Talking with the child and adolescent psychiatrist

May 1, 2008

Child and adolescent psychiatrists may reach out to their pediatric counterparts for assistance in ruling out medical causes for behavioral problems, evaluating medication risks, and more. What should you know and do to be ready?

This article reviews the medical aspects of psychiatric evaluation and treatment in an effort to assist primary care pediatricians in understanding these requests. Practice parameters from the American Academy of Child and Adolescent Psychiatry and psychiatric literature will be highlighted. Ultimately, however, the individual provider must determine which examinations are indicated, based on the specific history and physical examination of each patient.

Teaming up during evaluation

At times, child psychiatrists are able to directly refer patients to pediatric subspecialists and order laboratory tests and examinations. Often, however, these referrals must be coordinated through the primary care provider either for insurance reasons, system of care requirements, or practical considerations (eg, when multiple out-of-network services must be coordinated). Common requests may include:

During evaluation, child psychiatrists may also have questions about co-morbid medical conditions (ADHD, autism, eating disorders, enuresis, etc.), which may impact not only the accurate diagnosis of a psychiatric disorder, but also the efficacy of treatment. Many psychoactive medications, for example, lower the seizure threshold, substantially induce weight gain, or affect cardiac conduction. Similarly, conditions such as asthma may be treated with albuterol, which could worsen the hyperactivity of a child with co-morbid ADHD.

The text in the subsequent pages details what examinations and laboratory tests a pediatrician may elect to perform, given a specific co-morbid disorder.

Collaborating during treatment with psychoactive meds

The available psychoactive medications prescribed by child psychiatrists, either with specific indications granted by the US Food and Drug Administration or more commonly prescribed off-label, vary in the degree of recommended medical evaluation at initiation and during treatment. While some child psychiatrists might provide all of this medical monitoring themselves, especially when the requirements are limited to monitoring vital signs and growth, others will ask to collaborate with the primary care provider.

In general, the medical assessment required before prescribing a specific psychoactive medication or during treatment can be divided into three categories: (1) none, (2) limited, and (3) extensive. Those medications that require no medical assessment include SSRIs, bupropion, and atomoxetine. Limited assessment (vital signs and growth measures) is required for stimulants and alpha-2 agonists. If a child has pre-existing cardiovascular disease or symptoms suggesting such disease, referral to cardiology for possible ECG and/or echocardiography is recommended prior to prescribing either stimulants or alpha-2 agonists.1,6 Extensive monitoring (ECG, EEG, laboratory studies) is required for tricyclic antidepressants, lithium carbonate, anticonvulsants, and antipsychotics.