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Use of Tandem Teams in Child Mental Health Training of Medical Students and Pediatric House Staff
Use of Tandem Teams in Child Mental Health Training of Medical Students and Pediatric House Staff
Theodore R. Lanning, M.D. and H. Paul Gabriel, M.D.
The psychiatric unit of the New York University Pediatric Project is part of a large inpatient and outpatient comprehensive pediatric service located in Bellevue Hospital. As originally established and described by Chess and Lyman (1969), it provided consultative evaluation services, crisis intervention, and short-term therapy to a wide variety of patients on an "immediate" basis. However, as early as 1962, there was increasing interest in training as well as service on the part of pediatric house staff and fourth-year medical students on elective in pediatrics. Initially, training was approached through the usual mechanism of clinic conferences, inpatient conferences, and ward rounds, with variable but slowly improving success. At the same time, a number of supervised outpatient electives had been offered for half-time and full-time trainees, who came for periods of 2 to 6 months. Evaluations were taught by the case supervision method, based on the usual model utilized in mental health clinics with mental health trainees who had some background in the field. While this was an honored and traditional method, the medical students, pediatric house staff, and clinic senior staff were dissatisfied for a number of reasons. For the medical students, who varied from second to fourth year, initial encounters with patient and/or parents provoked anxiety. Furthermore, they felt that written interview guides and standard descriptions of play sessions were not helpful in interpreting children's behavior. The pediatric house staff shared some of the students' feelings and also reflected varying Dr. Lanning i.1 Clinical Assistant Professor 0/ Psychiatry; Dr. Gabril'! i.1 Associate Professor 0/ Psychiatrv, Neu: York University Schoo! 0/ Median P. This paper ll't/.l presented at the 50lh Allllua/ Meeting of the AIIlPrira" Orthopsschiatrir Association ill Neu: York Cit», Ma)' 31, 1973. The lI'ork wa,l in pari supported h)' NYU's Children and Youth Project #605, Maternal and Child Health Service, H.E. W. Reprints lIlay be requestedfrom Dr. Lanning, 2-17 East 49 Street, Neu: York, N.Y. 10017.
142
Use a/Tandem Teams in Training
143
degrees of theoretical and practical backgrounds in child development from their previous educational settings. On the other hand, the senior staff felt that there was much confused floundering on the part of the trainees, and that gaining diagnostic skills should have a higher priority in the training program . By 1970, it was decided to reorganize the evaluative process so that trainees could be trained by direct observation, at least during their initial period of exposure to the psychiatry unit. ORGANIZATION OF PERMANENT TEAMS
In its evolution, the outpatient clinic staff had been loosely organized into two teams, each consisting of a staff psychiatrist, psychologist , and social worker for service purposes. Now permanent teams were established so that time allocations could be planned for each member. Before we introduced trainees into the system, the teams functioned as units for at lea st three months, during which time the following procedures evolved. A short screening form was developed for the initial contact with the general clinic pediatrician who made the referral. This form was used as the basis for a sho r t preliminary meeting of the team on a morning set aside for a more complete evaluation. Most of the time, it was a simple matter to have the child seen by the psychiatrist in one room, while the social worker saw the parents in another. After this initial hour, the team met with the psychologist to review the data gathered , give a few preliminary psychological tests, and plan an y necessary revisits. It was also found useful to provide the famil y with an initial interpretation. Since we felt that adequate service was being efficiently provided to the patients through this method , the incorporation of training then became the major thrust of the group. TRAINING METHODOLOGY
A half-hour before the family arrived, the team met with the two trainees who were assigned for the day. Usually the trainees had gone over available material the day before. At this preliminary mini-conference, the referral form , screening report (made by one of the professionals or trainees under direct supervision on a previous occasion), and medical cha r ts had been reviewed . From this, initial questions had been defined which in part determined strategies that might be useful in the clinical interview. The trainees
144
Theodore R. Lanning and H. Paul Gabriel
