key: cord-0773222-8f0xvq2x
authors: Lázaro, Luisa
title: The long road to the creation of the specialty of child and adolescent psychiatry in Spain
date: 2022-01-07
journal: Eur Child Adolesc Psychiatry
DOI: 10.1007/s00787-021-01916-1
sha: 9c261ab0e8aeb4b8327037ceb522ad6ad5d7b856
doc_id: 773222
cord_uid: 8f0xvq2x

nan

The Spanish Association of Child and Adolescent Psychiatry (AEPNyA) is a professional medical organization composed of psychiatrists trained to evaluate, diagnose, and treat children and adolescents affected by mental disorders. It was founded in 1950, and its first meeting was in Barcelona in 1952. Since then, there has been a meeting almost every year, with the 64th National Congress, this year held in the city of Cádiz. Over these 7 decades, the number of members has increased to reach 430. Ninety percent of members are psychiatrists and the rest are clinical psychologists dedicated to the care of children and adolescents. AEPNyA has been a long-time member of the European Society of Child and Adolescent Psychiatry (ESCAP), the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP), and the Union of European Medical Specialties (UEMS).

I have been part of the society for over 25 years, and have witnessed the effort made to promote and participate in the creation of the specialty of child and adolescent psychiatry differentiated from that of psychiatry. Over the years, successive boards of directors, headed by their presidents, have defended the need for this specialty in government offices. Political leaders have frequently responded positively, but their deeds have not corresponded with their words, so we have come down a long and difficult road. As far as I know, together with Bulgaria and Albania, we were the only European countries that did not have this specialty. This issue has just been resolved with the approval of a royal decree to create the speciality in August 2021 by the Spanish Government's Council of Ministers.

Among the main arguments that we have put forward for years is the European Commission's recognition since 2005 of child and adolescent psychiatry as separate from general psychiatry and its subspecialties [1] . This concept was recognized in 2006 by two-thirds of the 34 European countries [2, 3] . In Spain, the Ministry of Education grants the degree of psychiatrist, a general specialty with possible non-compulsory subspecialties. It is not separated by law from child psychiatry. In the training of a resident medical intern in psychiatry, which lasts 4 years, it is only compulsory to complete 4 months in child psychiatry. However, since 2008, it has been easier for resident psychiatrists who wish to specialize in child psychiatry to complete the last year of training in this field. This is a step forward, although not all hospitals and centres in which psychiatric residents are trained offer this possibility and some hospitals are not willing to provide it.

What has happened since 2008? In 2008, we were clearly bringing up the rear in the EU. The work of scientific societies was joined by citizen initiatives, including the ''Platform of families for the creation of the specialty of child and adolescent psychiatry''. This platform highlighted ''the need for good professionals to take care of children''. It organized a collection of signatures and held public demonstrations before the Ministry of Health to make the absence of this specialty visible to the rest of society. The platform requested the official approval of the specialty of child psychiatry in Spain in May 2008 [4] . At this time, the Senate requested information on the planning of public health resources to care for children and adolescents with psychiatric disorders. The president of AEPNyA, Dr M a Jesús Mardomingo appeared and ended her speech with the following words: ''If paediatric diseases were the great challenge of the twentieth century, psychiatric disorders in children are the great health challenge of the twenty-first century, and Spain cannot be left behind'' [4] .

A favourable situation was created, so that in March 2009, the Delegate Commission of the Interterritorial Health Council prepared a report on the mental health of children and adolescents. It concluded that: (1) the absence of the specialty of psychiatry and clinical psychology of children and adolescents cannot guarantee that the professionals who work in this field have the necessary training and experience; (2) in some autonomous communities, children referred by the paediatrician or general practitioner are cared for by adult psychiatrists; (3) those who are usually responsible for most facilities are less aware of and involved in the needs and problems of affected children and adolescents; (4) Spain does not comply with the recommendations of European organizations, and (5) the lack of this specialty is anachronistic and does not correspond with the economic level or the quality of the public health system [5] . A few weeks later, the health minister announced that his ministry approved the creation of the speciality of child psychiatry. However, the day after this was announced coincided with a remodelling of the government and replacement of the health minister, so the approval of the specialty remained in the air.

At the end of 2012, a draft royal decree was published regulating groups of related medical specialties and other aspects of the training system in the health sciences. It established the common topics of the groups of specialties and the characteristics of each of the specialities/fields. Finally, in July 2014, a royal decree was approved by which medical specialties are organized into groups. One of the groups was psychiatry, which included the specialties of psychiatry and child and adolescent psychiatry. The specialities in this group would consist of 2 years of general training, followed by the years of specific training. At the same time, the child and adolescent psychiatry specialty commission and the psychiatry core subject commission were created, which worked on the development of the training programme, the definition of accreditation criteria for teaching units, and the design of an objective training test to get the degree to professionals. The president of AEPNyA at that time, Dr Josefina Castro was part of both commissions, pending the development of criteria for accrediting teaching units. It seemed then that the future specialty of child and adolescent psychiatry was within reach. However, all this was frustrated when at the end of 2016, the Supreme Court annulled the royal decree that regulated the groups of specialties because of disagreement with the legal system.

