Core Competencies

3.05 Specialized Services: Chronic Behavioral and Psychiatric Conditions

Introduction

Behavioral issues are increasingly noted in hospitalized children, either as comorbidity or as the primary focus for admission. Yearly, 1 out of 5 children living in the United States experiences a mental disorder. Chronic mental health disorders can affect many children but may manifest differently when occurring in children with chronic medical conditions. Because of different etiologies and contexts, the approach toward inpatient care and treatment may also differ. Hospital systems vary in resources and, in particular, the availability of mental health units, including specialized units needed for children with eating disorders. Pediatric hospitalists often encounter children with behavioral needs and play a key role in the advocacy and care for these patients.

Knowledge

Pediatric hospitalists should be able to:

  • List chronic neurodevelopmental disorders that may require acute behavioral and/or psychiatric management in the hospital setting, such as global developmental delay or intellectual disability due to varied etiologies, genetic disorders such as Rett syndrome or Down syndrome, neurodevelopmental conditions such as autism spectrum disorders, and others.
  • Cite commonly encountered mood disorders (such as depression and anxiety) and chronic psychiatric conditions (such as conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), eating disorders, and others).
  • Summarize the relationship between mental health conditions (such as autism spectrum disorder, disruptive behavior disorder, anxiety, or depression) and common chronic medical conditions (such as diabetes, cystic fibrosis, sickle cell and others).
  • Define disruptive behavior disorders and discuss strategies to mitigate the impact of these on care team members.
  • Review the differences between “internalizing” and “externalizing” behaviors.
  • Identify underlying triggers for escalating behavioral problems in these patients which are commonly encountered in the hospital setting, such as overstimulation from environmental cues, sleep loss, changes in routine and daily structure, fear of a new environment, and others.
  • Describe safety precautions needed for the patient, staff, and the family/caregivers when a patient is agitated or emotionally dysregulated, including awareness of surroundings, objects that can be used for self-harm or harm to others, and others.
  • Give examples of behaviors that may manifest from child abuse or neglect in this population, including aggression, withdrawal, and refusal of treatment or care.
  • Identify some commonly used evidence-based treatments for different behavioral conditions, such as Applied Behavioral Analysis (behavior modification for autism spectrum disorder), Parent-Child Interaction Therapy (PCIT) (parenting skills training for behavior disorders and trauma), Cognitive Behavioral Therapy (CBT), Exposure therapy, and Dialectical Behavioral Therapy (DBT).
  • List indications and possible side effects of medications commonly used in this population, including antidepressants, antipsychotics, psychostimulants, and others.
  • Discuss basic characteristics of each of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM)-5 eating disorder diagnoses including anorexia nervosa - restricting type (AN-R), anorexia nervosa - binge-eating/purging type (AN-BP), bulimia nervosa (BN), Avoidant Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding and Eating Disorder (OSFED).
  • Cite examples of laboratory testing commonly used to identify organic causes of feeding intolerance, growth delay, and malnutrition.
  • State the signs and symptoms of eating disorders that require hospitalization, including hemodynamic instability, bradycardia, and severe malnutrition.
  • Give examples of potential maladaptive behaviors that may occur in family members of patients with chronic behavioral and psychiatric conditions, such as maternal or paternal psychopathology, poor parent relationships, and sibling conflicts.
  • Review alternative communication modes that may be of value in this population such as drawing, use of symbols, sign language, photos, and computers.
  • Identify examples of secondary gain underlying behavioral problems for some children, including school or home avoidance.
  • Summarize medical and mental health care treatment needed for this population after hospital discharge, including access to mental health providers, residential or partial hospitalization programs, and coordination of care with the medical home.

Skills

Pediatric hospitalists should be able to:

  • Utilize locally available screening tools to identify patients with potential for behavioral and psychiatric disorders.
  • Identify adverse drug events related to medications used for behavioral health conditions.
  • Order appropriate monitoring, medications, and treatments to prevent or manage escalation of chronic maladaptive behaviors.
  • Coordinate care, with patients, the family/caregivers, and healthcare providers to ensure a safe environment for the child within the hospital setting, with attention to elective admission, procedures, and surgical events.
  • Consult, collaborate with, and/or coordinate an interdisciplinary team in the management of this population, including child life, social work, psychology, psychiatry, rehabilitation medicine, physical therapy, occupational therapy, speech therapy, and others within local context.
  • Diagnose conditions with both medical and behavioral/psychiatric components and create an effective, safe, and integrated management plan to address each.
  • Consult other subspecialists and appropriately refer or coordinate transfer of patients.
  • Identify patients who may benefit from evidence-based testing, such as imaging, genetic testing, hormonal testing, and others, and initiate orders as appropriate.
  • Demonstrate the use of physical exam and communication skills that are appropriate for the patients’ cognitive and developmental abilities.
  • Deliver care that is consistent and effective using behavioral and communication skills to support positive behavior choices.
  • Identify the potential for and manage aggressive or maladaptive behavior using environmental, behavioral, and medication modalities as appropriate.
  • Order and interpret common data including intake, output, vital signs, sleep habits, and nutritional needs for this population, and make care plan changes to address concerns.
  • Create a comprehensive discharge plan in coordination with the patient, the family/caregivers, primary care provider, mental health providers, residential or partial hospitalization programs, and others.
  • Provide support and empathy for health care providers and hospital staff facing challenging behaviors.

Attitudes

Pediatric hospitalists should be able to:

  • Reflect on the importance of maintaining respect and compassion when speaking with and caring for this population.
  • Role model professionalism by exemplifying patience and creating a positive therapeutic environment for patients, the family/caregivers, colleagues, and hospital staff.
  • Recognize that care plans may need to be adapted to accommodate a child’s changing medical and behavioral needs.
  • Realize that eating disorders occur in all genders, cultures, ethnicities, and socioeconomic classes.
  • Reflect on the importance of education and advocacy for the population of patients with eating disorders, noting that eating disorders are mental health disorders with physiological manifestations.
  • Recognize that children with neurodevelopmental disorders and disruptive behavioral disorders are at higher risk for abuse.
  • Reflect on the value of acquiring and utilizing coping skills for patients, the family/caregivers, colleagues, hospital staff, and self.

Systems Organization and Improvement

In order to improve efficiency and quality within their organization, pediatric hospitalists should:

  • Work with hospital administration to develop and implement training for healthcare providers, hospital staff, and trainees around the approach toward care for this population.
  • Work with hospital administration to develop and provide a safe and non-judgmental environment of care for this population.
  • Collaborate with healthcare providers and hospital staff to determine roles and responsibilities that optimize each member’s strengths and training when managing patient behaviors.
  • Collaborate with hospital administration and community partners to develop and sustain referral networks for family members to appropriate community resources, including respite care, social services, and therapy.
  • Lead, coordinate, or participate in organizational efforts to educate community providers on recognition of and criteria for hospitalization for children with eating disorders.

References

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