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Leading article
Paediatricians and psychiatrists working together: what works best? Andrew Court Since paediatrician Joseph Brenneman wrote of ‘the menace of psychiatry’ in 19311 complaining of the ‘psychiatrising’ of children’s normal behaviour, there has been recognition that the relationship between paediatricians and child and adolescent psychiatrists has been problematic. Fritz noted in 20032 when discussing challenges to the development of healthy collaboration between both disciplines that every 10 years or so since then there have been important reviews written by influential paediatricians and psychiatrists on the state of the relationship with problems noted and solutions offered. Over the last 10 years there has been an emphasis on the need to support paediatricians by the trialling of collaborative approaches with psychiatrists.3 There is also recognition from some psychiatrists that they need to be more collaborative in order to continue to enjoy a satisfying professional life.4–6 There have been changes to the ways medical care is managed, with issues of cost and cost-effectiveness increasingly driving how services are delivered.7 8 Evidence shows that paediatricians continue to feel unskilled in managing many mental health problems but also that they perceive psychiatrists to be unavailable.9 10 On the other hand, despite the breadth of potentially effective treatments available to psychiatrists, there is pressure on them to focus on prescribing medication with a perception that other more fulfilling models of their work are undervalued.4 When reviewing what works best in the working relationship between paediatricians and psychiatrists, much of what has been written over many decades remains relevant and highlights the need to recognise and respect the differences between the two disciplines. Only through such understanding can the ongoing barriers to healthy collaboration be removed. This review is written by a psychiatrist who initially trained and worked as a paediatrician. He works both in the public and private healthcare systems and is
Correspondence to Dr Andrew Court,Consultation Liaison Psychiatry, Royal Children’s Hospital, 50 Flemington Rd, Parkville, VIC 3052, Australia; [email protected] 708
active in developing collaborative relationships with paediatricians.
DIFFERENCES Much has been written about the differences between the working practices of paediatricians and psychiatrists (table 1). Enzer et al11 showed that they seem to have different character traits with different perceptions of how childhood is experienced, differences that predate their training. Training in child development in paediatrics has a focus on normal biologically driven development and its variations.12 In contrast, the emphasis in child psychiatry has historically been on theoretical psychodynamic and attachment models of development with the purpose of psychological understanding of abnormal clinical presentations.6 Though there has been a shift towards more biological and empirically based models of understanding for psychiatrists, these differences in emphasis persist.2 6 Differences in outlook and subsequent training contribute to different clinical working practices.2 12 Paediatricians are adept at gathering clinically relevant and often symptom-focused histories in a timelimited structure, are active and ‘problem solving’ in their consultative role and use language that is centred on symptom description and diagnosis.12 Psychiatrists, on the other hand, take longer to assess their patients, taking detailed biopsychosocial developmental histories. They do this to formulate the clinical case, to understand why this patient is presenting with a particular problem at a particular time in their developmental trajectory.6 13 Psychiatrists are more reflective both with patients and with colleagues, and use language that is more focused on understanding symptoms rather than on describing symptoms.2 Recognising that these differences can hinder good collaborative practice, many authors have commented that they should 12 be acknowledged and used.2 Psychiatrists are becoming more experienced in evidence-based treatments and in the prescription of psychotropic medication.14 Better use of these skills may prove helpful to paediatricians, who could also benefit from skills that enable deeper
understanding of complex patients. Models of collaboration should involve paediatricians identifying and managing more mental illness through direct collaborative clinical work. They should also become comfortable in assessing which patients need more intensive psychiatric assessment and management.15
THE NEED TO COLLABORATE It is estimated that up to 20% of children and adolescents have a diagnosable mental health disorder16 and that up to 50% of patients who see paediatricians have significant behavioural and mental health problems17 either as their presenting problem or as comorbidity. The role of paediatricians has changed considerably over time with a shift from acute medicine to what was termed ‘the new morbidity’18 when describing the significant increase in behavioural and emotional problems seen by paediatricians in place of many lifethreatening illnesses for which cures have been found. In addition, there is evidence that patients with mental illness are more likely to present with medical problems16 and that chronic medical illness is associated with mental illness.19 As well as comorbidity between medical presentations and mental illness, there are also conditions where there is the need for input from both disciplines. These include somatising disorders, eating disorders, gender dysphoria and pervasive developmental disorders. Even when management of these conditions involves input from both disciplines, there is not always open collaboration between them.20 It has been repeatedly shown that paediatricians acknowledge that they have a role in identifying mental health problems but do not believe they have the training or ability to treat them (with the exception of ADHD).9 10 21–23 Paediatricians have been documented as wanting help in clarifying diagnosis of complex patients and of comorbidities, in prescribing of psychotropic medication, in the treatment of depression and anxiety disorders and in crisis management of suicidal patients.10 24 25 Paediatricians recognise that they commonly do not have the time or expertise to manage complex patients.9 26 Increasingly, however, they are pressured to do so because of the numbers they see, but also because of external pressures such as managed-care funding arrangements.4 There is some risk that in response to these pressures, paediatricians may prescribe psychotropic medications inappropriately. In contrast, psychiatrists are under pressure to Court A. Arch Dis Child August 2014 Vol 99 No 8
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Leading article Table 1 Differences between paediatricians and psychiatrists
Background Outlook11 Developmental training6
Practice Time2 12 Information gathered6 Stance12 Language6 12 Prescribing
Paediatricians
Psychiatrists
Childhood as carefree Neurodevelopmental Biological
Childhood as struggle Psychodynamic/theoretical Biopsychosocial ‘understanding response to patient’ (‘transference’)
Short sessions Symptom focused Active Symptom/Dx focus Less psychotropic use
Longer sessions Attachment history/psychological development Reflective Formulation (‘understanding’) focused Psychotropic experienced
respond to increasing demand on their services by providing shorter assessments and briefer treatments that undermine their more extensive understanding of child and adolescent mental illness.4 Never has there been a clearer need to develop and validate good collaborative relationships between the two disciplines.
