A running conversation about children

Harold Bornstein knew the woman he called Mary from her birth until her death almost 30 years later, first as a pediatrician, then as a friend and adviser to her family. A difficult adolescence led her to drink and drugs, and in 1986, when she had a child, she and her son tested positive for HIV. Her family turned to Bornstein for help in handling the resulting medical and social problems.

He, in turn, sought advice from a group of colleagues with whom he had long discussed complex cases. The group, which calls itself the Compleat Pediatricians, was founded in 1957 on the notion that its members would benefit from a better understanding of the psychological and social aspects of their young patients’ lives. The patients, too, they believed, would benefit from their increased knowledge of psychology. In the beginning, eight pediatricians and a child psychiatrist/psychoanalyst met weekly to discuss cases involving a range of issues, from sleep disturbance and toilet training to the management of wild behavior, anxiety and depression. Before each conference, the child psychiatrist and pediatrician on the case often would have met with the patient and family and worked together on a treatment plan; later, they would report on the case to their colleagues.

Last October, Bornstein, M.D. ’53, H.S. ’56, and several of his colleagues illustrated the model they devised by describing Mary’s case at grand rounds in Fitkin Amphitheater. Breaking from the familiar norm of a lecturer disseminating knowledge with notes and slides, they engaged in a bit of collective remembering, approaching the lectern one by one to reconstruct the case. As the story unfolded, the physicians and nurses who had participated joined in the discussion from around the amphitheater. By the end of the hour, grand rounds closely resembled one of the conferences this group of physicians holds twice a month.

Pediatrician and child psychiatrist working together was a model quite different from the usual course of treatment, in which the pediatrician would refer a case to a psychiatrist, who would then resolve it independently. “It is rare that a pediatrician and a child psychiatrist sit down together and discuss patients,” says Robert LaCamera, M.D., who trained at Yale in the 1950s and is one of the group’s founders.

This meeting of the minds can be traced to a paper published in 1954 in the journal Pediatrics. The authors were Albert J. Solnit, M.D., now commissioner of Connecticut’s Department of Mental Health and Addiction Services, and the late Milton J.E. Senn, M.D., who was then chair of the Department of Pediatrics and director of the Yale Child Study Center. Together, Solnit and Senn argued that knowledge of human behavior and society should be incorporated formally into the teaching of pediatrics. The patient, they wrote, “should be considered as a human being in a family setting, not a diseased organ or system.” Senn established the Child Study Center in 1948 as the successor organization to Arnold Gesell’s Child Development Clinic and was succeeded as director in 1966 by Solnit, who remains on the faculty and is a regular participant in the Compleat Pediatricians. Donald J. Cohen, M.D., is the current director of the Child Study Center.

Over the years, the group has influenced the practice of pediatrics at Yale by integrating the theoretical and clinical insights from psychoanalysis and child psychiatry as Senn envisioned. “I think there’s a much broader concern today about psychosocial issues relating to children and the importance of behavioral health,” says pediatrics chair Joseph B. Warshaw, M.D. “Their accomplishment has been to stress what should seem obvious, but is very often overlooked. Anyone taking care of children has to deal with issues relating to the family and to the child’s social environment.” The model developed at Yale has been replicated at medical schools and community practices in 14 states.

The group now numbers 18 and includes nurses and a psychologist. They meet two mornings a month over coffee in a conference room named in Senn’s honor, beneath the gaze of distinguished psychiatrists whose portraits line the walls. The meeting resembles less a formal presentation than a casual, but enthusiastic, conversation among old friends.

Large problems and small

Assessing the collaboration in a 1968 article for The International Journal of Psycho-Analysis, Solnit noted that members were better prepared both for the handful of complex cases that came their way as well as more routine matters touching on psychology: Is a child’s moodiness part of his personality or a cause for concern? How do parents talk with their children about death, or sex? How do they adjust to the changes surrounding puberty?

About 15 years ago, LaCamera recalled, he sought his colleagues’ advice on how to respond to a situation that had not arisen before in his practice. The divorced mother of two adolescent girls felt uncomfortable with their father’s request that his daughters visit him in his new home, which he shared with his male partner. The discussion with his colleagues reinforced LaCamera’s own feeling that the girls would benefit from seeing, rather than imagining, their father in his new lifestyle. “The mother still had some reservations,” LaCamera said, “but it turned out well and the kids had a good time.”

In other instances, discussion makes it clear that a case from the clinic is clearly beyond the purview of either pediatrics or child psychiatry. Jane Milberg, M.S.N., looked to the group for suggestions that would help a 10-year-old boy with abdominal problems that seemed to have no medical basis. She recommended a high-fiber diet to address his physical condition, but over time it emerged that his difficulty was very likely related to a wrenching family situation and a dispute over custody. “This is really law and Jane is a nurse, not an attorney,” said John E. Schowalter, M.D., a psychiatrist in the Child Study Center who frequently moderates the discussions. The group concurred with Milberg’s decision to refer the case to a social worker with expertise in custody matters and advise the boy’s father to obtain legal advice.

The tale of Mary and her son also required psychological and social insights. She would live only six and a half years after her son was born and she could provide no stable home for him. “Mary was in and out of institutions, jails and hospitals with great regularity,” Bornstein told the audience at grand rounds. Meanwhile, difficult decisions had to be made about the boy’s future. Although he no longer presented traces of HIV, the stigma of AIDS had ruled out the family’s plan to place the baby for adoption. Mary’s older sister, who had another son, took him into her home. The next step was explaining the topsy-turvy social structure to the boy. “The decision was made that he should know that his mother was indeed his mother, but that functionally, his aunt and uncle were his parents,” said Bornstein. The boy has fit into his new family, which has legally adopted him.

At grand rounds, the discussion bounced around the room, drawing in members of the group and others involved in the case, including Warren A. Andiman, M.D., professor of pediatrics and epidemiology who specializes in pediatric AIDS, and Joyce Simpson, R.N., pediatric HIV coordinator in the AIDS care program. Warshaw summed up the discussion with a question. “How,” he asked Bornstein, “did this end up helping you be a more effective pediatrician?”

“It was very helpful to have experienced colleagues expressing their feelings,” Bornstein responded. “In 1986 AIDS was a very fearsome disease. HIV-positive children were not allowed to go to school. They were isolated. With support from our group, I was much more comfortable in dealing with the baby who was thought to be infected at that time.”

Schowalter added that the collaboration is more than a typical consultation. “It’s a synergy when the group really gets to know each other,” he said. “A lot of the support comes from pediatricians who bring in their decades of experience. Because we have all been together so long, it really is a collaboration where both sides give to each other.”