Special Article
This article reviewed the brief history of child and adolescent psychiatry and the present status of clinical practice for children and adolescents in Korea. We postulated the training system for child and adolescent psychiatry fellowship: the history during past 25 years, and the training agenda for board certification. There were several suggestions about future directions and tasks of Korean child and adolescent psychiatry.
Correspondence: Young Sik Lee M.D., Department of Neuropsychiatry,Chung-Ang University Medical Center. 224-1, Heukseok-dong, Dongjak-gu, Seoul 156-755, Korea
Tel: +82-2-6299-1518, Fax: +82-2-825-8474, E-mail: hawkeyelys@hanmail.net
Brief History of Child and Adolescent Psychiatry in Korea1,2
The origin of child and adolescent psychiatry (CAP) and child mental health services can be traced back to Korean independence from Japan in 1945. A document from that time shows that the juvenile court house requested consultations from a psychiatrist. The Namsan juvenile counseling center was built, and psychiatrists, psychologists, and social workers discussed child mental health problems at the center.
During and after the Korean War of 1950-1953, the U.S. military Medical Service introduced modern western medicine to Korea. Psychiatry was one of the areas that benefited from it; the needs for child psychiatry were advocated by a group of military psychiatrists. In 1958, Judge Kwon opened the Seoul Child Guidance Center, the first one of its kind. A group of psychiatrists, psychologists, educators, and social workers were involved in the center's activities. They imported the model from the United States and were active in providing psychological tests and consultations, parent education, and other services. However, the child guidance movement did not continue for long, partly because of the shortage of experts and qualified child psychiatrists on the team. Since then, educational/school psychologists have carried out most of the psychological services for emotional and behavioral disorders, especially for school-aged children.
In 1968, a couple of psychiatrists went to the United States for formal child psychiatry training. Meanwhile, a group of psychiatrists were active in research on normal and delinquent adolescents. Child psychiatry services opened at the Catholic Medical Center in 1967 and at Seoul National University Hospital in 1969.
Nevertheless, formal child psychiatry services did not begin until 1980, when Professor K. M. Hong returned from the United States after finishing his general and child psychiatry training. He immediately opened the first child psychiatry clinic and day treatment center for autistic children, established the first division of child psychiatry at Seoul National University Hospital, and started the child psychiatry fellowship training program. Since then, many Korean child psychiatrists have gone abroad for training. Qualified child psychiatrists (including professors Peter Kim, Kyung Sun Noh, and Sung Do Hong) trained in the United States have returned and have been running child psychiatric clinics at several university hospitals in Korea.
Korean Academy of Child and Adolescent Psychiatry
The work group for CAP was organized in 1983, and The Korean Academy of Child and Adolescent Psychiatry (KACAP) was organized in 1985. In 1986, 2 academic meetings, spring and autumn, were held. In 1990, the Journal of Korean of Academy Child and Adolescent Psychiatry began to publish its official journal twice a year. In 1996, KACAP set up the first board certification system. Now there are over 92 board-certified child psychiatrists, 95 eligible board members, and 18 fellows in ten fellowship training centers.
It seems that child psychiatry in Korea is flourishing, mostly due to the availability of formal training centers as well as board certification system. Korean child psychiatry has done a great job promoting the awareness of child mental health problems, has conducted numerous public lectures, and has stimulated other professions to emerge and develop for the last 20 years. Special education, child psychology, medical social work, speech therapy and other professions have grown a great deal.
In 1996, KACAP contributed significantly to the foundation of the Asian Society of Child and Adolescent Psychiatry and Allied Professions (ASCAPAP) in Tokyo. From May 6 to May 7 of 1999, the Second Congress of ASCAPAP was held in Seoul in which KACAP played a key role as a local host.
Korean child psychiatry has been active and supportive in establishing the Korean Society of Autism and the Korean Association of Child Abuse and Neglect. The association contributed significantly to the revision of the Child Protection Act in 1999 and setting up of nationwide child abuse and neglect prevention centers.
