Dr Rene Nassen Child and Adolescent Psychiatry Dept of Psychiatry

1. Where does Child Psychiatry fit into paediatric practice?UCT Paediatric Refresher Course February 2010 Dr Rene Nassen Child and Adolescent Psychiatry Dept of Psychiatry Stellenbosch University/Tygerberg Hospital

2. This presentation • A brief history and overview of relationship between Paediatrics and C-L Psychiatry • Red Cross Children’s Hospital Consultation-Liaison service • Case examples • Conclusion

3. What is consultation liaison psychiatry? • Consultation: Services performed for physically ill patients and families, often at the bedside in a general hospital, upon referral of the attending physician or other health care professional • Liaison: Services provided for the physician and staff, tying together the treatment of the patient and family, using educational conferences, psychosocial teaching rounds and holistic treatment plans

4. Involves collaboration between two teams who differ in their main focus of interest and methods of working.

5. Paediatrician- established a physician-patient relationship - primary case manager Psychiatrist -brief consultations -acute setting -distressed child -communication problems -absence of parent

6. History

7. Paediatrics and Child psychiatry: 6 decades of the relationship • 1937-Kanner L ‘The development and present status of psychiatry and pediatrics’ Pediatrics 11:418-435 • 1946-Senn M ‘The relationship of pediatrics and psychiatry’ Am j Dis Child 71;537-549 • 1959-Creak M ‘Child health and child psychiatry, neighbours or colleagues? Lancet 7;481-485 • 1967-Eisenberg L’The relationship between psychiatry and pediatrics, a disptable view’ Pediatrics 39;645-647 • 1977-Anders T ‘ Child psychiatry and pediatrics: the state of the relationship’ Pediatrics 60;616-620 • 1982-Jellinek M ‘The present status of child psychiatry in pediatrics’ N Engl J Med 306;1227-1230 • 1990-Fritz Gk ‘consultation Liaison in child psychiatry and the evolution of pediatric psychiatry’ Psychosomatics 31;85-90

8. Donald Winnicott (1896 - 1971)

9. ‘Common Ground’ • Collaboration around common goals • Clinical population at psychological risk • Holistic treatment • Prevention • Multidisciplinary models of care

10. Red Cross Children’s Hospital Consultation-Liaison Service • Team • Services • Teaching • Research • Future- training?

11. Role of liaison team • Diagnostic • Psychosocial meetings/ward rounds • Multidisciplinary team meetings • Psychological management- group therapy - individual • Psychotropic medication • Staff support • Family support • Transition to adult services

12. Common reasons for referral • Critically ill child • ?Depression,?Psychosis (delirium), ?PTSD • Behaviourly disturbed, unmanageable child • Clinical presentations for which no medical explanation (? Conversion) • The non compliant teenager • Transplant assessment

13. Case 1: The critically ill child Reason for referral: • Referred by S/W on the ICU team 2/52 after admission • Extensive burns following fire at home • ?PTSD ?Depression Identifying data: • Pearl • 10yr 10 month old girl • Xhosa and English-speaking • Grade 5

14. Medical Details • Admitted 13/8/05 with >70% burns following fire at home • Most of body affected, face & head spared • Multiple operations, including colostomy and many skin grafts • Multiple visits to theatre for change of dressings • Septicaemia • Significant to severe pain • No previous medical/surgical history; no previous admissions

15. Medications & Management • Panado • Methadone • Clonidine • Modazolam • Amitryptiline • Antibiotics • Multiple vitamins • Nutritional supplementation • Tube-fed • Colostomy • IV lines • Extensive dressings • Multiple and regular visits to theatre for grafting or dressing changes

16. Staff involved • Nursing staff • Social worker • Medical: Burns team, ICU team, Pain team • Physiotherapist • Occupational therapist • Dietitian • Aromatherapist • Volunteers • Psychiatry

17. Mental State Examination Appearance, behaviour, speech • Lying on back in bed in ICU almost covered in bandages and with multiple tubes • Engaged well, good eye contact • Soft speech, not spontaneous Mood and affect • Objectively sad, but came across as optimistic • Subjectively: “happy because my face is not burnt” • restricted Anxiety/PTSD symptoms: • Nightmares at night that woke her • Thought about the fire and could sometimes ‘see’ fire

