The psychiatrist who is asked to provide a service to a school or college should be aware of a number of ways in which a regular relationship with a school may affect the usual procedures of clinical assessment and management. Four points in particular become important, one clinical, one developmental, one concerning the school as an organization, and one concerning the special ethical and medico-legal issues that can arise.

First, while the psychiatrist will be consulted about a wide range of clinical disorders (and all the conditions seen in adult psychiatry have their equivalents in child and adolescent psychiatry), he or she should be alert for less well-defined problems involving teaching staff and peer relationships as well as the child and family, and where the focus of work may be to help the pupil to cope with the school and its expectations, and vice versa, rather than dealing with more familiar clinical syndromes and psychopathology. Psychiatrists often find, when they step outside the controlled environment of their clinics, that 'the community' is a less tidy place, and working with a school is an important facet of community psychiatry.

Second, educational settings, from nursery schools through to universities, are powerfully influential on individual development, not only in terms of academic achievement, social skills, and emotional development, (i2) but also because the first significant emotional relationships with peers and adults outside the family are important transitional stages for the development of identity and self-confidence. Lindsey (3) discusses this helpfully in relation to consultation with teachers and parents in nursery and junior schools. As psychiatrists we deal with strengths and solutions as well as weaknesses and problems, and the psychiatrist working in educational settings will be helped by familiarity with the developmental perspective of child psychiatry, (4.,5) and with the social psychology of organizations and how to work with them.(6,Z,8 and 9

Third, the type of school or college will powerfully influence the problems that present. Educational settings differ widely in their functioning, purpose, and type of student, quite apart from their less obvious differences. An educational setting for young people with learning difficulties or epilepsy will have different expectations of its students and of the psychiatrist than, for example, a college in a university or a private school. However, schools differ in more subtle ways than these, for example in how much or how little pastoral care or counselling they provide themselves, and indeed their attitude to these things, and in the ways they relate to parents.

Fourth, it is important to clarify at the beginning what type of service is expected of the psychiatrist.

This needs proper discussion at the outset, and with the right person. Although this may seem obvious, such details can be neglected in the first flush of a discussion with an enthusiastic member of staff; it is not uncommon for chains of command, communications, and decision-making to be quite disorganized in even the most impressive organizations. A relationship with an institution and the quality of the work being done can go awry if there is misunderstanding between the psychiatrist, the person he or she is negotiating with, and other influential people in the school, about the psychiatrist's role. For example, a psychiatrist may wish to take a health educational and preventitive role in the school (discussed below), and, while a headteacher may think this an excellent idea, the school governors may have been thinking of a purely clinical service. Or the children the school authorities are most concerned about may not be the sort of young people the psychiatrist is particularly experienced or interested in. There may also be a surprising lack of imagination or foresight about such matters as office facilities, secretarial time, record-keeping, message taking, and how the service is to be funded. It should not be assumed that even the most worldly wise will take the initiative over such matters or even have thought of them. Nor should it be assumed that even the well-informed necessarily know what is meant by 'psychiatry', 'psychiatric problems', 'psychotherapy', or 'counselling', and this refers not to epistemological hair-splitting but to what the psychiatrist is expected to do.

Whatever emerges from the initial discussions should be confirmed in a contract or letter of agreement, and it can be helpful to agree a date for a meeting with key people to review progress and developments after around 6 or 12 months, at which point the contract can be reviewed if necessary. Preparing the ground along these lines provides a solid basis for tackling the complexities of child and adolescent psychiatry in a non-clinical setting ( Table 1).


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Table 1 A classification: types of contact between psychiatrist and a school or college

Finally, this would be the time to consider whether to collect data systematically about the service and user reactions. This would be useful for a future operational review, even if a research project was not planned at this stage. To summarize:

• be prepared for a very wide range of problems

• be aware of educational influences on child development

• clarify what you are being asked to do, and what you are offering. Clinical work

Many psychiatrists will first think of their clinical skills when asked to provide a service to a school or college—as indeed may the institution itself—and some of this might involve direct collaboration with, for example, a school medical officer, psychologist, or counsellor. However, consultative and educational roles are also important.

From the clinical point of view, details of assessment and treatment of particular conditions is discussed elsewhere. The main matters considered here from the clinical perspective are whether the visiting psychiatrist sees his or her role as primarily a general clinician or primarily in psychotherapeutic terms, some aspects of the organization of work, and the type of clinical presentations to expect.

The terms psychotherapy, counselling, and pastoral care raise questions of definition and practice, and there is considerable variation and some controversy about what is practised and with whom, standards of training, and the availability, quality, and use of supervision. 'Pastoral care' is another widely used term which may mean anything from a vaguely well-intended consciousness about the wider non-academic needs of pupils to actual strategies within the school for helping young people manage their feelings and their lives. What is important at the stage of planning an association with a school is to get to know what has been going on there so far, what different people do, and how their work is regarded.

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