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Melanie Cole (Host): Welcome to the show. Our topic today is Pediatric Psychiatry Telephone Consultations, and my guest is Dr. Ginger Nicol. She’s at Washington University Child and Adolescent Psychiatrist at St. Louis Children’s Hospital. Dr. Nicol, tell us about the breadth of Psychiatry Services offered at St. Louis Children’s Hospital some of the conditions that you see everyday.

Dr. Ginger Nicol (Guest): Hi, Melanie. It’s nice to be on your show. The breadth of services really – we have a lot of wonderful expertise in Child Psychiatry that’s pretty rare. We also do General Psychiatry. We have a very robust consult service within the hospital, so any child who is hospitalized at St. Louis Children’s Hospital with a mental health condition in addition to their medical issue receives really expert consultation service and mental health care while they’re inpatient. We also have an outpatient Child and Family Center where we see children and their families from preschool and infancy all the way up to young adulthood. We have many specialty areas that are covered – preschool psychiatry, autism, early-onset psychosis, depression, anxiety, obesity, eating disorders – so, we really cover a broad spectrum, I would say.

Melanie: Tell us about some of the expertise – you mentioned it just a little bit there – of the Child and Adolescent Psychiatry Center staff. Tell us about your team.

Dr. Nicol: We have several really expert attending Child, an Adolescent Child Psychiatrists who have been here a number of years who do really important nationally and internationally recognized research in these areas. I mentioned preschool psychiatry. We also have an Infant Psychiatry specialist – infants and mother psychiatry --, and then we also have a pretty robust autism research group here that also has a clinical center that’s part of our clinic. We have, like I said, individual faculty members that specialize in childhood-onset anxiety disorders, depression, suicidality, eating disorders, and then we also have expertise in child trauma and a pretty robust clinic around working with families and children who have been traumatized and trying to reunite them and work through that.

Melanie: When do you feel it’s important to seek a Pediatric-Trained Psychiatrist, and what would you like Pediatricians to know about that and when to refer?

Dr. Nicol: Well, I’m really glad you brought that up because as you know, there are just not enough Child Psychiatrists in this country. We have really been facing a shortage for a number of years, and despite a lot of heroic efforts at the national level to increase our workforce, we still have not enough Child Psychiatrists.

Here, at Washington University, we have been trying to tackle that issue the best we can, by of course training more Child Psychiatrists, but then also trying to reach out into the community to work with our partners in primary care. They are really the ones who are seeing these kids on the frontlines, and they have to do the first line of treatment, often without very much help. We wanted to try to reach out to them and provide a resource because here we have all of this expertise, and we may not have enough people to see all the patients, but we certainly have the ability to reach out and partner.

Our pediatrician partners in the community that are already part of the St. Louis Children’s Hospital network often do informally contact us and ask us questions – “I have a patient who looks depressed. What is the first line treatment?” -- questions like that. Some of the common things pediatricians encounter might be depression, ADHD, anxiety – those are really I think the top three -- and then, of course, developmental disorders like autism. As I said, those are very common things that pediatricians encounter and usually can do the first step of treatment. When that doesn’t work, or things get more complicated, or it looks like there is more than one thing going on – many children have two diagnoses, so it’s pretty common to have ADHD plus something else -- that’s usually when a pediatrician would contact us and say, “Hey, we need a little bit of help here. What do you recommend? What’s the next step?”

Melanie: Such an important point, Dr. Nicol, given the national shortage of child mental health specialists and the continuing role that pediatricians are going to play. Now, tell us how this telephone consult service came to fruition?

Dr. Nicol: It really came out of – selfishly, my wanting to help them and reach out to the community. We have an unusual service at Children’s Hospital in that we don’t have an inpatient unit. As Child Psychiatry at the hospital, we have a different way of interacting with our partners that are admitting patients, but also with the community. We actually didn’t have a consultation hotline like many of the other services did. We know that this was happening informally, and we wanted to try to make it a more formal way to work with our partners in the community giving the shortage and given the lack of access.

We went ahead and decided we were going to develop a workflow to be able to handle calls from pediatricians to our call center. We basically developed a program where we could train the people answering the calls to be able to access then the Child Psychiatrist who is on call, answer those calls, record the call, help us with facilitating whatever the outcome might be. It might be that we make a recommendation for – here might be the first step or the second step, or have you considered these additional services in the community. It might even be gosh, you need to send that child over to us so that we can have a formal evaluation.

Melanie: It certainly has a potential advantage over traditional models, Dr. Nicol, doesn’t it – by providing that almost immediate access to specialists, while potentially enhancing a pediatricians’ understanding of mental health treatment. Is this service unique to the area? Are any other hospitals offering it? If they are, what makes your different?

Dr. Nicol: That’s a good question. This sort of telephonic consultation has been done in other states usually in a setting like Children’s Hospital, Wash U – so, in the academic milieu, if you will. This is now really an evidence-based practice; we’ve been able to show – in other parts of the country – that telephonic consultation, when it’s easily, readily, immediately accessible, does help pediatricians feel more confident, competent, and it leads to better outcomes for patients.

