THE
INTEGRATION
OF
A
MENTAL
HEALTH
PROGRAM
AND
A CHILD
PSYCHIATRY
UNIT
INTO
A
PEDIATRIC
HOSPITAL
By Veronica B. Tisza, M.D., and Marianne Richardson, M.S.
Boston Floating Hospital and Departments of Pediatrics and Psychiatry, School of Medicine, Tufts University
ADDRESS: (V.B.T.) 20 Ash Street, Boston 11, Massachusetts.
SPECIAL
ARTICLE
104
I
N RECENT years there has been a growingconcern with preventive mental health
problems in pediatric hospitals. More and
more hospitals have developed Child
Psy-chiatry Departments whose functions vary
according to the needs and the organization
of the parent institution. This paper aims to
describe one experience where the mental
health program and the work of the child
psychiatry unit has been molded into the
life of the hospital as an integral part of a
comprehensive pediatric approach.
During the past few years, the concept
of “the total care of the child” has become
the governing philosophy of the Boston
Floating Hospital. At the beginning the
ideas which served as the original
motiva-tions were far from crystallized and the
mental health program evolved through trial
and error under the influence of the
dy-namic forces inherent in the concept of
comprehensive medicine. This underlying philosophy calls for flexibility and is
con-stantly modified by the feedback effect of
practice. Since the expression of individual
needs is encouraged, the program has been
shaped by meeting individual problems as
they emerged. Just as it is hard to pin down
the exact beginnings of this process, so the
description of the major turning points is
not easy. The details of the development
did not follow a straight path; only the
basic goal, the concern with the “whole
child” remained unaltered.
The Boston Floating Hospital is the
75-bed, general pediatric unit of the New
Eng-land Medical Center-the pediatric
teach-ing hospital of Tufts University Medical
School. Its main functions are: the medical
and surgical care of sick children from the
newborn period to h8 years of age;
under-graduate, graduate and postgraduate
teach-ing in pediatrics, and training in pediatric
nursing on an undergraduate and graduate
level. As an institution for acute illnesses
and also a diagnostic center, the hospital
serves an extended community. The patients
are referred from the out-patient clinic,
pri-vate doctors, and public and private social agencies.
The immediate care of the child rests
with one of the house officers to whom the
patient is assigned on admission.
Super-vision and consultation is given by the
visit-ing staff. The children are in 5-cubicle
wards, and a few private rooms give
tern-porary accommodations for the very sick
ones. On a separate floor with single and
double rooms an experimental rooming-in
arrangement is in process.
The development of comprehensive
mcdi-cal care in this hospital setting was made
possible by the gradual appreciation of its
value by the professional and
administra-tive leaders of the hospital. There has been
an evolution in the understanding of what
“the total care of the child” means as this
concept was translated into practical terms.
At first the approach was primary
“child-oriented.” Since illness and hospitalization
were recognized as very meaningful and
potentially traumatic events, efforts were
directed toward making the hospital a
happier place for the child. There was
in-creasing interest in the individual needs of
each patient beyond his strictly medical
requirements. For instance, the admitting
infor-SPECIAL ARTICLE 105
mation concerning the child’s preferences,
daily routines, little habits and favorite toys.
The nurses were encouraged to play with
the children, and the student nurse who just
held and cuddled a restless baby knew that
her interest was approved by her superiors.
The play-program, which since has gone
through many changes, originated in this
era, to provide more normal activities and
constructive outlets for the hospitalized
child. At the same time, daily visits by the
parents were encouraged and the hours
be-came more flexible. This last development
had far-reaching effects. The hospital
work-ers came into closer contact with the parents
and had the opportunity to observe the
family unit in action. As the doors of the
hospital were opened for the family, the
doctors and the nurses gradually ceased to
have the tendency to “own” the patient. The
parents were present with all their conflicts
and anxieties, actively seeking out the
peo-plc who shared their interest in the child’s
needs. The resulting cooperation served as
a protection against overidentification with
the child, a bias that people working in a
pediatric hospital have so frequently.
