Chronic medical illness increases the risk for psychiatric conditions in children and adolescents, with rates two- to fourfold those in the general population. Concomitant medical illness may color the presentation of behavioral difficulties. Further complications can arise given the significant stress experienced by parents and other family members (e.g., with higher rates of stress-related symptoms and even posttraumatic stress disorder [PTSD]). Consultation issues can arise in different contexts (e.g., outpatient or emergency settings) but most typically arise in the context of pediatric inpatient hospitalization. As described in Chapter 23, different models of care and options for treatment can arise, and an understanding of the nature of the differences between medical and psychiatric models of care is important.

A typical medical consultation in pediatrics can often be obtained quickly with a treatment plan rapidly in place, but in psychiatry, even when the initial assessment is expeditious, intervention may be a long-term process. Other issues include sensitivities to issues of confidentiality and privacy. An appreciation of both the biomedical and biopsychosocial approaches is helpful in providing effective consultation. Some appreciation of the nature of underlying medical conditions may be highly relevant (e.g., are symptoms a feature of the underlying disorder or might they be a manifestation of treatment?). In some circumstances, such as head trauma or central nervous system (CNS) radiation as part of cancer treatment, the potential brain contributions to behavioral difficulties may be easy to appreciate.

Medical procedures may be painful and stressful and are often associated with behavioral and emotional difficulties. Similarly, acute and chronic medical problems can represent different challenges for children and family members. Previous patterns of coping may be used with varying degrees of success. The reactions and behaviors of parents may also be important factors in relation to levels of distress in the child. Peer relationships may also be important (e.g., management of type I diabetes in which the availability of more supportive peers results in better control). The age and cognitive level of the child also have an impact on children’s understanding of and responses to illness and medical procedures. Using Piaget’s approach (see Chapter 2), Lewis (2002) noted the ways in which children’s cognition color their responses
to illness, physical functioning, and disease; this can inform intervention. Over time, children have an increased ability to understand cause and effect, but children in the phase of concrete operations (roughly early primary school) may see their illness as a punishment and may benefit from an explanation. In contrast, adolescents are capable of abstract thought and have a more adult understanding of pathophysiology, although in adolescents, a sense of invulnerability may complicate compliance with medical treatments.

Mental health professionals can provide a broad range of services with either a narrow or broad focus. Consultants must be aware of the context in which they are asked to consult and be familiar with the range of problems frequently encountered along with their potential treatments. For psychiatrists, a familiarity with issues of differential diagnosis and potential behavioral and psychiatric symptoms and complications associated with specific illnesses and treatments is important. In addition to work around a specific case, consultants are ideally involved on a longer term basis, providing suggestions for programmatic approaches designed to minimize stress, maximize coping, and facilitate outcomes.

Mental health professionals can draw on a number of treatments that have been used with support, to varying degrees, in the research literature. These include treatments for pain, encopresis, and obesity as well as interventions specific to disease such as sickle cell disease and other conditions. Methods from cognitive behavior therapy (CBT; see Chapter 22) have been adapted for procedure-related pain. These methods may also help ensure adherence to treatment for children with asthma, juvenile rheumatoid arthritis, and type 1 diabetes. A range of theories and model approaches exist for pediatric consultation (Table 25.1).

The Resource Consultation Model (also referred to as the Independent Functions Model) usually focuses on a specific diagnostic concern with a goal of obtaining diagnostic clarification, recommendations, and potential resources both for the medical team and family with usually no further involvement of the consultant. This is the approach similar to that of other specialists who consult with the primary care provider. Although it has the potential to serve, over time, as a bridge to other more complex models of consultation, this model has limitations intrinsic to limited contact and a highly specific and narrow focus (e.g., it might not address relevant system issues). In contrast, the process (or educative) model may involve work primarily with the medical staff with, potentially, little or no actual contact with the patient. In this approach, the consultant provides relevant information to the primary provider. Broadly viewed, this model includes a range of educational activities and has the great potential advantage of “spreading the wealth” of information broadly. Limitations stem from the problems of variable knowledge base on the parts of the primary care providers and potential lack of specificity to the individual child’s problems. In the collaborative team model, there is a sharing of responsibility and decision making and more intensive collaboration between the mental health consultant and medical personnel. If things go well, this model has the potential for influencing an entire system of care but it does, of course, intrinsically require a substantial commitment on the part of all concerned. Other approaches have attempted to take a broader systems perspective looking, for example, at how the family, school, and medical care system all interact to influence care. The family systems framework considers differences in family interaction and communication as well as disease management practices. Involving schools and the educational system may also be important. Some psychiatric and developmental problems have clear implications for school-based services, and children with medical conditions can also present issues relative to school reentry after illness or hospitalization. These issues are becoming increasingly common as children with serious medical illnesses are surviving more frequently and may present to schools with problems that impact their ability to profit from usual educational programs, as we discuss at the end of this chapter. Issues of school-based consultation are addressed subsequently in this chapter.

