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Practice Parameter for the Psychiatric Assessment and Management of Physically Ill Children and Adolescents

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Abstract

This practice parameter describes the psychiatric assessment and management of physically ill children and adolescents. It reviews the epidemiology, clinical presentation, assessment, and treatment of psychiatric symptoms in children and adolescents with physical illnesses and the environmental and social influences that can affect patient outcome.

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Methodology

The literature review included bibliographies of books, book chapters, and review articles and consultations with clinicians and researchers with specific expertise in this area. PubMed and PsycINFO searches used the following text words: physically ill, children, adolescents, pediatric, consultation, and psychosomatic. The searches covered the period 1986–2006 and yielded approximately 275 articles, of which only the most relevant are included in this document.

Epidemiology

Between 10 and 20 million American children are estimated to have an ongoing physical health condition.1 Although most of these conditions are relatively mild and interfere little with a child's usual activities, at least 10% of children with physical illness have symptoms severe enough to have an impact on their daily lives.1 Advances in the treatment of physical illnesses over the past few decades have resulted in improved health and prognosis. Whereas many youngsters previously died of

Mental Health Clinicians Should Understand How to Collaborate Effectively With Medical Professionals to Facilitate the Health Care of Physically Ill Children

The mental health clinician working with physically ill children should work toward establishing effective collaborations with primary care physicians and other medical professionals (pediatric health care team). The clinician must demonstrate flexibility and adaptability to perform several roles: evaluation, advocacy, support, and education (see Shaw and DeMaso7(pp3–6) for a review).

During the assessment, the clinician's primary role is to identify comorbid psychiatric illness. The assessment

The Family Context Should Be Understood and Addressed

More than 50% of families with a physically ill child establish a healthy level of functioning, although individual family members may be prone to anxiety, depression, anger, and somatic complaints.91 The degree of predictability, amount of disability, associated stigma, degree of monitoring required, and prognosis are illness factors that have an impact on family adjustment. In addition, parental behavior should be understood in a historical context based on family beliefs and previous

Adherence to the Medical Treatment Regimen Should Be Evaluated and Optimized

Failure to follow through with treatment regimens is a major health concern.*98, 99 Reviews suggest that 33% of patients with acute health conditions, and 50% to 55% of those with chronic illnesses fail to adhere to their treatment regimens.99, 100 Nonadherence may result in poor medical outcome, increased financial costs, and decreased quality of life. Individual, family, disease, and treatment correlates have been identified as important risk factors for treatment nonadherence (Table 5).

The Use of Complementary and Alternative Medicine Should Be Explored

Complementary and alternative medicine (CAM) comprises a group of diverse health care practices that are used either together with conventional medicine (complementary) or instead of conventional medicine (alternative).101 Families or clinicians may consider CAM when conventional treatments are deemed unacceptable or insufficient. Treatments such as acupuncture, herbal remedies, homeopathy, massage, and spiritual healing have been used for centuries, but they have not been subjected to the

Religious and Cultural Influences Should Be Understood and Considered

Cultural and religious beliefs may affect the child's and family's understanding of medical issues, acceptance of intervention, treatment adherence, and, ultimately, prognosis.105 There is growing evidence that racial and ethnic minorities are at greater risk for morbidity and mortality with a number of chronic illnesses, particularly those associated with social and behavioral factors.106 Recognition of the family's beliefs and traditions may identify potential sources of support for the child

Family Contact With Community-Based Agencies Should Be Considered and Facilitated Where Indicated

School. Physical illness may interfere with the child's academic and social functioning as well as engender anxiety in peers and teachers.108, 109, 110 The mental health clinician can help improve collaboration between health care and school systems.92 School interventions can include educating school personnel and peers about the physical illness and its treatment, advocating for special services, participating in academic decisions (e.g., having a child attend summer school or repeat a

Legal Issues Specific to Physically Ill Children Should Be Understood and Considered

The mental health clinician should have a working understanding of the legal and forensic issues related to treatment consent, confidentiality, and privilege. The clinician should be aware of relevant statutes in his or her jurisdiction and should know when to obtain legal consultation (see Shaw and DeMaso 7(pp59–74) for a review).

