- Email: [email protected]
Pediatricians’ Perceptions of Child Psychiatry Consultations
Pediatricians' Perceptions of Child Psychiatry Consultations C. BURKET, M.D. JON D. HODGIN, M.D.
ROGER
To ascertain pediatrician's expectations of child psychiatric consultants at our facility, a self-report questionnaire was sent to the 135 members of the Department of Pediatrics, The University of Florida Health Science Center, in 1991. The 73 respondents (54%) reported high rates ofemotional problems and adverse family situations in their patients, and a majority said they used psychiatric consultation sometimes or often. Adolescents were the patient group most frequently referred, and behavioral problems were the most frequent reasons for consultation requests. Pediatricians most valued a timely response and accessibility from consultants. These results are discussed with reference to the further development of a consultation-liaison service within a child and adolescent psychiatry training program.
C
onsultations on children and adolescents with severe physical illness and liaison with other disciplines are important elements of the recommendations by the American Academy of Child and Adolescent Psychiatry for training future child psychiatrists. I Prior investigations have studied various aspects of pediatric referral practices and the psychopathology found in children with medical illness. 2- s Fritz et a1. 5 found that pediatricians tended to refer many patients with emotional disorders to behaviorally oriented pediatricians or other mental health professionals even though the pediatricians had rather positive views of child psychiatrists. Only potential cases of depression Received October 31, 1991; revised April 7, 1992; accepted June 17. 1992. From the Depanment of Psychiatry, Division of Child and Adolescent Psychiatry. the University of Florida. Gainesville. Address reprint requests to Dr. Burket, Division of Child and Adolescent Psychiatry. P.O. Box 100234. University of Florida Health Science Center. Gainesville, FL 32610-0234. Copyright © 1993 The Academy of Psychosomatic Medicine.
402
or anorexia nervosa were referred to child psychiatrists. Other authors have focused on the evolution of the relationship between pediatrics and child psychiatry and their differing approaches to patient care.6-8 However, because of the unique nature of consultation-liaison work, many institution-specific practices and expectations may have an effect on the child consultants' responsibilities. As part of an expansion of the consultation-liaison training component in the Division of Child and Adolescent Psychiatry at our institution, we surveyed our pediatric faculty members and residents to determine their expectations of our division's service and to measure referral patterns. We felt it was important to gain an understanding of these factors in a training center in view of Fritz's finding that pediatricians who had frequent contact with the field of child psychiatry during residency tended to collaborate and consult more often with child psychiatrists later on, For discussion purposes, the traditional definitions of consultation and liaison will be used. Consultation means the process in which PSYCHOSOMATICS
Burket and Hodgin
the child psychiatrist evaluates the patient, fonns an opinion, and makes recommendations to the referring pediatrician. In liaison work, the child psychiatrist becomes more involved with the pediatric treatment team on a continuing basis in order to contribute to a given patient's care when appropriate. Most often, some combination of a consultation and liaison approach is used depending on the clinical needs, personal desires, and practical limitations of the situation and the individuals involved. Psychiatric consultation-liaison with pediatrics shares many characteristics and problems encountered in adult consultation-liaison work, including a lack ofcontrol over the implementation of patient care recommendations given by the consultant, professional isolation, unpredictable work loads, and financial constraints. However, Fritz9 noted that certain characteristics of pediatricians and their training background present unique challenges for the child psychiatrist. Both disciplines train their physicians to promote nonnal development, work with families, and value prevention strategies. This similar interest in mental health, psychosocial, and developmental issues can lead to a more sophisticated collaboration, or lead to the development of an "anyone can do it" attitude by those who may feel that child psychiatry adds little benefit to the work done by pediatricians. 9 This makes it particularly important for the child psychiatric consultant to accurately identify the areas and situations where the consultant's input is appropriate and to structure the consultation-liaison service to attain treatment goals. METHODS
Subjects The sample consisted of the 135 members (including faculty, residents, and fellows) of the department of pediatrics at a large university medical center. These clinicians represented a broad spectrum, from intern to senior faculty member, inpatient to outpatient clinical focus, and primary care provider to pediatric subVOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
