One Year's Survey of Child Psychiatry Consultations in a Pediatric Hospital
William Sack, M.D., Stanley Cohen, Ph.D., and Christine Grout, B .A.
Abstract. A one-year retrospective survey of child psychiatry consultations in a pediatric hos-
pital is presented and the findings are compared to a previous study from another part of the country. Over half of the children in this series came from families who had experienced significant stress in the year prior to hospitalization. These "di sordered" families used the mental health care system after hospitalization less frequently than did the "nondisordered" families. The pediatric hospitalization is conceptualized as an implicit form of crises intervention for some children in families showing significant psychosocial disarray.
Our consultations were performed as part of a broad child psychiatry-pediatric liaison effort. We define liaison as do Naylor and Mattsson (1973) as a close bond between the two disciplines, a connection that fosters mutual understanding and includes not only consultation, but collaboration, education, ongoing management, support, and coordination of care. It was within this larger context that we wished to survey our experience with consultation. While child psychiatrists have long been interested in the emotional problems of the hospitalized child and have been active proponents of a more humane hospital milieu for children (Prugh and Jordan, 1975), they have rarely systematically surveyed their own interventions. An important exception was the work of Monnelly and his colleagues (1973). We were curious to see how similar our experience was to theirs. In addition, we asked ourselves a number of questions about consultation for which no information could be found in the literature: (1) What were the characteristic family Dr. Sack is Director of Child Psychiatry and Assistant Professor of Psychiatry and Pediatrics; Dr. Cohen is Associate Professor of Psychiatry; and C. Grout is a Research Associate; Department ofPsychiatry, University ofOregon Health Services Center, Portland, Oregon . A modified version of this paper was presented at the 1975 Annual Meeting of the American Acadnny ofChild Psychiatry, SI. Louis, Mo . Part of the research described was supported by a state educational grant cproject Impact #73 -008008.) Reprint> may b. requested from Dr. Sack, at 3181 S.W. Sam fackson Park Road, Portland, OR 97201 .
716
Consultations in a Pediatric Hospital
717
backgrounds of the children who received a psychiatric consultation? (2) How did they utilize this liaison service? (3) Where did these children go when they left the hospital? What health services did they use in their aftercare? (4) What was their general behavioral adjustment one to two years later? DESCRIPTION OF STUDY
The Setting and the Staff
The Doernbecher Pediatric Hospital is a teaching hospital for the University of Oregon Health Sciences Center in Portland, Oregon. It has 103 beds and admits children from birth through age 15. It serves the entire state as a referral hospital. All patients are the responsibility of the house staff. During the year of this survey, the liaison team was in the fourth year of its development. Our program functioned quite similarly to that described by Naylor and Mattsson (1973) at the University of Virginia Medical Center. Two child psychiatry fellows spent about one third of their work week for a 6-month rotation on the liaison service. Three child psychiatry faculty spent a total of about 12 hours a week in the various functions of the liaison service. Two child psychiatric nurses spent half of their work week on the wards and anchored the continuity of the liaison work in a very important way. Members of hospital social service, medical psychology, and public health nursing, though not part of the core liaison team, also made contributions. Each child psychiatry fellow spent about ;) hours per consultation, in interviewing the family and child, obtaining information from outside sources, explaining the findings to the ward staff, and coordinating aftercare. About a third of these fi hours was spent away from the bedside. While our overall aim was to make the pediatrician competent to handle comprehensively all aspects of the psychosocial problems of his patients, we still found ourselves doing a good deal of care coordination. Naylor and Mattsson (1973) found this coordination function to be an important part of their work consultation experience. Methods
We reviewed the medical charts of the 98 children seen in psychiatric consultation from July I, 1973 to July I, 1974. One of us (CG) read the entire record and then completed a questionnaire designed to elicit the information we sought. A dual review of 10 per-
718
William Sack et al.
