Pediatric Consultation-Liaison Psychiatry—Yesterday, Today, and Tomorrow

Pediatric consultation-liaison psychiatry (P-CLP) is a specialized area of psychiatry whose practitioners have particular expertise in the diagnosis and management of psychiatric disorders in complex physically ill children and adolescents. In the relatively short time that P-CLP has been in existence, it has grown into a major subspecialty that provides expert consultation as well as support for pediatricians dealing with the complexity of traumatic medical conditions.

Yesterday

Over 20 years ago, P-CLP was described as a flourishing specialty offering an opportunity for the innovative application and extensive deployment of the special skills of the child and adolescent psychiatrist. Yet major issues facing the field were also apparent, including the lack of a firm patient base, precarious or insufficient funding, lack of research, and a small number of individuals active in the specialty with a resultant lack of mentorship.

Over 10 years ago, the first U.S. survey describing P-CLP practice patterns noted the market forces in the nation’s health care system were creating increasing pressure to control medical costs with the effect that the funding of many P-CLP programs seemed in jeopardy, with many national programs reporting a decrease in financial support. Interestingly, this same survey also found an increasing demand for expert psychiatric consultation in the pediatric setting with few P-CLP services citing the aforementioned “lack of a firm patient base.” This apparent escalating service demand was postulated to occur in the context of higher patient medical acuity combined with the growing recognition on the part of pediatricians regarding the impact of mental health conditions on their practices. The survey described the increasing applicability and helpfulness of P-CLP psychiatrists in the diagnosis, management, and disposition of patients with complex conditions in the era of managed health care.

Today

Fast forward to today: The most recent U.S. survey of practice patterns found that P-CLP program expansion, particularly in academic medical centers, has indeed occurred in the context of rising patient medical acuity and the appreciation that the presence of comorbid physical and psychiatric illnesses significantly add to patient and family burden as well as total medical expenditures. Pediatric hospitals are now grappling with some of the most challenging psychiatric issues of our time. These include complex clinical populations, such as patients with complex neurocognitive disturbances (pediatric autoimmune neuropsychiatric syndrome and autoimmune encephalitis); and patients coping with the impact of life-threatening physical illnesses, such as cancer, solid organ transplantation, and cystic fibrosis. There are also troubling social and service dilemmas, most evident in the tremendous increase in the number of youth boarding in emergency rooms and medical/surgical beds across the nation. Furthermore, the significant increase in the amount of research, funded by the National Institutes of Health and multiple other agencies, has helped establish the emotional and physical health benefits of psychiatric consultation in the pediatric setting, a fact long recognized by primary and specialty care pediatric practitioners.

While adequate resources remained a core issue, the survey found an increased willingness by hospital administrators to fund P-CLP services, viewing them as mission critical services. Mandates for integrated psychiatric consultants for specific high-risk physically ill patient populations have in part driven this process. According to the results of the survey, the prior focus on sustainability of services based on professional billings, something never considered a viable option given the necessary non-billable liaison work with a patient’s pediatric providers, appeared to play a less important role in hospital budgets as population management approaches have become an important strategy for managing their health care systems.

Tomorrow

Looking forward, it is easy to envision the continued strengthening of P-CLP in the context of a national health care system struggling to care for youth with increasingly complex physical and emotional disorders. P-CLP has a demonstrated ability to partner with the pediatric community in the provision of integrated mental health care. P-CLP programs that have taken (and will take) the risk of reaching out and providing embedded point-of-care services within the pediatric subspecialty clinics have seen (and will see) rich rewards in terms of expanding clinical services and critically needed collaborative research. These same efforts are now being expanded to increasing reach beyond specialty care into primary care.

The specialty of P-CLP will allow child and adolescent psychiatrists to remain firmly rooted within the practice of clinical medicine while grappling with some of the most fascinating and complex dilemmas of our time. Knapp and Harris wrote over 20 years ago that the “child psychiatrist’s training and skill in the integration of biological, pharmacological, developmental, intrapsychic, and family assessment are more valuable than ever” has proven to be prescient. The P-CLP psychiatrist of tomorrow will provide critically needed consultation and educational services to both primary care and subspecialty pediatric practitioners and in doing so help increase critically needed access to mental health services for children and their families.

Implications for Psychiatry

P-CLP is a dynamic specialty that lies on the interface between pediatrics and psychiatry. It is a bridge that can be leveraged to foster support from hospitals for the development of clinical and education programs as well as research and quality improvement initiatives. However, practitioners in P-CLP also face some unique obstacles. Patients are often not self-referred, and time and skill are needed to engage patients who may not understand the value or necessity of psychiatric consultation. Liaising with the pediatric team, while usually not reimbursed, is also an essential part of the P-CLP role to help develop a referral base and to educate pediatricians about the interaction between physical and psychological factors in their patients’ illness.

In a larger sense, the P-CLP can be seen as the psychiatrist for the hospital in general, providing expert consultation but also support and empathy for pediatricians dealing with the complexity of traumatic medical conditions. As such, practitioners require a wide range of skills that encompass psychopharmacology, individual and family therapy, knowledge of behavioral intervention strategies, and a deep understanding of how systems work. P-CLP is above all a social and team-based specialty that relies upon the three A’s: availability, affability, and ability. These qualities will help maintain the relevance of psychiatry in the medical setting. ■

References

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2. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health: The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care. Pediatrics. 2001; 108(5): 1227-1230.

3. DeMaso DR, Shaw RJ (2017). Evolution of Pediatric Psychosomatic Medicine—Yesterday and Today. AACAP News. 2017; 48: 6-7.

4. Knapp PK, Harris ES. Consultation-liaison in child psychiatry: a review of the past 10 years. Part I: Clinical findings. J Am Acad Child Adolesc Psychiatry. 1998a; 37(1):17-25.

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10. Walter HJ, Vernacchio L, Trudell IK, Bromberg J, Goodman E, Barton J, Young GJ, DeMaso DR, Focht G (2019). Five-year outcomes of behavioral health integration in pediatric primary care. Pediatrics. 2019; 144(1): e20183243.