Child Psychiatric Ward Rounds on Pediatrics

Ake Mattsson, M.D.

Abstract. The aUlhor describes lhe child psychialric rounds on Pedialrics and lheir major educalional goals: lo leach a developmental approach lo evalualion and lrealment planning of somalopsychic reaclions and emotional problems common in pedialrics; lO promole early recognilion of management problems; lo assisl lhe professional maluration of lhe pedialricians in lraining. The paper iIluslrales lhe use of family interviews during lhe ward rounds; lhe diagnoslic and lrealment lopics discussed wilh lhe ward slaff regarding lhe firsl 125 palients presented; and common concerns of lhe young pedialricians relaled lo lheir lrainee slalus and laxing palient care.

Some of the literature on child psychiatric-pediatric consultation and liaison service has suggested psychiatric rounds on the pediatric wards as an effective component in teaching comprehensive care in pediatrics (Adams, 1968; Lourie, 1962; Rothenberg, 1968; Schowalter, 1971). The pediatric house staff and nurses become accustomed to integrating social and psychological considerations in the medical work-up and care of their patients and have many opportunities for informal consultations regarding children with emotional problems. Except for Schowalter's (1971) description of the child psychiatric-pediatric collaboration on an adolescent ward, however, there are no accounts of the many possible goals of joint psychiatricpediatric ward rounds and conferences. In addition, data are sparse on how pediatric house officers utilize these teaching sessions in terms of learning a biopsychosocial approach to patient care (Green and Senn, 1958; Lipowski, 1967, 1971), improving the communication among ward staff, and strengthening their identifications as young pediatricians. This paper will describe goals, contents, and vicissitudes of weekly child psychiatric ward rounds on pediatrics at the University of Virginia Medical Center. These rounds began five years ago, soon after its Division of Child and Adolescent Psychiatry was founded. Our Division wanted to establish a pediatric liaison proDr. Mattsson is Professor of Psychiatry and Pediatrics, University of Virginia School of Medicine, Box 202, Charlottesville, VA 22901, where reprints may be requested. This study was supported in part by U.S. Public Health Service Grant No. 5T01 -MH 12904-02.

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gram as quickly as possible based on our conviction that a close working relationship with the pediatric house officers and attending physicians is essential in order to promote comprehensive pediatric care. The overall development of our pediatric liaison service, including the roles of the social worker and the psychiatric nurse, was described in an earlier paper (Naylor and Mattsson, 1973a). In our liaison efforts, the weekly pediatric ward rounds have become a major teaching component. PEDIATRIC INPATIENT SETTING AND CHILD PSYCHIATRIC LIAISON TEAM

The inpatient pediatric unit comprises two wards totalling 64 beds. Each ward is under the charge of a head nurse and some 40 additional nursing staff. The physician coverage consists of an attending staff pediatrician, five pediatric house officers, and one or two senior medical students. The fact that the physician staff usually rotates in its entirety each month is an unfortunate obstacle to the promotion of consistent care. Two ward school teachers and one pediatric social worker complete the pediatric inpatient personnel. The child psychiatric liaison team consists of two senior child psychiatrists, of whom I am one, a psychiatric nurse specialist, a child psychiatric resident, and the pediatric social worker. In contrast to the pediatric ward staff, our members have remained the same except for the psychiatric resident who rotates every six months. The latter, supervised by a staff child psychiatrist, handles most of the consultations on pediatrics. A majority of the pediatric inpatients are children from distant parts of Virginia. This factor frequently causes difficulties in providing comprehensive aftercare. Therefore, there are high expectations of our psychiatric liaison team to provide thorough evaluations and short-term treatment of those hospitalized children who show behavior problems. As unrealistic as these expectations often are, continuing education of the young pediatricians is required to help them understand our limited ability to effect major improvements in many of these situations. WARD ROUNDS

The pediatric-psychiatric ward rounds began in November 1970, when I invited myself, the pediatric social worker, our psychiatric nurse, and the child psychiatric resident on consultation service to

