Differences

Much has been written about the differences between the working practices of paediatricians and psychiatrists (table 1). Enzer et al11 showed that they seem to have different character traits with different perceptions of how childhood is experienced, differences that predate their training.

Training in child development in paediatrics has a focus on normal biologically driven development and its variations.12 In contrast, the emphasis in child psychiatry has historically been on theoretical psychodynamic and attachment models of development with the purpose of psychological understanding of abnormal clinical presentations.6 Though there has been a shift towards more biological and empirically based models of understanding for psychiatrists, these differences in emphasis persist.2 ,6

Differences in outlook and subsequent training contribute to different clinical working practices.2 ,12 Paediatricians are adept at gathering clinically relevant and often symptom-focused histories in a time-limited structure, are active and ‘problem solving’ in their consultative role and use language that is centred on symptom description and diagnosis.12 Psychiatrists, on the other hand, take longer to assess their patients, taking detailed biopsychosocial developmental histories. They do this to formulate the clinical case, to understand why this patient is presenting with a particular problem at a particular time in their developmental trajectory.6 ,13 Psychiatrists are more reflective both with patients and with colleagues, and use language that is more focused on understanding symptoms rather than on describing symptoms.2

Recognising that these differences can hinder good collaborative practice, many authors have commented that they should be acknowledged and used.2 ,12 Psychiatrists are becoming more experienced in evidence-based treatments and in the prescription of psychotropic medication.14 Better use of these skills may prove helpful to paediatricians, who could also benefit from skills that enable deeper understanding of complex patients. Models of collaboration should involve paediatricians identifying and managing more mental illness through direct collaborative clinical work. They should also become comfortable in assessing which patients need more intensive psychiatric assessment and management.15

The need to collaborate

It is estimated that up to 20% of children and adolescents have a diagnosable mental health disorder16 and that up to 50% of patients who see paediatricians have significant behavioural and mental health problems17 either as their presenting problem or as comorbidity. The role of paediatricians has changed considerably over time with a shift from acute medicine to what was termed ‘the new morbidity’18 when describing the significant increase in behavioural and emotional problems seen by paediatricians in place of many life-threatening illnesses for which cures have been found.

In addition, there is evidence that patients with mental illness are more likely to present with medical problems16 and that chronic medical illness is associated with mental illness.19 As well as comorbidity between medical presentations and mental illness, there are also conditions where there is the need for input from both disciplines. These include somatising disorders, eating disorders, gender dysphoria and pervasive developmental disorders. Even when management of these conditions involves input from both disciplines, there is not always open collaboration between them.20

It has been repeatedly shown that paediatricians acknowledge that they have a role in identifying mental health problems but do not believe they have the training or ability to treat them (with the exception of ADHD).9 ,10 ,21–23 Paediatricians have been documented as wanting help in clarifying diagnosis of complex patients and of comorbidities, in prescribing of psychotropic medication, in the treatment of depression and anxiety disorders and in crisis management of suicidal patients.10 ,24 ,25 Paediatricians recognise that they commonly do not have the time or expertise to manage complex patients.9 ,26 Increasingly, however, they are pressured to do so because of the numbers they see, but also because of external pressures such as managed-care funding arrangements.4 There is some risk that in response to these pressures, paediatricians may prescribe psychotropic medications inappropriately. In contrast, psychiatrists are under pressure to respond to increasing demand on their services by providing shorter assessments and briefer treatments that undermine their more extensive understanding of child and adolescent mental illness.4 Never has there been a clearer need to develop and validate good collaborative relationships between the two disciplines.

Barriers

Worldwide, Child and Adolescent Mental Health Services (CAMHS) are under-resourced with too few psychiatrists to service the populations they treat.27 This is recognised as a significant reason as to why paediatricians consider psychiatrists and CAMHS to be unresponsive to requests for help.9 ,25 ,28 ,29

Second, there are financial restraints that limit appropriate input from psychiatrists.9 Increasingly in the USA, where managed care has replaced fee-for-service, insurance companies are able to drive management plans. Psychiatrists are finding themselves pushed to focus on prescribing of psychotropic medication, while other less expensive mental health professionals take on psychotherapeutic roles.4 ,14 When psychiatrists do see patients, there may be financial barriers preventing what is seen to be appropriate treatment (eg, low reimbursements when working with parents alone).8

Administratively, there is a long history of fragmentation of medical and mental health services that do not have clear pathways of referral.12 ,28 Streamlining the management structures that deliver these services carries significant cost and requires government support.

