Handbook of Consultation-Liaison Psychiatry

24. Children and Adolescents

Anthony Guerrero and Courtenay Matsu

CONTENTS

24.1 General Principles Relevant to Children and Adolescents on a Consultation-Liaison Service

24.1.1 Preparing for the Pediatric Consultation-Liaison Encounter

24.1.2 The Developmental Perspective

24.1.3 The Family and Systems Perspective

24.1.4 Psychopharmacologic Principles

24.2 Specific Consultation-Liaison Scenarios that Are Common or High-Risk

24.2.1 Suicide Attempts

24.2.2 Eating Disorders

24.2.3 Possible Somatoform Disorder to Explain General Medical Symptoms

24.2.4 Chronic or Severe Medical Illness

24.3 Other Issues in Pediatric Consultation-Liaison Psychiatry

24.3.1 Outpatient Child and Adolescent Consultation-Liaison Psychiatry

24.4 Educational and Administrative Aspects

24.5 Summary

24.6 Illustrative Cases

24.6.1 Case 1: Eating Disorder

24.6.2 Case 2: Change in Mental Status

24.6.3 Case 3: Adjustment to New Diagnosis/Trauma

24.6.4 Case 4: Medical Illness and Compliance

The field of consultation-liaison child and adolescent psychiatry is an important and vital sub-subspecialty of both child and adolescent psychiatry and psychosomatic medicine. The leading causes of morbidity and mortality among young people [e.g., accidents, homicide, malignancies, and suicide among youth ages to 19 years of age (Hoyert et al., 2006)] suggest that there is much that psychiatrists can potentially contribute to general medical physicians striving to provide the best possible preventive and treatment-oriented care to children and adolescents.

This chapter is intended primarily for the benefit of consultation-liaison psychiatrists who encounter children and adolescents on a general medical service, and secondarily for the benefit of child and adolescent psychiatrists who wish to learn more about the practical aspects of working in and administering a pediatric consultation-liaison service.

24.1 General Principles Relevant to Children and Adolescents on a Consultation-Liaison Service

24.1.1 Preparing for the Pediatric Consultation-Liaison Encounter

Before seeing a pediatric patient, as with any other patient on a consultationliaison service, it is important to discuss the case with the referring provider so as to have a clear idea of the issues to address in the consultation. Where applicable, one should get an idea of the prognosis of the general medical condition. Because children are usually not legally autonomous, it is advisable (except in unusual circumstances) to ensure that the parents have been informed about, and have agreed to, the consultation. The effectiveness of the consultationliaison psychiatrist is limited if the initial encounter with the parents is awkward or confrontational merely because they had not been informed that a psychiatric consultation was requested. For the purposes of documenting medical necessity (and, in many cases, for billing purposes), the consultant should ensure that the referring medical team has either written an order for the consultation or documented that a consultation is necessary and therefore being requested.

In the interests of maintaining the most optimal relationships with the system of care surrounding a pediatric patient, the consultant should always remember this advice: there is no such thing as an inappropriate consultation request. Even if the identified patient were to seem fine, every consultation request suggests that someone in the system whether a family member, health care professional, or other interested party is concerned and therefore potentially able to benefit from a systems-sensitive intervention. In our institution's consultation-liaison service, we instruct our residents that even though most of us in the consultationliaison business operate on fixed salaries, we should nevertheless all take the perspective of bright and eager new physicians who are grateful for the privilege to work in the medical center, and who are always pleased to find work that can support their practice. We find that adopting such an attitude improves the overall quality of the consultation-liaison service and, ultimately, the care the patients and families receive.

24.1.2 The Developmental Perspective

The saying "children are not miniature adults" applies just as well to psychiatry as it does to the rest of medicine. Most prominently, children and adolescents are developing physically and cognitively, so it is very important to consider the developmental level of the patient. Although a comprehensive review of child and adolescent development is beyond the scope of this chapter, we will review key aspects of development, particularly as they apply to understanding of and adaptation to general medical illnesses.

One key principle is that development is a continuous process that builds on success in earlier stages. The consultation-liaison psychiatrist working in pediatric settings should therefore recognize the potential disruption that medical illnesses may have on normal child development.

Table 24.1 summarizes the key stages of development (predominantly social and cognitive) that may be of particular clinical importance in the context of general medical illnesses. Children's developmental levels are important to consider when discussing coping with illness (and associated treatments) and death and dying. For example, 6-year-olds may have erroneous (though developmentally age-appropriate) beliefs about human physiology, believing that they can lose all of their blood from a blood draw on injection, in spite of well-meaning reassurances that the pain will not be severe. As another example, a 6-year-olds might believe that justice can emanate from inanimate objects, and thus (unknown to their parents or caregivers) blame themselves for a personal illness or otherwise be afraid of reporting symptoms. Older children, in spite of more accurate perceptions about the causation of illness, may still not be able to appreciate all of the mechanisms that lead to illness. Hence, relatively straightforward explanations about the need for certain treatments (including medications) may be most appropriate.