BARRIERS Worldwide, Child and Adolescent Mental Health Services (CAMHS) are underresourced with too few psychiatrists to service the populations they treat.27 This is recognised as a significant reason as to why paediatricians consider psychiatrists and CAMHS to be unresponsive to requests for help.9 25 28 29 Second, there are financial restraints that limit appropriate input from psychiatrists.9 Increasingly in the USA, where managed care has replaced fee-for-service, insurance companies are able to drive management plans. Psychiatrists are finding themselves pushed to focus on prescribing of psychotropic medication, while other less expensive mental health professionals take on psychotherapeutic roles.4 14 When psychiatrists do see patients, there may be financial barriers preventing what is seen to be appropriate treatment (eg, low reimbursements when working with parents alone).8 Administratively, there is a long history of fragmentation of medical and mental health services that do not have clear pathways of referral.12 28 Streamlining the management structures that deliver these services carries significant cost and requires government support. Even without the practical barriers that can be associated with bringing about collaboration between paediatricians and psychiatrists, there is a history of separation between the two disciplines that comes from a longstanding ambivalence that has Court A. Arch Dis Child August 2014 Vol 99 No 8
been argued to result from their different clinical approaches.12 For example, when paediatricians refer to psychiatrists, they often perceive them to be non-responsive due to the lack of communication from the psychiatrist that the referring paediatrician expects after referral.9 10 It is also well recognised that stigma remains a barrier to mental health referrals, with patients and families often reluctant to make an appointment following referral; medical illness continues to be more socially acceptable than mental illness.14 29 Finally, there has historically been less investment in the development of the evidence base for treatment of mental illnesses affecting children and adolescents. This has compounded a perception by some paediatricians that psychiatrists do not have effective treatments to offer anyway.12 14
COLLABORATIVE MODELS Despite such problems, there are many examples of healthy collaborative partnerships between paediatricians and psychiatrists (see box 1). For the most part, these examples come from inspired individuals who have helped create conjoint academic units, advocate for Consultation Liaison Child and Adolescent Psychiatric Services, and describe the benefits of collaboration.13 15 30 Clear patterns emerge from these descriptions of what works in these partnerships. Individual relationships need to be developed with face-to-face clinical discussion and informal meetings.25 28 There needs to be recognition and respect for differences in clinical styles and treatment paradigms, an appreciation that such differences are healthy and that each discipline can learn from the other.28 30 Dual training in paediatrics and psychiatry (‘triple board training’) has been
Box 1 Collaborative models Dual training Collaborative office rounds Consultation liaison psychiatry Joint guidelines for treatment Co-location models Telephone/collaborative consultation models Joint assessment and treatment clinics (eating disorders/somatising/PDD/ gender dysphoria)
occurring in specific locations for many decades. Though the training is strenuous and the numbers of dual trainees are small, graduates bring benefits from both training programmes into their clinical work and help to develop a bridging relationship between the groups.31 My own experience of dual training was that as a psychiatrist it was initially hard to let go of thinking and acting as a paediatrician. The process of recognising that I had become a psychiatrist, informed by having been a paediatrician, was instrumental in being respected by both disciplines. Collaborative supervision and discussion groups involving both paediatricians and psychiatrists are not uncommon. Described as productive,32 they are dependent on interested parties taking the lead.33 Within the long history of Consultation Liaison Child and Adolescent Psychiatry,19 good relationships have been described between medical and mental health teams with recognition of the need for mental health input into infants with serious illness or unwell parents, patients with chronic medical illness, somatising presentations, eating disorders, suicidal and selfharming adolescents and patients with comorbidity. Unfortunately, despite qualitative descriptions of the value of these services, there has been little evaluation of their cost-effectiveness, a feature that has led to limited support from bureaucratic funding sources.34 There are some descriptions of joint assessment and treatment clinics involving paediatricians and psychiatrists in areas of clearly overlapping expertise such as somatising disorders and eating disorders.28 35 36 These services provide practical ways of bringing paediatricians and psychiatrists together, and would benefit from greater visibility and evaluation.20 When consultant paediatricians are asked what they may need from psychiatrists, there is consensus about the 709