gained some understanding of the nature of adequate pediatric referrals, and the need for careful review of medical chart notes. Before the team broke up, the two trainees were assigned a role for the morning and became either a psychiatrist-psychologist or a social worker under the direct surveillance of two supervisors. The psychiatrist-psychologist roles overlapped at times, and if there was need for further psychological testing, this could be done by that trainee or by the psychologist whom the trainee observed while more sophisticated tests were administered. The two trainees then introduced themselves to the patient and parents, and the team then observed the child for a 10- to 20minute period in a playroom which offered activities for various age levels for the general clinic population. The child's interaction with peers and playroom personnel were noted, as well as his functions within this play setting. The team then met with parent and child for a period of about 10 minutes to observe child-parent interaction. This meeting served to allay distortions that may have occurred in the child or parent regarding the purpose of the evaluation as well as to allow observations of interpersonal dynamics. Separate child and parent interviews facilitated this further. The embarrassing topics of child-parent hostility or the more intimate details of the parents' marital relationship were avoided and reserved for the one-to-one interviews. The trainee was also taught to allay anxiety and to motivate the patient with a trial period of play. Warm-up questions and answers are used, such as: Do you know why you are here? What kind of doctor am I? If fears of "craziness" come up with either child or parent, the trainee is taught how to reassure in age-appropriate language and to indicate that he usually works with people who sometimes have worries or are "nervous." Meeting with Child The trainee, under direct observation, now functions as the psychiatrist-psychologist-medical person and uses his own personal and professional experience to enter into a relationship with the child. He is taught to use the fundamental observational tools as defined by Chess (1959), who places less emphasis on mechanical medical questioning, and more on input to the basic senses. In other words: What do I feel, externally and internally? What do I see? What do I hear? What do I think and say? Initially, the senior supervisor may demonstrate one or two clinical interviews as a gradual introduction to child-adult relationships. In any event, the trainee already has some preliminary hypothesis
Use oj Tandem Teams in Training
145
on the basis of available data as well as direct observation. He will continue to verify or will discard his "hunches" by observation of temperament as well as environmental interaction (e.g., a slow-towarm-up child), child-parent interaction (distant, overly independent, dependent-clinging), gross medical or neurological abnormalities, activity level, and bizarre or manneristic behavior. Further areas the trainee may wish to pursue, depending on what he observes, can include factual data or information of a verbal projective nature. These would include school likes and dislikes; teacher, peer, and sibling relationships; areas of special competence or incompetence; who is at home, what they are like; living and sleeping arrangements; dreams and nightmares; and a preliminary mental status evaluation if this is deemed relevant. Further, the trainee is taught how to give and interpret figure drawings and pencil-and-paper tasks. Organization and sophistication of whatever play activities the child spontaneously chooses are also evaluated. If the trainee runs into difficulty, the senior supervisor, who is always present, may offer suggestions or may take over temporarily. The psychologist may also assume this type of role later in the session . Furthermore, the ps ychologist will teach the trainee to administer the Bender Visual Motor Gestalt Test (1938) and the Developmental Test of Visual-Motor Integration (Beery and Butenican, 1967), will help him assess the figure drawings (tree, house, animal, person, family), and will select other psychological items as they are needed. The trainee learns to handle resistances of a patient who may assume these tests are school tasks. In many instances, initial items from the screening report or from direct observation indicate a need for a neurological survey. This is then performed to evaluate the possibility of central nervous system malfunction or plasticity, with emphasis on correlation with developmental norms and their latitudes. History Taking with the Parents
When separation of parents and child occurs, the parents are invited by the second trainee, accompanied by a senior social worker, to a separate room for a more formal history. Previously mentioned techniques of exploration and allaying anxiety are again used . Priority is given to the following topics: current and past strengths and weaknesses ; behavioral and interpersonal relations; birth, developmental, and medical history; economic, household, sibling, and school history; details of marital relationships; family aspirations, methods of discipline, and activities of daily living.
