Child Psychiatry and Human Development Volume 1, Number 1, Fall, 1970
Child Psychiatry and Pediatrics in Medical School Medical Center Settings* William S. Langford, M.D.
Children's Psychiatric Services, Columbia. Presbyterian Medical Center, New York
ABSTRACT: The various ways in which Child Psychiatry can function in relation to Pediatrics in Medical School Medical Center settings are outlined and summarized; the author draws on his own experience and on those of others working in a number of different settings. While the precise details of teaching arrangements and clinical activities depend on the nature of individual settings, the general goals and approaches are common to all, as are the multiple functions of the child psychiatrist in his clinical and didactic teaching, his consultative, diagnostic and treatment activities. Although the greater part of his efforts are usually directed to the attending and resident pediatric staff, nurses and all of the other hospital staff involved in the care of the child patients are included to varying degrees in the teaching and consultative operations. His influence on the hospital administration is of highest importance. The relationship of a medical school to its clinical services does not follow a uniform pattern in the United States. There may be a true university hospital whose clinical departments are administratively an integral part of the medical school. The clinical services may be situated in one or more affiliated hospital services which retain to a large extent their own institutional and administrative identity. In a particular medical school setting the relationship of the Department of Pediatrics to the Division of Child Psychiatry to a large extent will depend on the local "ground rules." The nature of the total clinical services and the administrative arrangements may be as important as the particular teaching and clinical personnel in Child Psychiatry vnd Pediatrics in determining the nature of the relationship. Some pediatric services have their own Divisions of Child Psychiatry which provide a spectrum of consultative, diagnostic, and treatment services; here the Child Psychiatry staff may be an integral part of the pediatric hospital staff or may be supplied on a full- or part-time basis by the Division of Child Psychiatry. Other patterns involve the provision by Child Psychiatry only o f consultative or referral services with little or no treatment being carried out in the Pediatric setting. * This paper was originally prescribed at the Conference of Child Psychiatry Division Chiefs, University of Florida, Gainesville, February, 1969.
W. S. Langford
27
It seems quite clear that the working relationship between Child Psychiatry and Pediatrics should be dose. Their mutual concerns for children and the overlapping clinical activities open vistas for many joint teaching and training opportunities, for clinical investigative programs, and for improving comprehensive health care for children. Althoughpediatric psychiatric liaison arrangements had their beginnings more than twoscore years ago, there are many areas where the rapprochement still wavers. Changes in departmental key personnel can lead to shifts in program emphasis as the attitudes of newly appointed younger staff and house staff are influenced by the trickling down from the top of new and different attitudes. The current tendency to finance departmental operations i n some pediatric settings by research grants has had its influence on the teaching of residents and medical students, and decreased the interest in many residents in going into pediatric practice. The availability Of specialized training stipends for pediatric subspecialties such as neonatology, hematology, cardiology has also tended to focus the learner's mind on disease categories and away from the comprehensive medical care of children. Recently a medical student critique gave "electrolyte rounds" as the best part of their pediatric clerkship. In the 1960's the emphasis on the whole Child is as much needed as it was thirty years ago ! In other settings the balance of research and comprehensive clinical care programs has been maintained. One director imported a comprehensive pediatric practitioner so that there would be someone on the staff who could teach residents and medical students how to take care of sick children, since the heavy emphasis on research had left no such person on the staff. The child psychiatrist finds himself more at ease in the latter type of situation. His efforts atcommunicating knowledge from his field find a more receptive ear. However, the demands for service for teaching, and for program consultation, may be too great for the Child Psychiatry Division to meet with limited staff and budget. This may lead to resentments and a breakdown of smooth working relationships unless good communications are fostered and constantly worked at. Most child psychiatrists would agree that the primary area of contact should be around particular clinical cases in which members of the pediatric staff are actively involved and interested with less emphasis on more didactic teaching sessions. In these clinical contacts he will find certain cases which might well be treated on a child psychiatry service; with these the basic clinical responsibility and therapeutic activity in psychiatric. Other clinical situations are best treated on the pediatric service; here the basic clinical responsibility is shared, as for example, ulcerative colitis. A third group of cases are those where the primary clinical responsibility remains with the pediatric staff and the child psychiatrist's role is that of the consultant. The basic goals of child psychiatric training on pediatric services are: 1. To aid the pediatrician-in-training to practice well rounded "comprehensive
28
Child Psychiatry and Human Development
pediatrics" with attention to and awareness of the emotional implications in all of his day-by-day activities with his child patients and their parents. 2. To aid the pediatrician in the preventive mental health aspects of his practice. 3. To develop in him a capacity to recognize clinical psychiatric syndromes, to understand his diagnostic and therapeutic competeneies and limitations, and to know how and where to refer those cases needing definitive child psychiatric care.
