Pediatric Consultation

Working With Clinical Staff

Child psychiatric consultation usually involves contact with more individuals than the patient and the referring physician. Parents are inherently a part of treatment as they give critical information and need to be actively involved in implementation of recommendations. During a hospitalization, nurses may assume some parental roles while the pediatric unit is the child's temporary home. Child and family behaviors have an impact on other patients and staff, and are likely to evoke intense feelings. Because many pediatric units encourage parental visitation and rooming-in, the potential impact of a distraught or disturbed parent on the entire floor is substantial. Lastly, patients with chronic illness may return repeatedly to the same floor over a 5- to 10-year period. Thus, many children become well known, and the depth of the staff's involvement grows over the years. Child psychiatric consultation includes an essential liaison role that is relevant to patient and family care, to inter-staff tensions, and to individual staff stress.

The model of primary nursing encourages continuity of care as one or two nurses are assigned to the child during the hospitalization, and often for repeated admissions as well. This practice is beneficial for the child's sense of trust, makes the nurse's role more personally satisfying, and can add a needed perspective if too many sub-specialists forget the child's needs. Unavoidably, primary nurses often become intensely involved in the child's personal and family life; thus, they have critical information and share the stress of the child's illness. The child psychiatrist can provide suggestions and supervision for dealing with difficult families or crises, review when psychiatric referral is indicated, and help in understanding the painful issues of chronic disease, suicide, and terminal illness.

For house staff, a common stressor is being relatively inexperienced and yet forced to deal with complex medical and psychological circumstances. This source of stress is clearest in the intensive care unit, where frustration mounts rapidly as children do not respond to treatment and can suffer life-long physical and neurologic damage. The consequences of multiple stressors (frustration with the patient's course, lack of sleep, and feeling incompetent) may lead to depression, substance abuse, or bitter tensions among house staff or nurses.

Part of the child psychiatrist's liaison function is to attend rounds, be aware of difficult clinical and family situations, get to know nurses and house staff through teaching and informal discussion concerning patients, and be aware of the early signs of behavior that are destructive to patient care and staff. With sufficient credibility, the child psychiatric consultant can organize family or multidisciplinary staff meetings that have a beneficial impact on the unit's functioning, and can relieve family or staff suffering.

Infancy

For the hospitalized infant, the key developmental challenge is to maintain the quality of the attachment between parent and child. The parental component of attachment begins while anticipating the infant's birth or adoption. An infant is a parent's most personal product, embodying the hopes that the child will ultimately possess the strengths and values the parent most values in himself or herself, and the wish that the child will have capacities that offset the parent's self-perceived deficiencies. No infant can meet all of the parents' conscious and unconscious expectations, yet most infants are accepted and loved when they enter the world. Parents adapt to the reality of the infant and embark on the life-long process of attachment that enables child and parent to weather the stresses and strains of caretaking and growing up while remaining committed and connected.

Parents with affective illness (including post-partum depression), anxiety disorders, psychotic disorders, character pathology, or intense guilt may have difficulty achieving the attunement that is necessary for attachment. The psychiatric consultant may be called on to differentiate between depression, character pathology, or anxious adjustment in the setting of inadequate parental attachment. Infants with medical conditions that interfere with feeding, limit access to holding and soothing, affect appearance, or cause irritability, present special challenges to the process of attachment. Ill infants require parents to be more mature because the unexpected circumstances may leave a parent feeling incompetent or unloved by the newborn. The medical staff can play a crucial role in successfully supporting new parents through this difficult early phase.

Infants and toddlers are largely non-verbal, and rely on a small, consistent number of caretakers who know them well enough to be attuned to their non-verbal communications. Therefore, the infant's experience of the stress of hospitalization is exacerbated by separations from the mother or primary caretaker. Bowlby's classic work on attachment described the three phases of separation anxiety seen in infants:

• 1.

  Protest : The infant acutely, vigorously, loudly, and thrashingly attempts to prevent departure of the mother or rapidly attempts to recapture her. In the older child, this phase may appear as clinging, nagging, or bargaining as a parent is about to leave.

• 2.

  Despair : The infant is less active, may cry in a monotone with less vigor, begins to withdraw, and appears hopeless. Sometimes the withdrawal phase is mistakenly seen as a good adjustment because the infant is quieter.