146
Theodore R. Lanning and H. PauL GabrieL
Summarizing Team Meeting A short team conference is again held, in which provisional diagnoses are discussed and specific psychological testing procedures are decided upon when appropriate. Tentative plans to return the patient to the original referral source with recommendations for another pla y interview , for counseling with or without medication, for further testing or psychotherapy are considered at some length. The parents are again seen, and an interpretation and/or so me initial counseling or suggestions are offered . Appointments for further interviews are also arranged if indicated. CASE EXAMPLE
A summary of a case evaluated by the trainees under this approach is presented below.
Intake A 6 Y2-year-old bo y was referred to the psychiatric unit because of poor appetite and vague a bd o m ina l complaints. Review o]' Referral and Medical Records
The bo y was the product of a full-term pregnancy, sma ll for gestational age, but otherwise normal. His mother "gave him" to his grandmother and a 22- year-old aunt to raise when he was few weeks of age. Pediatric history revealed relatively normal growth and development, although his height and weight persisted below the third percentile. Numerous outpatient visits included frequent upper respiratory infections, a number of episodes of otitis media, and more recentl y multiple visits necessitated by abdominal complaints, for which no organic reasons were ever found.
Family Interineui In addition to the abdominal complaints, the aunt added that the boy was often "dreamy" and seemed unwilling or unable to do schoolwork. While in kindergarten, the boy was accused of frequent daydreaming and irrelevant remarks. Since his school had tutorial services, he was referred for special tutoring in the first grade . A mild degree of school phobia occurred for the first few weeks of first grade . Past relevant history revealed irregular and tumultuous sleep habits, a high activity level , temper tantrums, fear of the outdoors, and clinging to the grandmother. The biological mother visited
Use of Tandem Teams in Training
147
very rarely, and the boy's addict father had deserted before his birth. The grandmother admitted to seeing the boy as helpless, feeding and bathing him as well as interceding for him at school, often staying with him during the lunch hour. Except for some delay in speech, the boy's other landmarks were within normal limits. Play Session and Patient Interuieui
The boy was friendly, with a full range of affect and no thought disorder, although moderate to severe anxiety was present. Perseveration was noted, both verbally and in graphic productions. A concern about violence was present, and he appeared generally immature for his age. Time and number concepts were limited; fantasy material was sparse and unrevealing. Psychological Testing
The results of this testing were quite variable. Performance IQ varied between low and high normal, with a verbal IQ consistently about 25 points lower. Specific testing was then requested with the aim of delineating a more useful tutorial program for the boy. Impression and Follow-Up
The impression was that of a developmentally immature boy who was below age expectancy in height, weight, language development, and visual-motor coordination. Added to the organismic immaturity has been infantilism by the grandmother, with exaggerated focus on the child's minor illnesses. The boy received special tutoring in school while the grandmother was followed and counseled by the social worker. The pediatrician saw the child monthly, correlated physical care of the child with the social worker's support of the grandmother, and reinforced the child's positive progress. Additional evaluation by the psychiatric unit was not required. DISCUSSION
The authors have had the usual traditional trammg approaches with case conference, didactics, and supervision. The senior author has had one small segment of group interview therapy training as well as his own teaching experience in medical school, hospital, and social work agencies. Very often, coordination and implementation of recommendations were lost because of inadequate training, referral, and communication. The co-author (Gabriel and Danilo-
148
Theodore R. Lanning and H. Paul Gabriel
wicz, 1969), on the basis of former experience with the National Institute of Mental Health, also wished to augment the traditional training approaches of pediatricians, a view shared by Lourie ( 1962). We feel that the tandem team approach with trainees overcomes some of the fragmentation of older approaches and represents an evolution of the team-approach innovations introduced by Healy early in the century (1915), and popularized by Meyer (Lief, 1948) and Kanner (1935) in the 1930s in training of students and pediatricians. This concept was further moved along by Eisenberg (1967) at Johns Hopkins in the 1950s and early 60s. All too few child psychiatry training programs attempt to complete a coordinated work-up in the same morning with a workable plan to share with parents, child, pediatrician, and other agencies. There are some notable exceptions to the above, including concepts used at Hawthorn Center in Northville, Michigan. Acting on our dissatisfactions with the current teaching of pediatricians and students, we inaugurated a tandem-team approach at our institution. Its function was to teach trainees in a pediatric clinic and hospital setting a more organized method of evaluation of emotional problems as well as to have them learn how to deal and cope with behavioral difficulties of children, how to bring out and understand emotional problems, and, above all, how to recognize early disturbances at a time when intervention could prevent further problems. There have been good results in achieving these goals and excellent feedback. To date, the eighteen trainees appreciate having a supervisor in the background to call on for immediate help if needed, and they feel that their competence has been improved. An occasional negative comment is that the child and/or parents resent, or are made anxious by, the presence of more than one person in the room. This occurs in less than 10 percent of the situations and is easily handled by appropriate use of traditional methods of one-to-one contact, repeat visits, playroom observation, school or home visit, and inpatient observation in the general medical or child psychiatry wards. Our method allows an efficient initial evaluation in one to three hours. Furthermore, it tends to cut down on dropouts, since parents have the feeling that much is being done and they do not need three or four return visits before obtaining an initial impression and advice. This is extremely important: most of our patients are ghetto residents and tend to need immediate feedback information.
