Perspectives on Consultation-Liaison in Child and Adolescent Psychiatry

Child and adolescent psychosomatic medicine, usually in the realm of the pediatric psychiatric consultation-liaison service, seeks to address the complex relationship between a child's physical illness and affective state with the goal of improving the child's emotional well-being.^1,2 As with adult psychiatry consultation services, child and adolescent consultation-liaison teams must define their psychiatric formulations based on the interplay between the child's medical illness and the needs of the treatment service requesting the consultation. For example, requests such as "please evaluate for possible depression," can mean anything from concern that the child is displaying signs of a mood disorder, to worry that the child's behavior is complicating the recovery process, to frustration that the child's progress has been slow and has not led to recovery.

These concerns are not exclusive, and the role of the consultation psychiatrist is to assess all of these potential issues and then to create a practical, accessible treatment plan. Thus, pediatric psychosomatic medicine can be defined as a combination of the psychiatrist's assessment of the psychiatric concerns in a medically ill child with a formulation and presentation to the pediatric service of all of the means by which psychiatric intervention might help in that child's coping and recovery.

The consultation process begins with the identification of the service requesting the consultation. Requests can be generated in an inpatient, outpatient, intensive care,or emergency department (ED) setting, and each setting carries distinct challenges for the psychiatric consultant. Inpatient medical or surgical services provide an opportunity for daily visits, constant observation, and rapid interventions. However, the consultant must also be cognizant of the varying needs of the different services providing care for the patient. Psychiatric evaluations in an ED are usually time limited and can be more focused on interventions such as hospitalization or mobilization of outpatient resources. In an outpatient setting, there is the opportunity to coordinate long-term care with the patient's various treatment teams, provide a more thorough assessment through continued visits, and implement, monitor, and modify treatment interventions. Nevertheless, treatment interventions may be affected by noncompliance outside of the hospital and/ or in a chaotic home environment.

Within each of these settings, the consultant should begin by identifying a "point person" from the requesting service--an individual, usually another physician, with whom the consultant can share impressions and recommendations, and from whom the consultant can obtain feedback and updates. Maintaining these open lines of communication is important, because the inclination is for busy services with multiple tasks to separate psychiatric issues and interventions from nonpsychiatric ones. Early establishment of a multidisciplinary approach is central to the success of the consultation.

Before performing an evaluation, the consultant should clarify that the patient and his or her family are aware of the pediatric service's request for psychiatric consultation and that they understand the rationale for psychiatric involvement. It is essential that there is a united message from all members of the patient's treatment team that psychological concerns may contribute to the patient's symptoms and that a psychiatric evaluation is a valuable and necessary part of the comprehensive care of the child. Preparation of the family is essential in establishing an alliance between the psychiatric consultant and the treatment team and in facilitating openness to psychiatric intervention for the child, his family, and other involved caregivers.

The psychiatric consultant should ask the requesting service to formulate a clear consultation question. Common concerns that prompt a request for consultation include observations made by the medical or surgical service regarding worrisome behavior in the patient, uncomfortable family interactions, or a sense among other caregivers that the patient's symptoms are not entirely accounted for by the existing medical, nonpsychiatric formulations. The consultant may also want to ask the requesting service to specify why the consultation request was generated at that particular time, and to offer an indication of the allotted time frame for the assessment, impressions, and recommendations. It is frustrating and disappointing to be asked to provide psychiatric consultation for a patient who is to be discharged within several hours.³

For the consultation to be most successful, the entire treatment team must set realistic goals for psychiatric input and involvement. For example, psychiatric or psychosocial distress felt by the patient, his family, and/or the primary service might not disappear despite psychiatric involvement. Nevertheless, the consultation service can help the child tolerate and/or manage the distress. In this light, questions posed to psychiatry can range from requests for assessment of a primary, underlying, or comorbid psychiatric disorder to assistance in the management of pain, delirium, or general agitation, an acute psychiatric safety evaluation, or, more broadly, helping the patient and the treatment team to cope with chronic illness.

In all of these scenarios, the consultant may be asked to provide both behavioral and psychopharmacological interventions. Goals for the consultation should focus on assisting the primary pediatric team to understand the interplay between the developmental level of the child and his corresponding interpretation/understanding of the illness. It is also important that there is an appreciation of the child's strengths and capacity for resilience, particularly with questions about coping with a serious illness such as cancer. Central to all of these goals is the necessity of helping the primary team to develop appropriate language for discussion of key issues with the patient and the family in empathic and ultimately therapeutic terms.

An essential aspect of consultation is the psychiatrist's role in assisting the team, the patient, and the family to manage difficult emotional responses to troubling circumstances. Transference and countertransference reactions are common in complicated cases and are especially likely with emotionally laden issues such as somatoform disorders, eating disorders, and terminal illnesses.