RESEARCH UPDATE REVIEW

This is the 16th in a series oflO-year updates in childand adolescentpsychiatry. Topics areselected in con­sultation with theAACAP Committee on Recertification, bothfor the importance ofnew research and itsclinicalor developmental significance. The authors have been askedtoplace an asterisk before thejive orsix mostseminalreferences.

].McD. and M.KD.

Consultation-Liaison in Child Psychiatry:A Review of the Past 10 Years. Part I: Clinical Findings

PENELOPE KRENER KNAPp, M.D., AND EMILY S. HARRIS, M.D.

ABSTRACT

ObJective: To critically review clinical reports on pediatric consultation-liaison psychiatry over the past 10 years. Method:

Articles contributing to the understanding of child psychiatric consultation in medical settings were reviewed. Results:

Information related to clinical issues was organized into categorical (disease-oriented), noncategorical, and family

studies. Newer articles on ethical considerations in caring for medically ill children are summar ized. Conclusions:

Research has continued to focus on and reflect the importance of the emotional and behavioral needs of children in

pediatric settings and the adaptation and stress within families who care for chronically ill children . Given the increased

complexity and demands of medical care, the training and skills of a child psychiatrist in pediatric consultation remain a

valuable component of comprehensive care for children. J. Am. Acad. Child Ado/esc. Psychiatry, 1998, 37(1):17-25.

Key Words: consultation-liaison , pediatric chronic illness.

Pediatric consultation-liaison psychiatry operates innumerous dimensions and domains. The dimensions ofconsultation activity extend from individual case-basedconsultation for a given patient about a particular ques­tion, to liaison with other caregivers, and participationin administrative activities. The identified client may bethe child, the parent, or a primary care provider caringfor children.

The discipline of consultation-liaison work origi­nated in medical settings, and it is in work with chron­ically ill children that basic questions in the field havebeen framed. What is the impact of adversity (e.g., ofan illness) on a child's development? What factors bufferor amplify the child's distress? How is quality of life tobe defined in childhood? Who does psychiatric con-

Acupud May 23. 1991.Dr. Knapp is Pro/mor. Department 0/ !'Jychiatry and Pediatrics. and Dr.

Harris is Assistant Pro/mor. Department of Psychiatry. University ofCalifornia

Davis.Reprint requests to Dr. Knapp . UCDMClPsychiatry. 4430 V. Stru t.

Sacramento. CA 95817.0890-8567/98/3701-00 17/$0 .300/0© 1998 by the Amer ican Academy of

Child and Adolescent Psychiatry.

J. AM. ACAD. CHILD ADOLES C. PSYCHIATRY. 37:1, JANUARY 19 98

sultations for ill children? The literature on mental dis­orders in pediatric settings is extensive. Chronic illness inchildren carries psychosocial risks (American Academyof Pediatrics, 1993; Bird et al., 1989; Canning, 1994;Pless et al., 1993) and does influence referral patternsboth to pediatricians and from pediatricians to childpsychiatrists (Blancquaert et al., 1992). Emotional andbehavioral problems have been found to affect 18% to

20% of children in pediatric primary care practices(Bird et al., 1988; Cohen and Brook, 1987; Costelloet al., 1988; Kashani et al ., 1988) , and rates ofemotional and behavioral disorders are likely to behigher than 20% in children with chronic illness (Eiser,1990; Gortmaker et al., 1990; Lavigne and Faier­Routman, 1992; Offord et al., 1987). Population-basedresearch shows that children with chronic disease haveincreased likelihood of psychiatric disorder, especially ifthey have physical disabilities (Breslau, 1985; Flemingand Offord, 1990; Offord et al., 1989). In an epi­demiological study of 11,699 children, aged 4 to 17years, Gortmaker et al. (1990) found that the odds ofhaving problems were higher if the child was younger,male, and had a single parent and low family income.

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KNAPP AND HARRI S

adolescent psychiatry, and nearly one third expressedinterest in consultation-liaison psychiatry as one area ofsubspecialization , along with adolescent psychiatry, sub­stance abuse, and geriatrics. Respondents in this surveyworked an average of 48 hours a week, two thirds indirect patient care, and in an average of 2.3 differentsettings. In comparison with responses from theauthors' 1988 survey, the number of those reportingprivate practice as their primary setting declined.

