History of Child Psychiatry in Utah
History of Child Psychiatry in Utah
By Merrit H. Egan, M.D. and Thomas A. Halversen, M.D.
Child psychiatry, conspicuously absent from Utah until the late 1940’s began at the Salt Lake County Hospital with the arrival of Leonard H. Taboroff, M.D., the first Director of the Division of Child Psychiatry, College of Medicine, University of Utah, and the first child psychiatrist in Utah. The establishment of the Utah Child Guidance Clinic, the initiation of traveling clinics to rural areas throughout Utah, and a consultation-liaison program with the University Department of Pediatrics soon followed. In 1949, the first pediatric resident rotated through the Division of Child Psychiatry initiating a close tie between pediatrics and child psychiatry in the College of Medicine which has persisted ever since.
With Dr. Taboroff’s untimely death, Frank Rafferty, M.D., the new Director of the Division of Child Psychiatry and C. H. Hardin Branch, M.D.. (then Chairman of the College of Medicine’s Department of Psychiatry) initiated the annual Dr. Leonard H. Taboroff Lectureship. During the 1950’s, the Division of Child Psychiatry continued the outpatient clinics, initiated an exemplary day treatment center, obtaining training accreditation from the American Association of Psychiatric Services for Children and acquiring a training grant from the National Institute of Mental Health. The first child psychiatry fellow began career training in child psychiatry on January 1, 1959.
Merritt H. Egan, M.D., a former Salt Lake City pediatrician assumed the directorship of the University Division of Child Psychiatry. Federal grants were subsequently obtained that permitted considerable expansion of training programs, both for career child psychiatry fellows and allied mental health professionals, the latter through an annual workshop. The consultation-liaison program with the University Department of Pediatrics was strengthened, a fact that has shaped the direction of child psychiatry in Utah ever since. The Primary Children’s Hospital started formal child psychiatry programs with the support of the University, the L.D.S. Church (then its owner) and dedicated hospital staff. In 1967, Paul L. Whitehead, M.D. became full-time Director of Child Psychiatry at Primary Children’s Hospital. He spearheaded establishment of school, day hospital, parent-education, inpatient and residential programs — the first comprehensive center for treatment of emotionally ill children in the Intermountain West. The hospital and the College of Medicine’s Division of Child Psychiatry on December 21, 1967 formally joined hands to augment child and adolescent psychiatric facilities and training — a monumental time for child psychiatry in Utah. The development of treatment and training facilities accomplished by the cooperation of these institutions had markedly changed the area’s child psychiatry diagnostic and treatment capacity, In 1975, separate accreditation of Primary Children’s Medical Center’s comprehensive child psychiatry program by the Joint Commission on Accreditation of Hospitals climaxed a decade of effort.
Major efforts were being expended elsewhere as well. Eugene Fox, M.D. established a new program for treating children separate from adults at the Utah State Mental Hospital and initiated other improved programs. Agnes M. Plenk, Ph.D. founded The Children’s Center in 1962 and has remained its Executive Director. Thomas A. Halversen, M.D. soon joined her as Medical Director. The Center has made major contributions to the treatment of emotionally disturbed preschoolers.
Child psychiatry came of age in Utah in the 1970’s.
Community mental health centers dominated the psychiatric expansion. P. Brent Petersen, M.D. became Medical Director of Children’s Services of the Salt Lake Community Mental Health Center. Adolescent Day Care, Children’s Behavior Therapy Unit, Adolescent Residential Treatment and Education Center, and many other programs made increasingly significant contributions to the treatment of mentally ill minors in the many community mental health centers that covered Utah.
In 1976, the LDS Hospital established an adolescent psychiatric inpatient and day treatment unit with Robert H. Burgoyne, M.D. as Medical Director.
Beginning with the Child Guidance Movement, allied mental health professionals, particularly child psychologists, social workers, recreational therapists and psychiatric nurses, were an integral part of the child and family treatment programs.
Recent years have witnessed a rapid increase of mental health practitioners in the private outpatient sector, supported in part by Utah law which precludes discrimination by insurance providers and supported by the increasing awareness of the large number of children and families needing treatment for emotional problems. Child psychiatrists play an important role in the private sector, but their growth in this area has not kept up with the need. There are 30,000 general psychiatrists in the United States and only 3,000 child psychiatrists though approximately one-half of the population falls within the child and adolescent category.
Greater emphasis on outpatient services and the greater availability of mental health practitioners has led to the development of more specialized services for unique populations. The Primary Children’s Medical Center has developed a Learning Problems Clinic to serve learning disabled and hyperactive children and their parents.
