including the special needs and problems of individual countries are elaborated upon in the specific chapters of this book. The prevailing impression is of considerable heterogeneity, with

Tabl

e 1.

Sur

vey

of th

e cu

rren

t situ

atio

n of

CAP

in 3

1 Eu

rope

an C

ount

ries

Cou

ntry

N

ame

of

Yea

r of f

ound

at.

Uni

vers

ity

Oth

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epar

tm.

MD

in C

P Po

pula

tion

Pers

ons

< 2

0 Y

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rson

s Pe

rs. <

20y

as

soda

t. de

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m. i

n CP

in

CP

(in 1

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'sl'

(in 1

,000

's)'

< 2

0 ye

ars

(%)

perM

Din

CP

1 A

ustri

a CA

Npl

1974

1

8 65

8,

134

1,85

9 23

28

,600

2

Belgi

um

CAP

1961

/76

4 (2

12)

19

300

10,1

75

2,38

5 23

8,

000

3 B

ulgar

ia CA

P 19

93

3 (O

chai

r)

9 46

8,

240

1,93

9 23

.5

42,0

00

4 C

roatia

CA

P 19

90

3 35

4,

672

1,12

5 24

32

,000

5

Czec

h Re

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CAP'

19

60

4 (O

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r) 13

11

6 10

,286

2.

524

24,S

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00

6 De

nmar

k CA

P' 19

53

4(1

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12

141

5,33

4 1,

263

23.6

9,

000

7 Es

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a CA

P'

1973

1

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1,42

1 37

2 26

18

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8

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CP

1956

5

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5ado

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6 5,

149

1,28

6 25

6,

600

9 Fr

ance

CP

19

37

33

120

2,00

0 58

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15

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25

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0 10

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man

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PP

1940

26

14

5 78

1 82

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17

,323

21

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11

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19

83

221

160

10,6

62

2,47

7 23

15

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gary

CA

P 19

90

7 55

10

,208

2,

499

24.5

45

,000

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80

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0 10

27

1 08

5 31

8,

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14 I

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CAP

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2

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3,61

9 I,

m

31

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15 I

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83

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0 16

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60

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998

27.7

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0 1

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15,7

31

3,80

0 24

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P 19

57

4 60

13

0 4,

420

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0 25

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21

Po

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l CA

P 19

89

0 99

9,

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2 24

24

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1992

10

20

0 22

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26.9

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92

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71

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a CP

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79

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nt

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2 47

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in

CAP

1978

17

20

0 39

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8)

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?:

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6

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) 24

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2 8,

887

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a a.

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315

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1

(2)5

40

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U.K.

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1971

16

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: Int

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2 C

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(197

9)

XVI Introduction

regard not only to the proportion of child psychiatrists, but also to the organisa­tion of departments and services, the structure of institutions and the research, training and continuing medical education which occurs within them.

3. Future perspectives

The countries which make up Europe are becoming ever closer; comparison, understanding the reasons for differences and the evaluation of disparate struc­tures is essential. The future development of the discipline of child and adolescent psychiatry has to be responsive to the changing needs of children and families. In addition, it must nurture an environment which facilitates good quality research, as well as high quality education for trainee and qualified psychiatrists and other mental health professionals.

While the chapters in this book reflect diversity rather than a homogeneous picture, it is nevertheless hoped that some goals for the future can be drawn from the data provided in this book:

.. Child and Adolescent Psychiatry must be integrated into the training curricula of medical students in every university in Europe. In order to achieve this, every medical faculty should establish a department for Child and Adolescent Psychiatry.

.. The training curricula for specialists in Child and Adolescent Psychiatry in Europe should be harmonized, giving trainees the opportunity to work in different countries and to exchange knowledge, as well as ideas. Within the European Union, the section of Child and Adolescent Psychiatry of the UEMS, as well as the ESCAP board, have taken the first steps in this direction. In the future, other European countries should be included in this process.

.. In comparison to other specialties, research in child and adolescent psychiatric disorders and child mental health in general has not been well supported or encouraged within Europe. The 5th framework of the BIOMED program of the European Union does not contain child mental health as a major area. It is, there­fore, vital that attempts be urgently made to bring these issues to the attention of the responsible bodies within Europe.

.. The structure and organization of services should be based on empirical grounds, using epidemiological data and modern methods of treatment evaluation and quality assurance.

.. Finally, the scientific communication within Europe should be facilitated by improving intra- and interdisciplinary communication. This can be achieved by means of scientific journals, European and international meetings and the setting up of a network of clinical studies, supported by countries both in- and outside the European Union.

In order to achieve these goals, a considerable joint effort will be required by all countries. The work involved will, however, be worthwhile, resulting not only in a good future for the discipline of Child and Adolescent Psychiatry, but also for the children and families whom we are trying to help.