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The authors conducted a study of3O hospitalized children who were referredfor psychiatric consultation and 60 hospitalized children who were not. They studied the medical charts ofthese children and administered a questionnaire including a checklist of behavioral symptoms to their parents. More psychopathology was f ound in the children referredfor consultation, but about 20 percent ofthe children not referred also showed a high degree ofpst’chopaihologv. Factors found to he associated with referralfor psychiatric consultation were older age, longer hospital slav, nzanv previous hospitalizations. and ambiguous diagnoses.

PSYCHIATRIC CONSULTANTS to medical or pediatric services have long been amazed by the factors that influence the process of referral. Some patients who need psychiatnc help are not referred, while some who do not need psychiatnic help are referred. A number of psychiatrists have come to suspect that there is no difference between patients who are referred and those who are not. The literature on the subject is minimal. Stocking and associates ( I ) studied the incidence of psychopathology, the frequency of its recognition, and the frequency of unnecessary hospitalizations in a pediatric hospital. According to their criteria, 64 percent of the children studied were in need of psychiatric help, but consultation was requested for only 1 1 percent of the sample. They also concluded that hospitalization was not necessary or advantageous for 30 percent of the children and that the incidence of psychopathology among the whole sample was high. In another study (2), these researchers found that factors related to pediatricians’ failure to recognize the need for psychiatric consultation included the acuteness of medical illness, its treatability, the age of the child, and the nature of the emotional disorder. Bolian (3) reported his experiences as a full-time hospital-based psychiatric consultant. Subsequent to his appointment to this position, there was a tenfold increase in formal consultation requests. He found that requests for adolescent patients predominated, that race was not a factor in referral, and that there were more consultations for girls than for boys and for free-care patients than for

Dr. Awad is Lecturer in Psychiatry, University of Toronto. and Staff Psychiatrist. Clarke Institute of Psychiatry Psychiatric Service of the Provincial Court, 950 Yonge St., Toronto, Ont., Canada M4W 2J4. Dr. Poznanski is Associate Professor of Psychiatry. University of Michigan Medical Center, Ann Arbor, Mich.

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private patients and those with health insurance, although the consultant was salaried. He also found that there were proportionately more referrals from the medical than the surgical services and that 14 percent of these referrals were for suicide attempts. Bolian concluded that the system of care delivery is inefficient, that it is a “nonsystem of health care delivery.” Monnelly and associates (4) reported their experience with 79 psychiatric consultations, which represented 1 percent of the total admissions to a children’s hospital in an I I -month period. The length of hospitalization of the patients who were referred for consultation was 5 days longer than the average hospital stay. and there was a higher proportion of girls referred. Most of the referrals in this study came from the medical services. The most common reasons for referral were symptoms of unknown etiology (30 percent), questions of depression (19 percent), behavior problems on the ward (13 percent), and specific symptom patterns ( 10 percent). Monnelly and associates reported only three suicide attempts, but the upper age limit in their study was 15 years, compared with 21 years in Bolian’s study. The authors of these papers pointed out some of the general characteristics and problems associated with the process of psychiatric consultation. However, they did not attempt to answer other questions about children who are referred and those who are not; all of the studies lacked a control group. We therefore started our study by posing some questions that arose from our previous consultation work. We then designed a project to attempt to answer them. We asked ourselves the following quesLions: 1. Is there a difference in the amount of psychopathology between a group of hospitalized children aged 5 to 12 years who were referred for psychiatric consultation and a matched group of hospitalized children who were not referred? 2. Do children get referred for consultation for certain types of behavior problems more frequently than for others? 3. Is referral for psychiatric consultation influenced by the ambiguity of diagnosis, the length and number of hospitalizations, and the severity of the child’s physical illness? 4. Do the demographic variables of age, sex, socioeconomic class, ordinal position in the family, and race influence the number of referrals? The influence of the attending pediatricians or house staff on the referral rate could not be studied because there was a rapid staff turnover rate on the services. The number of children of different races was too small to

Am J Psychiatry

/32:9,

September

1975

915

PSYCHIATRIC

reach race.

any

CONSULTATIONS

conclusion

IN A PEDIATRIC

as to the

influence

HOSPITAL

of the

variable

of

METHOI)

The study was conducted in C.S. Mott Children’s Hospital of the University of Michigan. We collected 30 referred patients and 60 control patients. By referred patients,” we mean hospitalized children who were referred by the pediatric staff for psychiatric consultation; our control group was composed of hospitalized children who were not referred for psychiatric consultation. The study was conducted between March 1972 and February 1973. The 30 referred patients were children aged 5 to 12 years. We excluded patients over the age of 12 because their consultations were handled by the adolescent service; we excluded children under the age of 5 because the questionnaire we used was designed for school-age children. We also excluded children aged 5 to I 2 years whose psychiatric referral was part of a routine medical workup. The control group consisted of 60 children randomly selected from a sample of 1 ,200 children aged 5 to I 2 years. We estimated 1,200 as the total admissions of the 5- to 12-year-old age group by determining the patterns of admissions of this age group for previous years. We studied the medical charts of all 90 children and administered a questionnaire to their parents. The questionnaires were given to the parents of the children in the control group by one of us (G.A.A.) and to the parents of the referred patients by the consulting psychiatrists. The questionnaire included items on demographic data and a modification of the behavioral symptom checklist devised by Wimberger and Gregory (5). The medical charts of the 90 children were studied to determine the length of current hospitalization, number and length of previous hospitalizations, details on the medical work-up, and final diagnosis. There was no reason to suspect that our study influenced the rate of psychiatric referrals. “

RESULTS

During the period of study, there were 77 referrals for psychiatric consultation. Of these, 31 did not qualify for the study according to the criteria listed above. Of the 46 referrals that were eligible for the study, 16 refused to participate. The reasons given for refusal varied; they included hostility to psychiatry, doubts as to our reasons for conducting the study, and complaints about the length of time needed to fill out the questionnaire. In contrast, there were no refusals to participate from the control group. A mount

TABLE Number Control

1 of Behavioral Patient.s

Si’mnpto’n.s

ii

30 Referred

Referred

Patients

Patients

and

Control

6()

Patients

NumberofSymptoms

N

Percent

N

Percent

1-10 10-20 20-30 Morethan30

14 10 2 4

47 33 7 13

40 15 4 1

67 25 7 2

of Psychopathology

It is our working assumption that the higher the number of behavioral symptoms, the higher the degree of psychopathology. Glidewell and associates (6) demonstrated that a reliable positive relationship exists between the

916

number, frequency, duration, and severity of behavioral symptoms reported by a child’s mother and the degree of sickness found in the child. In our sample, the mean number of symptoms for the referred patients was 14.3 (range, 4-45), while the mean for the patients in the control group was 9.8 (range, 1-34) (p

Psychiatric consultations in a pediatric hospital.

The authors conducted a study of 30 hospitalized children who were referred for psychiatric consultation and 60 hospitalized children who were not. Th...
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