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Psychosomatic Medicine

Textbook of Pediatric Psychosomatic Medicine by Richard J. Shaw, David R. DeMaso (American Psychiatric Publishing) Psychosomatic pediatric psychiatry is one of the most complex specialties of medicine. This textbook manages to provide practitioners with all the necessary tools to successfully operate in this domain and provide children, parents, and pediatricians with much needed support and assistance in managing the overlap between psychiatric and pediatric illness. Psychosomatic medicine was recently recognized as a subspecialty by the American Board of Psychiatry and Neurology, prompting creation of the first comprehensive edited volume on pediatric psychosomatic medicine by leading U.S. and international practitioners. Textbook of Pediatric Psychosomatic Medicine is a scholarly, authoritative, evidence-based review of the field designed to meet the needs of a wide range of professionals, including psychiatrists, pediatricians, psychologists, nurses, medical students, and social workers who work with children in medical settings. Notable are substantive chapters on often-neglected but critical topics, such as pediatric palliative care, Munchausen syndrome by proxy, and pediatric feeding disorders. There is also a detailed review of the topic of psychopharmacology in the physically ill child, as well as coverage of key legal and forensic issues in pediatric psychosomatic medicine. With a plethora of tables referencing psychopharmacological agents; assessment templates; and flowcharts illustrating step-by-step, pragmatic approaches to pain and somatoform disorders, the textbook offers clinicians a comprehensive, empirically based review of assessment and treatment issues in children and adolescents with physical illness.

Excerpt: Pediatric psychosomatic medicine is the term used to describe the subspecialty of child and adolescent psychiatry that is dedicated to providing mental health services to youngsters with physical illness. Lipowski (1967) defined the specialty as including those diagnostic, therapeutic, teaching, and research activities provided by psychiatrists in the nonpsychiatric part of the general hospital. Herzog and Stein (2001) outlined the goals of a pediatric consultation-liaison psychiatry service as follows: 1) to facilitate the early recognition and treatment of psychiatric disorders in physically ill children and adolescents; 2) to help differentiate psychological illnesses presenting with physical symptoms; 3) to help avoid unnecessary diagnostic tests and procedures; 4) to support pediatric patients and their families in coping with their disease and its treatment; and 5) to assist the medical team in understanding the reactions and behaviors of physically ill children, adolescents, and their families.

Patients seen in this subspecialty commonly fit into one of three categories: 1) patients with comorbid psychiatric and physical illnesses that complicate each other's management, 2) patients with somatoform and functional disorders, or 3) patients with psychiatric symptoms that are a direct consequence of a primary physical illness or its treatment. The term coincidental comorbidity may be used to describe patients with unrelated psychiatric and physical illnesses, whereas causal comorbidity refers to instances in which the psychiatric disorder is a direct result of physical illness or has a significant impact on the course or severity of the illness. Causal co-morbidity also captures psychological symptoms that develop as a direct result of the stress of the illness or its treatment (Shaw and DeMaso 2006).

This chapter provides a brief historical overview of the field of pediatric psychosomatic medicine and the development of the specialty within the United States. This section is followed by a description of how services are organized based on a small number of national surveys, including data on issues related to funding and reimbursement. The chapter concludes with a section describing the psychosomatic services from an international perspective.

The history of child and adolescent psychiatry as a medical specialty in the United States dates back to the beginning of the twentieth century (Rothenberg 1979). Several historical events have marked the progress of the specialty, including the establishment of the first child guidance clinic in Chicago in 1909 and, in 1930, the first full-time psychiatric clinic in the department of pediatrics at the Johns Hopkins School of Medicine. An influential 1932 report on the relationship between pediatrics and psychiatry advocated for greater integration of mental health disciplines into the pediatric hospital and the development of liaison programs to help increase awareness of the psychological issues affecting physically ill children (Fritz 1993; Work 1989). In 1935, Leo Kanner published the first edition of his textbook, Child Psychiatry, and the Rockefeller Foundation funded the development of several psychosomatic medicine units in U.S. teaching hospitals. In 1953, The American Academy of Child and Adolescent Psychiatry (AACAP) was founded, followed shortly afterward by board certification in child psychiatry. Further growth of the specialty occurred following the decision of the National Institute of Mental Health to fund training grants and research during the 1970s and 1980s.

Psychosomatic medicine has more recently been recognized as a separate psychiatric subspecialty by the American Board of Medical Specialties. In the past, it has been designated by several other names, including consultation-liaison psychiatry, medical-surgical psychiatry, psychological medicine, behavioral psychology, and pediatric psychology. The field overlaps with the pediatric specialty of developmental and behavioral pediatrics. In 2001, the Academy of Psychosomatic Medicine applied to the American Board of Psychiatry and Neurology (ABPN) for recognition of the name psychosomatic medicine as a subspecialty, using the name that was introduced by Felix Deutsch in 1922 and that has been associated with the ABPN's history, national organizations, and journal publications.