Use ofTandem Teams in Training
149
Our current impression is that this method could be used at all levels of training, since supervision is always immediate and based on direct observation. It is true that TV tapes and one-way screens might he as useful in specific instances, hut our method works in all circumstances. What has been most gratifying to all concerned is the relative ease with which students and pediatricians have been trained to do an adequate diagnostic evaluation. SUMMARY
A system of trairnng medical students and pediatric house staff, using tandem teams consisting of psychiatrists, psychologists, psychiatric social workers, recreation workers, and a remedial teacher, has been used to provide mental health training which is relevant to the future activities of these trainees as general pediatricians or in child-oriented occupations. The psychiatric consultation unit is based within a comprehensive pediatric care clinic, and the wards are located in an active municipal hospital. The basis on which the training has evolved is the increasing need for pediatricians to collaborate with a wide variety of mental health professionals in meeting the social and psychological needs of children. In order to teach a variety of skills, a system was devised in which pediatricians and students undertake the function of every member of a mental health team. Initially, they are under direct surveillance and supervision, but later they can evolve into independent functioning. The formal structure of this program delivers good care, and the results of these efforts to train the students and house staff adequately in a relatively short time appear to be excellent. REFERENCES BEEK\', K. & Bt'TE:-;ICA:-;, B. (19tii), Drrclotnncntn! 1'",1 oll·illltll-Alolo,. Lntrgration, Chicago: Follett Educational Corporation. BE:-;m:K, I.. (I ~nH), ,-I Visual Motor (;,'"Itlil Trst and 11,\ Clinira! C',It'. l\ew York: American Ortho psvrluaui« Associ"tioll Research :'-tollograph !\:o. :1. CHESS. S. (1959), An l ntrodurtion 10 Child Pssrhiatrx. :\ew York: (;rune & St ratron. 19ti9. - - & LnIA:-;, :'\1. S. (19ti9). A psvchi.uri« unit in a gennal hospital pediatric clini«, AII/n. j. O,.lho!H\'thitll., :\9:ii-H5. EISE:-;BEKl;, I.. (19tii), The relationship bctwccn psvchiat rv and pediatrics. Pediatrics, :Hl: ti4 5-114 i . (;ABKtEl., H. P. & Dxxu.own.z. D. A. (191;<1), Psychiatric concepts in pediatric residl'ncies.}. Alt'il. Edllt'., 44:9:\9-944. HEAl.Y, W. (1~1I5), The lndn-idual Drlinqu t'III. Boston: Lillie, Brown. KA:-;:-;EK, I.. (19:\5), Child Psvchiatr», Springfield, III: Thomas. :\nl ed .. I ~15 i. LIEF, A. (1941'), The COII/II/OI/It'I/,t' Psvrhiatrv o! .ldol] AI,'w'", l\ew York: :'\k( -raw-Hill. LOl'KIE, R. S. (I ~lli2), The leaching ;,r chil;1 psvchiarrv 'in pediatrics. Thj,.!olll"lltll, 1:4 ii-4H9,
Theodore R. Lanning, M.D. and H. Paul Gabriel, M.D.
