Pediatrician as a defacto Child Psychiatrist?

[FBurnaby]

A pediatrician was explaining to what extent psych issues come up in his primary care pediatrics, and that due to child psychiatrist shortages he handles almost all psych (and all adhd) on his own. Is this common? I'm actually interested in the possibility of doing general peds with a day of functionally being a child psychiatrist, or the ability to moonlight child psych gigs, is this possible without going back for a fellowship? I'm aware of such programs as triple board or PPPP but that seems more geared for those who want to be psychiatrists first and pediatricians second. Thanks for any insight.

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[SurfingDoctor]

The triple-boards are about 1/2 pediatrics, 1/2 psychiatric. They are about 5 years, with the first half mostly peds and the second half mostly psych.

Its been quite awhile since residency and general practice stuff, but I think general behavioral guidance is the job of a general practice pediatrician. Likewise, I think ADHD management, at least the more milder cases, are within the scope of a general pediatrician. Beyond that, I have seen pediatricians do depression, bipolar, psychosis, etc, however in my limited experience its mostly medication based without actual therapy and it didn't go well in the limited cases I've seen (super aggressive behavior, successful suicide attempts, etc.). Again, being in PICU, I only see when things go wrong, so take my experiences with a grain of salt.

As far as moonlighting, I suppose it would be possible, but it would likely be based on how desperate the need of the system is. There is a lot of child psych in the ER (from what I remember) that is triaged by social workers and nurses (eg admit to psych hospital, outpatient follow up). I suppose you could find a role in that capacity, but in general, I doubt you would be able to do much more than triage (well, you could order emergency psych drugs, eg Haldol). Usually speaking from a hospital standpoint; no board certification, no job. If it was your own practice, you could offer therapy as you see fit, but if you don't have credentials for the treatment you provide, you open yourself up to litigation if something goes awry.

If it's something that you really want to do, I would suggest getting the proper training.

 

[mvenus929]

In my experience (with a single child psychiatrist in our system, and maybe a handful more in the area that are qualified to handle pediatrics), most of our routine psychiatric stuff is managed in house. We manage most all ADHD on our own. Simple depression or anxiety we can also manage on our own. But the intense aggression, the psychosis, those that are intensely suicidal or homocidal (to the point of pulling knives on their parents) get referred out. We also have an extensive program of therapists to help with straight behavioral issues and CBT. We don't do any therapy ourselves beyond recommendations for parenting strategies, but do handle the med management part of things.

 

[FBurnaby]

So is it safe to say that med management of routine psych (depression, anxiety, and certainly ADHD) is expected of general peds? Referring out only high risk/high need cases and for talk therapists?

 

[FlowLimited]

So is it safe to say that med management of routine psych (depression, anxiety, and certainly ADHD) is expected of general peds? Referring out only high risk/high need cases and for talk therapists?

A general pediatrician is certainly expected to screen for and recognize ADHD and depression. How willing or comfortable they are in management is more pediatrician-dependent. I think that many pediatricians are comfortable with basic management and refer out for more complex or refractory cases.

 

[nogolfinsnow]

I have decent peds psych accessibility, but they're busy. I know if I can do the "routine" ADHD and mild anxiety and depression, I can hopefully free up psychiatry for the more complex kids. I do think these are well within the realm of what a well rounded pediatrician should be able to manage.

 

[ifailedmcat]

I read somewhere a few years ago that statistically, ADHD is managed primarily by general pediatricians with child psychiatrists coming in second. If I recall, the same study correlated this with the shortage of specialists and general pedi taking up the slack. I would say that this has been my experience as well. Even though our practice is in a large suburb with a large metro access, child psych takes 4 mo - 1 year for new appointments. Many of us have been been "forced" to manage these patients. I know some pedis who do not mange any ADHD, but most including myself and others in this thread manage simple ADHD, screen for and treat simple depression and anxiety. If you do gen pedi, you will likely see a lot of this but it is up to you if you want to manage it or not.

 

[calvnandhobbs68]

Experience is mostly the same as the above posters, at our hospital though our inpatient psych consult team handles almost all remotely psychiatric issues. On the outpatient side, I've seen even fairly complex ADHD cases where meds have had to be titrated up to max dosage, multiple med switches and multiple meds at once handled by gen peds. Very basic depression/anxiety with giving maybe one med a shot I've seen handled by outpatient general pediatrician. Anything past that though gets referred out. Never seen any antipsychotics/mood stabilizers given by anyone besides psychiatrists.