Consultation/Liaison in Child

1
Consultation/Liaison in Child Adolescent
Psychiatry

• Zaid B Malik, MD
• Assistant Professor
• Vice Chief of Child Psychiatry
• Asst. Residency Director
• Medical Director, PYA
• Director CL

2
What do we know about CL
3
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?

4
TYPES OF REQUESTS
5
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

6
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.

7
Collaborative Care of Children with Stress
Sensitive Illness

• 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.

8
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.

9
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.

10
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.

11
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.

12
Risk Factors??

• Consider following case..

13
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 parentscurrently feeling
  depressed psych called..

14

• 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

15

• Thoughts??

16
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.

17

• Inadequate psychological preparation for hospital
  and invasive procedures.
• Parents inadequate understanding of illness.
• Involvement of other non medical agencies ( DPS,
  Police, Law ).

18
In general, psychological distress is likely to
be more, if

• Use of multiple medical consults.
• Hospital staffs inadequate response to or
  understanding of the psychological meaning of the
  illness.
• Hospital staffs inadequate awareness of
  transference and counter transference issues.

19
Models Of Consultation

• Anticipatory Model
• Case Finding Model
• Education and Training Model
• Emergency Response Model
• Continuing and Collaborative Care Model.

20
Basic Consultation Process

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

21
Availability ??
22
Relationship?
23
Level of Consultation??
24
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.

25
Preparation for Consultation?

• This can make your life easy or..

26
Preparation for Consultation

• Who
• What
• When
• Why
• How
• Consent
• Hospital Record Review.

27
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??

28
Report
29
Confidentiality ?
30
Follow up
31
All running smooth

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

32
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.

33

• 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.)

34

• Limited opportunity for continuity of care in
  pediatric training.
• Compartmentalized, disease oriented research,
  rather than biopsychosocial research.
• Inadequate outcome studies.

35
Questions?