Disease-Oriented (Categorical) Approaches

to Consultation

In the past decade, reports focusing on particular dis­orders have sought to define the interaction of medical,psychological, and psychiatric factors ; determine therisk of these factors to a child's development and psy­chosocial adaptation; and explore treatment approaches(Drotar, 1989; Fritz and Spirito, 1993; Garrison andMcQuiston , 1989; Krener and Wasserman, 1994).Every chronic childhood illness has been studied. Theliterature is largest for those frequently occurring ill­nesses that have salient interaction with psychologicaland psychosocial factors: asthma. diabetes, and malig­nancies. A number of studies apply parallel inquiry tomore than one disorder (e.g., Drotar, 1994). The pastdecade has also seen the rise of human immuno­deficiency virus (HIV) infection in children andadolescents and the new availability of high-technology

Authors Identifying Factor

TABLE 1Risk Factors in Chronic Illness in Ch ildren

Haupt et al., 1994; Moehleand Berg, 1985

Breslau, 1985; Offord er al.,1989

Perrin and Maclean, 1988

Gorrmaker et al., 1990

Akerman er al., 1988

Thapare and McGuffin,1996

Krener and Adelman, 1988;Timko et al., 1992

Breslau, 1985

Parent perception, parentsymptoms

Brain dysfunction as a result ofillness

Brain dysfunction as a result oftreatment

Physical disability

Risk Factor

Pain frequency

Young age, single parent,low family income

Male gender (immunoreactivetheory)

Genetic loading

Recent theories explaining selective male afflictioninclude the immunoreactive theory (Akerman et al.,1988) and genetic theories (Thapare and McGuffin,1996) (Table 1).

Despite the epidemiological findings suggestinggreater overall risk, chronically ill children surveyed byself-report often acknowledge fewer, or similar numbersof, depressive symptoms compared with healthy con­trols or available norms (Kaplan et al., 1987; Worchelet al., 1988) . Some authors suggest that this reflectseffective coping by using denial as an effective strategyto downplay and minimize distress. Others suggest thatimportant differences in individual adaptive style maydirectly and indirectly influence, in both a positive andnegative direction, psychological and medical outcomeassociated with illness (Canning et al., 1992a). Addi­tional factors complicate the assessment and identi­fication of emotional and behavioral symptoms inchronically ill children, including conflicting or dis­crepant reports form child, parent, and pediatrician(Canning et al., 1992b) and the poor performance ofcommonly used child psychiatric instruments andscreening measures in children and adolescents withchronic medical conditions (Canning and Kelleher,1994; Harris et al., 1996).

Social factors may either buffer or amplify the child'sdistress. If a child has a chronic illness, his or her psy­chosocial adjustment will be affected by the parent'sperception of disease severity, parent control (e.g., indiabetes), visible impairments (e.g., in end-stage renaldisease), or frequency of pain (e.g., for school perform­ance in children with sickle cell disease) (Perrin et al.,1992). Studies comparing children with different dis­ease groups (e.g., Breslau, 1985) find that if the disorderinvolves brain function, the child is likelier to havepersistent and severe emotional and behavioral prob­lems. The age of the child is also a factor: younger chil­dren are more affected in school tasks and achievement,whereas older children experience more difficulties insocial adjustment.

Finally, who does psychiatric consultation? Consulta­tion-liaison services have been an area where thetraining of psychologists and psychiatrists can co­mingle synergistically (Olson et al., 1988), although thisvaries from one practice setting to another. In a 1988­1989 survey of 19,431 active U.S. psychiatrists,Dorwart er al. (1992) found that more than 20%reported formal fellowship training in child and

18 J . AM . ACAD. C H I LD ADOLES C . PSYCHIATRY. 37 :1. JANUARY 1998

interventions such as organ transplantation, generatingnew challenges for consultation-liaison psychiatrists.

Asthma. In certain medical disorders, attachment fac­tors have been found to be associated with a more severecourse. Attachment problems have been studied in asth­matic children (Kashani et al., 1988; Mrazek et al.,1991) in relation to emotional symptoms (Fritz er al.,1996; Miller and Wood, 1994; Wamboldt et al., 1996),parental anxiety, and parenting patterns (Gustafssonet al., 1987). Elevated serum IgE may playa role inworsening illness manifestation (Burrows et al., 1989;Mrazek et al., 1990), and asthma is more severe in chil­dren with depression (Mrazek, 1985). Children withasthma had less depression than children with cancer,but, although they had lower self-esteem, they missedschool lessoften (Padur et al., 1995). These findings raiseinteresting questions about the relationship of functionalstatus, affective adjustment, and school attendance.