The basic body of knowledge developed in the field of child psychiatry and other disciphnes with the teaching program includes at various levels and in different teaching arrangements (lecture, conference, seminar, ward rounds, direct supervision, etc.) includes the following topics: 1. Mental (emotional, social, intellectual) growth and development and behavior of infants from birth to maturity with the consideration of the interplay of somatic, psychologic, interpersonal, and cultural forces. 2. The psychological implications of child rearing, especially in terms of parent-child relationships. 3. The psychologic concomitants of physical illness and the role of the physician, nurse, and hospital in the treatment of children, sick and convalescent, as well as their role in parental guidance. 4. Deviant personality structure and psychopathology, especially psychosomatic relationships with emphasis on genesis, prevention, diagnosis, and treatment. 5. Opportunities for psychotherapy in pediatric practice along with knowledge of the limitations of such endeavors. The teaching arrangements through which these goals are reached vary on pediatric services where a child psychiatrist might be assigned. They include: 1. Formal conferences where cases with psychiatric import are presented and discussed. 2. Seminars for discussion of personality growth and development, parentchild interactions, adaptations to illness, etc. 3. Attendance of the child psychiatrist on pediatric ward rounds with his participation in the discussion of various cases. 4. Consultation services on referred cases from the wards or outpatient service. 5. Consultation services in the well baby clinic. 6. Availability of the child psychiatrist for consultation by the pediatric staff on an informal basis on the wards, in the outpatient department, in the dining room, utilizing whatever comes up as grist for the teaching mill. 7. Rotation of the pediatric house officer through the child psychiatry service for a specified period of time for experience in supervised diagnostic and treatment work with selected children and their parents, and a more intensive learning experience than can be achieved through other teaching arrangements.
W. $. Langford
29
The child psychiatrist attached to a pediatric service functions in a variety of ways. His clinical activities serve as a base for his teaching, and would seem important for him no matter what the nature of the local pediatric setting, Teaching in the absence of dinieal activity is a dull and sterile process for most physicians. These functions include: 1. Direct diagnosis of children to varying degrees depending on the amount of service the child psychiatrist or child psychiatric unit provides on the pediatric setting. 2. Direct treatment of children in psychotherapy and with pharmacological agents (see I above), 3. Direct counselling or psychotherapy of parents. 4. Consultation. This will comprise a large segment of his activities. It includes consultation with all those individuals concerned with the care of the child on the pediatric service: a. Pediatric staff h. Other medical staff including general and special surgical staff, roentgenology and radiotherapy, physiatry, endocrinology, anesthesiology, etc. c. Nursing staff d. Recreational personnel e. Physiotherapists and occupational therapists f. Ward aids and kitchen maids g. Administrative staff h. Visiting pediatric staff around patients from their practice 5. Supervision and clinical teaching. a. Of child psychiatry trainees as they rotate through the pediatric service for training b. Of pediatric residents as they are assigned to the child psychiatry unit or as they continue to take care of a child where the child psychiatrist does not assume the primary dinical responsibility c. Of medical students on the child psychiatry or pediatric clerkship d. Of nurses and student nurses (clinical teaching) 6. Didactic teaching. The child psychiatrist assigned to a pediatric service may be asked to give lectures to: a. Pediatric residents and staff b. Medical students c. Staff or student nurses d. Occupational and physiotherapists e. Non-professional ward staff for indoctrination purposes f. Other professional groups such as dental and orthodontal students 7. Research-planning or participation. The child psychiatrist may be consulted in the planning of research by various members of the pediatric or other medical staff. He may participate directly in
30
Child Psychiatry and Human Development