specialist. The 73 questionnaires that were promptly returned represent a response rate of 54%. Forty-four (60.3%) were from faculty members and 29 (39.7%) were from housestaff (residents and fellows, both in training). Instruments The questionnaire contained seven questions, four of which were multiple choice, and was designed for rapid completion (in less than 2 minutes), which helped maximize our response rate. Two questions required numerical answers, and one question required rank ordering. Included in the survey were questions designed to assess the frequency of child psychiatric consultation requests, identify the patient age groups for which consultation was most frequently requested, the reasons for consultation, and the pediatrician's expectations of the service provided by the consultant. The respondents were also asked to give numerical estimates of the percentage of their patients with emotional problems as well as those with adverse family situations that they felt negatively affected the patient's emotional or physical well-being. The complete questionnaire is shown in the Appendix. Procedure We used the university's mail system to send the questionnaire to the individual's work address. It was also designed so that it could be anonymously returned through the same mail system. All questionnaires returned within 6 weeks were included in the data analysis. The vast majority of the surveys were returned within I week after mailing. The collected data were compiled in aggregate fonn. In addition, the appropriate statistical tests were applied to detennine if any significant differences were present between the faculty responses and those from residents and fellows. 403
Perceptions of Child Psychiatry Consultations
RESULTS Out of the 73 respondents who returned questionnaires, 62 said they felt that 30.3% of their patients had emotional problems. Individual answers to this specific question ranged from 0% to 100% of patients. However, there was no significant difference between the percentage given by faculty and the percentage given by residents and fellows (combined), with the former responding on average that they felt that 32.0% of their patients had emotional problems and the latter responding that they felt that on average 27.7% of their patients had emotional problems. Sixty-nine respondents felt that 50.2% of their patients had an adverse family situation that negatively affected their emotional orphysical well-being. Individual answers to this specific question again ranged from 2% to 100% of patients, but there was no significant difference between the percentage given by faculty and the percentage given by both residents and fellows (combined), which were 53.0% and 46.0%, respectively. Figure I depicts the frequency of consultation use by residents and fellows (combined), and faculty. Although not rigorously quantified, the frequency of consultation use (number of psychiatric referrals of patients) was separated into three patient referral categories ("rare" = 1 in 50 patients, "sometimes" = I in 20, and "often" = I in 10). Overall, of the 71 respondents who answered this question, 10 (14.1%) used psychiatric consultation often, 31 (43.7%) sometimes, 25 (35.2%) rarely, and 5 (7%) never. Compared with the resident/fellow group, the faculty group used psychiatric consultation significantly less often (X 2 =7.16, df = I, P < 0.01), with 24 (54.5%) reporting that they "rarely" or "never" used psychiatric consultation. Only 6 (22.2%) of the group of residents and fellows reported that they rarely or never used consultation. Figures 2 and 3 depict the most frequent reasons for child psychiatric consultation as reported by the respondents, who were asked to choose three alternatives from the list. There 404
were no significant differences between the resident/fellow and faculty group responses. Figure 4 depicts the frequency of consultation requests for various age groups. Of significance, 47 (65.3%) of the respondents indicated that they most often referred adolescents (age range = 13-18 years) for child psychiatric connGURE I. Frequency of c:oosultations Never Rarely "'"'7777,...---:-_ _---1 47 .7
Often
o
10
20
30
40
50
60
70
80
% of Respondents ~ ResidenllFellow
0
Faculty
FIGURE 2. Reasons for child psychiatric consultations 119.2
o
10
20
30
40
50
60
70
% 01 Respondenla
nGURE 3. Reasons for child psychiatric consultations Abuse Evaluation
1.4
DisposIllon Problems
5.5
Stall Problems
8.2
MedIcalIon
9.6
PsychIalric Dlllerential
13.7
F";;;;r;;"""'-"T"'""--r-r---r----.
o
10
20
30
40
50
60
70
% 01 Reepondents
PSYCHOSOMATICS
Burket and Hodgin
sultation. Six (8.3%) indicated no difference in the numbers they referred from the various age groups. Again, there were no significant differences between the resident/fellow and faculty group responses. Finally, Figure 5 lists 7 factors in descending order that were ranked as important by pediatricians, which they used to evaluate a child psychiatric consultant. Accessibility was a factor that was considered very important by both the resident/fellow and faculty groups. There was little difference between the groups, except that faculty tended to rate a timely response by the consultant as most important, while the residents/fellows valued follow-up planning and liaison as the most important factors. Participation in team rounds was given a low priority by both groups. FIGURE 4. Most frequent age groups for consultations 50 Ul
C Q)
"0
c 0
a.
