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One Year's Survey of Child Psychiatry Consultations in a Pediatric Hospital
One Year's Survey of Child Psychiatry Consultations in a Pediatric Hospital
William Sack, M.D., Stanley Cohen, Ph.D., and Christine Grout, B .A.
Abstract. A one-year retrospective survey of child psychiatry consultations in a pediatric hos-
pital is presented and the findings are compared to a previous study from another part of the country. Over half of the children in this series came from families who had experienced significant stress in the year prior to hospitalization. These "di sordered" families used the mental health care system after hospitalization less frequently than did the "nondisordered" families. The pediatric hospitalization is conceptualized as an implicit form of crises intervention for some children in families showing significant psychosocial disarray.
Our consultations were performed as part of a broad child psychiatry-pediatric liaison effort. We define liaison as do Naylor and Mattsson (1973) as a close bond between the two disciplines, a connection that fosters mutual understanding and includes not only consultation, but collaboration, education, ongoing management, support, and coordination of care. It was within this larger context that we wished to survey our experience with consultation. While child psychiatrists have long been interested in the emotional problems of the hospitalized child and have been active proponents of a more humane hospital milieu for children (Prugh and Jordan, 1975), they have rarely systematically surveyed their own interventions. An important exception was the work of Monnelly and his colleagues (1973). We were curious to see how similar our experience was to theirs. In addition, we asked ourselves a number of questions about consultation for which no information could be found in the literature: (1) What were the characteristic family Dr. Sack is Director of Child Psychiatry and Assistant Professor of Psychiatry and Pediatrics; Dr. Cohen is Associate Professor of Psychiatry; and C. Grout is a Research Associate; Department ofPsychiatry, University ofOregon Health Services Center, Portland, Oregon . A modified version of this paper was presented at the 1975 Annual Meeting of the American Acadnny ofChild Psychiatry, SI. Louis, Mo . Part of the research described was supported by a state educational grant cproject Impact #73 -008008.) Reprint> may b. requested from Dr. Sack, at 3181 S.W. Sam fackson Park Road, Portland, OR 97201 .
716
Consultations in a Pediatric Hospital
717
backgrounds of the children who received a psychiatric consultation? (2) How did they utilize this liaison service? (3) Where did these children go when they left the hospital? What health services did they use in their aftercare? (4) What was their general behavioral adjustment one to two years later? DESCRIPTION OF STUDY
The Setting and the Staff
The Doernbecher Pediatric Hospital is a teaching hospital for the University of Oregon Health Sciences Center in Portland, Oregon. It has 103 beds and admits children from birth through age 15. It serves the entire state as a referral hospital. All patients are the responsibility of the house staff. During the year of this survey, the liaison team was in the fourth year of its development. Our program functioned quite similarly to that described by Naylor and Mattsson (1973) at the University of Virginia Medical Center. Two child psychiatry fellows spent about one third of their work week for a 6-month rotation on the liaison service. Three child psychiatry faculty spent a total of about 12 hours a week in the various functions of the liaison service. Two child psychiatric nurses spent half of their work week on the wards and anchored the continuity of the liaison work in a very important way. Members of hospital social service, medical psychology, and public health nursing, though not part of the core liaison team, also made contributions. Each child psychiatry fellow spent about ;) hours per consultation, in interviewing the family and child, obtaining information from outside sources, explaining the findings to the ward staff, and coordinating aftercare. About a third of these fi hours was spent away from the bedside. While our overall aim was to make the pediatrician competent to handle comprehensively all aspects of the psychosocial problems of his patients, we still found ourselves doing a good deal of care coordination. Naylor and Mattsson (1973) found this coordination function to be an important part of their work consultation experience. Methods
We reviewed the medical charts of the 98 children seen in psychiatric consultation from July I, 1973 to July I, 1974. One of us (CG) read the entire record and then completed a questionnaire designed to elicit the information we sought. A dual review of 10 per-
718
William Sack et al.
cent of the records yielded no significant interrater problems. The data, being retrospective, were subject to inevitable errors of incompleteness and distortions of emphasis. The psychiatric diagnoses were made by one of us (WS), based, as in the Monnelly et al. study (1973), on the DSM II Manual of the American Psychiatric Association. The second part of the project was aimed at obtaining follow-up information about general behavioral adjustment since hospitalization, use of medical and mental health care services, and change in family structure or living arrangements in these former patients. A questionnaire containing multiple choice and open-ended questions was mailed to the parents or caretakers of these children. By making initial phone contact or working through social agencies or physicians, we were able to trace 78 of the 98 children. We explained the study and obtained written consent to use the information they provided. Fifty-two questionnaires were returned, representing a return rate of 79% of those we mailed and 54% of our original sample. We utilized the X 2 test in our statistical analysis of parts of the data. RESULTS AND DISCUSSION
Comparison with Another Study
The information we gathered will be presented in a series of tables. Table I compares demographic variables from our Oregon survey with comparable figures from the St. Louis study by Monnelly et al. (1973). Pediatricians remain the main source of referral in both series. The average length of stay was 13 days in each series, or :'> days over the average stay for all children. Probably due to a large number of infants and toddlers referred for failure to thrive and child abuse, the mean age of referral of our children was 2 years less than in the St. Louis series. Table 2 compares the major reasons for psychiatric referral in the Oregon and St. Louis series. Again similarities predominate, with the exception that we were seeing more children described as ward behavior problems and fewer for symptoms of unknown etiology. Table 3 compares the diagnostic breakdown of the children in the two series. The diagnoses in Monnelly's series were made in a prospective fashion, while our diagnoses were made retrospectively from a chart review. Our diagnoses of hysteria could not be made
719
Consultations in a Pediatric Hospital
from the criteria of Feighner et at. (1972) because we did not have the raw data, but were made retrospectively in suggestible children whose symptoms seemed to symbolize significant problems for which no organi c cause could be found. While it ma y not be accurate to compare the di agnosis of h ysteri a made in these different ways. we found th at in both ser ies one third of the females from 9 to 15 years of age were diagnosed as having h ysterical reactions. The high figures fo r "no psychiatric illness" in the St. Louis series ma y be a reflection of our clinical impression that pediatrician s Tahlc I Compar iso n of Psychi atric Consultations in Two C hild re n's Hospitals SI. Louis Serie s Patients referred during tim e stud ied T ime period of study Pe rcentage o f IOta I patien ts refe r red Length of hospital stay for refe rr ed pat ients Length o f hosp ital sta y for no n r e fe rred patien ts Age range Fc ma les refe rred ('if) Referral SOUITe fr om ge nera l ped iatrics (%) Pr esenting problems (orga n syste m in volved ) (%) <:.:'-J.S.
