CHILD PSYCHIATRY AND PEDIATRICS: AN INTEGRATED APPROACH*
SAUL V. LEVINE, M.D. 1 ARTHUR P. FROESE, M.D.2 DONALD A. STEWART, M.D. 3
Much has been written in recent years about the gap existing between child psychiatry and pediatrics (2,5,12,13,15,16). Many authors cite the lack of mutual understanding, little integrated theory, training, practice, and poor communication as some of the causes of the schism between the two professions. In spite of a growing crisis in both fields (3,25) the gulf appears to be widening - in child psychiatry the authors have been particularly concerned regarding a growing core of elitists whose work often has little to do with reality, and who certainly do not fulfil the expectations or satisfy the needs of pediatricians. There is now voluminous and reliable literature reinforcing the valid criticisms that many children manifest signs of emotional disturbance (8,9,17-19,22), that many more who need psychological intervention do not get it (8,17-19), that lower socioeconomic children who are more in need get even less than their proportionate share of help (8,17,18), and that those children most at long-term risk are least attended to (21,23), that traditional child psychiatric practice systematically rejects 'Manuscript received September 1973. 'Director, Mental Health Clinic, Hospital for Sick Children, Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. 'Assistant Director, Mental Health Clinic, Hospital for Sick Children, Assistant Professor, Department of Psychiatry, University of Toronto. 'Medical Director of Ambulatory Pediatrics, Hospital for Sick Children, Associate Professor of Pediatrics, University of Toronto. Can. Psychiatr. Assoc. J. Vol. 20 (1975)
many children for treatment (4) and the results with those who are treated are not spectacular (6,7,14). Most pediatricians feel that they are overwhelmed by the extent of the prevalence of emotional problems in their patients, and by the lack of good psychiatric services There is no doubt that, given child psychiatry's traditional approach to patients, it will be a millenium before there are adequate numbers of trained personnel doing therapeutic work. Bearing the brunt of the onslaught of children and families in trouble will increasingly continue to be the pediatrician and the family doctor. Thus there is a further paradox, in that professionals with limited training in handling psychosocial problems are on the front lines attempting to handle problems for which they never bargained. Until recently the General Medical OutPatient Clinic of the Hospital for Sick Children in Toronto was suffering from these problems (II). This particular clinic handles more than 50,000 cases a year. As has been reported well over 10 percent of children need some form of psychiatric intervention (8,9,22). This would simply mean that about 5,000 cases a year would be referred to the psychiatry department from the medical outpatient department alone an obviously overwhelming caseload. In the past it had been very difficult for physicians in the medical outpatient department to arrange any kind of referral to the regular psychiatry clinic in this hospital. The
47
48
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Psychiatric Outpatient Clinic, like most others in the city, had operated along mainly traditional lines; there were the inevitable long waiting lists, cases in longterm treatment with an already overburdened and undermanned staff, limitations of physical space, and extensive teaching and service commitments. Thus there was a significant number of patients requiring psychiatric attention (at least evaluation) and not getting it - a common predicament in most child psychiatry facilities. An opportunity for change arose from the interest of the outpatient pediatricians in having a rapid psychiatric intervention centre right on the 'firing line' with them. They also wanted to handle many of the cases themselves and to expand their own knowledge of the management of psychosocial problems of the children and families they were seeing. Mental Health Clinic Consulting earlier models (1, 24, 26) it was decided to establish a new kind of mental health facility in the heart of the Medical Outpatient Department to overcome some of these problems (10, 11). The objectives were (and still are): rapid assessment of the emotional and social problems of patients and their families; consultation to medical personnel in the general medical clinics; brief individual, group or family therapy where indicated and when possible; referral to and close liaison with appropriate community agencies and resources; teaching medical and psychiatric residents and other paramedical staff. The underlying philosophy had four main components - one to serve as a crisis clinic in the pediatric outpatient department for cases requiring relatively immediate attention; the second to serve the needs of a large segment of the inner city population heretoforce largely neglected by psychiatric services; a third goal was to educate as many people as possible in the techniques of psychiatric assessment, interviewing, and management. It was hoped that more and different kinds of patients would present and that preventive work could be done by early case finding and intervention. Fi-
Vol. 20, No.1
nally, it was hoped that this clinical operation would help to bridge the gap between psychiatry and pediatrics in both education and practice. The Mental Health Clinic began as a one morning-a-week psychiatric effort, involving one staff member (S. V.L.) and a psychiatric resident. Within a few weeks people in other departments of the hospital not only became interested but volunteered to work in the clinic, and now at least five separate hospital departments are involved. During each of the five half days the clinic operates there is a different multidisciplinary team - a psychiatric resident, social worker, psychologist and public health nurse. Frequently the referring physician (staff, resident or medical student) plays an integral part in the assessment procedure, but at times it has been necessary to 'reach out' to the patients in order to overcome fear and mistrust of the institution or service. In addition to writing to each family confirming the appointment, they are visited in advance by the public health nurse (arranged by the pediatrician), and reminded the day before the appointment. The public health nurse is an important team member functioning in the community - she visits the home and sees that social histories, school reports, and other information pertinent to each particular case are available before the team meets the family. Sometimes use is made of interpreters, community or indigenous workers, extended family members, already-involved professions or agency personnel to facilitate interviews. Assessments Each team divides its work in the clinic into two parts. During the first part, children and families who had been screened a few days earlier are given a full but rapid psychosocial assessment. In addition to scheduled assessments, there is a drop-in clinic where patients referred from the emergency ward for short-term follow-up are seen, and back-up service offered when the on-call psychiatric resident is over extended. It is also during this first part that individual team members may be doing