38.9
40
30
26.4
Ul Q)
a:
20
'0 :>!! 0
10 0
9.7
11.1
Under6 6-9 10-12 13-15 16-18
All
FIGURE 5. Features of a child psychiatric consultant in rank order of importance
_ _ ~ ~ ~
CJ CJ _
Accessibility Timeliness Follow-up Liaison Specific recommendations Knowledge of ward Participation In rounds Very Important ~ Important CJ Somewhat Important
VOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
DISCUSSION The pediatricians in this study believed that emotional problems were quite common (30.3%) in their patients. This figure is somewhat higher than the 20% that Ostrov et al. lo found in an adolescent community sample, but lower than the 47% pediatricians reported in a clinic sample of latency-age children studied by Garralda and Bailey. II In addition, the pediatricians in this study were also sensitive to adverse family situations that affected their patient's physical or emotional well-being. Taken together, these data imply that the pediatricians are able to routinely recognize most situations where psychiatric consultation may be appropriate. This is in contrast with earlier reports summarized by Costello,2 which suggested that pediatricians tended to identify only about onehalf of children and adolescents who present with emotional problems. Although it is not possible from this study to determine the exact percentage of patients referred for consultation, it is clear from the responses in Figure I that only a minority of patients with emotional concerns are referred. This is in keeping with referral practices of pediatricians in various settings as summarized by Costello,2 as well as the referral practices in general hospital settings with adult med-surg patients. 12 In our setting, this may indicate that the severity of the problem was judged to be such that a referral was not necessary, the pediatrician had the resources to handle the situation alone, or referral to another mental health professional was made. The finding that more senior pediatricians tended to use psychiatric consultations less than residents-in-training may indicate that the former may feel more secure in their abilities to handle certain emotional problems themselves. This may also reflect some lingering attitudes on the part of more senior pediatricians who feel that child psychiatry represents a "menace" or intrusion into their specialty.6 In looking at the reasons for psychiatric referral, it is notable that behavioral problems and observable emotional manifestations, such 405
Perceptions of Child Psychiatry Consultations
as suicidal ideation, self-destructiveness, severe anxiety/depressive reactions, or difficulty dealing with illness, were as common here as they are in most settings. These situations likely cause problems for the ward staff or obvious distress for the patient, thus a referral may be prompted. In contrast, more technical reasons, such as psychiatric differential diagnosis or evaluation for psychotropic medications, were less common. Of note, the results indicate that psychiatric consultation was rarely requested in abuse situations, reflecting the presence of a very active and well-staffed child protection team within the pediatrics department. Not surprisingly, accessibility of the consultant and timeliness of response were ranked as most important by the pediatricians, who were almost uniform in their response to this question. It is clear that the pediatricians value an efficient, prompt consultation; however, their responses indicated somewhat less interest in liaison aspects, including participation in pediatric team rounds or gaining knowledge of ward policy and capabilities. This is also consistent with the finding of a relatively low frequency of requests for assistance to help pediatric staff deal with problems in their patient care duties. Lipowski discussed the reservations of many psychiatrists and other physicians about the role of liaison in consultation work. 13 He concluded that the liaison role is inseparable from consultations, but stressed that it must be integrated as appropriate into each individual case and facility. Some limitations of this study are worth noting. First, all data are the recollections and perceptions of the respondents and might not reflect their actual referral practices if a caseby-case count was made. Fritz et al. found that child psychiatrists misperceived the timing and frequency of the pediatric consultation requests they received. 14 They suggested that the discrepancy may in part have been due to respondents who give disproportionate "weight" to a few memorable or unpleasant experiences. Similarly, the pediatricians in our study may have responded in this fashion regarding their own referral practices. A second limitation is 406
that these results may not be applicable to other facilities because they reflect the distinctive characteristics of this institution and the personnel involved. Finally, additional areas for further study might include information on 1) reasons why some respondents rarely use psychiatric consultation, 2) current satisfaction with services provided by the consultation service, and 3) the pediatrician's degree of comfort in dealing with various emotional problems. These subjects might form the basis for a future survey at our facility. CONCLUSION Several implications from this study are useful in expanding and redefining the role of a child psychiatry consultation-liaison service. First, because timeliness and accessibility are most valued by consultees, efforts should be made to ensure adequate staffing of the service on a 24-hour basis for ready access and prompt response. Second, because the pediatricians appear to frequently recognize emotional and family problems but refer only selected patients, it may be worthwhile to analyze these cases for underlying similarities (i.e., severity, anger, age, conflicts with staff, etc.). Child psychiatric fellows doing consultation-liaison work could then be alert for and focus on those aspects of the cases when making recommendations to the treatment team. If these recommendations lead to more effective patient care, the consultant may become more valued by the consultee, who may then refer additional cases. Next, the rather uniform agreement of faculty and trainees on most survey items implies that residents/fellows may be (appropriately) learning their psychiatric referral practices from their faculty mentors. Thus, methods for increasing direct contact on specific cases between pediatric and psychiatric faculty should be explored to help increase pediatric faculty awareness of psychiatrists' interest in collaborative efforts. Finally, in situations where the pediatric service refers few cases because they tend to handle the problem internally (i.e., evaluations of abuse, staff problems, etc.), the consultant may best PSYCHOSOMATICS
Burket and Hodgin
contribute to effective patient care by recommending and providing needed additional services, rather than risking the possibility of duplicating efforts that are already under way. In conclusion, this survey provided data on pediatricians' child psychiatric referral patterns that are in many ways consistent with those seen in most facilities. However, some institutionspecific patterns emerged that can be useful in the further development of a consultation-
liaison service. Psychiatrists may wish to consider utilizing tools such as this survey in their consultation-liaison planning and program evaluation.
