Peds vs adult psychiatry for an almost 18 year old

[flightdoc09]

Advertisement - Members don't see this ad

ED Doc here. Had a 17 year old who I was going to refer to mental health. But he turns 18 in 4 months. I know wait time for pediatric psych can be pretty long, and figured it would be better to just refer to adult psych, but wasn't sure if some adult psychs wouldn't feel comfortable taking on a 17 year old - I have seen internists and surgeons refuse to consult on 16/17 year olds that are adult sized - but not sure if that's an insurance thing or malpractice thing or what.

So I guess my question is, who should I have referred him to?

 

[clozareal]

Many adult psychiatrists feel comfortable working with 16+ year olds. If he's so close to 18, I would probably just refer to adult psych if you can't find a child/adolescent psychiatrist. The big issue is working with the parents in terms of getting the consent for medications and the evaluation. Most adult psychiatrists hate working with parents.

 

[Bartelby]

I would feel totally comfortable working with a 17 year old who turns 18 in a few months, but I actually think my malpractice policy does not cover that so would decline the referral. It's an interesting dilemma.

 

[DareGreatly]

I would say it somewhat depends on the state. Most states allow consent for mental health care at an age below 18. In general, this patient would be appropriate for an adult psychiatrist.

 

[Stagg737]

I feel quite comfortable working with kids as young as 14-15 yo as a general psychiatrist but don’t for several reasons.

As Clozareal said, the parents are a big part of that. Even for a 17 yo soon turning 18 there can be major problems involving parents. One I’ve encountered twice that many docs don’t think about is just that once patients turn 18, parents no longer have the right to dictate or even be involved in the patients care if the patient doesn’t want them to be involved. Going from having to tell the parents everything to not being able to tell them anything is a massive dynamic shift that I don’t care to deal with.

 

[comp1]

I find the process interesting. An ED MD actually sets up a referral to a particular provider? Doesn't the patient's insurance determine who they will be seeing post ED discharge? Unless this is some sort of managed care organization, in which case, doesn't the system have a rule for this? Same for county (Medicaid)?

 

[Merovinge]

It's good to know your local area. Some places you would need 4 months to get in with a child/adolescent psychiatrist. In other places if you have commercial insurance you can easily get in within a month. If you fall into the later area don't overthink it and just refer the peds patient to a pediatric psychiatrist. If you know your local area has bad availability, it's certainly reasonable to refer to adult psych as well.

 

[Stagg737]

I find the process interesting. An ED MD actually sets up a referral to a particular provider? Doesn't the patient's insurance determine who they will be seeing post ED discharge? Unless this is some sort of managed care organization, in which case, doesn't the system have a rule for this? Same for county (Medicaid)?

Sure, it all depends resources available though. In our ER we provide resources/refer to our local CMHCs all the time. They all have walk-in intakes, so it’s essentially a referral.

 

[flightdoc09]

I find the process interesting. An ED MD actually sets up a referral to a particular provider? Doesn't the patient's insurance determine who they will be seeing post ED discharge? Unless this is some sort of managed care organization, in which case, doesn't the system have a rule for this? Same for county (Medicaid)?

Yes, it's not something we enjoy having to figure out as ED docs. But in my case, I'm military, and so when I place a referral I have to select "psychiatry "or "psychiatry, pediatric." I wish systems were easier, as well as access to care.

Also, thanks for everyone's input. Seems like most adult psych would take care of older kids. What about pediatric psych, do you ever continue care till someone is 19-20+? I know some pediatric hematologists will follow their sickle cell patients into their 20's, same with a few other specialties like pediatric cardiology.

 

[Stagg737]

Yes, it's not something we enjoy having to figure out as ED docs. But in my case, I'm military, and so when I place a referral I have to select "psychiatry "or "psychiatry, pediatric." I wish systems were easier, as well as access to care.

Also, thanks for everyone's input. Seems like most adult psych would take care of older kids. What about pediatric psych, do you ever continue care till someone is 19-20+? I know some pediatric hematologists will follow their sickle cell patients into their 20's, same with a few other specialties like pediatric cardiology.