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attend regular rounds one morning a week. The pediatric chairman had forcefully supported this innovation and convinced perhaps a third of the staff pediatricians that the child psychiatric input would provide a valuable forum for discussion of behavioral pediatrics and ward management problems. The ward personnel as well as our liaison team soon found that these walking rounds offered little opportunity for a detailed discussion of any patient. After two months the pediatric house staff requested that one attending round a week be given over to our liaison team and for them to form a joint pediatric-psychiatric teaching round. The pediatric interns and residents wanted to present one or two cases to us, and also to have the child and his parents, if possible, interviewed by the leader of the conference. These teachin~ rounds, lasting an hour and a half, have been conducted practIcally every week for the past five years, usually by me. The attendance varies from 8 to 15 persons, including pediatric house officers, nurses, and medical students. In addition to interviewing the patient and his parents in front of the group, I direct the ensuing discussion which centers on developmental and psychosocial issues as they related to the child's disease process. The conference ends by formulating recommendations for the comprehensive care of the patient and his family. The house officers select the childr("n to be discussed and bring specific questions related to psychosoci.l1, diagnostic, and therapeutic issues. Below is a summary of the broad diagnostic categories of the first 125 patients presented and the attendant 'TIajor topics discussed. 1. Long-term physical illness including major revision surgery: about 35 percent of all patients. Most common disorders: congenital heart disease, renal failure, diabetes, asthma, epilepsy, anorexia nervosa, and colitis. Discussion of psychological reactions of the child, his family, and the staff. Delineation of adaptive/maladaptive coping behavior and sociomedical aspects of chronic care (Green, 1967; Mattsson, 1972; Mattsson and Agle, 1972). 2. Eventually fatal disorders: about 15 percent (usually leukemia, malignant tumors, and anemias). Discussion of reaction to and coping with life-shortening disease as experienced by the child and his environment (Easson, 1970; Friedman, 1968; Friedman et aI., 1963; Schowalter, 1970). 3. Acute physical illness complicated by management problems due to acute brain syndrome, anxiety state, and parental overconcern or uncooperativeness: about 12 percent. Discussion of ward management, including use of psychopharmaca and crisis interven-

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tion with patient and parents by child psychiatric staff (Naylor and Mattsson, 1973b; Mattsson and Naylor, 1975). 4. Physical syndromes of less serious nature than (I) to (3), with varying degrees of psychogenic contributory factors, e.g., colic, feeding and growth problems, encopresis, obesity, school phobia, conversion reactions, tension headache, migraine: about 30 per cent. Discussion of organic versus psychosocial determinants, essential diagnostic procedures, and strategies for behavioral pediatric care, emphasizing ambulatory and preventive aspects (Senn and Solnit, 1968; Chamberlin, 1974). 5. Disorders with marked social and legal consequences, e.g., battered child syndrome; mental retardation with issues of appropriate schooling and of court-ordered sterilization: about 8 per cent. Discussion of prompt involvement of our hospital's Child Protection Committee and other appropriate community agencies. The ward discussions have been oriented toward four major educational goals: l. Teaching a developmental approach to the evaluation of somatopsychic reactions and emotional problems encountered in pediatric practice, and to outline realistic recommendations for their immediate and long-term treatment (Green and Senn, 1958). We emphasize, with Lipowski (1972), that a liaison conference confined to a discussion of diagnostic and psychodynamic facets is of little value. Its educational merits depend upon the practical conclusions it can provide. 2. Promoting the understanding of the hospitalized child and his family in terms of their socioemotional interaction in illness and in health (Mason, 1965). The interview of the child, together with the ward observations, usually enables the conference leader to highlight the child's cognitive and social achievements, and to demonstrate emotional factors associated with his illness and his methods of coping with them. 3. Promoting early recognition of management problems with difficult patient and parent situations. Common areas of concern have been the dying child and the "hopeless cases," the acutely disturbed, frightened, or combative child, the markedly anxious and the manipulative parent, and instances of frustration and confusion among house officers and nurses when they find themselves caught in the middle of "superconsultants," often providing opposing instructions. Venting such concerns usually restores good communication among the ward staff, with a direct benefit to the patients. 4. Assisting the professional maturation of the pediatric house

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officers. This additional usefulness of the ward rounds was not conceptualized initially as an important feature of our program. The house officers themselves have made us aware of our broadened role as educators, when several times during the past five years they have requested us to keep our teaching rounds limited to their group for a time, to the exclusion of the attending and any non physician personnel. They have claimed that the teaching value of the rounds can better be retained on as "high a medical plane as possible" by limiting the attendance. A look at some recurrent issues raised by the pediatric trainees during our "closed" sessions disclose their deeper needs, beyond "the high medical plane." First, we often have listened to the house officers' venting of strong personal reactions to certain hospitalized children and their families, situations that caused them to question their competence both in terms of factual knowledge and empathetic interaction with the patients. When alone with us, the house staff have felt that they can "let their hair down" and share their dislikes, frustrations, anger, and anxiety in regard to some aspects of their work. With the ancillary personnel present, they hesitate to show their conflicting emotions, which might be viewed as signs of "weakness." Secondly, the pediatric trainees have used the smaller joint rounds to express occasional criticism of some attending physician and consultants. They might complain about a senior physician who did not inform them about his treatment plan, or who gave explanations to the parents in ways different from the instruction given to them. Some staff pediatricians are said to have little patience with complex social situations and only push for diagnosis and early discharge. Or an attending physician "leaves too much responsibility to us [house staff] in deciding on controversial treatment procedures." Remarks such as these at times reflect misunderstanding and communication difficulties that are unavoidable on any teaching ward. Our liaison team keeps in mind, however, that much of the criticism of the senior staff is derived from the trainee's feelings of incompetence and hewilderment ahout his handling of a patient. He might tend to deal with such distressing feelings by finding fault in his teacher. In this area, we can help the house officer to look beyond his critical, angry attitudes and make him more aware of his own sense of inadequacy and discomfort. On the whole, we have been successful in maintaining the broader educational format of the ward rounds, encouraging the participation of nurses and social workers. Actually, many times the pediatric residents have emphasized the need for all staff to be present at a patient interview and discussion. This was done in a