The authors thank Lynn Robbins. 8.S.,for her assistance in data analysis. This paper was presented at the Academy of Psychosomatic Medicine 38th Annual Meeting. Atlanta. GA. October J99 J•
APPENDIX. ChUd and adolescent psychiatric consultation survey
I. I am currently a _
Faculty member _
2. I use psychiatric consultation: _ _ _
Resident Physician _
Other, specify
_
often (I in 10 cases) sometimes (I in 20 cases) rarely (I in 50 cases) never
3. Please check the three most common situations from the list below when you have asked for child psychiatry consultations (check only three): _ evaluation of behavioral problems _ assessment for suicide problems _ evaluation of family problems _ psychiatric differential diagnosis needed evaluation of child abuse _ assessment for anxiety or depressive reaction evaluation of child's reaction to illness _ evaluation of possible conversion disorder _ disposition problems _ problems experienced by the staff in dealing with the patient
4. I fmll that I request psychiatric consultations most frequently on the following age group (check only one): _ 13-15 years _ under 6 years _ 6-9 years _ 16-18 years _ 10-12 years no difference 5. What percentage of your patients do you feel may have emotional problems that relate to their medical illnesses? _ _%
6. What percentage of your patients do you feel have family situations that impact upon their emotional or physical well-being? _% 7.
How important do you feel the following factors are in psychiatric consultation? (Please rate on a with I being not necessary and 7 being very necessary.) Circle the COJTeCt number: a. timeliness of reply 1 2 3 4 5 b. accessibility of consultant I 2 3 4 5 c. liaison with treatment team I 2 3 4 5 d. consultantawareness of ward policy and capabilities I 2 3 4 5 e. provision of specific rather than general recommendation I 2 3 4 5 f. arrangement of psychiatric follow-ups I 2 3 4 5 g. panicipation in team rounds I 2 3 4 5
1 to 7 scale
6 6 6 6 6 6 6
7 7 7 7 7 7 7
Thank You!
VOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
407
Perceptions of Child Psychiatry Consultations
References 1. American Academy of Child Psychiatry: Child psychiatry: A Plan for the Coming Decades. Washington. DC. American Academy of Child Psychiatry. 1983 2. Costello EJ: Primary care pediatrics and child psychopathology: a review of diagnostic. treatment. and referral practices. Pediatrics 1986; 78: 1044-1051 3. Rait OS, Jacobsen PB. Lederberg MS, et a1: Characteristics of psychiatric consultations in a pediatric cancer center. Am J Psychiatry 1988; 145:363-364 4. Simonds JF: Psychiatric consultations for 112 pediatric inpatients. South Med J 1977; 70:980-984 5. Fritz OR, Bergman AS: Child psychiatrists seen through pediatricians' eyes: results of a national survey. J Am Acad Child Adolese Psychiatry 1985; 24:81-86 6. Work HH: The "menace of psychiatry" revisited: the evolving relationship between pediatrics and child psychiatry. Psychosomatics 1989; 30:86--93 7. Jellinck MS: The present status of child psychiatry in pediatrics. N Engl J Med 1982; 306: 1227-1230 8. Anders TF: Child psychiatry and pediatrics: the state of
408
the relationship. Pediatrics 1977; 60:616--620 9. Fritz OR: Consultation-liaison in child psychiatry and the evolution of pediatric psychiatry. Psychosomatics 1990; 31 :85-90 10. Ostrov E. Offer D. Harttage S: The quietly disturbed adolescent, in Patterns of Adolescent Self-Image. edited by Offer D. Ostrov E. Howard Kl. San Francisco. CA. Jossey-Bass, 1984 II. Oarralda ME. Bailey D: Paediatrician identification of psychological factors associated with general paediatric consultations. J Psychosom Res 1990; 34:303-312 12. Wallen J. Pinus HA. Goldman HH. et a1: Psychiatric consultations in short-term general hospitals. Arch Oen Psychiatry 1987; 44: 163-168 13. Lipowski ZJ: Consultation-liaison psychiatry: The first half century. Oen Hosp Psychiatry 1986; 8:305-315 14. Fritz OK. Pumariega AJ, Fishhoff J: Child psychiatrists' perceptions of timing and frequency of consultation request. J Am Acad Child Adolese Psychiatry 1987; 26:425-427
PSYCHOSOMATICS
ROGER
To ascertain pediatrician's expectations of child psychiatric consultants at our facility, a self-report questionnaire was sent to the 135 members of the Department of Pediatrics, The University of Florida Health Science Center, in 1991. The 73 respondents (54%) reported high rates ofemotional problems and adverse family situations in their patients, and a majority said they used psychiatric consultation sometimes or often. Adolescents were the patient group most frequently referred, and behavioral problems were the most frequent reasons for consultation requests. Pediatricians most valued a timely response and accessibility from consultants. These results are discussed with reference to the further development of a consultation-liaison service within a child and adolescent psychiatry training program.