Beyond just the cognitive understanding of illness, the emotional adjustment to illness is heavily influenced by developmental level. For example, it is likely that a preadolescent who must cope with a physical deformity may be more vulnerable to emotional difficulties, compared to a younger child, who may have a less developed body image, or an older adolescent, who may be more cognitively mature.

In order for children to optimally adjust to issues related to death and dying, they need to understand that death is irreversible, final, inevitable, and causally explained. Children facing death (whether their own or in a family member) at a developmental age earlier than that when these principles are understood are vulnerable to experiencing adjustment difficulties. For example, a child who does not realize that death is inevitable or causally explained may consider death to be a punishment for wrongdoing. During this stage children may also feel guilt, manifest regression, and have separation anxiety. During latency the child may also show regression as well as denial, and in adolescence there may be anger. Therefore, parents and caregivers often benefit from briefings about how to discuss challenging topics, such as death and illness, in a developmentally appropriate manner, and are often best able to gauge their child's cognitive development.

24.1.3 The Family and Systems Perspective

Children, both legally and developmentally, are not autonomous beings, and therefore are part of a complex system (whether explicit or not) that includes the family and other professionals involved in the child's care. While state laws may differ somewhat on the degree to which adolescents can consent to certain aspects of medical care (e.g., related to family planning, sexually transmitted diseases treatment, and substance abuse treatment), most states require parental consent for most types of behavioral health care. Additionally, most child and adolescent psychiatrists would agree that conscientious, systems-sensitive involvement of the family in the care of a child or adolescent (or even adult), whether legally mandated or not, usually constitutes the most optimal clinical care.

Consultation-liaison psychiatrists who are not primarily child and adolescent psychiatrists often wonder what is the best way to approach child or adolescent patients and their family: should the patient be interviewed first, or should the family be interviewed first, or should the patient and family be interviewed together? In our clinical experience, we have found that there is no correct answer to this question. We recommend that (1) the patient and available family at bedside can be introduced to the context of the consultation and then asked about how they would like to proceed; (2) time may be set aside to interview the patient and parents separately (particularly if there are concerns about abuse or other sensitive issues); and (3) a solid biopsychosocial formulation with attention to family and systems perspectives should guide the titration of the amount of time spent with the patient alone, with the parents alone, and with the patient and parents together (for instance, if improving communication between the patient and parents is an important focus of the intervention).

Children and adolescents rarely request psychiatric consultations on their own. The requests for psychiatric assistance and the reporting of psychiatric symptoms are therefore often seen through the lens of the family or requesting health care providers. It is therefore of utmost importance to (1) build and maintain solid working relationships with the health care team (through rounds and other collaborative meetings with pediatric medical, nursing, social work, chaplain, and other staff); and (2) determine why the consultation is being requested, which facilitates deciding which aspects of the system warrant attention and intervention. For example, was it someone other than the child or family who requested the consultation, in which case part of an effective consultation must include directly addressing that person's concerns. Consultation-liaison psychiatry is the perfect venue to practice the biopsychosocial formulation, which can guide the intervention on multiple levels. An example is given in the section on suicide attempts.

Many requests for consultation arise from concerns about emotional or behavioral symptoms in a parent or other family member involved in the child's care. These are entirely appropriate reasons to consult psychiatry, since the family is part of the whole system affecting the child's health. Therefore, while it is certainly appropriate to clarify the intent of the consultation with the referring provider, we recommend against "hassling" the medical team about the fundamental request for help. In such situations, it is important to document the consultations from the perspective that the child is the identified patient, even though observations about the parent or other caregiver may also be included. If a parent or other family member needs follow-up as an identified patient, then this can be part of the recommendation.

Common family-related situations and the potential role for the consultationliaison psychiatrist are summarized in Table 24.2.

24.1.4 Psychopharmacologic Principles

The consultation-liaison psychiatrist in pediatric settings should have basic knowledge of child and adolescent psychopharmacology. Once again, children are not "miniature adults" when it comes to responses to medications. It is important to note that most psychotropic medications are not approved by the Food and Drug Administration (FDA) for children and adolescents. Also, children and adolescents generally metabolize medications differently (usually faster) than adults. Finally, the responses of children and adolescents to medication are such that the risk/benefit profile (for instance, in the case of certain antidepressant medications) may not necessarily be the same as what it is for adults.