Oregon Series
7~
~8
II mos.
12 mos . 7
I :~ .H days
13.6 da ys
H.I d avs aver. 2-1" {rs. m ~an : 10 .7 yr s. 55
8.6 da ys aver. I mo .-1 5 yrs. me an 7 . ~ )TS. 50
flO
36 28 5 :H
( ;.L
Endocri ne Othe r syste ms Speci fic med ical o r surgica l di sch arge d iagn o sis (% )
Ei
sn
44 Table 2
Cornp.uisou of Psy('hiau'ic COllsuhatioll in 'T wo C hil clJ'C' Il's Itospitals
l\f'Uor Reaso ns for Referral I. Symptom of unkn own e tio logy (poss ibly psycho so mati c) 2. Question of dep ressi o n s. Beh avior p ro ble m on ward 4. Specific symplO m p robl em 5 . Question of psych osis 6. Parent with psychiat r ic p robl em. a nd other
SI. Loui s Study %
Oregon Study %
so
17 14
I~
I :i 10
"
2:-1
2~
12 5 2:i
720
William Sack et al. Table
:~
Comparison of Psychiatric Consultation in Two Children's Hospitals
Diagnosis Hysterical reaction Hyperactive child syndrome Depression Organic brain syndrome Mental retardation Other personality disorders Anorexia nervosa Anxiety reaction Enu resis/encopresis No psychiatric illness Child abuse Failure to thrive Undiagnosed psychiatric illness
SI. Louis Study %
Oregon Study %
18,9
12
IV;
10 18 7 9
8,9 8,9 :>,1 7,6 :~.8 ~.:l
l.~
18.9
u.s
II
2 2 2 2 14 8 ~
often request consultation from child psychiatrists when the parents show significant emotional or psychiatric problems. Monnelly et al. mention that over half of such cases were referred because of problems in mothers. I n our stud y 14 cases of potential child abuse and 8 cases of failure to thrive were referred. A comparison of child psychiatry consultation work in two parts of the country is hazardous at best because of differences in method, process, and philosophy that inevitably exist between any two teaching hospitals. Nevertheless, such a comparison does suggest two things. One is that pediatricians in hospitals consult child psychiatrists for a core group of children with similar problems, in which differential diagnosis and case management predominate. Beyond that point, the particularities of the relationship between the two services determine how the consultant will be used. We had a high overall referral rate (7% of all hospitalized children) because of our particular outreach efforts in the area of child abuse and failure to thrive. Our child fellows were quite visible on the wards and were called in as consultants to help in managing a large number of ward behavior problems. As Bolian (1971) points out, one can almost titrate the consultation request How by the type of interest the consultant shows and the relationship he develops with the hospital staff. Family Stress
In reviewing the medical charts, we were impressed by the extent of psychosocial turmoil in the families of the children we had seen. At times it was a specific instance of stress that preceded the hospi-
721
Consultations in a Pediatric Hospital
talization, and at other times chronic chaos seemed to prevail. The source of this information was often scattered throughout the record. While we were aware of the incompleteness of our data source, we decided to group families whose turmoil was part of their medical record. Table 4 lists 80 such instances or events found in 58 of the 98 families of the children in this series. We came to call these families "disordered." Our definition of family disorder is broad and covers issues of marital strife and divorce, loss of health or death in a family member, loss of work or community standing in a family member (such as imprisonment), recent change in location, and particular strife between parent and child, such as abuse or sexual molestation. Many times we found several such events in a family. Although we could never be sure that the medical chart contained a complete record of these "disorder" events, we nevertheless divided "disordered" and "nondisordered" families into two separate groups as shown in table 5. We then examined a number of other variables that might be associated with such disorder. As might be expected, the Hollingshead Socioeconomic Scale position (S.E.S.) score averages were different in the two groups, but the difference was not statistically significant at the .05 level. The more disordered families tended to come from a lower socioeconomic level. The younger average age in the disordered group is largely accounted for by the cases of failure to thrive and child abuse which fell into this group. Associated marital and economic problems, of course, continued to characterize the "disordered" family group. We scored a family as having economic problems if they were on welfare or if the medical record indicated a recent job loss or finanTable 4 Family "Disorder" Events in Year Prior
10
Hospitalization Number
Marual turmoil (fiKhts between parents or caretakers) Recent divorce Recent death of parent. siblinK. or relative Serious illness in parent or caretaker Recent move or change in family li\'inK arrangements Alcoholism in one or more parent Parent in prison or before cou rts Recent change in financial situation Sexual provocation or molestation of child by parent Parent-child battles Change in parent or caretaker Total in 5H families
I:! 10 10
7 H
!J (j
7 4 4 :-l
HO
722
William Sack et al Table :, Comparison of Two Groups of Families " Disordered" Families (;,H) Number Perce III
Age (average. years) S.E.S. Score (average) Marital status: child living with both natural parents Recent marital problems Recent economic problems "Psychiatric" problems in a parent Disposition (recommendations at time of hospital discharge) placement outside home outpatient counseling or psychotherapy medical follow-up only no specific recommendation
~
7 ;'.H Iti 4:!