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Leading article desirability of a co-located model of health delivery where they can have easy access to psychiatrists for secondary consultation.9 10 24 37 Several models have been developed in the USA with varying degrees of co-location. For example, the Massachusetts Child and Adolescent Psychiatry Access Project (MCAPAP), set up in 2005,38 was based on a collaborative care model known as Targeted Child Psychiatric Services. Teams of psychiatrists and other mental health workers provide easy access of consultation to paediatricians. There are regular visits to paediatric clinics to provide education, together with hotline access to telephone consultation with psychiatrists. Telephone consultation may lead to an assessment from psychiatrists following which the patient is either returned back to the paediatrician for ongoing care (with support) or referral to local mental health services is instigated. The project has shown some success in engaging local paediatricians.3 37 39 In addition to expressing satisfaction with the service and accessibility of psychiatrists, paediatricians also stated that they felt more confident in their ability to care for children and adolescents with mental health problems. Other models based on the MCAPAP model have been generally organised along similar lines, with consultation with psychiatrists either occurring in person or by teleconferencing.14 40 Some services offer short-term treatment but otherwise refer back to paediatricians or to appropriate local MHS. An alternative model is the Connecticut Behavioural Health Partnership41 that focuses on improved access to mental health agencies. Services that can demonstrate accessibility and high standard treatment can gain access to additional funds. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have also collaborated to create educational materials to help paediatricians manage mental illness. For example, Bright Futures and DSM-PC have been developed to help foster common language between paediatricians and psychiatrists.8 The ability to develop collaborative relationships will very much depend on the setting and shared understanding of need for such collaboration. A public hospital with a captive patient group requiring input from both medical and mental health teams is very different from an outpatient setting. Outpatient settings, either public or private, require motivating forces in addition to those provided by individual practitioners in order to 710
develop collaborative practices in response to specific clinical needs. There has been a push in some parts of the world to develop Youth Mental Health services separate to CAMHS42 that are co-located with other medical and social services. Such arrangements are likely to improve accessibility and decrease stigma. It is important that meaningful collaborative practice is supported and encouraged in such settings in addition to the practical co-location.
MEASURING WHAT WORKS BEST There is no consensus on how to measure the effectiveness of collaboration between paediatricians and psychiatrists. Suggested measurables that need development are summarised in box 2. Paediatricians want ease of access to psychiatrists, to consult and get advice when needed and to hand over management of complex patients when appropriate.10 Psychiatrists are looking for new ways to engage and work in order to deal with pressures from external sources to be costeffective.6 Both need to feel that they are professionally valued and that they are personally satisfied. In addition, there is likely to be a need for the measurement of patient outcome benefit in order to justify expenditure on collaborative programmes. The collaborative programmes trialled in the USA have focused on qualitative measurements of paediatricians’ satisfaction with the service, and the perceived improvements in paediatricians’ skills following the collaboration.39 While these outcomes are positive, the numbers participating in the evaluation are small. There have been no quantitative measurements of improved patient care through collaborative interventions.14 Measuring outcomes of interventions to support clinical decision making in children’s mental health is far more difficult than assessing clinical outcomes for other medical conditions (eg, survival with chemotherapy). Measuring improved symptoms of psychological conditions is
Box 2 Measuring what works best Paediatricians/psychiatrists satisfaction with model (including evidence of augmented skills) Access to mental health services Medical service use School attendance Quality-of-life measurements Patient experience measures
problematic for many reasons (eg, symptoms naturally change over time/difficulties in defining a control group).7 Proposed potential targets for assessment include improved access to mental health professional care,10 decreased use of medical services,25 improved school attendance25 and improved quality-of-life measurements.7 The development of assessment tools that use patient experience would be another approach to demonstrate the value of collaborative interventions. The need to measure the effectiveness of collaborative interventions is likely to be an ongoing necessity given the focus on cost and cost-effectiveness in healthcare delivery. From an economic perspective, there has been little reason to invest in child psychiatric outcome research in the absence of innovative research tools that can show tangible and varied benefits. Subsequently, some services such as mental health inpatient admissions and lengths of stay have been cut without any strong evidence to do so.7
