The ANZJP and child psychiatry

Historically, the Australian and New Zealand Journal of Psychiatry (ANZJP) has been an important forum for those child psychiatrists with academic aspirations to test their scholarly and writing skills. I clearly remember a scathing early review from an early editor, when I naively thought that the editor would correct errors and appropriate journal style. Hopefully, I learnt fast. My most cited article could still be: ‘The dopamine theory of attention deficit hyperactivity disorder ([ADHD], [Levy, 1991])’. To my mind this publication illustrated at least two important ANZJP strengths, namely the willingness to publish a theoretical article (though it was based on clinical, animal and neuropharmacological studies), written by a local child psychiatrist – unknown at the time. In some ways, this set the basis for the rest of my academic career.

I suspect that Michael Sawyer’s career might reflect a similar trajectory after the publication of ‘The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being’ (Sawyer et al., 2001). This key publication provided vital information about the size of the Australian child and adolescent mental health problem and the struggle to provide adequate services. It was one of the first national studies of this kind and set the scene for service developments over the next decade. Interestingly, a previous ANZJP editorial written by Scott Henderson had drawn attention to the lack of adequate epidemiological studies of the adolescent age group. Though the use of psychiatric services of 5.6 per thousand was similar to that of adults, he found that ‘the conclusion to be made from these data is that turmoil there may be, but there is no excess of formal mental illness reaching the psychiatrist’.

In this regard, the recent second Australian survey has provided important findings of the size of the problem and the continuing struggle to provide adequate services. Zubrick et al. (2016) discussed suicidality data from the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Of the approximately 5600 young people who participated up to 7.5 percent of 12- to 17-year-olds reported suicidal ideation, and 2.4 percent or 41,400 had attempted suicide. Importantly, the presence of a mental disorder was the largest significant association with suicidal ideation or self-harm. This raises the question of a possible ‘epidemiological transition’ or secular trend. But whether the current flood of adolescents presenting to Accident and Emergency is best understood in terms of social vs psychiatric aetiologies, there is no denying that the demand for these services has steadily increased.

Perhaps an equally important Journal role has been the airing of important controversies and debates related to child psychiatry. At the controversial level, I clearly remember the excitement and indignation stirred by Neil McConaghy’s (1979) article ‘Maternal deprivation: when will its ghost be laid?’ McConaghy claimed that the hypothesis that early separation from a maternal figure resulted in later mental health problems had been widely accepted but did not meet the requirements of scientific methodology, and did not allow for the effects of heredity and environmental disadvantage. He also claimed that ‘as advanced, Bowlby’s attachment hypothesis is so vaguely stated it will explain anything and predict nothing’. The article prompted a vigorous response from Eisen and others. Fortunately, more recent epigenetic studies and reviews such as Curley and Champagne (2016) have highlighted the epigenetic influence of maternal care on the developing brain, including sex-differences in effects and sensitive periods – probably settling the debate. It would appear that the interplay of nature/nurture is quite complex and includes both the effects of maternal stress during pregnancy as well as chromosomal epigenetic effects. Nevertheless, it was important to pose the question and this is an approach the Journal has continued to champion – especially more recently.

While the ‘longest’ debate in relation to the use of stimulant medications for ADHD has also aroused passions in protagonists on both sides of the argument, the Journal remains an important publication site in which reasoned discussion can occur. Given the increased availability of tailored long-acting and skin patch administration of dopaminergic and noradrenergic formulations in the United States, where the psychopharmacological culture, and much greater number of clinical and academic child psychiatrists differs from our small Australian Faculty, it is important that local research and practice has an academic voice. The pros and cons of child psychopharmacological approaches can be argued, but the relatively small size of the Faculty and the relatively large need for adolescent and child services makes the task of child and adolescent clinical academia both difficult and challenging. In this context, it should be pointed out that unlike the United Kingdom and the United States, there is no child psychiatry journal in Australia and New Zealand, though the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Faculty of Child & Adolescent Psychiatry has publishes newsletters. Child psychiatry both benefits and loses from the RANZCP structure where priorities are largely directed to adult and adolescent issues, often leaving the ‘non-voting’ pre-pubertal population under-represented.

If I reflect about differences between the Journal of 1975 and the present I am reminded of a published address by Professor David Maddison given at the first Pacific Congress of Psychiatry entitled ‘Take me to your leader: The psychiatrist in the Health Care system’. Maddison used an analogy based on A.A. Milne’s ‘Winnie the Pooh’. Christopher Robin leads Pooh, a social worker and conscience of the group, and Rabbit, an administrator, as well as Piglet and others, on an expedition to discover the North Pole. When Roo falls into a stream, Pooh rescues him with a long stick, at which point Christopher Robin, the community (child) psychiatrist, pronounces that Pooh has found the North Pole, and sticks the pole in the ground, with a message ‘North Pole: Discovered by Pooh: Pooh discovered it’.

While the Journal of today may be somewhat more formal, child psychiatry may still be seeking its North Pole, and hopefully the Journal will continue in its above roles.