• 3.

  Detachment : The infant seems more alert and accepting of nursing care. These new attachments are superficial, however, and the infant concomitantly shows a loss of affect or positive feeling when the mother appears. With chronic disease that requires numerous prolonged hospitalizations, the infant or young child may make many brief, inconsistent attachments and suffer numerous losses if the primary caretaker is regularly absent and many different surrogate caretakers interact with the infant. Spitz referred to the overwhelmed infant's state as hospitalism .

Antecedents of Bowlby's more pronounced phases of separation occurring over minutes when a mother is unresponsive to her infant's attempts at relating have been found. In response to these findings of short-term and long-term consequences of maternal separations, hospitals encourage mothers to stay overnight with children and to participate in their child's care. In addition, nursing departments have instituted a primary nursing model to limit the number of nurses who care for each child.

Pre-School Age

Medical conditions in the pre-school phase (ages 3 to 6 years) are affected by three important aspects of the child's emotional and cognitive development: egocentricity, magical thinking, and body image anxiety. Egocentricity is the child's perception that all life events revolve around him or her. The child cannot imagine that others see the world from a vantage point different from his or her own. Magical thinking is the creative weaving of reality and fantasy to explain how things occur in the world. The combination of egocentricity and magical thinking may lead the pre-school-aged child to imagine that medical conditions are punishment for the child's own bad thoughts or deeds. For example, a 4-year-old with leukemia reported he got his “bad cells” from eating too many cookies. The young child needs ongoing support from family and medical staff to understand that the medical condition is not punishment or secondary to some unrelated experience. Without this support, the child's anxiety is likely to be much greater and be expressed as inhibition and withdrawal, or as behavioral outbursts. One understanding of the cause of body image anxiety comes from the pre-schooler's cognitive development, which leads the child to envision the body as a shell (skin) filled with blood, food, and stool, which could ooze out of any hole in the skin. This concept of the body being like a tire or water balloon that can be punctured with dire results may explain the preoccupation with bandages at this age, as well as fear of needle sticks and surgical procedures that seem to exceed what can be explained by painful experiences alone.

Some regression is to be expected in the stressed pre-schooler. This may take the form of enuresis in a previously toilet-trained child, increased dependence on parents for help with dressing or eating, and episodes of unwillingness to use words to express wishes or use of baby talk. Each of these regressed behaviors serves to engage parents and nursing staff in a style of caretaking that may be more commonly associated with a baby or toddler.

Treatment approaches can assist the pre-schooler with adjustment to medical illnesses and interventions and can minimize regression. Pain should be controlled or eliminated whenever possible, even when it is not the fastest way to proceed. Procedures should be explained in simple terms to the child. The child needs to hear in the most basic terms what will be done, why it is needed, and what parts will be uncomfortable or painful. They will want to know where their parents will be before, during, and after the procedure. Interventions should be performed in designated locations, such as treatment rooms, and there should be safety zones, usually the child's hospital room and the playroom, in which no procedures are done. It is crucial for children of all ages to have safe places within the hospital setting, so that they are not on “high alert” at all times. Similarly, warning children about impending procedures may lead to protest acutely, but over time allows children to relax and not be constantly anticipating an unpleasant “surprise attack.”

School Age

School age (6 to 12 years), also referred to as latency, is characterized by a host of new and developing skills in many arenas—academic, athletic, and artistic. The world outside the family becomes more important with the advent of best friends and status in friendship or interest groups. In the context of medical illness, the age-appropriate investment in mastery of skills may lead to improved coping with a better understanding of medical illnesses (although still rudimentary), pride in learning to anticipate regular treatments, medications, and procedures, better capacity to verbalize needs, and establishment of relationships with nursing staff and physicians. Children with pre-morbid competencies may weather the stress of illness somewhat better than their less capable peers. The stress of medical conditions, however, routinely leads to regression in all age-groups, so the improved coping skills of latency may not be observed in the hospital setting. Regression is common early in a chronic illness, with the potential for developing better coping after there has been time for adjustment. The level of function fluctuates according to the individual stressors (e.g., mood, malaise, pain, procedures, and prognostic changes) and family function. Offering age-appropriate activities (such as board games, video games, computers, puzzles, arts and crafts), and school tutors, helps children to function closer to their pre-morbid level and serves as a counterweight to the regressive pull of dependency, helplessness, and loss of control that often accompanies hospitalization. Later in a chronic illness, flexible denial can be a healthy component of coping. Flexible denial denotes the child's ability to suppress thoughts about the illness and invest in an array of activities, without abandoning the appropriate measures necessary for treatment of the illness.

