Handbook of Psychiatric Consultation with Children and Youth PDF
Preview Handbook of Psychiatric Consultation with Children and Youth
HANDBOOK OF PSYCHIATRIC CONSULTATION WITH CHILDREN AND YOUTH Edited by Nonnan R. Bernstein, M.D. Department of Psychiatry University of Illinois Chicago, Illinois and James Sussex, M.D. Department of Psychiatry University of Miami Miami, Florida MTPi!~ LIMITED International Medical Publishers Published in the UK and Europe by MTP Press, Limited Falcon House Lancaster, England Published in the US by SPECTRUM PUBLICATIONS, INC. 175 -20 Wexford Terrace Jamaica, NY 11432 Copyright © 1984 by Spectrum Publications, Inc. Softcover reprint of the hardcover 1st edition 1984 All rights reserved. No part of this book may be repro duced in any form, by photostat, microfilm, retrieval sys tem, nor any other means without prior written permission of the copyright holder or his licensee. ISBN-13: 978-94-011-6706-2 e-ISBN-13: 978-94-011-6704-8 DOl: 10.1007/978-94-011-6704-8 Dedicated to Marilyn, Genya and Michael Contributors Robert S. Adams, M.D .• Psychiatrist-Director, The Child Guidance Clinic of Waterbury, Inc., Waterbury, Connecticut; Associate Clinical Professor, Yale Child Study Center, New Haven, Connecticut Nonnan R. Bernstein, M.D .• Professor of Psychiatry, University of illinois, Chicago, Illinois John G. Clark, Jr., M.D .• Director, The American Facmily Foundation, Weston, Massachusetts; Assistant Clinical Professor, Harvard Medical School at Massa chusetts General Hospital, Boston, Massachusetts Raquel Cohen, M.D. • Associate Director of Child/Adolescent Division, and Associate Professor of Psychiatry, University of Miami School of Medicine, Miami, Florida Donald D. Dunton, M.D .• Professor of Psychiatry, Columbia University, New York, New York Philip DiMattia, Ph.D .• Principal Director of the Gaebler School, Waltham, Massachusetts; Assistant Professor of Special Education and Rehabilitation, Boston College, Chestnut Hill, Massachusetts Norbert B. Enzer, M.D .• Associate Dean of Academic Affairs, and Professor of Psychiatry, Michigan State University College of Human Medicine, East Lansing, Michigan Susan M. Fisher, M.D. • Lecturer and Consultant Psychiatrist, University of Chicago Pritzker School of Medicine, Chicago, illinois v vi CONTRIBUTORS Donald S. Gair, M.D .• Professor and Chairman, Department of Child Psychiatry Boston University School of Medicine, Boston, Massachusetts; Superintendent, Gaebler Children's Center, Waltham, Massachusetts Joseph M. Green, M.D .• Professor of Psychiatry and Director of Child Psy chiatry, University of Wisconsin, Madison, Wisconsin Thomas P. Hackett, M.D .• Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts; Chief of Psychiattic Service, Massachusetts General Hospital, Boston, Massachusetts Richmond Holder, M.D .• Director of Training, Adolescent Psychiatry, Mclean Hospital, Belmont, Massachusetts; Instructor, Harvard Medical School, Boston, Massachusetts Irving Hurwitz, Ph.D .• Professor of Educational Psychology, Boston College, Chestnut Hill, Massachusetts Michael D. Lagone, Ph.D .• Director of Research, The American Family Founda tion, Weston, Massachusetts John F. McDermott, Jr., M.D .• Chief of Psychiatry, University of Hawaii at Monoa, Honolulu, Hawaii Joseph D. Noshpitz, M.D .• Professor of Psychiatry, Department of Psychiatry, Children's Hospital, George Washington University, Washington, D.C. Eva Poznanski, M.D .• Professor of Psychiatry, University of illinois Health Sci ences Center, Chicago, illinois Elizabeth Aub Reid, M.D .• Director of Training and Psychiatrist to Harvard University Health Service, Cambridge, Massachusetts; Assistant Clinical Pro fessor, Tufts University, Medical School, Boston, Massachusetts; Instructor of Psychiatry, Harvard Medical School, Boston, Massachusetts John B. Reinhart, M.D. • Professor of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania William H. Sack, M.D .• Professor of Psychiatry and Chief of Child Psychiatry, University of Oregon, Portland, Oregon CONTRIBUTORS vii Marshall D. Schechter, M.D .• Professor and Director, Division of Child and Adolescent Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania James Sussex, M.D .• Professor and Chairman, Department of Psychiatry, Univ ersity of Miami, Miami, Florida George Tatjan, M.D .• Professor Emeritus of Psychiatry and Chief, Division of Child Psychiatry and Mental Retardation, University of California, Los Angeles; Past President, American Academy of Child Psychiatry, Washington, D.C.; Pres ident, American Psychiatric Association, Washington, D.C. Hugh C. Thompson, M.D .• Professor of Community Medicine (pediatrics), University of Arizona, Tucson, Arizona Jack C. Westman, M.D .• Professor of Psychiatry, University of Wisconsin, Mad ison, Wisconsin Virginia N. Wilking, M.D .• Fonner Director, Division of Child Psychiatry, Har lem Hospital Medical Center, New York, New York; Special Lecturer, College of Physicians and Surgeons, Columbia University, New York, New York Lee H. Willer, M.D .• Associate Clinical Professor, Tufts University School of Medicine, Boston, Massachusetts Herbert M. Woodcock, M.D .• Associate Professor of Psychiatry and Pediatrics, University of Oregon, Portland, Oregon Henry H. WOJK, M.D .