Referral Patterns

Most surveys of pediatric psychosomatic medicine services suggest an increasing demand for consultation in recent years (Shaw et al. 2006). Wiss et al. (2004), in a French study, reported an increase in activity of 33% between 1994 and 2000. Services most commonly requested from and provided by departments of psychiatry in children's hospitals are inpatient and outpatient consultation-liaison psychiatry services (Campo et al. 2000). Despite this increasing demand, other studies suggest that referral rates for psychiatric consultation for pediat-ric patients average only 2% of the hospital population, indicating that psychiatric illness in many physically ill children and adolescents goes unrecognized (Frank and Schafert 2001).

Rates of referral may be even lower in countries with less established psychiatric consultation services. For example, in a study of 18,808 pediatric inpatients in Mexico, Buriân et al. (1978) reported a referral rate of only 0.31%. However, McFadyen et al. (1991) found that both awareness of psychological issues and referrals for psychiatric consultation can be increased as a result of administrative decisions to expand and improve psychiatric services in a general hospital. In the group of patients that are referred for consultation, school-age children and adolescents tend to be overrepresented, whereas preschool children are commonly underrepre-sented. Physicians, most commonly pediatricians, generate the bulk of referrals, with a smaller number coming from nurses, social workers, child life specialists, and family members (Black et al. 1990; Ramchandani et al. 1997).

Most pediatric psychosomatic medicine services report a high frequency of referrals for the assessment of suicide attempts and adjustment to illness (Black et al. 1990; Shaw et al. 2006; Wiss et al. 2004). According to Burket and Hodgin (1993), the major reasons for psychiatric consultation are behavior problems, suicide evaluation, depression, and reaction to illness. The high frequency of requests for consultations regarding parents' adjustment to a child's illness suggests that recognition of the effect of the child's illness on parental adaptation is increasing. Another important role of pediat-ric psychosomatic medicine services is that of staff education and support (Chan 1996). Table 1-1 lists the most common reasons for pediatric psychiatric consultation.

Table 1-1. Common reasons for pediatric psychiatry consultation requests

Adjustment to illness Delirium

Differential diagnosis of somatoform disorder

Disposition and referral

Disruptive behavior

Medication consult

Nonadherence with treatment

Pain management

Parental adjustment to illness

Procedural anxiety

Protocol assessment

Suicide assessment

Source. Reprinted from Shaw RJ, DeMaso DR: "Pediatric Psychosomatic Medicine," in Clinical Manual of Pediatric Psychosomatic Medicine: Consultation With Physically Ill Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2006, p. 11. Copyright American Psychiatric Publishing, 2006. Used with permission.

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