Child and Adolescent Consultation-Liaison Service

The fellow will learn the provision of consultation-liaison services at SLCH, including:

• Clarification of consult questions and the goals and objectives of consult as a dynamic process that starts at the outset and continues throughout the consultative process.
• Approaching hospital patients and families who may or may not be enthusiastic about psychiatric consultation.
• Assessing the impact of chronic disease on children, adolescents, and their families.
• Refinement of child and family therapeutic interviewing skills in a busy hospital setting.
• Observing and interpreting family, ward, health care, and other relationships and their pertinence to the presenting consult question.
• Producing recommendations to implement that are clear and practical for the healthcare team, patient, and family.
• Assessment of risk and appropriateness of outpatient (vs. more intensive) treatment post-hospital stay.
• Prevention of self-harm and harm to others.
• Assessment of psychiatric follow-up needs and the facilitation of follow-up care.
• Familiarity and competence with psychopharmacological interventions in children with multiple medical problems and often on multiple medications, including attention to drug-drug interactions and drug contraindications.
• Psychoeducation of patients, families, and healthcare team members.
• Supportive therapy and grief/loss counseling.
• Hospital behavioral management.

The fellow will gain medical knowledge through working in a clinical team, attending didactics, and reading the pertinent consultation-liaison, child and adolescent psychiatry, and related literature. Knowledge developed on this rotation will include:

• Presentations of major child psychiatric disorders in acute pediatric settings including knowledge of epidemiology, known etiological or risk factors, disorder phenomenology, diagnostic criteria, and the predictive value of diagnosis (adjustment disorders, depressive and anxiety disorders, abnormal illness behaviors, psychological factors complicating medical conditions, psychiatric disorders secondary to medical factors, delirium, and cognitive and behavioral impairments related to medical factors).
• Understanding the appropriate use of laboratory testing and adjunctive data collection in the elucidation of clinical presentation in the hospital setting.
• Understanding the appropriate elicitation of information from pediatric colleagues to appreciate fully the medical phenomenology of illness.
• Basic knowledge of pediatric disorders that commonly affect patients that the fellow is consulting (overdoses and sequelae, diabetes, sickle cell, cystic fibrosis, dystrophies, and epilepsy).
• Critical knowledge of effective treatment strategies, including psychopharmacological and psychotherapeutic approaches, and strengths and limitations of approaches (combined or not combined).
• Knowledge of the consultation role and its boundaries.
• Use of electronic systems to access hospital care, medical, and scientific information.

The fellow will develop competence in continuous learning and improvement through practice and related activities, including:

• Active participation in didactics and conferences which are particularly salient to practice in the hospital setting (e.g., as applicable psychotherapy seminar, early bird rounds, pediatric grand rounds, interdisciplinary conferences).
• Active case-based learning in the hospital.
• Critical review of the patient’s records.
• Integration of literature findings into patient care and/or communication with others.
• Ability to research and troubleshoot complexities and difficulties that arise in consultation.

The fellow will show sensitivity and compassion to children and adolescents affected by
psychopathology and to their families or their caretakers. The fellow will continue to develop relationships with other professionals, or professionals in training, including supervisors, colleagues, students, and allied professionals. On the consultation-liaison rotation, major aspects of professional development will include:

• Perform a consultation that respectfully addresses the referring physician’s specific questions.
• Develop intra-professionally by managing adaptively your emotional reactions to other medical providers, healthcare team members, youth, and families seen in the hospital.
• Responsibility for the consultation role by responding promptly and communicating with families, attendings, and other health professionals. Also responsible for the passing of salient information to other fellows (e.g., before weekend call).
• Acknowledgement and remediation of errors.
• Intra-professionalism and the ability to understand and remedy factors that interfere with
  one’s proper professional conduct.

The fellow will effectively communicate with the members of the pediatric care team, including key members of the team responsible for consultation initiation, patients, their families, and all other members of the treatment team. The fellow will develop competence in:

• Conducting age-appropriate interview techniques, as well as comprehensive mental status examination on children and adolescents in the hospital setting. This may include the use of less anxiety-provoking observational settings, such as the playroom.
• Effective communication with all those involved in the care of the patient, including verbal, non-verbal, written communication, and oral communication of written recommendations to key individuals.
• The ability to efficiently summarize findings and recommendations promptly, while being respectful of the rapid pace of hospital care.
• Leadership and teaching of medical students and neurology residents assigned to the consult team (e.g., allowing these trainees to progress during their one-month rotation to an evaluative role under the supervision of a fellow).
• Develop and support therapeutic alliances with the healthcare team, patients, and families, and troubleshoot difficulties met in the maintenance of therapeutic alliances (e.g., splitting, blaming, triangulations, and poorly understood perspective differences).
• Empathy and understanding for the role and burdens of different members of the healthcare team as applicable (e.g., pediatricians, nurses, pediatricians in training, ward staff, social workers, child abuse team members, and psychology staff).
• Collaborative relationships with psychology.

A quintessential rotation to gain competence in system-based care by providing consultations requested by multiple systems and participating in interdisciplinary meetings where multiple systems of care intersect. The fellow will develop competence in:

• Understanding the roles of other professionals, including pediatricians, sub-specialists, psychologists, nursing staff, social workers, occupational therapists, and the child abuse team.
• Development of time management skills, including management of other clinical responsibilities during the consultation-liaison rotation.
• Familiarity with consultation billing procedures.
• Appreciation of the perception of psychiatric systems of care by others.
• Understanding the limitations of community mental health care for children and its impact on mental health care at St. Louis Children’s Hospital.