Perspectives on Consultation-Liaison in Child and Adolescent Psychiatry

Child and adolescent psychosomatic medicine, usually in the realm of the pediatric psychiatric consultation-liaison service, seeks to address the complex relationship between a child's physical illness and affective state with the goal of improving the child's emotional well-being.^1,2 As with adult psychiatry consultation services, child and adolescent consultation-liaison teams must define their psychiatric formulations based on the interplay between the child's medical illness and the needs of the treatment service requesting the consultation. For example, requests such as "please evaluate for possible depression," can mean anything from concern that the child is displaying signs of a mood disorder, to worry that the child's behavior is complicating the recovery process, to frustration that the child's progress has been slow and has not led to recovery.

These concerns are not exclusive, and the role of the consultation psychiatrist is to assess all of these potential issues and then to create a practical, accessible treatment plan. Thus, pediatric psychosomatic medicine can be defined as a combination of the psychiatrist's assessment of the psychiatric concerns in a medically ill child with a formulation and presentation to the pediatric service of all of the means by which psychiatric intervention might help in that child's coping and recovery.

Varying needs in different settings

The consultation process begins with the identification of the service requesting the consultation. Requests can be generated in an inpatient, outpatient, intensive care,or emergency department (ED) setting, and each setting carries distinct challenges for the psychiatric consultant. Inpatient medical or surgical services provide an opportunity for daily visits, constant observation, and rapid interventions. However, the consultant must also be cognizant of the varying needs of the different services providing care for the patient. Psychiatric evaluations in an ED are usually time limited and can be more focused on interventions such as hospitalization or mobilization of outpatient resources. In an outpatient setting, there is the opportunity to coordinate long-term care with the patient's various treatment teams, provide a more thorough assessment through continued visits, and implement, monitor, and modify treatment interventions. Nevertheless, treatment interventions may be affected by noncompliance outside of the hospital and/ or in a chaotic home environment.

Within each of these settings, the consultant should begin by identifying a "point person" from the requesting service--an individual, usually another physician, with whom the consultant can share impressions and recommendations, and from whom the consultant can obtain feedback and updates. Maintaining these open lines of communication is important, because the inclination is for busy services with multiple tasks to separate psychiatric issues and interventions from nonpsychiatric ones. Early establishment of a multidisciplinary approach is central to the success of the consultation.

Identifying a need for a psychiatric consultant

Before performing an evaluation, the consultant should clarify that the patient and his or her family are aware of the pediatric service's request for psychiatric consultation and that they understand the rationale for psychiatric involvement. It is essential that there is a united message from all members of the patient's treatment team that psychological concerns may contribute to the patient's symptoms and that a psychiatric evaluation is a valuable and necessary part of the comprehensive care of the child. Preparation of the family is essential in establishing an alliance between the psychiatric consultant and the treatment team and in facilitating openness to psychiatric intervention for the child, his family, and other involved caregivers.

The psychiatric consultant should ask the requesting service to formulate a clear consultation question. Common concerns that prompt a request for consultation include observations made by the medical or surgical service regarding worrisome behavior in the patient, uncomfortable family interactions, or a sense among other caregivers that the patient's symptoms are not entirely accounted for by the existing medical, nonpsychiatric formulations. The consultant may also want to ask the requesting service to specify why the consultation request was generated at that particular time, and to offer an indication of the allotted time frame for the assessment, impressions, and recommendations. It is frustrating and disappointing to be asked to provide psychiatric consultation for a patient who is to be discharged within several hours.³

The role of the consulting psychiatrist

For the consultation to be most successful, the entire treatment team must set realistic goals for psychiatric input and involvement. For example, psychiatric or psychosocial distress felt by the patient, his family, and/or the primary service might not disappear despite psychiatric involvement. Nevertheless, the consultation service can help the child tolerate and/or manage the distress. In this light, questions posed to psychiatry can range from requests for assessment of a primary, underlying, or comorbid psychiatric disorder to assistance in the management of pain, delirium, or general agitation, an acute psychiatric safety evaluation, or, more broadly, helping the patient and the treatment team to cope with chronic illness.

In all of these scenarios, the consultant may be asked to provide both behavioral and psychopharmacological interventions. Goals for the consultation should focus on assisting the primary pediatric team to understand the interplay between the developmental level of the child and his corresponding interpretation/understanding of the illness. It is also important that there is an appreciation of the child's strengths and capacity for resilience, particularly with questions about coping with a serious illness such as cancer. Central to all of these goals is the necessity of helping the primary team to develop appropriate language for discussion of key issues with the patient and the family in empathic and ultimately therapeutic terms.

Multiple aspects of consultation

An essential aspect of consultation is the psychiatrist's role in assisting the team, the patient, and the family to manage difficult emotional responses to troubling circumstances. Transference and countertransference reactions are common in complicated cases and are especially likely with emotionally laden issues such as somatoform disorders, eating disorders, and terminal illnesses.

CASE VIGNETTE

A 12-year-old girl with no formal past psychiatric history was admitted to the pediatric service with the chief complaint of inability to walk. She had been in her usual state of health until just days before admission when, while running during an activity at her overnight camp, she fell and hurt her ankle. She was brought to the camp infirmary where the nurse diagnosed a minor ankle sprain. However, by the next morning, the patient was unable to stand or bear any weight, and she was transferred by ambulance to the hospital near her home.

