An approach to psychiatric referrals in pediatric patients. Psychosomatic complaints.

Psychiatric referral is an important aspect of clinical pediatric practice. This paper discusses referral to a family-oriented psychiatrist of difficult families with children who have an acute or chronic psychosomatic complaint. It is the responsibility of primary care physicians to develop facility in making psychiatric referrals. In this way the physician will be equipped to deal effectively with cases requiring attention beyond his time and expertise, as well as cases that he will manage alone. The paper considers five decision-points relevant for pediatricians making effective referrals of children with somatic complaints. (1) The pediatrician decides whether to conduct the evaluation on an outpatient or inpatient basis. In either case the work-up should be completed rapidly. A diagnostic hospitalization, whereby the parents agree to accept the results of a clearly defined evaluation as definitive, may be used with inpatient evaluations. The proposal of such a diagnostic hospitalization is considered. (2) After the medical evaluation is completed, the pediatrician decides whether to manage the case alone or to make a psychiatric referral. (3) A family conference can be used to initiate pediatric management or to make a psychiatric referral. A joint meeting, with both pediatrician and psychiatrist present, may be a crucial part of the management of difficult psychosomatic cases. The four stages of a typical joint meeting are described. (4) The utility of giving indirect rather than direct explanations of the meaning of a somatic symptom is described. By scapegoating the symptom rather than either the child or the parents, indirect explanations are often less threatening and more acceptable to the family. (5) Similarly, psychiatric involvement is often best proposed by recommending evaluation rather than treatment, since evaluation is less binding and takes into account the natural reluctance of many families to see the psychiatrist. After the referral has been made, ongoing contact between psychiatrist and pediatrician is important.