Plenty of CAP trained PP psychiatrists keep their patients into adulthood. I’d guess it’s less common for a CAP to fire their patient because they aged out and far more common that the patient grows up, moves on to other stages of their life, and just stops seeing the CAP.

 

[futureapppsy2]

I feel quite comfortable working with kids as young as 14-15 yo as a general psychiatrist but don’t for several reasons.

As Clozareal said, the parents are a big part of that. Even for a 17 yo soon turning 18 there can be major problems involving parents. One I’ve encountered twice that many docs don’t think about is just that once patients turn 18, parents no longer have the right to dictate or even be involved in the patients care if the patient doesn’t want them to be involved. Going from having to tell the parents everything to not being able to tell them anything is a massive dynamic shift that I don’t care to deal with.

A lot of my supervisees work with teenage to early 20s populations, and I always tell them the importance of knowing when a patient's 18th birthday is and what changes on that date in terms of consent, confidentiality, etc.

 

[calvnandhobbs68]

Yes, it's not something we enjoy having to figure out as ED docs. But in my case, I'm military, and so when I place a referral I have to select "psychiatry "or "psychiatry, pediatric." I wish systems were easier, as well as access to care.

Also, thanks for everyone's input. Seems like most adult psych would take care of older kids. What about pediatric psych, do you ever continue care till someone is 19-20+? I know some pediatric hematologists will follow their sickle cell patients into their 20's, same with a few other specialties like pediatric cardiology.

Yeah I'll keep people forever if they want and we can.

It's different than peds in that you actually have to be board certified in adult psych first before you can get boarded in child psych. So actually different than peds cards or peds heme/onc for instance which is a peds subspecialty, NOT an IM/adult cards subspecialty.

More like peds anesthesia or pediatric ENT or something where the actual initial board cert is in the adult specialty so theoretically at some point you were perfectly capable of seeing adults lol. Not that I want or will see a 65yo.

 

[yomike333]

ED Doc here. Had a 17 year old who I was going to refer to mental health. But he turns 18 in 4 months. I know wait time for pediatric psych can be pretty long, and figured it would be better to just refer to adult psych, but wasn't sure if some adult psychs wouldn't feel comfortable taking on a 17 year old - I have seen internists and surgeons refuse to consult on 16/17 year olds that are adult sized - but not sure if that's an insurance thing or malpractice thing or what.

So I guess my question is, who should I have referred him to?

At 17 I still try child psych first, even if they turn 18 soon. The developmental piece matters, family work matters, school coordination matters. Adult psychiatrists vary a lot in comfort with minors and some clinics just will not schedule under 18 regardless of size. It is usually policy and training, not insurance.

If access is going to take months and the kid is high risk, I would call around and see which adult groups locally will take 17 year olds, some do 16 and up quietly. Transitional age youth programs are ideal if you have one, that 16 to 25 bracket fits this case perfectly.

If stable and four months from 18, you could also bridge with close PCP follow up and line up an adult intake timed right after birthday, but only if risk is low and family is solid. For anything complex, SI, psychosis, eating disorder, I would still push hard for child psych.

 

[flightdoc09]

At 17 I still try child psych first, even if they turn 18 soon. The developmental piece matters, family work matters, school coordination matters. Adult psychiatrists vary a lot in comfort with minors and some clinics just will not schedule under 18 regardless of size. It is usually policy and training, not insurance.

If access is going to take months and the kid is high risk, I would call around and see which adult groups locally will take 17 year olds, some do 16 and up quietly. Transitional age youth programs are ideal if you have one, that 16 to 25 bracket fits this case perfectly.

If stable and four months from 18, you could also bridge with close PCP follow up and line up an adult intake timed right after birthday, but only if risk is low and family is solid. For anything complex, SI, psychosis, eating disorder, I would still push hard for child psych.

That's a good point I didn't think about regarding child psych. I always just assumed it was more focused on simply the child, and how they're different from adults, in terms of their brain/psychology, etc. Hadn't really thought of the training also including a lot on the nuances of family, school, etc.