FUTURE DIRECTIONS As professionals from both disciplines have suggested, what works best are models where psychiatrists have developed individual working relationships with individual paediatricians. By being available to provide consultative advice that is perceived as helpful, psychiatrists are able to expand their input that helps create a cultural shift that values their conceptual input to clinical diagnosis and decision making above that of psychotropic prescription and the management of ‘complex patients’.6 15 25 While it has been noted that treatment models of mental health problems for children and adolescents should not be primarily driven by cost,7 12 it will be beholden on both paediatricians and psychiatrists to invest in evaluation that can better measure the outputs of collaborative models that are likely to both improve patient outcome and be cost-effective. Several prominent authorities have stated that there should be advocacy from administrative bodies of both paediatricians and psychiatrists together to push for ongoing support of collaborative models.13 22 The AAP and the AACAP have jointly advocated for appropriate funding and reimbursement for the provision of mental health services to paediatricians.8 Further advocacy around such collaboration will be needed to sustain pressure to reform funding arrangements. Further work is also needed to determine best models of care. This includes models Court A. Arch Dis Child August 2014 Vol 99 No 8
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Leading article of training paediatricians towards becoming more competent at managing mental health illnesses and the development of guidelines as to when it is appropriate both for consultation and/or transfer of care to psychiatrists or CAMHS.22 25 Consultation Liaison Child and Adolescent Psychiatry, while recognised by most authorities as being an important and necessary component of medical care in major hospitals, continues to lack universal support from administrative bodies.34 43 Further work is needed to research methods that better demonstrate the costs and benefits of mental health input into medical hospital treatment and to use this to advocate for service development. Targeted interventions to further develop formalised collaboration in illnesses (such as somatising disorders) that share mental health and medical assessment and treatment is one area of potential development.5 20 The understanding that child psychiatrists can shift their roles from those that purely provide direct clinical care to also include consultation and collaboration is gathering momentum.6 Child psychiatry training programmes must adapt to this change and put greater emphasis on the importance of functioning within systems, on speaking the language of paediatricians and in participating in conjoint education and training experiences.6 Given the significant burden of mental health problems affecting patients that paediatricians treat and the relative lack of child and adolescent psychiatrists, strategies are needed to support and increase collaboration. Alliances are needed to advocate for mental health parity, for the further development of conjoint training in both disciplines and for outcomes research that is needed to drive service development. Committed and charismatic individuals are still needed from both professional bodies to advance and promote this agenda.
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Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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19
To cite Court A. Arch Dis Child 2014;99:708–711. Received 11 December 2013 Revised 25 March 2014 Accepted 2 April 2014 Published Online First 23 April 2014 Arch Dis Child 2014;99:708–711. doi:10.1136/archdischild-2013-304594
Court A. Arch Dis Child August 2014 Vol 99 No 8
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22
Brennemann J. The menace of psychiatry. Am J Dis Child 1931;42:376–402. Fritz GK. Promoting effective collaboration between pediatricians and child and adolescent psychiatrists. Pediatric Annals 2003;32:383, 7–9. Aupont O, Doerfler L, Connor DF, et al. A collaborative care model to improve access to pediatric mental health services. Adm Policy Ment Health 2013;40:264–73. Pohl RL. Consultation to pediatricians. J Am Acad Child Adolesc Psychiatry 1998;37:1129–30. McNeil GN Jr. The collaboration between psychiatry and primary care in managed care. Psychiatric Clinics of North America 2000;23:427–35, ix. McCarthy M, Abenojar J, Anders TF. Child and adolescent psychiatry for the future: challenges and opportunities. Psychiatr Clin North Am 2009;32:213–26. Jellinek M, Little M. Supporting child psychiatric services using current managed care approaches: you can’t get there from here. Arch Pediatr Adolesc Med 1998;152:321–6. American Academy of Pediatrics. Committee on psychosocial aspects of child and family health and task force on mental health. Policy statement—the future of pediatrics: mental health competencies for pediatric primary care. Pediatrics 2009;124:410–21. Davis DW, Honaker SM, Jones VF, et al. Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models. Clin Pediatr 2012;51:978–82. Ross WJ, Chan E, Harris SK, et al. Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder, depression, and anxiety. Clin Pediatr 2011;50:37–43. Enzer NB, Singleton DS, Snellman LA, et al. Interferences in collaboration between child psychiatrists and pediatricians: a fundamental difference in attitude toward childhood. J Dev Behav Pediatr 1986;7:186–93. Perrin EC. Presidential address: the promise of collaborative care. J Dev Behav Pediatr 1999;20:57–62. Schowalter JE, Solnit AJ. Working with the primary care physician. Child Adolesc Psychiatr Clin N Am 1998;7:599–613. Gabel S. The integration of mental health into pediatric practice: pediatricians and child and adolescent psychiatrists working together in new models of care. J Pediatr 2010;157:848–51. Kraemer S. “The menace of psychiatry”: does it still ring a bell? Arch Dis Child 2009;94:570–2. Costello EJ, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60:837–44. Cassidy LJ, Jellinek MS. Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care. Pediatr Clin N Am 1998;45:1037–52. American Academy of Pediatrics. Committee on psychosocial aspects of child and family health. The pediatrician and the “new morbidity”. Pediatrics 1993;92:731–3. 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 1998;37:17–25. Garralda E. Need for paediatric-psychiatric liaison. Br J Psychiatry 2001;179:369. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics 2007;120:e1313–26. Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for
