Evaluation of psychiatric consultation-liaison in primary care settings

This article considers eight methodologic issues in the evaluation of psychiatric consultation-liaison services in primary care settings. What should be evaluated--standardized treatment regimens administered to highly selected patient groups or individualized treatments administered to heterogeneous patient groups? How can patient groups be selected to test for generic outcomes resulting from individualized treatments? When should randomized designs be employed? Should patients or physicians be randomized? How should diagnostic classification of study subjects be accomplished? What outcomes should be measured? How can study design be accommodated to patient flow in clinical settings? What resources are required to establish a productive program of research in liaison psychiatry?     

Child psychiatry, the question of a kiss

What should child psychiatry care workers do when a child spontaneously embraces or kisses them? This questioning goes far beyond the fact of kissing and raises the question of the nature of the healthcare relationship and environment. While theoretical knowledge is necessary, it is not sufficient for achieving phronesis or "practical wisdom".     

Process of institutional child guidance counseling reflected by the Central Continuing Education of the Federal Conference for Child Guidance Counseling

The Bundeskonferenz für Erziehungsberatung (bke) is the federation for child guidance and family-counseling in Germany. Members are the working groups for child guidance and family-counseling of the L?nder, where the employees of the child guidance are organized. The federation was founded in 1962. It is sponsored by the Federal Ministry for Family, Seniors, Women and Youth. Further education for professional youth workers is central mission of bke. The constitution of the federation lais down these contents. Every autumn the bke publishes the program for further education for the following year in a brochure called Zentrale Weiterbildung--the program for child guidance, family counseling and youth counseling. A special Kommission Zentrale Weiterbildung acquires the contents of the program for further education und selects the referents. Since 1968 the Zentrale Weiterbildung of Bundeskonferenz für Erziehungsberatung offers events for professional youth workers in child guidance, family counseling. The program for further education contributes the quality of the institution of child guidance. After a time with above average use of the program for further education with therapeutical focal point, the orientation of the program changes to child and youth services. A constant number of counselors use the program. Beside the change of contents there was a change to effectiveness of contents and a reduction of participants.     

Emotional reactions to the sudden death of a child: the challenge to emergency care providers

The death of a child has the potential to traumatize everyone involved. Child deaths caused by auto crashes, suicides, murders, gun accidents, drowning, fires, natural disasters, sudden illness, and other events trigger painful and profound emotional grief reactions in family members, and, at times, for emergency care providers. What grief reactions do family members experience when their child dies suddenly? What emotional struggles take place with siblings? How do emergency care providers cope with the tragic and painful deaths of children? We are guided by the literature and by our own experiences in pediatric emergency departments in trying to supply answers to the questions posed.     

Comprehensive care of pregnant mentally ill women

Since the onset of deinstitutionalization, there has been an unanticipated and dramatic increase in pregnancies among women with chronic mental illness, with no specific planning for how to address the unique clinical needs of this high-risk population. Shortcomings in delivering care to mentally ill women within general health care systems are reviewed, including failure to assist with family planning, failure to observe worsening mental health during pregnancy, inadequate planning for child custody, lack of access to services, and omitted pelvic examinations. Necessary components of a system to provide comprehensive and coordinated care for pregnant mentally ill women are described. These include assessment of adaptation to pregnancy and competency to care for an infant, somatic and psychotherapeutic treatment, parenting skills training, family planning services, outreach, and close liaison with obstetric services. A Chicago-based collaborative program is described as an example of providing comprehensive, specialized care with limited financial resources.     

Intervention for autistic spectrum disorders

A comprehensive approach to the assessment of any child with autism must be matched specifically to each individual child and family. This premise holds for medical therapies and special education services as well as psychopharmacologic interventions. Behavioral, as opposed to pharmacologic, treatment is the hallmark of effective intervention for autism. Physicians involved in the care of children with autism need to become familiar with educational law and intervention recommendations. Goals should include improved functional verbal and nonverbal communication and social skills, increased engagement in developmentally appropriate activities, improved fine and gross motor skills, and the development of independent academic and organizations skills, as well as replacement of problem behaviors with developmentally appropriate behaviors. Medicating children with autism is difficult, but is often necessary for chronic behavioral difficulties. In the absence of clear and present guidelines, we have attempted to use evidence and clinical experience to suggest an algorithm based on symptom clusters. Although children with autism may be responsive to medications at lower doses and more susceptible to side effects than other children, medical intervention can produce a significant improvement in the quality of life for the child and family. Careful thought leading to correct identification of target behaviors can appropriately direct better alternatives for medication. Although these approaches are costly and time-consuming endeavors, the expenditure of such efforts is the only available pathway to improve the potential outcomes for individuals with autism as well as decrease the lifetime societal costs for each individual.     