"Nondisordererl" Families (40) Number Percent
:~~
rz
,-
2:;
10
(p>.OI) (p>.OI) (p>.OI) (p>.OI)
7
IH
(p>.OI)
:!I
;i2
(p>.OI) (p<.O;')
:~
:~fi
C')
:~O
;'1
4 4
~:)
H
2:~)
H 7 7
4 4
(p<.O;')
4.7
r)
7
fiO 7 10
I~
IH
cial difficulties. Likewise, we put "psychiatric" problems in quotes, to include not only medical record descriptions of psychosis, but also evidence of previous psychiatric hospitalization, suicidal gesture, chronic depression, and other evidence of emotional distress. A greater number of children from the "disordered family" group received a recommendation to be placed outside the home at the time of discharge than did the so-called "nondisordered" group. While this does not mean that all children with such recommendations actually did leave their homes, it does indicate that the problems in these families impressed a variety of pediatricians and their consultants as being considerable. Outpatient psychotherapy recommendations were made more frequently in the nondisordered families, probably because they seemed more receptive and likely to follow through. Strife-laden families often required other forms of more immediate intervention. A comparison of the psychiatric diagnoses the children received in these two groups yielded no distinct differences. Family turmoil did not predispose children to present in anyone fashion. Older children from disordered families could be depressed, have a conversion symptom, act out, be a behavior problem, while younger children from disordered families most often presented as failure to thrive or child abuse. Although family disorder was present in over half the cases referred for psychiatric consultation, we were unsure whether there was any relationship between family disorder and the consultation per se. Perhaps all children hospitalized might show such family
723
Consultations in a Pediatric Hospital
turmoil. We therefore selected a control group of children on the wards who during the year of this study were not involved in a psychiatric consultation, but who were matched for age, sex, S.E.S. score, and requiring medical or surgical services. Table 6 indicates that overall, the incidence of family turmoil was twice as great in cases seen in psychiatric consultation. Most of the difference was in the preschool and adolescent group. The roughly 25% of family disorder in the matched controls demonstrates that famil y problems often are part of the picture in a variety of children in the pediatric hospital. Why some were referred and not others is a question needing further study. How are we to understand the relationship between family disorder and a child's symptoms? The idea that children can reflect disturbances in their environment is certainly not new. Roghmann and Haggerty (1973), in a carefully designed study, showed that illness in children occurred 2.5 times more frequently than expected by chance immediately following a stress episode such as a family argument or job loss. This stress also increased the use of certain parts of the health care system, particularly the emergency room, the telephone, and the nonappointment visit to the clinic. The relationship between family stress and accidental ingestions in young children was well documented by Lewis et al. (1966). Our broad definition of family disorder includes stress episodes and chronic turmoil. Family stress followed by a symptomatic child was present in over half the consultations we reviewed. Child psychiatry consultations have more often focused on the stresses accompanying acute or chronic illness and the hospitalization itself. Yet the symptomatic child in the pediatric hospital may be the end-stage product of considerable prior family turmoil. A number of studies (Phillips, 1963; Gerdine and Bragg, 1970; Ludwig and Gibson, 1969) have shown that the medical care system is the first to be used when people have emotional problems. Table «; "Family Disorder" Cases Seen in Consultation Compared to Cases Not Seen in Consultation. But Matched for Age. Sex, S.E.S. Score, and Medical or Surgical Service Agc Range
0-5 6-11 1~-16
Total
Consultation Cases Family Disorder Total Number ~4/:H
% 70
Control Cases Family Disorder Total Number
II/:~O ~ :~/:H
69
8/:H 9130 9/:H
5H/98
59
~ti/98
:~6
% :~O
~6
(p > .O) (p < .05) (p>.lll)
~7
(p >.OI)
~ :~
724
William Sack et al.
The mental health care system is often entered only after a series of referrals, with an "M.D." referral the most potent way of gaining such entrance. It is then not surprising that a pediatric hospital receives many children in need of emotional help, who have gained entrance with "medical" symptoms. One study estimated that on entrance to a pediatric hospital, 64% of children had emotional problems, yet only 11 % were referred to psychiatry (Stocking et aI., 1972). In looking at the extent of prior emotional disturbance in the children we saw, we found that 41 of 57 school-age children were described as behaviorally disturbed long before hospital admission, the disturbance often extending back more than a year. Child psychiatrists in teaching centers need to make the assessment of the family life of children who come for care as intriguing for pediatricians as that of a metabolic syndrome. Yudkin (1961) has called this process of psychosocial diagnosis "making the second diagnosis." While physicians are usually aware of the psychosocial aspects of their patient's life, they often find it difficult to integrate these aspects into an operational scheme. Occasionally, psychosocial problems are seen as extraneous, static irritants that "gum up" the machinery of medical diagnosis and treatment and keep the physician from performing his more traditional duties. Making psychosocial issues a "second" diagnostic category would incorporate the concept in a way compatible with more traditional medical procedures.