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children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr 2008;29:262–9. Olfson M, Marcus SC, Druss BG. Effects of Food and Drug Administration warnings on antidepressant use in a national sample. Arch Gen Psychiatry 2008;65:94–101. Williams J, Palmes G, Klinepeter K, et al. Referral by pediatricians of children with behavioral health disorders. Clin Pediatr 2005;44:343–9. Wilson H, Payne D. Real medicine. J Paediatr Child Health 2012;48:E161–4. Stein RE, Horwitz SM, Storfer-Isser A, et al. Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 2008;8:11–7. Kim WJ. Child and adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatry 2003;27:277–82. Kimber D, Radovini A. CAMHS & paediatricians working together, 2011. http://www.mindful.org.au/ Research/CAMHS-and-Paediatricians-Project.aspx (accessed 28 Nov 2013). Trude S, Stoddard JJ. Referral gridlock: primary care physicians and mental health services. J Gen Intern Med 2003;18:442–9. Kelleher KJ, Stevens J. Evolution of child mental health services in primary care. Acad Pediatrics 2009;9:7–14. Gleason MM, Fritz GK. Innovative training in pediatrics, general psychiatry, and child psychiatry: background, outcomes, and experiences. Acad Psychiatry 2009;33:99–104. Schwam JS, Maloney MJ. Developing a psychiatry study group for community pediatricians. J Am Acad Child Adolesc Psychiatry 1997;36:706–8. Thomasgard M, Collins V. Collaborative office rounds between pediatricians and child psychiatrists. Clin Pediatrics 1998;37:327–30. Campo JV, Kingsley RS, Bridge J, et al. Child and adolescent psychiatry in general children’s hospitals. A survey of chairs of psychiatry. Psychosomatics 2000;41:128–33. Hudson LD, Court AJ. What paediatricians should know about eating disorders in children and young people. J Paediatr Child Health 2012;48:869–75. Hughes EK, Le Grange D, Court A, et al. Implementation of family-based treatment for adolescents with anorexia nervosa. J Pediatr Health Care 2013. pii: S0891-5245(13)00229-0. Sheldrick RC, Mattern K, Perrin EC. Pediatricians’ perceptions of an off-site collaboration with child psychiatry. Clin Pediatrics 2012;51:546–50. Connor DF, McLaughlin TJ, Jeffers-Terry M, et al. Targeted child psychiatric services: a new model of pediatric primary clinician—child psychiatry collaborative care. Clin Pediatrics 2006;45:423–34. Sarvet B, Gold J, Bostic JQ, et al. Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project. Pediatrics 2010;126:1191–200. Kuehn BM. Pediatrician-psychiatrist partnerships expand access to mental health care. JAMA 2011;306:1531–3. Pidano AE, Marcaly KH, Ihde KM, et al. Connecticut’s enhanced care clinic initiative: early returns from pediatric-behavioral health partnerships. Fam Syst Health 2011;29:138–43. McGorry PD, Tanti C, Stokes R, et al. Headspace: Australia’s National Youth Mental Health Foundation —where young minds come first. Med J Aust 2007;187:S68–70. Garralda ME. The interface between physical and mental health problems and medical help seeking in children and adolescents: a research perspective. Child Adolesc Ment Health 2004;9:146–55.
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Paediatricians and psychiatrists working together: what works best? Andrew Court Arch Dis Child 2014 99: 708-711 originally published online April 23, 2014
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Leading article
Paediatricians and psychiatrists working together: what works best? Andrew Court Since paediatrician Joseph Brenneman wrote of ‘the menace of psychiatry’ in 19311 complaining of the ‘psychiatrising’ of children’s normal behaviour, there has been recognition that the relationship between paediatricians and child and adolescent psychiatrists has been problematic. Fritz noted in 20032 when discussing challenges to the development of healthy collaboration between both disciplines that every 10 years or so since then there have been important reviews written by influential paediatricians and psychiatrists on the state of the relationship with problems noted and solutions offered. Over the last 10 years there has been an emphasis on the need to support paediatricians by the trialling of collaborative approaches with psychiatrists.3 There is also recognition from some psychiatrists that they need to be more collaborative in order to continue to enjoy a satisfying professional life.4–6 There have been changes to the ways medical care is managed, with issues of cost and cost-effectiveness increasingly driving how services are delivered.7 8 Evidence shows that paediatricians continue to feel unskilled in managing many mental health problems but also that they perceive psychiatrists to be unavailable.9 10 On the other hand, despite the breadth of potentially effective treatments available to psychiatrists, there is pressure on them to focus on prescribing medication with a perception that other more fulfilling models of their work are undervalued.4 When reviewing what works best in the working relationship between paediatricians and psychiatrists, much of what has been written over many decades remains relevant and highlights the need to recognise and respect the differences between the two disciplines. Only through such understanding can the ongoing barriers to healthy collaboration be removed. This review is written by a psychiatrist who initially trained and worked as a paediatrician. He works both in the public and private healthcare systems and is
Correspondence to Dr Andrew Court,Consultation Liaison Psychiatry, Royal Children’s Hospital, 50 Flemington Rd, Parkville, VIC 3052, Australia; [email protected] 708
active in developing collaborative relationships with paediatricians.