Insulin-Dependent Diabetes Mellitus. Associationsbetween poor emotional adjustment and poor controlof diabetic symptoms have long been noted (e.g .,Wilkinson, 1987). Psychological factors complicateadjustment and jeopardize compliance (Kovacs et al.,1994), and they may necessitate parental involvementto maintain optimal diabetes management (Weist et al.,1993).

Cancer. Children with malignancies form a hetero­geneous patient population because of the range ofmorbidities associated with different oncology diseases.Leukemia is among the most common and has receivedthe most attention (e.g., Sawyer et al., 1986). It tends tobe a chronic rather than terminal illness, with anincreasingly high cure rate. Among children receivingcranial irradiation, those who develop neuropsycho­logical deficits have greater difficulties adjusting (e.g.,Haupt et al., 1994; Moehle and Berg, 1985). Familyand sibling factors have also been studied in leukemiapatients, in conjunction with prolonged and regulartreatments (Cohen et al., 1994, Rait et al., 1992) .Children and adolescents treated for leukemia werefound to have higher emotional and behavioral symp­tom levels than siblings or controls, and their parents

-reported themselves as less "effective" (Sawyer et al.,1986). However, only raw (not normed) scores werereported, and the measure of family functioning used inthis study was not standardized. Other studies of chil­dren with cancer have noted lower levels of depressivesymptoms compared with normal controls , however.

J. AM. ACA D . C H I LD AD OL ESC. PSYCHIATRY, 37:\, JANU AR Y 1998

CONSULTATION -LIAI SON REVIEW: CLINICAL

HIV. There is an expanding body of literaturedescribing the struggle of children with HIV infection,in the context of their often devastated families(Adnopoz et al., 1994; Krener, 1991a,b, 1992; Mellingsand Ehrhardt, 1994; Nozyce et al., 1994; Raffin et al.,1993; Trad et al., 1994) . Children with severe HIVsymptomatology are at high risk for impairment in bothmental and psychomotor development compared withinfected children who are not highly symptomatic orcompared with uninfecred children of HIV-infectedmothers (Krener, 1996; Nozyce et al., 1994) . Socialostracism of HIV-positive families, and inequity oftreatment availability for these families if they areminority or substance-abusing persons, have stimulatedreview of ethical issues for children and adolescentswith acquired immunodeficiency syndrome (AIDS)(Etemad, 1995).

Organ Transplantation. Replacing a malfunctioningorgan with an intact one may "cure" a terminal con­dition, but the child and family continue to face thechallenges associated with chronic illness. The psycho­social treatment outcomes may not always be as good asthe medical ones. Conclusions about treatment efficacyare mixed and depend on the choice of outcome mea­sure. Cardiac transplantation is offered as an example;in this study, functional status increased after cardiactransplantation, but psychosocial function did not(Uzark et al., 1992) . After heart transplantation, 49children did not differ from their peers on self-reportmeasures of self-concept and anxiety, but they showedless social competence and more behavior problemsthan did controls . Their behavior problems weresuggestiveof depression and were associated with familystress. Psychosocial adaptation was better for childrenwho were able to verbalize and talk about their feelingsand concerns after the cardiac transplantation.

Other Childhood Disorders. The effect of a childhoodcardiac illness on family adaptation has been studied byseveral authors. Child adjustment was associated withparental mental health and level of stress: better adjust­ment on the Child Behavior Checklist (CBCL)(Achenbach and Edelbrock, 1986) was associated withless maternal depression and more emotional closenessand empathy (DeMaso er al., 1991). In studies of chil­dren with cystic fibrosis, Simmons et al. (1987), usingthe CBCL and Thompson er al. (1990), using a semi­structured diagnostic interview, found that childrenwith cystic fibrosis had more somatic profiles and more

19

KNAPP AND HARRIS

psychiatric symptoms (particularly internalizingsymptoms) than did normal controls, but less than chil­dren with psychiatric d isorders. In contrast, childrenwith recurrent abdominal pain had significantly higherlevels of anxiety and depression and significantly lowerChildren's Global Assessment Scale scores than normalcontrols or children with organic abdominal pain, andin fact, they more closely resembled children with psy­chiatric diagnoses (Wasserman et al., 1998). Similarly,mothers of children with recurrent abdominal painwere significantly more anxious and depressed thanmothers of healthy controls (Garber et al., 1990).

