Pediatric and Psychiatric Comorbidity

Pediatric and Psychiatric Comorbidity

Editorial Pediatric and Psychiatric Comorbidity Part I: The Future of Consultation-Liaison Psychiatry HANS STEINER, M.D., F.A.P.M. GREGORY K. FRITZ, M...

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Editorial Pediatric and Psychiatric Comorbidity Part I: The Future of Consultation-Liaison Psychiatry HANS STEINER, M.D., F.A.P.M. GREGORY K. FRITZ, M.D. DAVID MRAZEK, M.D. JUNIUS GONZALES, M.D. PETER JENSEN, M.D.

Received October I. 1992: accepted October 6. 1992. From the Division of Child Psychiatry and Department of Pediatric Psychiatry. Packard Children's Hospital at Stanford, Palo Alto, CA: the Department ofChild and Family Psychiatry, Brown University, Providence, RI: the Department of Psychiatry. Children's National Medical Center. Washington. DC; the departments of Psychiatry and Pediatrics, George Washington University School of Medicine. Washington, DC: and the Services Research Branch and Child and Adolescent Disorders Research Branch, Division of Applied and Services Research, National Institute of Mental Health, Bethesda, MD. Address reprint requests to Dr. Steiner, Children's Hospital at Stanford, 725 Welch Road, Palo Alto, CA 94304. Copyright e> 1993 The Academy of Psychosomatic Medicine.

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has become abundantly clear that medical and psychiatric comorbidity is costly to patients, their families, and society alike. The coexistence of psychiatric and medical problems in a patient usually leads to more complex diagnostic assessments, increased health care costs, and less satisfactory outcome than in those without comorbidity. This realization has led to a vigorous interest in the overlap between medical and psychiatric disorders and, by extension, in the consultationliaison (C-L) field. The status of the field of child and adolescent C-L psychiatry is receiving more scrutiny in part because of an increasing number of innovative programs leading to triple board certification (i.e., pediatrics, psychiatry, and child psychiatry) and producing trainees particularly well suited for developing child psychiatric C-L services and research. In addition, there is now a small but critical mass of clinicianresearchers working in pediatric psychiatry who are beginning to build an appropriate data base; thus it is an appropriate time to assess strengths, weaknesses, and voids in the field. The amount and quality of research in an area of medicine is usually taken as an index of the maturity of a field. Scientific knowledge enlarges the rational base for diagnostic and treatment decisions. Research also confirms the validity of a field in that it allows practitioners, clinicians, and administrators to be held to a standard, promoting self-evaluation and selfcriticism as well as cost accountability. Thus, stimulation of research at all levels-clinical, basic, and service orientedshould strengthen the field, ensure its growth, and ultimately benefit patients. Until recently, research in C-L psychiatry lagged far behind that in general psychiatry. Output was spurred by a conference sponsored by the National Institute of Mental Health (NIMH) Services Research Branch in the mid-1980s' and was followed by an unprecedented outpouring of federal funding for research in adult C-L psychiatry. Since then, a respectable scientific data base has been produced. A similar level of funding has not been allocated to enhance child and adolescent C-L psychiatry, although issues related to comorbidity are equally important in child psychiatry. C-L psychiatry may well be more important in our young patients, who are often particularly vulnerable to adverse influences and perhaps also uniquely responsive to preventive or curative intervention. From the few prospective studies available, we know that the risk for deviant development and psychopathology is increased in children with illness and disability. Prolonged medical illness may adversely affect all areas of functioning: interpersonal, intrapsychic, and, later in life, economic and vocational. 2•3 Thus, in childhood we have a unique opportunity to prevent future psychosocial morbidity with