DIFFERENCES Much has been written about the differences between the working practices of paediatricians and psychiatrists (table 1). Enzer et al11 showed that they seem to have different character traits with different perceptions of how childhood is experienced, differences that predate their training. Training in child development in paediatrics has a focus on normal biologically driven development and its variations.12 In contrast, the emphasis in child psychiatry has historically been on theoretical psychodynamic and attachment models of development with the purpose of psychological understanding of abnormal clinical presentations.6 Though there has been a shift towards more biological and empirically based models of understanding for psychiatrists, these differences in emphasis persist.2 6 Differences in outlook and subsequent training contribute to different clinical working practices.2 12 Paediatricians are adept at gathering clinically relevant and often symptom-focused histories in a timelimited structure, are active and ‘problem solving’ in their consultative role and use language that is centred on symptom description and diagnosis.12 Psychiatrists, on the other hand, take longer to assess their patients, taking detailed biopsychosocial developmental histories. They do this to formulate the clinical case, to understand why this patient is presenting with a particular problem at a particular time in their developmental trajectory.6 13 Psychiatrists are more reflective both with patients and with colleagues, and use language that is more focused on understanding symptoms rather than on describing symptoms.2 Recognising that these differences can hinder good collaborative practice, many authors have commented that they should 12 be acknowledged and used.2 Psychiatrists are becoming more experienced in evidence-based treatments and in the prescription of psychotropic medication.14 Better use of these skills may prove helpful to paediatricians, who could also benefit from skills that enable deeper
understanding of complex patients. Models of collaboration should involve paediatricians identifying and managing more mental illness through direct collaborative clinical work. They should also become comfortable in assessing which patients need more intensive psychiatric assessment and management.15
THE NEED TO COLLABORATE It is estimated that up to 20% of children and adolescents have a diagnosable mental health disorder16 and that up to 50% of patients who see paediatricians have significant behavioural and mental health problems17 either as their presenting problem or as comorbidity. The role of paediatricians has changed considerably over time with a shift from acute medicine to what was termed ‘the new morbidity’18 when describing the significant increase in behavioural and emotional problems seen by paediatricians in place of many lifethreatening illnesses for which cures have been found. In addition, there is evidence that patients with mental illness are more likely to present with medical problems16 and that chronic medical illness is associated with mental illness.19 As well as comorbidity between medical presentations and mental illness, there are also conditions where there is the need for input from both disciplines. These include somatising disorders, eating disorders, gender dysphoria and pervasive developmental disorders. Even when management of these conditions involves input from both disciplines, there is not always open collaboration between them.20 It has been repeatedly shown that paediatricians acknowledge that they have a role in identifying mental health problems but do not believe they have the training or ability to treat them (with the exception of ADHD).9 10 21–23 Paediatricians have been documented as wanting help in clarifying diagnosis of complex patients and of comorbidities, in prescribing of psychotropic medication, in the treatment of depression and anxiety disorders and in crisis management of suicidal patients.10 24 25 Paediatricians recognise that they commonly do not have the time or expertise to manage complex patients.9 26 Increasingly, however, they are pressured to do so because of the numbers they see, but also because of external pressures such as managed-care funding arrangements.4 There is some risk that in response to these pressures, paediatricians may prescribe psychotropic medications inappropriately. In contrast, psychiatrists are under pressure to Court A. Arch Dis Child August 2014 Vol 99 No 8
Downloaded from http://adc.bmj.com/ on June 2, 2015 - Published by group.bmj.com
Leading article Table 1 Differences between paediatricians and psychiatrists
Background Outlook11 Developmental training6
Practice Time2 12 Information gathered6 Stance12 Language6 12 Prescribing
Paediatricians
Psychiatrists
Childhood as carefree Neurodevelopmental Biological
Childhood as struggle Psychodynamic/theoretical Biopsychosocial ‘understanding response to patient’ (‘transference’)
Short sessions Symptom focused Active Symptom/Dx focus Less psychotropic use
Longer sessions Attachment history/psychological development Reflective Formulation (‘understanding’) focused Psychotropic experienced
respond to increasing demand on their services by providing shorter assessments and briefer treatments that undermine their more extensive understanding of child and adolescent mental illness.4 Never has there been a clearer need to develop and validate good collaborative relationships between the two disciplines.
