Recommendations for Pediatricians, Family Practitioners, Psychiatrists, and Non-physician Mental Health Practitioners.

Introduction

Child and adolescent psychiatrists are physicians trained to provide multi-system assessment, diagnosis, and treatment planning for children and adolescents with a psychiatric illness. Families seek the services of these specialists when they are concerned about the mental health of their child or adolescent. Others may present to a primary care physician, pediatrician, family physician, general psychiatrist or non-physician practitioner. Some managed behavioral health care organizations direct patients to non-physicians for initial evaluation. While many children and adolescents with mental health disorders are successfully treated by these practitioners, there are situations when intervention by a child and adolescent psychiatrist is recommended. The intervention is determined by a combination of factors including the:
  • clinical presentation of the patient,
  • training, skill and experience of the practitioner,
  • family and environmental situation,
  • availability of support services and personnel, and
  • availability of a child and adolescent psychiatrist with relevant experience.
Types of Referrals
Practitioners should consider the following types of referrals:
  • Referral for evaluation and ongoing treatment.
  • Referral for evaluation and initial treatment with referral back for continued care.
  • Consultation and an evaluation but without the assumption of ongoing medical responsibility.
  • Consultation and an evaluation with continued supervision of treatment provided by other practitioners.
  • Consultation without a face-to-face evaluation of the patient. This may occur through a treatment team within a clinic or an intervention team within a school.
In addition to these formal referrals, professionals may have informal professional discussion about patient care issues. These may also occur through informal processes such as a telephone, email or direct discussion with the treating practitioner and may be a prelude to a formal consultation request. Please note that physicians must adhere to all state and federal HIPAA regulations regarding transfer of information.

Specific Criteria for Referrals
The referring practitioner should consider the following criteria when considering the decision to refer.
  1. When a child or adolescent demonstrates an emotional or behavioral problem that constitutes a threat to the safety of the child/adolescent or the safety of those around him/her. (e.g. suicidal behavior, severe aggressive behavioral, an eating disorder that is out of control, other self-destructive behavior),
  2. When a child or adolescent demonstrates a significant change in his/her emotional or behavioral functioning for which there is no obvious or recognized precipitant. (e.g. the sudden onset of school avoidance, a suicide attempt or gesture in a previously well functioning individual),
  3. When a child or adolescent demonstrates emotional or behavioral problems (regardless of severity), and the primary caretaker has serious emotional impairment or substance abuse problem. (e.g. a child with emotional withdrawal, whose parent is significantly depressed, a child with behavioral difficulties whose parents are going through a “hostile” divorce),
  4. When a child or adolescent demonstrates an emotional or behavioral problem in which there is evidence of significant disruption in day-to-day functioning or reality contact. (e.g. a child/adolescent who has repeated severe tantrums with no apparent reason, a child reports hallucinatory experiences without an identifiable physical cause),
  5. When a child or adolescent is hospitalized for the treatment of a psychiatric illness,
  6. When a child or adolescent with behavioral or emotional problems has had a course of treatment intervention for six to eight weeks without meaningful improvement,
  7. When child or adolescent presents with complex diagnostic issues involving cognitive, psychological, and emotional components that may be related to an organic etiology or complex mental health/legal issues,
  8. When a child or adolescent has a history of abuse, neglect and/or removal from home, with current significant symptoms as a result of these actions,
  9. When a child or adolescent whose symptom picture and family psychiatric history suggests that treatment with psychotropic medication may result in an adverse response. (e.g. the prescription of stimulants for a hyperactive child with a family history of bipolar disorder or schizophrenia),
  10. When a child or adolescent has had only a partial response to a course of psychotropic medication or when any child is being treated with more than two psychotropic medications,
  11. When a child under the age of five experiences emotional or behavioral disturbances that are sufficiently severe or prolonged as to merit a recommendation for the ongoing use of a psychotropic medication, or
  12. When a child or adolescent with a chronic medical condition demonstrates behavior that seriously interferes with the treatment of that condition.
If a patient is a member of a health plan that provides behavioral health services through a managed care network, the behavioral health care manager has the responsibility to locate appropriate care. The services of the behavioral health managed care organization should help the referring practitioner secure an appropriate referral/consultation.