Consultations to Systems of Care
Essential Concepts
Clarification of the role of the consultant is essential to successful consultation to any system.
As a consultant, address each of the “Who, What, Where, When, Why, How?” questions.
Consultations occur to many systems and in many venues. Consultations to systems require a broad perspective and expertise about how the system works and how to negotiate within each system.
Intervening in disasters is a systems-based consultation that provides services to optimize outcomes for a large number of traumatized children and families.
General Principles and Clinical Considerations
The consultation role is very different from a treatment role. Child and adolescent psychiatrists may consult to many different systems: pediatric inpatient, outpatient, and specialty services, courts, schools, mental health service agencies, disaster victims and service providers, policy-makers, the media, and many others. Although there are many unique aspects of consultation to a specific system, there are also many similarities. The present chapter will set a framework for systems-based consultations, with special attention to consultation-liaison to pediatrics, court-ordered consultations, systems consultations to schools and service agencies, and crisis consultation after a disaster.
Framework for Consultations
The clearer roles, responsibilities, and expectations are prior to a consultation, the more satisfied all will be with the consultant’s involvement and the more helpful the recommendations will be.
WHO? The Consultee and Confidentiality Parameters
Who is requesting the consultation? What is the system involved?
Clarify the multidisciplinary staff that may be affected by the consultation—clarify their goals and ensure their input and involvement.
Clarify confidentiality, with whom the consultant will interact, informed consent around consultant interactions (if relevant), and nature of the recommendations (written report, verbal, case conference, etc.) and with whom it will be shared.
WHAT? Clarification of the Consultation Question and Wishes/Needs of the Consultee
What are the consultation questions? Seek to understand the consultee’s concerns and help focus the consultation question.
Are the goals for the consultation realistic? Success depends on realistic expectations and a shared consensus about the nature of the problem.
Clarify the role of the consultant—whether the consultation is direct (direct observation/assessment of an individual child with recommendations) or indirect (consultation to treaters or personnel only).
Clarify (if possible) if the request is for a “hired gun” vs. an impartial consultant.
WHERE? Where will the consultation take place?
Choose the location that is most convenient
Be sure that you are “in the mix” with the personnel, students, patients, etc. to whom you are providing the consultation.
WHEN? What is the time frame to complete the consultation?
Is there time to complete the consultation requested?
WHY? Why is the request for consultation being made at this time?
Sometimes the ostensible reason for the request covers a “hidden agenda,” such as staffing issues, conflict among staff, difficult parents, or others.
HOW? How will the consultation proceed?
How much of the workup has been done before proceeding with the consultation?
How will the consultant get the information needed to proceed with the consultation?
How will the results of the consultation be communicated?
Models of Consultation-Liaison to Pediatricians
Several models of consultation-liaison have been developed in response to the kinds of consultations requested by pediatricians and to the kinds of psychological reactions prominent in hospitalized pediatric patients and their families.
Anticipatory Model—this is a consultation to a child and family in anticipation of a difficult procedure. Pretreatment psychiatric consultation to assess the strengths and vulnerabilities of the family and to prepare the child and family accordingly may be very helpful. This process may help avert serious psychological reactions or ensure that psychiatric support is in place if or when they occur.
Case Finding Model—this includes liaison work—regular ward meetings with pediatric and nursing staff that enhance the functioning of the unit and help with early identification of patients at risk. This model may encompass the (often not specifically requested) identification of staff communication or systems and relational issues to be addressed.
Education and Training Model—training for pediatricians, pediatric house-staff, nurses, and collaborative case conferences and didactics enhance the effectiveness of all the treaters of the children and families.
Emergency Response Model—this model ensures consultation coverage for children and adolescents in acute crisis. The consultation request is typically urgent, such as how to manage an acutely upset, aggressive, or suicidal patient on the wards.
Continuing and Collaborative Care Model—this is best suited for children with recurring or chronic medical illnesses and may occur in inpatient or outpatient settings, or both.
Consultation to the Courts
Court-ordered consultations may include psychiatric assessments of children and youth who have committed crimes (such as competency to stand trial and “amenability to treatment” evaluations), custody evaluations, or expert witness testimony.
Juvenile Court
Mental health professionals are called on by the juvenile court to perform evaluations, make treatment and program recommendations, and provide consultation and expert testimony. Youth who have been accused of committing
a crime are often released to the custody of a parent or guardian unless a judge deems detention necessary for the protection of the community or is otherwise in the child’s best interest. The juvenile delinquency proceeding includes the “adjudication hearing” (trial). If the youth is found guilty, he is “adjudicated” (convicted). If there has been adjudication, the case proceeds to the “dispositional” (sentencing) phase. At the preadjudicatory and postadjudicatory stages of a juvenile delinquency proceeding, the need for treatment, appropriate type of treatment, and likelihood of benefit from treatment are questions posed to mental health treaters. Issues of competency to stand trial are usually more relevant for older youth who have been referred to the adult criminal court due to the youth’s age, seriousness, or chronicity of offenses.
a crime are often released to the custody of a parent or guardian unless a judge deems detention necessary for the protection of the community or is otherwise in the child’s best interest. The juvenile delinquency proceeding includes the “adjudication hearing” (trial). If the youth is found guilty, he is “adjudicated” (convicted). If there has been adjudication, the case proceeds to the “dispositional” (sentencing) phase. At the preadjudicatory and postadjudicatory stages of a juvenile delinquency proceeding, the need for treatment, appropriate type of treatment, and likelihood of benefit from treatment are questions posed to mental health treaters. Issues of competency to stand trial are usually more relevant for older youth who have been referred to the adult criminal court due to the youth’s age, seriousness, or chronicity of offenses.
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