February, 1975
CHILD PSYCHIATRY AND PEDIATRICS
short-term psychotherapy, counselling and follow-up interviews. In the formal assessment the team meets with the entire family. After preliminary agreement on the issues to be resolved, the team breaks up into work units. Usually the psychiatric resident sees the child, but not always. After the interviews, the team meets for a discussion of findings and suggestions for intervention. Following this the findings are discussed and recommendation made to the family. These might involve psychotherapy of all types (behaviour, short term, family, and so on), counselling medication, contacts with community resources, referrals or collaboration with other agencies, - Big Brother, Family Service, Children's Aid, legal aid, and so on - day care centres, or nurseries, ethnic services, job retraining, financial support, mother's helpers and home visits. The teams are autonomous and hence vary in their approaches; the members' special interest and talents are taken into consideration when assigning specific clinical roles or duties, and they often function as coordinators of community resources rather than as traditional psychotherapists - that is, they involve themselves in effecting change. They make the contacts, appointments and other arrangements in those cases necessitating referral to more appropriate resources. In assessments, there is a tendency to deal more from the point of view of family strengths rather than psychopathology, and more with current or recent environmental stresses than with presumed historical derivation. In therapeutic work, orientation must take a practical approach, and function in any way which will achieve the goals in the shortest possible time. The task is removal or amelioration of circumscribed debilitating symptoms, relief of the family's complaints and answering the questions posed by the pediatrician. For these types of intervention to be successful the individual team members must be considerably more active and flexible than orthodox theory permits. The referring pediatricians who are involved playa role in both the evaluation and the corrective
49
intervention. With experience and readily available back-up, many of the techniques employed can be used by pediatricians, medical students, nurses, and other workers. Consultation The second part of the team's work is even more valuable because during this period consultation to the pediatric staff, house staff and medical students is the main concern, teaching and enabling them to manage cases on their own. Due to the location within the heart of the general medical clinic itself, access and visibility are not problems. To these are added availability - the team is there to be utilized, to be approachable and cooperative. Pediatricians often bring their clinical problems and the cases are either discussed without seeing them personally from the points of view of what to look for, diagnosis, management, referrals, or the team sits in with the consultee for a brief direct clinical evaluation of the child and family. However, this may not involve the whole team, so that a number of consultations can be done simultaneously. In most cases it can be decided on the basis of either of these methods which is the best form and plan of intervention. If the consultant feels that more investigation is indicated he brings the child back on his team's day for a more complete assessment, as described above. All referrals to the Mental Health Clinic are made by the pediatricians in the various outpatient clinics, but all will have been discussed in consultation prior to a more formal assessment. In this way the team does the 'intake' and 'screening' for its own evaluation work. Due mainly to the second method of functioning, two important results are obtained - the staff of the Mental Health Clinic are considered to be an integral part of the health team, (there is an active give-andtake, mutual respect and 'good vibes'); the pediatricians are doing their own initial evaluations and screening, and are becoming increasingly adept at managing many cases on their own. Because of the nature of this operation, screening, evaluating, and treating many
50
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
more patients in a shorter period of time by teams of people assuming various roles is done. For a detailed breakdown of patients' ethnic, socioeconomic, clinical characteristics, and related methods of intervention, readers can consult an earlier publication (11). The waiting list for formal assessments is negligible and families and children in crisis can be seen at the time of their most urgent need and the best for intervention. Management of the individual cases depends upon a variety of factors, such as the diagnosis, chronicity versus crisis state, sociocultural background of the family, availability of resources, and so on. It is important to note that only five percent of all the patients seen have been referred for intensive psychotherapy. Most children and their families seem to do well with the approaches outlined earlier. It has been found most valuable to retain a flexible stance, not only from the point of view of the children's needs but from the perspective of the satisfaction and effectiveness of the staff. This is not an easy patient population to work with and the track record of similar ventures has not been impressive. The team's approach has been in operation for four years, and is likely to expand into a full-time