Transcript Consultation/Liaison in Child & Adolescent Psychiatry

Consultation/Liaison in
Child & Adolescent
Psychiatry
Zaid B Malik, MD
Assistant Professor
Vice Chief of Child Psychiatry
Asst. Residency Director
Medical Director, PYA
What do we know about C&L
You get a call from ACH
What you need to know,
What kind of request this is??
What can be risk factors ?
What consultation model ?
What consultation process?
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TYPES OF REQUESTS
EMERGENCIES:
Most commonly, suicide. Also, physical abuse (
sometime presenting as Munchausen syndrome
by proxy), sexual abuse, drug abuse, acute
agitation, acute psychotic reaction and family
crises.
 Sometimes, conditions that require emergent
care, like Anorexia Nervosa with critical weight
loss, management of delirium, etc

DIFFERENTIAL DIAGNOSIS OF
SOMATOFORM DISORDERS:
Anxiety and depression may be the
underlying cause of pediatric symptoms as
recurrent abdominal pain, headache, and
failure to thrive.
 Somatoform Disorders: Somatization
disorder, hypochondriasis, conversion
disorders.

Collaborative Care of Children with
Stress Sensitive Illness
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Acute episodes of illnesses like Asthma,
diabetic acidosis, ulcerative colitis can be
precipitated by psychological stress.
Psychological assessment and care may be
essential for comprehensive treatment.
Diagnosis of Psychiatric Illness after
a Somatic Illness.
Some illnesses linger long after the acute
phase in the form of prolong depression.
 E.g Infectious Mononucleosis.
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Chronic Illnesses
Any type of Chronic illness, with recurrent
hospitalization is a psychological stressor
for a child.
 Rate of psychiatric illness in children with
both chronic medical condition and
disability is 3 times greater than in
noncompromised children.

Reaction to Major Pediatric
Treatment Techniques.
BMT, gives rise to considerable anxiety
and depression.
 Surgical repair for injury and burns.
 Cranial irradiation can give rise to
cognitive deficits.

Reaction to Pediatric Illness or
Trauma.

Depend on developmental level and
premorbid state of child, the state and
reaction of the family and the seriousness
of the illness.
Risk Factors??

Consider following case..
Jason vs. Justin
Jason and Justin, both 14 year old
Caucasian males admitted with same Axis
III Diagnosis. Abdominal pain…
 Jason is a diagnosed case of Ulcerative
Colitis, no past psych hx, no family psych
hx, good family support, educated
parents…currently feeling depressed…
psych called…..


Justin, has multiple prior admission for
similar abdominal pain, team still unclear
about cause, patient has hx of depression,
family hx of bipolar illness, today an
invasive procedure is recommended,
family and patient appear clueless about
the nature of procedure…. Patient feeling
depressed… psych called
Thoughts??
Psychological Risk Factors:
Premorbid psychopathology.
 Poor parent child relationship.
 Psychiatric disturbance in either parent.
 Infancy
 Severe and ambiguous medical illness.
 Chronic Illness and multiple
hospitalization.

Inadequate psychological preparation for
hospital and invasive procedures.
 Parents’ inadequate understanding of
illness.
 Involvement of other non medical
agencies ( DPS, Police, Law ).

In general, psychological distress is
likely to be more, if
Use of multiple medical consults.
 Hospital staff’s inadequate response to or
understanding of the psychological
meaning of the illness.
 Hospital staff’s inadequate awareness of
transference and counter transference
issues.
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Models Of Consultation
Anticipatory Model
 Case Finding Model
 Education and Training Model
 Emergency Response Model
 Continuing and Collaborative Care Model.

Basic Consultation Process
Availability.
 Relationship.
 Delineate the level Of Consultation.
 Preparation of Consultation.
 Procedure.
 Report.
 Confidentiality.
 Follow up.

Availability ??
Relationship?
Level of Consultation??
Level Of Consultation
Inner life of Child
 Dynamic b/w child and parent
 Relationship b/w child and family and
various ward staff
 Interdisciplinary dynamics.
 Relationship of hospital staff to an outside
agency.
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Preparation for Consultation?
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This can make your life easy or..
Preparation for Consultation
Who
 What
 When
 Why
 How
 Consent
 Hospital Record Review.

Procedure?
How to see client, with parent/ without
parent/ parent first/ child first??
 What to access ? And How to?? Who
should be included in assessment??
 What to document and how much to
document?
 Once done writing than what??

Report…
Confidentiality ?
Follow up
All running smooth…
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What can be the issues even if we are
doing every thing right???
Impediment to Consultation Liaison
In Pediatrics
Failure to understand how pediatrician
work.
 Lack of Child Psychiatrist
 Professional Identity problems
 Different perception of patient ( health vs
disorder)
 Different interviewing techniques.

Anxiety among pediatrician in dealing with
emotional problems.
 Transference and counter transference
issues.
 Time constraints.
 Financial consideration.
 Ambivalent support of multideceplenary
care.( Who is the boss here….)
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Limited opportunity for continuity of care
in pediatric training.
 Compartmentalized, disease oriented
research, rather than biopsychosocial
research.
 Inadequate outcome studies.
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Questions?