18. Vegetative symptoms: • Difficult to assess in view of medical condition, but difficulty sleeping noted Thoughts and perceptions: • No abnormalities Cognitions: • Alert • Orientated to month and year Insight: • Fair

19. Summary 10yr old girl admitted after severe burns injury In a critical medical condition No past medical/psychiatric history Good family support Symptoms of acute stress disorder (later PTSD) and possibly depression

20. Multiaxial Diagnoses Axis I: • PTSD • Depressive disorder Axis II: • nil Axis III: • Severe burns • septicaemia • GIT complications/ colostomy Axis IV: • Medical condition • Hospitalisation Axis V: • 60

21. Management Biological: Optimal pain management ?Rationalisation of meds Fluoxetine 5mg/day Psychological: Provide source of support to patient & family Encourage ongoing regular visits Suggest routine in terms of staff visits Dealing with death and dying Social: Contacting school and parents work

22. Outcome Patient died 17/10/05 due to overwhelming sepsis, 1 week prior to her 11th birthday

23. CASE 2: Symptoms for which no medical cause found Reason for referral: • Recurrent, unexplained vomiting • Referred by neurology registrar during admission for further investigations Identifying data • 10yr old girl • Saldanha Bay • Grade 4 • English-speaking • Muslim

24. Medical Details • 2yr history of recurrent vomiting severe enough to cause oesophageal tears, oesophagitis and dehydration with electrolyte abnormalities • Associated headaches and abdominal pain • Admitted now with severe dehydration, acute renal failure and for further investigations • 1 previous documented UTI • No other medical/surgical history • No psychiatric history • Multiple admissions to RXH and local hospital

25. Investigations Blood: • FBC & Diff, LFT’s normal • U&E abnormal 2° vomiting and dehydration, otherwise normal • Endocrine • Metabolic screens • Amino acid analysis • VMA’s Urine: • 1 episode E.coli UTI, otherwise normal • VMA’s and NMA’s

26. Imaging: • CT x 2 • MRI • Ultrasound UKB EEG: normal Muscle Biopsy: normal GIT Endoscopy: normal

27. Treatment Admissions for IV fluids Medication: Omeprazole, anti-emetics,Carbamazepine

28. Mental state examination Appearance, behaviour, speech Sitting up in bed, drip IV, relaxed, playing with puzzle Appeared young for age, shy Engaged poorly, unconcerned Spoke softly, answered “I don’t know” or shrugged shoulders frequently Gave poor account of illness Mood and affect Euthymic , not anxious Affect: Inappropriate

29. Thoughts: • No abnormalities • Couldn’t think of 3 wishes No perceptual disturbances Cognitive function: • Orientated, alert, poor cooperation Insight poor

30. Summary • 10 year old girl from a large nuclear family, presents with long history of unexplained vomiting. History of 1° nocturnal enuresis and shy and nervous temperament. • Maternal history of depression • Marital discord • Possible abuse

31. Differential Diagnosis Axis I: • Conversion disorder? • Undifferentiated somatoform disorder? • Factitious disorder? • V code: ??sexual abuse Axis II: defer Axis III: Recurrent vomiting Axis IV: ? Axis V: ?60-70

32. Outcome • Admission to child psychiatry • Selectively mute • Emotional distress expressed via somatization • Uncooperative parents • Several transfers to medical ward • Further multidisciplinary meetings • Long term admission vs ‘removal’ from parents care • Settled after admission to St Josephs Children’s Home

33. Ethical dilemmas/end of life decisions • 11yo male • MVA pedestrian • C2 resection, paralysed, ventilator • Cognitively intact and alert • Prognosis very poor • Withdrawal of treatment

34. Child psychiatry consult • What to tell the child? • Right to be informed? • Consent/assent • Counselling: death/dying • Parent’s wishes

35. Outcome • Met with parents • Multidisciplinary team meeting • Ethical principle of ‘best interest of the child’, non maleficence, benificance • Sedation maintained and ventilator turned off • Follow up sessions with family

36. Conclusion • End of life • Hospital environment • Multiple drug regimens • Tolerating diagnostic uncertainty

37. C-L/ Paediatrics • Limited human resources • Effective Collaboration • Multidisciplinary approach • Collaborative clinical services • Teaching and training • Collaborative research

38. “Child psychiatry and Paediatrics have enjoyed a long flirtation. It is high time they were married if only for the sake of the children” (Apley, 1984)

39. THANK YOU