In-stead, the impossibility of treating the child
as an isolated entity became clear and the
personnel grew more consciously aware of
the sick child as part of the family unit.
Thus from “child-oriented” the concept of
the comprehensive approach became
“fam-ily-oriented.”
Today we all realize that our efforts to
understand the child are fruitless without
understanding the emotional interactions
and social forces operating in his immediate
environment. We are constantly aware that
the illness and the separation experience
create anxiety and grief not only for the
child but for the parents as well. Also, hos-pitalization seems to have a catalytic effect
on the dynamic relationships within the
family. This may be a maturing effect when
a family can share its anxieties and prove its
strength in the face of trouble. Frequently,
however, these experiences open up and lay
bare dormant confficts which jeopardize the
previous equilibrium. In such a crisis
situa-tion, because of the changed emotional
rela-tionships and the resulting insecurity,
peo-plc may be unusually receptive to help. If
this is available, the equilibrium can be re-gained, or sometimes an even better level of functioning can be attained. Otherwise, the family unit may be left with increased ten-sion as result of the upsurge of guilt and
ambivalence precipitated by the events.
The following case, which is one of the
many we encountered, illustrates to what an extent the child’s illness can threaten the
emotional balance of the family:
CASE 1 : Tom F., an 8-year-old boy, was ad-mitted to the hospital because of increasingly severe frontal headaches of approximately 10
months duration. Because of the history of
re-peated headtrauma, subdural hematoma was suspected. His young and very anxious mother traveled 50 miles by bus and spent long hours with him every day, but except for the time of
admission, Mr. F. had not come in during the
first week. The pediatrician and the nurses in
charge of Tom noted this and also realized that
Mrs. F. leaned heavily on Tom for emotional
support, clinging physically to him, talking about his being, “my sweetheart”-their “having
a date,” and asking for many kisses and physi-cal expressions of affection.
Because of the boy’s obvious accident prone-ness, the Child Psychiatry Unit was asked to participate in the initial diagnostic study. Mrs.
F. related quickly to the psychiatric social
worker and came forth with the conviction that
her son had a “brain tumor”-a fear that she
never shared with any of the boy’s physicians. This mother underwent several operations
dur-ing the preceding 2 years for multiple benign
tumors and had phobic concerns about cancer.
She spoke angrily of the doctors’ failure in the
past to give her explanations concerning her
own operations. Nor would Tom’s doctors now
give her any information about his condition.
In the reality, she did not ask pertinent ques-tions and avoided discussions with the physi-cians. While this avoidance was partially due to her anxiety and to her overidentification with Tom-Mrs. F. had obvious conflicts about “ac-cepting” from anybody, including her closest
relatives. She had a tendency to deprive herself, then to feel miserably exploited and in turn to become hostile and punishing toward the people
she wanted filled her with guilt feelings. For
in-stance, the social worker found out that the
family was in great financial difficulty because of medical expenses, but Mrs. F. neglected to mention their indebtedness to the admitting officer. She had to accept her own mother’s
offer to care for the other children while she
visited Tom and was plagued with the idea that her mother did not really want to help. The
support given by the social worker in their
initial contact enabled the mother to ask the
neurosurgeons more specific questions about
Tom’s condition-questions which were stimu-lated by her cancer phobia-and to listen to
and be reassured by their answers. Any of the
social worker’s overtures about ways of finding
help for the other problems only met with as-surances that Mrs. F. had always been the strong one and that she would manage to get through this, with a “stiff upper lip.”
The social worker recognized that Mrs. F
went as far as she was able to go at that
moment in accepting help. She reassured the
mother that she will always be available for her
and gave over the further handling of the case to the house officer.
The diagnosis of chronic subdural hygroma
was confirmed and Tom was making good re-covery from the craniotomy. However, Mrs. F.’s manifest anxiety failed to abate. The pedi-atric house officer trusting his own good rela-tionship with the mother, remarked during one of their talks, that it must be hard on her to make the daily long trips to the hospital alone.
