Chapter 1. Pediatric Consultation-Liaison Psychiatry
Publication: Clinical Manual of Pediatric Consultation-Liaison Psychiatry
Pediatric consultation-liaison psychiatry (CLP), also known as pediatric psychosomatic medicine, is the subspecialty of child and adolescent psychiatry that focuses on providing mental health services to physically ill children and adolescents. Consultants specializing in this field must have in-depth knowledge regarding the way medical, neurological, and other conditions; medications; and metabolic problems interact to cause psychiatric symptoms. Also important is the ability to understand the interaction between psychiatric and medical issues and to recommend the most appropriate treatments (American Academy of Consultation-Liaison Psychiatry 2019).
The field of CLP or psychosomatic medicine has existed for many decades (Ali et al. 2006; Shaw et al. 2010). It has also been designated by other names, including medical psychiatry, medical-surgical psychiatry, psychological medicine, behavioral psychology, and pediatric psychology (Shaw et al. 2010). The field has overlaps with the pediatric specialty of developmental and behavioral pediatrics.
In 2003, the American Board of Psychiatry and Neurology (ABPN) granted psychiatry subspecialty recognition for psychosomatic medicine. In 2017 (effective January 1, 2018), the ABPN changed the official subspecialty name from psychosomatic medicine to consultation-liaison psychiatry. This name change occurred in the context of concern that use of the term psychosomatics was thought to suggest that the field’s sole focus was on somatic symptom disorders as opposed to the field’s much broader approach that integrates biological, psychological, social, and developmental factors into a whole-person multifactorial approach to patients facing physical illnesses (Boland et al. 2018). It is this developmental biopsychosocial framework that lies at the foundation of this clinical manual and our interchangeable use of the terms pediatric consultation-liaison psychiatry and pediatric psychosomatic medicine.
Building a Collaborative Care Bridge to Pediatrics
The term consultation generally refers to activities that involve patient-focused evaluations and recommendations that occur at bedside. By contrast, liaison describes activities that focus on the pediatric team and its relationship with the patient. In its broadest interpretation, liaison may also include ongoing programmatic developments, policy and protocol issues, and collaborative research.
In bringing together these two activities, consultants serve as bridges for the provision of collaborative mental health care services in the pediatric setting. Ranging along a spectrum from minimal to full collaboration, the following collaborative care models are generally used: 1) coordinated care, in which the consultant and pediatric team are in separate facilities with separate systems, communicating intermittently as initiated by the pediatric team; 2) co-located care, in which the consultant and pediatric team are in the same facility with some shared systems and communicate frequently about shared patients, although care may still not be coordinated; and 3) integrated care, in which the consultant and pediatric team are in the same space within the same facility with shared systems and communicate regularly in person, with resultant practice change (Heath et al. 2013).
Across these bridging models, the framework for collaborative mental health care ideally matches the level of complexity of a patient’s needs (de Voursney and Huang 2016). Most commonly, this framework is characterized by a stepped care approach whereby the “right person” in the “right place” delivers the “right care” at the “right time” (Collins et al. 2010; Garrity 2016; Walter et al. 2018). Within this framework, the intensity of treatment ascends based on the severity of the patient’s presentation. For example, patients with mild-to-moderate psychiatric disorders are treated within the pediatric setting, whereas those with nonresponsive mild-to-moderate disorders or severe psychiatric disorders are referred for specialty psychiatric assessment and treatment (Collins et al. 2010; Garrity 2016; Walter et al. 2018).
Consultants are thought to be most effective when they work in co-located or integrated care models, whether in outpatient specialty programs or in inpatient hospital settings. Within these bridging models, consultants must appreciate the roles of the professional disciplines involved in the care of physically ill children or adolescents (Table 1–1).