these activities; he may also set up studies of his own. These have involved a host of clinical conditions on which child psychiatrists assigned to pediatric services have reported. These include the psychological implications of rheumatic fever and rheumatic heart disease, diabetes, coeliac disease, ulcerative colitis, anorexia nervosa, leukemia, familial dysautonomia and other chronic illnesses, surgical experiences the reactions of children and their families to illness, to death, to visiting privileges. In addition to these clinically centered investigative projects, others have become involved in more basic psychiatric investigations concerned with paranatal hypoxia, individual differences in newborns, etc. The opportunity is present and most pediatric services encourage such activities. 8. Community education-prevention. Child psychiatrists working on pediatric services are frequently called to serve on community board committees having to do with various aspects of child welfare or child health. These include medical society child welfare committees to child care agencies. They may also be invited to speak at pediatric meetings or staff meetings, or other hospitals about emotional aspects of children, or more specifically, on topics related to preventive psychiatry. A good deal of the activity with the pediatric staff is related to the preventive aspects of pediatric practice. 9. Administration. The child psychiatrist in the pediatric setting may have great influence on administrative decisions relating to hospital or outpatient care of children. These include admission procedures, visiting regulations, various hospital routines, provision of recreational and educational programs, etc. Such decisions may be made by either the medical chief or the hospital administrator. A good working relationship with these individuals is of highest importance. In addition, depending on the particular setting, the child psychiatrist may be involved in the administration of a child psychiatry unit with all of the usual administrative aspects of such a clinical facility. In order to function optimally on a pediatric service, the child psychiatrist, in addition to being well trained, should have great flexibility. It may be very difficult to introduce into a pediatric service procedures and techniques developed in other settings. For example, when a consultation request is received from a pediatric ward, a formal intake procedure which works well in a child psychiatry clinic will leave the pediatrician frustrated if he needs immediate help on the management of an oppositional three year old on the ward. The child psychiatrist should have some knowledge of the usual pediatric practice in hospitals, outpatient departments, and private offices. He should have some awareness of the background and level of understanding of the pediatric and other groups involved so that in his teaching arrangements he can "begin where they are." A respect for the validity o f the professional activities o f the pediatrician and an awareness of his special problems is of great importance in all consultation and teaching work. The child psychiatrist may, in his frustration
W. S. Langford
31
when some o f his pet notions are n o t being accepted at face value, retire to ex cathedra statements or, in his insecurity in his new setting, regress to the previous level of comfortable functioning and apply in toto the methodologies with which he feels most at ease. "When in doubt, do a formal mental status[" Where clinical psychologists and psychiatric case workers are a part of the child psychiatry unit in the pediatric setting, some shifts in the traditional approach may become important as they work directly with the pediatric or hospital staff. In setting up child psychiatry units or assigning child psychiatrists to a pediatric setting, it is important that the child psychiatrist be reasonably comfortable in the medical setting; that he know that there are limitations in his knowledge and experience, as well as in the field; that he be willing to learn something about pediatric practice and problems if he is not already familiar with them; that he b e flexible and personally mature with a respect and tolerance for other people and their foibles. He should not become unduly anxious when faced with severe illness in children or chronic illness with fatal outcome. He should not become frustrated or impatient with new residents, new students, or new nursing staff rotating through the teaching service and seem to shred the careful educative work he has clone before. A pediatric background may help but may also be a hindrance; a particular individual may have left the field because of personal dissatisfaction and harbor a real disaffection for pediatrics and pediatricians which can seriously impair his effectiveness as a liaison child psychiatrist. A pediatric service with child psychiatry liaison can provide opportunities for supplementing the learning experiences trainees in child psychiatry have in the basic child psychiatry setting. These include: 1. Acute emergency outpatient problems. In the medical school medical center setting, children with acute problems (including psychiatric) are usually brought to the pediatric emergency clinic. The child psychiatry trainee can then have an opportunity to see these early and should have a regular "on call" rotation. 