Epilepsy, although usually not associated with defor­mity or delay, presents a painful example of perceivedvulnerability and loss of control occurring during theyears when development of autonomy and mastery areexpected (Hoare and Kerley, 1991; Kindlon et al., 1988;Krener and Wasserman, 1994). Child psychiatrists maybe challenged to help parents of children with seizuredisorders to find a difficult balance between protectingand encouraging their child. Other studies of theimpact of child chronic illness on parents includemothers of children with sickle cell anemia, who mustassist their children in coping with pain (Sharp et al.,1994), and a longitudinal study of the adaptation ofparents of children with rheumatic diseases (Timkoet al. , 1992) . Such approaches incorporate the emo­tional context of the child's relationships into theunderstanding of how the parent and child cope withillness. They teach us that the child's relationship withthe parent who cares for him or her is affected by, and inturn affects, the course of the illness. In addition, a largeminority of caregivers to children with chronic medicalconditions experience significant psychological distress.This is appears to be related to the stress associated withthe increased burden of caregiving, chronic functionalimpairment in the child, and limited economicresources (Canning et al., 1997).

Newly described disorders have also been investigatedin children. A study of 44 pediatric patients withchronic fatigue syndrome found that the median age ofthose affected was 14 years, and they tended to befemale (60%), Caucasian, from middle to uppersocioeconomic status (SES), and to demonstrate no lab­oratory abnormalities (Carter et al. , 1995) . Twenty ofthe chronic fatigue patients underwent psychologicaltesting; when their scores were compared with those ofnormal controls and patients referred for depression,

20

they were found to have higher scores for either depres­sion or somatization, suggesting that psychological eval­uation may be warranted in chronic fatigue.

Disorders Predominantly Psychiatric. Munchausensyndrome by proxy is a malignant parenting pattern,recognized for more than a decade, in which thecaregiver fabricates physical or psychological symptoms.The syndrome continues to present itself and to Hour­ish, particularly in the technologically sophisticated,multiply staffed modern medical center (Feldman,1994; Schreier and Libow, 1994). Somatization dis­order, renamed but recurrent, also remains in thedomain of the consulting psychiatrist. In the OntarioChild Health Study, prevalence rates of somatizationsyndromes were estimated at 4.5% for boys and 10.7%for girls aged 12 to 16 years (Offord et al., 1987). Intheir comprehensive review of 119 empirical studies ofsomatization in children, Campo and Fritsch (1994)found that medically unexplained physical symptomsare common in childhood and include, in descendingorder of frequency, headaches, recurrent abdominalpain , limb pain, chest pain, and fatigue . Pseudo­neurological symptoms are uncommon. An associationbetween physical symptoms and psychiatric disorders orlife events has been demonstrated , as well as anassociation with life events (e.g., genitourinary and gas­trointestinal symptoms in victims of sexual abuse)(Campo and Fritsch, 1994) . The skills of a child psy­chiatrist may be particularly valuable in evaluating med­ical facts in the context of psychological factors which,if not understood and treated, may drive the soma­tization process to unnecessary disability or medicalinterventions.

Noncategorical Approaches to Consultation

In the past decade, the focus of research of chronicillness in childhood has shifted from types of illness tothe child. Different constructs of psychiatric morbidity,comorbidity, functional limitation or adaptation, andinformant bias have emerged. The DSM-IV term"somatization disorder" has redefined the behaviorpattern, emulating illness, previously called conversiondisorder in DSM-III-R, and both terms have replacedthe older paradigm of illness-associated personalities,although classic conversion disorders may still bedescribed (Siegel and Barthel, 1986) . The "noncat­egorical approach" is the approach to the child as aperson with an illness who, with his or her family, is

J . AM . ACAD. C H I LD ADOL ESC . PSYCHIATRY, 37 :1, JANUARY 19 9 8

experiencing stress that is due to being ill and not tospecific factors associated with a particular disease. Withthis perspective, a child 's psychosocial morbidity andfunctional adaptation are considered independent ofthe specific disease, in order to understand the effects ofmore global illness experiences such as pain. fatigue, dis­figurement, or missed school days.

