Original article 188
Liaison Psychiatry in Pediatric Surgery - A Promising Approach ]. Unger-Köppel, R. Nüssli, U. G. StaufJer Abteilung Psychiatrie und Chirurgi che Klinik der l'ni\'ersilälskinderkJinik Zürich. Sch\\eiz
que c10il eLre solidcmenl impIanlee en chirurgie pedialrique dc mcme qu 'elle I'esl depuis !onglemps en pedialrie.
Liaison psychialry in pedialric surgcry is describcd and lhe experiences allhe Cni\'ersily Children's I lospilal in Zurich are reported. The palienls seen by lhe child psychialrisl in surgery are pecified and compared "'ilh lhose seen in pediatrics. For lhe most part lhe same psychialric diagnoses "'ere made in bolh groups wilh some differences in frequcncy. It is conc1uded that liaison psychialry should be implemenled in pedialric surgery, as has long been lhe case in pedialrics. Ke.)' words Liaison psychialry
Resume La coIIaboration a\'ec un psychialre en Chirurgie Pediatrique esl analysee el]e experience failes a J'Höpilal niversitaire pour Enfanls de Zurich sonl decrites. Les malades vus par]e psychiatre d'enfanls en milieu chirurgical sonl compares avec ceux vus en milieu pediatrique. Pour Ie plus grand nombre, les diagnostics psychialriques onl ele identiques dan ]es deux groupes avec que]ques differences en frequence. On en concJu que ]a liaison psychiatri-
Introduction
Liaison p ychiatry is a growing field. The European consultation-]iaison work group has recenUy pub]i hed an o\'er\'iew of the currenl situation in general hospitals in Europe (]). Liaison psychialry is weU established in pedialric hospitals wilh papers ha\'ing been publi hed in yarious pediatric journals (2). As yellhe possibilities for communicalion between pedialric surgeons and child psychiatrisls remain mosUy unexamined. The following artic1e describes lhe liaison psychialry program implernenled in pedialric surgery allhe uni\'ersily children 's hospita] in Zurich since 1988. Hecel\ ed '\o\ember 2U. I \)\J I
ua
Eur I Pedialr Surg 2 ( IUU2) 188-1 .\\asson Editeur Pans
© Hippokrales \'erlag Slullgali
.\lols-eles Liaison psychialrique
Zusammenfassung Die Liaisonpsychialrie in der Kinderchirurgie \\'ird dargeslelll und über die Erfahrungen an der L'ni\'ersilälskinderklinik Zürich berichlet. Die Palienlen, welche \'om Psychiater auf der Chirurgie gesehen wurden, werden beschrieben und mil jenen auf der Pädiatrie \-erglichen. Prinzipiell \\'erden in beiden Fachgebieten dieselben psychialrischen Diagnosen bei den Kindern gefunden, wenn auch mil gewissen Häufigkeilsunlerschieden. Daraus wird gefolgert, daß die Liaisonpsychialrie in der Kinderchirurgie ebenfalls ihren festen Platz haben sollle, wie dies in der Pädialrie schon länger der Fall ist.
Schlüsselwörler Liaisonpsychiatrie
Child p ychiatry in pedialric surgery is normalIy employed in the form of consultalion psychialry. That is to say, lhe pediatric surgeon relies on his own knO\dedge of child psychialry lo a sess whelher or not con ultalion \\'ith his colleague is required. The psychialrist lhen gi\'es his opinion, but the enlire responsibilily for lhe case remains wilh the surgeon. In liaison psychialry ef\'ice the procedure is different. Through c10se cooperalion bel\\'een psychialrisl and surgeon al ready lhe necessily for a psychialric inlef\'enlion is assessed logelher. If it is required, responsabililies can be shared lhroughoul case management. In Zurich, children, after se\-ere head injuries, are lrealed by both specialisls: whereas lhe pedialric surgeon has hi e labli hed and \\'ell,known functions, lhe child psychiatri t concenlrates on psychosocial aspecls. Throughout lhe rehabililalion lhe parenls and lhe siblings are assisled in copi ng \\ ilh lhe difficull siluation. On lea\'ing lhe ho pilal, lhe children often show dislUI'bances of conducl due lo lhe brain damage. \\'hile
Downloaded by: University of British Columbia. Copyrighted material.
Summary
Ellr J Pediatr SlIrg 2 (/992)
Liaison Psyclliatry in Pediatric IIrgery - A Prollli,ing Approach
189
---
lhe brain regain its normal function, the parents need ad\'ice hall' to handle the tran gel)' beha\-ing child Lo pre\-ent secondary neurotic disorders. The child ps)'chiatrist is also able to amid unnecessary \\'ork through earl)' inter\'ention:
:;::::::~. ..•...:..•••.... ..:::.:::::::::::: '.....:-........•.. :::::::.::::.:.:.:.: ~
I·:·:·:·:·:·:::::::~ .:.:.:.: :-.