Forensic evaluation of trauma syndromes in children

There are significant differences between a clinical evaluation and a forensic evaluation [289-291]. These differences must be kept solidly in mind in performing the evaluation. The forensic evaluator needs to assess the validity of complaints, including the possibility of malingering and the child's ability to describe symptoms accurately, the connection between the symptoms and a given incident, and the potential long-term sequelae of a trauma. The goal of the interview is not to treat, but to obtain information. Assessing the validity of complaints is perhaps the greatest challenge. This requires obtaining and reconciling data from numerous sources, including interviews with the child and parents, and information from other sources, as well as rating scales and validity testing. One must be very cautious in asking leading questions and using standardized PTSD protocols, lest they teach the parents and child about the symptoms of PTSD and thereby distort the information they provide as a result. The forensic interviewer should consider what will be needed when called to testify in court. What data will convince the jury? How might the opposing attorney challenge the assessment? What scientific studies support the findings and conclusions concerning the diagnosis, functional impairment, and validity. The precise DSM-IV-TR diagnosis is not always key in a forensic evaluation. What is essential is establishing the connection between the trauma and ensuing emotional problems. All of the symptoms the individual has as a result of the trauma become important, whether or not they contribute to fulfillment of DSM-IV-TR criteria. This contrasts with a clinical evaluation in which one needs to demonstrate the existence of a DSM-IV-TR diagnosis for reimbursement purposes. Finally, the forensic evaluator should be familiar with current practice guidelines for examination of children with PTSD. Any deviation may need to be explained in court [264,292].     

Research on a children's psychiatric inpatient service

It is widely recognized that child psychiatry needs to expand its research enterprise. Psychiatric inpatient units that serve children and adolescents should serve important roles in clinical research in child psychiatry. This paper reviews the need for research on the nature and treatment of psychiatric disorders on children's psychiatric inpatient services and discusses the resources necessary for a productive inpatient research program. The intrinsic relationship between clinical care and clinical study is emphasized.     

Architecture, budget and dignity

Drawing on its dynamic strengths, a psychiatric unit develops various projects and care techniques. In this framework, the institute director must make a number of choices with regard to architecture. Why renovate the psychiatry building? What financial investments are required? What criteria should be followed? What if the major argument was based on the respect of the patient's dignity?     

A model for planning interagency coordination.

This paper discusses key issues with regard to planning interagency coordination of services for the mentally disabled. Basic questions which planners should address are: What is coordination? What functions are to be coordinated? What are the costs and benefits? What is the target population of clients and services? What type of structure is required and how should it be implemented? A continuum is constructed, along which various coordination structures are placed according to the degree of control exerted upon participating organizations. Requirements for successful coordination include skilled staff with positive attitudes; carefully developed procedures; good information systems; adequate funding; and facilitative policy that provides a clear mandate and direction.     

Face aux dilemmes éthiques,quelle démarche ? À propos d’une alimentation entérale chez un enfant polyhandicapé

The clinical condition of a young 15-year old patient with multiple disabilities, gradually deteriorated: atrophy, vicious attitudes, weight loss… The meals, which lasted a very long time, were “an ongoing battle” exhausting for the young patient, staff and parents. We, caregivers, considered the interest of a gastrostomy. What to do or not, what decision to make? What level of support is considered not to be in an unreasonable obstinacy? When a child cannot speak for himself or herself, who owns the decision: parents, caregivers? Ethics entails the permanent adaptation of moral values to the needs of society, allowing it to keep its humanity, especially towards the weakest and sickest. It is convened in our questioning; it is not simple: what is the “right action”, the “good care”, whose “own good” do we want? Our care should focus on both the young patient who expresses neither desire nor need, nor satisfaction and his family. What to do when caring for the patient might disrupt the care of the family? Moreover, does taking into consideration the family's word guarantee the respect for the patient? Facing this clinical situation where uncertainty prevails, the ethical approach, genuine area of authorization of thought, can give meaning to the practices and facilitate making the least bad decision possible. In this article, first the ethical dilemma is identified (to perform, or not, a gastrostomy), then the clinical situation of the young patient is analysed by a dual approach: classic technical – medical, ethical, legally and innovative – ethical principles by convening autonomy, beneficence, non-maleficence and justice.     