representation in the medical outpatient department. This partly attributed to the relative longevity of the team structure - the different members serve to stimulate, reinforce, and support each other. This is especially important when the going gets tough, when the work is not resulting in the immediate feedback of satisfaction learned in medical school. Finally, pediatric staff are now seen (and see themselves) as integral members of the clinic. They are willing to take responsibility for some cases which heretofore were referred elsewhere, and not only do they take part in the work of the Mental Health Clinic but, if supervised, are often eager to assess and manage some cases on their own. As a by-product of providing this service, an interesting phenomenon has taken place. The small teams of the Mental Health Clinic are incorporated into the larger family health team structure in the medical clinic as a whole, where a free and communicative atmosphere pervades the working environ-
Vol. 20, No.1
ment, which is a mandatory criterion for this type of setup. The relationships between the pediatricians and psychiatrists in the outpatient department are unique in their frankness, mutual respect .and acceptance. Here the psychiatrist is accepted as a full partner in the health-care delivery program and there is an easy give-and-take and exchange of ideas, which has greatly facilitated the working together during the latter part of the half-day sessions -- that is during consultations. The pediatricians (faculty, staff, resident) do not utilize the service as a dumping ground, but they feel increasingly free to discuss problems, criticize the mental health team's opinion and playa role in the organization and functioning of the Mental Health Clinic. They also give the Mental Health Clinic a high priority and make themselves available for cases in which they are involved. Further, and most important, the pediatricians are learning a tremendous amount about picking up, assessing, and managing emotional problems of all types in the families they are seeing. There are, of course, some cases which require psychiatric or other intensive intervention, but for a large variety of psychosocial problems the pediatrician or family doctor can manage perfectly well. Part of the task is to learn to discriminate between those cases which can be managed alone, and those 'needing' consultation or referrals. Over a period of time, the pediatricians become adept at some forms of crucial psychological intervention. They fully realize that the Mental Health Clinic team will work closely with them, supervise if requested, consult on demand, and take direct action if necessary. Similarly, cases can be reconsidered if it is felt that some issues have been overlooked, or if management can just as readily be provided by the pediatrician. This flexible method of operation lends itself to the teaching and training of a wide variety of professionals and students. In addition to medical students, pediatric interns, pediatric residents and psychiatric residents, social work students, nursing students, psychology undergraduates and graduate students all use the Mental Heald,
February, 1975
CHILD PSYCHIATRY AND PEDIATRICS
Clinic as an integral part of their training. The pediatric trainees learn the developmental aspects of emotions, psychosocial issues, normal coping mechanisms and adaptive processes, transitional stages and crises, family and individual dynamics, psychopathological states, assessment procedures, theories and techniques of intervention, and how to function with a number of different professionals on a team. They learn about community organization and how to best utilize the resources in the community. They develop a sense of competence and self-confidence when confronted with emotional problems in their patients. On the other hand, the psychiatric trainees learn these, and much more about normal development, physical illnesses and their effects on children and their families, rapid assessments and intervention techniques, and a realistic appraisal of their part in the total health delivery schema. They learn which kinds of cases lend themselves best to their particular expertise and which can be handled as well by others, also about the frustrations of others in working with large numbers of emotionally disturbed families and being unable to get adequate psychiatric help. They also learn humility, the limitations of their work, and some reality is interjected into their education. Conclusion The method of functioning of the Mental Health Clinic and its close liaison with Pediatrics have had a significant impact on service and education. There is tremendous interest in this work, both theoretically and practically, so much so that one wonders about a radical departure from the traditional concepts of teaching and practising child psychiatry. It is felt that this model could serve as a prototype for the provision of psychological services to children and families and for the training of both mental health professionals and pediatricians. There are serious problems facing pediatrics and child psychiatry and more medical care is being provided on an outpatient basis, and heretofore underserviced and neglected populations are finally clamouring for good physical and mental health
51
care. The psychological needs of the community wiII not be served by child psychiatry as it is now practised. The theory, practice, number of personnel, implicit biases - all mitigate against these goals. No attempt is being made to make second rate psychiatrists out of pediatricians. However, it must be realized that many of the emotional problems of children and adolescents can be successfully resolved by the correct intervention at the right time, and that this can be accomplished by different people with the proper training and experince. Pediatricians probably see more of these youngsters than do other professionals (followed by teachers) and psychiatrists only see a miniscule proportion of children harbouring symptoms and signs of emotional distress. It must also be admitted that even if traditional psychiatric techniques were proven to be effective (a big 'if'), the mental health needs of the children and adolescents in the community would stilI never be satisfied. It would be more logical to deploy a variety of trained people to do assessment and treatment, with psychiatrists