2. Consultations on physically ill children enable the child psychiatry resident to learn much about the ways in which children of different ages handle the stresses of illness, hospitalization, anesthesia, surgery, and various diagnostic procedures. These children exposed to acute, and at times almost overwhelming, stress give the child psychiatry trainee new insights. 3. Supervised learning experiences in the art of consultation can be provided in the pediatric setting. Many residents are more comfortable in medical settings and the basic principles of consultative activities are more easily learned by many in this setting than in others. I have tried to sketch in the highlights of Child Psychiatry activities in pediatric settings. It seems to me that the relationship between a Division of
32
Child Psychiatry and Human Development
Child Psychiatry and a Department of Pediatrics is most clearly defined by describing what a child psychiatrist can do as he works in a pediatric clinical service and takes part in its activities. In the foregoing I have stressed what he can impart to the pediatric staff if the opportunity is ripe. My observations of necessity have been colored by thirty-three and a half years (since October, 1935) of close work with a pediatric service. In this professional lifetime there have been many rewards, many frustrations, and many occasions when I wanted to run for cover. The rewards came when at Medical Center reunions young and older graduates of the school and the services pop in and tell me about children they have seen and how they have tried to help them and their parents. These are the rewards of one who tries to share what he has learned with others - the gut satisfactions that mean the most. Dr. Langford is Professor in Psychiatry, and Chief, Division of Child Psychiatry, College of Physicians and Surgeons, Columbia University, and Director of the Children's Psychiatric Services, Columbia.Presbyterian Medical Center, New York.
Child Psychiatry and Pediatrics in Medical School Medical Center Settings* William S. Langford, M.D.
Children's Psychiatric Services, Columbia. Presbyterian Medical Center, New York
ABSTRACT: The various ways in which Child Psychiatry can function in relation to Pediatrics in Medical School Medical Center settings are outlined and summarized; the author draws on his own experience and on those of others working in a number of different settings. While the precise details of teaching arrangements and clinical activities depend on the nature of individual settings, the general goals and approaches are common to all, as are the multiple functions of the child psychiatrist in his clinical and didactic teaching, his consultative, diagnostic and treatment activities. Although the greater part of his efforts are usually directed to the attending and resident pediatric staff, nurses and all of the other hospital staff involved in the care of the child patients are included to varying degrees in the teaching and consultative operations. His influence on the hospital administration is of highest importance. The relationship of a medical school to its clinical services does not follow a uniform pattern in the United States. There may be a true university hospital whose clinical departments are administratively an integral part of the medical school. The clinical services may be situated in one or more affiliated hospital services which retain to a large extent their own institutional and administrative identity. In a particular medical school setting the relationship of the Department of Pediatrics to the Division of Child Psychiatry to a large extent will depend on the local "ground rules." The nature of the total clinical services and the administrative arrangements may be as important as the particular teaching and clinical personnel in Child Psychiatry vnd Pediatrics in determining the nature of the relationship. Some pediatric services have their own Divisions of Child Psychiatry which provide a spectrum of consultative, diagnostic, and treatment services; here the Child Psychiatry staff may be an integral part of the pediatric hospital staff or may be supplied on a full- or part-time basis by the Division of Child Psychiatry. Other patterns involve the provision by Child Psychiatry only o f consultative or referral services with little or no treatment being carried out in the Pediatric setting. * This paper was originally prescribed at the Conference of Child Psychiatry Division Chiefs, University of Florida, Gainesville, February, 1969.