After only so much prompting, Mrs. F. poured
out a long list of complaints against her hus-band. The pediatrician heard her out, and
sug-gested that she talk all this over with the social worker. Mrs. F. agreed, and during the
follow-ing few days, she and the social worker had a
series of interviews.
It turned out that Mrs. F. got married at the
age of 17, against the strong disapproval of
her long widowed mother. She was driven into
this early marriage by her desire to escape from the home where she felt deprived of love
and loaded down with responsibilities. Mrs. F.
seemed to hope to get from her husband the
“mothering” she had so missed as a child. The
couple had 3 children in quick succession, the
oldest being Tom. Mother’s operations and
some periods of unemployment of the husband
had placed tremendous burdens on the family,
but the marriage had remained harmonious and
they had blamed fate for their many reverses.
When Tom became ill and was in danger, Mrs.
F. felt as if the whole foundation had been
pulled out from under her. She became aware
of the feeling which she had for a long time
tried to push away: that her husband’s made-quacy was the real cause of her misfortunes and deprivations. It was apparent that the young husband was not able to satisfy Mrs. F.’s great emotional demands and that she was left as frustrated by him as she had been formerly by the maternal grandmother. One way she handled her resentment was by having an cx-elusive relationship with Tom, a relationship which became an emotional crutch to Mrs. F.
It seemed that when Tom was in danger,
mother’s hostility broke open. She blamed her
husband, kept him away from the hospital, telling him she did not need him and that he must work on a second night job to earn more money, yet resenting his not coming. Now, mother felt, they were poles apart and talked about divorce.
The social worker listened and sympathized
with Mrs. F.’s story, mentioning that wanting to be loved and to love was natural and
some-thing we all wanted. She thought Mrs. F. had
had much more of a burden to carry than
any-one could carry alone, and wondered whether
her husband might be able to help, if Mrs. F.
could only talk with him and let him know
she wanted him. She wondered if his working
constantly on 2 jobs and thus being unable ever
to visit Tom with Mrs. F. would really solve
the financial problem, and was able to enlist
Mrs. F.’s cooperation in a plan to find some
financial assistance in their local community. A few days later, Mrs. F. called the social
worker to introduce her to Mr. F., who had
come with her to visit Tom. In a later inter-view, she confided that she had been surprised
and pleased when Mr. F. had seemed so
will-ing to come in, as soon as she had asked if he
thought he might take the time off. She said,
“I’m learning to say what I think-and to ask.”
When later follow-up visits confirmed the
psychiatrist’s impression that there were still
many unsolved emotional problems for Tom
and his family, following his recovery, plans were made for them to return for regular
child-guidance visits to the Out-Patient Clinic.
How-ever, the threat of disaster to the family equi-librium created by Tom’s illnes was averted, and the basic relationship through which more
permanent help could be offered was
The parents responded gratefully when
psy-chological testing and subsequent help with
the planning was offered to them. The testing was performed in the Out-Patient Clinic some 4 weeks following discharge because it was felt that this apprehensive little boy would not function at his best in the hospital while under
the impact of his separation anxiety. The
test-ing confirmed the clinical impression that Paul’s
average performance was on 3-year-old level.
The clinical psychologist discussed the result
with the parents, answered their many
ques-(ions and recommended that Paul should
at-tend for 1 or 2 years a Kindergarten type
of playgroup before being registered for the special class in school. From the clinical psy-chologist, the parents returned to the social worker, who in 2 interviews began to handle
the feelings of guilt, grief, and disappointment
which came to the surface when the parents could not anymore deny the fact that their son was mentally retarded. The relationships estab-lished at the hospital were the bridge by which
this family could accept referral to their local
Family Service Agency. There they could have help in tapping the local school resources and continue to have support and help with their feelings as they planned a realistic future for
Paul.