providing supervision, consultation, and back-up service. The wide array of trainees and students trained in the Mental Health Clinic attests that therapeutic intervention with troubled families is not the sole domain of the psychiatrist. There have been many criticisms leveled at the contemporary training and practice of pediatricians: not enough attention paid to child development (20), insufficient regard for patients' emotions (14), too many patients per hour (25) and so on. It would be inappropriate for child psychiatrists to join that chorus and litany - our own house cleaning must be done. Child psychiatrists often act as if their task were ordained by Divine Right. There is no cause for complacency or self-satisfaction; there are many major theoretical and practical dilemmas (4). The results are questionable, the patients highly selected, and too often hypothetical conjecture or theoretical dogma is treated as empirically corroborated evidence. Child psychiatrists are stilI single-case-oriented, and tend to avoid well-controlled research. Child guidance
52
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Vol. 20, No.1
clinics and child psychiatrists often remain 6. Heinicke, C. M. and Goldman, A.: Research on psychotherapy with children: a wedded to a rigid protocol and single review and suggestions for further study. theoretical bias, a constant method of interAm. J. Orthopsychiatry. 30: 3,1960. vention. Child psychiatry is in fact a profession at 7. Hood-Williams, 1.: The results of psychotherapy with children: a rethe crossroads (12, 13). It can either prove evaluation. Am. J. Orthopsychiatry. 24: 1, itself to be a viable profession and grow in 1960. stature and importance or it can die an 8. Joint Commission on Mental Health of ignoble death - a demise hastened by Children: Crisis of child mental health, New irrelevance, inefficiency and invalidity. York, Harper and Row, 1970. There are as many prognosticators predict9. Lapouse, R. and Monk, M.: An ing the one as the other. It stands in danger epidemiological study of behavioural characteristics of children. Am. J. Public of isolating itself from adult psychiatry, Health. 48: 35,1958. basic science, behavioural science, medicine, social services and social issues 10. Levine, S. V.: Proverty and psychiatry: a mini approach to a maxi problem. Canada's and of isolating itself out of existence. Mental Health. 18: 2,1970. If the two professions (child psychiatry 11. Levine, S. V.: The inner city: setting, suband pediatrics) could be more integrated in groups, psychopathology, service. Am. J. their training programs and actual clinical Orthopsychiatry. 41: 1, January, 1971. work, the patients and their doctors would 12. Levine, S. V.: Objectives and priorities in benefit. To echo Eisenberg (3) If Not Now, child psychiatry training, or "Somethin' is When? Happenin' But You Don't Know What It Is, Do You, Mr. Jones?". Presentation to LaidSummary law Foundation Workshop, Val David, Traditional child psychiatry cannot meet Quebec, 1974. the heavy demands placed upon it for ser- 13. Levine, S. V.: The future of child psychiatvice, partly because of its anachronistic ry: mandate for change. Presentation to theoretical and clinical approaches. In an American Orthopsychiatry Association Meeting, San Franciso, 1974. innovative multidisciplinary program the authors have attempted to overcome some 14. Levitt, E.: The results of psychotherapy with children. J. Consult. Clin Psychol. 21: of these problems by integrating mental 189-196,1957. health teams in the pediatric outpatient de15. Lourie, R.: The teaching of child psychiatry partment, where the action is. It has been in pediatrics. J. Am. Acad. Child Psychiatfound that teaching and practise in both ry.I: 477,1962. specialties are enhanced by this approach, 26. Lourie, R. Communication between pediatand may have significant implications for rician and psychiatrist: retrospect and prostraining programs and clinical work. pect. Pediatrics. 37: 6, 1966. Refereuces 1. Chess, S. and Lyman, M.: A psychiatric
unit in a general hospital pediatric clinic. Am. J. Orthopsychiatry. 39: 1, 77-85, 1969. 2. Eisenberg, L.: The relationship between psychiatry and pediatrics: a disputations view. Pediatrics. 39: 5, 1967. 4. Eisenberg, L.: Child Psychiatry: The past quarter century. Am. J -. Orthopsychiatry. 39:389-401,1969. 5. Gabriel, H. and Danitowicz, D.: Psychiatry concepts in pediatric residencies. NIMH supported training Program Review. 44: 939,1969.
27. One Million Children - The Ce1dic Report: National Study of Canadian Children with Emotional and Learning Problems. Crainford, Ontario, 1970. 20. Richmond, J.: Child development: a basic science for pediatrics. Pediatrics. 39: 5, 1967. 21. Robins, L.: Deviant Children Grown Up. Baltimore, Williams and Wilkins, 1966. 22. Rutter, M., Tizard J. and Whitmore, K.: Education, Health and Behaviour. New York, Wiley, 1971. 23. Ryan, W.: On distrubed children: who is to care for them? The National, June, 1966. 24. Schowalter, 1. and Solnit, A.: Child psychology consultation in a general hospi-
February, 1975
CHILD PSYCHIATRY AND PEDIATRICS
tal emergency room. J. Am. Acad. Child Psychiatry. 5: 534,1966. 25. Smith, Richard T.: Pediatrics at a crossroad. Pediatrics. 40: 5,1968. 26. Tisza, V. and Richardson, M.: The integration of a mental health program and a child psychiatry unit into a pediatric hospital. Pediatrics. 17: 1,1956.
Resume La psychiatrie infantile traditionnelle ne peut repondre a la pressante demande de
53
service que l'on attend d'elle, en partie a cause de ses conceptions theoriques et cliniques depassees. Les auteurs, grace aun programme multidisciplinaire original, ont cherche a surmonter certaines de ces difficultes, en integrant les equipes de sante mentale au service externe de pediatrie ou se donnent les consultations. On a constate qu' enseignement et exercice se trouvent ameliores dans les deux disciplines grace a cette facon de faire. On peut, de la, tirer d'importantes consequences pour les programmes de formation et Ie travail clinique.
Ifyou take a way a sick Childfrom its Parent or Nurse you break its Heart immediately: also, if there must be a Nurse to each Child what kind ofan Hospital must there be to contain any Number ofthem . .. . Add to all this it very seldom happens that a Mother can conveniently leave the Rest ofher Family to go into an Hospital to attend her sick infant.