C
onsultations on children and adolescents with severe physical illness and liaison with other disciplines are important elements of the recommendations by the American Academy of Child and Adolescent Psychiatry for training future child psychiatrists. I Prior investigations have studied various aspects of pediatric referral practices and the psychopathology found in children with medical illness. 2- s Fritz et a1. 5 found that pediatricians tended to refer many patients with emotional disorders to behaviorally oriented pediatricians or other mental health professionals even though the pediatricians had rather positive views of child psychiatrists. Only potential cases of depression Received October 31, 1991; revised April 7, 1992; accepted June 17. 1992. From the Depanment of Psychiatry, Division of Child and Adolescent Psychiatry. the University of Florida. Gainesville. Address reprint requests to Dr. Burket, Division of Child and Adolescent Psychiatry. P.O. Box 100234. University of Florida Health Science Center. Gainesville, FL 32610-0234. Copyright © 1993 The Academy of Psychosomatic Medicine.
402
or anorexia nervosa were referred to child psychiatrists. Other authors have focused on the evolution of the relationship between pediatrics and child psychiatry and their differing approaches to patient care.6-8 However, because of the unique nature of consultation-liaison work, many institution-specific practices and expectations may have an effect on the child consultants' responsibilities. As part of an expansion of the consultation-liaison training component in the Division of Child and Adolescent Psychiatry at our institution, we surveyed our pediatric faculty members and residents to determine their expectations of our division's service and to measure referral patterns. We felt it was important to gain an understanding of these factors in a training center in view of Fritz's finding that pediatricians who had frequent contact with the field of child psychiatry during residency tended to collaborate and consult more often with child psychiatrists later on, For discussion purposes, the traditional definitions of consultation and liaison will be used. Consultation means the process in which PSYCHOSOMATICS
Burket and Hodgin
the child psychiatrist evaluates the patient, fonns an opinion, and makes recommendations to the referring pediatrician. In liaison work, the child psychiatrist becomes more involved with the pediatric treatment team on a continuing basis in order to contribute to a given patient's care when appropriate. Most often, some combination of a consultation and liaison approach is used depending on the clinical needs, personal desires, and practical limitations of the situation and the individuals involved. Psychiatric consultation-liaison with pediatrics shares many characteristics and problems encountered in adult consultation-liaison work, including a lack ofcontrol over the implementation of patient care recommendations given by the consultant, professional isolation, unpredictable work loads, and financial constraints. However, Fritz9 noted that certain characteristics of pediatricians and their training background present unique challenges for the child psychiatrist. Both disciplines train their physicians to promote nonnal development, work with families, and value prevention strategies. This similar interest in mental health, psychosocial, and developmental issues can lead to a more sophisticated collaboration, or lead to the development of an "anyone can do it" attitude by those who may feel that child psychiatry adds little benefit to the work done by pediatricians. 9 This makes it particularly important for the child psychiatric consultant to accurately identify the areas and situations where the consultant's input is appropriate and to structure the consultation-liaison service to attain treatment goals. METHODS
Subjects The sample consisted of the 135 members (including faculty, residents, and fellows) of the department of pediatrics at a large university medical center. These clinicians represented a broad spectrum, from intern to senior faculty member, inpatient to outpatient clinical focus, and primary care provider to pediatric subVOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