Follow-Up While the follow-up rate of 54% does not allow us to claim comprehensive knowledge about the fate of this group of children, we did find the information illuminating in a number of ways. Table 7 presents the follow-up data grouped according to "disordered" and "nondisordered" families. "A change in family living" refers to a change in home or caretaker, or subsequent disruption in the family constellation through illness or death. Nearly half of the 31 "disordered" families responding to the questionnaire listed such an event following hospitalization, while less than a fourth of the "nondisordered" families listed such. It seemed that some upheaval continued to characterize the families we described as "disordered" after hospitalization. Most of the families that completed the questionnaire described their children as "generally improved" following the hospitalization. We gave each parent or caretaker an opportunity to rate his or her child's overall behavioral adjustment by indicating whether the child was better, worse, or unchanged. There was
725
Consultations in a Pediatric Hospital
ample space to explain the answer. All the school-age children who were listed as improved were attending school regularl y, according to the parents' account. We cannot be at all sure whether the hospitalization per se had an y connection with this reported improvement, but one third of the reporting families spo ntaneo u sly and specifically mentioned the hospital as being of benefit to them. The lower part of table 7 deals with the issue of posthospital health care delivery. The rate of follow-through for formal posthospital counseling appear-s different in the two groups. The "disordered" group was less likel y to follow through on formal arrangements for co u nseling than the "nondisordered" family group. The children in either group were more likely to see a physician than a mental health professional. However, we also knew that 75% of the "disordered" families were having or had contact with one or more social agencies, while 34% of the "nondisordered" families had such contact. Such data challenge us to "square" the follow-up plans we make with the realities of life of some of our more crises-prone families who use specific services that meet concrete needs more than the less tangible benefits of counseling or psychotherapy. We sho u ld improve our treatment plans in order to bridge the gap between hospital and community. The thrust of the data we have presented suggests that the children's hospital often functions as a mental health facility for a sizable group of children who ma y not use other entries into the health care system . The pediatric hospitalization seems to serve as an implicit form of cri ses intervention following a varied period of prior famil y upheaval. That many families reported improvement Tahle 7 Results of 1- to ~-Year Follow- Up Questionna ire
Qu<-,sli()l1flairl'~
ret u ruc-d
Chang« in family li\'in~ pall el'lls since hospitalizariou Child improved since hospitalization No change " Do n'l know" Child saw a ph ysician sinc e hospi talization Child sa w a co n nselo r afwr hospitalization Fam ily nu-mhcr saw a co unselor Afte rcare counselin g recommended
" Diso r d e re d " Families (:',H)
" No ud iso rd e red " Families (40)
:\1
~l
IIi
4
(1' > .01)
14 7
(p <.O :i)
14
(1'< .0 ;; )
o
~l
:1 4
IH
(1' > .0 1) <1'< .0 :', ) (p < .O:i )
William Sack et al.
in their children without ongoing mental health aftercare also suggests the "crises" nature of the hospital experience. These preliminary findings raise questions about the uses of the pediatric hospital for comprehensive care of children whose prior family upheaval may render them symptomatic The advantages of the hospital are several: it initially allows the contours of the problem to be sketched out in "medical" terminology and the "mental health" label avoided: it provides the child a temporary refuge: it legitimizes the problem as in need of immediate attention: it brings the multidisciplinary resources of a variety of professionals to bear; and it may mobilize the community care system to respond in specific ways. No more visible symbol of health care exists in our society than the hospital which bestows a certain legitimacy on all kinds of problems. As more pediatric care becomes ambulatory, the future hospital patient population seems unclear. Our own pediatric wards have shown a dropping census in recent years. Certainly, child psychiatrists will continue to help the pediatrician manage some of the chronic and life-threatening illnesses in children, which now make up a sizable part of the census. Our study underlines the potential benefits of child psychiatry liaison with pediatrics in reaching still another group of children in emotional trouble who have no "medical or surgical" illness, but who use the medical care system for help. In these cases it has been our experience that a comprehensive psychosocial workup can be done efficiently and early intervention can be decisive in a hospital setting. Furthermore, the pediatrician can gain experience in integrating the broader dimensions of psychosocial diagnosis and treatment planning as part of his clinical skills. We feel that the pediat ric hospital will be under increasing pressure in the future to do this kind of work as other aspects of pediatric care are handled on an outpatient basis.
REFERENCES HOI,IAl\;. (;,
nal,
c. (I !J71).
Psvchiarrir consuharion within a community of sick children, ThisJOIlT'
IO::!9:~-:~07,
D, (1!17~). The si!{nificalKe of life events as eliologic factors in the diseases of children : I.]. P,I.veho,wm. Rp,I.• lli :7-IH. FU(all\;EK • .J. P.• ROIlISS . E.• ( ; n:t:. S. H . • WOO()KI 'H . R . A.• JK .. WINOKI'K , C. , & \ l l ·NO/. • R . (I !'7~). Diagllosl i(' crircria fe'" use in psvchiatri« research . ATCh. GPII . Psychial.• ~fi::;7-fi~ . (;EKIlINt:. \1. w. & BKA(;( ;. R . I.. (1!170). Referral pallerllS amollg mental health agents in three suburban communities. Ama. J. Orthopsychiat.• 40 :H41-H44. HA(;(a:II.T\" R. J. (1974), Th e pedianician and the child ps ych iatrist. Rhud« lslnnd Med.].. 57 :41:!-415. COI)J)Il\;(;-(Ul\;. R ,
Consultations in a Pediatric Hospital
727
HEISEL,J. S., REA~I, 5 ., RAITZ , R., RAPPAPORT, M., & CODDINGTON, R. D. (1973), The significance of life events as contributing factors in the diseases of children : III.]. Pediat., 83:119-123 . HOLMES , T. H . & ROHR, R . B. (1967), The social readjustment rating scale.]. Psychosom. Res., 11:213-218. LEWIS , M., SOl.NIT, A. J., STARK, M. H ., GABRIELSON, I. W., & KLATSKIS, E. H . (1966). An exploratory stud y of accid ental ingestion of poison in yo u ng children. This Journal, 5:255-271 . LVDWI G, E. G . & GtHSON, (; . (1969), Self perception of sic kn ess and the seeking of medical care.]. Hlth & Soc. Behav. , 10:125-133 . MONSELI.V , E. P., IANZITO, B. M., & STEWART, M. A . (1973), Psychiatric consultations in a children's hospital. Am".]. Psychiat., 130:789-790. NAYLOR , K. A. & MATTSSON, A. (1973), "For the sake of the c h ild re n ." PsychinI. in Med ., 4:389-402 . PHlLI.II'S, D. 1.. (1963), Rejection : a possible consequence of seeking help for mental disorders. A mer. Sociol. Reu. , 28: 963 -972. PRUGH, D. G. & JORDAN , K. (1975), Physical illness or injury. In : Advocacy for Child Mental Health, ed. 1. N. Berlin. New York: Brunner/Mazel, pp. 208-250. ROGIIMANN, K. J. & HAGCa:RTv, R. J. (1973), Daily stress, illness and the use of health services in young families . Pediat. Res., 7:520-526. STOCKING, M., ROTHNt:\' , W.. GROSSt:R, A., & GOODWIN , R. (1972), Psychopathology in the pediatric hospital. Am". J. Pub . Hlth, 62:551-556 . YUDKIN, S. (1961), Six children with coughs. Lancet, 2 :561-562.
