Consultation/Liaison in Child & Adolescent Psychiatry Zaid B Malik, MD Zaid B Malik, MD Assistant Professor Vice Chief of Child Psychiatry Asst. Residency.

Consultation/Liaison Consultation/Liaison in Child & Adolescent in Child & Adolescent

PsychPsychiatryiatry

Zaid B Malik, MDZaid B Malik, MD

Assistant ProfessorAssistant Professor

Vice Chief of Child Vice Chief of Child PsychiatryPsychiatry

Asst. Residency DirectorAsst. Residency Director

Medical Director, PYAMedical Director, PYA

Director C&L Director C&L

What do we know about What do we know about C&LC&L

You get a call from ACHYou get a call from ACH

What you need to know,What you need to know,

What kind of request this is??What kind of request this is??

What can be risk factors ?What can be risk factors ?

What consultation model ?What consultation model ?

What consultation process? What consultation process?

TYPES OF REQUESTSTYPES OF REQUESTS

EMERGENCIES:EMERGENCIES:

Most commonly, suicide. Also, physical Most commonly, suicide. Also, physical abuse ( sometime presenting as abuse ( sometime presenting as Munchausen syndrome by proxy), sexual Munchausen syndrome by proxy), sexual abuse, drug abuse, acute agitation, acute abuse, drug abuse, acute agitation, acute psychotic reaction and family crises.psychotic reaction and family crises.

Sometimes, conditions that require Sometimes, conditions that require emergent care, like Anorexia Nervosa with emergent care, like Anorexia Nervosa with critical weight loss, management of critical weight loss, management of delirium, etcdelirium, etc

DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF SOMATOFORM DISORDERS:SOMATOFORM DISORDERS:

Anxiety and depression may be the Anxiety and depression may be the underlying cause of pediatric underlying cause of pediatric symptoms as recurrent abdominal symptoms as recurrent abdominal pain, headache, and failure to thrive.pain, headache, and failure to thrive.

Somatoform Disorders: Somatization Somatoform Disorders: Somatization disorder, hypochondriasis, disorder, hypochondriasis, conversion disorders.conversion disorders.

Collaborative Care of Children Collaborative Care of Children with Stress Sensitive Illnesswith Stress Sensitive Illness

Acute episodes of illnesses like Acute episodes of illnesses like Asthma, diabetic acidosis, ulcerative Asthma, diabetic acidosis, ulcerative colitis can be precipitated by colitis can be precipitated by psychological stress. Psychological psychological stress. Psychological assessment and care may be assessment and care may be essential for comprehensive essential for comprehensive treatment.treatment.

Diagnosis of Psychiatric Illness Diagnosis of Psychiatric Illness after a Somatic Illness.after a Somatic Illness.

Some illnesses linger long after the Some illnesses linger long after the acute phase in the form of prolong acute phase in the form of prolong depression.depression.

E.g Infectious Mononucleosis.E.g Infectious Mononucleosis.

Chronic IllnessesChronic Illnesses

Any type of Chronic illness, with Any type of Chronic illness, with recurrent hospitalization is a recurrent hospitalization is a psychological stressor for a child.psychological stressor for a child.

Rate of psychiatric illness in children Rate of psychiatric illness in children with both chronic medical condition with both chronic medical condition and disability is 3 times greater than and disability is 3 times greater than in noncompromised children.in noncompromised children.

Reaction to Major Pediatric Reaction to Major Pediatric Treatment Techniques.Treatment Techniques.

BMT, gives rise to considerable BMT, gives rise to considerable anxiety and depression.anxiety and depression.

Surgical repair for injury and burns.Surgical repair for injury and burns. Cranial irradiation can give rise to Cranial irradiation can give rise to

cognitive deficits.cognitive deficits.

Reaction to Pediatric Illness Reaction to Pediatric Illness or Trauma.or Trauma.

Depend on developmental level and Depend on developmental level and premorbid state of child, the state premorbid state of child, the state and reaction of the family and the and reaction of the family and the seriousness of the illness.seriousness of the illness.

Risk Factors??Risk Factors??

Consider following case..Consider following case..

Jason vs. JustinJason vs. Justin

Jason and Justin, both 14 year old Jason and Justin, both 14 year old Caucasian males admitted with same Caucasian males admitted with same Axis III Diagnosis. Abdominal pain…Axis III Diagnosis. Abdominal pain…

Jason is a diagnosed case of Jason is a diagnosed case of Ulcerative Colitis, no past psych hx, Ulcerative Colitis, no past psych hx, no family psych hx, good family no family psych hx, good family support, educated parents…currently support, educated parents…currently feeling depressed… psych called…..feeling depressed… psych called…..