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early intervention. Nowhere else in child psychiatry is the need for intervention as evident and the potential benefits so great. Although there is general agreement that research in pediatric psychiatry is an important area ofchild mental health and ofpublic health, there remains a significant discrepancy between the acknowledgment of the need and productivity in the field. Some important projects are underway that focus on juvenile diabetes,4,s psychooncology,6 and asthma,7 (and Fritz OK, unpublished observations, 1992) to name a few; yet, federally funded projects are rare and a coherent overall research agenda is missing. From a pragmatic viewpoint, pediatric psychiatry can be broadly divided into five relevant areas: 1) the psychiatric complications of chronic illness and disability, such as depression associated with diabetes mellitus; 2) psychiatric complications of acute illness, such as organic brain syndromes and febrile states; 3) psychiatric complications of medical interventions, such as traumatic reactions after transplantation; 4) psychiatric illness leading to pediatric morbidity, such as anorexia nervosa or Munchausen'sby-proxy; and 5) the complications ofcoincidental psychiatric and pediatric comorbidity, such as compliance problems in an asthmatic child with oppositional disorder. Although some reliable information has been collected in each area, much work remains. In recognition of these problems, the American Academy of Child and Adolescent Psychiatry and the Services Research Branch and Child and Adolescent Disorders Research Branch of the NIMH cosponsored a workshop in the spring of 1992. The purpose of the workshop was to I) review and coordinate existing research efforts in child psychiatry; 2) identify obstacles that significantly impede research; and 3) set an agenda to promote research for the next 10 years. This editorial summarizes the results of the conference and suggests solutions to some of the research problems. Attendance at the workshop was competitive and based on the submission of a meritorious preliminary proposal. From 30 such submissions, 13 full proposals were chosen that represented II academic institutions around the United States. Proposals addressed a wide range of problems: risk factors for psychiatric morbidity, recognizing depression in chronically ill children, psychopathology accompanying seizure disorder and traumatic brain injury, HIV prevention in adolescents, diagnosis of attachment problems by primary care physicians, psychotherapy with burned children, anxiety and traumatic disorders in cancer patients with bone marrow transplantations, compliance with treabnent in cystic fibrosis, comorbidity in chronic pediatric illness, epidemiological study of Munchausen's-by-proxy, psychopathology in end-stage kidney disease, and somatization disorder and health care utilization. Despite the wide range of topics, it is clear that there are significant areas of medical need and public interest not 108

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addressed by the proposals. These include studies in problems associated with disabilities, the most frequent of chronic child ailments; the impact and management of transplantation, an increasingly common intervention in children; compliance issues, which can be especially problematic for adolescents; the efficacy and cost effectiveness of C-L services, with special regard to combined medical-psychiatric units; preventive screening and health education programs in schools; diagnostic and therapeutic issues pertaining to pain and the trauma of medical procedures; and the interaction of social, psychological, and physiological variables in the disease process. Discussion identified three types of obstacles to producing more and better research: clinical, personnel, and methodological. CLINICAL ISSUES There was general consensus that the current structure of pediatric C-L programs was a major impediment to progress. In most programs, there was a perceived lack of a firm patient base. Obtaining information vital to provision of mental health care and scheduling logistics is difficult when patients are seen at the behest of another service. Protocol assessments, accrual of a patient base, follow-up, and the like are also difficult. Funding of programs was almost uniformly precarious, with low reimbursement rates and nearly nonexistent support from other services. At their best, C-L services are provided by multidisciplinary teams, which are hard to coordinate and steer; at worst, one or two individuals struggle with an unpredictable case load. Another clinical-type obstacle to good research is that available diagnostic nomenclature is not always applicable to children. For example, there is no appropriate diagnostic category of somatization relevant to children, and Munchausen's-by-proxy is not included in the DSM-III-R or in the ICD-9. In addition, pediatric patients are being treated in ever smaller clinic pools; a child psychiatry consultation therefore necessitates collaboration with many pediatric subspecialists. Some of these clinical problems could be solved by creating a service structure with its own inpatient and outpatient base that operates within pediatrics. There are several operating models that demonstrate the feasibility of such an expanded structure; a discussion of one of these follows in Part II of this editorial, which will appear in a separate issue of this journal. PERSONNEL ISSUES There are only a small number of individuals active in pediatric C-L and even fewer pursue research. In any given program, there are rarely enough individuals available for cooperative study. Collaboration between institutions is needed, with all the allenVOLUME 34· NUMBER 2· MARCH - APRD.. 1993