Professional disciplinea | Roles | Comments |
|---|---|---|
Primary team members | ||
Attending physician | Leader of pediatric team Develops diagnostic formulation and treatment interventions Has final medical responsibility for patient | May have long-established relationships with patient and family Oriented toward immediate concerns of patient Potential for ambivalent feelings toward the consultant |
Resident | Frontline clinician involved in assessment and management Has trainee status as participant in residency training program | Short-term clinical rotations with lack of continuity Frequently dealing with time constraints and excessive burden of clinical work Lack of familiarity with role of the consultant |
Nurse | Implements bedside treatment interventions Provides education of patient and family Provides psychosocial support for patient and family Serves as liaison between family and pediatric team | Most frequent, direct contact Closest exposure to physical and emotional distress of the patient Lack of continuity due to shift changes and staffing issues |
Ancillary team members | ||
Physician (including psychiatrist) consultants | Consult to primary team to provide specialty input into patient’s care | May be part of primary team in integrated/colocated care models |
Social worker | Assists with basic social services for family Serves as liaison with outside agencies, including child protective agencies in cases of abuse and neglect Provides psychosocial support for patient and family Provides individual and family therapy Oversees referral to and coordination of outpatient services | May be part of primary team in integrated/colocated care models May have long-established relationship with patient and family Has established relationship with pediatric team Potential for “turf” issues with consultant due to overlap in clinical role |
Case manager | Coordinates resources and services inside facilities, outside facilities, and between care environments Works with patients, families, and other professionals to ensure proper resources and service utilization Serves as liaison with insurance companies for authorization of medical/behavioral health services | Generally, case manager is a nurse, although behavioral health support may fall to a social worker and/or a resource specialist |
Occupational and physical therapists | ||
Provides support with activities of daily living Oversees rehabilitation of patients after surgery and medical illness Provides treatment of feeding difficulties | ||
Nutritionist | Provides nutritional counseling and assists with calculation of caloric needs | Has an important role in treatment of patients with eating disorders and pediatric feeding disorders |
Child life specialist | Helps with coping with challenges of hospitalization, surgery, and disability | |
Coordinates hospital-based play and recreation services | ||
Chaplain | Provides spiritual assessment of patients and families | |
Provides psychosocial and religious support for patient and family | ||
a
Primary care team is the core team responsible for the care of the patient; ancillary care team comprises those specialists who may or may not be brought into the care of an individual patient.
Source. Adapted from Fritz 1993.
Roles of the Consultant
The consultant has a complex position within the pediatric setting that requires flexibility and adaptability to perform several interrelated roles: assessment and management, patient and family advocacy, liaison activities with pediatric team, and clinical innovation and research.
Assessment and Management
The consultant’s primary role is to provide psychiatric assessment and management of physically ill children and adolescents. The American Academy of Child and Adolescent Psychiatry’s clinician-oriented practice parameter has outlined core principles (see Chapter 3, “Assessment in Pediatric Consultation-Liaison Psychiatry”) to guide consultants in approaching pediatric patients and their families who are facing physical illnesses (DeMaso et al. 2009).
In the assessment, consultants aim to identify comorbid psychiatric illness as well as to recognize the direct effects of physical illnesses that mimic emotional symptoms and physical symptoms that are associated with emotional distress (DeMaso et al. 2009). Consultants can recognize maladaptive coping styles and behaviors that interfere with a patient’s health care as well as strengths that promote resilience (DeMaso et al. 2009). Assessment and management are facilitated when consultants assume an engaging and spontaneous therapeutic stance that deviates from the more traditional anonymity, abstinence, and neutrality of therapy (DeMaso and Meyer 1996).
Referral Questions
Three types of consultation requests are made of consultants by pediatric practitioners and/or teams: 1) diagnostic (e.g., differential diagnosis of somatic symptoms, depression, delirium, or anxiety—What does this patient have?); 2) management (e.g., procedural distress, disruptive behavior, pain management, nonadherence, parental adjustment to illness, or medication—Please take care of this patient’s behavior); and 3) disposition (e.g., suicide assessment and psychiatric hospitalization—Please move this patient into a mental health setting) (DeMaso et al. 2009). These requests are often interrelated, with the relative importance of each request to the individual pediatric practitioner or team varying on a case-to-case basis.
Classification Framework
Figure 1–1 shows a useful framework for consultants to use in organizing the psychiatric issues in physically ill youth by considering the issue of comorbidity. The term coincidental comorbidity is used when patients have unrelated psychiatric and physical illnesses, whereas the term causal comorbidity is used when the psychiatric disorder is a direct result of physical illness and/or has a significant impact on the course or severity of the physical illness. Causal comorbidity also captures psychological symptoms that develop as a direct result of the stress of the illness or its treatment.
