|Year : 2017 | Volume
| Issue : 1 | Page : 40-44
Pediatric referrals to psychiatry in a Tertiary Care General Hospital: A descriptive study
Bheemsain Tekkalaki1, Veerappa Y Patil2, Sameeran S Chate1, Nanasaheb M Patil1, Sandeep Patil1, V Sushruth1
1 Department of Psychiatry, K.L.E University's, J.N Medical College, Belgaum, Karnataka, India
2 Department of Addiction Medicine, NIMHANS, Bengaluru, Karnataka, India
|Date of Web Publication||14-Jul-2017|
Department of Psychiatry, J N Medical College, K L E University's, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Children with chronic physical illnesses frequently have psychiatric comorbidities, which often go un-noticed and may lead to more resource utilization and morbidity. Pediatric liaison services can be effectively used to bridge this gap. Literature on pediatric liaison services is sparse. Aims: To study the referral patterns, reasons for referrals, psychiatric diagnoses and interventions in children and adolescents referred to psychiatry department in a tertiary care hospital. Materials and Methods: A retrospective chart analysis of all children and adolescents below 19 years of age, referred to psychiatry department from 2010 to 2015, was done. Data was collected and statistical analysis was done. Results: Two hundred and nine subjects were included in the study. Mean age of sample was 12.15 (±4.20) years, with about 66.02% being males. About 54.06% of the participants were referred from pediatricians. Almost three fourth (72.25%) of children had no diagnosable physical illness. Intellectual disability (19.62%) was the most common psychiatric diagnosis, followed by depressive disorders (14.35%), and dissociative disorders (12.92%). Conclusions: In our study, majority of the referrals were the adolescent males from pediatric department. Intellectual disability, depressive disorder, and stress-related disorders were the common diagnoses. The fact that three-fourth of the referred children had no physical illness implies lack of awareness, stigma toward mental illness, and pathway of care.
Keywords: General hospital psychiatry, liaison psychiatry, pathway of care, pediatric liaison
|How to cite this article:|
Tekkalaki B, Patil VY, Chate SS, Patil NM, Patil S, Sushruth V. Pediatric referrals to psychiatry in a Tertiary Care General Hospital: A descriptive study. J Mental Health Hum Behav 2017;22:40-4
|How to cite this URL:|
Tekkalaki B, Patil VY, Chate SS, Patil NM, Patil S, Sushruth V. Pediatric referrals to psychiatry in a Tertiary Care General Hospital: A descriptive study. J Mental Health Hum Behav [serial online] 2017 [cited 2020 Jul 8];22:40-4. Available from: http://www.jmhhb.org/text.asp?2017/22/1/40/210710
| Introduction|| |
Epidemiological studies suggest that more than 10% of children and adolescents in community suffer from psychiatric illness;, however, only 10% of them receive specialist care. Literature also suggests that one in four children attending general practice have psychiatric problems,, and nearly one in three children seen by pediatrician have mental health issues. It is also clear that the children with chronic physical illness often have comorbid psychiatric illness. Comorbid physical illness and hospitalizations may lead to anxiety symptoms, and chronic illnesses may lead to negative body image and low self-esteem.
Patients with psychiatric illness make 20%–100% more non-mental health visits and cost 20% more per year for treatment of non-mental health problems. However, psychiatric comorbidities in these children usually go undetected or undertreated.
Pediatric liaison services can be effectively utilized to bridge the treatment gaps mentioned above. Pediatric consultation-liaison (CL) comprises all consultations, liaison, diagnostic, therapeutic, teaching, support, and research activities carried out by psychiatrists and other mental health professionals in pediatric ward. Despite the potential role of pediatric liaison psychiatry in general hospitals, there is a dearth of studies focusing on this area. To the best of our knowledge, there are no published studies from India on pediatric liaison services in a general hospital.
We took up this retrospective descriptive study with the aims of identifying the referral patterns, psychiatric diagnoses, and interventions in children and adolescents referred to psychiatry department in a tertiary care hospital.
| Materials And Methods|| |
The study was carried out in a tertiary care super-specialty teaching hospital of a South Indian city. The institute runs a postgraduate psychiatry department with round-the-clock liaison psychiatry services. Teams consisting of a consultant psychiatrist and a postgraduate trainee are available on rotation basis for the management of psychiatric references, both bedside/outpatient department (OPD) referrals. Initial assessment is done by the on duty postgraduate trainee, a provisional diagnosis is made as per the International Classification of Diseases-10 guideline, and treatment is started, later to be reviewed by the consultant psychiatrist on the same day or the next one. Assistance from clinical psychologist and psychiatric social worker is taken whenever necessary.