Given these differences, it is of utmost importance for psychiatrists treating children and adolescents to engage in solid psychopharmacologic practice, which includes the following:

1. Clearly defining and monitoring target symptoms (and utilizing collateral information where appropriate)

2. Carefully considering the existing standards of care and treatments that are best supported by evidence, whether FDA approved or not

3. Determining and considering the patient's and family members' previous responses to medications

4. "Starting low and going slow" in the titration of the medication

5. Continuing to raise the dose until one has satisfactorily treated all symptoms, reached the recommended upper dose limit of the medication, encountered side effects that make further titration intolerable, or reached a plateau in improvement or worsening of symptoms with an increase in dose

6. Following recommended guidelines in monitoring vital signs, other physical parameters, and laboratory values

7. Recognizing medically ill patients' potential sensitivity to medication side effects

Table 24.3 summarizes the usual first-line medications and recommended doses for common diagnoses and scenarios encountered in pediatric consultationliaison psychiatry.

Because of the likelihood that patients in pediatric consultation-liaison settings will have general medical comorbidities and may be on other medications, the reader is referred to specific chapters in this book on psychopharmacology in the context of specific general medical illnesses and to tables on drug-drug interactions.

Finally, specific to the pediatric population, we recommend the following "rules":

1. Very carefully consider the evidence for medication safety and efficacy in children and adolescents.

2. One medication is (generally) better than two medications, which is (generally) better than three medications, which is (generally) better than four medications, etc.

3. Although FDA approval is not necessarily everything, pay attention to the various categories of medications:

a. FDA-approved for treating children/adolescents with the condition you are prescribing the medication for (examples: stimulants for attention-deficit hyperactivity disorder, fluoxetine for major depressive disorder)

Fig. 24.1 Specific consultation-liaison scenarios that are common and/or high-risk.

b. FDA-approved for treating adults with the condition but also approved for treating children/adolescents with a different condition (example: valproic acid for pediatric bipolar disorder)

c. FDA-approved for treating adults with the condition, and with some evidence for safety/efficacy for children/adolescents with the condition (example: certain atypical antipsychotics for pediatric psychotic disorders)

d. Not FDA-approved either for the condition being treated or for children/adolescents for any indication

4. When multiple conditions amenable to psychopharmacologic treatment are possibly present, consider a rough (and potentially modifiable, depending on new evidence) hierarchy of evidence for safety and efficacy: stimulants > serotonin-selective reuptake inhibitors > mood stabilizers > antipsychotics.

5. Finally, "it's more than just medication." Particularly in pediatric settings, where a complex network of people surrounds the patient, it is important to realize that good psychopharmacology depends on various other components, arranged in the form of a pyramid (Fig. 24.1).

24.2 Specific Consultation-Liaison Scenarios that Are Common or High-Risk

24.2.1 Suicide Attempts

Suicide attempts or concerns about suicidality are likely to be among the more common concerns presented to a consultation-liaison psychiatrist on a pediatric service (Shaw et al., 2006).

First, it is important to follow whatever policies exist in the medical center regarding the management of patients who are suicidal or potentially suicidal. For many medical centers, doing so includes assigning a risk level (e.g., low, moderate, high) and implementing orders appropriate to the assigned risk level. The orders may address the following areas:

• Psychiatry consultation optional or mandatory

• Whether or not the patient may leave the unit, and if so, under whose supervision

• Allowed clothing (e.g., hospital clothing)

• Patient/room search for dangerous articles

• Allowed visitors

• Need for 1:1 staff supervision

• Frequency of nursing checks

Next, while keeping close contact with the referring medical team and nursing staff, the consulting psychiatrist should seek opportunities for crisis intervention where appropriate. As suggested previously, the psychiatrist, particularly when working with children and adolescents, should ask, "Why did this crisis happen now, on this day, at this time of day?" and "What are all of the biologic, psychological, and social stressors that led to this crisis?" The answers to these questions often help determine what should be done to resolve the crisis. Examples of common precipitating factors are shown in Table 24.4.

Once the patient is cleared for discharge from the medical unit, a decision needs to be made on whether or not the patient should be discharged home or admitted to an inpatient psychiatric unit. This decision can often be approached by considering the preferences of the patient and the family, since the benefit from inpatient hospitalization is often dependent on the patient's and family's openness to treatment. If neither the patient nor the family wants psychiatric admission, and if the patient is not acutely dangerous (wherein state-specific involuntary commitment criteria are met), the patient should be discharged following medical stabilization, but with an appropriate follow-up plan.