The psychiatric unit of the New York University Pediatric Project is part of a large inpatient and outpatient comprehensive pediatric service located in Bellevue Hospital. As originally established and described by Chess and Lyman (1969), it provided consultative evaluation services, crisis intervention, and short-term therapy to a wide variety of patients on an "immediate" basis. However, as early as 1962, there was increasing interest in training as well as service on the part of pediatric house staff and fourth-year medical students on elective in pediatrics. Initially, training was approached through the usual mechanism of clinic conferences, inpatient conferences, and ward rounds, with variable but slowly improving success. At the same time, a number of supervised outpatient electives had been offered for half-time and full-time trainees, who came for periods of 2 to 6 months. Evaluations were taught by the case supervision method, based on the usual model utilized in mental health clinics with mental health trainees who had some background in the field. While this was an honored and traditional method, the medical students, pediatric house staff, and clinic senior staff were dissatisfied for a number of reasons. For the medical students, who varied from second to fourth year, initial encounters with patient and/or parents provoked anxiety. Furthermore, they felt that written interview guides and standard descriptions of play sessions were not helpful in interpreting children's behavior. The pediatric house staff shared some of the students' feelings and also reflected varying Dr. Lanning i.1 Clinical Assistant Professor 0/ Psychiatry; Dr. Gabril'! i.1 Associate Professor 0/ Psychiatrv, Neu: York University Schoo! 0/ Median P. This paper ll't/.l presented at the 50lh Allllua/ Meeting of the AIIlPrira" Orthopsschiatrir Association ill Neu: York Cit», Ma)' 31, 1973. The lI'ork wa,l in pari supported h)' NYU's Children and Youth Project #605, Maternal and Child Health Service, H.E. W. Reprints lIlay be requestedfrom Dr. Lanning, 2-17 East 49 Street, Neu: York, N.Y. 10017.
142
Use a/Tandem Teams in Training
143
degrees of theoretical and practical backgrounds in child development from their previous educational settings. On the other hand, the senior staff felt that there was much confused floundering on the part of the trainees, and that gaining diagnostic skills should have a higher priority in the training program . By 1970, it was decided to reorganize the evaluative process so that trainees could be trained by direct observation, at least during their initial period of exposure to the psychiatry unit. ORGANIZATION OF PERMANENT TEAMS
In its evolution, the outpatient clinic staff had been loosely organized into two teams, each consisting of a staff psychiatrist, psychologist , and social worker for service purposes. Now permanent teams were established so that time allocations could be planned for each member. Before we introduced trainees into the system, the teams functioned as units for at lea st three months, during which time the following procedures evolved. A short screening form was developed for the initial contact with the general clinic pediatrician who made the referral. This form was used as the basis for a sho r t preliminary meeting of the team on a morning set aside for a more complete evaluation. Most of the time, it was a simple matter to have the child seen by the psychiatrist in one room, while the social worker saw the parents in another. After this initial hour, the team met with the psychologist to review the data gathered , give a few preliminary psychological tests, and plan an y necessary revisits. It was also found useful to provide the famil y with an initial interpretation. Since we felt that adequate service was being efficiently provided to the patients through this method , the incorporation of training then became the major thrust of the group. TRAINING METHODOLOGY
A half-hour before the family arrived, the team met with the two trainees who were assigned for the day. Usually the trainees had gone over available material the day before. At this preliminary mini-conference, the referral form , screening report (made by one of the professionals or trainees under direct supervision on a previous occasion), and medical cha r ts had been reviewed . From this, initial questions had been defined which in part determined strategies that might be useful in the clinical interview. The trainees
144
Theodore R. Lanning and H. Paul Gabriel