Schizophrenia.

Schizophrenia occurring in childhood and adolescence has similar diagnostic, prognostic, and treatment ramifications as those noted with adult-onset schizophrenia. In assessing a child or adolescent suspected of having schizophrenia, care must be given to document DSM-III-R diagnostic criteria within the developmental framework of the patient's functioning, while thoroughly evaluating for other potentially confounding disorders or conditions. Antipsychotic therapy is the only specific treatment for schizophrenia, and should be a fundamental component with a multimodal treatment program that also addresses the psychological, social, and educational needs of the patient and his or her family. Strategies for medication management vary depending on several factors, including the stage of the disorder, noted or potential side effects, and the response of the patient to treatment, and need to be coordinated for the long term by a child or adolescent psychiatrist familiar with the diagnosis and treatment of schizophrenia in this age group.     

An evaluation of a family psychoeducation program in community mental health

The aim of the research project was to identify the efficacy of the family psychoeducation program as a strategy for reducing the hospital admissions of young people. It also aimed to determine if the family psychoeducation program had an impact on the experience of caregiving and knowledge and satisfaction of services provided by the mental health service. A retrospective chart audit compared readmission history of 27 clients whose families attended a psychoeducation program with readmission history of a matched group of young people whose families did not attend the program. A telephone survey was conducted for both groups of families to investigate knowledge and understanding of services and burden of care. The results indicated that family participation in a brief multiple family psychoeducation program did not reduce the number or duration of admissions of the young people. There was no impact on the level of care for families who attended the psychoeducation program, however, this group showed some evidence of increased knowledge and understanding of services as compared to the control group.     

Bioethics, Assisted Suicide, and the “Right to Die”

Physician-assisted suicide is much talked about. But confusion remains as to what precisely it is, and debate continues about its ethical implications. Is physician-assisted suicide distinguishable from refusal of treatment? Is there a “right to die?” Does assisted suicide necessarily have to mean physician-assisted suicide? What is the relationship of physician-assisted suicide to end-of-life care? How should physicians deal with a request for assisted suicide? These issues are explored in this paper, along with a review of the ethical arguments for and against physician-assisted suicide. The paper concludes that society should encourage individuals not to see assisted suicide as their best option. A better policy than widespread legalization of physician-assisted suicide is to provide the necessary social support, health care including mental health care, hospice care, and compassion to those who feel they face an undignified life, or an undignified painful death. This paper is based on a presentation made at the AACP 2000 Annual Meeting, October 14, 2000.     

Pediatric inflammatory bowel disease

The treatment of children and families affected by pediatric IBD requires an awareness of the diverse psychobiologic effects of the disorder over the course of child, adolescent [53], and adult development [52]. Optimal treatment requires careful coordination of various medical, educational, and rehabilitative services and concerned, empathetic, continuity of care by knowledgeable clinicians [4]. In many cases, this care must also include individual psychotherapeutic work with affected youngsters at crucial junctures to help deal with the social and psychological stresses of IBD, as well supportive casework for parents and siblings.     

Community services outcomes for families and children with autism spectrum disorders

In an era in which evidence based practices are becoming the standard of care, there is little evidence that the current array of services commonly delivered for those with autism is helpful. This study describes community-based service utilization and caregiver-rated outcomes of services on symptoms of 113 children with autism spectrum disorders and their families. Parents/caregivers reported on nine types of services, received in the prior 6 months, which were evaluated against child and family outcomes. Caregivers rated in-home behavior therapy as providing the best outcomes overall for the child and respite care as providing the best outcomes for the family. Younger children were reported to have better outcomes than older children. Polytherapy was the rule, rather than the exception, as children used a mean of 3.5 different services. The frequency of services and the number of different types of services utilized correlated with family but not child outcomes. Examination of the potentiating effect of medication on outcomes of psychosocial interventions was not significant.     

Geriatric psychiatry and managed care.

