History of Child and Adolescent Psychiatry at Central Institute of Psychiatry: Journey of Erna Hoch Centre for Child and Adolescent Psychiatry.

Child and adolescent psychiatry has not been considered as an established field until the early 1900s till first such unit was started by Leo Kanner in 1930. In India, the first child guidance clinic was founded in 1938 in Mumbai by Dr. Clifford Manshardt. The child and adolescent Psychiatry unit at Central institute of Psychiatry has been into existence for the last 55 years and since then it has been an integral part of the institute in providing high-quality patient care, promoting substantial growth in research, and imparting education to the post graduate trainees and scholars in the field of child psychiatry. The journey embarked by it has been a phenomenal one and many laurels have already been achieved so far.

“There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they can grow up in peace.”

Kofi Annan, Secretary General (United Nations)

INTRODUCTION

The discipline of child and adolescent psychiatry has now been well established in academic medicine for around 50 years,[1] especially in the Twentieth Century where significant growth has been made. The need for having a separate discipline was realized as many problems unique to children needed to be tackled. Apart from that, it was realized that stringent measures have to be taken to alleviate the sufferings of the children as adult psychopathology, and mental health problems are only an extension of child mental health problems and continuum in psychopathology.[2]

India with its 1.29 billion people constitutes the second most populous country in the world, while children (0–14 years) represents 39% of the total population of the country, which is way ahead of the entire population of the Australian continent. Speaking of the mental health facilities in India catering to the needs of children, we have yet a long way to go with the number of child psychiatrists in India being just a handful.

HISTORY OF CHILD PSYCHIATRY WORLDWIDE

Child and adolescent psychiatry was not considered as an established field until the early 1900s. Early recognition of the field began in Germany, when Johannes Truper founded a school in the year 1892, where several doctors took training in child psychiatry. It was there that Theodor Ziehen, regarded as one of the pioneers of child psychiatry, gained practical child psychiatric experience as a consultation-liaison psychiatrist. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894–1981), an Austrian immigrant, under the direction of Adolf Meyer at the Johns Hopkins Hospital, Baltimore, Maryland in the United States.[1] In India, the first child guidance clinic was founded in 1938 in Mumbai by Dr. Clifford Manshardt.[3]

COMMENTARY

The mental hygiene movement which essentially dealt with the promotion of mental health extended its focus not just to adults but also to children, became popular in the early part of the twentieth century. According to Marfatia, one of the pioneers of child psychiatry in India, ‘child psychiatric services are not only useful for treatment of psychiatric disorders but are an endeavour in the field of mental hygiene. Despite some of the pioneering efforts, the beginning of child psychiatry as a discipline was rather slow in India, it has received its due distinction as a subspecialty in the last two to three decades. Yet, only a few centers have well-established facilities in the area of child psychiatry. In this context, the story of the development of child psychiatric services at the Central Institute of Ranchi provides a historical framework of how new services develop. It is appropriate that the services are named after Dr Erna Hoch, who conducted the earliest research in child psychiatry in India in the late 1950s and 1960s. As the CIP commemorates its centenary year, it is timely to review an important service and its growth. The development of child psychiatric services and its expansion, from treating children with severe psychiatric disorders and intellectual disability to expanding to school mental health programs probably mirrors the growth of this discipline in other centers as well.

GROWTH OF CHILD PSYCHIATRY AT CENTRAL INSTITUTE OF PSYCHIATRY, RANCHI

The Child and Adolescent Psychiatry Unit at Central Institute of Psychiatry (CIP) has been into existence for the last 55 years, and since then, it has been an integral part of the institute in providing high-quality patient care, promoting substantial growth in research, and imparting education to the postgraduate trainees and scholars in the field of child psychiatry. The department, which was called the “child guidance clinic” at its inception, has been renamed the Erna Hoch Centre for Child and Adolescent Psychiatry in 2012. The center is named after the eminent Swiss psychiatrist Dr. Erna Hoch, who spent most of her professional career in Kashmir, working for children. After a humble beginning, the vision and hard work of the stalwarts related to the institute have made it possible for the department to have scaled new heights and in making significant contribution in this field.