Training in pediatric psychosomatic medicine, which generally occurs in a pediatric consultation-liaison service, is a mandatory component of training in ABPN-accredited residency programs in child and adolescent psychiatry. Recently, investigators have developed specific diagnostic criteria for psychosomatic research to help researchers and clinicians with operational criteria for psychosomatic syndromes most commonly identified in the medical setting.

In 1967, Logan Wright introduced the term pediatric psychology. The field of pediatric psychology experienced rapid growth associated with the formation in 1968 of the Society of Pediatric Psychology, an independent section of the Division of Clinical Psychology of the American Psychological Association. In addition, a number of national and international organizations are dedicated to the specialty, including the Academy of Psychosomatic Medicine, American Psychosomatic Society, European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP), International Organization for Consultation-Liaison Psychiatry, and Society of Pediatric Psychology. The EACLPP has taken a number of initiatives to help establish consensus on the contents and organization of training in psychosomatic medicine within the European Union. The AACAP also sponsors two committees, the Committee on the Physically In Child and the Committee on Collaboration with Medical Professionals, that focus on clinical and research issues specifically related to pediatric psychosomatic medicine. A number of journals specialize in topics related to the field, including Psychosomatic Medicine, Psychosomatics, Journal of Psychosomatic Research, and Journal of Pediatric Psychology, and various specialized journals focus on specific disorders, such as oncology and transplant psychiatry.

Psychiatric consultation for physically ill children and adolescents is provided by a number of professional disciplines, often with different service models. Traditional pediatric psychosomatic medicine services, more commonly referred to as pediatric consultation-liaison services, are generally located in large academic medical centers or pediatric hospitals (Campo et al. 2000). Such services are usually housed administratively within a department of psychiatry under the directorship of a child and adolescent psychiatrist. Services are often multidisciplinary in nature, with representation from child and adolescent psychiatry as well as pediatric psychology. These services commonly have a strong teaching role with trainees from both disciplines.

Recent data on the composition and staffing of such services are limited, although Shaw et al. (2006) reported that results from a national survey indicated that pediatric programs have a relatively low staff-to-patient ratio compared with comparable adult services. The ratio of pediatric attending consultation-liaison staff to number of hospital beds is also significantly lower than that recommended by Fink and Oken (1976) for adult services. Campo et al. (2000) reported that psychiatry consultation services are in deficit in the vast majority of children's hospitals, and 43% of the U.S. pediatric psychosomatic programs reported inadequate staff to meet clinical need.

Consultation to pediatricians is also commonly provided by pediatric psychologists, who may be hired by a hospital or a pediatric department (Campo et al. 2000). Pediatric psychologists may consult to a single program, providing both inpatient and outpatient services, and may or may not be affiliated administratively with an academic department of psychology or psychiatry. National data on the location and composition of these services is limited, although the volume of service provided in these arrangements is likely greater than that provided by the traditional hospital-based pediatric psychosomatic medicine services. Social work clinicians are also an important group who provide mental health services, including triage and assessment of physically ill children. Lack of integration of such services may result in duplication of effort and confusion related to the referral of patients for mental health consultation. Models of outpatient psychosomatic medicine services vary widely, depending on the roles of and the nature of relationships between pediatric and mental health care providers.

Funding has been cited as a major problem for pediatric psychosomatic medicine services, and a longstanding disagreement exists over who should be financially responsible for psychiatric consultation services in the pediatric setting. A survey by Anders (1977) found that cross-departmental financial support between pediatrics and psychiatry for consultation services was rare. More recent surveys suggest that these issues persist and that the majority (40%) of pediatric consultation-liaison funding comes from departments of psychiatry.

Although funding from patient fees appears to have increased in recent years, reimbursement rates for psychiatric consultation services average only 30%, limiting the extent to which hospital-based pediatric psychosomatic medicine services can be financially self-sufficient. Campo et al. (2000), in a survey of 45 U.S. general children's hospitals, reported that one-half of psychiatry programs operated at a deficit and required subsidy. Many program directors have commented on the difficulty of negotiating with managed care companies to obtain reimbursement for psychiatric services. Pressure to generate billing income by seeing more patients potentially reduces time available for nonbillable liaison activities.