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ward meeting regarding the complex management problems of a "hopeless case." Case Illustration. Linda, 14 months old, had been deaf and blind since birth and suffered from chronic respiratory distress of unknown origin, possibly due to cardiac vascular malformation. She had been on the ward for several months and remained a diagnostic enigma. Linda was exceedingly difficult to care for in terms of her feeding problems, her respiratory irregularity, and her unresponsiveness due to the sensory defects. Most of the house officers and the nurses voiced great frustration at the hopelessness of Linda's condition. The resident had concentrated on elaborate investigations and inconclusive laboratory findings and overlooked the family problems associated with the case. He was poorly informed about the family history, which showed that Linda's mother had suffered a postpartum depression requiring hospital admission. The parents had felt unable to care for their ill and only child during the short periods of time she had been able to stay at home. The house officers had not told the parents about Linda's critical course in the hospital and had not involved the pediatric social worker who was readily available to them. In coping with their sense of frustration, the house officers complained that some of the many consultants gave partial advice regarding various procedures, but failed to take the whole child into consideration. There was some validity to this criticism which highlighted the lack of continuity in the care of Linda. Two residents felt that the 14-month-old girl was a "worthless case" and that she would "grow up to be a continuous burden to society." One intern strongly voiced the wish that the attending physician should take the responsibility of deciding about a course of inactive treatment of the girl, i.e., euthanasia. One of the child psychiatrists suggested that such a decision is difficult to make even for a senior pediatrician with considerable experience. Several nurses mentioned how they tended to pass the little girl over at rounds, wishing that little would be done in terms of maintaining Linda's life. Another member mentioned that "some of these children just don't die" but continue to live and end up in institutions for the mentally retarded. One nurse called for some "heroic diagnostic measures" which might possibly disclose Linda's underlying disorder and might as well end her life. It became clear that the nurses, representing the continuity of care, were markedly frustrated and angry each time a new house officer or attending physician became involved with the case and ordered additional diagnostic and treatment procedures.

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Our liaison team tried to focus on Linda's "forgotten parents" and their feelings about their seriously ill child. The ward conference ended with the general acknowledgment of our difficulty as physicians to accept readily the care of a "hopeless case, a dying child, a diagnostic enigma." It goes against our grain to accept that "everything possible has been done." The house officers became more aware of how these physician characteristics, along with the monthly turnover of the pediatricians, create significant problems for the nursing staff as well as for the patients and their families.

DISCUSSION

Among the four functions of consultation-liaison psychiatry-diagnostic, therapeutic, teaching, and research activities (Lipowski, 1967, 1971 )-teaching represents a challenging opportunity for the child psychiatrist to demonstrate the practical value of a unified, i.e., developmental and psychosomatic, approach to the investigation and treatment of childhood diseases. The weekly liaison rounds on the pediatric wards have centered on directing the house staff's attention to the biopsychosocial approach to their patients, many of whom suffer from chronic and fatal illnesses. At the same time, we try to provide relevant advice on the diagnostic and therapeutic work with the children presented. Being useful to the staff is the key to successful integration of the child psychiatry team into the pediatric ward functions (Green and Senn, 1958; Lipowski, 1972; Rothenberg, 1968; Schowalter, 1971). Additional advantages of our psychiatric rounds for the pediatric trainees have been their exposure to interviewing techniques with children and families, and the demonstration of positive and negative aspects of patient-parent-staff relationship on the ward (Naylor and Mattsson, 1973b). Finally, the house staff have utilized many ward sessions to share some of their conflicting emotions related to

their trainee status, professional growth, and taxing patient care. At the beginning of each academic year, one or two new pediatric house officers have expressed surprise about the weekly child psychiatric ward rounds. "The other pediatric subspecialists have less frequent formal input on the ward," they correctly note. Their incredulous attitudes toward the value of "so much pediatric psychiatry" have usually waned after a few months, and several of the initially skeptical young pediatricians have requested electives in our child psychiatry division during their senior residency. Formal

