Before seeing a pediatric patient, as with any other patient on a consultation-liaison service, it is important to discuss the case with the referring provider so as to have a clear idea of the issues to address in the consultation. Where applicable, one should get an idea of the prognosis of the general medical condition. Because children are usually not legally autonomous, it is advisable (except in unusual circumstances) to ensure that the parents have been informed about, and have agreed to, the consultation. The effectiveness of the consultation-liaison psychiatrist is limited if the initial encounter with the parents is awkward or confrontational merely because they had not been informed that a psychiatric consultation was requested. For the purposes of documenting medical necessity (and, in many cases, for billing purposes), the consultant should ensure that the referring medical team has either written an order for the consultation or documented that a consultation is necessary and therefore being requested.

In the interests of maintaining the most optimal relationships with the system of care surrounding a pediatric patient, the consultant should always remember this advice: there is no such thing as an inappropriate consultation request. Even if the identified patient were to seem fine, every consultation request suggests that someone in the system—whether a family member, health care professional, or other stakeholder—is concerned and therefore potentially able to benefit from a systems-sensitive intervention. In our institution’s consultation-liaison service, we instruct our residents that even though most of us in the consultation-liaison business operate on fixed salaries, we should nevertheless all take the perspective of bright and eager new physicians who are grateful for the privilege to work in the medical center, and who are always pleased to find work that can support their practice. We find that adopting such an attitude improves the overall quality of the consultation-liaison service and, ultimately, the care the patients and families receive.

The saying “children are not miniature adults” applies just as well to psychiatry as it does to the rest of medicine. Most prominently, children and adolescents are developing physically and cognitively, so it is very important to consider the developmental level of the patient. Although a comprehensive review of child and adolescent development is beyond the scope of this chapter, we review key aspects of development, particularly as they apply to understanding of and adaptation to general medical illnesses.

One key principle is that development is a continuous process that builds on success in earlier stages. The consultation-liaison psychiatrist working in pediatric settings should therefore recognize the potential disruption that medical illnesses may have on normal child development.

Table 32.1 summarizes the key stages of development (predominantly social and cognitive) that may be of particular clinical importance in the context of general medical illnesses. Children’s developmental levels are important to consider when discussing coping with illness (and associated treatments) and death and dying. For example, 6-year-olds may have erroneous (though developmentally age-appropriate) beliefs about human physiology, believing that they can lose all of their blood from a blood draw on injection, in spite of well-meaning reassurances that the pain will not be severe. As another example, 6-year-olds might believe that justice can emanate from inanimate objects, and thus (unknown to their parents or caregivers) blame themselves for a personal illness or otherwise be afraid of reporting symptoms. Older children, in spite of more accurate perceptions about the causation of illness, may still not be able to appreciate all of the mechanisms that lead to illness. Hence, relatively straightforward explanations about the need for certain treatments (including medications) may be most appropriate.

Beyond just the cognitive understanding of illness, the emotional adjustment to illness is heavily influenced by developmental level. For example, it is likely that a preadolescent who must cope with a physical deformity may be more vulnerable to emotional difficulties, compared to a younger child, who may have a less developed body image, or an older adolescent, who may be more cognitively mature.

In order for children to optimally adjust to issues related to death and dying, they need to understand that death is irreversible, final, inevitable, and causally explained. Children facing death (whether their own or in a family member) at a developmental age earlier than that when these principles are understood are vulnerable to experiencing adjustment difficulties. For example, a child who does not realize that death is inevitable or causally explained may consider death to be a punishment for wrongdoing. Therefore, parents and caregivers often benefit from briefings about how to discuss challenging topics, such as death and illness, in a developmentally appropriate manner, and are often best able to gauge their child’s cognitive development.

Children, both legally and developmentally, are not autonomous beings, and therefore are part of a complex system (whether explicit or not) that includes the family and other professionals involved in the child’s care. While state laws may differ somewhat on the degree to which adolescents can consent to certain aspects of medical care (e.g., related to family planning, sexually transmitted diseases treatment, and substance abuse treatment), most states require parental consent for most types of behavioral health care. Additionally, most child and adolescent psychiatrists would agree that conscientious, systems-sensitive involvement of the family in the care of a child or adolescent (or even adult), whether legally mandated or not, usually constitutes the most optimal clinical care.