Now, of course, that doesn’t answer the question of what happens when a patient needs to be seen and how do we deal with the waiting list, but this is a way to – like you said, help primary care doctors feel more comfortable dealing with these issues -- not feeling like they’re out there swimming with the sharks, so to speak, and without any help – but that also helps them learn, so that each time they call they’re calling with something just a little bit more complex or different and really feeling like they’re learning too.

Now, in terms of what’s available in the region right now, currently, St. Louis Children’s Hospital is the only place that has this sort of service available. Really excitingly, we have been able to bring some funding into the region to be able to expand this service, and so this is, like I said, an evidence-based practice that we know will be growing and we’re really proud that we started it here.

Melanie: And what should the phone service not be used for as far as appointment or referral line, that sort of thing?

Dr. Nicol: I’m glad that you brought that up because it is not necessarily a service to call to get an appointment. Now, that might be one of the outcomes of a call, but really this is a service to be able to help somebody at the moment, so to speak -- so that you can call and within 15 to 30 minutes get a call back from an attending psychiatrist here at Children’s Hospital – that can help you with a question that you might have.

Some examples would be, “I have a teenager who has been self-harming, and she’s got a history of depression. What should I be thinking about? Have I covered all of my safety bases?” And that might be a situation where the patient is still in the office waiting to determine whether she is safe to leave. Another question might be, “I have a 7-year-old child with ADHD, and I have already tried the first-line treatments, the stimulant medications, and they didn’t work. I’m not sure what to do next.” That might be the situation where the child was safe to leave, but there is still the question about management that the pediatrician can follow up on the next day after they have gotten some guidance.

We don’t tend to be able to offer as much for emergency consultations, and obviously, that’s for safety reasons. We would just recommend – gosh, send that kid right over to our Emergency Room, and we’ll go ahead and see them for an urgent or emergent sort of situation. But even then, a caller might call with an emergent situation like that, and then our staff is going to screen for that and make sure that that issue gets addressed right away. Those would be some of the reasons that somebody might call that might get assistance that’s useful, but for emergencies, we would definitely recommend that people come physically to be evaluated in our Emergency Room.

Melanie: And does Children’s have psychiatry information available to patients and family as well, Dr. Nicol?

Dr. Nicol: Yes, so there are several different ways that families can get information from how to access us and an appointment to all the way to how to navigate the system of mental health -- which can be very confusing even for physicians sometimes – so we have a nice website that’s got a lot of educational information. We also sometimes field calls through the doctor hotline from family members, and we definitely have some resources that are specific to families. We have a hotline that is specifically for families called 454.TEEN. Even though it says 454.TEEN, it’s actually for all kids, and it’s through our Department of Psychology at the hospital. They can offer really helpful advice to callers during business hours about how to handle psychological and behavioral challenges, but then they also have a really nice database of psychotherapy providers in the community and can make referrals.

Melanie: If a referral takes place, what can a referring physician expect from the Pediatrician and Adolescent Psychiatry Center team?

Dr. Nicol: For a referral, an outcome for a call might be that a specific type of psychotherapy is recommended, so Parent-Child Interaction Therapy might be something that a pre-school child who is acting out might really benefit from. Most of our providers know who in the community provides that service and can just give the caller that information right away, and they can follow up on that, and it’s actionable immediately.

Sometimes, there might be a referral that’s less specific, so we might say gosh, there might be two or three different types of psychotherapy that might be helpful for the problem that the caller is asking for assistance for. We might make a referral to 454.TEEN and say, “This is the place to go for a more specific referral about who in the community provides that service.” In some cases, we might say that child really needs to be seen and has a condition that really is very unique or specific to some of the expertise that we have here at Wash U, so then we might say that would end up in a referral to our clinic and we would route that in the appropriate clinic and the referral process gets started.

Melanie: In summary, DR. Nichol, tell other physicians what you’d like them to know about the Pediatric Psychiatry Telephone Consultation Service from St. Louis Children’s Hospital, and when to refer?

Dr. Nicol: I guess what I would like for Pediatricians and Primary Care Doctors in the community to know is that we appreciate what they do. We know it’s hard. We know that they are doing most of the psychiatry work for their patients and we want to be accessible to them. Whenever a question occurs, whether it be “is this something to worry about,” or “is this an emergency” even, we want them to call and ask us for help. It’s not something that often takes much of our time, and we know that we can be helpful that way. The hotline is from 7am to 6pm. We tried to extend it outside of business hours to try to accommodate that that might be when it’s easiest to call. We like to have people to call whenever they need help. We’re very available and interested in talking with our partners in the community to help them better manage their patients.

Melanie: Thank you so much, Dr. Nicol, for being with us today. With the Telephone Consultation Service, primary care providers seeking advice in the management of acute and chronic pediatric behavioral health disorders have direct access to speak with a Washington University Pediatric Psychiatrist or a physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks so much, for listening.