William Sack, M.D., Stanley Cohen, Ph.D., and Christine Grout, B .A.
Abstract. A one-year retrospective survey of child psychiatry consultations in a pediatric hos-
pital is presented and the findings are compared to a previous study from another part of the country. Over half of the children in this series came from families who had experienced significant stress in the year prior to hospitalization. These "di sordered" families used the mental health care system after hospitalization less frequently than did the "nondisordered" families. The pediatric hospitalization is conceptualized as an implicit form of crises intervention for some children in families showing significant psychosocial disarray.
Our consultations were performed as part of a broad child psychiatry-pediatric liaison effort. We define liaison as do Naylor and Mattsson (1973) as a close bond between the two disciplines, a connection that fosters mutual understanding and includes not only consultation, but collaboration, education, ongoing management, support, and coordination of care. It was within this larger context that we wished to survey our experience with consultation. While child psychiatrists have long been interested in the emotional problems of the hospitalized child and have been active proponents of a more humane hospital milieu for children (Prugh and Jordan, 1975), they have rarely systematically surveyed their own interventions. An important exception was the work of Monnelly and his colleagues (1973). We were curious to see how similar our experience was to theirs. In addition, we asked ourselves a number of questions about consultation for which no information could be found in the literature: (1) What were the characteristic family Dr. Sack is Director of Child Psychiatry and Assistant Professor of Psychiatry and Pediatrics; Dr. Cohen is Associate Professor of Psychiatry; and C. Grout is a Research Associate; Department ofPsychiatry, University ofOregon Health Services Center, Portland, Oregon . A modified version of this paper was presented at the 1975 Annual Meeting of the American Acadnny ofChild Psychiatry, SI. Louis, Mo . Part of the research described was supported by a state educational grant cproject Impact #73 -008008.) Reprint> may b. requested from Dr. Sack, at 3181 S.W. Sam fackson Park Road, Portland, OR 97201 .
716
Consultations in a Pediatric Hospital
717
backgrounds of the children who received a psychiatric consultation? (2) How did they utilize this liaison service? (3) Where did these children go when they left the hospital? What health services did they use in their aftercare? (4) What was their general behavioral adjustment one to two years later? DESCRIPTION OF STUDY
The Setting and the Staff
The Doernbecher Pediatric Hospital is a teaching hospital for the University of Oregon Health Sciences Center in Portland, Oregon. It has 103 beds and admits children from birth through age 15. It serves the entire state as a referral hospital. All patients are the responsibility of the house staff. During the year of this survey, the liaison team was in the fourth year of its development. Our program functioned quite similarly to that described by Naylor and Mattsson (1973) at the University of Virginia Medical Center. Two child psychiatry fellows spent about one third of their work week for a 6-month rotation on the liaison service. Three child psychiatry faculty spent a total of about 12 hours a week in the various functions of the liaison service. Two child psychiatric nurses spent half of their work week on the wards and anchored the continuity of the liaison work in a very important way. Members of hospital social service, medical psychology, and public health nursing, though not part of the core liaison team, also made contributions. Each child psychiatry fellow spent about ;) hours per consultation, in interviewing the family and child, obtaining information from outside sources, explaining the findings to the ward staff, and coordinating aftercare. About a third of these fi hours was spent away from the bedside. While our overall aim was to make the pediatrician competent to handle comprehensively all aspects of the psychosocial problems of his patients, we still found ourselves doing a good deal of care coordination. Naylor and Mattsson (1973) found this coordination function to be an important part of their work consultation experience. Methods
We reviewed the medical charts of the 98 children seen in psychiatric consultation from July I, 1973 to July I, 1974. One of us (CG) read the entire record and then completed a questionnaire designed to elicit the information we sought. A dual review of 10 per-
718
William Sack et al.
cent of the records yielded no significant interrater problems. The data, being retrospective, were subject to inevitable errors of incompleteness and distortions of emphasis. The psychiatric diagnoses were made by one of us (WS), based, as in the Monnelly et al. study (1973), on the DSM II Manual of the American Psychiatric Association. The second part of the project was aimed at obtaining follow-up information about general behavioral adjustment since hospitalization, use of medical and mental health care services, and change in family structure or living arrangements in these former patients. A questionnaire containing multiple choice and open-ended questions was mailed to the parents or caretakers of these children. By making initial phone contact or working through social agencies or physicians, we were able to trace 78 of the 98 children. We explained the study and obtained written consent to use the information they provided. Fifty-two questionnaires were returned, representing a return rate of 79% of those we mailed and 54% of our original sample. We utilized the X 2 test in our statistical analysis of parts of the data. RESULTS AND DISCUSSION
Comparison with Another Study
The information we gathered will be presented in a series of tables. Table I compares demographic variables from our Oregon survey with comparable figures from the St. Louis study by Monnelly et al. (1973). Pediatricians remain the main source of referral in both series. The average length of stay was 13 days in each series, or :'> days over the average stay for all children. Probably due to a large number of infants and toddlers referred for failure to thrive and child abuse, the mean age of referral of our children was 2 years less than in the St. Louis series. Table 2 compares the major reasons for psychiatric referral in the Oregon and St. Louis series. Again similarities predominate, with the exception that we were seeing more children described as ward behavior problems and fewer for symptoms of unknown etiology. Table 3 compares the diagnostic breakdown of the children in the two series. The diagnoses in Monnelly's series were made in a prospective fashion, while our diagnoses were made retrospectively from a chart review. Our diagnoses of hysteria could not be made
719
Consultations in a Pediatric Hospital
from the criteria of Feighner et at. (1972) because we did not have the raw data, but were made retrospectively in suggestible children whose symptoms seemed to symbolize significant problems for which no organi c cause could be found. While it ma y not be accurate to compare the di agnosis of h ysteri a made in these different ways. we found th at in both ser ies one third of the females from 9 to 15 years of age were diagnosed as having h ysterical reactions. The high figures fo r "no psychiatric illness" in the St. Louis series ma y be a reflection of our clinical impression that pediatrician s Tahlc I Compar iso n of Psychi atric Consultations in Two C hild re n's Hospitals SI. Louis Serie s Patients referred during tim e stud ied T ime period of study Pe rcentage o f IOta I patien ts refe r red Length of hospital stay for refe rr ed pat ients Length o f hosp ital sta y for no n r e fe rred patien ts Age range Fc ma les refe rred ('if) Referral SOUITe fr om ge nera l ped iatrics (%) Pr esenting problems (orga n syste m in volved ) (%) <:.:'-J.S.