Coincidental comorbidity refers to cases in which an emotional disorder that developed before or after the onset of the physical illness is related to factors other than the illness itself. Functionally impairing psychiatric disorders have been estimated to occur in one of every five youth in the United States (Merikangas et al. 2010). When these disorders in youth are untreated, they persist over time, becoming less responsive to treatment while causing progressively greater academic, social, and economic consequences (Copeland et al. 2015). In addition to these findings, evidence indicates that youth with chronic pediatric conditions and co-occurring psychiatric disorders have more than twice the annual medical payments of those with pediatric conditions alone; in this context, psychiatric consultation as a means for early identification and intervention has become an increasingly important consideration for youth facing chronic physical illnesses (Perrin et al. 2019).
Causal comorbidity refers to instances in which psychiatric symptoms either contribute to or result from the onset of physical illness. Disorders may be classified as psychosomatic or somatopsychic. Patients are diagnosed with psychosomatic disorders when physical symptoms are caused by psychiatric illness. Examples include patients with eating disorders who develop medical complications as a result of malnutrition or patients who develop medical complications as a result of failure to adhere to their medical treatment. Similarly, patients with somatic symptom and related disorders have physical symptoms that are primarily a manifestation of underlying psychiatric issues with no demonstrable medical etiology.
Somatopsychic illnesses involve the production of psychiatric symptoms as a direct consequence of a physical illness and/or its treatment. Consultants should be particularly alert to this possibility when psychiatric symptoms develop suddenly, worsen or persist over time, are unresponsive to treatment, and/or have atypical clinical features. One category of patients with somatopsychic illness includes those who develop psychiatric symptoms for which the underlying etiology is medical or medication related. This category includes patients with delirium or a mood disorder due to a medical condition. A second category of patients with somatopsychic illness includes those who develop symptoms of an adjustment disorder or medically related posttraumatic stress disorder as a result of the stress of the physical illness.
Consultant Interventions
Hospital-based treatment interventions are often limited by the lack of time and staff available for their implementation, in addition to the challenge of coordinating the child’s care with the large number of hospital staff involved in the patient’s overall care. In many cases the consultation is limited to triage and referral to outside agencies. The three most common treatment interventions have been reported to be the use of psychoactive medications, supportive psychotherapy, and assistance with discharge planning by referral or transfer to another facility. Also, consultations have often been reported to involve family therapy, preparation for procedures, and behavioral modification (Ramchandani et al. 1997).
Psychiatric consultants must have a strong grounding in the use of psychotropic medications, including knowledge of potential drug interactions and the need to adjust dosages in patients with physical illnesses (Brown et al. 2000). Common medication requests include the management of delirium, acute symptoms of anxiety or agitation, and insomnia, as well as the use of adjunctive pain medications (see Chapter 5, “Delirium”; Chapter 6, “Neurocognitive Disturbances”; Chapter 7, “Depressive Symptoms and Disorders”; Chapter 8, “Anxiety Symptoms and Trauma/Stress Reactions”; Chapter 10, “Pediatric Pain”; and Chapter 17, “Psychopharmacological Approaches and Considerations”).
Psychotherapy by consultants is affected by the current realities of a patient’s physical illness and its treatment (O’Dowd and Gomez 2001). Other constraints are the frequent interruptions and the lack of privacy in the hospital setting. As a result, psychotherapy in the inpatient setting is generally supportive in nature. Adjunctive family therapy may also be useful for parents and siblings and to help resolve conflicts that arise between family members (see Chapter 15, “Psychotherapy in the Pediatric Setting,” and Chapter 16, “Family Interventions”).
Hospital-based behavior modification can be a simple yet effective treatment intervention. Examples include programs to facilitate cooperation with medical procedures, feeding issues, and activities of daily living. Patients with chronic pain or physical disabilities may respond to programs that are presented as part of inpatient rehabilitation treatment. General principles of behavior modification include positive reinforcement of desired behaviors, ignoring negative behaviors, and consistency in the implementation of the program.