Confusion often occurs as to whether psychiatric services for hospitalized medical patients should be paid by the medical part of the patient's health care plan or by the psychiatric benefits, which are often carved out to paneled providers who may not be credentialed by the hospital. Frequently, neither side is willing to pick up the payment, and the consultant is left with the dilemma of whether to provide services that will not be reimbursed (Goldberg and Stoudemire 1995). These complicated payment arrangements interfere with continuity of care for patients after discharge from the hospital. In addition, it should be noted that psychologists providing inpatient mental health consultations are often limited in their ability to bill for their services, because they cannot use traditional evaluation and management codes.

Most surveys of pediatric psychosomatic medicine services suggest an increasing demand for consultation in recent years (Shaw et al. 2006). Wiss et al. (2004), in a French study, reported an increase in activity of 33% between 1994 and 2000. Services most commonly requested from and provided by departments of psychiatry in children's hospitals are inpatient and outpatient consultation-liaison psychiatry services (Campo et al. 2000). Despite this increasing demand, other studies suggest that referral rates for psychiatric consultation for pediatric patients average only 2% of the hospital population, indicating that psychiatric illness in many physically ill children and adolescents goes unrecognized.

Rates of referral may be even lower in countries with less established psychiatric consultation services. For example, in a study of 18,808 pediatric inpatients in Mexico, Burián et al. (1978) reported a referral rate of only 0.31%. However, McFadyen et al. (1991) found that both awareness of psychological issues and referrals for psychiatric consultation can be increased as a result of administrative decisions to expand and improve psychiatric services in a general hospital. In the group of patients that are referred for consultation, school-age children and adolescents tend to be overrepresented, whereas preschool children are commonly underrepresented. Physicians, most commonly pediatricians, generate the bulk of referrals, with a smaller number coming from nurses, social workers, child life specialists, and family members.

Most pediatric psychosomatic medicine services report a high frequency of referrals for the assessment of suicide attempts and adjustment to illness. According to Burket and Hodgin (1993), the major reasons for psychiatric consultation are behavior problems, suicide evaluation, depression, and reaction to illness. The high frequency of requests for consultations regarding parents' adjustment to a child's illness suggests that recognition of the effect of the child's illness on parental adaptation is increasing. Another important role of pediatric psychosomatic medicine services is that of staff education and support. This lists the most common reasons for pediatric psychiatric consultation:

  • Adjustment to illness
  • Delirium
  • Differential diagnosis of somatoform disorder Disposition and referral
  • Disruptive behavior
  • Medication consult
  • Nonadherence with treatment
  • Pain management
  • Parental adjustment to illness
  • Procedural anxiety
  • Protocol assessment
  • Suicide assessment

In the current volume, the editors goal has been to help articulate the current evidence base for pediatric psychosomatic medicine. Although the relatively recent establishment of the certification process of psychosomatic medicine by the American Board of Psychiatry and Neurology has drawn increased attention to psychosomatic medicine, we felt that it was important that pediatric issues receive their own unique and separate attention. This opinion has been further strengthened by their experience in developing the textbook's first chapter, which reviews the international practice of pediatric psychosomatic medicine. The widely varied allocation of resources to address the psychological issues of physically ill children across countries and continents emphasized for the editors the fact that support for the specialty cannot be taken for granted. The editors believe it is imperative not only to continue but also to intensify efforts to establish the clinical and economic benefits of mental health intervention in the medical setting.

In developing an outline for this textbook, the editors decided to focus primarily on evidence-based work in the field. This objective is in contrast to the more practical applications that were emphasized in the Clinical Manual. In addition, due to constraints on length, we selected the most common clinical areas to cover in depth rather than conducting a more superficial review of the entire field. For this reason, certain topics—including spinal cord injury and several disorders in the specialties of hematology, rheumatology, and dermatology—are notably absent. The editors made a conscious decision to omit topics that are classically associated with child and adolescent psychiatry, such as enuresis, encopresis, and attention-deficit/hyperactivity disorder. Although patients with these disorders frequently present in the medical setting, the editors believe that numerous outstanding texts are available on the management of these disorders. For similar reasons, mental retardation, autism, and developmental disorders are not specifically addressed.

This textbook is organized into four main parts. As in the Clinical Manual, the first four chapters provide a general introduction to the specialty of pedi atric psychosomatic medicine, a discussion of the areas of adaptation and coping, an exploration of assessment, and an examination of legal and forensic concerns. In Part 2, "Referral Questions," the authors of Chapters 5-13 cover the common psychiatric consultation requests in the inpatient and outpatient setting. Part 3, "Specialties and Subspecialties," includes Chapters 14-27 and addresses the most common pediatric subspecialties. In the final section, "Treatment," the authors of Chapters 28-31 discuss evidence-based treatments of the physically ill child.


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