This study is a retrospective review. The study was approved by institutional ethical committee. Case files of all children and adolescents (up to 19 years of age) referred to psychiatry department for a period of 5 years from January 1, 2010, to December 31, 2015, were analyzed. Sociodemographic and clinical details were collected using a semi-structured pro forma. Data was tabulated, and appropriate statistical tests were applied using Epi Info-7 (by CDC- Centers for Disease Control and prevention) software.
| Results|| |
A total of 232 children and adolescents were referred during this period. Out of 232, 23 children were excluded from the study as data available was incomplete. Two hundred and nine children were included in the study.
Mean age of the sample was 12.15 (±4.20) years, with male sex being predominant (66.02%). About half of the children were referred from the department of pediatrics (54.06%). The next most common sources of referrals were departments of neurology (26.79%) and internal medicine (6.22%). Only about 10% of these children had a family history of psychiatric illness [Table 1].
The most striking characteristic of our sample is, though referred from various medical or surgical departments, about three-fourth of these children (72.25%) had not received any medical or surgical diagnoses. Among those who had comorbid physical illness, the most common was epilepsy (46.55%), followed by other neurological illness (17.24%), febrile seizure (5.17%), and head injury (5.17%) [Table 1].
The most common reasons for referral were externalizing symptoms (49.28%), followed by unexplained physical symptoms (30.14%), internalizing symptoms (17.7%) and poor scholastic performance (10.52%). The most common presenting complaints were hyperactivity (15.31%), followed by irritability (14.88%), poor scholastic performance (13.34%), and headache (12.92%). Mental retardation was the most common psychiatric diagnostic category (19.62%), followed by depressive disorders (14.35%), dissociative disorders (12.92%), and stress-related disorders (10.53%). Six children (2.87%) were referred for evaluation of intentional self-harm and around 6.22% of children had no diagnosable psychiatric condition. Around 68.9% of them required some pharmacotherapy [Table 1].
We further divided the sample into two age groups as children (younger than 12 years) and adolescents (12–19 years) and made the comparisons [Table 2]. The mean age of group comprising children was 8.20 (±2.62) years and that of adolescents was 15.18 (±2.17) years. Significantly a large number of children were referred for their externalizing symptoms when compared to adolescents (39.56% and 25.42%, respectively, P = 0.0424). Whereas, internalizing symptoms was the reason for referral in adolescents more often than in children (24.58% and 8.79%, respectively, P = 0.0054). Significantly a large number of adolescents received the diagnosis of depressive disorder (19.5% of adolescents and 7.7% of children; P = 0.0269) whereas children more often received the diagnoses of pervasive development disorder (13.19% of children and 1.7% of adolescents, P = 0.0026) and hyperkinetic disorder (15.39% of children, 7.66% of adolescents, P = 0.0006) [Table 2].
|Table 2: Comparison of clinical characteristics of child and adolescent age groups|
Click here to view
| Discussion|| |
To the best of our knowledge, this is the first study focusing on the pediatric referrals to psychiatry from the Indian subcontinent. Given the striking differences in the pathway of care of psychiatric illnesses, help-seeking behavior, stigma, and the sociocultural aspects of Indian patients, especially when it comes to child mental health issues, we thought it is worthwhile to explore this un-touched area.
Mean age of the sample was 12.15 (±4.20) years, which is well within the age range (9–14 years) reported from most of the previous researchers.,,,,, Difference in the inclusion criteria and study settings may be the reason for this wide age range. Twenty-six (12.44%) children referred were younger than 6 years of age and only 4 (1.9%) of them were younger than 3 years of age, whereas 14% of the children were younger than 3 years in a Turkey-based study. Moreover, the epidemiological data of child psychiatric illness in Indian community suggest that children of age group 0–3 years had higher prevalence of psychopathology than their older counterparts. These discrepancies may suggest the lack of awareness among parents and medical fraternity about the mental health issues of infants, toddlers, and preschool age children in our country.
Boys (66.02%) outnumbered girls, a finding similar to that of many previous studies.,, On contrary, a widely acclaimed and community based Indian epidemiological study of child and adolescent mental health reported no sex differences. Sociocultural influences in help seeking may be an important reason behind this, as Indian parents probably are more concerned about the health issues of their male children than females.