Overall, in planning for disposition options, the consulting psychiatrist should match clinical need with location of service (Table 24.5). Also, in keeping with the American Academy of Child and Adolescent Psychiatry's (2001) practice guidelines, the clinician should make sure to do the following prior to discharging any patient for whom suicidal risk had been a concern:

• Ask the family about any unsupervised access to firearms or other dangerous materials in the home.

• Give the patient and family resources for after-hours emergencies.

• Ensure timely follow-up.

24.2.2 Eating Disorders

At our institution, because of the inherently higher risks involved, we instruct trainees to ensure that consultations for suicidal patients or patients with potential eating disorders are set up as soon as possible regardless of whether or not the requesting physician has described the consultation as being urgent.

Consultation-liaison psychiatrists typically encounter patients with eating disorders in the context of relatively brief medical hospitalization for general medical sequelae (e.g., cachexia, autonomic instability, or electrolyte abnormalities).

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 2000), diagnostic criteria for each of the eating disorders, the key features of anorexia nervosa include a refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., 85% of that expected), intense fear of gaining weight, body image distortion, and amenorrhea (absence of at least three consecutive menstrual cycles); and the key features of bulimia nervosa include hinging with a sense of lack of control coupled with purging or starvation or excessive exercise (at least twice per week for 3 months) and body image concerns. The disturbances that might otherwise suggest bulimia nervosa should not occur exclusively in the context of anorexia nervosa. Because of the generally more serious complications associated with anorexia nervosa than with the other eating disorders, we believe it is particularly important to identify the diagnosis of anorexia nervosa, binge-eating/purging type, when, on the surface, the clinical presentation may suggest a diagnosis of bulimia nervosa.

To thoroughly assess both the type and severity of an eating disorder, we recommend that the consulting psychiatrist obtain a careful history and physical examination as detailed below.

24.2.2.1 History

The history should address the following issues:

• Restricting behaviors (duration, context, etc.)

• Exercise history (duration, context, etc.)

• Binging behaviors (duration, context, etc.)

• Purging behaviors (duration, context, etc.)

• Menstrual history

• Physical symptoms (light-headedness, palpitations, fatigue, syncope, bloating, constipation, swelling)

• Mood symptoms

• History of abuse/harm/threats

24.2.2.2 Physical Examination

Generally, the physical examination will have been done by the time the psychiatric consultation is requested, and it should be consulted for the following information:

• Height (in centimeters)

• Weight (in kilograms)

• Body mass index (BMI)

• Vital signs, including temperature and sitting/standing pulse and blood pressure

• Physical stigmata of eating disorders

• Swelling

In deciding whether or not the patient should be admitted and what the eventual disposition should be, it is important to carefully review existing standards of care, particularly the American Psychiatric Association Practice Guidelines (American Psychiatric Association, Work Group on Eating Disorders, 2006). It is especially important to be familiar with recommended criteria for inpatient hospitalization; if the patient meets these criteria, listed below, then discharge to a lower level of care may not be feasible:

• Heart rate in the 40s

• Orthostatic blood pressure changes (>20 bpm increase in heart rate or >10 to 20 mm Hg drop)

• Blood pressure below 80/50 mm Hg

• Hypokalemia

• Hypophosphatemia

• Suicidal intent and plan

• Weight <75% of ideal body weight (for children and adolescents: acute weight decline with food refusal even if not <75% below healthy body weight)

• Very poor to poor treatment compliance/motivation: preoccupied with egosyntonic thoughts, cooperative only in highly structured environment

• Presence of any existing psychiatric disorder that would require hospitalization

• Needing supervision during and after all meals or needing nasogastric/special feeding

• Complete role impairment: inability to eat by oneself and gain weight; structure required to prevent patient from compulsive exercising

• Needing supervision during and after all meals and in bathrooms

• Severe family conflict, problems, or absence, thus precluding the provision of structured treatment at home, or patient lives alone without adequate support system

• Lives too distantly from treatment setting to make intensive treatment feasible

Because "ideal weight" is determined not only by height but also by stage of physical development, we recommend the following steps in determining the ideal weight for the patient:

1. Determine what the ideal (approximately 50th percentile) BMI should be for the patient's age, by referring to appropriate growth charts from the Centers for Disease Control and Prevention (http://www.cdc.gov/nchs/data/nhanes/ growthcharts/set2clinical/cj411074.pdf)

2. Determine, for the patient's height, what weight should correspond to the ideal BMI, by referring to a BMI normogram or table (http://www.cdc.gov/ nccdphp/dnpa/bmi/00binaries/bmi-checkbook.pdf)

