Download Diagnosis Dilemmas in Paediatric Consultation - Vula

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
This presentation
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A brief history and overview of relationship
between Paediatrics and C-L Psychiatry
Red Cross Children’s Hospital ConsultationLiaison service
Case examples
Conclusion
What is consultation liaison psychiatry?
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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
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Involves collaboration between two
teams who differ in their main
focus of interest and methods of
working.
Paediatrician- established a physician-patient relationship
- primary case manager
Psychiatrist -brief consultations
-acute setting
-distressed child
-communication problems
-absence of parent
History
Paediatrics and Child psychiatry: 6 decades
of the relationship
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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
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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
Donald Winnicott (1896 - 1971)
‘Common Ground’
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Collaboration around common goals
Clinical population at psychological risk
Holistic treatment
Prevention
Multidisciplinary models of care
Red Cross Children’s Hospital
Consultation-Liaison Service
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Team
Services
Teaching
Research
Future- training?
Role of liaison team
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Diagnostic
Psychosocial meetings/ward rounds
Multidisciplinary team meetings
Psychological management- group therapy
- individual
Psychotropic medication
Staff support
Family support
Transition to adult services
Common reasons for referral
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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
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
Medical Details
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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
Medications & Management
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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
Staff involved
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Nursing staff
Social worker
Medical: Burns team, ICU team, Pain team
Physiotherapist
Occupational therapist
Dietitian
Aromatherapist
Volunteers
Psychiatry
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
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
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
Multiaxial Diagnoses
Axis I:
 PTSD
 Depressive disorder
Axis II:
 nil
Axis III:
 Severe burns
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septicaemia
 GIT complications/ colostomy
Axis IV:
 Medical condition
 Hospitalisation
Axis V:
 60
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
Outcome
Patient died 17/10/05 due to overwhelming
sepsis, 1 week prior to her 11th birthday
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
Medical Details
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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
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
Imaging:
 CT x 2
 MRI
 Ultrasound UKB
EEG: normal
Muscle Biopsy: normal
GIT Endoscopy: normal
Treatment
Admissions for IV fluids
Medication:
Omeprazole, anti-emetics,Carbamazepine
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
Thoughts:
 No abnormalities
 Couldn’t think of 3 wishes
No perceptual disturbances
Cognitive function:
 Orientated, alert, poor cooperation
Insight poor
Summary
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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
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
Outcome
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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
Ethical dilemmas/end of life decisions
11yo male
 MVA pedestrian
 C2 resection, paralysed, ventilator
 Cognitively intact and alert
 Prognosis very poor
 Withdrawal of treatment
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Child psychiatry consult
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What to tell the child?
Right to be informed?
Consent/assent
Counselling: death/dying
Parent’s wishes
Outcome
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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
Conclusion
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End of life
Hospital environment
Multiple drug regimens
Tolerating diagnostic uncertainty
C-L/ Paediatrics
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Limited human resources
Effective Collaboration
Multidisciplinary approach
Collaborative clinical services
Teaching and training
Collaborative research
“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)
THANK YOU