In 1999, the school consultation networks were formed at the 12 juvenile counseling centers in Seoul. In 2004 and 2005, the screening days for children with ADHD were held. In 2005, the 'Korean Textbook of Child Psychiatry', edited by Hong K.M, was published. This is the first textbook written in Korean language (Hangeul).
From 1983 to 2002, the president of KACAP led the academy. However, in 2003, a board of directors led the academy. The Figure 1 presents the KACAP organization.
The Present Status of Clinical Practice in Korea
The main role of the child psychiatrist is the head of a multimodal treatment team. The co-working specialists are psychiatry-certified nurses, clinical psychologist, language therapist, learning therapist, occupational therapist, play therapist, special educator and clinical social workers. The therapeutic team members are formed differently according to the children's age, mental problems and clinic characteristics. Most child psychiatrists in Korea work together with some of the forementioned specialists.
Many kinds of individual or group special treatment programs have been developed for the patients and their parents. Popular multimodal treatment team programs are day hospital for developmental problem children, sensory integration treatment for autistic children, learning enhancement program for learning disability children, social skill training for disturbed or socially isolated children, individual play therapy for those with emotional problems, and cognitive-behavioral therapy for those with depression, obsessive compulsive disorder or drug dependence.
Management of the parents is a very important job in child psychiatric service. Family therapy or family education programs are commonly applied in Korea to attachment disorders in order to enhance parental attachment and to disruptive behavior disorders. Through this program, parents can understand the cause of their children's problem, how to manage their children's behavioural problems and how to communicate with their children. In Korea, parents' clinics for autism and ADHD are very popular.
Figure 2 shows the general population and the number of child psychiatrists in each region. Table 1 presents the nationwide distribution of child psychiatry services including university hospitals, general hospitals and private clinics.
Training of Child and Adolescent Psychiatrist in Korea
History
Despite its relatively short history, KACAP has achieved quantitative and qualitative growth in the aspect of training and education. The history of regular fellowship training of Korean CAP dates back to 1981 at Seoul National University. Every year, 1 to 4 fellows were trained with intensive one-to-one supervision by an experienced supervisor and gained experience in the outpatient unit, inpatient unit and autism day care unit for 1 year of fellowship training.3 In 1996, the Korean board of CAP was established and made provision for the certification of CAP and for the requirements for approved training program. The Korean board of CAP consists of 10 senior child and adolescent psychiatrists who are experienced and committed to the training. Its present major role is to review and accredit the CAP fellowship training programs and applicants for the board of CAP. The other important roles are encouraging the development of an effective curriculum for fellowship training in quality, collaborating with other organizations concerned with training in CAP, and modulating continuous education of graduates of CAP fellowship.
There are 10 training programs approved by the Korean board of CAP at present: Chungang university medical center, Hanyang university medical center, Inha university hospital, Kangbuk Samsung Medical Center, Samsung Medical Center, Seoul National Mental Hospital, Seoul national university Bundang Hospital, Seoul national university Hospital, Yonsei university Severance Hospital, and Yonsei university Yongdong Severance Hospital. From 15 to 20 new fellows are trained in these programs every year. The number of fellows has increased rapidly in recent years (Figure 3).
Certification and training
Application to the board of CAP in Korea is a lengthy and arduous process. Those who want to get a board certification of CAP have to complete the special clinical training in an approved program for at least 12 years: 6 years of medical school after which the Doctor of Medicine (M.D.) degree is awarded; one year of supervised general medical practice in an approved residency program as an intern, four years of supervised training as a general psychiatry resident, and then at least one year of supervised training working with children, adolescents, and their families in an approved CAP fellowship program.
After this long and hard training course, those who want to take the board certification of Korean CAP can obtain the primary qualification for this special board. Among the graduates of the 1-year fellowship, those who want to take the board certification of CAP should take an additional education course as determined by the provision for certification of the Korean board of CAP. On the other hand, the graduates who have gone through regular fellowship training for 2 years are able to take the board certification of CAP without any additional education course. These certification processes take place in the Korean board of CAP. There are 90 board certified child and adolescent psychiatrists and presently over 60 psychiatrists are in additional education courses for the board certification of CAP in Korea (Figure 4).