Oregon Series
7~
~8
II mos.
12 mos . 7
I :~ .H days
13.6 da ys
H.I d avs aver. 2-1" {rs. m ~an : 10 .7 yr s. 55
8.6 da ys aver. I mo .-1 5 yrs. me an 7 . ~ )TS. 50
flO
36 28 5 :H
( ;.L
Endocri ne Othe r syste ms Speci fic med ical o r surgica l di sch arge d iagn o sis (% )
Ei
sn
44 Table 2
Cornp.uisou of Psy('hiau'ic COllsuhatioll in 'T wo C hil clJ'C' Il's Itospitals
l\f'Uor Reaso ns for Referral I. Symptom of unkn own e tio logy (poss ibly psycho so mati c) 2. Question of dep ressi o n s. Beh avior p ro ble m on ward 4. Specific symplO m p robl em 5 . Question of psych osis 6. Parent with psychiat r ic p robl em. a nd other
SI. Loui s Study %
Oregon Study %
so
17 14
I~
I :i 10
"
2:-1
2~
12 5 2:i
720
William Sack et al. Table
:~
Comparison of Psychiatric Consultation in Two Children's Hospitals
Diagnosis Hysterical reaction Hyperactive child syndrome Depression Organic brain syndrome Mental retardation Other personality disorders Anorexia nervosa Anxiety reaction Enu resis/encopresis No psychiatric illness Child abuse Failure to thrive Undiagnosed psychiatric illness
SI. Louis Study %
Oregon Study %
18,9
12
IV;
10 18 7 9
8,9 8,9 :>,1 7,6 :~.8 ~.:l
l.~
18.9
u.s
II
2 2 2 2 14 8 ~
often request consultation from child psychiatrists when the parents show significant emotional or psychiatric problems. Monnelly et al. mention that over half of such cases were referred because of problems in mothers. I n our stud y 14 cases of potential child abuse and 8 cases of failure to thrive were referred. A comparison of child psychiatry consultation work in two parts of the country is hazardous at best because of differences in method, process, and philosophy that inevitably exist between any two teaching hospitals. Nevertheless, such a comparison does suggest two things. One is that pediatricians in hospitals consult child psychiatrists for a core group of children with similar problems, in which differential diagnosis and case management predominate. Beyond that point, the particularities of the relationship between the two services determine how the consultant will be used. We had a high overall referral rate (7% of all hospitalized children) because of our particular outreach efforts in the area of child abuse and failure to thrive. Our child fellows were quite visible on the wards and were called in as consultants to help in managing a large number of ward behavior problems. As Bolian (1971) points out, one can almost titrate the consultation request How by the type of interest the consultant shows and the relationship he develops with the hospital staff. Family Stress
In reviewing the medical charts, we were impressed by the extent of psychosocial turmoil in the families of the children we had seen. At times it was a specific instance of stress that preceded the hospi-
721
Consultations in a Pediatric Hospital
talization, and at other times chronic chaos seemed to prevail. The source of this information was often scattered throughout the record. While we were aware of the incompleteness of our data source, we decided to group families whose turmoil was part of their medical record. Table 4 lists 80 such instances or events found in 58 of the 98 families of the children in this series. We came to call these families "disordered." Our definition of family disorder is broad and covers issues of marital strife and divorce, loss of health or death in a family member, loss of work or community standing in a family member (such as imprisonment), recent change in location, and particular strife between parent and child, such as abuse or sexual molestation. Many times we found several such events in a family. Although we could never be sure that the medical chart contained a complete record of these "disorder" events, we nevertheless divided "disordered" and "nondisordered" families into two separate groups as shown in table 5. We then examined a number of other variables that might be associated with such disorder. As might be expected, the Hollingshead Socioeconomic Scale position (S.E.S.) score averages were different in the two groups, but the difference was not statistically significant at the .05 level. The more disordered families tended to come from a lower socioeconomic level. The younger average age in the disordered group is largely accounted for by the cases of failure to thrive and child abuse which fell into this group. Associated marital and economic problems, of course, continued to characterize the "disordered" family group. We scored a family as having economic problems if they were on welfare or if the medical record indicated a recent job loss or finanTable 4 Family "Disorder" Events in Year Prior
10
Hospitalization Number
Marual turmoil (fiKhts between parents or caretakers) Recent divorce Recent death of parent. siblinK. or relative Serious illness in parent or caretaker Recent move or change in family li\'inK arrangements Alcoholism in one or more parent Parent in prison or before cou rts Recent change in financial situation Sexual provocation or molestation of child by parent Parent-child battles Change in parent or caretaker Total in 5H families
I:! 10 10
7 H
!J (j
7 4 4 :-l
HO
722
William Sack et al Table :, Comparison of Two Groups of Families " Disordered" Families (;,H) Number Perce III
Age (average. years) S.E.S. Score (average) Marital status: child living with both natural parents Recent marital problems Recent economic problems "Psychiatric" problems in a parent Disposition (recommendations at time of hospital discharge) placement outside home outpatient counseling or psychotherapy medical follow-up only no specific recommendation
~
7 ;'.H Iti 4:!