Guided imagery, relaxation, and mindfulness interventions are potentially useful in the treatment of pain, anxiety, and insomnia. Patients who are admitted for stressful procedures may benefit from early referral for these services. Hypnosis may be useful for patients with refractory issues of procedural anxiety or pain management (see Chapter 18, “Preparation for Procedures”).
Consultants will commonly educate the family regarding what to expect regarding a child’s emotional reaction to his or her physical illness. Hospitalization is generally a stressful time in which the family experiences feelings of loss and a lack of control. Education may include information about regression as well as about how a child’s level of development affects his or her understanding of the illness.
Patient and Family Advocacy
Advocacy for the child or adolescent serves an important function in supporting and enhancing the provision of patient- and/or family-centered care. Using their biopsychosocial lens, consultants are in the unique position of being able to provide to the family and pediatric team insight into a patient’s view of his or her illness, which is influenced by the patient’s developmental stage. Adolescents with terminal illness, for example, may wish to be told about their prognosis or have strong opinions about whether to continue their treatment but may find it difficult to convey these thoughts to the pediatric team. Consultants can be a useful conduit for this information and can help promote consideration of and attunement to each patient’s perspective. Similarly, consultants are also uniquely positioned to advocate on behalf of the family in their relationship with the pediatric team.
An increasingly important critical advocacy area for consultants involves supporting the patient’s health care transition from adolescence to adulthood. The transition from pediatric, parent-supervised health care to more independent, patient-centered adult care represents risk and vulnerability to many patients (White et al. 2018). Those with complex pediatric conditions pose special challenges that might require refinements in the transition process, including flexibility in age of transfer to adult medical care, delayed scheduling of specialist transfers, condition-specific protocols, and/or pediatric consultation arrangements (White et al. 2018). Consultants can be helpful in developing an effective transition program through their attunement to and understanding of the developmental psychosocial needs of individual patients combined with their knowledge of both pediatric and adult health care settings.
Liaison Activities With Pediatric Team
Consultants can help support pediatric practitioners and/or teams during the difficult clinical situations that frequently arise with physically ill youth. This support might involve helping the individual pediatric practitioner or team stay engaged with patients who are acting out or rejecting treatment. Liaison activities may involve work with terminally ill children where feelings of guilt and hopelessness may result in avoidance on the part of practitioners. Referrals for consultation may carry an implied request that the consultant assist in sharing the emotional burden that may be involved in the management of a physically ill child.
Consultants are well positioned to educate the pediatric team in approaching and managing patients’ mental health issues. Consultants can help pediatric practitioners to better understand the behavior of patients and to provide guidance on how to work more effectively with them and their families. Education serves to raise practitioners’ awareness of the biopsychosocial issues faced by physically ill patients and to encourage early and appropriate referrals. At times, consultants can help individual practitioners to better manage their countertransference reactions and thereby reduce the risk of responding adversely to patients whom they find difficult to approach and manage.
Given that half of U.S. physicians may have symptoms of burnout (work-related emotional exhaustion, depersonalization, and sense of diminished accomplishment), consultants should be alert for this phenomenon, particularly given its adverse impact on patient care (Rotenstein et al. 2018; Rothenberger 2017; Shenoi et al. 2018). It is not unusual for consultants to be sought out by their pediatric and nursing colleagues for personal advice and support. Thoughtful listening and problem solving, with referrals as indicated, are often well received by individual practitioners.
Clinical Innovation and Research
Consultants may have the opportunity to collaborate with pediatric colleagues in quality improvement and/or research initiatives. For example, the significant improvements in pediatric care over the last few decades that have resulted in most children surviving into adulthood have been accompanied by ongoing efforts to better understand and optimize health-related quality of life in children and their families. By bringing their psychiatric expertise into innovative clinical performance improvement initiatives and/or research studies, consultants have the opportunity to significantly impact ongoing patient care while simultaneously enhancing the integration of their own positions into the pediatric setting and advancing their own academic interests.