cent of the records yielded no significant interrater problems. The data, being retrospective, were subject to inevitable errors of incompleteness and distortions of emphasis. The psychiatric diagnoses were made by one of us (WS), based, as in the Monnelly et al. study (1973), on the DSM II Manual of the American Psychiatric Association. The second part of the project was aimed at obtaining follow-up information about general behavioral adjustment since hospitalization, use of medical and mental health care services, and change in family structure or living arrangements in these former patients. A questionnaire containing multiple choice and open-ended questions was mailed to the parents or caretakers of these children. By making initial phone contact or working through social agencies or physicians, we were able to trace 78 of the 98 children. We explained the study and obtained written consent to use the information they provided. Fifty-two questionnaires were returned, representing a return rate of 79% of those we mailed and 54% of our original sample. We utilized the X 2 test in our statistical analysis of parts of the data. RESULTS AND DISCUSSION
Comparison with Another Study
The information we gathered will be presented in a series of tables. Table I compares demographic variables from our Oregon survey with comparable figures from the St. Louis study by Monnelly et al. (1973). Pediatricians remain the main source of referral in both series. The average length of stay was 13 days in each series, or :'> days over the average stay for all children. Probably due to a large number of infants and toddlers referred for failure to thrive and child abuse, the mean age of referral of our children was 2 years less than in the St. Louis series. Table 2 compares the major reasons for psychiatric referral in the Oregon and St. Louis series. Again similarities predominate, with the exception that we were seeing more children described as ward behavior problems and fewer for symptoms of unknown etiology. Table 3 compares the diagnostic breakdown of the children in the two series. The diagnoses in Monnelly's series were made in a prospective fashion, while our diagnoses were made retrospectively from a chart review. Our diagnoses of hysteria could not be made
719
Consultations in a Pediatric Hospital
from the criteria of Feighner et at. (1972) because we did not have the raw data, but were made retrospectively in suggestible children whose symptoms seemed to symbolize significant problems for which no organi c cause could be found. While it ma y not be accurate to compare the di agnosis of h ysteri a made in these different ways. we found th at in both ser ies one third of the females from 9 to 15 years of age were diagnosed as having h ysterical reactions. The high figures fo r "no psychiatric illness" in the St. Louis series ma y be a reflection of our clinical impression that pediatrician s Tahlc I Compar iso n of Psychi atric Consultations in Two C hild re n's Hospitals SI. Louis Serie s Patients referred during tim e stud ied T ime period of study Pe rcentage o f IOta I patien ts refe r red Length of hospital stay for refe rr ed pat ients Length o f hosp ital sta y for no n r e fe rred patien ts Age range Fc ma les refe rred ('if) Referral SOUITe fr om ge nera l ped iatrics (%) Pr esenting problems (orga n syste m in volved ) (%)
William Sack, M.D., Stanley Cohen, Ph.D., and Christine Grout, B .A.
Abstract. A one-year retrospective survey of child psychiatry consultations in a pediatric hos-
pital is presented and the findings are compared to a previous study from another part of the country. Over half of the children in this series came from families who had experienced significant stress in the year prior to hospitalization. These "di sordered" families used the mental health care system after hospitalization less frequently than did the "nondisordered" families. The pediatric hospitalization is conceptualized as an implicit form of crises intervention for some children in families showing significant psychosocial disarray.
Our consultations were performed as part of a broad child psychiatry-pediatric liaison effort. We define liaison as do Naylor and Mattsson (1973) as a close bond between the two disciplines, a connection that fosters mutual understanding and includes not only consultation, but collaboration, education, ongoing management, support, and coordination of care. It was within this larger context that we wished to survey our experience with consultation. While child psychiatrists have long been interested in the emotional problems of the hospitalized child and have been active proponents of a more humane hospital milieu for children (Prugh and Jordan, 1975), they have rarely systematically surveyed their own interventions. An important exception was the work of Monnelly and his colleagues (1973). We were curious to see how similar our experience was to theirs. In addition, we asked ourselves a number of questions about consultation for which no information could be found in the literature: (1) What were the characteristic family Dr. Sack is Director of Child Psychiatry and Assistant Professor of Psychiatry and Pediatrics; Dr. Cohen is Associate Professor of Psychiatry; and C. Grout is a Research Associate; Department ofPsychiatry, University ofOregon Health Services Center, Portland, Oregon . A modified version of this paper was presented at the 1975 Annual Meeting of the American Acadnny ofChild Psychiatry, SI. Louis, Mo . Part of the research described was supported by a state educational grant cproject Impact #73 -008008.) Reprint> may b. requested from Dr. Sack, at 3181 S.W. Sam fackson Park Road, Portland, OR 97201 .