As the concept of the “total care of the
child” went through this gradual
develop-ment, the attempts of putting the
philoso-phy in practice resulted in a mental health
program. This program belongs to the
whole hospital, and all the groups working
there are members of a mental health team
geared toward the common goal of helping
the parent-child unit. The co-ordination of
this program has been entrusted to the
Child Psychiatry Unit. Thereby, this group
has become a hospital “team-mate” with
supervisory and co-ordinating
responsibili-ties. It is important to note that it was the
hospital which adopted the philosophy of
comprehensive medical care and started to
develop the mental health program. The
child psychiatrist was brought in during the
course of this development to give more
specialized help and to assist in the
clarifi-cation of mental health concepts. The
struc-ture of the Child Psychiatry Unit was
influ-enced by the fact that from the beginning it
107
SPECIAL ARTICLE
The “family orientation” also leads to the
recognition of emotional problems, not
directly related to the illness or
hospitaliza-tion. These problems come to light because
of the interest of the hospital in the total
functioning of the child. One frequently
finds that parents who would otherwise
prefer to struggle along with the problem
than to admit that they are in need, become
receptive as the pediatrician suggests that
they try to remedy the situation. The
neces-sity of surrendering their child to
profes-sionally qualified agents, creates feelings of helplessness and stimulates increased de-pendency needs in the parents. To be in a dependency relationship with the medical
doctor is acceptable in our culture. When
these needs are gratified through having the
child helped, the physician is in a position
to transfer both the dependence and the
trust to the psychiatric team.
CASE 2: Paul A., a 63-year-old boy, was
hos-pitalized for 4 days for the investigation of his
bronchial asthma, and at the time of admission only the problems pertaining to his medical illness were mentioned by the parents. It was obvious to all the observers, that Paul was not only mentally retarded, but that he was a very
anxious little boy. He was fearfully withdrawn
from contacts with children, and needed con-siderable encouragement from adults. Before
the child was discharged from the hospital, first
the pediatric house officer, then the social
worker had long discussions with the parents for more detailed background information and tried to feel out what Paul’s inadequate func-tioning meant to them. They found that while
the parents had some awareness of the boy’s
difficulties, they never faced them and
main-tamed the hope that he would “catch up to
himself.” Especially the father, a very ambitious
man, could not believe that his only son should
be “slow” and put quite a pressure upon him
for better achievements. Paul had very few
playmates, did not participate in group situa-tions, and was never sent to Kindergarten. In
September 1954, he started the first grade, but a few weeks later he was excluded from the
class because of his inability to comprehend the instruction. The parents stood bewildered in this situation, did nothing to secure
appro-priate schooling and simply kept the boy at
was a core part of the hospital and not a
specialty service unit only. It is broadly
organized and includes the traditional
child-guidance team-psychiatrist, clinical
psy-chologist, and psychiatric social
worker-plus the medical social worker and the
members of the play-program.
Within the hospital, the work of the Child
Psychiatry Unit falls into 3 main categories.
One is the teaching function, the
descrip-tion of which is beyond the scope of this
paper. The remaining 2 are as follows:
1) The Unit participates in the “total
evaluation” of the patient through
psychia-tric case studies when these are requested
by the pediatrician.
Requests for diagnostic evaluation may come in different types of cases. For in-stance, in cases where the somatic
symp-toms seem to have emotional components,
and in cases of social and emotional malad-justment not directly related to the illness
and hospitalization. A psychiatric study
usually consists of several interviews with
the child psychiatrist, interviews with the
parents-generally by the social worker, and
if needed specialized testing by the clinical psychologist. In addition, discussion with
the nurses and with the members of the
play-program rounds out the picture. The Unit
evaluates the material in terms of the psy-chodynamic factors involved, and discusses it with the pediatrician as part of the com-prehensive medical evaluation. This inte-grated study forms the basis for an
mdi-vidualized remedial plan worked out jointly
with the medical staff.
These plans are as varied as the problems
which arise and the existing co-operation
and communication between the hospital
groups permits great flexibility in carrying
them out. They vary from simple medical
reassurance to very complex projects in
which every hospital group participates.