Even without the practical barriers that can be associated with bringing about collaboration between paediatricians and psychiatrists, there is a history of separation between the two disciplines that comes from a longstanding ambivalence that has been argued to result from their different clinical approaches.12 For example, when paediatricians refer to psychiatrists, they often perceive them to be non-responsive due to the lack of communication from the psychiatrist that the referring paediatrician expects after referral.9 ,10

It is also well recognised that stigma remains a barrier to mental health referrals, with patients and families often reluctant to make an appointment following referral; medical illness continues to be more socially acceptable than mental illness.14 ,29

Finally, there has historically been less investment in the development of the evidence base for treatment of mental illnesses affecting children and adolescents. This has compounded a perception by some paediatricians that psychiatrists do not have effective treatments to offer anyway.12 ,14

Collaborative models

Despite such problems, there are many examples of healthy collaborative partnerships between paediatricians and psychiatrists (see box 1). For the most part, these examples come from inspired individuals who have helped create conjoint academic units, advocate for Consultation Liaison Child and Adolescent Psychiatric Services, and describe the benefits of collaboration.13 ,15 ,30

Clear patterns emerge from these descriptions of what works in these partnerships. Individual relationships need to be developed with face-to-face clinical discussion and informal meetings.25 ,28 There needs to be recognition and respect for differences in clinical styles and treatment paradigms, an appreciation that such differences are healthy and that each discipline can learn from the other.28 ,30

Dual training in paediatrics and psychiatry (‘triple board training’) has been occurring in specific locations for many decades. Though the training is strenuous and the numbers of dual trainees are small, graduates bring benefits from both training programmes into their clinical work and help to develop a bridging relationship between the groups.31 My own experience of dual training was that as a psychiatrist it was initially hard to let go of thinking and acting as a paediatrician. The process of recognising that I had become a psychiatrist, informed by having been a paediatrician, was instrumental in being respected by both disciplines.

Collaborative supervision and discussion groups involving both paediatricians and psychiatrists are not uncommon. Described as productive,32 they are dependent on interested parties taking the lead.33

Within the long history of Consultation Liaison Child and Adolescent Psychiatry,19 good relationships have been described between medical and mental health teams with recognition of the need for mental health input into infants with serious illness or unwell parents, patients with chronic medical illness, somatising presentations, eating disorders, suicidal and self-harming adolescents and patients with comorbidity. Unfortunately, despite qualitative descriptions of the value of these services, there has been little evaluation of their cost-effectiveness, a feature that has led to limited support from bureaucratic funding sources.34

There are some descriptions of joint assessment and treatment clinics involving paediatricians and psychiatrists in areas of clearly overlapping expertise such as somatising disorders and eating disorders.28 ,35 ,36 These services provide practical ways of bringing paediatricians and psychiatrists together, and would benefit from greater visibility and evaluation.20

When consultant paediatricians are asked what they may need from psychiatrists, there is consensus about the desirability of a co-located model of health delivery where they can have easy access to psychiatrists for secondary consultation.9 ,10 ,24 ,37 Several models have been developed in the USA with varying degrees of co-location.

For example, the Massachusetts Child and Adolescent Psychiatry Access Project (MCAPAP), set up in 2005,38 was based on a collaborative care model known as Targeted Child Psychiatric Services. Teams of psychiatrists and other mental health workers provide easy access of consultation to paediatricians. There are regular visits to paediatric clinics to provide education, together with hotline access to telephone consultation with psychiatrists. Telephone consultation may lead to an assessment from psychiatrists following which the patient is either returned back to the paediatrician for ongoing care (with support) or referral to local mental health services is instigated. The project has shown some success in engaging local paediatricians.3 ,37 ,39 In addition to expressing satisfaction with the service and accessibility of psychiatrists, paediatricians also stated that they felt more confident in their ability to care for children and adolescents with mental health problems.

Other models based on the MCAPAP model have been generally organised along similar lines, with consultation with psychiatrists either occurring in person or by teleconferencing.14 ,40 Some services offer short-term treatment but otherwise refer back to paediatricians or to appropriate local MHS.

An alternative model is the Connecticut Behavioural Health Partnership41 that focuses on improved access to mental health agencies. Services that can demonstrate accessibility and high standard treatment can gain access to additional funds.

The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have also collaborated to create educational materials to help paediatricians manage mental illness. For example, Bright Futures and DSM-PC have been developed to help foster common language between paediatricians and psychiatrists.8

The ability to develop collaborative relationships will very much depend on the setting and shared understanding of need for such collaboration. A public hospital with a captive patient group requiring input from both medical and mental health teams is very different from an outpatient setting. Outpatient settings, either public or private, require motivating forces in addition to those provided by individual practitioners in order to develop collaborative practices in response to specific clinical needs.