Slow, steady weight gain (for example, 2 pounds per week in inpatients and 1 pound per week in outpatients) is the goal for medical treatment of an eating disorder typically anorexia nervosa with cachexia and other physiologic complications. Weight gain, achieved through medical refeeding, is important to address not only the physiologic complications of the eating disorder but also the behavioral and emotional symptoms, which often improve dramatically with restoration of nutrition. During medical hospitalization for an eating disorder, it is extremely important to monitor for signs and symptoms of refeeding syndrome, which may include bloating and abdominal distress, edema, and, in severe cases, hypophosphatemia and cardiac failure. We recommend that the clinician perform a daily review of systems in order to assess these symptoms.

It is also very important to tailor psychotherapeutic interventions to the immediate goal of restoring normal physiologic functioning. While the clinician should convey significant support for the patient and acknowledge how emotionally challenging the "refeeding" stage is, it is important not to view apparently in-depth psychological revelation and discussion (on the patient's part) as an adequate substitute for the needed goal of weight gain. In working with the patient, the family, and other health care providers, the clinician needs to be aware that patients may not like the requirement to gain wait and may therefore (with the support of their families and possibly other health care providers) "doctor shop."

Because of the significant risks involved with both the eating disorder itself as well as its medical treatment, we recommend that consultation-liaison teams consider the use of pathways of care and standard orders for the management of eating disorders typically anorexia nervosa with cachexia. The standard orders used at our institution are as follows:

• Dietary consult

• Electrocardiogram with rhythm strip

• Urinalysis

• Blood: erythrocyte sedimentation rate, thyroid-stimulating hormone with reflex, chemistry panel with calcium, phosphorus, and magnesium (these are not necessarily part of the panels typically ordered)

• Cardiorespiratory monitor

• Vital signs with orthostatic blood pressures

• Daily weights (after first void, dressed in hospital gown)

• Strict assessment of input/output

• Chemistries every other day or as appropriate (to evaluate for metabolic complications of refeeding syndrome, such as hypophosphatemia)

• No outside food

• Limited fluids

• Modest starting diet

• Postmeal restriction from using the bathroom

• Limited activity

24.2.3 Possible Somatoform Disorder to Explain General Medical Symptoms

It is not unusual for children and adolescents to have somatic symptoms associated with emotional distress. It is likewise fairly common for the pediatric team to request a consultation to address the issue of differential diagnosis of a somatoform disorder (Shaw et al., 2006). When the psychiatric team is consulted, the medical team is not infrequently frustrated by a symptom or sign that does not seem to have a clear organic etiology, and the team wants an additional blessing from psychiatry to make sure that an organic etiology has not been missed.

Koranyi (1979) described how a substantial number of patients in a psychiatric setting may have serious general medical illness that is either undiagnosed or labeled as psychosomatic. Of interest, even Freud (1901) described how a 14-year-old girl, who reportedly "fell ill of an unmistakable hysteria, which did in fact clear up quickly and radically under [his] care," died 2 months later "of sarcoma of the abdominal glands." He admitted that he "had perhaps overlooked the first signs of the insidious and incurable disease."

We believe that the consultation-liaison psychiatrist has a potentially important role in helping the general medical team cautiously approach the challenge presented by patients who present with possible psychosomatic symptoms in a pediatric hospital setting. To appropriately rule in or rule out psychiatric causes for general medical symptoms, we suggest that the consultation-liaison psychiatrist go through the following steps (adapted from Guerrero, 2003):

A. Adequately consider differential diagnoses:

1. Correctly identify the chief complaint (without being inappropriately biased toward psychiatric etiologies at the exclusion of general medical etiologies).

2. Identify mechanisms behind the chief complaint to establish an initial list of differential diagnoses (again, to avoid being narrowly focused on only psychiatric etiologies).

3. Carefully elicit and examine other coexisting signs and symptoms to test the hypotheses.

4. Ask "Why now?" to evaluate further which hypotheses best explain why the patient is having the symptoms at this time.

B. Specifically consider life-threatening conditions:

5. Observe the vital signs and specifically consider the most life-threatening explanations (e.g., unexplained hypertension and bradycardia, possibly associated with a space-occupying brain lesion; unexplained tachycardia, possibly associated with substance or medication toxicity; etc.).

C. Consider child development and specific pediatric conditions:

6. Apply knowledge of child development to the interpretation of presenting symptoms (e.g., preverbal children may manifest pain as unusual behavioral symptoms such as head-banging).