It is common for latency-age and older children to have distorted or magical notions of the cause of the illness, which are typical of the thinking of younger children. It is helpful to invite all questions—by saying things like “I like to hear what children wonder about” or “There is no such thing as a silly question”—and invite fantasies about the medical condition by direct questions such as “What do you think might have caused your cancer?” Some children may be uncomfortable expressing themselves in a direct dialogue but may be willing to draw a picture of their cancer or to write a story about a child with an illness. Any outlet for expression can be helpful to elucidate the fears that underlie the child's anxiety.

In chronic illness, the latency-age years offer a less conflicted opportunity to foster positive health-related behaviors. The child should be able to give a simple, accurate explanation of the illness. The child should be learning the names of medications, their purpose, and when they are to be taken. At this age, a partially independent relationship between the child and the treating physician can be developed. Psychiatric intervention is warranted if the child is resistant to learning about the illness, if the child is regressed, if parents are noted to be intrusive or over-involved in the health care regimen, or if non-adherence to the medical treatment plan has become a means of fighting between child and parent. Allowing these patterns to proceed into adolescence will likely increase the risk of dysfunction and make intervention more difficult.

Adolescence

The adolescent, similar to an adult, enters the medical setting with the capacity to understand the meaning of an illness, including its possible ramifications. Developmentally, adolescents venture out with a more independent posture and leave behind the intense dependency on parents that is seen in younger children. This brings with it a particular sensitivity and vulnerability. The multiple demands of hospitalization (including deciphering the meaning of diagnoses and treatments while bearing the physical discomfort, limitations, pain, impact on appearance, and fears about the present and future) may overwhelm the adolescent's ability to exercise newly acquired independence in a developmentally appropriate way. The physical limitations imposed by illness may put adolescents at risk for major depression, especially when the illness interferes with activities that are key to the adolescent's emerging self-image.

The assault on the teenager's autonomy may be particularly difficult to bear because it coincides with the strong developmental pull to individuate from parents and to establish an independent identity. Often the illness occurs at a time when other tensions between the adolescent and parent make relying on the parents uncomfortable or unacceptable. Faced with this emotionally complex dilemma, some teens become sullen, aggressive, non-adherent, or withdrawn, whereas others are able to negotiate the discomfort of returning to a more dependent, supportive relationship with parents.

Interview styles should respect the adolescent's wish for autonomy. One should engage the adolescent first before looking to the parents for their input. Adolescents should also be offered private time to share information that may not be easily shared in the company of parents. Sexual experiences or concerns and worries about parental coping or even death may not be voiced without privacy. The risks and benefits of treatments need to be presented to the adolescent with the recognition that his or her adherence is central to the success or failure of any treatment plan.

Family-Centered Care

In recent years, the concept of “family-centered care” has emerged as a care philosophy that highly values effective collaboration among patients, families, and healthcare providers, and promotes principles and practices that improve this collaboration. It can be helpful to use this term when communicating with pediatric healthcare providers, who may be less accustomed than child psychiatrists to thinking about the family in a systemic manner, in order to share a common language about the need to include families in psychiatric assessments and treatment planning.

The child cannot be understood separately from the family. Serious or chronic illness in a child is a family crisis. The parents must cope with the uncertainty and the highs and lows associated with hospitalization. Abnormal laboratory results, adverse reactions, life-threatening crises, limitations on the child's future, and the specter of death suddenly become their reality. They observe their child in distress and they often feel fundamentally unable to protect the child. The hospital environment brings with it a host of medical professionals with as many personalities as there are consultants and caregivers; often, each seems to hold a crucial piece of the puzzle. Small nuances in the presentation of data or differing styles of optimism or pessimism among staff may radically shift the family's mood. There is rarely much privacy and sometimes none at all, whether in a shared room or in an intensive care unit.