Noncategorical approaches have also been applied tostudies of families of ill children. The challenge in inter­preting findings of maternal response to a child's illnessis demonstrated by a study of 209 inner-city childrenwith various chronic illnesses. Multiple instrumentswere used to measure psychiatric symptoms, functionalstatus, the clinician's estimate of the overall burden ofcare, and the impact of the illness on the family. Theauthors found that overall functional status wasassociated with increased psychiatric symptoms, but itsimpact was lowered when the social context and otherhealth concerns were accounted for in the model.However, because the study did not include a controlsample, the stress in the sampled families cannot be dis­tinguished from the stress faced by many inner-cityfamilies (jessop et al., 1988).

Parents of chronically ill children may be more likelyto use mental health services because they are exposed tothe servicesas part of their experience with hospitals anddoctors. Thus their situat ion may cause their distress tobe recognized more frequently. Conversely, there may befactors, such as poverty, divorce, and parental mental ill­ness, that are likelier to occur in families with a med­ically ill child, and which, when recognized, lead topsychiatric referral. It is difficult to evaluate whether theservices they receivesubsequently lower their distress.

Studies of Family Responses to Child Illness

Ideally, the child's family cultivates the child 's devel­opment, comforts the child, absorbs the child's stress,conveys the child for medical care when needed, com­municates with the physician without reporting bias,complies with recommended treatments, and shouldersthe economic burden generated by the child's illness.Hence, studies of chronically ill children's families have.assessed aspects of family functioning that foster thechild's development, have tracked utilization of servicesand sibling relationships (Fisman et al., 1996; Lobotoer al., 1988), and have assayed parental emotionalreactions to the illness, compliance with treatment, andfamily strain.

J . AM . ACAD. CHILD ADOLE SC . PSY CHIATRY, 37: 1, JANUARY 1998

CONSULTATION-LIAISON REVIEW: CLINICAL

A study of both stresses on and coping by parents ofchildren with juvenile rheumatoid arthritis found thatchildren had more functional disability in families inwhich parental adaptation appeared constrained becauseof the parents' excessive use of avoidance as a primarydefense (Timko et al., 1992). In a multicenter study,mothers ' ratings of their children's functional status andtheir medical care utilization were less related to themothers' own psychological distress than to factorsrelated to the illness, specifically the mothers' beliefsabout or attributions to the illness. These two studiessuggest that the child psychiatrist needs to understandboth the parent's explanatory model of illness and thedefensive style or coping skills the parent uses to dealwith his or her distress about the child's illness. Parents'responses to a child's chronic illness may range fromhealthy adaptation to behaviors that can sabotage thechild's care in the service of the parent's psychologicalneeds (Krener and Adelman, 1988). This may take the ex­treme form of Munchausen by proxy syndrome (Schreierand Libow, 1994), as mentioned above, an illness that islikelier to be both perpetuated and detected in tertiarycare settings, where both chronically ill children andchild consultation-liaison psychiatrists tend to gravitate.

Are mothers' emotional symptoms related to illnessseverity, to illness duration, or to the child's behaviorsand symptoms? To answer this question, Kovacs et al.(1990) followed 95 children with newly diagnosedinsulin-dependent diabetes mellitus, using measures ofmetabolic control, diabetic management, child anxiety,and parental symptomatology. Immediately after initialdiagnosis, children tended to experience depression anddistress. Thereafter, there was no association betweendistress and depressive symptoms reported by the chil­dren themselves or by their mothers. Children with lesspsychiatric disturbance coped better with ongoingdemands of the illness.

Pediatric Liaison Issues in Child Psychiatry

Psychiatric consultation to pediatrics has a venerabletradition, yet it faces new obstacles in an era of hightechnology but economically managed care (Steineret al., 1993). Pediatricians value and want timelyresponse and accessibility from consultants (Spiritoet al., 1988), and they most frequently refer adolescents(Burket and Hodgin, 1993) . However, pediatricians'level of satisfaction with psychiatric consultation hasbeen found to be low (Ozbayrak and Coskun, 1993).

