Pediatric Consultation/Liaison Service
Richard D’Alli, MD, MEd, ScM
Nikhil Rao, MD, MSc
The Department of Psychiatry has recruited Dr. Richard D’Alli, in August 2015, a child psychiatrist most recently from Duke with many years of experience in providing consultations at academic institutions, to develop and expand the Consultation-Liaison experience for the Child Psychiatry Fellowship.
This is a required 3-month rotation either in the first or the second year requiring 10% of the resident’s time. During their time on the Pediatric Consultation-Liaison Service,, residents learn to conduct comprehensive consultations to medically ill children and their families in inpatient treatment settings. They learn to evaluate consultation requests, manage the physical, interpersonal, and system boundaries inherent to the psychiatric consultant in a pediatric setting, differentiate pathological from normal behavioral and emotional responses to a medical illness, and work with a multidisciplinary team to devise appropriate treatment plans for children and their families. Residents provide consultations to the child and adolescent inpatients units at UF Health Shands Children’s Hospital.
A. Required during the first year at the UF Health Shands system, allowing for exposure to inpatients within the inpatient medical/surgical hospital and/or inpatient rehabilitation hospital settings.
B. Faculty consists of 1 full-time Child Psychiatrist and 2 full-time Adult Psychiatrists with adolescent training.
C. Residents see up to 4 new consults. All cases are seen and staffed by faculty.
D. The pediatric C/L service sees about 2-3 patients per week. The demographics of this population are 60% female and 40% male patients, with an age range of 2 to 17 years; 70% of referrals are for teenagers and 30% for younger children. About 70% of patients are Caucasian, 25% African American and the remainder from Asian or Hispanic backgrounds. Diagnoses particular to the C/L populations include: depression in the general medical setting, including suicide/overdose (30%), anxiety in the general medical setting and somatoform disorders (30%), depressive disorders (30%), autism spectrum disorders (5%) and the remainder at less than 5-10% include coping with illness, death, dying, and bereavement, delirium/agitation, pain, psychiatric manifestations of medical and neurological illness, and psychological factors affecting medical conditions. Of the patients evaluated, about 30% get transferred to the psychiatric inpatient setting, 25% receive specific cognitive-behavioral interventions and 50% receive recommendations for medication management for the referring pediatrician. Brief and supportive therapy modalities are also utilized in a large number of cases.
E. An average caseload for a resident consists of 2 to 3 patients at a given time, which are seen for medication management, brief psychotherapies and disposition planning.
F. All new and follow up patients are staffed by the faculty and cases are discussed with residents on an individual basis.
G. Following are the goals and objectives for this rotation:
Goals: To be able to provide pediatric psychiatric inpatient consultation for children and adolescents with a range of psychiatric disorders and behavioral health problems at a level consistent with his/her level of training during the first year.
The resident should have a basic fund of knowledge about problems commonly encountered in the area of pediatric consultation and liaison, including:
To know accurately the role of the C/L psychiatrist
- To know the diagnostic criteria and pathogenesis of conditions commonly encountered in the C/L setting, such as psychosomatic illness; comorbid psychiatric and medical illness; Munchausen’s Syndrome by Proxy; maladaptive reactions to acute and chronic psychosocial stressors; PTSD secondary to medical illness and interventions; grief and bereavement. To know the relationship of underlying personality and the patient’s previous experiences and the manifestation of physical symptoms.
- To know the principles of treatment of psychiatric patients with medical illness.
- To know about psychiatric comorbidities and sequelae of medical conditions and medical treatments, including psychiatric symptoms arising from medical drugs and metabolic factors.
- To have a clear knowledge of the interaction of psychotropic medications and commonly used medical drugs.
- To have a clear knowledge of the side effects and medical complications of psychotropic drugs.
The child resident should demonstrate the ability to:
- Negotiate a consultation request; determining what is needed, in what time frame and who authorized the consultation.
- Manage the physical, interpersonal, and system boundaries inherent to consultation in a medical setting.
- Conduct a comprehensive psychiatric assessment of patients on non-psychiatric wards of a general hospital, including obtaining collateral history from families and other sources.
- Clearly record findings of such an assessment in a manner easily understandable by the referral source. Such record to include a clear formulation of the case, addressing the pathogenesis of the disorder and the role of perpetuating factors.
- Develop expertise in dealing with psychiatric emergencies on medical/surgical wards.
- Apply current knowledge to the interpretation and organization of data gathered through the assessment process.
- Prescribe and carry out bio psychosocial treatments in an effective manner in liaison with medical colleagues and other health professionals in the context of multi-disciplinary framework. Treatment recommendations to focus on acute as well as long-term rehabilitative care and placement considerations as indicated.
- Be sufficiently familiar with medical/surgical conditions frequently encountered in a C/L practice.
- To have a clear rationale for decisions regarding transfer of patients to a psychiatric unit.
The child resident should demonstrate:
- Commitment to being responsive to requests for consultation.
- Sensitivity to patients and their families when in crisis.
- Respect for the expertise of those requesting consultation.
- Confidence in using a flexible treatment program to accommodate the needs of patients with concurrent medical and psychiatric illness.
- A balanced patient centered approach to patients using a bio psychosocial model and to emphasize integration of this approach into the patient’s overall treatment.
- Ability to liaise with medical colleagues and other members of the health care team (e.g. nursing, psychology, etc.) while providing concurrent care to patients.
- Awareness of counter transference feelings that tend to be evoked when dealing with medically ill patients and to know when to seek supervision around this issue.
- Commitment to learning how to provide the highest standard of patient care, including the use of the literature to guide treatment and quality parameters to evaluate treatment.