PSYCHIATRIST 22

PSYCHIATRIST

 

1. The initial evaluation of the child is conducted by the psychiatrist, or if

necessary, by another appropriate clinician. The interview includes the family

and separate interviews with the child and parents if possible. The psychiatrist

interviews the child as soon as possible and within 24 hours if the psychiatrist

is unable to conduct the initial evaluation.

2. The initial evaluation includes the criteria for inpatient psychiatric hospitalization

described in the “American Academy of Child and Adolescent Psychiatry

Guidelines.” These guidelines include but are not limited to:

a) The psychiatric disorder must be of such severity as to cause significant impairment of daily functioning and at least two important areas of the child or adolescent’s life such as school performance, social interactions, or family relationships;

b) Other less restrictive treatment resources must have been considered and determined to be not available or not appropriate to the patient’s needs or have been attempted and proved unsuccessful. Examples of these restrictive treatment resources include, but are not limited to, residential treatment, day treatment or intensive outpatient care;

c) The treatment proposed must be relevant to the problems diagnosed and adjudged likely to benefit the patient. Unless there are compelling clinical reasons to the contrary, or serious limitations and availability, child and adolescents younger than 16 years of age should be admitted only to programs that are designed for children and adolescents and physically distinct from programs for adult psychiatric patient.

3. The goals of the treatment plan and the length of time expected to achieve these

goals is discussed with the parents. They should understand that hospitalization

is one phase in the treatment process and their active involvement in the

treatment is expected to continue.

4. It is the psychiatrist’s responsibility that these standards are met either

personally or at his/her direction.

5. For the purpose of this protocol, a qualified psychiatrist is defined as set forth

in Chapter 4 (CORE Guidelines. A. 8.,page 38, revised Feb. 1989).

Responsible physician will be Qualified Child and Adolescent Psychiatrist as defined in Sections A. or B., immediately below:

a) A licensed physician who has completed successfully an approved “Child and Adolescent Psychiatry Training Program.”

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b) A licensed physician and a “Qualified Psychiatrist”, by reason of having completed successfully an Approved Residency Program in General Psychiatry”, who is qualified by both documented experience and documented training to practice with both those of the patient’s age and with the families of this age patient; such training and experience to assure competence to acquire, complete and integrate data including a comprehensive evaluation, formulation, differential diagnosis with DSM Axis, treatment goals, treatment plans, discharge planning and school consultation and collaboration.

6. The decision to admit a child is determined either from an evaluation conducted

personally by the admitting child psychiatrist or on the basis of an evaluation

at the time of admission by the admitting child psychiatrist using the findings

of an appropriate clinician. In every case the admitting decision must be

confirmed within 24 hours on the basis of a personal examination by a child

psychiatrist. If a decision is made to admit the child, the child’s psychiatrist

in cooperation with he appropriate clinician arranges for a hospital bed and has

the parents accompany the child into the hospital to complete the Consent for

Treatment Form. Prior to having the parents’ consent to the child’s treatment,

the appropriate clinician talks with the parent and addresses the following

questions for that parent:

a) Why is psychiatric inpatient treatment being recommended for our child and how will it help?

b) What are the other treatment alternatives and how do they compare?

c) Is our child being admitted to the hospital by a child and adolescent psychiatrist?

d) What does the hospital’s treatment program include and how will our child keep up with school work?

e) What are the responsibilities of the child and adolescent psychiatrist and other people on the treatment team?

f) How long will our child be in the hospital, and how will we pay for these services?

g) What will happen if we can no longer afford to keep our child in this facility and inpatient treatment is still needed?

h) How will we as parents be involved in our child’s hospitalization, including the decision for discharge and aftercare treatment?

i) Is this hospital approved by the Joint Commission for the Accreditation of Health Care Organizations as a treatment facility for youngsters of our child’s age, or will my child be in a specialized unit or in a program accredited for treatment of children and adolescents?

j) How will the decision be made to discharge our child from the hospital?

k) When our child is discharged, what are the plans for follow-up treatment?

These questions are from the “American Academy of Child and Adolescent Psychiatry” recommendations. If the child or adolescent is being admitted through involuntary commitment procedures and/or because of immediate danger, these questions may not be appropriately addressed until the admission procedure is completed.

