Pregnancy and diabetes. Team approach.

Each year, 10,000 babies are born to diabetic women. Gestational diabetes occurs in 2% of all pregnant women, resulting in 60,000 to 90,000 cases of gestational diabetes yearly. Prior to 1922 and the discovery of insulin, fetal mortality for the pregnant diabetic was almost 100%. Today, total fetal mortality for the pregnant and gestational diabetic is approaching that of the nondiabetic. This has been achieved by extremely tight control of blood glucose levels throughout pregnancy, with blood glucose levels averaging under 100 mg/dL/day and glycosylated hemoglobin levels in the normal range throughout pregnancy. An increased number of malformations in fetuses of pregnant diabetic women is still a problem. However, animal and human studies indicate that a normal level of glycosylated hemoglobin at conception may significantly reduce these malformations.

Training health professionals in the care of the elderly.

Twenty-seven projects for the development of interdisciplinary geriatric curricula were supported by the Health Resources Administration's Bureau of Health Professions in fiscal 1979. A variety of clinical training sites were used (e.g., university gerontology centers, VA medical centers, senior citizen facilities, adult health care centers), and innovative teaching approaches were developed. For example, a combined medical/dental/optometry clinic is conducted by students at the three professional schools; medical students accompany volunteers serving Meals on Wheels; and dental students treat patients in nursing homes in a mobile dental unit. Students have gained insights into the problems of the elderly and the roles of other health professionals through the interdisciplinary-team training courses. Nurse-practitioner programs to prepare nurses to provide primary health care to the elderly were also supported by the Bureau, as were special projects to develop short-term in-service basic training programs for nurses' aides and orderlies in nursing homes, to upgrade the skills of the paraprofessionals who care for the elderly. In other projects, the geriatric educational needs of pharmacy students were assessed, and dental schools promoted remote-site training to improve access to dental care for the elderly.

Multidimensional problems and findings in developmentally disabled children.

The background factors, problems, findings, and recommendations emerging from the interdisciplinary evaluation of 301 children referred to the Duke Developmental Evaluation Center for assessment of suspected development disabilities are analyzed. The perspective on developmental disabilities gained from utilization of a problem-oriented clinical record and a functional rather than a categorical approach is discussed. Particular attention is directed toward the frequency of findings in various dimensions of functioning and the implications arising from this comprehensive analysis for the roles of pediatricians, parents, and teachers in case management.

Inpatient behavior therapy: the St. Louis University model.

Many of the problems that impede the practice of behavior therapy on traditional psychiatric and medical inpatient services can be avoided by a separate behaviorally-oriented inpatient unit, but few guidelines exist for establishing such a unit. The present paper describes the inpatient Behavioral Treatment Unit developed at St. Louis University Medical Center. Critical administrative and clinical features of the Unit are discussed, including the administrative philosophy which emphasizes unit autonomy and participative management, the central role of nursing staff, the importance of the clinical team system, the development of referral sources, admission procedures and criteria, and basic approaches to assessment and treatment.

The shared field: a precursor stage in the development of a psychotherapeutic alliance with the hospitalized chronic schizophrenic patient.

Psychotherapeutic work with chronic schizophrenic patients is difficult for both patient and therapist. Such patients lack many of the capacities necessary to participate in psychotherapy: motivation, observing ego, the ability to communicate verbally about thoughts and feelings, the capacity to sustain a relationship. Treatment of such patients may require phases in which such capacities are nurtured until the patient is able to form a therapeutic alliance of the ordinary kind. This paper discusses the ways in which hospitalization can be helpful during pre-alliance phases of psychotherapeutic work, through the provision of a protected setting and a team approach, in conjunction with individual psychotherapy. A perspective is offered for conceptualizing the early relationship between patient and hospital staff as a stage in the development of an alliance.

A model of intervention in child-abusing families: a wider systems view.

This paper describes the application of some principles, taken from the modern psychotherapies by a therapeutic team, to the assessment and treatment of serious child abuse. Factors and dilemmas identified from the assessment and decision-making process are outlined, with particular reference to the roles of the various statutory and community agencies involved with such families. The paper demonstrates the ways in which the range of community and professional agencies may play a pathological role, unintentionally contributing to and maintaining child-abusing dynamics in families. The significance of dangerous unintended consequences of well-meaning agency interventions and of covert interagency activities are stressed.

Pediatrician and psychiatrist as co-therapists.

Co-therapy is a neglected method of learning and integrating important concepts of behavioral pediatrics. This report describes a unique enterprise: pediatrician and psychiatrist as co-therapists. This is a situation in which the responsibility for patient care is shared to its maximum extent because the interaction involves diagnostic technique, interpretation and therapeutic management.