gained some understanding of the nature of adequate pediatric referrals, and the need for careful review of medical chart notes. Before the team broke up, the two trainees were assigned a role for the morning and became either a psychiatrist-psychologist or a social worker under the direct surveillance of two supervisors. The psychiatrist-psychologist roles overlapped at times, and if there was need for further psychological testing, this could be done by that trainee or by the psychologist whom the trainee observed while more sophisticated tests were administered. The two trainees then introduced themselves to the patient and parents, and the team then observed the child for a 10- to 20minute period in a playroom which offered activities for various age levels for the general clinic population. The child's interaction with peers and playroom personnel were noted, as well as his functions within this play setting. The team then met with parent and child for a period of about 10 minutes to observe child-parent interaction. This meeting served to allay distortions that may have occurred in the child or parent regarding the purpose of the evaluation as well as to allow observations of interpersonal dynamics. Separate child and parent interviews facilitated this further. The embarrassing topics of child-parent hostility or the more intimate details of the parents' marital relationship were avoided and reserved for the one-to-one interviews. The trainee was also taught to allay anxiety and to motivate the patient with a trial period of play. Warm-up questions and answers are used, such as: Do you know why you are here? What kind of doctor am I? If fears of "craziness" come up with either child or parent, the trainee is taught how to reassure in age-appropriate language and to indicate that he usually works with people who sometimes have worries or are "nervous." Meeting with Child The trainee, under direct observation, now functions as the psychiatrist-psychologist-medical person and uses his own personal and professional experience to enter into a relationship with the child. He is taught to use the fundamental observational tools as defined by Chess (1959), who places less emphasis on mechanical medical questioning, and more on input to the basic senses. In other words: What do I feel, externally and internally? What do I see? What do I hear? What do I think and say? Initially, the senior supervisor may demonstrate one or two clinical interviews as a gradual introduction to child-adult relationships. In any event, the trainee already has some preliminary hypothesis
Use oj Tandem Teams in Training
145
on the basis of available data as well as direct observation. He will continue to verify or will discard his "hunches" by observation of temperament as well as environmental interaction (e.g., a slow-towarm-up child), child-parent interaction (distant, overly independent, dependent-clinging), gross medical or neurological abnormalities, activity level, and bizarre or manneristic behavior. Further areas the trainee may wish to pursue, depending on what he observes, can include factual data or information of a verbal projective nature. These would include school likes and dislikes; teacher, peer, and sibling relationships; areas of special competence or incompetence; who is at home, what they are like; living and sleeping arrangements; dreams and nightmares; and a preliminary mental status evaluation if this is deemed relevant. Further, the trainee is taught how to give and interpret figure drawings and pencil-and-paper tasks. Organization and sophistication of whatever play activities the child spontaneously chooses are also evaluated. If the trainee runs into difficulty, the senior supervisor, who is always present, may offer suggestions or may take over temporarily. The psychologist may also assume this type of role later in the session . Furthermore, the ps ychologist will teach the trainee to administer the Bender Visual Motor Gestalt Test (1938) and the Developmental Test of Visual-Motor Integration (Beery and Butenican, 1967), will help him assess the figure drawings (tree, house, animal, person, family), and will select other psychological items as they are needed. The trainee learns to handle resistances of a patient who may assume these tests are school tasks. In many instances, initial items from the screening report or from direct observation indicate a need for a neurological survey. This is then performed to evaluate the possibility of central nervous system malfunction or plasticity, with emphasis on correlation with developmental norms and their latitudes. History Taking with the Parents
When separation of parents and child occurs, the parents are invited by the second trainee, accompanied by a senior social worker, to a separate room for a more formal history. Previously mentioned techniques of exploration and allaying anxiety are again used . Priority is given to the following topics: current and past strengths and weaknesses ; behavioral and interpersonal relations; birth, developmental, and medical history; economic, household, sibling, and school history; details of marital relationships; family aspirations, methods of discipline, and activities of daily living.
146
Theodore R. Lanning and H. PauL GabrieL
Summarizing Team Meeting A short team conference is again held, in which provisional diagnoses are discussed and specific psychological testing procedures are decided upon when appropriate. Tentative plans to return the patient to the original referral source with recommendations for another pla y interview , for counseling with or without medication, for further testing or psychotherapy are considered at some length. The parents are again seen, and an interpretation and/or so me initial counseling or suggestions are offered . Appointments for further interviews are also arranged if indicated. CASE EXAMPLE
A summary of a case evaluated by the trainees under this approach is presented below.