Justin, has multiple prior admission Justin, has multiple prior admission for similar abdominal pain, team still for similar abdominal pain, team still unclear about cause, patient has hx unclear about cause, patient has hx of depression, family hx of bipolar of depression, family hx of bipolar illness, today an invasive procedure illness, today an invasive procedure is recommended, family and patient is recommended, family and patient appear clueless about the nature of appear clueless about the nature of procedure…. Patient feeling procedure…. Patient feeling depressed… psych calleddepressed… psych called

Thoughts??Thoughts??

Psychological Risk Factors:Psychological Risk Factors:

Premorbid psychopathology.Premorbid psychopathology. Poor parent child relationship.Poor parent child relationship. Psychiatric disturbance in either Psychiatric disturbance in either

parent.parent. InfancyInfancy Severe and ambiguous medical illness.Severe and ambiguous medical illness. Chronic Illness and multiple Chronic Illness and multiple

hospitalization. hospitalization.

Inadequate psychological Inadequate psychological preparation for hospital and invasive preparation for hospital and invasive procedures.procedures.

Parents’ inadequate understanding Parents’ inadequate understanding of illness.of illness.

Involvement of other non medical Involvement of other non medical agencies ( DPS, Police, Law ).agencies ( DPS, Police, Law ).

In general, psychological In general, psychological distress is likely to be more, ifdistress is likely to be more, if

Use of multiple medical consults.Use of multiple medical consults. Hospital staff’s inadequate response Hospital staff’s inadequate response

to or understanding of the to or understanding of the psychological meaning of the illness.psychological meaning of the illness.

Hospital staff’s inadequate Hospital staff’s inadequate awareness of transference and awareness of transference and counter transference issues.counter transference issues.

Models Of ConsultationModels Of Consultation

Anticipatory Model Anticipatory Model Case Finding ModelCase Finding Model Education and Training ModelEducation and Training Model Emergency Response ModelEmergency Response Model Continuing and Collaborative Care Continuing and Collaborative Care

Model.Model.

Basic Consultation ProcessBasic Consultation Process

Availability.Availability. Relationship.Relationship. Delineate the level Of Consultation.Delineate the level Of Consultation. Preparation of Consultation.Preparation of Consultation. Procedure.Procedure. Report.Report. Confidentiality.Confidentiality. Follow up.Follow up.

Availability ??Availability ??

Relationship?Relationship?

Level of Consultation??Level of Consultation??

Level Of ConsultationLevel Of Consultation

Inner life of ChildInner life of Child Dynamic b/w child and parentDynamic b/w child and parent Relationship b/w child and family and Relationship b/w child and family and

various ward staffvarious ward staff Interdisciplinary dynamics.Interdisciplinary dynamics. Relationship of hospital staff to an Relationship of hospital staff to an

outside agency.outside agency.

Preparation for Preparation for Consultation?Consultation?

This can make your life easy or..This can make your life easy or..

Preparation for ConsultationPreparation for Consultation

WhoWho WhatWhat WhenWhen WhyWhy HowHow ConsentConsent Hospital Record Review.Hospital Record Review.

Procedure?Procedure?

How to see client, with parent/ How to see client, with parent/ without parent/ parent first/ child without parent/ parent first/ child first??first??

What to access ? And How to?? Who What to access ? And How to?? Who should be included in assessment??should be included in assessment??

What to document and how much to What to document and how much to document? document?

Once done writing than what??Once done writing than what??

Report…Report…

Confidentiality ?Confidentiality ?

Follow upFollow up

All running smooth…All running smooth…

What can be the issues even if we What can be the issues even if we are doing every thing right???are doing every thing right???

Impediment to Consultation Impediment to Consultation Liaison In PediatricsLiaison In Pediatrics

Failure to understand how Failure to understand how pediatrician work.pediatrician work.

Lack of Child PsychiatristLack of Child Psychiatrist Professional Identity problemsProfessional Identity problems Different perception of patient Different perception of patient

( health vs disorder)( health vs disorder) Different interviewing techniques.Different interviewing techniques.

Anxiety among pediatrician in dealing Anxiety among pediatrician in dealing with emotional problems.with emotional problems.

Transference and counter transference Transference and counter transference issues.issues.

Time constraints.Time constraints. Financial consideration.Financial consideration. Ambivalent support of Ambivalent support of

multideceplenary care.( Who is the multideceplenary care.( Who is the boss here….)boss here….)

Limited opportunity for continuity of Limited opportunity for continuity of care in pediatric training.care in pediatric training.

Compartmentalized, disease oriented Compartmentalized, disease oriented research, rather than biopsychosocial research, rather than biopsychosocial research.research.

Inadequate outcome studies.Inadequate outcome studies.

Questions?Questions?