Consultation-liaison psychiatrists who are not primarily child and adolescent psychiatrists often wonder what is the best way to approach child or adolescent patients and their family: should the patient be interviewed first, or should the family be interviewed first, or should the patient and family be interviewed together? In our clinical experience, we have found that there is no correct answer to this question. We recommend that (1) the patient and available family at bedside can be introduced to the context of the consultation and then asked about how they would like to proceed; (2) time may be set aside to interview the patient and parents separately (particularly if there are concerns about abuse or other sensitive issues); and (3) a solid biopsychosocial formulation with attention to family and systems perspectives should guide the titration of the amount of time spent with the patient alone, with the parents alone, and with the patient and parents together (for instance, if improving communication between the patient and parents is an important focus of the intervention).

Children and adolescents rarely request psychiatric consultations on their own. The requests for psychiatric assistance and the reporting of psychiatric symptoms are therefore often seen through the lens of the family or requesting health care providers. It is therefore of utmost importance to (1) build and maintain solid working relationships with the health care team (through rounds and other collaborative meetings with pediatric medical, nursing, social work, chaplain, and other staff); and (2) determine why the consultation is being requested, which facilitates deciding which aspects of the system warrant attention and intervention. For example, was it someone other than the child or family who requested the consultation, in which case part of an effective consultation must include directly addressing that person’s concerns. Consultation-liaison psychiatry is the perfect venue to practice the biopsychosocial formulation, which can guide the intervention on multiple levels.

Many requests for consultation arise from concerns about emotional or behavioral symptoms in a parent or other family member involved in the child’s care. These are entirely appropriate reasons to consult psychiatry, since the family is part of the whole system affecting the child’s health. Therefore, while it is certainly appropriate to clarify the intent of the consultation with the referring provider, we recommend against “hassling” the medical team about the fundamental request for help. In such situations, it is important to document the consultations from the perspective that the child is the identified patient, even though observations about the parent or other caregiver may also be included. If a parent or other family member needs follow-up as an identified patient, then this can be part of the recommendation.

Common family-related situations and the potential role for the consultation-liaison psychiatrist are summarized in Table 32.2.

The consultation-liaison psychiatrist in pediatric settings should have basic knowledge of child and adolescent psychopharmacology. Once again, children are not “miniature adults” when it comes to responses to medications. It is important to note that most psychotropic medications are not approved by the Food and Drug Administration (FDA) for children and adolescents. Also, children and adolescents generally metabolize medications differently (usually faster) than adults. Finally, the responses of children and adolescents to medication are such that the risk–benefit profile (for instance, in the case of certain antidepressant medications) may not necessarily be the same as what it is for adults.

Given these differences, it is of utmost importance for psychiatrists treating children and adolescents to engage in solid psychopharmacologic practice, which includes the following:

Table 32.3 summarizes the usual first-line medications and recommended doses for common diagnoses and scenarios encountered in pediatric consultation-liaison psychiatry.

Because of the likelihood that patients in pediatric consultation-liaison settings will have general medical comorbidities and may be on other medications, the reader is referred to specific chapters in this book on psychopharmacology in the context of specific general medical illnesses and to tables on drug–drug interactions.

Finally, specific to the pediatric population, we recommend the following “rules”:

Suicide attempts or concerns about suicidality are likely to be among the more common concerns presented to a consultation-liaison psychiatrist on a pediatric service (Shaw et al. 2006).

First, it is important to follow whatever policies exist in the medical center regarding the management of patients who are suicidal or potentially suicidal. For many medical centers, doing so includes assigning a risk level (e.g., low, moderate, high) and implementing orders appropriate to the assigned risk level. The orders may address the following areas:

Next, while keeping close contact with the referring medical team and nursing staff, the consulting psychiatrist should seek opportunities for crisis intervention where appropriate. As suggested previously, the psychiatrist, particularly when working with children and adolescents, should ask, “Why did this crisis happen now, on this day, at this time of day?” and “What are all of the biologic, psychological, and social stressors that led to this crisis?” The answers to these questions often help determine what should be done to resolve the crisis. Examples of common precipitating factors are shown in Table 32.4.