The child guidance clinic was first started by the CIP in 1950 at the Sadar hospital, Ranchi, following the initiatives of Dr. (Maj.) R. B. Davis and Erna Hoch [Figures 1 and 2] who was then medical superintendent of this institute. Although the initial response of the public toward the child guidance clinic was poor, these efforts paved the way for the weekly visits to St. Xavier's School in Ranchi [Figures 3-5].

Figure 1

Dr. (Maj) R B Davis, Founder of child psychiatry services at CIP

Figure 2

Erna hoch

Figure 3

Sadar hospital at Ranchi

Figure 5

CIP OPD running in child psychiatry building

St xavier's college at Ranchi

The visits provided the much-needed impetus to the clinic at the CIP by attracting more patients. Subsequently, the outpatient services for children were started at the technical block inside the hospital premises. The children with scholastic difficulties were seen at St. Xavier's School, whereas those having epilepsy or intellectual disabilities had to consult the hospital. In those days, the admissions to the child psychiatry unit were scarce, and in case children (only above 10 years) got admitted, they were admitted along with the adult patients. The necessity of going to the community was realized to help the underprivileged and improve awareness, and subsequently, the earliest rural mental health clinic was started at Mandar, Ranchi, in 1967.[4] In the next decade, the number of patients consulting the institute increased, and in the year 1966, a total of 196 child and adolescent cases were seen, of which 144 cases were newly registered. Common diagnoses included intellectual disability and schizophrenia and some had organic pathology. The institute witnessed an enthusiasm in research and thereby a study was undertaken at the institute in the year to see the “patterns of Rorschach responses on normal and schizophrenic children.” A survey was carried out in various schools in Ranchi to assess the mental morbidities in school-going children from Kanke.[5]

This went on till 1969 when the need of collaboration of other disciplines such as psychology and psychiatric social work with child psychiatry was felt and more staff were recruited to help the expansion of child psychiatry unit. In the same year, Dr. A. N. Verma joined in the department of psychiatric social work along with Dr. R. G. Sharma who joined as a faculty member in the department of clinical psychology. This brought a major change in the unit as now the psychological tests were done in a more meticulous way under the guidance of Dr. R. G. Sharma, and in the very same year, psychological tests were administered on the 209 children for clinical and research purpose, referred from the child guidance clinic.[6]

In the 1970s, the need for having a separate building dedicated to the children and adolescents was realized by Dr. Bhaskaran (medical superintendent), and in 1975, an independent 50-bed child and adolescent psychiatry unit was conceived and constructed.[4] Subsequently, Dr. Shashi Pande took over as the director and showed the same enthusiasm as his predecessors and improved the infrastructure further by buying child-friendly furniture for the building. The number of patients attending the child guidance clinic started to increase, and in between 1970 and 1980, around 1366 patients visited and were diagnosed as cases of psychosis (30% cases), mental retardation (34% cases), epilepsy (18% cases), and others.[3] The growth of the child psychiatry unit continued albeit not as swiftly, and the ever-increasing load of the outpatient crowd made the authorities convert the child psychiatry ward into the outpatient department (OPD) and shift the child psychiatry unit to another building which is currently the psychosocial unit [Figure 6].