Majority of patients were referred from the department of pediatrics (54.06%). A similar trend was observed by most other researchers.,, The age factor is the obvious reason here. Another reason is that the psychiatric problems in children often manifest with physical symptoms, leading to pediatric consultation. The next major source of referrals was the department of neuromedicine (26.79%), this can be explained by the fact that many psychiatric disorders such as conversion reactions, dissociative motor disorders, and sensory disorders resemble neurological disorders. Studies have showed that about 15% of the patients seen by neurologists have no physical basis for their symptoms, and in another 15%, the symptoms are out of proportion to the underlying cause.,
The most common physical diagnoses among these children were epilepsy (46.55%), other neurological illness (17.24%), febrile seizures (5.17%), and head injury (5.17%). Kiliç et al. have also observed that brain pathologies are the most common medical illness among the referred children. These findings are not unexpected as neurological illnesses have a very close association with psychiatric symptoms due to shared neurobiological etiology.
The most striking observation of this study is that 151 (72.25%) children referred from various departments had no diagnosable physical illness. This is in contrast to the observations done by Al-Haidar 2003 (18.4% had no medical diagnoses) and Kiliç et al. 2007 (6.6% had no medical diagnoses). This may be because of high levels of stigma, lack of awareness among the parents, and predominant somatic manifestations as described above, which makes them to go to a pediatrician/physician before consulting a psychiatrist. The pathway of care for psychiatric illness is another issue to be considered, as in India, mental health professionals are rarely contacted first for psychiatric problems.
Evaluation of externalizing symptoms was the most common reason for referral (49.28%), followed by unexplained physical symptoms (30.14%), internalizing symptoms (17.7%) and poor scholastic performance (10.52%). In a similar study, majority of children were referred for the assessment of comorbid psychiatric disorder and evaluation of cognitive development.
Similar to what we have observed, depressive disorders, hyperkinetic disorders, and stress-related disorders are the common psychiatric diagnoses among the referred children in most of the earlier studies.,,,,,, It is a well-known fact that chronic physical illness in children often is associated with psychological consequences such as depression and anxiety. Moreover, as one can observe, many children in this study were suffering from epilepsy and other neurological illness. Depression is a common comorbidity of these neurological illnesses, may be due to shared neurobiological etiology or as a reaction to the disability. Hyperkinetic and other behavioral disturbances are also common comorbidities of epilepsy, brain pathologies, and intellectual disability.
Six children (2.87%) were referred for the assessment of intentional self-harm behavior. In a large hospital-based study from India, Grover et al. have observed that 0.82% of children and adolescents were referred for evaluation of self-harm behavior. In contrast, significantly large proportion of children had intentional self-harm in studies abroad.,, Difference in the study setup (for e.g. studies done in emergency department) may be one reason for this discrepancy. Under-reporting of intentional self-harm in India, due to stigma and fear of legal consequences, may be the other reason.
The fact that hyperkinetic and disruptive disorders begin during younger age compared to depressive and anxiety disorders explains the findings that children were more often referred for externalizing symptoms and more often received the diagnosis of hyperkinetic disorders than adolescents, whereas adolescents were more often referred for the internalizing symptoms and more often received the diagnosis of depressive disorder than children.
Heavy reliance on pharmacotherapy (68.9%) compared to the studies done elsewhere ,,, implies the preferred mode of treatment by the psychiatrists. It also indicates shortage of trained workforce and lack of expertise to deliver various nonpharmacotherapies. Type of the patients seen in CL psychiatry (CLP) setup could be another factor. Agitated patients and patients with severe physical illness commonly come across in this setup, who often require pharmacological management. The attitude of Indian patients and caregivers also influences the treatment chosen by the therapist. Indian patients expect that the therapist would follow a medical model rather than a psychological approach. They also expect him/her to play an active authoritative role, making it difficult to maintain “therapeutic neutrality.” Worth noting here is the observation made by Avasthi et al. that one of the reasons for dissatisfaction with the current CLP practice is exclusive reliance on psychotropic drugs.
Strengths of this study are this being the first study focusing on pediatric liaison psychiatric services from India and also the adequate sample size. Primary limitation of this study is that it is a retrospective chart analysis and hence the diagnosis in most cases is clinical with no standardized diagnostic tools being used. Longitudinal studies focusing on referral practice patterns, effects of psychiatric interventions, and effectiveness of various nonpharmacological interventions are needed in the future.
| Conclusions|| |
Majority of participants referred were male adolescents, referred from the department of pediatrics or neuromedicine. About three-fourths of participants had no diagnosable physical illness, and neurological illnesses were the most common physical comorbidities in the remaining participants. Externalizing symptoms, and unexplained physical symptoms, were the most common reasons for referral. Intellectual disability, depressive disorders, and dissociative disorders were the most common psychiatric diagnoses made. On comparing across the age groups, children more often received the diagnoses of hyperkinetic disorders and persistent developmental disorders, whereas adolescents more often received the diagnosis of depressive disorder. Majority of the participants received pharmacotherapy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bowman FM, Garralda ME. Psychiatric morbidity among children who are frequent attenders in general practice. Br J Gen Pract 1993;43:6-9.
Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P, et al.
Epidemiological study of child & adolescent psychiatric disorders in urban & rural areas of Bangalore, India. Indian J Med Res 2005;122:67-79.
Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Burns BJ, Brent D. Psychopathology in pediatric primary care: The new hidden morbidity. Pediatrics 1988;82(3 Pt 2):415-24.
Garralda ME, Bailey D. Children with psychiatric disorders in primary care. J Child Psychol Psychiatry 1986;27:611-24.
Ortiz P. General principles in child liaison consultation service: A literature review. Eur Child Adolesc Psychiatry 1997;6:1-6.
Kiliç BG, Uslu R, Aysev A. A preliminary evaluation of consultation-liaison psychiatry services for children at a university hospital: Lessons learned to enhance efficacy. Yeni Symp 2007;45:163-9.
Starfield B, Borkowf S. Physicians' recognition of complaints made by parents about their children's health. Pediatrics 1969;43:168-72.
Al-Haidar FA. Inpatient child and adolescent psychiatric referrals in Saudi Arabia: Clinical profiles and treatment. East Mediterr Health J 2003;9:996-1002.
Carter BD, Kronenberger WG, Baker J, Grimes LM, Crabtree VM, Smith C, et al.
Inpatient pediatric consultation-liaison: A case-controlled study. J Pediatr Psychol 2003;28:423-32.
Grupp-Phelan J, Mahajan P, Foltin GL, Jacobs E, Tunik M, Sonnett M, et al.
Referral and resource use patterns for psychiatric-related visits to pediatric emergency departments. Pediatr Emerg Care 2009;25:217-20.
Hoare P, Norton B, Chisholm D, Parry-Jones W. An audit of 7000 successive child and adolescent psychiatry referrals in Scotland. Clin Child Psychol Psychiatry 1996;1:229-49.
Encarnação R, Moura M, Gomes F, da Silva PC. Characterization of the cases referred and consulted in a child and adolescent psychiatry clinic. A retrospective study. Acta Med Port 2011;24:925-34.
Garralda ME, Bailey D. Psychiatric disorders in general paediatric referrals. Arch Dis Child 1989;64:1727-33.
Olson RA, Holden EW, Friedman A, Faust J, Kenning M, Mason PJ. Psychological consultation in a children's hospital: An evaluation of services. J Pediatr Psychol 1988;13:479-92.
Rodrigue JR, Hoffmann RG, Rayfield A, Lescano C, Kubar W, Streisand R, et al.
Evaluating pediatric psychology consultation services in a medical setting: An example. J Clin Psychol Med Settings 1995;2:89-107.
Stone J, Carson A, Duncan R, Coleman R, Roberts R, Warlow C, et al.
Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: How often does the diagnosis change at follow-up? Brain 2009;132(Pt 10):2878-88.
Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998;316:582-6.
Trivedi JK, Jilani AQ. Pathway of psychiatric care. Indian J Psychiatry 2011;53:97-8.
] [Full text]
Lee J, Korczak D. Emergency physician referrals to the pediatric crisis clinic: Reasons for referral, diagnosis and disposition. J Can Acad Child Adolesc Psychiatry 2010;19:297-302.
Kar SK, Tekkalaki B, Mohapatra S, Saha R. Mental health perspectives of epilepsy: Focus on anxiety disorders. Delhi Psychiatry J 2015;18:7-15.
Bakare MO. Attention deficit hyperactivity symptoms and disorder (ADHD) among African children: A review of epidemiology and co-morbidities. Afr J Psychiatry (Johannesbg) 2012;15:358-61.
Grover S, Sarkar S, Chakrabarti S, Malhotra S, Avasthi A. Intentional self-harm in children and adolescents: A study from psychiatry consultation liaison services of a tertiary care hospital. Indian J Psychol Med 2015;37:12-6.
] [Full text]
Sethi BB, Trivedi JK. Psychotherapy for the economically less privileged classes (with special reference to India). Indian J Psychiatry 1982;24:318-21.
] [Full text]
Avasthi A, Sharan P, Kulhara P, Malhotra S, Varma VK. Psychiatric profiles in medical-surgical populations: Need for a focused approach to consultation- liaison psychiatry in developing countries. Indian J Psychiatry 1998;40:224-30.
] [Full text]
[Table 1], [Table 2]