:~t~::::-"
~
.~
Case reporLs •
67% (49)
severe head injuries and bums
~
23% (24)
other accidents
Case 1
111 Zuncb tbc liaisoll psycbiatn sl'nice is in ih orgall izatlon based Oll tbree main struclures. tbc child ps~ebiatnstls prlH,ellt at tbc \\ eekl.\ mUlld b~ tbe bead of tbc depal1menl. Iiere, in ma1l\ e,N'S psyebosocial aspech are discussed togetber \\itb tbe surgical procedure In \\ eekl,l pS,1 ebosocial mUllds, \\ here nurses, teacbers ami sociahlOrkers al'e presenl. important detail \\ork ean iJe done. Fixed struclures for management of special risk groups sucb as childl'en \\ itb e\'ere bead IIljuries, burn patienh ami \'ictims of cbild abuse ami ne glect are no\\ \\ell established. Besides the direct benefit to tbc cbildren, the constantly changing residenh in pediatric surger~ gain practical ex perience through dose cooperation \\ ith the psyebiatrist. They can then generalize this to other cases,
Patients For the follo\\ing data only those children are considered \\ho ha\e been een themseh'es by the p ychiatri tor psychologi ls, There ha\'e been man)' more cases \\here the psychiatri t just ga\'e an adlice as in Case I. Figure I shows thatt\\'o thirds of the children \\'ere admitted after accidenls. J\lost of the rest \\'ere treated in the different fields of pediatric surgery. A fell' children were admittedunder surgical diagnoses bul turned oulto ha\'e a psychological problem, ,\Iore detailed analysis of the children after accidents i hown in Figure 2, T\\o third of all children \\ere seen \\'ithin the fixed structures for management of special risk groups, The rest \\ere \'ictims of other accident .
General chlldsurgery Others
~
1 '.: ""
o
Fig, 1 S a' j ag' -Jses . re ch Id psy' rlalr sI 1989-1990
Subtypes
0
aCCiden s as '
h\'l
In Figure 1
Table 1 C ass,' c.a'lor n ch d ps/chla ry Jses a 'ru l,ax a l approa, r a ~ordlng I ::'1O's CD 9 (4
Orga lIi:.a I iOIl
Acclden s
Fig. 2
20
,'p
40
66 % (73)
AXls 1 AXls 2 AXls 3 AXls 4 AXIS 5
CI,nlcal psych,alrrc syndrome (emollonal d sorder condu t d s 'lrder etc ) Speci c delays n developmen 'developmenla l speech diS order. speC'flc readlng retardation. elc I Intelleclual level (normal. mlldly relarded. elc) Medlcal cond,tlons (head InJury, aslhma. elc) Abnormal psychosoclal slluatlons (famlly discord. Inadequale Ilngulsllc stlmulallon. etc )
Case 2 A three-year-old boy \\'as adlllilled with uncomplical cd bone fractures after a motor \ehiele accident. Inthe same accidenl his father died, In the beginning the mother \\as helped to tellthe boy the ad message, After fe\\ sessions in the hospital. furlher psychiatric treat ment \\"as organized near the liling place of the family, In Figure 3 the elassificatiom, of the elinical psychiat ric syndromes of a1l cases seen 89 and 90 in the deparlmenls of pediatrics and pediatric surgery atthe l'ni\'ersity Children's Ilospital in 7..urich are sho\\'n. 175 cases \\ere seen in pediatrics and III cases in pediatric surgery. For the most pal1the same psychiatric diagnoses \\ cre made in both groups. In surgery more acute reactions to stres \\ ere seen, but adju tment reaclions are fairly frequent, too. .\n old elinical experience that h~-peracti\'e children tend to ha\(' more accidents seems to be \·erified. According to referral habils, less physical conditions aris ing from mental factors and special symptoms not else\\ here elassified \\ere seen in the surgical dep,1I1I11ent, although they are seen. Of this group upto:50 % ha\'e no psychiatric disorder. There are t\\O explana tions for this: First of all, the children ma.1 ha\'e disturbances in other axes (Table 1). The second is that in our fixed structures for man agement of special risk graups \\l' intend to \\ork pre\entati\el.I.:o \\e sec a lot of cbildren after selere Iwad injunes \\ itb no p'.ITbiatm disor ders. \\ Iwn'as tbc literature finds d 111gb incidence of up to '7IJ oe t:ll
( n = 111
Conrlu~ion~
60
seer . per) al'
80
00
.-\ccording 10
Liaison Psychiatry in Pediatric Surgery - A Promising Approach ]. Unger-Köppel, R. Nüssli, U. G. StaufJer Abteilung Psychiatrie und Chirurgi che Klinik der l'ni\'ersilälskinderkJinik Zürich. Sch\\eiz
que c10il eLre solidcmenl impIanlee en chirurgie pedialrique dc mcme qu 'elle I'esl depuis !onglemps en pedialrie.