specialist. The 73 questionnaires that were promptly returned represent a response rate of 54%. Forty-four (60.3%) were from faculty members and 29 (39.7%) were from housestaff (residents and fellows, both in training). Instruments The questionnaire contained seven questions, four of which were multiple choice, and was designed for rapid completion (in less than 2 minutes), which helped maximize our response rate. Two questions required numerical answers, and one question required rank ordering. Included in the survey were questions designed to assess the frequency of child psychiatric consultation requests, identify the patient age groups for which consultation was most frequently requested, the reasons for consultation, and the pediatrician's expectations of the service provided by the consultant. The respondents were also asked to give numerical estimates of the percentage of their patients with emotional problems as well as those with adverse family situations that they felt negatively affected the patient's emotional or physical well-being. The complete questionnaire is shown in the Appendix. Procedure We used the university's mail system to send the questionnaire to the individual's work address. It was also designed so that it could be anonymously returned through the same mail system. All questionnaires returned within 6 weeks were included in the data analysis. The vast majority of the surveys were returned within I week after mailing. The collected data were compiled in aggregate fonn. In addition, the appropriate statistical tests were applied to detennine if any significant differences were present between the faculty responses and those from residents and fellows. 403
Perceptions of Child Psychiatry Consultations
RESULTS Out of the 73 respondents who returned questionnaires, 62 said they felt that 30.3% of their patients had emotional problems. Individual answers to this specific question ranged from 0% to 100% of patients. However, there was no significant difference between the percentage given by faculty and the percentage given by residents and fellows (combined), with the former responding on average that they felt that 32.0% of their patients had emotional problems and the latter responding that they felt that on average 27.7% of their patients had emotional problems. Sixty-nine respondents felt that 50.2% of their patients had an adverse family situation that negatively affected their emotional orphysical well-being. Individual answers to this specific question again ranged from 2% to 100% of patients, but there was no significant difference between the percentage given by faculty and the percentage given by both residents and fellows (combined), which were 53.0% and 46.0%, respectively. Figure I depicts the frequency of consultation use by residents and fellows (combined), and faculty. Although not rigorously quantified, the frequency of consultation use (number of psychiatric referrals of patients) was separated into three patient referral categories ("rare" = 1 in 50 patients, "sometimes" = I in 20, and "often" = I in 10). Overall, of the 71 respondents who answered this question, 10 (14.1%) used psychiatric consultation often, 31 (43.7%) sometimes, 25 (35.2%) rarely, and 5 (7%) never. Compared with the resident/fellow group, the faculty group used psychiatric consultation significantly less often (X 2 =7.16, df = I, P < 0.01), with 24 (54.5%) reporting that they "rarely" or "never" used psychiatric consultation. Only 6 (22.2%) of the group of residents and fellows reported that they rarely or never used consultation. Figures 2 and 3 depict the most frequent reasons for child psychiatric consultation as reported by the respondents, who were asked to choose three alternatives from the list. There 404
were no significant differences between the resident/fellow and faculty group responses. Figure 4 depicts the frequency of consultation requests for various age groups. Of significance, 47 (65.3%) of the respondents indicated that they most often referred adolescents (age range = 13-18 years) for child psychiatric connGURE I. Frequency of c:oosultations Never Rarely "'"'7777,...---:-_ _---1 47 .7
Often
o
10
20
30
40
50
60
70
80
% of Respondents ~ ResidenllFellow
0
Faculty
FIGURE 2. Reasons for child psychiatric consultations 119.2
o
10
20
30
40
50
60
70
% 01 Respondenla
nGURE 3. Reasons for child psychiatric consultations Abuse Evaluation
1.4
DisposIllon Problems
5.5
Stall Problems
8.2
MedIcalIon
9.6
PsychIalric Dlllerential
13.7
F";;;;r;;"""'-"T"'""--r-r---r----.
o
10
20
30
40
50
60
70
% 01 Reepondents
PSYCHOSOMATICS
Burket and Hodgin
sultation. Six (8.3%) indicated no difference in the numbers they referred from the various age groups. Again, there were no significant differences between the resident/fellow and faculty group responses. Finally, Figure 5 lists 7 factors in descending order that were ranked as important by pediatricians, which they used to evaluate a child psychiatric consultant. Accessibility was a factor that was considered very important by both the resident/fellow and faculty groups. There was little difference between the groups, except that faculty tended to rate a timely response by the consultant as most important, while the residents/fellows valued follow-up planning and liaison as the most important factors. Participation in team rounds was given a low priority by both groups. FIGURE 4. Most frequent age groups for consultations 50 Ul
C Q)
"0
c 0
a.