A wide gap exists in the American health care system between what we know good geriatric mental health care services should look like and the types of services generally available. Cost effective treatment requires a continuum of care in which geriatric psychiatry and primary care geriatric services are integrated in an aggressively case managed model. MCOs have the infrastructure and tools at their disposal to make this work, but they must incorporate into their programs and approaches expert knowledge of the unique clinical problems of the frail elderly.     

Education rights and the special needs child

A child with a disability has a federally protected right to special education and related services when he or she needs them to benefit from education. The term "disability" is not limited to physical disability but rather includes mental disability, including mental retardation, serious emotional disturbance, autism, traumatic brain injury, specific learning disabilities, and other health impairments. A parent may request that a child be evaluated by the school district for special education and related services. The law sets forth specific guidelines for the evaluation, assessment, and eligibility determination. Unique to each child, the IEP is the written plan that documents the child's special education and related services. The initial IEP is developed at a meeting among parents, various school personnel, and others whom the parents may wish to invite. Parents are an integral part of the team and are involved in all decisions by the team. The IEP must be reviewed annually, with attention given to whether educational objectives have been met. For a child with mental health issues, the IEP likely contains "related services," such as counseling, and measurable goals to improve behaviors in the school setting. When a child's condition is such that he or she cannot benefit from education in the regular school setting, other placements are considered. The school district maintains the ultimate responsibility of the cost of all such education placements, including residential care. A child with behaviors that result in frequent suspensions should have a functional analysis assessment by the school psychologist. The results of the assessment can be used to create a behavioral intervention plan. (If the school refuses to perform an assessment or develop a plan, the usual remedy of a due process hearing is available to the parents.) This plan should address problem behaviors and include strategies for redirecting the child's behavior. Even if a special education child is "expelled" from school, the district maintains the responsibility of providing FAPE. For this reason, districts--even in their own interests--should be proactive in dealing with these children, which often has not been the case. The Supreme Court has said that a child with services under IDEA (a child with an IEP) must receive some benefit from his or her education [31]. The issue of "how much benefit is enough benefit" is still troubling to parents and schools alike. The court also has ruled that related services, even costly ones such as a one-to-one nursing aide, must be provided if a qualifying child needs such services to access education [29]. Children with disabilities were long excluded from the public education system in this country. Obvious exclusion rarely occurs in the current education system, although exclusion through isolation does. Children with disabilities, especially mental disabilities, need and deserve the same educational benefit offered to children without those differences.     

Practice parameter on child and adolescent mental health care in community systems of care

This parameter presents overarching principles and practices for child and adolescent mental health care in community systems of care. Community systems of care are defined broadly as comprising the wide array of child-serving agencies, programs, and practitioners (both public and private), in addition to natural community supports such as religious and consumer organizations. Recommended principles and practices are derived from the system-of-care approach to service delivery. Based on the principles of the Child and Adolescent Service System Program, this approach has had a major influence on community systems of care through extensive federally funded projects and initiatives. The system-of-care model emphasizes that care should be tailored to the individual needs and strengths of the child and family and provided in the most community-based and least restrictive setting that meets their needs. Families are included as partners in the clinical process and are also involved in program development and evaluation. Services are coordinated and integrated into a comprehensive care plan. This model can be practiced even in the absence of formal systems of care or protocols, with the individual clinician promoting interagency coordination and child and family collaboration. This parameter is written for a broad audience of mental health professionals, with special emphasis on the roles of child and adolescent psychiatrists in community systems of care.     

Mental health of primary family caregivers with children with intellectual disability who receive a home care programme

Background The aims of the present study were to describe the change in mental health over time in a group of family caregivers with a child with intellectual disability (ID) and to explore the effect of a home care service on the psychological well‐being of the caregiver. Methods The authors identified children with ID who received home care services in the southern part of Taiwan. A total of 46 primary family caregivers (age range = 21–65 years) were recruited for the present study. The study design was a quasi‐experimental follow‐up analysis. The children with ID and their families regularly received home‐based care. The 12‐item version of the Chinese Health Questionnaire (CHQ) was used to evaluate the subjects’ mental health at three time points: (1) baseline, (2) 3 months and (3) 9 months. The validity and reliability of the CHQ have been tested in Taiwan. The Generalized Estimating Equation was used to conduct longitudinal data analyses. Results The authors found that the family caregivers showed a significant improvement in their mental health by month 9. Conclusions The preliminary findings of this study accredit the effect of home care services and suggest that home care services are necessary for family caregivers.