Wednesday, March 15, 2017
Making of a Child Psychiatrist: (65) The General Practitioner (10) A bit of Child Psychiatry
Jan had been recommended a great pre-school, and given Jonathan’s thirst for knowledge and activity, we both thought it would be a good idea. So in our second year, he began attending ‘Miss Breckels’. Jan stuck around for a bit to get an idea of what went on, but also to ensure Jonathan would not get upset. No chance; he was having fun! He didn’t even seem to miss his brother much although they were inseparable at home. Roderick, on the other hand, began to fret at leaving his brother behind, but it was thought he would not be old enough to attend for at least another year.
Part of the idea was to provide input to expand the minds of the boys, and ensure they knew how to make friends. On the other hand, Jan needed some time for herself. Despite this, rather oddly, we added to the burden at home by buying a dog. I think someone in the practice may have suggested it, and perhaps I had come across someone trying to offload a puppy. We discussed the issues. Jan had not had the experience of having a dog during her childhood, even though her uncle and aunt kept a bit of a menagerie. My early experiences had been with a not very energetic dachshund that ran away and hid every time you mentioned the word ‘walk’. But we thought it might be good for the boys to have exposure to animals. In the end we gained a pedigree springer spaniel. As a puppy, he was delightful, and of course needed lots of attention, and carrying at the end of a walk. The first signs of trouble began in response to a weekly delivery of vegetables to our back door, as well as a dozen fresh eggs. ‘Scamp’ decided he really quite liked raw eggs, and got into the unbreakable habit of raiding the egg box. Apart from using up most of the egg supply for the week, he also reacted to a surfeit of egg with powerful smelling farts over several days. As time went on, he became a bit of a neighbourhood menace, was self-willed and pulled strongly on the leash, which made life difficult if you were also pushing a wheelchair. He also seemed to enjoy finding rotting or oil covered seabirds on the beach and rolling in them, and on occasion seemed to be able to escape the walled garden of Old Gates whenever a female dog in the neighbourhood was on heat. He ended up making Jan’s life almost intolerable and, after about two years, with much sadness we found a good home for him. I am not sure we were awfully good at owning and training a dog, even if he was very much loved for the vast majority of the time.
Somewhere about the same time, during the summer months, both of the boys began to enjoy painting, and were no more happy than when set up with a large piece of art paper stuck to the fence, with a pot of water and brushes and lots of watercolours. I had acquired a video camera by this stage, and so I would film the sequence of painting and the boy’s interactions. The following summer we persuaded them to repeat the ‘paintathon’ to give me the chance to video again. I had the fantasy of eventually putting together a timeline film of these maturing artistic endeavours, but life was about to spring some novel events that were to lead eventually to major change in our lives.
It began innocently enough. Reading the local newspaper, I saw an advertisement for a session at a Child Guidance Clinic in Canterbury. I talked it through with Jan, and she was on the one hand enthusiastic because it was focussed on my interests, and also would bring in just a little bit of extra money. On the other hand she was not happy that I might be spending yet more time away from home. But she encouraged me to enquire further, which I did. A Dr Kenneth Munro Fraser asked me for a brief CV further to my phone call, and then asked me to go for an interview. He asked me about my time at King’s and why I had not gone on with psychiatry after the first year, given I seemed to have loved it so much. We talked about being overwhelmed by some of the cases, and coping with depression, and how opportunities come out of the blue – like a general practice in your old home area close to families, and then children of your own who need a stable home.
Despite my lack of experience in child psychiatry, and my becoming overwhelmed during that first full time year, Ken offered me the session and we became really good colleagues, even if he was much more experienced than I. There were few other child psychiatrists around at the time, and he had become increasingly overwhelmed by the other part of his job as Director of the Inpatient Service at Lanthorne House in Broadstairs, which housed 25 young people on the third floor of an old brick building originally built to house severely mentally and physically handicapped children. Jan was keen to hear about my interview and impressions of the clinic, and resigned to the possibility of my goofing off and not being available for yet another afternoon. Dear Jan; always supportive!
Having been offered the session, carefully negotiated to be on my nominal day off from the practice each week, I thought I had better clear it with John. He was surprisingly enthusiastic about my doing a session, making the point that all the local GPs in Thanet were able to support one service or another in addition to practice duties.
So I began with some excitement. The clinic was traditional in the sense that the psychologist did psychology, the social worker did social work, and the psychiatrist did psychiatry. The way that worked was that a new referral would be discussed, the social worker would see the parents to gain a family history of the presenting problems, the psychologist would see the child for brief assessment and testing, and then the psychiatrist would see the child for brief assessment. This was all followed by a brief professional group discussion, and then the psychiatrist would meet with the family and discuss options for intervention or therapy. There was a problem with this bit of the process, because Ken was so busy as the only psychiatrist, that it might be three weeks before a definitive plan was agreed and put into action. From time to time, in the meantime, the psychologist would go to the relevant school to get an idea of how the problem was expressed there (if at all), and discuss possible interventions if warranted. Therapy when it happened was mostly brief, mainly behavioural and with the individual child. There were family sessions organised by the social worker, but these were not called ‘therapy’; rather they were ‘supportive’ of the therapy with the child, although a range of strategies were explored with the parents in an effort to change the presenting behaviour. That all sounds very logical, utilised the primary skills of each of the professions, but it was a bit boring over time for the psychologist if they did not meet the family, perplexing for the social worker if they did not get to meet the child, and boring for the psychiatrist if their function was mainly coordinating or bureaucratic. And all three of the main professional groups had therapeutic skills not being used to their full extent. Further, there were professionals such as occupational therapists who were asked to do specific time limited programs of work with a child, but who never attended the planning meetings, because they were there on other days. And there were also a number of nursing staff who had therapeutic training, but did not often get the opportunity to put it into practice.
Finally, though after several weeks I was able to become part of the professional planning group, I really wanted to be able to do assessments as well as therapy with children. So, being me (the young upstart), and having been asked at a general clinic meeting to give my impressions of the clinic, I simply asked the question as to whether everyone thought the assessment process was time efficient? Well, you could have heard a pin drop.