38.9
40
30
26.4
Ul Q)
a:
20
'0 :>!! 0
10 0
9.7
11.1
Under6 6-9 10-12 13-15 16-18
All
FIGURE 5. Features of a child psychiatric consultant in rank order of importance
_ _ ~ ~ ~
CJ CJ _
Accessibility Timeliness Follow-up Liaison Specific recommendations Knowledge of ward Participation In rounds Very Important ~ Important CJ Somewhat Important
VOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
DISCUSSION The pediatricians in this study believed that emotional problems were quite common (30.3%) in their patients. This figure is somewhat higher than the 20% that Ostrov et al. lo found in an adolescent community sample, but lower than the 47% pediatricians reported in a clinic sample of latency-age children studied by Garralda and Bailey. II In addition, the pediatricians in this study were also sensitive to adverse family situations that affected their patient's physical or emotional well-being. Taken together, these data imply that the pediatricians are able to routinely recognize most situations where psychiatric consultation may be appropriate. This is in contrast with earlier reports summarized by Costello,2 which suggested that pediatricians tended to identify only about onehalf of children and adolescents who present with emotional problems. Although it is not possible from this study to determine the exact percentage of patients referred for consultation, it is clear from the responses in Figure I that only a minority of patients with emotional concerns are referred. This is in keeping with referral practices of pediatricians in various settings as summarized by Costello,2 as well as the referral practices in general hospital settings with adult med-surg patients. 12 In our setting, this may indicate that the severity of the problem was judged to be such that a referral was not necessary, the pediatrician had the resources to handle the situation alone, or referral to another mental health professional was made. The finding that more senior pediatricians tended to use psychiatric consultations less than residents-in-training may indicate that the former may feel more secure in their abilities to handle certain emotional problems themselves. This may also reflect some lingering attitudes on the part of more senior pediatricians who feel that child psychiatry represents a "menace" or intrusion into their specialty.6 In looking at the reasons for psychiatric referral, it is notable that behavioral problems and observable emotional manifestations, such 405
Perceptions of Child Psychiatry Consultations
as suicidal ideation, self-destructiveness, severe anxiety/depressive reactions, or difficulty dealing with illness, were as common here as they are in most settings. These situations likely cause problems for the ward staff or obvious distress for the patient, thus a referral may be prompted. In contrast, more technical reasons, such as psychiatric differential diagnosis or evaluation for psychotropic medications, were less common. Of note, the results indicate that psychiatric consultation was rarely requested in abuse situations, reflecting the presence of a very active and well-staffed child protection team within the pediatrics department. Not surprisingly, accessibility of the consultant and timeliness of response were ranked as most important by the pediatricians, who were almost uniform in their response to this question. It is clear that the pediatricians value an efficient, prompt consultation; however, their responses indicated somewhat less interest in liaison aspects, including participation in pediatric team rounds or gaining knowledge of ward policy and capabilities. This is also consistent with the finding of a relatively low frequency of requests for assistance to help pediatric staff deal with problems in their patient care duties. Lipowski discussed the reservations of many psychiatrists and other physicians about the role of liaison in consultation work. 13 He concluded that the liaison role is inseparable from consultations, but stressed that it must be integrated as appropriate into each individual case and facility. Some limitations of this study are worth noting. First, all data are the recollections and perceptions of the respondents and might not reflect their actual referral practices if a caseby-case count was made. Fritz et al. found that child psychiatrists misperceived the timing and frequency of the pediatric consultation requests they received. 14 They suggested that the discrepancy may in part have been due to respondents who give disproportionate "weight" to a few memorable or unpleasant experiences. Similarly, the pediatricians in our study may have responded in this fashion regarding their own referral practices. A second limitation is 406
that these results may not be applicable to other facilities because they reflect the distinctive characteristics of this institution and the personnel involved. Finally, additional areas for further study might include information on 1) reasons why some respondents rarely use psychiatric consultation, 2) current satisfaction with services provided by the consultation service, and 3) the pediatrician's degree of comfort in dealing with various emotional problems. These subjects might form the basis for a future survey at our facility. CONCLUSION Several implications from this study are useful in expanding and redefining the role of a child psychiatry consultation-liaison service. First, because timeliness and accessibility are most valued by consultees, efforts should be made to ensure adequate staffing of the service on a 24-hour basis for ready access and prompt response. Second, because the pediatricians appear to frequently recognize emotional and family problems but refer only selected patients, it may be worthwhile to analyze these cases for underlying similarities (i.e., severity, anger, age, conflicts with staff, etc.). Child psychiatric fellows doing consultation-liaison work could then be alert for and focus on those aspects of the cases when making recommendations to the treatment team. If these recommendations lead to more effective patient care, the consultant may become more valued by the consultee, who may then refer additional cases. Next, the rather uniform agreement of faculty and trainees on most survey items implies that residents/fellows may be (appropriately) learning their psychiatric referral practices from their faculty mentors. Thus, methods for increasing direct contact on specific cases between pediatric and psychiatric faculty should be explored to help increase pediatric faculty awareness of psychiatrists' interest in collaborative efforts. Finally, in situations where the pediatric service refers few cases because they tend to handle the problem internally (i.e., evaluations of abuse, staff problems, etc.), the consultant may best PSYCHOSOMATICS
Burket and Hodgin
contribute to effective patient care by recommending and providing needed additional services, rather than risking the possibility of duplicating efforts that are already under way. In conclusion, this survey provided data on pediatricians' child psychiatric referral patterns that are in many ways consistent with those seen in most facilities. However, some institutionspecific patterns emerged that can be useful in the further development of a consultation-
liaison service. Psychiatrists may wish to consider utilizing tools such as this survey in their consultation-liaison planning and program evaluation.