21

KNAPP AN D HARRI S

Awareness of previously unrecognized connectionsbetween life events and the psychological equilibrationof the developing child has led to the description ofcertain illnesses in new terms . For example , theexperience of children being brought by their mothersfor sometimes painful treatments for cancer has beenanalogized to the experience of children whose mothersfail to protect them from physical or sexual abuse byadulrs in the home. This results in conceptualizing theconsultation differently, as alterations in the medicalapproach may be required, in addition to psychiatricintervention.

The recognition of posttraumatic stress disorder(PTSD) in children has led in turn to the connectionbetween catastrophic injury and the symptoms of acutePTSD. Sudden physical trauma, including burns, com­monly seen in terti ary medical centers (Lewandowskiand Baranoski, 1995), is an example of this. Recog­nition of the PTSD syndrome will lead to differentmanagement of the child's symptoms, as detailed in thecompanion article (Knapp and Harris , in press). Thosecaring for the child may be vicariously traumatized.Liaison work is frequenrl y necessary in the care of achild with a devastating trauma, as nursing staff mayexperience intense feelings of attachment to the childand sympathy for the family (or indign ation in cases inwhich they believe the child was not adequatelyprotected) and may be vulnerable when the child dem­onstrates upset or distress when telling about theexperience. The consultant may assist by facilitatingexpression of feelings and offering support, problem­solving, or conflict resolution .

Another recent development in the care of childrenwith disorders requiring "high-tech" interventions isthat the media may become an unplanned part of the"treatment team." This has been seen to occur in situ­ations in which a child requires an organ transplant,particularly if media support is offered to either locate adonor organ or to raise funds to pay for the child's care.The media may also seek information related to the careof victims of unusual child abuse. If police interviewsare necessary, the presence of the child psychiatricconsultant may assist, and the psychiatrist may alsoassist in preventing the media from becoming anadditional overwhelming stress for the child.

Newer understanding of the interpersonal context ofchildren's subjective experiences has led to reevaluatingthe problem of assessing children's pain in the medical

22

setting. Parents' cues may strongly affect the child'scoping: e.g., if the parent makes a negative comment"Doesn't it hurt?" this may encourage poor copingresponses in the child . On the ocher hand, if the parentdoes not permit the child to express pain or fear, thechild may not be able to allow himself or herself toexperience this, and his or her behavior may be rated asnot showing pain. The skills of the child psychiatristare very valuable in evaluating not only the child 'sfeelings bur also the parent-child communicationparrerns in order to figure our whether the parents'reactions to the child's pain are interfering with how thechild copes with the pain.

Numerous therapeutic options are available to thechild psychiatrist (Krener and Mrazek , 1995), and theseare detailed in the companion article (Knapp andHarris , in press); however, whether any of these optionsin child consultation-liaison work depends on the con­text in which the child psychiatrist is working. The ageof the child may affect acceptance of treatment; thechild's age has been found to be related to adherencewith procedure-related tasks (Manne et al., 1993).Psychosocial or culrural factors may limit treatment;Manne et al. found that families with lower SEScanceled more clinic visits, or came late to them, anddid not promptly report children's reactions to treat­ment.

Ethical Issues in Consultation Psychiatry

Defin ing a question from multiple points of view isan inherent part of consultation: translating differentindividuals' points of view to each other is an inherentaspect of liaison work . Moral principles and practiceparrerns of the providers inform and influence thesepoints of view. Medical ethics, a dynamic field con­cerned with the moral principles of medical care, expe­riences a resurgence under the twin pressures ofmanaged care and "superhuman" technological ad­vances in medicine. The consultation-liaison psychia­trist interfaces in two ways with the medical ethicsphilosopher: by confronting intricate clinical problemsand by relying on the principles of medical ethics todevise their solutions.

The classic ethical triad (the Georgetown model)counterpoises (I) what the patient wants (patientautonomy), with (2) what the physician thinks is bestfor the patient (physician beneficence), and (3) thelimitations of what society can afford to provide (dis-

J . AM. ACAD . C H ILD ADOLESC. PSYCH IAT RY, 37 : 1, JAN UARY 1998

tributive justice). Traditionally, the psychiatric con­sultant has catalyzed the articulation of the patient'spoint of view and has therefore usually advocated forpatient autonomy (e.g., Bloomberg et al., 1992).