In 2017, the president of AEPNyA, Dr Dolores Moreno, asked for the health ministry's approval to create the specialty through a royal decree independent of the group of specialties, since the programme for training in child and adolescent psychiatry was written and completed on time. In January 2018, the health ministry announced the draft of a royal decree by which two specialties were defined: child and adolescent psychiatry and adult psychiatry, announcing that the minimum duration of both programmes would be 5 years [6] . However, this draft royal decree, approved by the Interterritorial Council of Autonomous Communities, did not reach the next phase of requesting the approval of the State Council. In February 2019, the vice president of the European Parliament's Subcommittee on Human Rights alerted the Spanish health minister of the Spanish government's serious irresponsibility for not having resolved the lack of the specialty of child and adolescent psychiatry in Spain, which is one of the essential recommendations of the European Union of Medical Specialties. The subcommittee urged Spain to create a specific specialty without delay [6] .

After the COVID-19 pandemic in the second quarter of 2020 with an increase in psychopathology in children and adolescents in the months after lockdown observed in Spain and in the rest of European countries [7, 8] , AEPNyA, together with other scientific societies, echoed this need and requested a new audience with ministerial experts from the health ministry's General Directorate of Professional Guidance (Direccio´n General de Orientacio´n Profesional). The response was immediate, and the willingness to refloat this legislation was total. They collected all the previous documentation, resolved possible technical doubts for its correct implementation, made the relevant consultations to the Council of State, and finally, in early August 2021, the Royal Decree on the Specialty of Child and Adolescent Psychiatry was approved with changes in the specialty of psychiatry. In the next announcement, which is estimated for 2023, both specialties will have a duration of 5 years and will share the skills to be acquired during the first 2 years of training.

We have not come all this way alone as a scientific society. We have always been accompanied by the Spanish Society of Child and Adolescent Psychiatry and Psychotherapy (SEPYPNA), represented by its president Dr Fernando González, and the Spanish Society of Psychiatry and the Spanish Society of Neuropsychiatry with their presidents Drs Celso Arango and Miquel Muñarriz. The four societies have not ceased to fight with resistance and perseverance for what they believed at all times necessary and fair for children and adolescents affected by mental illness and their families.

With the creation of the specialty, a fundamental objective will be achieved: complete, excellent training for future medical specialists in child and adolescent psychiatry. Professionals will no longer have to make an effort to train as best as possible when they can, according to their criteria and possibilities, some helped by foundations, such as the Alicia Koplowitz Foundation that has granted scholarships for psychiatry specialists for the last 17 years to train for 2 years in prestigious international centres.

We have had to wait until the beginning of the second decade of the twenty-first century for the creation of the long-desired specialty to be achieved. This comes 70 years after the foundation of AEPNyA as a scientific society whose associates have met year after year in national congresses and at refresher courses to share the evidence of scientific research on mental disorders that occur in children and adolescents. Hopefully, the journey to create the specialty is over, and there will be no more obstacles at the end of this long and winding road. We are all aware that children and adolescents in Spain and their families deserve the best training of the professionals who treat them, and the most complete network of facilities and resources for their therapeutic approach. All this is difficult to achieve without the specialty. The current knowledge of training in child and adolescent psychiatry in Europe [9] will help us to carry out the best available training programme in Spain. The first doctors specializing in Child and Adolescent Psychiatry will probably finish their training in 2028. Without a doubt, at that time, we will have excellent professionals belonging to the internationally recognized Spanish National Health System.

Directive 2005/36/EC of the European Parliament of the Council of 7 September 2005 on the recognition of professional qualifications

Child and adolescent psychiatry training in Europe: differences and challenges in harmonization

Training of adult psychiatrists and child and adolescent psychiatrists in Europe: a systematic review of training characteristics and transition from child/adolescent to adult mental health services

Historia de la Asociación Española de Psiquiatría del Niño y del Adolescente (AEPNyA) en su setenta aniversario

Informe sobre la salud mental de niños y adolescentes

Ambito y desarrollo de la psiquiatría de la infancia y la adolescencia. Manual de Psiquiatría de la Infancia y la Adolescencia

COVID-19 Child and Adolescent Psychiatry Consortium, Klauser P (2021) ESCAP CovCAP survey of heads of academic departments to assess the perceived initial

COVID-19 Child and Adolescent Psychiatry Consortium, Klauser P (2021) Perceived impact of the COVID-19 pandemic on child and adolescent psychiatric services after 1 year

The child and adolescent psychiatry: study of training in Europe (CAP-STATE)