W. S. Langford
27
It seems quite clear that the working relationship between Child Psychiatry and Pediatrics should be dose. Their mutual concerns for children and the overlapping clinical activities open vistas for many joint teaching and training opportunities, for clinical investigative programs, and for improving comprehensive health care for children. Althoughpediatric psychiatric liaison arrangements had their beginnings more than twoscore years ago, there are many areas where the rapprochement still wavers. Changes in departmental key personnel can lead to shifts in program emphasis as the attitudes of newly appointed younger staff and house staff are influenced by the trickling down from the top of new and different attitudes. The current tendency to finance departmental operations i n some pediatric settings by research grants has had its influence on the teaching of residents and medical students, and decreased the interest in many residents in going into pediatric practice. The availability Of specialized training stipends for pediatric subspecialties such as neonatology, hematology, cardiology has also tended to focus the learner's mind on disease categories and away from the comprehensive medical care of children. Recently a medical student critique gave "electrolyte rounds" as the best part of their pediatric clerkship. In the 1960's the emphasis on the whole Child is as much needed as it was thirty years ago ! In other settings the balance of research and comprehensive clinical care programs has been maintained. One director imported a comprehensive pediatric practitioner so that there would be someone on the staff who could teach residents and medical students how to take care of sick children, since the heavy emphasis on research had left no such person on the staff. The child psychiatrist finds himself more at ease in the latter type of situation. His efforts atcommunicating knowledge from his field find a more receptive ear. However, the demands for service for teaching, and for program consultation, may be too great for the Child Psychiatry Division to meet with limited staff and budget. This may lead to resentments and a breakdown of smooth working relationships unless good communications are fostered and constantly worked at. Most child psychiatrists would agree that the primary area of contact should be around particular clinical cases in which members of the pediatric staff are actively involved and interested with less emphasis on more didactic teaching sessions. In these clinical contacts he will find certain cases which might well be treated on a child psychiatry service; with these the basic clinical responsibility and therapeutic activity in psychiatric. Other clinical situations are best treated on the pediatric service; here the basic clinical responsibility is shared, as for example, ulcerative colitis. A third group of cases are those where the primary clinical responsibility remains with the pediatric staff and the child psychiatrist's role is that of the consultant. The basic goals of child psychiatric training on pediatric services are: 1. To aid the pediatrician-in-training to practice well rounded "comprehensive
28
Child Psychiatry and Human Development
pediatrics" with attention to and awareness of the emotional implications in all of his day-by-day activities with his child patients and their parents. 2. To aid the pediatrician in the preventive mental health aspects of his practice. 3. To develop in him a capacity to recognize clinical psychiatric syndromes, to understand his diagnostic and therapeutic competeneies and limitations, and to know how and where to refer those cases needing definitive child psychiatric care.
The basic body of knowledge developed in the field of child psychiatry and other disciphnes with the teaching program includes at various levels and in different teaching arrangements (lecture, conference, seminar, ward rounds, direct supervision, etc.) includes the following topics: 1. Mental (emotional, social, intellectual) growth and development and behavior of infants from birth to maturity with the consideration of the interplay of somatic, psychologic, interpersonal, and cultural forces. 2. The psychological implications of child rearing, especially in terms of parent-child relationships. 3. The psychologic concomitants of physical illness and the role of the physician, nurse, and hospital in the treatment of children, sick and convalescent, as well as their role in parental guidance. 4. Deviant personality structure and psychopathology, especially psychosomatic relationships with emphasis on genesis, prevention, diagnosis, and treatment. 5. Opportunities for psychotherapy in pediatric practice along with knowledge of the limitations of such endeavors. The teaching arrangements through which these goals are reached vary on pediatric services where a child psychiatrist might be assigned. They include: 1. Formal conferences where cases with psychiatric import are presented and discussed. 2. Seminars for discussion of personality growth and development, parentchild interactions, adaptations to illness, etc. 3. Attendance of the child psychiatrist on pediatric ward rounds with his participation in the discussion of various cases. 4. Consultation services on referred cases from the wards or outpatient service. 5. Consultation services in the well baby clinic. 6. Availability of the child psychiatrist for consultation by the pediatric staff on an informal basis on the wards, in the outpatient department, in the dining room, utilizing whatever comes up as grist for the teaching mill. 7. Rotation of the pediatric house officer through the child psychiatry service for a specified period of time for experience in supervised diagnostic and treatment work with selected children and their parents, and a more intensive learning experience than can be achieved through other teaching arrangements.