Practice Patterns in Pediatric Consultation-Liaison Psychiatry
An understanding of national practice patterns in pediatric CLP can be gained from the results of a 2016 survey of 89 academic pediatric CLP programs in the United States and Canada (Shaw et al. 2016). With a 52.5% response rate, this survey revisited a previous 2006 survey to describe the service composition, clinical consultation services, service demand, and service funding and challenges encountered by these CLP programs (Shaw et al. 2006, 2016).
Service Composition
Of pediatric CLP programs responding to the survey, 96% had an attending psychiatrist (Shaw et al. 2016). The average number of psychiatrists was 2.19 ± 1.79 in small hospitals (< 100 beds) and 2.23 ± 1.72 in large hospitals (> 100 beds). In terms of full-time faculty equivalents (FTE), 78.2% of small hospitals indicated that the total number for psychiatrists was 0.5–1.0 FTE, with the remainder having > 1.0 FTE. Of the large hospital programs, 64.3% indicated that the total for psychiatrists was 0.5–1.0 FTE, with the remainder having > 1.0 FTE. There was no significant difference in the number of psychiatrists stratified by hospital size.
Nearly half (46.2%) of surveyed programs had a staff clinical psychologist, with a mean of 2.23 psychologists in small hospitals and 2.48 in large hospitals. Only 25.9% of the programs reported employing social workers, with means of 2.60 and 2.36 social workers (when present) in small and large hospitals, respectively. Advanced practice nurses were employed by 7.8% of the surveyed programs. Most programs utilized trainees—child and adolescent psychiatry fellows (82.7%), general psychiatry residents (25.3%), psychology interns (38.7%), and postdoctoral psychology fellows (15.1%)—with means ranging from 1.13 to 1.52 for each type of trainee when present.
Although most programs reported increased staffing in the past 5 years, it is evident that pediatric CLP services are on average covered by part-time clinicians who also work in other clinical settings.
Clinical Consultation Services
The most frequent reasons for referral to the surveyed pediatric CLP programs were suicide assessment (78.5%), differential diagnosis of medically unexplained symptoms (72.3%), adjustment to illness with depressed mood (58.5%) or anxiety (55.4%), psychotropic medication evaluation (49.2%), delirium (29.2%), and treatment nonadherence (24.6%). The management of psychiatric patients admitted to medical beds because of lack of intensive psychiatric services (“psychiatric boarding”) was reported by 23.1% of the programs. Among small hospitals, most programs (70.4%) reported 1–5 new consults per week on average, whereas large hospitals experienced a wider distribution—32.5% reported 1–5 consults per week, 30.0% reported 6–10 per week, 17.5% reported 11–14 per week, and 20.0% reported having greater than 15 consults per week.
The most frequent services offered were assessment (100.0%), parent psychoeducation (100.0%), psychiatric medications (98.4%), patient psychoeducation (96.9%), liaison activities (89.1%), supportive psychotherapy (87.5%), coordination with outside provider (85.9%), facilitating outpatient and inpatient psychiatric referrals (78.1% and 71.9%, respectively), behavioral modification interventions (67.2%), and cognitive-behavioral therapy (64.1%). There was a high average frequency of collateral contacts with other providers, including outpatient providers and primary care physicians; daily (38.8%) or more than daily (41.8%) collateral contacts were common. All programs reportedly respond to consults within 24 hours, with the majority (59.7%) responding on the same day.
Only 39.1% of surveyed programs rely on screening tools as part of routine assessment. The most frequently used screening tools included the Screen for Child Anxiety Related Disorders (52.0%), Vanderbilt Assessment Scales (32.0%), Children’s Depression Inventory (28.0%), Cornell Assessment of Pediatric Delirium (16.0%), and Pediatric Health Questionnaire (16.0%). Only 8.1% of programs reportedly use outcome measures, the most frequent being the Children’s Global Assessment Scale. Nearly half of the programs surveyed (45.3%) were actively involved in independent or collaborative research, with the most common areas of investigation being chronic physical illness, health service delivery, somatic symptom disorders, and/or delirium.
Service Demand
The majority (89.2%) of surveyed pediatric CLP programs reported an increase in the number of new consults compared with 5 years earlier, with the most cited reasons for the increase being increased demand for mental health services (87.9%), increased psychiatric boarding on pediatric units (43.1%), and expansion of hospital/institutional clinical services to all patients (27.6%). Of programs reporting the increased demand, 54.5% noted that the demand resulted in less direct patient time; decreased time for liaison, teaching, and research activities; and increased consultant burnout.