7. Consider specific pediatric illnesses in the differential diagnosis (e.g., genetic syndromes associated with particular behavioral phenotypes; infections that are statistically probable in children and adolescents such as Epstein-Barr virus infections for depression, streptococcal infections for obsessive-compulsive spectrum disorders; etc.).

D. Advocate for optimal general medical care:

8. Consider the rarity of certain psychiatric conditions relative to the general medical conditions being ruled out (e.g., many of the specific somatoform disorders are, from a statistical standpoint, relatively rare compared to other general medical conditions).

9. Consider other general medical conditions that may be comorbid or underrecognized in the context of a psychiatric condition or challenging psychosocial circumstance (e.g., sexually transmitted diseases in homeless or runaway youth).

10. Use liaison skills in managing bias and countertransference and working with the general medical team.

E. Effectively communicate and listen:

11. Consider asking families what they fear may happen to their child to guide supportive explanation.

12. Listen to other people's suggestions about diagnostic possibilities.

Given the complex nature of many of these cases, we recommend that the consulting psychiatrist follow these patients closely and work closely with the medical team. Even if it is obvious that a patient does not need psychiatric hospitalization, it is not sufficient to see the patient only once and then recommend "outpatient follow-up" without addressing the issue of the unexplained somatic symptom. Finally, in determining whether or not a patient with a possible somatoform disorder can be safely discharged, we recommend performing a final checklist:

1. Have general medical conditions been adequately ruled out?

2. Have patient/family concerns about what they are most worried is causing these symptoms been addressed?

3. Have threats to the patient's safety, including abuse/neglect, been adequately ruled out through individual and family interview?

4. Has the patient and family been "prescribed" a face-saving expected course of recovery?

5. Is there a follow-up plan?

24.2.4 Chronic or Severe Medical Illness

Often, consultations are requested for pediatric patients with chronic or severe medical illnesses, including congenital heart disease, cystic fibrosis, asthma, chronic renal failure, immunodeficiency, diabetes mellitus, cancer, seizure disorders, and various rheumatologic illnesses. We refer the reader to other chapters in this textbook for discussions of the specific illnesses. However, we believe that, in consults on pediatric patients with these conditions, it is often helpful to keep a checklist of the possible individual, family, and staff issues that may need to be addressed (while still being mindful of the specific consultation question and context of the consultation request). The checklist that we use at our institution is shown in Table 24.6.

24.3 Other Issues in Pediatric Consultation-Liaison Psychiatry

24.3.1 Outpatient Child and Adolescent Consultation-Liaison Psychiatry

A discussion of the entire specialty of child and adolescent psychiatry is beyond the scope of this handbook, but it is important for administrators of consultation-liaison psychiatric services to recognize their potential role in the provision of quality preventive and treatment-focused behavioral health care in primary care settings, including pediatric and family practice clinics.

Table 24.7 lists the suggested screening areas where consultation-liaison psychiatrists may be a helpful resource for primary care clinicians who primarily practice in outpatient settings.

When acting as a resource for outpatient primary care providers for children and adolescents and their parents, the psychiatrist should be mindful of the major causes of morbidity and mortality in children and adolescents, including accidents (often related to childhood behavioral problems or psychosocial adversities in the family), homicide, and suicide (Guerrero et al., 2003). We recommend that consultation-liaison psychiatrists should be prepared to take the following steps in preventing violence-related causes of morbidity and mortality:

• Early identification and intervention for children, adolescents, and families at risk for or involved in violence

• Facilitation of families' access to mental health care services

• Reduction of youth's unsupervised access to firearms

• Education of parents on alternatives to corporal punishment for behavior management (American Academy of Pediatrics, 1999; Commission for the Prevention of Youth Violence, 2000)

24.4 Educational and Administrative Aspects

Pediatric consultation-liaison may often not be financially viable based on direct revenue. According to Shaw et al. (2006), collection rates for professional billing for pediatric consultation-liaison services appear to average around 30%. Nevertheless, pediatric consultation-liaison services can prove their significant value to the sponsoring medical center (which often provides a substantial "coverage contract" to the service) by enhancing the overall quality and efficiency of care that children and adolescents receive and by contributing to the education and training of pediatric and other health care providers. We believe that it is of utmost importance to maintain collaborative attitudes with, and financial and administrative accountability to, all stakeholders in a pediatric consultationliaison service. Given Campo et al.'s (2000) finding that financial viability of pediatric consultation-liaison services is correlated with integration of the psychiatry program within the medical center and adequate fiscal information being provided to the psychiatry chair, we recommend regular meetings with hospital administration and the establishment of a process that allows for financial and revenue cycle issues to be regularly reviewed. We also recommend a process that allows for continuous improvement of the quality and value of the consultation-liaison service (Table 24.8).