W. $. Langford
29
The child psychiatrist attached to a pediatric service functions in a variety of ways. His clinical activities serve as a base for his teaching, and would seem important for him no matter what the nature of the local pediatric setting, Teaching in the absence of dinieal activity is a dull and sterile process for most physicians. These functions include: 1. Direct diagnosis of children to varying degrees depending on the amount of service the child psychiatrist or child psychiatric unit provides on the pediatric setting. 2. Direct treatment of children in psychotherapy and with pharmacological agents (see I above), 3. Direct counselling or psychotherapy of parents. 4. Consultation. This will comprise a large segment of his activities. It includes consultation with all those individuals concerned with the care of the child on the pediatric service: a. Pediatric staff h. Other medical staff including general and special surgical staff, roentgenology and radiotherapy, physiatry, endocrinology, anesthesiology, etc. c. Nursing staff d. Recreational personnel e. Physiotherapists and occupational therapists f. Ward aids and kitchen maids g. Administrative staff h. Visiting pediatric staff around patients from their practice 5. Supervision and clinical teaching. a. Of child psychiatry trainees as they rotate through the pediatric service for training b. Of pediatric residents as they are assigned to the child psychiatry unit or as they continue to take care of a child where the child psychiatrist does not assume the primary dinical responsibility c. Of medical students on the child psychiatry or pediatric clerkship d. Of nurses and student nurses (clinical teaching) 6. Didactic teaching. The child psychiatrist assigned to a pediatric service may be asked to give lectures to: a. Pediatric residents and staff b. Medical students c. Staff or student nurses d. Occupational and physiotherapists e. Non-professional ward staff for indoctrination purposes f. Other professional groups such as dental and orthodontal students 7. Research-planning or participation. The child psychiatrist may be consulted in the planning of research by various members of the pediatric or other medical staff. He may participate directly in
30
Child Psychiatry and Human Development
these activities; he may also set up studies of his own. These have involved a host of clinical conditions on which child psychiatrists assigned to pediatric services have reported. These include the psychological implications of rheumatic fever and rheumatic heart disease, diabetes, coeliac disease, ulcerative colitis, anorexia nervosa, leukemia, familial dysautonomia and other chronic illnesses, surgical experiences the reactions of children and their families to illness, to death, to visiting privileges. In addition to these clinically centered investigative projects, others have become involved in more basic psychiatric investigations concerned with paranatal hypoxia, individual differences in newborns, etc. The opportunity is present and most pediatric services encourage such activities. 8. Community education-prevention. Child psychiatrists working on pediatric services are frequently called to serve on community board committees having to do with various aspects of child welfare or child health. These include medical society child welfare committees to child care agencies. They may also be invited to speak at pediatric meetings or staff meetings, or other hospitals about emotional aspects of children, or more specifically, on topics related to preventive psychiatry. A good deal of the activity with the pediatric staff is related to the preventive aspects of pediatric practice. 9. Administration. The child psychiatrist in the pediatric setting may have great influence on administrative decisions relating to hospital or outpatient care of children. These include admission procedures, visiting regulations, various hospital routines, provision of recreational and educational programs, etc. Such decisions may be made by either the medical chief or the hospital administrator. A good working relationship with these individuals is of highest importance. In addition, depending on the particular setting, the child psychiatrist may be involved in the administration of a child psychiatry unit with all of the usual administrative aspects of such a clinical facility. In order to function optimally on a pediatric service, the child psychiatrist, in addition to being well trained, should have great flexibility. It may be very difficult to introduce into a pediatric service procedures and techniques developed in other settings. For example, when a consultation request is received from a pediatric ward, a formal intake procedure which works well in a child psychiatry clinic will leave the pediatrician frustrated if he needs immediate help on the management of an oppositional three year old on the ward. The child psychiatrist should have some knowledge of the usual pediatric practice in hospitals, outpatient departments, and private offices. He should have some awareness of the background and level of understanding of the pediatric and other groups involved so that in his teaching arrangements he can "begin where they are." A respect for the validity o f the professional activities o f the pediatrician and an awareness of his special problems is of great importance in all consultation and teaching work. The child psychiatrist may, in his frustration