716
Consultations in a Pediatric Hospital
717
backgrounds of the children who received a psychiatric consultation? (2) How did they utilize this liaison service? (3) Where did these children go when they left the hospital? What health services did they use in their aftercare? (4) What was their general behavioral adjustment one to two years later? DESCRIPTION OF STUDY
The Setting and the Staff
The Doernbecher Pediatric Hospital is a teaching hospital for the University of Oregon Health Sciences Center in Portland, Oregon. It has 103 beds and admits children from birth through age 15. It serves the entire state as a referral hospital. All patients are the responsibility of the house staff. During the year of this survey, the liaison team was in the fourth year of its development. Our program functioned quite similarly to that described by Naylor and Mattsson (1973) at the University of Virginia Medical Center. Two child psychiatry fellows spent about one third of their work week for a 6-month rotation on the liaison service. Three child psychiatry faculty spent a total of about 12 hours a week in the various functions of the liaison service. Two child psychiatric nurses spent half of their work week on the wards and anchored the continuity of the liaison work in a very important way. Members of hospital social service, medical psychology, and public health nursing, though not part of the core liaison team, also made contributions. Each child psychiatry fellow spent about ;) hours per consultation, in interviewing the family and child, obtaining information from outside sources, explaining the findings to the ward staff, and coordinating aftercare. About a third of these fi hours was spent away from the bedside. While our overall aim was to make the pediatrician competent to handle comprehensively all aspects of the psychosocial problems of his patients, we still found ourselves doing a good deal of care coordination. Naylor and Mattsson (1973) found this coordination function to be an important part of their work consultation experience. Methods
We reviewed the medical charts of the 98 children seen in psychiatric consultation from July I, 1973 to July I, 1974. One of us (CG) read the entire record and then completed a questionnaire designed to elicit the information we sought. A dual review of 10 per-
718
William Sack et al.
cent of the records yielded no significant interrater problems. The data, being retrospective, were subject to inevitable errors of incompleteness and distortions of emphasis. The psychiatric diagnoses were made by one of us (WS), based, as in the Monnelly et al. study (1973), on the DSM II Manual of the American Psychiatric Association. The second part of the project was aimed at obtaining follow-up information about general behavioral adjustment since hospitalization, use of medical and mental health care services, and change in family structure or living arrangements in these former patients. A questionnaire containing multiple choice and open-ended questions was mailed to the parents or caretakers of these children. By making initial phone contact or working through social agencies or physicians, we were able to trace 78 of the 98 children. We explained the study and obtained written consent to use the information they provided. Fifty-two questionnaires were returned, representing a return rate of 79% of those we mailed and 54% of our original sample. We utilized the X 2 test in our statistical analysis of parts of the data. RESULTS AND DISCUSSION
Comparison with Another Study
The information we gathered will be presented in a series of tables. Table I compares demographic variables from our Oregon survey with comparable figures from the St. Louis study by Monnelly et al. (1973). Pediatricians remain the main source of referral in both series. The average length of stay was 13 days in each series, or :'> days over the average stay for all children. Probably due to a large number of infants and toddlers referred for failure to thrive and child abuse, the mean age of referral of our children was 2 years less than in the St. Louis series. Table 2 compares the major reasons for psychiatric referral in the Oregon and St. Louis series. Again similarities predominate, with the exception that we were seeing more children described as ward behavior problems and fewer for symptoms of unknown etiology. Table 3 compares the diagnostic breakdown of the children in the two series. The diagnoses in Monnelly's series were made in a prospective fashion, while our diagnoses were made retrospectively from a chart review. Our diagnoses of hysteria could not be made
719
Consultations in a Pediatric Hospital
from the criteria of Feighner et at. (1972) because we did not have the raw data, but were made retrospectively in suggestible children whose symptoms seemed to symbolize significant problems for which no organi c cause could be found. While it ma y not be accurate to compare the di agnosis of h ysteri a made in these different ways. we found th at in both ser ies one third of the females from 9 to 15 years of age were diagnosed as having h ysterical reactions. The high figures fo r "no psychiatric illness" in the St. Louis series ma y be a reflection of our clinical impression that pediatrician s Tahlc I Compar iso n of Psychi atric Consultations in Two C hild re n's Hospitals SI. Louis Serie s Patients referred during tim e stud ied T ime period of study Pe rcentage o f IOta I patien ts refe r red Length of hospital stay for refe rr ed pat ients Length o f hosp ital sta y for no n r e fe rred patien ts Age range Fc ma les refe rred ('if) Referral SOUITe fr om ge nera l ped iatrics (%) Pr esenting problems (orga n syste m in volved ) (%)