Clinicians' fallacies in psychiatric practice.

Eleven common clinicians' fallacies have been briefly described. Based on experience, the authors of this article believe these are the most common and pernicious ones in interdisciplinary psychiatric treatment. These patterns may lead to erroneous interdisciplinary treatment decisions for many patients. In order to protect the well-being of psychiatric patients, their families, and the integrity of interdisciplinary treatment teams, it behooves each and every team member to become knowledgeable about clinicians' fallacies. Those aware of clinician's fallacies will reason more soundly basing judgments on empirical evidence, careful observation, measurement, and a determination not to be influenced by emotional appeals.

Pattern of discussion in traditional and novel ward-round procedures.

A novel ward-round procedure was introduced on an acute psychiatric admissions ward. There was an equal balance in number of staff and patients attending the meetings simultaneously, and all team members participated in the interviewing and discussion. This was compared to the traditional type of ward-round procedure in which one patient attends at any given time, and the consultant is the exclusive interviewer and director of team discussion. The content of negotiation in the traditional ward round was compared to that in the novel style of meeting and it was found that the novel format produced a swing away from medical and diagnostic issues to domestic and social matters.

Multidisciplinary or nondisciplinary: evaluation of staff functioning in a community mental health centre.

This paper describes the staffing aspects of an experimental community mental health centre (Melville Clinic). The different components of staff roles of members of a team consisting of different health professionals, crystallised during the three-year period with a shift from a 'nondisciplinary' to a 'multidisciplinary' approach, with preservation of 'generalised' and 'specialised', 'clinical' and 'community' roles of all staff members. The decision-making in the centre oscillated between group decisions by all staff members, and the acceptance of the leading role of the psychiatrist with the active multidisciplinary teamwork in community mental health centres.

Team family therapy training: conceptual and pragmatic considerations.

This paper presents a family therapy training model that can be used to teach conceptual and executive skills to beginning therapists in community and academic settings. The model is based on the organization and philosophy of family therapy teams and the methods of live supervision. The goals, structure, and leadership of traditional family therapy teams are discussed and contrasted with the proposed team training model. Pragmatic details of the training program are described and advantages and disadvantages explored. Team leadership skills are categorized by context and future directions proposed.

Primary care teams and the elderly in Northern Ireland.

The results of a questionnaire were used to examine how primary care workers set about the management and surveillance of their elderly patients. The majority of practices had attached visitors (76 per cent) and attached district nurses (59 per cent), while 61 per cent of general practitioners worked in health centres. Over half of the responding practices had agesex registers. Few of the practices (14 per cent) had screened their elderly patients in the last five years and maintained an ;at-risk' register. Twenty per cent of practices held a regular meeting concerning their elderly patients but only half of these reviews involved the available health visitors and district nurses.At least half of the general practitioners and district nurses plus three quarters of the health visitors felt dissatisfied with the care of the elderly.A single and systematic review of elderly patients conducted jointly by general practitioners, health visitors and district nurses would do much to improve the care of this group of patients and the morale of these workers.

A paediatric home therapy programme for developmental progress in severely handicapped infants.

An effort has been made to influence the development of severely handicapped infants and improve the quality of life for their families in one health care district. Weekly visits to the homes by a 'developmental therapist' for 2 years after the initial suspicion of major developmental delay have taken place. The visits have been carried out by senior professional staff in the therapeutic professions who normally deal with a young handicapped population working within a closely knit team directed by a paediatrician and a psychologist. Success and difficulties met by children, families, therapists and team are described. Appreciation of the child's individual characteristics and his family's particular accommodation to them has been the task of therapists, who appear to have successfully crossed the parent-professional barrier. Evaluation of maternal attitudes in this group and a comparison group from another health care district is being carried out. This paper is the first of three. The next two will describe the observed effects in the children and the families respectively.

The crisis intervention team at Christchurch Hospital.

It is clear that the Crisis Intervention Team has a vital part to play in the provision of acute psychiatric care in Christchurch. Over the past ten years it has undergone a number of changes in response to the needs of those using the service. Although it is hard to measure its effectiveness, the figures the team has so far collected compare favourably with those of teams operating in other countries. It seems that as pressure comes to bear on the existing services, other centres are looking at the feasibility of setting up their own Crisis Intervention Teams. It may be that as a result, the Canterbury Hospital Board will soon lose the lead it has had in this area, as teams are set up in other main centres around New Zealand.