BARRIERS Worldwide, Child and Adolescent Mental Health Services (CAMHS) are underresourced with too few psychiatrists to service the populations they treat.27 This is recognised as a significant reason as to why paediatricians consider psychiatrists and CAMHS to be unresponsive to requests for help.9 25 28 29 Second, there are financial restraints that limit appropriate input from psychiatrists.9 Increasingly in the USA, where managed care has replaced fee-for-service, insurance companies are able to drive management plans. Psychiatrists are finding themselves pushed to focus on prescribing of psychotropic medication, while other less expensive mental health professionals take on psychotherapeutic roles.4 14 When psychiatrists do see patients, there may be financial barriers preventing what is seen to be appropriate treatment (eg, low reimbursements when working with parents alone).8 Administratively, there is a long history of fragmentation of medical and mental health services that do not have clear pathways of referral.12 28 Streamlining the management structures that deliver these services carries significant cost and requires government support. Even without the practical barriers that can be associated with bringing about collaboration between paediatricians and psychiatrists, there is a history of separation between the two disciplines that comes from a longstanding ambivalence that has Court A. Arch Dis Child August 2014 Vol 99 No 8
been argued to result from their different clinical approaches.12 For example, when paediatricians refer to psychiatrists, they often perceive them to be non-responsive due to the lack of communication from the psychiatrist that the referring paediatrician expects after referral.9 10 It is also well recognised that stigma remains a barrier to mental health referrals, with patients and families often reluctant to make an appointment following referral; medical illness continues to be more socially acceptable than mental illness.14 29 Finally, there has historically been less investment in the development of the evidence base for treatment of mental illnesses affecting children and adolescents. This has compounded a perception by some paediatricians that psychiatrists do not have effective treatments to offer anyway.12 14
COLLABORATIVE MODELS Despite such problems, there are many examples of healthy collaborative partnerships between paediatricians and psychiatrists (see box 1). For the most part, these examples come from inspired individuals who have helped create conjoint academic units, advocate for Consultation Liaison Child and Adolescent Psychiatric Services, and describe the benefits of collaboration.13 15 30 Clear patterns emerge from these descriptions of what works in these partnerships. Individual relationships need to be developed with face-to-face clinical discussion and informal meetings.25 28 There needs to be recognition and respect for differences in clinical styles and treatment paradigms, an appreciation that such differences are healthy and that each discipline can learn from the other.28 30 Dual training in paediatrics and psychiatry (‘triple board training’) has been
Box 1 Collaborative models Dual training Collaborative office rounds Consultation liaison psychiatry Joint guidelines for treatment Co-location models Telephone/collaborative consultation models Joint assessment and treatment clinics (eating disorders/somatising/PDD/ gender dysphoria)
occurring in specific locations for many decades. Though the training is strenuous and the numbers of dual trainees are small, graduates bring benefits from both training programmes into their clinical work and help to develop a bridging relationship between the groups.31 My own experience of dual training was that as a psychiatrist it was initially hard to let go of thinking and acting as a paediatrician. The process of recognising that I had become a psychiatrist, informed by having been a paediatrician, was instrumental in being respected by both disciplines. Collaborative supervision and discussion groups involving both paediatricians and psychiatrists are not uncommon. Described as productive,32 they are dependent on interested parties taking the lead.33 Within the long history of Consultation Liaison Child and Adolescent Psychiatry,19 good relationships have been described between medical and mental health teams with recognition of the need for mental health input into infants with serious illness or unwell parents, patients with chronic medical illness, somatising presentations, eating disorders, suicidal and selfharming adolescents and patients with comorbidity. Unfortunately, despite qualitative descriptions of the value of these services, there has been little evaluation of their cost-effectiveness, a feature that has led to limited support from bureaucratic funding sources.34 There are some descriptions of joint assessment and treatment clinics involving paediatricians and psychiatrists in areas of clearly overlapping expertise such as somatising disorders and eating disorders.28 35 36 These services provide practical ways of bringing paediatricians and psychiatrists together, and would benefit from greater visibility and evaluation.20 When consultant paediatricians are asked what they may need from psychiatrists, there is consensus about the 709
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Leading article desirability of a co-located model of health delivery where they can have easy access to psychiatrists for secondary consultation.9 10 24 37 Several models have been developed in the USA with varying degrees of co-location. For example, the Massachusetts Child and Adolescent Psychiatry Access Project (MCAPAP), set up in 2005,38 was based on a collaborative care model known as Targeted Child Psychiatric Services. Teams of psychiatrists and other mental health workers provide easy access of consultation to paediatricians. There are regular visits to paediatric clinics to provide education, together with hotline access to telephone consultation with psychiatrists. Telephone consultation may lead to an assessment from psychiatrists following which the patient is either returned back to the paediatrician for ongoing care (with support) or referral to local mental health services is instigated. The project has shown some success in engaging local paediatricians.3 37 39 In addition to expressing satisfaction with the service and accessibility of psychiatrists, paediatricians also stated that they felt more confident in their ability to care for children and adolescents with mental health problems. Other models based on the MCAPAP model have been generally organised along similar lines, with consultation with psychiatrists either occurring in person or by teleconferencing.14 40 Some services offer short-term treatment but otherwise refer back to paediatricians or to appropriate local MHS. An alternative model is the Connecticut Behavioural Health Partnership41 that focuses on improved access to mental health agencies. Services that can demonstrate accessibility and high standard treatment can gain access to additional funds. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have also collaborated to create educational materials to help paediatricians manage mental illness. For example, Bright Futures and DSM-PC have been developed to help foster common language between paediatricians and psychiatrists.8 The ability to develop collaborative relationships will very much depend on the setting and shared understanding of need for such collaboration. A public hospital with a captive patient group requiring input from both medical and mental health teams is very different from an outpatient setting. Outpatient settings, either public or private, require motivating forces in addition to those provided by individual practitioners in order to 710
develop collaborative practices in response to specific clinical needs. There has been a push in some parts of the world to develop Youth Mental Health services separate to CAMHS42 that are co-located with other medical and social services. Such arrangements are likely to improve accessibility and decrease stigma. It is important that meaningful collaborative practice is supported and encouraged in such settings in addition to the practical co-location.
