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Keywords:

  • consultation/liaison;
  • paediatrics;
  • psychiatry;
  • supervision;
  • training

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

A substantial part of a paediatrician's work increasingly involves caring for children and young people with mental health, developmental, emotional and behavioural problems. Over time, recognition of these aspects has redefined and broadened the notion of what classically constitutes ‘Paediatrics.’ This paper discusses the ways in which paediatricians and psychiatrists can support each other in this work. It highlights the role of supervision and specifically advocates for the expansion of consultation/liaison psychiatry services.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

A conversation overheard in the doctors' common room recently:

‘The surgeons have referred us a 14-year-old girl with abdominal pain. They don't think it's surgical.’

‘Is it real pain?’

A second quote, from a meeting of clinical academics discussing the teaching of communication skills and teamwork to medical students:

‘When are we going to get back to teaching them some real medicine?’

Key Points

  • 1
    An increasing proportion of a paediatrician's work involves caring for children and families with mental health, developmental, emotional and behavioural problems.
  • 2
    Paediatricians must use every opportunity to advocate for an appropriate level of funding for these disorders.
  • 3
    Paediatric consultation/liaison psychiatry services provide a valuable opportunity for paediatricians and psychiatrists to work side by side.

The Changing Pattern of the Burden of Paediatric Disease

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

A continuing decline in the impact of paediatric infectious disease has been accompanied by a corresponding increase in the burden of chronic and disabling conditions, including developmental and psychiatric disorders. In a prospective survey of Australian paediatricians' outpatient practice, almost one in five (18.3%) of all consultations was for attention deficit hyperactivity disorder (ADHD).1 A review of children and adolescents seen at a paediatric developmental/behavioural clinic in Melbourne reported that those attending had a comparable burden of emotional/behavioural symptoms to those referred to the neighbouring Child and Adolescent Mental Health Service (CAMHS).2 Data from the Australian Institute of Health and Welfare show that 23% of the burden of disease amongst 0–14-year-olds is attributable to mental health and developmental/behavioural problems (including anxiety, depression, ADHD and autism spectrum disorders), with chronic respiratory disorders (mostly asthma) and neonatal conditions accounting for 18% and 16%, respectively.3 For adolescents and young adults, suicide is the second most common cause of death among 12–24-year-olds (after land transport accidents), while mental health problems account for 61% of the non-fatal burden of disease among those aged 15–24 years.4

What Does this Mean for Paediatric Training?

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

For today's medical students and trainees in paediatric and adolescent medicine, what constitutes the ‘real medicine’ (indicated in the second quote) that we should be teaching them? Acute general paediatrics, intensive care, neonatology (and its long-term consequences) and the traditional subspecialty rotations are all key aspects of a paediatrician's training, along with emerging subspecialties such as child protection, metabolic, rehabilitation and adolescent and young adult medicine. The data, however, speak for themselves: a substantial part of a paediatrician's work involves caring for children, young people and families with mental health, developmental and behavioural problems.5 In current paediatric practice, this is core business (Table 1). This is real medicine.

Table 1.  Paediatric problems associated with emotional/behavioural symptoms
Chronic medical conditions
• epilepsy
• diabetes
• cancer
• asthma, cystic fibrosis
• inflammatory bowel disease
• spina bifida
Developmental and behavioural problems
• ADHD, autistic spectrum disorder
• learning difficulties
• disruptive behaviour disorders
• Down's syndrome
Psychiatric disorders presenting with physical symptoms
• anxiety, depression
• somatoform and conversion disorder
• deliberate self-harm
Organic diseases presenting with psychiatric symptoms
• thyrotoxicosis
• encephalitis
• temporal lobe epilepsy
• drug misuse
Psychosocial problems
• problems associated with parental mental illness
• child abuse (physical, sexual, neglect)
Severe trauma
• burns
• admissions to intensive care

The Royal Australasian College of Physicians has taken steps to recognise this shift, with several advanced training curricula (community child health, general paediatrics, adolescent and young adult medicine) including specific competencies in mental health.6 It is vital for senior staff to provide trainees with opportunities to see first hand how prevalent and important developmental and psychiatric disorders are. Trainees must be allowed to gain skills in the management of these disorders and experience the dramatic improvements that expertise, as well as patience, can produce. These skills include being able to work effectively with families; assess the impact of family relationships on the development and maintenance of emotional disorders; and recognise the presence of mental health problems among parents or carers.