George Armstrong d. 1781
SAUL V. LEVINE, M.D. 1 ARTHUR P. FROESE, M.D.2 DONALD A. STEWART, M.D. 3
Much has been written in recent years about the gap existing between child psychiatry and pediatrics (2,5,12,13,15,16). Many authors cite the lack of mutual understanding, little integrated theory, training, practice, and poor communication as some of the causes of the schism between the two professions. In spite of a growing crisis in both fields (3,25) the gulf appears to be widening - in child psychiatry the authors have been particularly concerned regarding a growing core of elitists whose work often has little to do with reality, and who certainly do not fulfil the expectations or satisfy the needs of pediatricians. There is now voluminous and reliable literature reinforcing the valid criticisms that many children manifest signs of emotional disturbance (8,9,17-19,22), that many more who need psychological intervention do not get it (8,17-19), that lower socioeconomic children who are more in need get even less than their proportionate share of help (8,17,18), and that those children most at long-term risk are least attended to (21,23), that traditional child psychiatric practice systematically rejects 'Manuscript received September 1973. 'Director, Mental Health Clinic, Hospital for Sick Children, Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. 'Assistant Director, Mental Health Clinic, Hospital for Sick Children, Assistant Professor, Department of Psychiatry, University of Toronto. 'Medical Director of Ambulatory Pediatrics, Hospital for Sick Children, Associate Professor of Pediatrics, University of Toronto. Can. Psychiatr. Assoc. J. Vol. 20 (1975)
many children for treatment (4) and the results with those who are treated are not spectacular (6,7,14). Most pediatricians feel that they are overwhelmed by the extent of the prevalence of emotional problems in their patients, and by the lack of good psychiatric services There is no doubt that, given child psychiatry's traditional approach to patients, it will be a millenium before there are adequate numbers of trained personnel doing therapeutic work. Bearing the brunt of the onslaught of children and families in trouble will increasingly continue to be the pediatrician and the family doctor. Thus there is a further paradox, in that professionals with limited training in handling psychosocial problems are on the front lines attempting to handle problems for which they never bargained. Until recently the General Medical OutPatient Clinic of the Hospital for Sick Children in Toronto was suffering from these problems (II). This particular clinic handles more than 50,000 cases a year. As has been reported well over 10 percent of children need some form of psychiatric intervention (8,9,22). This would simply mean that about 5,000 cases a year would be referred to the psychiatry department from the medical outpatient department alone an obviously overwhelming caseload. In the past it had been very difficult for physicians in the medical outpatient department to arrange any kind of referral to the regular psychiatry clinic in this hospital. The
47
48
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Psychiatric Outpatient Clinic, like most others in the city, had operated along mainly traditional lines; there were the inevitable long waiting lists, cases in longterm treatment with an already overburdened and undermanned staff, limitations of physical space, and extensive teaching and service commitments. Thus there was a significant number of patients requiring psychiatric attention (at least evaluation) and not getting it - a common predicament in most child psychiatry facilities. An opportunity for change arose from the interest of the outpatient pediatricians in having a rapid psychiatric intervention centre right on the 'firing line' with them. They also wanted to handle many of the cases themselves and to expand their own knowledge of the management of psychosocial problems of the children and families they were seeing. Mental Health Clinic Consulting earlier models (1, 24, 26) it was decided to establish a new kind of mental health facility in the heart of the Medical Outpatient Department to overcome some of these problems (10, 11). The objectives were (and still are): rapid assessment of the emotional and social problems of patients and their families; consultation to medical personnel in the general medical clinics; brief individual, group or family therapy where indicated and when possible; referral to and close liaison with appropriate community agencies and resources; teaching medical and psychiatric residents and other paramedical staff. The underlying philosophy had four main components - one to serve as a crisis clinic in the pediatric outpatient department for cases requiring relatively immediate attention; the second to serve the needs of a large segment of the inner city population heretoforce largely neglected by psychiatric services; a third goal was to educate as many people as possible in the techniques of psychiatric assessment, interviewing, and management. It was hoped that more and different kinds of patients would present and that preventive work could be done by early case finding and intervention. Fi-
Vol. 20, No.1
nally, it was hoped that this clinical operation would help to bridge the gap between psychiatry and pediatrics in both education and practice. The Mental Health Clinic began as a one morning-a-week psychiatric effort, involving one staff member (S. V.L.) and a psychiatric resident. Within a few weeks people in other departments of the hospital not only became interested but volunteered to work in the clinic, and now at least five separate hospital departments are involved. During each of the five half days the clinic operates there is a different multidisciplinary team - a psychiatric resident, social worker, psychologist and public health nurse. Frequently the referring physician (staff, resident or medical student) plays an integral part in the assessment procedure, but at times it has been necessary to 'reach out' to the patients in order to overcome fear and mistrust of the institution or service. In addition to writing to each family confirming the appointment, they are visited in advance by the public health nurse (arranged by the pediatrician), and reminded the day before the appointment. The public health nurse is an important team member functioning in the community - she visits the home and sees that social histories, school reports, and other information pertinent to each particular case are available before the team meets the family. Sometimes use is made of interpreters, community or indigenous workers, extended family members, already-involved professions or agency personnel to facilitate interviews. Assessments Each team divides its work in the clinic into two parts. During the first part, children and families who had been screened a few days earlier are given a full but rapid psychosocial assessment. In addition to scheduled assessments, there is a drop-in clinic where patients referred from the emergency ward for short-term follow-up are seen, and back-up service offered when the on-call psychiatric resident is over extended. It is also during this first part that individual team members may be doing