24.5 Summary

A checklist before doing a pediatric consultation should include the following:

• Understand the context, including the general medical condition and its prognosis

• Ensure parent/guardian consent, and documentation of consultation request

The differences between pediatric and adult consultation/liaison encounters are as follows:

• The psychiatrist needs to more prominently consider the developmental level of the patient, in assessing the psychological impact of the general medical condition and its treatment.

• The psychiatrist needs to more prominently consider the family context in assessment and management, but being careful not to assume inappropriate or inadvertent roles (e.g., forensic investigator, psychiatrist providing individual treatment for a family member, etc.).

• The psychiatrist needs to appreciate the differences in responses to medications, and to become familiar with commonly used medications in pediatric consultation-liaison psychiatry.

Tips for managing suicidal or potentially suicidal patients:

• Follow hospital policies (e.g., risk assessments, standard orders, etc.).

• Ask "why now?" and use the biopsychosocial approach to crisis intervention and determination of disposition.

• Use checklists (e.g., no unsupervised access to firearms) to optimize the safety of patients being discharged.

Tips for managing eating disorders:

• Utilize existing practice guidelines to determine optimal site of treatment.

• Medical refeeding and slow, steady weight gain is the cornerstone of treatment in anorexia nervosa.

• Consider using standard orders or pathways of care to implement practice guidelines.

Tips for managing possible somatoform disorders:

• Help the team to thoroughly and conscientiously consider general medical etiologies or comorbidities.

• Help the parents to express what they are most concerned about.

• Assess the risk situations (e.g., abuse/neglect).

Tips for consultations on patients with chronic or severe medical illnesses:

• Ensure a comprehensive approach that anticipates potential areas of intervention to benefit the patient, family, and staff.

Overall tips:

• Remember the leading causes of morbidity and mortality in children and adolescents (including accidents, homicide, suicide) and the prevalence of mental health conditions in children and adolescents.

• Remember our duty and our potential value to our stakeholders.

24.6 Illustrative Cases

24.6.1 Case 1: Eating Disorder

The patient is an 17-year-old girl, a cosmopolitan 11th grader, who was initially brought to the outpatient clinic by her mother, who was concerned about "depression." She was subsequently admitted to the inpatient pediatric unit, and a psychiatric consultation is requested for a likely eating disorder (labeled as "anorexia/bulimia.")

She reports that, ever since a breakup 1 year ago, her life has been "headed downhill." For the past 3 or 4 months, she has experienced depression, anhedonia, difficulty concentrating, and intermittent suicidal thoughts. Previously a straight-A student, she has experienced a marked decline in grades this past semester, which is nearly complete.

There is no history of any symptoms suggestive of mania or hypomania. In terms of any substance abuse, she endorses tasting alcohol at a party "once or twice," trying marijuana once, and (because she learned that it could help her to lose weight) "focusing pills," supplied by a friend. "But it was only a few times ... I know better than to get hooked on pills."

Upon specific questioning, the patient reluctantly discloses that, for the past 5 or 6 months, she has been skipping meals, using her fingers to induce vomiting, and running several miles per day. She also has been consuming large amounts of water and caffeinated beverages. She says that, for her body type, she thinks her ideal weight should be around 90 pounds. She has lost 25 pounds since 5 or 6 months ago. She admits to thinking constantly about her weight, and to being overwhelmed with feelings of needing to lose more weight to avoid becoming fat.

Around 1.5 year ago, for a few months after quitting cross-country running, she would consume large quantities of food in a short period of time and then induce vomiting by using her fingers. She denies any history of consuming emetics, laxatives, or diuretics. "But I researched them at one point." She has been amenorrheic since 3 months ago, and has not been sexually active since her breakup.

Past medical history is negative for any significant illnesses. She is on no chronic medications and has no allergies.

24.6.1.1 Family History

The patient has two older brothers, ages 21 and 25. Her mother is 50 years old and in good health, and her father is 57 years old, with a history of hypertension. Family history is also significant for lupus in a maternal aunt, hypothyroidism in the paternal mother, and leukemia in her brother's infant daughter.

24.6.1.2 Social History

Patient had previously been involved in numerous extracurricular activities, and she had been popular among her friends. Also, her mother reports a good mother-daughter relationship throughout most of her daughter's life. However, recently, the patient has been more isolative. The patient denies any past history of physical or sexual abuse.

24.6.1.3 Examination

A review of systems is significant for fatigue, cold sensitivity, and episodes of light-headedness. The patient also tends to be constipated.

