1. Consultation/Liaison in Child & Adolescent Psychiatry Zaid B Malik, MD Zaid B Malik, MD Assistant Professor Vice Chief of Child Psychiatry Asst. Residency Director Medical Director, PYA Director C&L

2. What do we know about C&L

3. You 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?

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. 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 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. 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. 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. 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. Some illnesses linger long after the acute phase in the form of prolong depression. E.g Infectious Mononucleosis. E.g Infectious Mononucleosis.

9. Chronic Illnesses Any type of Chronic illness, with recurrent hospitalization is a psychological stressor for a child. 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. 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. BMT, gives rise to considerable anxiety and depression. Surgical repair for injury and burns. Surgical repair for injury and burns. Cranial irradiation can give rise to cognitive deficits. 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. 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.. 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 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….. 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…..

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 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?? Thoughts??

16. Psychological Risk Factors: Premorbid psychopathology. Premorbid psychopathology. Poor parent child relationship. Poor parent child relationship. Psychiatric disturbance in either parent. Psychiatric disturbance in either parent. Infancy Infancy Severe and ambiguous medical illness. Severe and ambiguous medical illness. Chronic Illness and multiple hospitalization. Chronic Illness and multiple hospitalization.

17. Inadequate psychological preparation for hospital and invasive procedures. Inadequate psychological preparation for hospital and invasive procedures. Parents’ inadequate understanding of illness. Parents’ inadequate understanding of illness. Involvement of other non medical agencies ( DPS, Police, Law ). 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. Use of multiple medical consults. Hospital staff’s inadequate response to or understanding of the psychological meaning of the illness. 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. Hospital staff’s inadequate awareness of transference and counter transference issues.

19. Models Of Consultation Anticipatory Model Anticipatory Model Case Finding Model Case Finding Model Education and Training Model Education and Training Model Emergency Response Model Emergency Response Model Continuing and Collaborative Care Model. Continuing and Collaborative Care Model.

20. Basic 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.

21. Availability ??

22. Relationship?

23. Level of Consultation??

24. Level Of Consultation Inner life of Child Inner life of Child Dynamic b/w child and parent Dynamic b/w child and parent Relationship b/w child and family and various ward staff Relationship b/w child and family and various ward staff Interdisciplinary dynamics. Interdisciplinary dynamics. Relationship of hospital staff to an outside agency. Relationship of hospital staff to an outside agency.

25. Preparation for Consultation? This can make your life easy or.. This can make your life easy or..

26. Preparation for Consultation Who Who What What When When Why Why How How Consent Consent Hospital Record Review. Hospital Record Review.

27. Procedure? How to see client, with parent/ without parent/ parent first/ child first?? 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 access ? And How to?? Who should be included in assessment?? What to document and how much to document? What to document and how much to document? Once done writing than what?? 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??? 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. Failure to understand how pediatrician work. Lack of Child Psychiatrist Lack of Child Psychiatrist Professional Identity problems Professional Identity problems Different perception of patient ( health vs disorder) Different perception of patient ( health vs disorder) Different interviewing techniques. Different interviewing techniques.

33. Anxiety among pediatrician in dealing with emotional problems. Anxiety among pediatrician in dealing with emotional problems. Transference and counter transference issues. Transference and counter transference issues. Time constraints. Time constraints. Financial consideration. Financial consideration. Ambivalent support of multideceplenary care.( Who is the boss here….) Ambivalent support of multideceplenary care.( Who is the boss here….)

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

35. Questions?