During the whole process, it is the
pediatri-cian who has the key-relationship to the
family. One always has to keep in mind
that the patients come to the hospital
be-cause they need and trust the medical
doctor. When the plans call for it, it is the
pediatrician who may share or transfer the
trust invested in him to other collaborating
people. In the actual working out of the
plans with the family, his role is very impor-tant. His basic acceptance of the integrated
approach plays a great part in enlisting the
family’s willingness to follow through.
2) We have indicated so far how the
Child Psychiatry Unit as a specialized
clini-cal team gives service to patients who are
referred for formal psychiatric study.
How-ever, the mental health program has broader
implications and concerns itself with every
child in the hospital. The Child Psychiatry
Unit as the overseer of this program also
has wider responsibilities. The center of
this activity is the play-program which we
describe in some detail.
The play-program includes every patient
in the hospital. The activity starts at 8:30
in the morning, when the play-teachers,
pushing carts loaded with toys, games and
books start their regular daily rounds. The
first visit is with the head nurse of each floor
for a short, informal conference. The nurse
gives the teachers the list of the children
who, with the doctor’s permission, may go
to the playroom that day, and they discuss
briefly their individual medical and
emo-tional needs. Subsequently, the teachers
visit with very child in the hospital from
the 2-month-olds and up. They get
ac-quainted with the new admissions-they
talk and play a bit with everyone in order
to discover and to encourage their specific
interests. The children who have to stay in
bed get the toys and games they desire,
and the ones who may go to the playroom
are dressed in playclothes (dungarees and
T-shirts). This group is usually ready for the
onrush to the playroom at about 9 :30. The
size of the group varies from day to day and
from morning to afternoon. It is relatively
large because the doctors like to mobilize
every patient as soon as it is medically
sound, even if some go in wheelchairs.
The playroom is a light, many windowed
room, situated on the floor above the wards.
It is adequate in size for its average
SPECIAL ARTICLE
109
of groups and compact so that no child is
lost from sight. The room is well equipped
with both toys and craft materials.
The playroom service is essentially a
non-directive activity program supervised by
people who are nursery school teachers by
training. It provides a permissive, friendly
and affectionate atmosphere with mother
substitutes who are ready to satisfy the
children’s need for personal attachment,
social support and a maximum opportunity
for legitimate play outlet. The freedom and
the activity of the playroom puts the empha-sis on the healthy part of the child while his special needs and disabilities are accepted
and the medical limitations are closely
ob-served. The pediatricians support the
pro-gram by their frequent informal visits with
the teachers and the children.
The usual playroom schedule is:
9:30-11:30 Free play (playroom).
11:30-12:15 Dinner in the playroom. The children sit around tables and
are served individually.
12: 15- 2:00 Return to wards for the rest
period.
2:00- 4:00 Free play (playroom).
The daily regular visiting hours of the
hospital are from 2:00 to 3: 00 in the
after-noon. The parents are invited to spend this
period in the playroom unless they prefer
the quieter privacy of the wards. The
mothers of the younger patients frequently
ask permission to spend some morning hours
\iTith their child in the playroom. Such
spon-taneous requests are always granted and in
some cases actively encouraged. The
“room-ing-in” mothers are frequent visitors, often
serving as parents to other than their own
children.
The patients who stayed on the ward are
taken care of by the nurses who, relieved
of the convalescent population, can devote
more time to their bedridden charges. An
occasional child with special needs may
receive prolonged daily visits from one of
the play-teachers.
Everybody returns to the wards at 4:00
P.M. for evening medications and supper.
The realization that the children tend to
become increasingly anxious toward the
evening led to the establishment of the
evening volunteer service. Four or five
woman volunteers arrive every evening
around 6:00 P.M. and they stay until 8:00
P.M. The play-teachers leave them the list
of the children who need special attention,
and after reporting to the head nurses for
instructions, the volunteers occupy
them-selves with the patients. They read bedtime
stories, play quiet games, and supervise the
group around the TV. They try to interest
the anxiously hyperactive child and give
sympathetic companionship to the
with-drawn and silent ones. These groups of
volunteers meet the head teacher at
fre-quent intervals for informal discussions.