Investment in training positions, as well as mentors, to provide these opportunities is essential. Training must reflect the conditions that consultants will be required to manage. Allocating a disproportionate amount of time to acute paediatrics, intensive care and neonatology will do little to prepare trainees adequately for the many hours they will spend in outpatients caring for children and young people with disruptive behaviour, school non-attendance and chronic pain.

Barriers to Effective Paediatric/Psychiatric Collaboration

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

Within the mental health budget, the relative importance of child and adolescent mental health continues to be under-recognised, and the potential dividends from investing in this field largely ignored. Because of funding constraints CAMHS have tended to restrict their focus to the management of those with very severe mental health problems. CAMHS can be stringent regarding referral criteria and well versed in outlining why a particular young person would be more suitable for another service. Consequently, paediatricians often perceive mental health services to be reluctant to accept referrals.

On more than one occasion has a paediatrician asked the question of psychiatrists: ‘Why are they being so precious with their time?’7 A response to this might be: ‘Why are paediatricians so threatened by not being able to provide a quick fix?’ There are obvious contrasts between the ways in which a paediatrician and a psychiatrist might evaluate a patient, none more apparent than the time required in providing appropriate assessment. Although each may be assessing the same person, the information desired, the way it is elicited and verified, the professional's interaction with the patient, the patient's willingness for assessment by the clinician and many other aspects differ substantially. Mutual respect between each specialty requires an understanding and appreciation of these differences, despite a desire at times for the other to operate more like our own.

Promoting Effective Paediatric/Psychiatric Collaboration

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

Advocacy

Paediatricians must therefore use all available opportunities to highlight the changing pattern of the burden of disease and to advocate for an appropriate level of funding for developmental and psychiatric disorders. Those involved in the planning of new services and new hospitals must ensure that mental health is at the heart of such developments and challenge views which attempt to maintain the status quo.

Consultation/liaison psychiatry

The need for paediatricians to manage those not meeting strict CAMHS criteria can leave clinicians feeling overwhelmed, tired and frustrated.8 At these times it is invaluable to have a psychologically minded colleague at our side to highlight that we may not be doing anyone – our patients or ourselves – any favours here. For paediatricians involved in managing young people with mental health problems, this is the key: to be able to call upon professionals with specific expertise who can listen to us, guide us, and occasionally take over management.

Paediatric consultation/liaison (CL) psychiatry is the term used to describe the service provided by psychiatrists who work primarily within a paediatric medical setting.7,9 For those fortunate enough to work alongside such a service, the benefits are obvious and many.10 However, as pointed out by Sebastian Kraemer, paediatricians who lack the experience of successful partnerships with psychiatry are in no position to advocate for the support they require.7 Perhaps the most important element of an effective collaboration between paediatrics and CL psychiatry is the opportunity for professionals from both disciplines to work literally side by side. Having psychiatrists seeing patients on paediatric medical and surgical wards or in the clinic room across the corridor, attending clinical meetings and grand rounds and sharing ideas over coffee are practical ways of breaking down the barriers and softening the prejudices that invariably exist. Such interactions provide the opportunity for psychiatrists to see first hand the day-to-day business of paediatrics, and vice versa.