The patient's relationship to his or her illness (whichhere includes the parent's relationship to the child's ill­ness) may, however, be complicated by psychologicalfactors that obfuscate the diagnosis, thwart and perplexthe treating physician, or sabotage medical compliance(e.g., Krener and Adelman, 1988). Somatization dis­order exemplifies this, and in this instance the bene­ficence of the medical care provider becomes misappliedin the service of the psychopathology of the patient.The consultation-liaison psychiatrist cannot intervenewithout both understanding the patient, that is,decoding the patient's dynamics, and translating thepatient's pathology to the referring physician. A relatedchallenge in this decoding and translating occurs whenthe medical care provider is evaluating and treating achild's symptoms through a parent who may not under­stand the child's needs, may communicate the child'sneeds inaccurately, or may not have the child's bestinterest at heart, as in child abuse, medical non­adherence, and Munchausen by proxy syndrome(Krener, 1995; Krener and Mancina, 1994).

Injustice in the distribution of medical resourcesparallels the inequality in the distribution of socialresources in our culture. Coupled with the capitalisticventure of proliferating medical technology and newhospitals, this inequality has exhausted the economicreserve for health care and widened the gap in deliveryof services, particularly mental health (Prosser andMcArdle, 1996). This has ushered in an alternative cap­italistic endeavor: the big business of health care, as ithas been transformed by managed care companies.Children with AIDS, the majority of whom are of lowSES, from ethnic minorities, and infected through theillness of their parents (Krener, 1991 b, 1996), aretypical of those underserved in either the old or the newsystems. Their situation presents unique ethical dilem­mas (Etemad, 1995), which are independent of thosepresented by managed care (McFarland and George,

, 1995).

Conclusion

In the past decade, the venerable tradition of childconsultation-liaison psychiatry has continued to flour­ish, despite changes in the patterns of health care deli-

J. AM. ACAD. CHILD AOOLESC. PSYCHIATRY, 37:1, JANUARY 1998

CONSULTATION-LIAISON REVIEW: CLINICAL

very and the advent of managed care. The reducedlength of stay in hospitals has been counterbalanced bya broader use of multidisciplinary teams in outpatientsettings where children with chronic medical conditionsreceive their care. During this time, research has con­tinued to focus on the emotional and behavioral needsof children in pediatric settings and the adaptation andstress within families who care for chronically ill chil­dren. The clinical issues are here reviewed (refer to

Knapp and Harris, in press, for review of research intreatment approaches and outcomes). Of particularinterest are the new problems presented by "high-tech"treatments, such as organ transplantation, by the HIVepidemic, and by recently described psychoneuroim­munological disorders such as chronic fatigue syn­drome. Given the premium on provider time inmanaged care settings, the child psychiatrist's trainingand skill in the integration of biological,pharmacological, developmental, intrapsychic, andfamily assessment are more valuable than ever.

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My Mother Caused My Illness: The Story of a Survivor of Miinchausen by Proxy Syndrome. Mary Bryk, RN, BSN. Patricia T.Siegel. PhD

Objective: Miinchausen by proxy syndrome (MBPS) is a form of child abuse in which a parent fabricates or produces illness in achild. Although the medical consequences of MBPS have been well described. there is no detailed published account of what itwas like to grow up in a family where the mother systematically induced serious illness . This article describes one victim'schildhood experiences. Methods:The medical history was obtained from a review of the original medical records. notes from theprimary physician, discussions with two physicians who provided treatment, and several meetings with the victim and the victim'stherapist. Results:This article chronicles the actual experiences of an MBPS victim through 8 years of medical abuse at the handsof her mother, reveals the victim's account of what happened to her , describes what her family was like, details the long-term con­sequences on emotional and physical development, identifies the factors that influence recovery, and details the impact on familyrelationships. Conclusions:Child maltreatment and MBPS need to be part of the differential diagnosis when the clinical pictureis atypical or does not appear medically plausible. The consequences of MBPS are psychological and physical and impact the entirefamily. Suggestions to assist health care providers recognize, assess, and repon cases of suspected MBPS are provided. Pediatrics

1997 ;100: 1-7

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