William M. McMahon, M.D., is the Director. The Children’s Behavior Therapy Unit of Salt Lake Community Mental Health Center provides highly specialized day treatment services to autistic children. In collaboration with an active parents organization, a residential treatment program was also begun there. The increasing awareness and high prevalence of sexual abuse of children has led to development of special treatment programs for victims and perpetrators at the Family Support Center, Primary Children’s Medical Center, Girl’s Village and other agencies in Utah. Parents United, a self-help organization, with strong voluntary support from mental health professionals, plays a vital role. The development of additional programs for children with affective disorders and eating disorders can be anticipated. Increasing attention to the rising costs of inpatient treatment will also lead to development of more day treatment and residential services as alternatives.
The Changing Clinical Picture
The growth of child psychiatric services in Utah has been paralelled by an increased understanding of child psychiatric disorders and improved treatment approaches. For example, childhood and adolescent depression was not even acknowledged in child psychiatry textbooks until after 1960. It is commonly recognized today, and its association with the rapidly escalating problem of adolescent suicide is a source of great concern. Family disruption, school failure, social isolation and the breakdown of communication are relevant psychologic issues. Genetic and biologic factors, however, are the subject of much research and clearly play a role. Antidepressant medication is often used in connection with individual and family therapy. Occasional cases of bipolar or manic depressive illness, a familial disorder, are recognized in adolescence and respond to treatment with lithium. The antecedents of this disorder are just beginning to be recognized amidst hyperactive and cyclic mood disturbances.
Whereas the child psychiatrist plays a more prominent role in the treatment of affective disorders, the opposite is true of infantile autism, an uncommon but very serious problem. Previously thought to be a consequence of lack of emotional attachment and faulty parenting, it is now recognized as a neurologic disorder with severe problems in social relatedness and language development. A comprehensive psychoeducational approach is recommended, including behavior modification and special education. Parent training is essential. The child psychiatrist plays a supportive but vital role. To this point medication has offered only symptomatic relief. Utah has received national attention as the site of a major genetic study into inheritance patterns of autism and is one of several sites of investigation into the use of fenfluramine in accelerating learning in autistic children.
Hyperactivity in children, by contrast, is a very common disorder of concern to all physicians who work with children. Because of its prevalence, it is estimated it affects approximately 5 percent of the population. It frequently leaves deep emotional scars secondary to the many failures experienced by these children at home, school and in the community due to their inattention, impulsivity and learning difficulties. The combined use of stimulant medication and child or family therapy has been accepted for many years. More recently we have become aware that problems with attention and impulse control may persist into the adolescent and adult years even though hyperactivity is diminished. Continued treatment is often necessary. University of Utah research child psychiatrist Paul H. Wender, M.D., has been a pioneer in the study and treatment of adult hyperactivity. More recently, concern has been raised that psychostimulant medications may occasionally induce movement disorders such as tics and Tourette’s syndrome. This is under investigation currently at Primary Children's Medical Center and elsewhere.
Another area of concern to all physicians is the physi- Lcally ill child. Stress related illnesses such as tension headaches and chronic or recurrent abdominal distress respond well to identification and reduction of stress and behavioral treatment approaches such as visual imagery and deep muscle relaxation. These techniques are also useful in children with chronic illnesses such as cystic fibrosis, bronchial asthma, diabetes and cancer where stress clearly compounds their symptoms. Self-hypnosis is a helpful adjunct with pain management. Family therapy with careful attention to issues of overprotectiveness, enmeshment or lack of role definition, and difficulties with problem solving and communication may be lifesaving.
The rapid increase in serious eating disorders has also served to bring child psychiatrists into a closer working relationship with their non-psychiatrist medical colleagues. Anorexia nervosa, though heavily shaped by current sociological attitudes and psychological conflicts, requires close medical collaboration and management to maintain adequate growth and nutrition, a fact made more evident by the increased awareness of life threatening late complications affecting neurologic, cardiovascular and gastrointestinal systems. Bulimia is also a source of concern but seems to more often afflict the older or college age adolescent.
Conduct disorders, especially those accompanied by antisocial behavior, remain of great concern to child psychiatrists and the community at large. The identification of learning disorders and attention deficit problems which are sometimes a part of this syndrome may lead to specific treatment approaches; however the common association with severe family disruption and multigenerational patterns of substance abuse require involvements of the extended family in treatment. Participation by schools is essential and placement outside the home is still required at times. This remains a major challenge for the future.
Thus we see that child psychiatry in Utah is in a state of rapid growth in all parameters. Since World War II a comprehensive delivery system has evolved including both the public and private sector, both agency and individual practitioner. The understanding of child psychiatric disorders has increased greatly, leading to more specific treatment approaches. Child psychiatry is more than ever in the mainstream of medicine and the community.