Figure 6

Psychosocial unit at CIP

Another major change was seen in the directorship of Dr. L. N. Sharma in 1987 when Dr. Rakesh Khanna was appointed as an assistant professor and given charge of child psychiatry unit in 1987. During his time, there were only 6 beds for admission of children. A senior resident got posted in child psychiatry unit along with the rotation posting of two junior residents. The trend of daily OPD services began and continues till date. To provide better care to the children, psychology trainee rotations were also started, and to increase the strength of the children consulting child psychiatry unit, great efforts were made by him by visiting the Paediatrics Department of Rajendra Medical College and Hospital, Ranchi. Gradually, the efforts started to pay off and the number of referrals increased, due to the increase in the awareness among people. More young ones with bipolar disorder, early-onset psychoses, attention-deficit hyperactivity disorder, intellectual disability with behavioral issues, and autism spectrum disorder started to visit the institute to seek consultation. Treatment involved mood stabilizers, antipsychotic medication, and tricyclic antidepressants along with psychological interventions.

Another change took place in 1998 during the times of Dr. S. Haque Nizamie as director, with the appointment of Dr. Vinod Kumar Sinha as consultant in charge of child psychiatry unit. Because of his insistence, the number of beds increased to 20 in the year 2001 which continues to be the same till date. Due to his diligence, the number of patients seeking consultation continued to be on a rise, and in the last decade, the number of patients getting registered at child guidance clinic has become almost 3-fold. In the year 2008, 4673 (new, 1418 and follow-up, 3255) patients visited for treatment at OPD,[7] which increased to 7730 patients (2094 new cases and 5636 follow-up cases) attending the OPD for treatment in 2014.[8]

Currently, there are daily OPD services for the patients and a psychology trainee is also posted at the OPD daily to take up the referred cases and carry out the assessments and counseling then and there. The OPD service consists of psychological evaluation and formal assessments, counseling, parental psychoeducation, individual psychotherapy, and pharmacological interventions. The admitted children are managed by the clinical team which consists of two consultant psychiatrist, one specialist medical officer, two senior residents, four to five junior residents, four clinical psychologists, one PhD scholar, two psychiatric social workers, and about a dozen of specially trained nurses. Twice in a week, rounds are held where the consultants, residents, and students discuss the cases in detail and the management plan is decided. To make the stay of the children pleasurable, various events are organized frequently in the ward such as celebration of various festivals, role plays, and drama. They are also motivated to take part in the annual foundation day cultural program, Independence Day, and Republic Day celebrations. Another change made in the recent past is the modification of the existing case record file which has been made more inclusive and meticulous so that there are no lacunae in the history taking and examination of the children.

ACADEMIC PROGRAMS AND RESEARCH RELATED TO CHILD PSYCHIATRY AT CENTRAL INSTITUTE OF PSYCHIATRY

Every year, apart from the departmental and institutional seminars and case presentations related to child psychiatry, continuing medical education (CME) programs are held to improve the knowledge regarding the subject. In the years 2013 and 2014, annual CME programs were held on childhood epilepsy in the institute.[8] The 36th Annual Conference of Indian Psychiatric Society, Eastern Zonal Branch (CEZIPS 2010), was held at the CIP on October 8 and 9, 2010. The theme of the conference was “Child and Adolescent Mental Health” [Figure 7].

Figure 7

CEZIPS 2010_CME on child and adolescent psychiatry

Speakers from various fields related to mental health of children spoke on diverse topics including life skills and promotion of mental health, suicidal behavior and substance-use disorders in children, psychological management in developmental disorders, childhood sexual abuse, and school mental health.[9] The emphasis on research studies related to child and adolescent psychiatry was always there with 23 theses being done on the subject till date. In the last 5 years, the number of research study has increased significantly, with 45 dissertations being done on various topics related to child and adolescent psychiatry by the residents and students of the institute. Another feather in the cap is the rotatory postings of postgraduate scholars from other medical colleges and universities to the child psychiatry unit for training every year.

DEEPSHIKHA: INSTITUTE OF CHILD DEVELOPMENT AND MENTAL HEALTH

Deepshikha is a nonprofit, nongovernment organization founded by Dr. Alka Nizamie, an alumnus of CIP. The liaison of this institute with Deepshikha began during the times of the director Dr. L. N. Sharma in 1991 to promote awareness of childhood epilepsy among people at grass root level. Every week, a team consisting of two assistant professors would go and treat children having childhood epilepsy and raise awareness showing short documentaries and by organizing camps. Another task that they undertook was the sensitization of people regarding developmental disabilities and epilepsy, and for that, training of anganwadi workers was done on a frequent basis. Since then, the residents and students of the institute have been going on rotation to continue the same and at the same time get an exposure of children with developmental disabilities.