Consent and authorization are required for all medical treatments and procedures except in unusual circumstances. Informed consent requires that patients or legal

The Influence of the Health Care System on the Care of a Physically Ill Child Should Be Considered

The mental health clinician's appreciation of the ramifications of physical illness should include recognition of the complex practical and financial burdens that affect the child's and family's emotional state, behaviors, lifestyle, illness treatment, and, ultimately, health outcome. Families are often confronted with limitations in obtaining necessary or optimal care. Many medical expenses are not covered by insurance (e.g., specialized infant formulas, supplies, uncompensated time away from

Parameter Limitations

AACAP practice parameters are developed to assist clinicians in psychiatric decision making. These parameters are not intended to define the standard of care; nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results. The ultimate judgment regarding the care of a particular patient must be made by the clinician in light of all the circumstances presented by the patient and his or her family, the diagnostic

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  • Cited by (0)

    This parameter was developed by David R. DeMaso, M.D., D. Richard Martini, M.D., Lucienne A. Cahen, M.D., primary authors, and the Work Group on Quality Issues (WGQI): Oscar Bukstein, M.D., M.P.H., and Heather J. Walter, M.D., M.P.H., Co-Chairs, and Scott Benson, M.D., Allan Chrisman, M.D., Tiffany Farchione, M.D., John Hamilton, M.D., Helene Keable, M.D., Joan Kinlan, M.D., Ulrich Schoettle, M.D., Matthew Siegel, M.D., and Saundra Stock, M.D. AACAP Staff Kristin Kroeger Ptakowski and Jennifer Medicus.

    The AACAP practice parameters are developed by the AACAP WGQI in accordance with American Medical Association policy. Parameter development is an iterative process between the primary author(s), the WGQI, topic experts, and representatives from multiple constituent groups, including the AACAP membership, relevant AACAP components, the AACAP Assembly of Regional Organizations, and the AACAP Council. Details of the parameter development process can be accessed on the AACAP Web site. Responsibility for parameter content and review rests with the author(s), the WGQI, the WGQI Consensus Group, and the AACAP Council.

    The AACAP develops both patient-oriented and clinician-oriented practice parameters. Patient-oriented parameters provide recommendations to guide clinicians toward the best treatment practices. Recommendations are based on empirical evidence (when available) and clinical consensus (when not) and are graded according to the strength of the empirical and clinical support. Clinician-oriented parameters provide clinicians with the information (stated as principles) needed to develop practice-based skills. Although empirical evidence may be available to support certain principles, principles are primarily based on expert opinion derived from clinical experience. This parameter is a clinician-oriented parameter.

    The primary intended audience for AACAP practice parameters is child and adolescent psychiatrists; however, the information contained therein may also be useful for other mental health clinicians.

    The authors wish to acknowledge the following experts for their contributions to this parameter: John Campo, M.D., Tami Benton, M.D., George Cohen, M.D., Gregory Fritz, M.D., Michael Jellinek, M.D., Maryland Pao, M.D., Richard Shaw, M.D., Benjamin Siegel, M.D., Anthony Spirito, Ph.D., Ruth Stein, M.D., and Margaret L. Stuber, M.D.

    This parameter was reviewed at the Member Forum at the AACAP Annual Meeting in October 2006.

    From September 2007 to February 2008, this parameter was reviewed by a Consensus Group convened by the WGQI. Consensus Group members, and their constituent groups were as follows: WGQI (Heather J. Walter, M.D., M.P.H., Chair; Scott Benson, M.D., Shepherd; Ulrich Schoettle, M.D., and Saundra Stock, M.D., Members), Topic Experts (John Campo, M.D., Richard Shaw, M.D., and Margaret Stuber, M.D.), AACAP Components (Read Sulik, M.D., Committee on Collaboration With Medical Professionals), AACAP Assembly of Regional Organizations (Sandra Sexson, M.D., and Lynn Taylor, M.D.), and AACAP Council (Aradhana Bela Sood, M.D., and Dorothy Stubbe, M.D.).

    Disclosures of potential conflicts of interest for authors and Work Group chairs are provided at the end of the parameter. Disclosures of potential conflicts of interest for all other individuals named above are provided on the AACAP Web site on the Practice Information page.

    This practice parameter was approved by the AACAP Council on June 5, 2008.

    This practice parameter is available on the Internet (www.aacap.org).

    Reprint requests to the AACAP Clinical Practice Department, 3615 Wisconsin Ave, NW, Washington, DC 20016.

    0890–8567/09/4802–0214©2009 by the American Academy of Child and Adolescent Psychitry.

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