Intake A 6 Y2-year-old bo y was referred to the psychiatric unit because of poor appetite and vague a bd o m ina l complaints. Review o]' Referral and Medical Records
The bo y was the product of a full-term pregnancy, sma ll for gestational age, but otherwise normal. His mother "gave him" to his grandmother and a 22- year-old aunt to raise when he was few weeks of age. Pediatric history revealed relatively normal growth and development, although his height and weight persisted below the third percentile. Numerous outpatient visits included frequent upper respiratory infections, a number of episodes of otitis media, and more recentl y multiple visits necessitated by abdominal complaints, for which no organic reasons were ever found.
Family Interineui In addition to the abdominal complaints, the aunt added that the boy was often "dreamy" and seemed unwilling or unable to do schoolwork. While in kindergarten, the boy was accused of frequent daydreaming and irrelevant remarks. Since his school had tutorial services, he was referred for special tutoring in the first grade . A mild degree of school phobia occurred for the first few weeks of first grade . Past relevant history revealed irregular and tumultuous sleep habits, a high activity level , temper tantrums, fear of the outdoors, and clinging to the grandmother. The biological mother visited
Use of Tandem Teams in Training
147
very rarely, and the boy's addict father had deserted before his birth. The grandmother admitted to seeing the boy as helpless, feeding and bathing him as well as interceding for him at school, often staying with him during the lunch hour. Except for some delay in speech, the boy's other landmarks were within normal limits. Play Session and Patient Interuieui
The boy was friendly, with a full range of affect and no thought disorder, although moderate to severe anxiety was present. Perseveration was noted, both verbally and in graphic productions. A concern about violence was present, and he appeared generally immature for his age. Time and number concepts were limited; fantasy material was sparse and unrevealing. Psychological Testing
The results of this testing were quite variable. Performance IQ varied between low and high normal, with a verbal IQ consistently about 25 points lower. Specific testing was then requested with the aim of delineating a more useful tutorial program for the boy. Impression and Follow-Up
The impression was that of a developmentally immature boy who was below age expectancy in height, weight, language development, and visual-motor coordination. Added to the organismic immaturity has been infantilism by the grandmother, with exaggerated focus on the child's minor illnesses. The boy received special tutoring in school while the grandmother was followed and counseled by the social worker. The pediatrician saw the child monthly, correlated physical care of the child with the social worker's support of the grandmother, and reinforced the child's positive progress. Additional evaluation by the psychiatric unit was not required. DISCUSSION
The authors have had the usual traditional trammg approaches with case conference, didactics, and supervision. The senior author has had one small segment of group interview therapy training as well as his own teaching experience in medical school, hospital, and social work agencies. Very often, coordination and implementation of recommendations were lost because of inadequate training, referral, and communication. The co-author (Gabriel and Danilo-
148
Theodore R. Lanning and H. Paul Gabriel
wicz, 1969), on the basis of former experience with the National Institute of Mental Health, also wished to augment the traditional training approaches of pediatricians, a view shared by Lourie ( 1962). We feel that the tandem team approach with trainees overcomes some of the fragmentation of older approaches and represents an evolution of the team-approach innovations introduced by Healy early in the century (1915), and popularized by Meyer (Lief, 1948) and Kanner (1935) in the 1930s in training of students and pediatricians. This concept was further moved along by Eisenberg (1967) at Johns Hopkins in the 1950s and early 60s. All too few child psychiatry training programs attempt to complete a coordinated work-up in the same morning with a workable plan to share with parents, child, pediatrician, and other agencies. There are some notable exceptions to the above, including concepts used at Hawthorn Center in Northville, Michigan. Acting on our dissatisfactions with the current teaching of pediatricians and students, we inaugurated a tandem-team approach at our institution. Its function was to teach trainees in a pediatric clinic and hospital setting a more organized method of evaluation of emotional problems as well as to have them learn how to deal and cope with behavioral difficulties of children, how to bring out and understand emotional problems, and, above all, how to recognize early disturbances at a time when intervention could prevent further problems. There have been good results in achieving these goals and excellent feedback. To date, the eighteen trainees appreciate having a supervisor in the background to call on for immediate help if needed, and they feel that their competence has been improved. An occasional negative comment is that the child and/or parents resent, or are made anxious by, the presence of more than one person in the room. This occurs in less than 10 percent of the situations and is easily handled by appropriate use of traditional methods of one-to-one contact, repeat visits, playroom observation, school or home visit, and inpatient observation in the general medical or child psychiatry wards. Our method allows an efficient initial evaluation in one to three hours. Furthermore, it tends to cut down on dropouts, since parents have the feeling that much is being done and they do not need three or four return visits before obtaining an initial impression and advice. This is extremely important: most of our patients are ghetto residents and tend to need immediate feedback information.