"Nondisordererl" Families (40) Number Percent
:~~
rz
,-
2:;
10
(p>.OI) (p>.OI) (p>.OI) (p>.OI)
7
IH
(p>.OI)
:!I
;i2
(p>.OI) (p<.O;')
:~
:~fi
C')
:~O
;'1
4 4
~:)
H
2:~)
H 7 7
4 4
(p<.O;')
4.7
r)
7
fiO 7 10
I~
IH
cial difficulties. Likewise, we put "psychiatric" problems in quotes, to include not only medical record descriptions of psychosis, but also evidence of previous psychiatric hospitalization, suicidal gesture, chronic depression, and other evidence of emotional distress. A greater number of children from the "disordered family" group received a recommendation to be placed outside the home at the time of discharge than did the so-called "nondisordered" group. While this does not mean that all children with such recommendations actually did leave their homes, it does indicate that the problems in these families impressed a variety of pediatricians and their consultants as being considerable. Outpatient psychotherapy recommendations were made more frequently in the nondisordered families, probably because they seemed more receptive and likely to follow through. Strife-laden families often required other forms of more immediate intervention. A comparison of the psychiatric diagnoses the children received in these two groups yielded no distinct differences. Family turmoil did not predispose children to present in anyone fashion. Older children from disordered families could be depressed, have a conversion symptom, act out, be a behavior problem, while younger children from disordered families most often presented as failure to thrive or child abuse. Although family disorder was present in over half the cases referred for psychiatric consultation, we were unsure whether there was any relationship between family disorder and the consultation per se. Perhaps all children hospitalized might show such family
723
Consultations in a Pediatric Hospital
turmoil. We therefore selected a control group of children on the wards who during the year of this study were not involved in a psychiatric consultation, but who were matched for age, sex, S.E.S. score, and requiring medical or surgical services. Table 6 indicates that overall, the incidence of family turmoil was twice as great in cases seen in psychiatric consultation. Most of the difference was in the preschool and adolescent group. The roughly 25% of family disorder in the matched controls demonstrates that famil y problems often are part of the picture in a variety of children in the pediatric hospital. Why some were referred and not others is a question needing further study. How are we to understand the relationship between family disorder and a child's symptoms? The idea that children can reflect disturbances in their environment is certainly not new. Roghmann and Haggerty (1973), in a carefully designed study, showed that illness in children occurred 2.5 times more frequently than expected by chance immediately following a stress episode such as a family argument or job loss. This stress also increased the use of certain parts of the health care system, particularly the emergency room, the telephone, and the nonappointment visit to the clinic. The relationship between family stress and accidental ingestions in young children was well documented by Lewis et al. (1966). Our broad definition of family disorder includes stress episodes and chronic turmoil. Family stress followed by a symptomatic child was present in over half the consultations we reviewed. Child psychiatry consultations have more often focused on the stresses accompanying acute or chronic illness and the hospitalization itself. Yet the symptomatic child in the pediatric hospital may be the end-stage product of considerable prior family turmoil. A number of studies (Phillips, 1963; Gerdine and Bragg, 1970; Ludwig and Gibson, 1969) have shown that the medical care system is the first to be used when people have emotional problems. Table «; "Family Disorder" Cases Seen in Consultation Compared to Cases Not Seen in Consultation. But Matched for Age. Sex, S.E.S. Score, and Medical or Surgical Service Agc Range
0-5 6-11 1~-16
Total
Consultation Cases Family Disorder Total Number ~4/:H
% 70
Control Cases Family Disorder Total Number
II/:~O ~ :~/:H
69
8/:H 9130 9/:H
5H/98
59
~ti/98
:~6
% :~O
~6
(p > .O) (p < .05) (p>.lll)
~7
(p >.OI)
~ :~
724
William Sack et al.
The mental health care system is often entered only after a series of referrals, with an "M.D." referral the most potent way of gaining such entrance. It is then not surprising that a pediatric hospital receives many children in need of emotional help, who have gained entrance with "medical" symptoms. One study estimated that on entrance to a pediatric hospital, 64% of children had emotional problems, yet only 11 % were referred to psychiatry (Stocking et aI., 1972). In looking at the extent of prior emotional disturbance in the children we saw, we found that 41 of 57 school-age children were described as behaviorally disturbed long before hospital admission, the disturbance often extending back more than a year. Child psychiatrists in teaching centers need to make the assessment of the family life of children who come for care as intriguing for pediatricians as that of a metabolic syndrome. Yudkin (1961) has called this process of psychosocial diagnosis "making the second diagnosis." While physicians are usually aware of the psychosocial aspects of their patient's life, they often find it difficult to integrate these aspects into an operational scheme. Occasionally, psychosocial problems are seen as extraneous, static irritants that "gum up" the machinery of medical diagnosis and treatment and keep the physician from performing his more traditional duties. Making psychosocial issues a "second" diagnostic category would incorporate the concept in a way compatible with more traditional medical procedures.
Follow-Up While the follow-up rate of 54% does not allow us to claim comprehensive knowledge about the fate of this group of children, we did find the information illuminating in a number of ways. Table 7 presents the follow-up data grouped according to "disordered" and "nondisordered" families. "A change in family living" refers to a change in home or caretaker, or subsequent disruption in the family constellation through illness or death. Nearly half of the 31 "disordered" families responding to the questionnaire listed such an event following hospitalization, while less than a fourth of the "nondisordered" families listed such. It seemed that some upheaval continued to characterize the families we described as "disordered" after hospitalization. Most of the families that completed the questionnaire described their children as "generally improved" following the hospitalization. We gave each parent or caretaker an opportunity to rate his or her child's overall behavioral adjustment by indicating whether the child was better, worse, or unchanged. There was
725
Consultations in a Pediatric Hospital
ample space to explain the answer. All the school-age children who were listed as improved were attending school regularl y, according to the parents' account. We cannot be at all sure whether the hospitalization per se had an y connection with this reported improvement, but one third of the reporting families spo ntaneo u sly and specifically mentioned the hospital as being of benefit to them. The lower part of table 7 deals with the issue of posthospital health care delivery. The rate of follow-through for formal posthospital counseling appear-s different in the two groups. The "disordered" group was less likel y to follow through on formal arrangements for co u nseling than the "nondisordered" family group. The children in either group were more likely to see a physician than a mental health professional. However, we also knew that 75% of the "disordered" families were having or had contact with one or more social agencies, while 34% of the "nondisordered" families had such contact. Such data challenge us to "square" the follow-up plans we make with the realities of life of some of our more crises-prone families who use specific services that meet concrete needs more than the less tangible benefits of counseling or psychotherapy. We sho u ld improve our treatment plans in order to bridge the gap between hospital and community. The thrust of the data we have presented suggests that the children's hospital often functions as a mental health facility for a sizable group of children who ma y not use other entries into the health care system . The pediatric hospitalization seems to serve as an implicit form of cri ses intervention following a varied period of prior famil y upheaval. That many families reported improvement Tahle 7 Results of 1- to ~-Year Follow- Up Questionna ire
Qu<-,sli()l1flairl'~
ret u ruc-d
Chang« in family li\'in~ pall el'lls since hospitalizariou Child improved since hospitalization No change " Do n'l know" Child saw a ph ysician sinc e hospi talization Child sa w a co n nselo r afwr hospitalization Fam ily nu-mhcr saw a co unselor Afte rcare counselin g recommended
" Diso r d e re d " Families (:',H)
" No ud iso rd e red " Families (40)
:\1
~l
IIi
4
(1' > .01)
14 7
(p <.O :i)
14
(1'< .0 ;; )
o
~l
:1 4
IH
(1' > .0 1) <1'< .0 :', ) (p < .O:i )
William Sack et al.