The authors thank Lynn Robbins. 8.S.,for her assistance in data analysis. This paper was presented at the Academy of Psychosomatic Medicine 38th Annual Meeting. Atlanta. GA. October J99 J•
APPENDIX. ChUd and adolescent psychiatric consultation survey
I. I am currently a _
Faculty member _
2. I use psychiatric consultation: _ _ _
Resident Physician _
Other, specify
_
often (I in 10 cases) sometimes (I in 20 cases) rarely (I in 50 cases) never
3. Please check the three most common situations from the list below when you have asked for child psychiatry consultations (check only three): _ evaluation of behavioral problems _ assessment for suicide problems _ evaluation of family problems _ psychiatric differential diagnosis needed evaluation of child abuse _ assessment for anxiety or depressive reaction evaluation of child's reaction to illness _ evaluation of possible conversion disorder _ disposition problems _ problems experienced by the staff in dealing with the patient
4. I fmll that I request psychiatric consultations most frequently on the following age group (check only one): _ 13-15 years _ under 6 years _ 6-9 years _ 16-18 years _ 10-12 years no difference 5. What percentage of your patients do you feel may have emotional problems that relate to their medical illnesses? _ _%
6. What percentage of your patients do you feel have family situations that impact upon their emotional or physical well-being? _% 7.
How important do you feel the following factors are in psychiatric consultation? (Please rate on a with I being not necessary and 7 being very necessary.) Circle the COJTeCt number: a. timeliness of reply 1 2 3 4 5 b. accessibility of consultant I 2 3 4 5 c. liaison with treatment team I 2 3 4 5 d. consultantawareness of ward policy and capabilities I 2 3 4 5 e. provision of specific rather than general recommendation I 2 3 4 5 f. arrangement of psychiatric follow-ups I 2 3 4 5 g. panicipation in team rounds I 2 3 4 5
1 to 7 scale
6 6 6 6 6 6 6
7 7 7 7 7 7 7
Thank You!
VOLUME 34 • NUMBER 5 • SEPTEMBER - OCTOBER 1993
407
Perceptions of Child Psychiatry Consultations
References 1. American Academy of Child Psychiatry: Child psychiatry: A Plan for the Coming Decades. Washington. DC. American Academy of Child Psychiatry. 1983 2. Costello EJ: Primary care pediatrics and child psychopathology: a review of diagnostic. treatment. and referral practices. Pediatrics 1986; 78: 1044-1051 3. Rait OS, Jacobsen PB. Lederberg MS, et a1: Characteristics of psychiatric consultations in a pediatric cancer center. Am J Psychiatry 1988; 145:363-364 4. Simonds JF: Psychiatric consultations for 112 pediatric inpatients. South Med J 1977; 70:980-984 5. Fritz OR, Bergman AS: Child psychiatrists seen through pediatricians' eyes: results of a national survey. J Am Acad Child Adolese Psychiatry 1985; 24:81-86 6. Work HH: The "menace of psychiatry" revisited: the evolving relationship between pediatrics and child psychiatry. Psychosomatics 1989; 30:86--93 7. Jellinck MS: The present status of child psychiatry in pediatrics. N Engl J Med 1982; 306: 1227-1230 8. Anders TF: Child psychiatry and pediatrics: the state of
408
the relationship. Pediatrics 1977; 60:616--620 9. Fritz OR: Consultation-liaison in child psychiatry and the evolution of pediatric psychiatry. Psychosomatics 1990; 31 :85-90 10. Ostrov E. Offer D. Harttage S: The quietly disturbed adolescent, in Patterns of Adolescent Self-Image. edited by Offer D. Ostrov E. Howard Kl. San Francisco. CA. Jossey-Bass, 1984 II. Oarralda ME. Bailey D: Paediatrician identification of psychological factors associated with general paediatric consultations. J Psychosom Res 1990; 34:303-312 12. Wallen J. Pinus HA. Goldman HH. et a1: Psychiatric consultations in short-term general hospitals. Arch Oen Psychiatry 1987; 44: 163-168 13. Lipowski ZJ: Consultation-liaison psychiatry: The first half century. Oen Hosp Psychiatry 1986; 8:305-315 14. Fritz OK. Pumariega AJ, Fishhoff J: Child psychiatrists' perceptions of timing and frequency of consultation request. J Am Acad Child Adolese Psychiatry 1987; 26:425-427
PSYCHOSOMATICS