Liaison psychialry in pedialric surgcry is describcd and lhe experiences allhe Cni\'ersily Children's I lospilal in Zurich are reported. The palienls seen by lhe child psychialrisl in surgery are pecified and compared "'ilh lhose seen in pediatrics. For lhe most part lhe same psychialric diagnoses "'ere made in bolh groups wilh some differences in frequcncy. It is conc1uded that liaison psychialry should be implemenled in pedialric surgery, as has long been lhe case in pedialrics. Ke.)' words Liaison psychialry
Resume La coIIaboration a\'ec un psychialre en Chirurgie Pediatrique esl analysee el]e experience failes a J'Höpilal niversitaire pour Enfanls de Zurich sonl decrites. Les malades vus par]e psychiatre d'enfanls en milieu chirurgical sonl compares avec ceux vus en milieu pediatrique. Pour Ie plus grand nombre, les diagnostics psychialriques onl ele identiques dan ]es deux groupes avec que]ques differences en frequence. On en concJu que ]a liaison psychiatri-
Introduction
Liaison p ychiatry is a growing field. The European consultation-]iaison work group has recenUy pub]i hed an o\'er\'iew of the currenl situation in general hospitals in Europe (]). Liaison psychialry is weU established in pedialric hospitals wilh papers ha\'ing been publi hed in yarious pediatric journals (2). As yellhe possibilities for communicalion between pedialric surgeons and child psychiatrisls remain mosUy unexamined. The following artic1e describes lhe liaison psychialry program implernenled in pedialric surgery allhe uni\'ersily children 's hospita] in Zurich since 1988. Hecel\ ed '\o\ember 2U. I \)\J I
ua
Eur I Pedialr Surg 2 ( IUU2) 188-1 .\\asson Editeur Pans
© Hippokrales \'erlag Slullgali
.\lols-eles Liaison psychialrique
Zusammenfassung Die Liaisonpsychialrie in der Kinderchirurgie \\'ird dargeslelll und über die Erfahrungen an der L'ni\'ersilälskinderklinik Zürich berichlet. Die Palienlen, welche \'om Psychiater auf der Chirurgie gesehen wurden, werden beschrieben und mil jenen auf der Pädiatrie \-erglichen. Prinzipiell \\'erden in beiden Fachgebieten dieselben psychialrischen Diagnosen bei den Kindern gefunden, wenn auch mil gewissen Häufigkeilsunlerschieden. Daraus wird gefolgert, daß die Liaisonpsychialrie in der Kinderchirurgie ebenfalls ihren festen Platz haben sollle, wie dies in der Pädialrie schon länger der Fall ist.
Schlüsselwörler Liaisonpsychiatrie
Child p ychiatry in pedialric surgery is normalIy employed in the form of consultalion psychialry. That is to say, lhe pediatric surgeon relies on his own knO\dedge of child psychialry lo a sess whelher or not con ultalion \\'ith his colleague is required. The psychialrist lhen gi\'es his opinion, but the enlire responsibilily for lhe case remains wilh the surgeon. In liaison psychialry ef\'ice the procedure is different. Through c10se cooperalion bel\\'een psychialrisl and surgeon al ready lhe necessily for a psychialric inlef\'enlion is assessed logelher. If it is required, responsabililies can be shared lhroughoul case management. In Zurich, children, after se\-ere head injuries, are lrealed by both specialisls: whereas lhe pedialric surgeon has hi e labli hed and \\'ell,known functions, lhe child psychiatri t concenlrates on psychosocial aspecls. Throughout lhe rehabililalion lhe parenls and lhe siblings are assisled in copi ng \\ ilh lhe difficull siluation. On lea\'ing lhe ho pilal, lhe children often show dislUI'bances of conducl due lo lhe brain damage. \\'hile
Downloaded by: University of British Columbia. Copyrighted material.
Summary
Ellr J Pediatr SlIrg 2 (/992)
Liaison Psyclliatry in Pediatric IIrgery - A Prollli,ing Approach
189
---
lhe brain regain its normal function, the parents need ad\'ice hall' to handle the tran gel)' beha\-ing child Lo pre\-ent secondary neurotic disorders. The child ps)'chiatrist is also able to amid unnecessary \\'ork through earl)' inter\'ention:
:;::::::~. ..•...:..•••.... ..:::.:::::::::::: '.....:-........•.. :::::::.::::.:.:.:.: ~
I·:·:·:·:·:·:::::::~ .:.:.:.: :-.