A designated member of the play-team
tries to be present at admissions, to assist
the parents if necessary. She is on the wards
during visiting hours and keeps aware of
the families’ reactions to the hospitalization.
Everything noteworthy is discussed with
the psychiatrist.
The psychiatrist’s relationship to the
play-program is a close one. The head teacher in
charge of the program is under her direct
supervision. The psychiatrist visits the
play-room every day. Sometimes only to get an
impression of the population and to have a
little talk with the teachers. At other times
observations of specific children and family
groups are carried out in this setting. The
informality of the room and the one-way
vision mirror at one end, make it a central
and natural study place for every member
of the psychiatric team.
The play-program not only gives direct
services to the patients and their families,
but it is the life-line of an informal
com-munication system, vital to the integration
of all the mental health activities. The
mem-bers of the play-program know the children
quite intimately. By their position they are
an important channel of communication
be-tween the psychiatric clinical team and
several of the other hospital groups. That
does not mean the simple transmission of
func-lion which works in both directions. They
discuss with the pediatricians and the
nurses the special needs of the child, which
leads to increased interest and a better
understanding on both sides. In specific
cases these discussions may prepare the
way for a well formulated request for a
psychiatric consultation. The play-teachers’
effect also works in the other direction. As
they discuss their concerns with the
psychia-trist, they alert the clinical team to particu-lar problems. Then in turn it is the
psychia-trist who takes active interest in the case
and works toward the collaboration of the
pediatricians and nurses.
Free and easy communication between all
the groups working in the hospital is
essen-tial for the effective functioning of this
whole comprehensive medical program. To
help people to share their observations and
experiences and to bring them together to
clarify their ideas in reference to the
mdi-vidual case, is the responsbility of the psy-chiatric clinical team.
Up to this point we have described the
more or less technical part of the
integra-tion of the mental health program and the
child psychiatry unit into a pediatric
hos-pital. But there are many intangible factors
involved in the success of such integrated
functioning-factors which make up what
we may call the emotional climate of the
hospital. The emotional climate of the whole
institution is determined by the basic
ac-ceptance of the philosophy of
comprehen-sive medical care with the individualization
implicit in this concept-and also by the
attitudes and relationships of the individual
workers and groups toward the patients,
and toward each other. It is natural that in
a hospital where the focus is directed upon
individual human needs there are always
cases in which the nature of the illness or
its circumstances create anxiety in the staff.
This anxiety may be expressed in relation
to the patient or the tension may be felt
among the co-workers. It is the
psychia-trist’s role to recognize the trouble spots and
to find the means to help the people to
handle their feelings. The psychiatrist and
the other members of the team are
con-stantly aware of the changes in the
emo-tional atmosphere of the hospital because
they are such an intimate part of it. They
go to ward rounds, participate in
confer-ences and teaching; even more important
are the casual case conferences and the
many informal contacts which naturally
occur.
Along with the inevitable problems which
arise from day to day, the dynamic forces
inherent in the concept of comprehensive
medical care seem to have a maturing effect
on the hospital. One cannot over and over
again concern himself with the unique
situ-ation of each child and family without
ex-periencing a change in his attitudes and
per-spective. Signs of increased “maturity” are
the relaxed atmosphere-the accepting and
supportive emotional climate experienced
equally by the patients and the hospital
workers-and the great degree of flexibility
without which individualized care within a
hospital is not possible.
SUMMARY
The evolution of the concept of
compre-hensive medical care as it is practiced at the
Boston Floating Hospital has been
de-scribed.
In the course of years, a mental health
program has been developed and a Child
Psychiatry Unit organized and integrated
into the life of the hospital. The structure and the functions of this Unit have been influenced by the fact that from the
begin-ning, it was a core part of the hospital and
not a specialty service unit only.
The functions of the Child Psychiatry
Unit have been elaborated and the play
program described in some detail. A
col-laborative approach in the handling of
mdi-vidual cases has evolved and the importance
of free and easy communication among the