On examination, her vital signs are as follows: temperature 96.8°F, sitting pulse 44 per minute, sitting blood pressure 84/54, weight 92 pounds, and height 5 feet 5 inches. She is dressed in thick clothing and makes fair eye contact. Her mood is depressed, and her affect is congruent and restricted. Her thoughts are linear, without delusions. There are no auditory or visual hallucinations. She denies any current suicidal or homicidal ideations. She is alert and oriented. Attention and concentration is intact. Registration is intact; however, she needs prompting to recall one of three objects after 5 minutes. Insight is questionable regarding her ability to connect her eating behaviors to her medical and psychological symptoms.

24.6.1.4 Questions

1. Calculate body mass index (BMI) (answer: 41.8 kg/1.65 m2 yields a BMI of 15.4). Calculate 50th percentile BMI for age (answer: 21). Calculate weight for height, corresponding to 50th percentile BMI for age (answer: 126 pounds). Calculate percentage of ideal body weight (answer: 92/126 = 73`/).

2. Present a biopsychosocial formulation, followed by a five-axis differential diagnosis (Table 24.9).

3. Work with the medical team to ensure appropriate management orders:

No outside food

Begin 1500-calorie diet

No fluids outside of agreed-upon diet

Meds:

Comprehensive metabolic profile with phosphorus and magnesium

Erythrocyte sedimentation rate

Thyroid-stimulating hormone with reflex to free thyroxine (T4)

Urinalysis

Electrocardiogram with rhythm strip

Daily basic metabolic profile with calcium, phosphorus, and magnesium

The patient is admitted to the medical unit for further management and refeeding. You see her daily. You provide individual and family psychoeducation, and work closely with the general medical team. With adequate stabilization of her physiological parameters and weight gain according to targeted goals, she is ready for discharge 1'h weeks later. You plan for close outpatient follow-up.

24.6.1.5 Further Questions

1. During the inpatient hospitalization, what complications of refeeding would you make sure to assess for on a frequent basis? (Answer: bloating, edema, hypophosphatemia.)

2. During the inpatient hospitalization, what would be the appropriate content of individual and family psychotherapy? (Answer: psychoeducation and building therapeutic alliance around primary importance of medical stabilization and weight gain.)

3. What would be the targeted rate of weight gain in an inpatient setting? (Answer: approximately 2 pounds per week.)

4. How would you assess readiness for discharge? (Answer: refer to APA practice guidelines.)

24.6.2 Case 2: Change in Mental Status

A 15-year-old boy who was previously healthy, with no past psychiatric history, presents with a change in behavior. His parents report that he has been talking to himself, not making any sense, and showing poor interaction with others. This had been ongoing for the past 1 to 2 days. He had otherwise been a welladjusted child attending school with no difficulties. They denied any family history of psychiatric illnesses and denied any knowledge of illicit drug use by the patient. His mental status exam is significant for thought blocking and possible visual hallucinations as well as poor concentration and attention. His urine drug screen was negative for alcohol, cannabinoids, cocaine, amphetamine, barbiturates, and opiates.

24.6.2.1 Questions

1. What findings may suggest a general medical etiology, and what specific general medical etiologies should be considered in the differential diagnosis? Statistically, how common (or rare) are primary psychiatric disorders, relative to these general medical etiologies?

2. How would you work with the pediatric medical team to ensure that appropriate general medical evaluation is done?

3. What treatment approaches might be recommended?

24.6.3 Case 3: Adjustment to New Diagnosis/Trauma

A 16-year-old girl who was previously healthy, vibrant, and popular in school was diagnosed with cancer. She lacks energy and interests and is isolative. Her parents have difficulty talking about her illness and disagree regarding the best treatment options for her.

24.6.3.1 Questions

1. What developmental issues would be important to consider in working psychotherapeutically with the patient?

2. How might you approach the issue of the parents' difficulty in talking about her illness and their disagreement regarding her treatment? Why may parental issues be important to address in optimally caring for the patient?

24.6.4 Case 4: Medical Illness and Compliance

A 12-year-old girl with a 2-year history of insulin-dependent diabetes mellitus (IDDM), poorly controlled, was admitted to the intensive care unit due to hyperglycemia. She is resistant to treatment providers (including physicians, nurses, and dietitians), and is difficult to engage. Her primary care providers are frustrated because she has been admitted to the pediatric intensive care unit on multiple occasions for similar IDDM complications.

24.6.4.1 Questions

1. What would be the differential diagnosis for the apparent noncompliance?

2. Describe your approach to working with the primary care providers' frustration.

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