The significant increase in psychiatric boarding comes in the context of children and adolescents seeking acute psychiatric care in larger numbers along with a dramatic reduction in the number of available psychiatric beds (Gallagher et al. 2017). The assessment and management of these boarding patients, who are generally either suicidal or behaviorally out of control, are not reviewed in this manual given this volume’s predominant focus on physically ill youth as well as the readily available alternative sources of information regarding the assessment of suicidal and at-risk youth (Walter and DeMaso 2018). Nevertheless, the time demands and emotional impact on consultants who must manage the care of these acutely ill patients represent a growing dimension to and time demand on their work in the pediatric setting.
Service Funding and Challenges
Although hospital support for CLP programs increased significantly from 8% in 2006 to 60.0% in 2016 (Shaw et al. 2006, 2016), departments of psychiatry and pediatrics continued to provide the majority of the financial support. Changes in reimbursement rates were fairly evenly split between those programs reporting either an increase or a decrease.
The CLP program funding issues reported in 2016—including poor rates of reimbursement (41.7%), inadequate or decreased funding (31.1% and 24.6%, respectively), and reliance on professional fees (14.8%)—remain a common challenge, as they were in the 2006 survey (Shaw et al. 2006, 2016). Access to outpatient psychiatry services (50%), lack of space (24.6%), inadequate service staffing (36.1%), and lack of administrative support (24.6%) are additional program challenges. Many (28.3%) of the programs reported a negative effect related to the management of medical boarders.
Conclusion
The field of pediatric CLP is in an increasingly stronger position in that the demand for psychiatric consultation for children and adolescents facing physical illnesses has increased over the past decade (Shaw et al. 2016). Pediatric care providers, whether they be primary care or specialty care physicians or large health care enterprises, have become increasingly aware of the importance of responsive pediatric CLP consultants to help with the diagnosis, management, and disposition of patients with complex pediatric conditions, along with the need to include mental health services in programs designated as a center of pediatric health care excellence.
The time-honored maxim for psychiatric consultants to follow has long been to “be available, be understandable, be practical,” while taking care to avoid psychiatric jargon (DeMaso and Meyer 1996; DeMaso et al. 2009). The subsequent chapters in this manual honor this maxim by supporting psychiatric consultants as they work to build bridges into pediatric care in order to reach children and adolescents facing troubling physical and psychiatric issues.
References
Ali S, Ernst C, Pacheco M, et al: Consultation-liaison psychiatry: how far have we come? Curr Psychiatry Rep 8(3):215–222, 2006 19817072
American Academy of Consultation-Liaison Psychiatry: What is consultation-liaison psychiatry? 2019. Available at: https://www.clpsychiatry.org/about-aclp/whatis-clp/. Accessed March 13, 2019.
Boland RJ, Rundell J, Epstein S, et al: Consultation-liaison psychiatry vs psychosomatic medicine: what’s in a name change? Psychosomatics 59(3):207–210, 2018 29254807
Brown TM, Stoudemire A, Fogel BS, et al: Psychopharmacology in the medical patient, in Psychiatric Care of the Medical Patient, 2nd Edition. Edited by Stoudemire A, Fogel BS, Greenberg DB. New York, Oxford University Press, 2000, pp 373–394
Collins C, Hewson D, Munger R, et al: Evolving models of behavioral health integration. The Milbank Quarterly, May 25, 2010. Available at: https://www.milbank.org/publications/evolving-models-of-behavioral-health-integration-in-primary-care/. Accessed March 13, 2019.