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7. The psychiatrist, in completing the psychiatric evaluation, completes an

evaluation for admission form, also known as “QPER,” which describes the

child’s behavior and other indications of mental illness and sets forth the reasons

why further treatment or evaluation in the particular facility is needed. There

should be sufficient facts set forth to support the conclusion that the child has

“A mental condition, other than mental retardation alone, that so impairs his/her

capacity to exercise age-adequate self-control or judgement in the conduct of his

activities or social relationships so that s/he is in need of treatment.” Specific

descriptions of problematic behaviors should be provided and conclusions such

as defiant, oppositional, hostile, promiscuous, assaultive and school problems

should be avoided. The evaluation must be legible, preferably typewritten. The

psychiatrist may include information that has not been observed. This

information is obtained from parents, staff, the child, the chart and other sources

and the source of such information should be indicated. The evaluation should

address why lesser measures, for example outpatient treatment, are insufficient.

The evaluation should address how the child will benefit from treatment and the

recommended length of admission. Attaching other information, such as

admission notes may be appropriate. The appropriateness depends upon whether

or not they contain confidential or sensitive information that could be divulged

through the court hearing.

8. Although a second evaluation is not legally required, the psychiatrist should

complete a second evaluation no more than 72 hours prior to the hearing in the

same manner as required above. This information facilitates the judicial process.

9. Early in the hospitalization and prior to the initial hearing, the psychiatrist or

someone at his direction should discuss the hearing process with the parents.

They should be informed that the process is intended to protect their child’s

civil rights and to insure that the child meets the court criteria:

a) The child is mentally ill based on the legal definition.

b) Further treatment is indicated at the particular facility.

c) Lesser measures are insufficient to the child’s treatment needs.

The parents should be informed that a lawyer will be appointed to represent their child and that lawyer will advocate for the child’s stated preference including the child’s release as indicated. The parents will not be represented unless they choose to employ council. Depending on the psychiatrist and the facility, the psychiatrist will not likely be present but the facility will be represented by a court liaison. The psychiatrist may choose to attend the hearing at the parents’ request.

10. The psychiatrist will talk personally with the parents as frequently as necessary

to keep them well informed. This information includes the child’s status and

treatment, the psychiatrist’s recommendations to the court and the parent role

in the treatment process. It is often difficult, but important to coordinate the

psychiatrist’s and the family’s schedule.

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11. The psychiatrist may also choose to discuss the hearing with the child,

explain the purpose of the hearing to the child and explain that the purpose of

the hearing is to protect the child’s rights. The child should also understand

that the attorney will speak to the child prior to the hearing and represent to the

child that the length of treatment, yet unapproved by the court, is not fixed and

that the child may be discharged prior to that time or that if additional treatment

is necessary, additional time may be approved for treatment beyond that date.

12. In complex or unusual cases, the psychiatrist may need to communicate with

the attorney in advance of the hearing.

13. During the hearing, the psychiatrist is welcome and encouraged to attend and

may call the Children’s Law Center to determine the most appropriate time to

appear. Alternatively, the psychiatrist may be subpoenaed to attend the hearing.

If the psychiatrist chooses not to attend the hearing, s/he should be accessible

by telephone during the time of the hearing. If the psychiatrist testifies, s/he

has the duty and responsibility to answer questions and to assist the court in

understanding the clinical nature of the child’s problems and the need for

inpatient hospitalization. The psychiatrist should avoid inflammatory or

adversarial comments which might damage the treatment relationship with the

child and family. The psychiatrist’s use of behavior examples rather than

conclusions provides more information to the court and is less conflictual for

the child and family.

14. If the child is released by the court, the psychiatrist must determine whether to

continue the child/physician relationship.

15. If the child is released by the court, the psychiatrist should not initiate or cause

to be initiated a new petition, either voluntary or involuntary regarding the same

child unless new facts occur that, subsequent to the court’s decision, warrant

the commencement of a new proceeding.

16. The psychiatrist has no responsibility for completing the notice of commitment

change form if the court releases the child. The physician may or may not

choose to make discharge recommendations under such circumstances.

17. Rehearing issues will be addressed by completing the appropriate form and

completing a new evaluation for admission, QPER, in the same manner as

before. These forms will be completed 16 days prior to the expiration of the

period of court authorized treatment, if additional treatment is necessary.

18. At or about the time of discharge by the psychiatrist, the notice of commitment

change will be completed and follow-up treatment planning will be discussed

with the child and family.

 

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