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and informal assessments of our ward rounds by the house staff have been highly positive. What are the major reasons for our mutual satisfaction with the joint teaching rounds? The support given by the pediatric chairman and an increasing number of the faculty has been essential. Similarly, the example set by the senior residents, who almost invariably attend our rounds and insist on making practical use of the patient demonstrations, counters skepticism among new house officers. The fact that our pediatric liaison team has remained the same for five years and represents persons with considerable experience in pediatric psychiatry, pediatric social work, and pediatric nursing is, in our opinion, a major reason for the successful launching of the teaching rounds. The Aurry of activities, the moments of anguish, frustration, and helplessness, the fatigue among house officers and nurses, the frequent resistances and impatience toward psychiatry, all intrinsic on a pediatric ward, constitute an atmosphere markedly different from that of most mental health workers' offices. It is our belief that an effective pediatric liaison service requires child mental health specialists with previous training and positive experience in pediatrics (Green and Senn, 1958; Lipowski, 1967; Lourie, 1962; Naylor and Mattsson, 1973a; Schowalter, 1971). After five years of conducting most of the pediatric-psychiatric rounds, I still experience some apprehension before each round. I am seldom informed in advance of the child and the family to be interviewed. My deficient knowledge of new advances in pediatric diagnostics and therapeutics often becomes obvious. Many of the patients prove to be difficult to interview, particularly in front of a large group. Yet, our liaison team usually leaves the pediatric wards with a fresh appreciation of the role of physical illness in the life of a child and his family. Further, we have had the gratifying experience of assisting our pediatric colleagues in comprehensive care planning. Pediatric ward rounds present hard-to-equal opportunities for effective "bedside teaching" of child psychiatry.

REFERENCES ADAMS, P. L. (1968), Techniques for pediatric consultations. In: Handbook of Psychiatm Constdlation. ed. J. J. Schwab. New York: Appleton-Century-Crofts, pp. 107-123. CHAMBERLlN, R. W. (1974), Management of preschool behavior problems. Pediat. Clin. N. Amer.• 21:33--47. EASSON. W. M. (1970), The Dying Child. Springfield, III.: Thomas.

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FRIEDMAN, S. B. (1968), Managemem of fatal illness in children. In: Ambulatory Pediatrics, ed. M. Green and R. J. Haggerty. Philadelphia: Saunders, pp. 753-759. - - - CHODOFF, P., MASON, J. W., & HAMBURG, D. A. (1963), Behavioral observations on parems amicipating the death of a child. Pediatrics, 32:610-625. GREEN, M. (1967), Care of Ihc child with a long-term life-thrcatcning illness. Pediatrics, 39:441-445. - - - & SENN, M. J. E. (1958), Teaching of comprehensive pediatrics on an inpatient hospital service. Pediatrics, 21 :476-490. LIPowsKl, Z. J. (1967), Review of consultation psychiatry and psychosomatic medicine. Psychosom. Med., 29: 153-171. - - - (1971), Consultation-liaison psychiatry in general hospital. Compr. Psychiat., 12:461-465. - - - (1972), Psychiatric liaison with neurology and neurosurgery. Amer. I Psychiat., 129: 136-140. LOURIE, R. S. (1962), The teaching of child psychiatry in pediatrics. This journal, 1:477-489. MASON, E. A. (1965), The hospitalized child. New Eng. I Med., 272:406-414. MATrSSON, A. (1972), Long-term physical illness in childhood. Pediatrics, 50:801-811. - - - & AGLE, D. P. (1972), Group therapy with parents of hemophiliacs. This journal, 11:558-571. - - & NAYLOR, K. (1975), Psychiatric emergencies on the pediatric ward. In: Emergencies in Child Psychiatry, ed. G. C. Morrison. Springfield, 11I.: Thomas, pp. 324-338. NAYLOR, K. & MATrSSON, A. (1973a), "For the sake of the children": Trials and tribulations of child psychiatry liaison service. Psychiat. in Med., 4:389-402. - - - - - - (1973b), Crisis precipitation as observed in pediatric-child psychiatric liaison. Child Psychiat. Hum. Droelpm., 4:86-97. ROTHENBERG, M. B. (1968), Child psychiatry-pediatrics liaison. This journal, 7:492-509. SCHOWALTER,J. E. (1970), Death and the pediatric house officer.I Pediat., 76:706-710. - - - (1971), The utilization of child psychiatry on a pediatric adolescem ward. This journal, 10:684-699. SENN, M. J. E. & SOLNIT, A. J. (1968), Problems in Child Behavior and Development. Philadelphia: Lea & Febiger.

Child psychiatric ward rounds on pediatrics.

Child Psychiatric Ward Rounds on Pediatrics Ake Mattsson, M.D. Abstract. The aUlhor describes lhe child psychialric rounds on Pedialrics and lheir m...
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