Neurological evaluation revealed full motor strength in all extremities and intact sensation. MRI scan, electromyograms, and CSF fluid analysis (biochemical, microbiological, and cytological) from the lumbar puncture were normal and unremarkable. Family history was notable in that the patient's mother had suffered a broken leg earlier in the spring but had since made a full recovery. The pediatric service was prepared to discharge the patient, but the patient remained unable to walk. Psychiatry was therefore consulted to rule out a psychogenic component to the patient's presentation and assist in identifying the appropriate disposition for the patient from the hospital.

In this case, physical therapy, treatment team meetings with family, and daily visits with psychiatry were implemented. The option for transfer to an inpatient psychiatric unit with an ability to address medical issues was discussed and the patient was subsequently transferred.

In managing this consultation request, the psychiatric consultant had to first ascertain the anticipated duration of hospital stay for this child (given the lack of a definitive organic cause to explain the symptoms) and clarify with the team that the child and her family had been informed of the request for psychiatric involvement. The consultant agreed that there likely was a psychogenic component to the child's presentation but needed to help the pediatric team appreciate the child's need for continued medical care (eg, physical therapy) to help her "regain" her strength, as well as her need for ongoing psychiatric treatment to address the reasons that she felt she could not walk.

The consultant might also have considered facilitating a discussion of the unconscious nature of the child's problems to deflect some of the angry feelings that members of the pediatric team may have experienced, such as "she's faking," or "she's taking up the time we could devote to someone who is really sick!"^4,5

With all consultations, treatment recommendations should be clear and concise. Lengthy notes with complex psychiatric formulations will be less valuable to the requesting services than suggestions for multidisciplinary approaches to address the issues that triggered the consultation request. In most circumstances, the consultation service provides assistance to the primary treatment team but does not assume primary responsibility or care for the patient unless the patient is transferred to a psychiatric setting. This process ameliorates the potential for unrealistic expectations of the treatment team by patient and family.

Finally, all recommended interventions should be discussed and agreed upon by the entire team before discussion with the family or treatment implementation. These practices can prevent the division of responsibility and emotional responses to the patient among different teams caring for the same patient. A notable exception to these limits includes psychiatric disposition planning. Because insurance regulations, approval processes, and available psychiatric transfer locations are rarely the purview of treaters other than those with psychiatric responsibility, the psychiatric consultant usually assumes substantially more responsibility in this arena.

CASE VIGNETTE

A 16-year-old girl with no psychiatric history was brought to the hospital after a motor vehicle accident in which she was a passenger. She was not wearing a seatbelt, and she experienced bilateral tibia/fibula fractures that required open reduction and a right distal radial fracture. The driver, her 18-year-old boyfriend, suffered only minor injuries. At presentation the patient's toxic screen was negative. The nurses noted that the patient frequently lay in bed with the covers pulled over her head, and psychiatric consultation was requested to assess for anxiety and depression.

On evaluation, the patient reported ongoing nightmares of the accident that she remembered in detail. She found herself ruminating about the events leading up to the accident; these thoughts made her extremely anxious. The pediatric service felt somewhat frustrated and angry that she did not recognize how lucky she was. She remained reluctant to speak about the accident because she found it too painful to remember. She also refused to see her boyfriend or any of her other friends, and she steadfastly refused to participate in physical therapy and, eventually, even to eat.

After an assessment by the psychiatrist, a complex acute stress reaction, which required more specialized services, was diagnosed, and she was transferred to a psychiatric facility with physical rehabilitation capacity.

In addition to her physical injuries, this patient sustained psychological trauma that required specialized care and attention. She evoked feelings of anger on the part of her treatment team because she could not see how minor her physical injuries were given the potential severity of her accident.

In a case such as this, psychoeducation, including defining and differentiating acute stress reactions and posttraumatic stress disorder (PTSD) for the patient, the family, and the nonpsychiatric medical team, may be helpful. In particular, the consultant can explicitly stress that the severity of the nonpsychiatric injuries (or lack thereof) does not always correlate with the degree of emotional or affective response or subsequent psychiatric sequelae.⁶

Increasingly, medical centers with multiple specialty services are incorporating child psychiatric consultants who subspecialize in consultation and liaison to fields as diverse as pediatric gastroenterology, cystic fibrosis, epilepsy, pediatric hematology and oncology, and organ transplantation.³ This subspecialization has led to new findings that are both specific to the disease processes being considered and generalizable to other medical predicaments. For example, some time ago it was observed that children and adolescents who survive malignancies through aggressive and often noxious treatment regimens are at risk for the development of PTSD and other anxiety and cognitive disorders later in life.⁷ This research has now been generalized to include examination for similar risks in solid organ transplantation. Current studies suggest that posttraumatic symptoms are more likely to develop if patients sense that their predicament is dire, regardless of the actual state of their health.⁸

Conclusions

Child and adolescent psychosomatic medicine involves a rich mixture of psychosocial, cultural, and biological concerns embroiled in the increasingly complex world of modern medical care. The pediatric consultation-liaison psychiatrist must take into consideration the patient's disease, the team responsible for treating the patient, the patient's family, the socio-cultural milieu, and possible comorbid psychiatric illnesses. In addition, for the child and adolescent psychiatrist who serves as a consultant, psychotherapeutic, biological, and multisystemic interventions all require equal consideration and careful implementation firmly grounded in a developmental context.

References:

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