Professor Bruce Tonge

Professor Bruce Tonge reflects on his career in child and adolescent psychiatry

Professor Bruce Tonge is an academic child and adolescent psychiatrist, who recently retired after 20 years as head of the Centre for Developmental Psychology and Psychiatry at Monash Medical Centre in Melbourne. He continues research and clinical work. His key research interest is developmental psychiatry, with an emphasis on autism and childhood anxiety and depression.

“I was lucky to have had inspiring teachers while at medical school at Monash. During a clinical placement, we had a visiting teacher from the United States, psychiatrist Professor George Engel. I introduced him to a young man who’d broken his legs in a car accident. I thought it was straightforward, but Professor Engel used open interviewing to discover what was behind the injuries. It turned out the man had become involved in the crash after an argument with his newly pregnant wife. That taught me the important lesson of ‘why now?’ Why does this patient present to a doctor now? It got me interested in the psychological aspects of disease.

After an internship at the Royal Brisbane Hospital, which stimulated my interest in psychological medicine, I travelled to Great Britain to begin psychiatry training. It was a comprehensive program, including psychotherapy training at the Tavistock Clinic, London. This deepened my understanding of how fundamental early attachment experiences are to ongoing mental health. I also completed a placement with child psychotherapist Frances Tustin, who introduced me to long-term psychotherapeutic work with children. I then got a senior registrar position in child psychiatry at Cambridge University. In that wonderful academic environment, I mixed with people who were fascinated by child development and were doing early studies on child mental health. That set the scene for my subsequent career.

While at Cambridge, I met a child with school refusal problems. He was quite uncommunicative but warmed to the ‘squiggle technique’, which involves asking the child to squiggle on a page and make something of it. His parents thought their son was having nightmares, so I had the idea of taking the technique a step further. I drew a child sleeping, with a balloon coming out of his head, and asked the boy to draw a picture of his bad dream. He immediately drew two monsters fighting. They were saying bad things to one another and the man monster was hitting the lady monster. I said, ‘I wonder if things like this sometimes happen at home?’ He started to cry and tell me about his witnessing domestic violence and parental conflict. He was not so much frightened about going to school as concerned that he needed to protect his mother. I subsequently wrote a paper on this ‘draw a dream’ technique, and it is now used internationally. John Murtagh even has it in his textbook. It’s a contribution of which I’m very proud.

I returned to Australia in 1976 when I was invited to help establish a child psychiatry clinic at the Austin in Melbourne. I was director of the child and adolescent psychiatry department at the Austin from 1980 to 1987. While there, I began to develop an interest in autism and helped establish autism assessment services across Victoria, which continue to operate today. I was also partly responsible for setting the accreditation standards for child psychiatry, which form the basis of the current standards.

In 1987, I was offered the foundation chair in child psychiatry at the University of Sydney. Around this time, I realised that children with development problems had a significant number of associated mental health problems but we didn’t have a good way of assessing this. My colleague, Stewart Einfeld, wanted to do an MD, so I supervised his doctorate and together we developed a parent-completed and teacher-completed questionnaire about emotional and behavioural difficulties in children with developmental problems. This ‘developmental behavioural checklist’ has now been translated into 21 languages and is used around the world to assess children — and recently adults — with developmental difficulties.

I established the Centre for Developmental Psychology and Psychiatry at Monash University in 1989. The centre provides research and teaching in developmental psychiatry and psychology. A major part of my research interest has been the mental health problems associated with autism. At Monash, we’ve had a series of National Health and Medical Research Council grants for work in this area. We’ve also looked at potential autism treatments. For instance, with my colleague Dr Avril Brereton, we have established that education and skills training for parents of children with autism can significantly improve parental mental health, reduce family stress and improve adaptive behaviours in the young people, which persist 2 years later.

With colleagues, I’ve developed a number of psychological treatments based on cognitive behaviour therapy to treat anxiety, particularly presenting as school refusal, and depression, particularly in teenagers. The treatments have been effective, and are now used by other clinicians. One of the things about research, however, is that it opens doors. The next question is how to improve the interventions for those who don’t respond.

Psychiatry, and particularly child psychiatry, has always been a passion. On the surface some mental health problems can seem insurmountable, but using the techniques I’ve learnt from others and honed over the years, and taking a family approach, can lead to a significant change for the child. It’s been a privilege.”