February, 1975
CHILD PSYCHIATRY AND PEDIATRICS
short-term psychotherapy, counselling and follow-up interviews. In the formal assessment the team meets with the entire family. After preliminary agreement on the issues to be resolved, the team breaks up into work units. Usually the psychiatric resident sees the child, but not always. After the interviews, the team meets for a discussion of findings and suggestions for intervention. Following this the findings are discussed and recommendation made to the family. These might involve psychotherapy of all types (behaviour, short term, family, and so on), counselling medication, contacts with community resources, referrals or collaboration with other agencies, - Big Brother, Family Service, Children's Aid, legal aid, and so on - day care centres, or nurseries, ethnic services, job retraining, financial support, mother's helpers and home visits. The teams are autonomous and hence vary in their approaches; the members' special interest and talents are taken into consideration when assigning specific clinical roles or duties, and they often function as coordinators of community resources rather than as traditional psychotherapists - that is, they involve themselves in effecting change. They make the contacts, appointments and other arrangements in those cases necessitating referral to more appropriate resources. In assessments, there is a tendency to deal more from the point of view of family strengths rather than psychopathology, and more with current or recent environmental stresses than with presumed historical derivation. In therapeutic work, orientation must take a practical approach, and function in any way which will achieve the goals in the shortest possible time. The task is removal or amelioration of circumscribed debilitating symptoms, relief of the family's complaints and answering the questions posed by the pediatrician. For these types of intervention to be successful the individual team members must be considerably more active and flexible than orthodox theory permits. The referring pediatricians who are involved playa role in both the evaluation and the corrective
49
intervention. With experience and readily available back-up, many of the techniques employed can be used by pediatricians, medical students, nurses, and other workers. Consultation The second part of the team's work is even more valuable because during this period consultation to the pediatric staff, house staff and medical students is the main concern, teaching and enabling them to manage cases on their own. Due to the location within the heart of the general medical clinic itself, access and visibility are not problems. To these are added availability - the team is there to be utilized, to be approachable and cooperative. Pediatricians often bring their clinical problems and the cases are either discussed without seeing them personally from the points of view of what to look for, diagnosis, management, referrals, or the team sits in with the consultee for a brief direct clinical evaluation of the child and family. However, this may not involve the whole team, so that a number of consultations can be done simultaneously. In most cases it can be decided on the basis of either of these methods which is the best form and plan of intervention. If the consultant feels that more investigation is indicated he brings the child back on his team's day for a more complete assessment, as described above. All referrals to the Mental Health Clinic are made by the pediatricians in the various outpatient clinics, but all will have been discussed in consultation prior to a more formal assessment. In this way the team does the 'intake' and 'screening' for its own evaluation work. Due mainly to the second method of functioning, two important results are obtained - the staff of the Mental Health Clinic are considered to be an integral part of the health team, (there is an active give-andtake, mutual respect and 'good vibes'); the pediatricians are doing their own initial evaluations and screening, and are becoming increasingly adept at managing many cases on their own. Because of the nature of this operation, screening, evaluating, and treating many
50
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
more patients in a shorter period of time by teams of people assuming various roles is done. For a detailed breakdown of patients' ethnic, socioeconomic, clinical characteristics, and related methods of intervention, readers can consult an earlier publication (11). The waiting list for formal assessments is negligible and families and children in crisis can be seen at the time of their most urgent need and the best for intervention. Management of the individual cases depends upon a variety of factors, such as the diagnosis, chronicity versus crisis state, sociocultural background of the family, availability of resources, and so on. It is important to note that only five percent of all the patients seen have been referred for intensive psychotherapy. Most children and their families seem to do well with the approaches outlined earlier. It has been found most valuable to retain a flexible stance, not only from the point of view of the children's needs but from the perspective of the satisfaction and effectiveness of the staff. This is not an easy patient population to work with and the track record of similar ventures has not been impressive. The team's approach has been in operation for four years, and is likely to expand into a full-time representation in the medical outpatient department. This partly attributed to the relative longevity of the team structure - the different members serve to stimulate, reinforce, and support each other. This is especially important when the going gets tough, when the work is not resulting in the immediate feedback of satisfaction learned in medical school. Finally, pediatric staff are now seen (and see themselves) as integral members of the clinic. They are willing to take responsibility for some cases which heretofore were referred elsewhere, and not only do they take part in the work of the Mental Health Clinic but, if supervised, are often eager to assess and manage some cases on their own. As a by-product of providing this service, an interesting phenomenon has taken place. The small teams of the Mental Health Clinic are incorporated into the larger family health team structure in the medical clinic as a whole, where a free and communicative atmosphere pervades the working environ-