Supervision

When illness occurs in textbook fashion, we can consult textbooks. However, on the occasions when this is not the case, what should our response be? Although there are times when a formal psychiatric opinion is required, there are a range of issues with which psychiatrists can assist, providing guidance from the sideline. These include initiation or adjustment of psychotropic medications (e.g. anti-depressants, atypical antipsychotics, stimulants), guidance on handling parents with mental health or drug and alcohol problems, an opinion related to a child protection case, or suggestions for a referral to an outside agency (e.g. a local psychologist or youth support network). A valuable resource is the opportunity for the apprehensive paediatrician, anticipating a tricky consultation with a family, to obtain advice about strategies that can be used to help defuse the situation. These include how to begin the consultation, questions one might ask and whether to see the parents separately from the child/young person. Taking the time to sit back, with a colleague, and look at the structure (how things are set up), process (what goes on, who says what, to whom) and content (what is actually said) of a consultation is not something that paediatricians typically do. Supervision is the word psychiatry uses to describe this process of reflection, or the structure that guides it. It is an integral part of psychiatry training and long-term practice, and one that is now recognised as an essential component of training and practice in community child health.6,8

Supervision may take a variety of forms or structures, but typically involves setting aside dedicated, protected time to discuss relevant issues.8 An example might be a young person with a chronic medical condition, whose behaviour and demeanour suggest depression. A referral to a specialist mental health professional may be required, but prior to this, a discussion between the paediatrician and the psychiatrist to consider possible causes is an appropriate first step. Is this the first time that the young person has become depressed? Could it be directly related to the medical condition or is it medication-related? Could it be demoralisation? More importantly, how has the young person continued to survive, thrive and develop whilst having the illness? Why this person, at this point in time, in this situation? Could this relate to family dynamics, peer group or schooling? Moreover, and of particular relevance to us as health professionals: what of the medical system that provides the young person's treatment? What are our own reactions to the young person, their family, their illness and the uncertainty?8 How do we ensure that we can deliver appropriate and sensitive care, and ensure we are strong enough to keep on doing it, within a system that seems to provide endless amounts of such work? Supervision may appear a luxury but, in essence, it is talking with a trained colleague and encouraging reflective practice, with the specific aim of improving outcomes for young people and their families. Through it, we are able to emerge from difficult situations, acknowledging the impact on our own experience and better able to encounter future situations with confidence and competence.

Measuring Outcomes

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

Does this approach work? Those who have experienced the benefits will say yes.10 Those who have only worked with psychiatrists at arm's length are likely to be more sceptical. Can outcomes be measured? We should certainly try. It has been argued that research in this area is more suited to qualitative rather than quantitative methodology.11 However, in paediatric CL psychiatry, there are objective measures that can be reported, such as school attendance and the number of unscheduled visits to a health professional, that provide insight into the success of the work. Where paediatrics operates on a more pragmatic level that lends itself to being evaluated with figures, mental health often operates within grey areas involving subjectivity (which can be especially difficult to elicit from young people). The dearth of evidence within mental health undoubtedly relates in part to the difficulties inherent in studying its outcomes.

For example, of the ‘talking therapies’ available to treat a given mental health problem, cognitive behavioural therapy (CBT) has the most substantial evidence base for a variety of conditions. This may indicate that CBT lends itself to being studied, being highly manualised, structured and easy to detect benefit. For a given patient – for example, our patient with the chronic medical condition – CBT may or may not be the most useful talking therapy. However, solely basing a decision on the evidence from the published literature would seem to indicate that it is.

Real Medicine

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

Finally, back to the question of real medicine and, for symmetry, two further quotes. First, a paediatrician and a child psychiatrist, writing together in 2008: ‘Safeguarding, child protection and the mental health of children and parents are inextricably intertwined and are as much the stuff of modern paediatrics as biochemistry, genetics or therapeutics.’12 And second, some advice offered by a colleague a few years ago: ‘If anyone tries to get you to say whether a problem is either physical or psychological, don't buy into their argument. It's always both.’

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References

This paper was inspired by an earlier article written by Dr Sebastian Kraemer,7 and subsequent correspondence with Dr Kraemer, encouraging paediatricians to advocate for consultation/liaison psychiatry. The authors would also like to thank their current colleagues, whose practice and ideas have informed this discussion.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Changing Pattern of the Burden of Paediatric Disease
  5. What Does this Mean for Paediatric Training?
  6. Barriers to Effective Paediatric/Psychiatric Collaboration
  7. Promoting Effective Paediatric/Psychiatric Collaboration
  8. Measuring Outcomes
  9. Real Medicine
  10. Acknowledgements
  11. References