Pahal club was conceived on January 26, 1991, with the initial aim to involve the children of the staff in extracurricular activities and to take extra classes for them. It later on extended to the patients getting admitted to the child psychiatry unit which would further solve the purpose of enhancing interaction between the patients and the typically developing children. It got its name from the Hindi word “Pahal” which literally means taking initiative, and rightly so, it was the initiative taken by everyone associated with child psychiatry unit to make the stay of the patients a productive one. It was initially started at the director's bungalow but later shifted to the female rehabilitation center inside the hospital to also involve the long-stay adult patients in the activities. The students, residents, faculty members, and the staff have been very proactive in the various activities of the Pahal club. At present, the patients visit Pahal club daily in the afternoons for 2 h where they learn singing, painting, or how to make crafts depending on their capabilities. Apart from that, they are also taught subjects such as English, Hindi, and Mathematics to make them capable to integrate with the mainstream. Every year, various competitions are arranged to help generate new ideas and enhance creativity in them. In the year 2011, various items made by the patients were displayed and sold to generate funds for the club at the National Mid Term CME of Indian Psychiatric Society held at Ranchi. People from all over the country appreciated the efforts made by the children and the members of the Pahal Club team [Figure 8].

Figure 8

Pahal club

SCHOOL MENTAL HEALTH PROGRAM INITIATIVE

The CIP has always played a pivotal role in promoting the community mental health programs, and as a part of that, school mental health initiative was taken to promote the well-being of school-going children. A dire need was felt in 2002 by the principal of a renowned school at Hazaribagh, Jharkhand, regarding the academic, emotional, or behavioral difficulties experienced by the students. It was further needed to reduce school bullying, provide training to the teachers to identify the psychological problems felt by the students, provide counseling for the same, and impart sex education to the students. A multidisciplinary team has been ever since visiting the school and delivering state of the art services over there. This led to an invitation from another school at West Bokaro the very next year, and for the last 15 years, effective school mental health program has been running over there as well. Recently, the rise in the number of suicide among school-going children led to another school being added to the ongoing programs. Since the very beginning, camps have been organized at various schools to facilitate the development and monitoring of prompt and culturally acceptable mental and behavioral health services of prevention and intervention. There are robust data in school mental health which has been generated as many residents and students have done research exploring the various aspects of it, and in last 15 years, there are seven dissertations on the subject. In the year 2014, two workshops were organized, one for 148 school teachers on “Early Identification and Prevention of Psychological Issues in School Going Children” and the second for 150 students on “Mental Health and Well-Being.”[8]

MULTISENSORY ROOM AND PLAYROOM

The playroom and the multisensory room saw the light of the day on August 15, 2014, due to the initiative of Dr. Alka Haque Nizamie and Dr. V. K. Sinha along with the residents and students posted over there. The goals were to create an environment where stimulation of a multisensory nature would match the sensory needs of the children with disabilities. This is not only for providing relaxation but also for providing various kinds of sensory stimulation and further helping to improve the skills of the children with special needs. Every day in the morning, the children are taken to the playroom and multisensory room and participate in the activities designed for them. This also provides the students the learning experience to work with such children and at the same time enjoy the whole experience [Figures 9 and 10]. Besides that, various research studies are being carried out in the field to improve our understanding on it.

Figure 9

Multisensory room at CIP

Figure 10

children participating in a drawing competition at CCAP

CONCLUSION

Ever since its conception, the child and adolescent psychiatry unit has made huge strides in the patient care and research. The journey embarked by it has been a phenomenal one, and many laurels have already been achieved so far.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.