Vol. 20, No.1
ment, which is a mandatory criterion for this type of setup. The relationships between the pediatricians and psychiatrists in the outpatient department are unique in their frankness, mutual respect .and acceptance. Here the psychiatrist is accepted as a full partner in the health-care delivery program and there is an easy give-and-take and exchange of ideas, which has greatly facilitated the working together during the latter part of the half-day sessions -- that is during consultations. The pediatricians (faculty, staff, resident) do not utilize the service as a dumping ground, but they feel increasingly free to discuss problems, criticize the mental health team's opinion and playa role in the organization and functioning of the Mental Health Clinic. They also give the Mental Health Clinic a high priority and make themselves available for cases in which they are involved. Further, and most important, the pediatricians are learning a tremendous amount about picking up, assessing, and managing emotional problems of all types in the families they are seeing. There are, of course, some cases which require psychiatric or other intensive intervention, but for a large variety of psychosocial problems the pediatrician or family doctor can manage perfectly well. Part of the task is to learn to discriminate between those cases which can be managed alone, and those 'needing' consultation or referrals. Over a period of time, the pediatricians become adept at some forms of crucial psychological intervention. They fully realize that the Mental Health Clinic team will work closely with them, supervise if requested, consult on demand, and take direct action if necessary. Similarly, cases can be reconsidered if it is felt that some issues have been overlooked, or if management can just as readily be provided by the pediatrician. This flexible method of operation lends itself to the teaching and training of a wide variety of professionals and students. In addition to medical students, pediatric interns, pediatric residents and psychiatric residents, social work students, nursing students, psychology undergraduates and graduate students all use the Mental Heald,
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CHILD PSYCHIATRY AND PEDIATRICS
Clinic as an integral part of their training. The pediatric trainees learn the developmental aspects of emotions, psychosocial issues, normal coping mechanisms and adaptive processes, transitional stages and crises, family and individual dynamics, psychopathological states, assessment procedures, theories and techniques of intervention, and how to function with a number of different professionals on a team. They learn about community organization and how to best utilize the resources in the community. They develop a sense of competence and self-confidence when confronted with emotional problems in their patients. On the other hand, the psychiatric trainees learn these, and much more about normal development, physical illnesses and their effects on children and their families, rapid assessments and intervention techniques, and a realistic appraisal of their part in the total health delivery schema. They learn which kinds of cases lend themselves best to their particular expertise and which can be handled as well by others, also about the frustrations of others in working with large numbers of emotionally disturbed families and being unable to get adequate psychiatric help. They also learn humility, the limitations of their work, and some reality is interjected into their education. Conclusion The method of functioning of the Mental Health Clinic and its close liaison with Pediatrics have had a significant impact on service and education. There is tremendous interest in this work, both theoretically and practically, so much so that one wonders about a radical departure from the traditional concepts of teaching and practising child psychiatry. It is felt that this model could serve as a prototype for the provision of psychological services to children and families and for the training of both mental health professionals and pediatricians. There are serious problems facing pediatrics and child psychiatry and more medical care is being provided on an outpatient basis, and heretofore underserviced and neglected populations are finally clamouring for good physical and mental health
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care. The psychological needs of the community wiII not be served by child psychiatry as it is now practised. The theory, practice, number of personnel, implicit biases - all mitigate against these goals. No attempt is being made to make second rate psychiatrists out of pediatricians. However, it must be realized that many of the emotional problems of children and adolescents can be successfully resolved by the correct intervention at the right time, and that this can be accomplished by different people with the proper training and experince. Pediatricians probably see more of these youngsters than do other professionals (followed by teachers) and psychiatrists only see a miniscule proportion of children harbouring symptoms and signs of emotional distress. It must also be admitted that even if traditional psychiatric techniques were proven to be effective (a big 'if'), the mental health needs of the children and adolescents in the community would stilI never be satisfied. It would be more logical to deploy a variety of trained people to do assessment and treatment, with psychiatrists providing supervision, consultation, and back-up service. The wide array of trainees and students trained in the Mental Health Clinic attests that therapeutic intervention with troubled families is not the sole domain of the psychiatrist. There have been many criticisms leveled at the contemporary training and practice of pediatricians: not enough attention paid to child development (20), insufficient regard for patients' emotions (14), too many patients per hour (25) and so on. It would be inappropriate for child psychiatrists to join that chorus and litany - our own house cleaning must be done. Child psychiatrists often act as if their task were ordained by Divine Right. There is no cause for complacency or self-satisfaction; there are many major theoretical and practical dilemmas (4). The results are questionable, the patients highly selected, and too often hypothetical conjecture or theoretical dogma is treated as empirically corroborated evidence. Child psychiatrists are stilI single-case-oriented, and tend to avoid well-controlled research. Child guidance