:~t~::::-"
~
.~
Case reporLs •
67% (49)
severe head injuries and bums
~
23% (24)
other accidents
Case 1
111 Zuncb tbc liaisoll psycbiatn sl'nice is in ih orgall izatlon based Oll tbree main struclures. tbc child ps~ebiatnstls prlH,ellt at tbc \\ eekl.\ mUlld b~ tbe bead of tbc depal1menl. Iiere, in ma1l\ e,N'S psyebosocial aspech are discussed togetber \\itb tbe surgical procedure In \\ eekl,l pS,1 ebosocial mUllds, \\ here nurses, teacbers ami sociahlOrkers al'e presenl. important detail \\ork ean iJe done. Fixed struclures for management of special risk groups sucb as childl'en \\ itb e\'ere bead IIljuries, burn patienh ami \'ictims of cbild abuse ami ne glect are no\\ \\ell established. Besides the direct benefit to tbc cbildren, the constantly changing residenh in pediatric surger~ gain practical ex perience through dose cooperation \\ ith the psyebiatrist. They can then generalize this to other cases,
Patients For the follo\\ing data only those children are considered \\ho ha\e been een themseh'es by the p ychiatri tor psychologi ls, There ha\'e been man)' more cases \\here the psychiatri t just ga\'e an adlice as in Case I. Figure I shows thatt\\'o thirds of the children \\'ere admitted after accidenls. J\lost of the rest \\'ere treated in the different fields of pediatric surgery. A fell' children were admittedunder surgical diagnoses bul turned oulto ha\'e a psychological problem, ,\Iore detailed analysis of the children after accidents i hown in Figure 2, T\\o third of all children \\ere seen \\'ithin the fixed structures for management of special risk groups, The rest \\ere \'ictims of other accident .
General chlldsurgery Others
~
1 '.: ""
o
Fig, 1 S a' j ag' -Jses . re ch Id psy' rlalr sI 1989-1990
Subtypes
0
aCCiden s as '
h\'l
In Figure 1
Table 1 C ass,' c.a'lor n ch d ps/chla ry Jses a 'ru l,ax a l approa, r a ~ordlng I ::'1O's CD 9 (4
Orga lIi:.a I iOIl
Acclden s
Fig. 2
20
,'p
40
66 % (73)
AXls 1 AXls 2 AXls 3 AXls 4 AXIS 5
CI,nlcal psych,alrrc syndrome (emollonal d sorder condu t d s 'lrder etc ) Speci c delays n developmen 'developmenla l speech diS order. speC'flc readlng retardation. elc I Intelleclual level (normal. mlldly relarded. elc) Medlcal cond,tlons (head InJury, aslhma. elc) Abnormal psychosoclal slluatlons (famlly discord. Inadequale Ilngulsllc stlmulallon. etc )
Case 2 A three-year-old boy \\'as adlllilled with uncomplical cd bone fractures after a motor \ehiele accident. Inthe same accidenl his father died, In the beginning the mother \\as helped to tellthe boy the ad message, After fe\\ sessions in the hospital. furlher psychiatric treat ment \\"as organized near the liling place of the family, In Figure 3 the elassificatiom, of the elinical psychiat ric syndromes of a1l cases seen 89 and 90 in the deparlmenls of pediatrics and pediatric surgery atthe l'ni\'ersity Children's Ilospital in 7..urich are sho\\'n. 175 cases \\ere seen in pediatrics and III cases in pediatric surgery. For the most pal1the same psychiatric diagnoses \\ cre made in both groups. In surgery more acute reactions to stres \\ ere seen, but adju tment reaclions are fairly frequent, too. .\n old elinical experience that h~-peracti\'e children tend to ha\(' more accidents seems to be \·erified. According to referral habils, less physical conditions aris ing from mental factors and special symptoms not else\\ here elassified \\ere seen in the surgical dep,1I1I11ent, although they are seen. Of this group upto:50 % ha\'e no psychiatric disorder. There are t\\O explana tions for this: First of all, the children ma.1 ha\'e disturbances in other axes (Table 1). The second is that in our fixed structures for man agement of special risk graups \\l' intend to \\ork pre\entati\el.I.:o \\e sec a lot of cbildren after selere Iwad injunes \\ itb no p'.ITbiatm disor ders. \\ Iwn'as tbc literature finds d 111gb incidence of up to '7IJ oe t:ll
( n = 111
Conrlu~ion~
60
seer . per) al'
80
00
.-\ccording 10