Child and adolescent psychiatrists are physicians who are uniquely qualified to integrate knowledge about human behavior and development from biological, psychological, familial, social, and cultural perspectives with scientific and collaborative approaches to the diagnosis, treatment and promotion of mental health. Training and education is a primary function of KACAP. Graduates of the CAP fellowship programs are prepared to assume responsibilities of caring for children and families as physicians, are capable of working collaboratively as active and leading treatment team members, and are ready for further development of their profession and their professional community. Fellowship programs of Korean CAP have developed continuously and are well systematized.
In the CAP fellowship training, the trainee acquires a thorough knowledge of normal child and family development, psychopathology, and treatment in the classrooms, clinical setting and supervisory setting. Special emphasis is given to disorders that appear in childhood, such as pervasive developmental disorder, attentiondeficit hyperactivity disorder (ADHD), learning disabilities, mental retardation, mood disorders, depressive and anxiety disorders, drug dependency and delinquency (conduct disorder). The child psychiatric trainee applies and develops psychiatric skills by treating youngsters and their families. The evaluation and treatment of inpatients and outpatients are important throughout the training and these are done with careful and intensive supervision by the program faculties. An experience of consultation with other physicians, mental health professionals, schools, and community agencies is an important part of training. In addiction, almost all fellows are able to participate in various ongoing research programs on child and adolescent mental health areas.
Future Directions and Tasks of Child and Adolescent Psychiatry in Korea3
(1) Expanding the viewpoint of the clinical activities
The clinical activities need to be diverse, not only emphasizing the treatment of children's mental disorders. Aspects that may be useful in the treatment of other emotional and behavioral problems of children and adolescents, which have not received a great deal of research attention, should also be studied and explored. Child psychiatrists should not only treat self-admitted patients, but should also proceed with preventive activities more broadly and actively in the community.
(2) Expected increase in patients suffering from mental disorder
Korea has achieved its modernization success at a rapid and remarkable speed compared with other countries. Consequently, Koreans are confronted with a crisis and confusion about how Koreans should educate and bring up their children. Women's viewpoints about occupation and gender equality are injecting confusion into the concept and role of sex for children, leading to the rise of the nuclear family, decreased number of children at home, and increased divorce rate, all of which combine to speed up the dismantlement of the families. The changes in society and the value, instability and confusion about the norm related to the control of psychology and behaviors will likely continue, with a corresponding increased risk of mental disorder.
(3) Active responses to the weakening role of family & dysfunction
The divorce rate in Korea has increasing ten-fold compared with a decade ago. With this increasing divorce and remarriage, the risk of mental disorders among children also increases. The problem is that there is no consideration for the mental health of children with greater emphasis being placed on the rights of the husband and wife in matters of divorce. Consequently, the tasks faced by psychiatrists in helping families secure mental health have increased, which necessitates a systematic approach and the inclusion of therapy at the family level as an indispensable element of the training.
(4) Protection of patients and families & appropriate guidelines on mental
health
Child psychiatrists should organize a team with experts from various academic fields to ensure that patients and families are provided with appropriate treatment or counseling. Therefore, child psychiatrists should play the role of team leader (coordinator, integrator), particularly in the formation of a systematic and integrated approach based on the theory of development.
(5) Active participation in the development policies of society and the
government
A variety of governmental policies and activities have a significant effect on the people's health and the treatment of mental disorders. Therefore, pediatric psychiatrists have a duty to participate in various committees, which make decisions on important policies within the field of child and adolescent psychiatry in Korea, and to provide assistance.
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KM Hong, K Yamazaki, CG Banaag, D Yasory. Systems of care in Asia. In: Helmut Remschmidt, Editor. Facilitating pathway; care, treatment and prevention in child and adoles-cent mental health. Springer 2004, pp58-70.
KM Hong.
Korean Child and Adolescent Psychiatry-a review of the past, the present and the future. J Korea Acad Child Adolesc Psychiatry 2003; 14 (2): 39-149.