MEASURING WHAT WORKS BEST There is no consensus on how to measure the effectiveness of collaboration between paediatricians and psychiatrists. Suggested measurables that need development are summarised in box 2. Paediatricians want ease of access to psychiatrists, to consult and get advice when needed and to hand over management of complex patients when appropriate.10 Psychiatrists are looking for new ways to engage and work in order to deal with pressures from external sources to be costeffective.6 Both need to feel that they are professionally valued and that they are personally satisfied. In addition, there is likely to be a need for the measurement of patient outcome benefit in order to justify expenditure on collaborative programmes. The collaborative programmes trialled in the USA have focused on qualitative measurements of paediatricians’ satisfaction with the service, and the perceived improvements in paediatricians’ skills following the collaboration.39 While these outcomes are positive, the numbers participating in the evaluation are small. There have been no quantitative measurements of improved patient care through collaborative interventions.14 Measuring outcomes of interventions to support clinical decision making in children’s mental health is far more difficult than assessing clinical outcomes for other medical conditions (eg, survival with chemotherapy). Measuring improved symptoms of psychological conditions is
Box 2 Measuring what works best Paediatricians/psychiatrists satisfaction with model (including evidence of augmented skills) Access to mental health services Medical service use School attendance Quality-of-life measurements Patient experience measures
problematic for many reasons (eg, symptoms naturally change over time/difficulties in defining a control group).7 Proposed potential targets for assessment include improved access to mental health professional care,10 decreased use of medical services,25 improved school attendance25 and improved quality-of-life measurements.7 The development of assessment tools that use patient experience would be another approach to demonstrate the value of collaborative interventions. The need to measure the effectiveness of collaborative interventions is likely to be an ongoing necessity given the focus on cost and cost-effectiveness in healthcare delivery. From an economic perspective, there has been little reason to invest in child psychiatric outcome research in the absence of innovative research tools that can show tangible and varied benefits. Subsequently, some services such as mental health inpatient admissions and lengths of stay have been cut without any strong evidence to do so.7
FUTURE DIRECTIONS As professionals from both disciplines have suggested, what works best are models where psychiatrists have developed individual working relationships with individual paediatricians. By being available to provide consultative advice that is perceived as helpful, psychiatrists are able to expand their input that helps create a cultural shift that values their conceptual input to clinical diagnosis and decision making above that of psychotropic prescription and the management of ‘complex patients’.6 15 25 While it has been noted that treatment models of mental health problems for children and adolescents should not be primarily driven by cost,7 12 it will be beholden on both paediatricians and psychiatrists to invest in evaluation that can better measure the outputs of collaborative models that are likely to both improve patient outcome and be cost-effective. Several prominent authorities have stated that there should be advocacy from administrative bodies of both paediatricians and psychiatrists together to push for ongoing support of collaborative models.13 22 The AAP and the AACAP have jointly advocated for appropriate funding and reimbursement for the provision of mental health services to paediatricians.8 Further advocacy around such collaboration will be needed to sustain pressure to reform funding arrangements. Further work is also needed to determine best models of care. This includes models Court A. Arch Dis Child August 2014 Vol 99 No 8
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Leading article of training paediatricians towards becoming more competent at managing mental health illnesses and the development of guidelines as to when it is appropriate both for consultation and/or transfer of care to psychiatrists or CAMHS.22 25 Consultation Liaison Child and Adolescent Psychiatry, while recognised by most authorities as being an important and necessary component of medical care in major hospitals, continues to lack universal support from administrative bodies.34 43 Further work is needed to research methods that better demonstrate the costs and benefits of mental health input into medical hospital treatment and to use this to advocate for service development. Targeted interventions to further develop formalised collaboration in illnesses (such as somatising disorders) that share mental health and medical assessment and treatment is one area of potential development.5 20 The understanding that child psychiatrists can shift their roles from those that purely provide direct clinical care to also include consultation and collaboration is gathering momentum.6 Child psychiatry training programmes must adapt to this change and put greater emphasis on the importance of functioning within systems, on speaking the language of paediatricians and in participating in conjoint education and training experiences.6 Given the significant burden of mental health problems affecting patients that paediatricians treat and the relative lack of child and adolescent psychiatrists, strategies are needed to support and increase collaboration. Alliances are needed to advocate for mental health parity, for the further development of conjoint training in both disciplines and for outcomes research that is needed to drive service development. Committed and charismatic individuals are still needed from both professional bodies to advance and promote this agenda.
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Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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To cite Court A. Arch Dis Child 2014;99:708–711. Received 11 December 2013 Revised 25 March 2014 Accepted 2 April 2014 Published Online First 23 April 2014 Arch Dis Child 2014;99:708–711. doi:10.1136/archdischild-2013-304594
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Paediatricians and psychiatrists working together: what works best? Andrew Court Arch Dis Child 2014 99: 708-711 originally published online April 23, 2014
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