W. S. Langford
31
when some o f his pet notions are n o t being accepted at face value, retire to ex cathedra statements or, in his insecurity in his new setting, regress to the previous level of comfortable functioning and apply in toto the methodologies with which he feels most at ease. "When in doubt, do a formal mental status[" Where clinical psychologists and psychiatric case workers are a part of the child psychiatry unit in the pediatric setting, some shifts in the traditional approach may become important as they work directly with the pediatric or hospital staff. In setting up child psychiatry units or assigning child psychiatrists to a pediatric setting, it is important that the child psychiatrist be reasonably comfortable in the medical setting; that he know that there are limitations in his knowledge and experience, as well as in the field; that he be willing to learn something about pediatric practice and problems if he is not already familiar with them; that he b e flexible and personally mature with a respect and tolerance for other people and their foibles. He should not become unduly anxious when faced with severe illness in children or chronic illness with fatal outcome. He should not become frustrated or impatient with new residents, new students, or new nursing staff rotating through the teaching service and seem to shred the careful educative work he has clone before. A pediatric background may help but may also be a hindrance; a particular individual may have left the field because of personal dissatisfaction and harbor a real disaffection for pediatrics and pediatricians which can seriously impair his effectiveness as a liaison child psychiatrist. A pediatric service with child psychiatry liaison can provide opportunities for supplementing the learning experiences trainees in child psychiatry have in the basic child psychiatry setting. These include: 1. Acute emergency outpatient problems. In the medical school medical center setting, children with acute problems (including psychiatric) are usually brought to the pediatric emergency clinic. The child psychiatry trainee can then have an opportunity to see these early and should have a regular "on call" rotation. 2. Consultations on physically ill children enable the child psychiatry resident to learn much about the ways in which children of different ages handle the stresses of illness, hospitalization, anesthesia, surgery, and various diagnostic procedures. These children exposed to acute, and at times almost overwhelming, stress give the child psychiatry trainee new insights. 3. Supervised learning experiences in the art of consultation can be provided in the pediatric setting. Many residents are more comfortable in medical settings and the basic principles of consultative activities are more easily learned by many in this setting than in others. I have tried to sketch in the highlights of Child Psychiatry activities in pediatric settings. It seems to me that the relationship between a Division of
32
Child Psychiatry and Human Development
Child Psychiatry and a Department of Pediatrics is most clearly defined by describing what a child psychiatrist can do as he works in a pediatric clinical service and takes part in its activities. In the foregoing I have stressed what he can impart to the pediatric staff if the opportunity is ripe. My observations of necessity have been colored by thirty-three and a half years (since October, 1935) of close work with a pediatric service. In this professional lifetime there have been many rewards, many frustrations, and many occasions when I wanted to run for cover. The rewards came when at Medical Center reunions young and older graduates of the school and the services pop in and tell me about children they have seen and how they have tried to help them and their parents. These are the rewards of one who tries to share what he has learned with others - the gut satisfactions that mean the most. Dr. Langford is Professor in Psychiatry, and Chief, Division of Child Psychiatry, College of Physicians and Surgeons, Columbia University, and Director of the Children's Psychiatric Services, Columbia.Presbyterian Medical Center, New York.