Use ofTandem Teams in Training
149
Our current impression is that this method could be used at all levels of training, since supervision is always immediate and based on direct observation. It is true that TV tapes and one-way screens might he as useful in specific instances, hut our method works in all circumstances. What has been most gratifying to all concerned is the relative ease with which students and pediatricians have been trained to do an adequate diagnostic evaluation. SUMMARY
A system of trairnng medical students and pediatric house staff, using tandem teams consisting of psychiatrists, psychologists, psychiatric social workers, recreation workers, and a remedial teacher, has been used to provide mental health training which is relevant to the future activities of these trainees as general pediatricians or in child-oriented occupations. The psychiatric consultation unit is based within a comprehensive pediatric care clinic, and the wards are located in an active municipal hospital. The basis on which the training has evolved is the increasing need for pediatricians to collaborate with a wide variety of mental health professionals in meeting the social and psychological needs of children. In order to teach a variety of skills, a system was devised in which pediatricians and students undertake the function of every member of a mental health team. Initially, they are under direct surveillance and supervision, but later they can evolve into independent functioning. The formal structure of this program delivers good care, and the results of these efforts to train the students and house staff adequately in a relatively short time appear to be excellent. REFERENCES BEEK\', K. & Bt'TE:-;ICA:-;, B. (19tii), Drrclotnncntn! 1'",1 oll·illltll-Alolo,. Lntrgration, Chicago: Follett Educational Corporation. BE:-;m:K, I.. (I ~nH), ,-I Visual Motor (;,'"Itlil Trst and 11,\ Clinira! C',It'. l\ew York: American Ortho psvrluaui« Associ"tioll Research :'-tollograph !\:o. :1. CHESS. S. (1959), An l ntrodurtion 10 Child Pssrhiatrx. :\ew York: (;rune & St ratron. 19ti9. - - & LnIA:-;, :'\1. S. (19ti9). A psvchi.uri« unit in a gennal hospital pediatric clini«, AII/n. j. O,.lho!H\'thitll., :\9:ii-H5. EISE:-;BEKl;, I.. (19tii), The relationship bctwccn psvchiat rv and pediatrics. Pediatrics, :Hl: ti4 5-114 i . (;ABKtEl., H. P. & Dxxu.own.z. D. A. (191;<1), Psychiatric concepts in pediatric residl'ncies.}. Alt'il. Edllt'., 44:9:\9-944. HEAl.Y, W. (1~1I5), The lndn-idual Drlinqu t'III. Boston: Lillie, Brown. KA:-;:-;EK, I.. (19:\5), Child Psvchiatr», Springfield, III: Thomas. :\nl ed .. I ~15 i. LIEF, A. (1941'), The COII/II/OI/It'I/,t' Psvrhiatrv o! .ldol] AI,'w'", l\ew York: :'\k( -raw-Hill. LOl'KIE, R. S. (I ~lli2), The leaching ;,r chil;1 psvchiarrv 'in pediatrics. Thj,.!olll"lltll, 1:4 ii-4H9,