in their children without ongoing mental health aftercare also suggests the "crises" nature of the hospital experience. These preliminary findings raise questions about the uses of the pediatric hospital for comprehensive care of children whose prior family upheaval may render them symptomatic The advantages of the hospital are several: it initially allows the contours of the problem to be sketched out in "medical" terminology and the "mental health" label avoided: it provides the child a temporary refuge: it legitimizes the problem as in need of immediate attention: it brings the multidisciplinary resources of a variety of professionals to bear; and it may mobilize the community care system to respond in specific ways. No more visible symbol of health care exists in our society than the hospital which bestows a certain legitimacy on all kinds of problems. As more pediatric care becomes ambulatory, the future hospital patient population seems unclear. Our own pediatric wards have shown a dropping census in recent years. Certainly, child psychiatrists will continue to help the pediatrician manage some of the chronic and life-threatening illnesses in children, which now make up a sizable part of the census. Our study underlines the potential benefits of child psychiatry liaison with pediatrics in reaching still another group of children in emotional trouble who have no "medical or surgical" illness, but who use the medical care system for help. In these cases it has been our experience that a comprehensive psychosocial workup can be done efficiently and early intervention can be decisive in a hospital setting. Furthermore, the pediatrician can gain experience in integrating the broader dimensions of psychosocial diagnosis and treatment planning as part of his clinical skills. We feel that the pediat ric hospital will be under increasing pressure in the future to do this kind of work as other aspects of pediatric care are handled on an outpatient basis.
REFERENCES HOI,IAl\;. (;,
nal,
c. (I !J71).
Psvchiarrir consuharion within a community of sick children, ThisJOIlT'
IO::!9:~-:~07,
D, (1!17~). The si!{nificalKe of life events as eliologic factors in the diseases of children : I.]. P,I.veho,wm. Rp,I.• lli :7-IH. FU(all\;EK • .J. P.• ROIlISS . E.• ( ; n:t:. S. H . • WOO()KI 'H . R . A.• JK .. WINOKI'K , C. , & \ l l ·NO/. • R . (I !'7~). Diagllosl i(' crircria fe'" use in psvchiatri« research . ATCh. GPII . Psychial.• ~fi::;7-fi~ . (;EKIlINt:. \1. w. & BKA(;( ;. R . I.. (1!170). Referral pallerllS amollg mental health agents in three suburban communities. Ama. J. Orthopsychiat.• 40 :H41-H44. HA(;(a:II.T\" R. J. (1974), Th e pedianician and the child ps ych iatrist. Rhud« lslnnd Med.].. 57 :41:!-415. COI)J)Il\;(;-(Ul\;. R ,
Consultations in a Pediatric Hospital
727
HEISEL,J. S., REA~I, 5 ., RAITZ , R., RAPPAPORT, M., & CODDINGTON, R. D. (1973), The significance of life events as contributing factors in the diseases of children : III.]. Pediat., 83:119-123 . HOLMES , T. H . & ROHR, R . B. (1967), The social readjustment rating scale.]. Psychosom. Res., 11:213-218. LEWIS , M., SOl.NIT, A. J., STARK, M. H ., GABRIELSON, I. W., & KLATSKIS, E. H . (1966). An exploratory stud y of accid ental ingestion of poison in yo u ng children. This Journal, 5:255-271 . LVDWI G, E. G . & GtHSON, (; . (1969), Self perception of sic kn ess and the seeking of medical care.]. Hlth & Soc. Behav. , 10:125-133 . MONSELI.V , E. P., IANZITO, B. M., & STEWART, M. A . (1973), Psychiatric consultations in a children's hospital. Am".]. Psychiat., 130:789-790. NAYLOR , K. A. & MATTSSON, A. (1973), "For the sake of the c h ild re n ." PsychinI. in Med ., 4:389-402 . PHlLI.II'S, D. 1.. (1963), Rejection : a possible consequence of seeking help for mental disorders. A mer. Sociol. Reu. , 28: 963 -972. PRUGH, D. G. & JORDAN , K. (1975), Physical illness or injury. In : Advocacy for Child Mental Health, ed. 1. N. Berlin. New York: Brunner/Mazel, pp. 208-250. ROGIIMANN, K. J. & HAGCa:RTv, R. J. (1973), Daily stress, illness and the use of health services in young families . Pediat. Res., 7:520-526. STOCKING, M., ROTHNt:\' , W.. GROSSt:R, A., & GOODWIN , R. (1972), Psychopathology in the pediatric hospital. Am". J. Pub . Hlth, 62:551-556 . YUDKIN, S. (1961), Six children with coughs. Lancet, 2 :561-562.