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CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
Vol. 20, No.1
clinics and child psychiatrists often remain 6. Heinicke, C. M. and Goldman, A.: Research on psychotherapy with children: a wedded to a rigid protocol and single review and suggestions for further study. theoretical bias, a constant method of interAm. J. Orthopsychiatry. 30: 3,1960. vention. Child psychiatry is in fact a profession at 7. Hood-Williams, 1.: The results of psychotherapy with children: a rethe crossroads (12, 13). It can either prove evaluation. Am. J. Orthopsychiatry. 24: 1, itself to be a viable profession and grow in 1960. stature and importance or it can die an 8. Joint Commission on Mental Health of ignoble death - a demise hastened by Children: Crisis of child mental health, New irrelevance, inefficiency and invalidity. York, Harper and Row, 1970. There are as many prognosticators predict9. Lapouse, R. and Monk, M.: An ing the one as the other. It stands in danger epidemiological study of behavioural characteristics of children. Am. J. Public of isolating itself from adult psychiatry, Health. 48: 35,1958. basic science, behavioural science, medicine, social services and social issues 10. Levine, S. V.: Proverty and psychiatry: a mini approach to a maxi problem. Canada's and of isolating itself out of existence. Mental Health. 18: 2,1970. If the two professions (child psychiatry 11. Levine, S. V.: The inner city: setting, suband pediatrics) could be more integrated in groups, psychopathology, service. Am. J. their training programs and actual clinical Orthopsychiatry. 41: 1, January, 1971. work, the patients and their doctors would 12. Levine, S. V.: Objectives and priorities in benefit. To echo Eisenberg (3) If Not Now, child psychiatry training, or "Somethin' is When? Happenin' But You Don't Know What It Is, Do You, Mr. Jones?". Presentation to LaidSummary law Foundation Workshop, Val David, Traditional child psychiatry cannot meet Quebec, 1974. the heavy demands placed upon it for ser- 13. Levine, S. V.: The future of child psychiatvice, partly because of its anachronistic ry: mandate for change. Presentation to theoretical and clinical approaches. In an American Orthopsychiatry Association Meeting, San Franciso, 1974. innovative multidisciplinary program the authors have attempted to overcome some 14. Levitt, E.: The results of psychotherapy with children. J. Consult. Clin Psychol. 21: of these problems by integrating mental 189-196,1957. health teams in the pediatric outpatient de15. Lourie, R.: The teaching of child psychiatry partment, where the action is. It has been in pediatrics. J. Am. Acad. Child Psychiatfound that teaching and practise in both ry.I: 477,1962. specialties are enhanced by this approach, 26. Lourie, R. Communication between pediatand may have significant implications for rician and psychiatrist: retrospect and prostraining programs and clinical work. pect. Pediatrics. 37: 6, 1966. Refereuces 1. Chess, S. and Lyman, M.: A psychiatric
unit in a general hospital pediatric clinic. Am. J. Orthopsychiatry. 39: 1, 77-85, 1969. 2. Eisenberg, L.: The relationship between psychiatry and pediatrics: a disputations view. Pediatrics. 39: 5, 1967. 4. Eisenberg, L.: Child Psychiatry: The past quarter century. Am. J -. Orthopsychiatry. 39:389-401,1969. 5. Gabriel, H. and Danitowicz, D.: Psychiatry concepts in pediatric residencies. NIMH supported training Program Review. 44: 939,1969.
27. One Million Children - The Ce1dic Report: National Study of Canadian Children with Emotional and Learning Problems. Crainford, Ontario, 1970. 20. Richmond, J.: Child development: a basic science for pediatrics. Pediatrics. 39: 5, 1967. 21. Robins, L.: Deviant Children Grown Up. Baltimore, Williams and Wilkins, 1966. 22. Rutter, M., Tizard J. and Whitmore, K.: Education, Health and Behaviour. New York, Wiley, 1971. 23. Ryan, W.: On distrubed children: who is to care for them? The National, June, 1966. 24. Schowalter, 1. and Solnit, A.: Child psychology consultation in a general hospi-
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CHILD PSYCHIATRY AND PEDIATRICS
tal emergency room. J. Am. Acad. Child Psychiatry. 5: 534,1966. 25. Smith, Richard T.: Pediatrics at a crossroad. Pediatrics. 40: 5,1968. 26. Tisza, V. and Richardson, M.: The integration of a mental health program and a child psychiatry unit into a pediatric hospital. Pediatrics. 17: 1,1956.
Resume La psychiatrie infantile traditionnelle ne peut repondre a la pressante demande de
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service que l'on attend d'elle, en partie a cause de ses conceptions theoriques et cliniques depassees. Les auteurs, grace aun programme multidisciplinaire original, ont cherche a surmonter certaines de ces difficultes, en integrant les equipes de sante mentale au service externe de pediatrie ou se donnent les consultations. On a constate qu' enseignement et exercice se trouvent ameliores dans les deux disciplines grace a cette facon de faire. On peut, de la, tirer d'importantes consequences pour les programmes de formation et Ie travail clinique.
Ifyou take a way a sick Childfrom its Parent or Nurse you break its Heart immediately: also, if there must be a Nurse to each Child what kind ofan Hospital must there be to contain any Number ofthem . .. . Add to all this it very seldom happens that a Mother can conveniently leave the Rest ofher Family to go into an Hospital to attend her sick infant.
George Armstrong d. 1781