There has been a push in some parts of the world to develop Youth Mental Health services separate to CAMHS42 that are co-located with other medical and social services. Such arrangements are likely to improve accessibility and decrease stigma. It is important that meaningful collaborative practice is supported and encouraged in such settings in addition to the practical co-location.

Measuring what works best

There is no consensus on how to measure the effectiveness of collaboration between paediatricians and psychiatrists. Suggested measurables that need development are summarised in box 2.

Paediatricians want ease of access to psychiatrists, to consult and get advice when needed and to hand over management of complex patients when appropriate.10 Psychiatrists are looking for new ways to engage and work in order to deal with pressures from external sources to be cost-effective.6 Both need to feel that they are professionally valued and that they are personally satisfied. In addition, there is likely to be a need for the measurement of patient outcome benefit in order to justify expenditure on collaborative programmes.

The collaborative programmes trialled in the USA have focused on qualitative measurements of paediatricians’ satisfaction with the service, and the perceived improvements in paediatricians’ skills following the collaboration.39 While these outcomes are positive, the numbers participating in the evaluation are small.

There have been no quantitative measurements of improved patient care through collaborative interventions.14

Measuring outcomes of interventions to support clinical decision making in children's mental health is far more difficult than assessing clinical outcomes for other medical conditions (eg, survival with chemotherapy). Measuring improved symptoms of psychological conditions is problematic for many reasons (eg, symptoms naturally change over time/difficulties in defining a control group).7 Proposed potential targets for assessment include improved access to mental health professional care,10 decreased use of medical services,25 improved school attendance25 and improved quality-of-life measurements.7 The development of assessment tools that use patient experience would be another approach to demonstrate the value of collaborative interventions.

The need to measure the effectiveness of collaborative interventions is likely to be an ongoing necessity given the focus on cost and cost-effectiveness in healthcare delivery. From an economic perspective, there has been little reason to invest in child psychiatric outcome research in the absence of innovative research tools that can show tangible and varied benefits. Subsequently, some services such as mental health inpatient admissions and lengths of stay have been cut without any strong evidence to do so.7

Future directions

As professionals from both disciplines have suggested, what works best are models where psychiatrists have developed individual working relationships with individual paediatricians. By being available to provide consultative advice that is perceived as helpful, psychiatrists are able to expand their input that helps create a cultural shift that values their conceptual input to clinical diagnosis and decision making above that of psychotropic prescription and the management of ‘complex patients’.6 ,15 ,25

While it has been noted that treatment models of mental health problems for children and adolescents should not be primarily driven by cost,7 ,12 it will be beholden on both paediatricians and psychiatrists to invest in evaluation that can better measure the outputs of collaborative models that are likely to both improve patient outcome and be cost-effective.

Several prominent authorities have stated that there should be advocacy from administrative bodies of both paediatricians and psychiatrists together to push for ongoing support of collaborative models.13 ,22 The AAP and the AACAP have jointly advocated for appropriate funding and reimbursement for the provision of mental health services to paediatricians.8 Further advocacy around such collaboration will be needed to sustain pressure to reform funding arrangements. Further work is also needed to determine best models of care. This includes models of training paediatricians towards becoming more competent at managing mental health illnesses and the development of guidelines as to when it is appropriate both for consultation and/or transfer of care to psychiatrists or CAMHS.22 ,25

Consultation Liaison Child and Adolescent Psychiatry, while recognised by most authorities as being an important and necessary component of medical care in major hospitals, continues to lack universal support from administrative bodies.34 ,43 Further work is needed to research methods that better demonstrate the costs and benefits of mental health input into medical hospital treatment and to use this to advocate for service development. Targeted interventions to further develop formalised collaboration in illnesses (such as somatising disorders) that share mental health and medical assessment and treatment is one area of potential development.5 ,20

The understanding that child psychiatrists can shift their roles from those that purely provide direct clinical care to also include consultation and collaboration is gathering momentum.6 Child psychiatry training programmes must adapt to this change and put greater emphasis on the importance of functioning within systems, on speaking the language of paediatricians and in participating in conjoint education and training experiences.6

Given the significant burden of mental health problems affecting patients that paediatricians treat and the relative lack of child and adolescent psychiatrists, strategies are needed to support and increase collaboration. Alliances are needed to advocate for mental health parity, for the further development of conjoint training in both disciplines and for outcomes research that is needed to drive service development. Committed and charismatic individuals are still needed from both professional bodies to advance and promote this agenda.