Parental anxiety negatively affects the child's capacity to cope; to expect a parent to be other than anxious is unthinkable. Parents are the child's most trusted and valuable resource; therefore, strategies to support the parents are crucial. Most parents evoke staff empathy and appreciate the skill and compassion of the treatment team. Certain parents are particularly challenging to support because of a particular combination of personality characteristics and coping style. Their distress, often fueled by a sense of helplessness, may be expressed either as devaluing staff or as apparent insensitivity to the sick child's needs. The consultant helps the team of caregivers understand the psychological meaning of the parents' troubling behavior so that they can continue to provide optimal care.

Siblings are often the forgotten sufferers in the context of chronic or life-threatening illness. They not only have worries about the sick sibling, but often they also lose the support of their parents. The parents may be physically absent, spending time at the hospital with the ill child and attempting to meet at least minimal work demands to support the family financially. They are often emotionally absent, depressed, or drained by the emotional demands of the sick child. Many parents feel angry at the well siblings for making any demands and for not selflessly understanding the seriousness of the ill child's predicament. This compounds the well siblings' guilt at the expectable feelings of resentment and jealousy toward the ill child who is receiving so much attention and so many gifts. If the illness results in death, the feelings of guilt and responsibility may become overwhelming.

Family interviews may aid in the assessment of the physically ill child and help the consultant target areas in the family system that may benefit from support. Families of ill children need to express their feelings about hospitalization and to obtain emotional support. Siblings often have distorted concepts of the child's illness that need to be corrected. A carefully planned family meeting can begin to clarify distortions, reduce family turmoil, improve coping skills, and dispel conflict between family and staff. During the meeting, the staff or the psychiatrist should evaluate the family's psychological state, including an assessment of coping mechanisms, anxiety level, available support, and ability to comprehend information.

Depression

Depression is a common disorder in hospitalized children. It may be a secondary response to acute or chronic illness, or it may be the primary diagnosis and present with somatic symptoms or behavioral problems. One of the obstacles to making the diagnosis of depression in the hospitalized child is the misconception that the child's dysphoric mood is appropriate to the stress of the situation and therefore does not deserve to be called depression. On the contrary, stress increases the likelihood that depression will occur; it does not invalidate the diagnosis.

Depression may be used to refer to a mood, symptom, or a syndrome. As a syndrome, depression in childhood is characterized by a persistent mood disorder and/or dysfunctional behavior, and, in older children, by self-deprecatory ideation. These symptoms or behaviors should represent a significant change in the child's pre-morbid function and not be a long-standing temperamental trait. The Diagnostic and Statistical Manual of Mental Disorders , 5th edition (DSM-5), characterizes a major depressive episode as 2 weeks or more of persistent depressed or irritable mood and/or loss of interest in all or almost all activities, along with at least four additional associated symptoms.

Although the criteria are the same for children and adults, there are some clinical differences in how the symptoms manifest. For children younger than 6 years of age, the hallmarks of depression can include poor appetite or failure to grow and gain weight appropriately, disturbance of sleep, hypoactivity, and indifference to the surroundings and to primary caretakers. Pre-pubertal children with an episode of major depression can present with separation anxiety, somatic complaints, irritability, or behavior problems. These children may not give an accurate self-assessment of sustained mood, so dysphoria must be observed by caretakers over a prolonged period. Making the diagnosis of depression can be difficult in children who are sick because many of the symptoms they exhibit (e.g., decreased energy or loss of appetite) may be attributed to their medical illness. Also, children who are sick can use denial as a coping mechanism and under-report their symptoms.

Treatment of depression often involves psychotherapy, as well as child-life and recreational therapy, to support the child and family; sometimes therapy is used in conjunction with antidepressant medications. In a 2015 review and meta-analysis, Varigonda and colleagues found that selective serotonin re-uptake inhibitor (SSRI) treatment gains for pediatric depression were greatest early in treatment, and overall the SSRI effect was smaller in children and adolescents compared to adults. Historically, there has been significant attention to the question of whether antidepressant treatment increases the likelihood of suicidal ideation in children and adolescents. In October 2004, the Food and Drug Administration (FDA) issued a “black-box warning” related to this concern, although, since then, there has been significant controversy in the research literature about the need for and impact of this warning. Regardless, this concern should be addressed in discussions with patients and families as part of the discussion about the risks and benefits of pharmacotherapy. (See Chapter 39 for further discussion of the use of psychopharmacologic agents in children.)