Pediatricians Gain 'Safety Net' Through Psychiatric Consults

Pediatrician Kenneth Gass, M.D., sits in a conference room at the offices of PeaceHealth in Bellingham, Wash., and starts talking about one of his young patients.

The boy has been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. He was abused by someone outside his family. His mother is a former meth addict with a new baby and a new boyfriend. He's taking a mood stabilizer and an antidepressant, as well as stimulants and guanfacine for the ADHD. Lately, though, the boy has reacted with anger to family members, especially late in the day, around dinnertime. Gass wonders if he can counter this new development by adjusting the boy's medication. Should he increase the stimulant dose?

“What are you using now?” asks psychiatrist Judith Koontz, M.D.

“Adderall, three times a day,” says Gass.

“Have you used the long-acting version?” “No.”

“How is he getting along with the baby?” “OK.”

“His pulse is 100,” says Gass. “He's already getting more than 1 mg/kg of guanfacine a day, in the morning and at 6 p.m., which is a lot.”

“I'd be leery of upping the dose,” agrees Koontz.“ Try moving the afternoon guanfacine dose up to when he gets home from school. And look at his family life. Is there a lot of stress when the mom's boyfriend comes home from work or when the biological dad comes to visit?”

Mental health takes up a lot of pediatricians' time these days. The excerpt above is drawn from one 45-minute conversation between Koontz, Gass, and two other pediatricians.

“I'm dealing with it every day, but in residency I had absolutely no training in it,” said Gass in an interview. He did manage to shadow a child psychiatrist for a few months back then, in the early 1970s, which served him in good stead. But the increasing diagnoses of childhood ADHD beginning in the 1980s and the expanded use of SSRIs in the 1990s were signals of an increased overlap between pediatrics and psychiatry—and the need for pediatricians and other primary care physicians to know more about mental health and its treatment (see Thinking Outside the Box to Stretch Resources).

Gass routinely uses several screening tools for ADHD, depression, and other disorders to begin the diagnostic process. In some cases, he prescribes medications and sends the child to a counselor, since he does no counseling himself. He may call Koontz or another child psychiatrist at least once a week for a formal consultation. However, if a case is more severe, or if the family history suggests a larger problem, he refers patients to a community mental health center with a psychiatrist on staff.

Koontz works with children and families for Catholic Community Services in Bellingham and backs up the agency's therapists with diagnostic help and case consultation. She also meets twice a month with Gass and three or four other pediatricians in his practice to talk over cases.

Catholic Community Services pays half her salary for the consultations with the pediatricians, and Whatcom County pays the other half.

Some of the children Koontz discusses with the PeaceHealth pediatricians are newly diagnosed, while others have been seen and stabilized by a child psychiatrist and are being followed by their pediatrician. Koontz helps solve their problems but also provides reassurance in gray areas.

“Talking with Judie Koontz gives me an incredible amount of comfort and more confidence about using medications,” said Gass.

“Pediatricians will feel comfortable prescribing and following patients if they can consult with a psychiatrist who serves as a safety net for them,” said Koontz. “They can follow more children on medications than if I do it alone.”

Koontz doesn't deliver formal lectures to the doctors but does discuss concepts with broad applicability that arise spontaneously out of discussions about specific children, she said. Medication is not the only topic discussed. The doctors often talk over family or psychosocial issues that affect a patient. Often the pediatricians may discuss a patient with the social worker or psychologist to whom they have initially referred the patient before meeting with Koontz.

The ongoing relationship with Koontz helps the pediatricians when a patient is severely ill or at acute risk for suicide or abuse. She or a colleague can help find appointments with other area psychiatrists or inpatient beds in acute cases.

Simple as it sounds, holding the bimonthly meetings is one more way to extend the reach of psychiatry into primary care.

“Pediatricians are pretty good about identifying a need,” said Koontz. “Overall, the collaboration is helpful and beneficial to the community to help families in difficult straits.” ▪