• Professor of Psychiatry, George Washington Medical School, Washington, D.C.; Deputy Director Emeritus, American Psychiatric As sociation, Washington, D.C. Preface I have spent the best part of the last quarter of a century working on the con sultation service at the Massachusetts General Hospital. Much of my satisfaction has stemmed from working with nonpsychiatric physicians, especially in having them come to realize the value of psychological methods in the treatment of their patients. It has always been my belief that learning to understand the patient's mental life was as much a part of medicine as the taking of vital signs. To treat adequately, certainly to treat well, a physician must know something of his patient's thought processes. Teaching others the value of this knowledge is the first step in educating them to seek ways of learning it themselves. Rarely can this be done in the lecture hall. One can best pique curiosity by demon strating worth, and that is done at the bedside or in whatever setting the con sultation is carried out. Every consultation then carries an implicit imperative to attest its value. It can be covert teaching at its best. I have found the practice of consultation psychiatry satisfying and compelling enough to want to remain in it for at least another quarter of a century . The consulting situations described in this excellent volume range through many settings, yet the core elements remain constant. Whether you are brought in to examine a frightened child in a pediatric intensive care unit or to talk with an anxious teenager in the ghetto, the consultant deals with nonpsychiatrists or nonphysicians who want an answer now and want it to work now. The con sultant must learn another vocabulary. He must be able to translate his thinking into a nontechnical, understandable language. Often, the consultant must be able to persuade someone to do something he doesn't want to do. And much of this must be conducted in territory that is alien and unfriendly. I think that the role of psychiatric consultant requires of the candidate a need for excitement. The authors assembled by Drs. Bernstein and Sussex are seasoned profes sionals who not only bear the mantle of authority, but bring to the reader a ix x PREFACE genuine sense of the action in their consultancies. These authors all share a trait that is a hallmark of the career consultant, a penchant for the practical. There is no time for lofty theorizing in the fast lane traffic described in these chapters. There is a message to be learned for all psychiatric consultants in whatever setting they may practice from the recent evolution of the consultation/liaison movement in this country. Prior to the mid-1970s consultation psychiatry (and I include the concept of liaison in this heading) was practiced by a small band of individuals. We all knew each other by ftrst name. Largely as the result of two forces, consultation psychiatry, in the last decade, has emerged as a subspecialty. The ftrst of these forces is Public Law 94-484, Health Professions Education Assistance Act of 1976. This legislation emphasized the need to increase the number of primary care doctors-internists, family medicine practitioners, and pediatricians. It also recognized the necessity to include psychosocial skills in their training. It did so by insuring that federal money would be available to pay for their training. In this way, psychiatrists could receive salary support for teaching nonpsychiatric physicians. The second factor was the policy of the Psychiatric Education Branch of the National Institute of Mental Health (NIMH) which, starting in 1974, gave speciftc encouragement in the form of fellowship program support to the development of consultation liaison services in general hospitals. Not since 1934, when Alan Gregg advised the Rockefeller Foundation to provide start-up funds for ftve psychiatric programs to be started in general hospitals, has consultation psychiatry received such a boost. The ftckleness of federal funding now threatens to put the blight on these programs for psychiatric consultation. Without federal support will the consulta tion movement wither? Our fate is largely in the hands of third-party payers. Unfortunately, this puts us in lively competition with other medical and surgical specialties, where we are handicapped from the outset by being a time-based specialty. We are further disadvantaged because we lack sufficient evidence to show that our interventions are cost effective. While we can do little to alter the fact that time units constitute our basis for payment, we can and must devise research projects to demonstrate the cost beneftt gains from consultation ac tivities. This can be done. It should have been attended to long ago. I would advise my fellow consultants, wherever they consult, to think of ways to prove that your efforts not only help patients, but save money for those who pay the bill. THOMAS P. HACKETT, M.D. Professor ofP sychiatry Harvard Medical School Chief, Psychiatric Service Massachusetts General Hospital Contents Contributors v Preface ix Thomas P. Hackett Acknowledgments xv Introduction 1 George Tarjan 1. The Temperament and Preparation of the Consultant 5 Norman R. Bernstein and H. Donald Dunton THE CONSULTANT, THE FAMILY, AND DIVORCE 2. The psychiatmt as a Consultant in Divorce and Custody 21 John F. McDermott, Jr. 3. The Child Psychiatrist in Consultation within the Legal System 47 Marshall D. Schechter 4. Family Assessment 71 Jack C. Westman xi xii CONTENTS 5. Consultation for Adolescents 85 Joseph D. Noshpitz THE CONSULT ANT IN THE CLINICAL SETTING 6. Child Psychiatry Consultation in a Pediatric Ward 105 William H. Sack and Herbert M. Woodcock 7. Consultation with Highly Stressed Mental Health Professionals- The "Anchor Wo Jker" 127 Susan M. Fisher and Irving Hurwitz 8. Consulting to a Rural Guidance Clinic 137 Joseph M. Green 9. Consultation in Outpatient Settings 149 Norbert B. Enzer THE CONSULTANT AND THE EDUCATIONAL SYSTEM 10. Teachers and Classrooms 169 Philip DiMattia 11. Administration and the Therapist: Consultation Conflicts and Alliances in the College Community 185 Elizabeth Aub Reid 12. Consulting at Boarding Schools 197 Richmond Holder 13. Consultation: Two Worlds in a Factory Town 213 Robert S. Adams 14. Staff Consultation in a Public School System 229 Lee H. Willer SPECIAL PERSPECTNES 15. The Pediatric Perspective 249 Hugh C. Thompson
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