Copeland WE, Wolke D, Shanahan L, et al: Adult functional outcomes of common childhood psychiatric problems: a prospective, longitudinal study. JAMA Psychiatry 72(9):892–899, 2015 26176785
DeMaso DR, Meyer EC: A psychiatric consultant’s survival guide to the pediatric intensive care unit. J Am Acad Child Adolesc Psychiatry 35(10):1411–1413, 1996 8885596
DeMaso DR, Martini DR, Cahen LA, et al; Work Group on Quality Issues: Practice parameter for the psychiatric assessment and management of physically ill children and adolescents. J Am Acad Child Adolesc Psychiatry 48(2):213–233, 2009 20040826
de Voursney D, Huang LN: Meeting the mental health needs of children and youth through integrated care: a systems and policy perspective. Psychol Serv 13(1):77–91, 2016 26845491
Fritz GK: The hospital: an approach to consultation, in Child and Adolescent Mental Health Consultation in Hospitals, Schools, and Courts. Edited by Fritz GK, Mattison RE, Nurcombe B, et al. Washington, DC, American Psychiatric Press, 1993, pp 7–24
Gallagher KAS, Bujoreanu IS, Cheung P, et al: Psychiatric boarding in the pediatric inpatient medical setting: a retrospective analysis. Hosp Pediatr 7(8):444–450, 2017 28716803
Garrity M: Evolving models of behavioral health integration: evidence update 2010–2015. The Milbank Quarterly, May 12, 2016. Available at: https://www.milbank.org/publications/evolving-models-of-behavioral-health-integration-evidence-update-2010–2015/. Accessed March 13, 2019.
Heath B, Wise R, Reynolds K: A review and proposed standard framework for levels of integrated healthcare for SAMHSA-HRSA center for integrated health solutions. March 2013. Available at: https://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf. Accessed March 13, 2019.
Merikangas KR, He JP, Brody D, et al: Prevalence and treatment of mental disorders among U.S. children in the 2001–2004 NHANES. Pediatrics 125(1):75–81, 2010 20008426
O’Dowd MA, Gomez MF: Psychotherapy in consultation-liaison psychiatry. Am J Psychother 55(1):122–132, 2001 11291188
Perrin JM, Asarnow JR, Stancin T, et al: Mental health conditions and healthcare payments for children with chronic medical conditions. Acad Pediatr 19(1):44–50, 2019 30315948
Ramchandani D, Lamdan RM, O’Dowd MA, et al: What, why, and how of consultation-liaison psychiatry: an analysis of the consultation process in the 1990s at five urban teaching hospitals. Psychosomatics 38(4):349–355, 1997 9217405
Rotenstein LS, Torre M, Ramos MA, et al: Prevalence of burnout among physicians: a systematic review. JAMA 320(11):1131–1150, 2018 30326495
Rothenberger DA: Physician burnout and well-being: a systematic review and framework for action. Dis Colon Rectum 60(6):567–576, 2017 28481850
Shaw RJ, Wamboldt M, Bursch B, et al: Practice patterns in pediatric consultation-liaison psychiatry: a national survey. Psychosomatics 47(1):43–49, 2006 16384806
Shaw RJ, Bassols AMS, Berelowitz M, et al: Pediatric psychosomatic medicine, in Textbook of Pediatric Psychosomatic Medicine. Edited by Shaw RJ, DeMaso, MD. Washington, DC, American Psychiatric Publishing, 2010, pp 3–20
Shaw RJ, Pao M, Holland JE, et al: Practice patterns revisited in pediatric psychosomatic medicine. Psychosomatics 57(6):576–585, 2016 27393387
Shenoi AN, Kalyanaraman M, Pillai A, et al: Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med 46(1):116–122, 2018 29016364
Walter HJ, DeMaso DR: Psychiatric emergencies: agitation, suicidality, and other psychiatric emergencies, in Mental Health Care in of Children and Adolescents. Edited by Foy JM. Itasca, IL, American Academy of Pediatrics, 2018, pp 399–432
Walter HJ, Kackloudis G, Trudell EK, et al: Enhancing pediatricians’ behavioral health competencies through child psychiatry consultation and education. Clin Pediatr (Phila) 57(8):958–969, 2018 29082768
White PH, Cooley WC; Transitions Clinical Report Authoring Group, et al: Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics 142(5):e20182587, 2018 30348754
Information & Authors
Information
Published In
Clinical Manual of Pediatric Consultation-Liaison Psychiatry
Pages: 3 - 21
History
Published in print: 16 September 2019
Published online: 5 December 2024
© American Psychiatric Association Publishing
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).