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Saturday, April 1, 2017

Making of a Child Psychiatrist: (68) The General Practitioner (13); A bit more Child Psychiatry +

The following week in clinic, Ken asked me how I got on, and I simply reported that the system was all new and might take me some time to grasp, but I had sat in on a staff meeting, done the tour of the ward, met some of the children and parents and “hoped I might be useful”. He smiled and changed topic.
When I returned to Lanthorne, the first thing I noted as I came out of the lift was a pile of faeces against one wall of the corridor. I found a nurse who grumbled about ‘Peter doing his thing again’ and said she would deal with it. I joined the meeting. They had completed two case discussions despite the fact that I was not more than 5 minutes late after my diversion, and again I was sat on the last available chair at the back. I listened carefully to how the cases were handled and was impressed with some of the changes reported in a couple of children to whom I had been introduced the previous week. The teacher was particularly pleased with a sudden beginning of excitement to learn in one of the children.
When we got to Peter, the discussion seemed very limited; they had ‘a program’, and needed to keep it going. I felt obliged to briefly report what I had seen on leaving the lift to cries of “Oh, not again…” and a couple of smirks. One of the staff was clearly angry, and began with “That makes me really cross. I told him what…” cut off by the charge nurse. She turned to me asking whether I had had any experience with ‘encopretics’? I said I had two small boys at home and that Jan and I had had some fun with potty training, reading favourite books or playing favourite music and rewarding anything that looked like a success. But no, I had not yet had experience working with ‘encopretics’. She looked away saying “I think we just need to keep on with the program, but getting angry with him will not help!” It was not until the following week that one of the nurses let me know quietly that she had suggested to Peter that they could read a book together while he was on the toilet, and this had been ‘fun’. He had had two ‘successes’, and enjoyed a biscuit from the ward kitchen after each occasion. She had discussed this ‘new’ idea with the parents, and three weeks later they were keen to have him home after a successful weekend visit (and an admission of four months). I never did really find out what ‘the program’ had been.
One of the recurring problems discussed in meetings was how to gauge when a young person had recovered. Was there an optimum time that would give confidence that change had occurred? How many symptoms needed to improve before parents would accept that their child had made sustainable progress? Who would be the judge of any given behaviour? Did it have to be a consensus score? Clearly it was the nurses who spent most time with the patients, so it made sense for the score to be agreed amongst them. With the charge nurse’s permission, we began the idea of charting key behaviours once a week in the meeting with an agreed score for each of them from 0 to 10 on severity. The most severe behaviour would probably occur before or around admission (and could be scored 10), and (hopefully) become less severe or less frequent with therapy and as time drew near for discharge. There emerged a rule of thumb that once each of the behaviours were down to 3 or 4 out of 10, discharge could be discussed with parents. Very crude sort of measure, yet pragmatically useful, and it became part of the language of team meetings.
There is, of course, nothing new in the world. Others had apparently devised a formal scale some years before (Honigfeld G, Gillis RD, Klett CJ. (1966). NOSIE-30: A treatment-sensitive ward behavior scale. Psychological Reports. 19, 180-182). This was a 30-item ‘Nurses Observation Scale for Inpatient Evaluation’ geared to measuring behaviours in adults with Schizophrenia. I do not believe I had heard about this formally or informally at any time prior. And in fact, given the content of items, the original scale would not have been of much use at Lanthorne. Our scale was developed for use with a wide array of children and their problems, was pragmatic, flexible, very brief, and focused on key behaviours (rather than symptoms of one disorder). It was also very much a consensus measure, and the process of scoring was as important as the ultimate total score. As befits the times, we would never have ever considered publishing such a thing.
At my third weekly visit, a young woman of 15 called Jenni was discussed in the team meeting. She had attempted suicide at home following recurrent arguments with her mother and was thought to be in serious danger. She had only been in a couple of days, but no-one felt they had made any headway in developing a relationship. She refused to talk, was sullen and resentful and refused to leave her room even for meals, which were barely touched even when brought to her room by a nurse prepared to sit with her.  Night staff had reported she prowled around the unit at night and they thought she was investigating avenues for escape. The unit had always been secure with windows that had limited ability to open, and access to the two lifts only available by key. These were worn on a lanyard around the neck of staff members. To date I had not yet been trusted with my own key and always had to ask a staff member to escort me into the lift and down to the ground floor. There were external emergency stairs, but the door was always locked, keys were kept in the charge nurse’s office, and I am not sure that Fire Drills had ever been thought about.
At the end of the meeting the charge nurse said that Dr. Fraser had suggested to her it might be a good idea for me to attempt some sort of therapy for Jenni; she did not look convinced. I simply said I would be delighted to see her. I read through the referral letter, some comments by Ken Fraser, and the daily nursing notes. There was a hint of angry trouble between Jenni and her mother’s boyfriend, the father having left the family home some years prior and not kept in contact.
I knocked on Jenni’s door, taking over the chair of a nurse who had been sitting with her. I explained who I was and how I thought I may be able to help. I told her that I had read through the notes, but people seemed to be perplexed about what had led to her trying to take her mother’s tablets. No comment or response. No eye contact. Not even a flicker of a reaction to anything I said. Just a dead look straight ahead. We sat in not very companionable silence, with me trying various speculations about what might have happened, and how I imagined she may have felt. No response. The chair was by a window, so I was able to look at treetops and distant roofs while trying to find another avenue. After nearly an hour of trying I explained that I had to leave, but that I would return the following week. In the meantime, I hoped she would get lots of rest, and perhaps get to know one or more of the nurses. No response.

I reported back to the charge nurse, and detected a hint of amused satisfaction. Perhaps I made that up.

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