Various issues and problems may serve to elicit requests for consultation relative to inpatients in pediatric settings (Table 25.2). These requests can vary from consultation on aspects of management of behavioral difficulties, issues of differential diagnosis, adherence to treatment, and so forth. Some of the more frequent requests involve issues of depression and suicidal ideality, management of anxiety and psychiatric symptoms, and lack of adherence to treatment. Referral rates vary widely and may be more frequent in some service areas than others (e.g., hematology, oncology, and general pediatric services are common sources of referral). It is common for patients referred to psychiatric consultation to have longer lengths of stay, reflecting various factors. On the other hand, various factors may make referral less likely, and much of the available literature suggests that this is indeed the case.

Various guidelines for conducting a psychiatric consultation have been proposed (see Campbell and Cardona, 2007). Generally, the consultant seeks to define the specific, explicit question being asked; reviews the record; and talks with the staff before actually interviewing the patient, parents, or both. After this, there may be suggestions for additional tests or assessments and perhaps coordination with other agencies or providers (e.g., schools or mental health service providers). The consultant should be continuously aware of potential issues of coordination and communication (or lack thereof) because these impact the patient. There will usually be a feedback with specific recommendations. Depending on the context, services may be provided, and the consultant will wish to follow up on the assessment.

Clarification of the referral question is the first step in the process. The consultant should be aware of both the explicit and implicit issues raised at the time of referral (e.g., the explicit question might concern the child or may be more truly focused on the parents). As part of this process, the consultant can also elicit exactly what has been told to the child and family about the consultation and be sure that they have been adequately prepared for it. As part of the review of the medical record, the consultant should be particularly alert to issues of poor or miscommunication and fragmentation of care that can potentially play an important role; this becomes particularly important in more complicated situations in which multiple medical subspecialties are involved. The observations of nurses in the record or in discussion provide important information on the child’s functioning and behavior. The consultant should be alert to potential behavioral or psychiatric effects of medications or medication combinations or the after effects of such agents (e.g., withdrawal symptoms). Often, the parents are interviewed before the child; as relevant, others “stake holders” (state child protective service agencies, foster parents, teachers, and others) may also provide important information. The consultant should aim to obtain a concise summary of the child’s history with emphasis on special issues such as vulnerabilities or difficulties antedating the current hospitalization, family and social factors that may relate to the referral, community and financial resources, and so on.

The interview with the child typically includes a comprehensive mental status examination appropriate to the child’s age and level of functioning (see Chapter 3). Observation of the child in the hospital setting can provide important information. At times, specific self-report inventories might be administered. If there are questions of potential CNS dysfunction or delirium, repeated interviews are essential to document baseline function and changes.

Depending on the situation, the consultant might ask for further procedures or tests (e.g., neuroimaging or electroencephalography [EEG]). Sometimes neuropsychological testing may be needed for children who have experienced CNS insults. The consultant has an important role in attempting to understand the relationships between the patient and family and other systems of care (educational, medical, or otherwise) that pose potential obstacles.

Even before the consultant places a formal summary of his or her assessment in the patient’s record, it is important that the results be communicated to both the medical staff and to the patient and family. The consultant should conduct a direct discussion of the various factors that are contributing to current difficulties and attempt to foster a thoughtful discussion with both the medical staff and the family about these issues.

As noted in Chapters 21, 22 and 23, a range of treatment procedures have been developed to help children and families coping with both acute and chronic illness. CBT methods can be used to help children deal with pain and anxiety around anticipated medical procedures. Other approaches can be used to target issues of treatment noncompliance within a family context. Depending on the context, psychopharmacological intervention may provide significant benefit (e.g., in management of anxiety, depression, or agitation). Although some interventions can
be instituted within a hospital settings others may require helping families access community- and school-based services.

Many barriers to providing effective consultation services exist. These include a shortage of potential consultants, limited insurance reimbursement, and differences in models of service delivery in the pediatric and mental health systems. The pace of pediatric care moves much more quickly than that of mental health work, and an adequate psychiatric consultation can take several hours. Other issues have to do with resistance, on the part of families and medical professionals, to use of mental health services. The complex issues of confidentiality (see Chapter 26) can also be an issue. Pediatricians and primary care providers may complain about a lack of willingness to share results and recommendations; this is particularly unfortunate given the importance of primary care providers in providing comprehensive care. The consultant should attempt to keep the assessment and recommendations understandable, action oriented, and concise. Lewis (2002) has suggested that on larger inpatient services, the occasional, or frequent, presence of the consultant can reduce barriers to communication and facilitate improved service delivery. This is most practical in teaching hospital settings.