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dant pitfalls and problems of multisite research. Professionals from other disciplines, such as health psychologists, participate in some pediatric programs; however, they are often sequestered from C-L services and may have infrequent interaction with psychiatric staff. The lack of critical mass is evident in the lack of senior mentorship in the field. Child psychiatry training programs also provide insufficient support for C-L services. Current training in child and adolescent psychiatry does not stress C-L, and often trainees receive only minimal exposure, which provides insufficient time for the trainee to establish a mentor relationship and develop new interests. METHODOLOGICAL ISSUES From the proposals received, it was clear that problems in measurement of clinical variables were universal. The validity of existing instruments for measuring psychopathology in comorbidly ill children has rarely been established, making problematic the use of many popular instruments. This is especially evident in the overlap between depression and chronic illness. There are few instruments that can be used to assess the severity of pediatric illnesses. Already mentioned was the inadequacy of available psychiatric nomenclature, which often does not capture the particular problems of children or omits significant syndromes. The current psychiatric diagnostic system is not easily taught to or used by pediatricians, thus curtailing their participation in C-L research. Research sampling problems are common. Choosing homogeneous samples means small sample size, but it is as yet unclear which are the best grouping factors for pediatric illnesses (i.e., visibility, disability, age at onset, severity ofdisability, and organ involvement). In addition, multiple informants are crucial to research in this area, given the cognitive limitations of young patients. Overall, the importance of developmental effects in children is a differentiating and complicating factor in pediatric C-L research, a factor not relevant in work with adults. In addition to generating the somewhat daunting catalogue of impediments, workshop participants were active in suggesting solutions. Some of the clinical and personnel problems can best be addressed by creation of departments of pediatric psychiatry, to be described in Part II of this editorial. There was consensus in the group that we are indeed studying a unique population that would otherwise go unstudied. While controlling for development and illness factors makes the study of psychopathology difficult, it is not impossible; rather, the difficulty forces us to create new instruments that in the long run may better serve our need. A major advantage in the field of pediatric C-L is that research does not need extensive justification; the need is fairly self-evident. Previously, funding for research in pediatric C-L had 110

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not been coordinated at NIMH. The Primary Care Research Pr0gram now has an active role in directing C-L researchers to establish connections with appropriate sections at NIMH and NIH. Many of the practitioners who attended the recent conference were not familiar with the Services Branch; the conference provided an opportunity to facilitate communication between researchers and the branch. Finally, there was recognition by the group that reaching its goals would require a national forum to discuss proposals and activities, present material from ongoing studies, and provide a cohesive group identity. To some extent, such a role is fulfilled by the Committee on the Physically III Child of the American Academy of Child and Adolescent Psychiatry. Although this group is specifically charged with the propagation and stimulation of research in the field, it does not address the needs of the practitioner who is not active in research, but needs collegial contact. Working only within the AACAP does not allow cross-fertilization of ideas with researchers in adult C-L psychiatry. Thus, it was decided to create a Child Psychiatry Section within the Academy of Psychosomatic Medicine, to be chaired by Hans Steiner, M.D., with Greg Fritz, M.D., acting as cochair. The hope is to stimulate considerable interest in pediatric C-L and to share achievements with research groups at other national meetings. At this year's APM meeting in San Diego, the group held its first organizational meeting to prepare special activities for the 1993 national meeting in New Orleans. Any persons interested in the section activities are invited to participate. We look forward to an exciting decade in research in pediatric C-L psychiatry. References 1. Larson DB. Kessler LC, Bums BJ, et al: A research development workshop to stimulate outcome research in consultation-liaison psychiatry. Hasp Community Psychiatry 1987: 38: 1106--1109 2. Cadman D, Boyle M. Szatmari P, et al: Chronic illness, disability. and mental and social weD-being. Pediatrics 1987: 79:805-813 3. Pless JB. Cripps HA. Davies lM. et al: Chronic physical iUness in childhood: psychological and social effects in adolescence and adult life. Dev Med Child Neuro11989: 31:746-755 4. Kovacs M, Iyengar S, Goldston D. et al: Psychological functioning of children with insulin dependent diabetes mellitus: a longitudinal study. J Pediatric Psychology 1990: 15:619-632 5. Hauser ST, Jacobson AM, Lavori P, et al: Adherence among children and adolescents with insulin-dependent mellitus over a four-year longitudinal foDow-up: n. Immediate and long-term linkages with the family milieu. J Pediatr Psychol199O; 15:527-542 6. Fritz GK, WiUiams JR, Amylon M: After treatment ends: psychosocial sequelae in pediatric cancer survivors. Am J Onhopsychiatry 1988; 58:552-561 7. Mrazek DA, Klinnen M, Mrazek P, et al: Early asthma onset: consideration of parenting issues. J Am Acad Child Adolesc Psychiatry 1991: 30:377-382

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