Shock in Child Psychiatry
Posted by Dr. Vollmer on October 14, 2011
Stacy, a child psychologist of a mutual patient, says “I have never seen a child psychiatrist be so thorough. The mom tells me you are going to do a school visit. I think that’s great.” Although I am flattered by the compliment, I am also dismayed that a thorough assessment is no longer the standard of care in child psychiatry. School visits, as with meeting both parents, as with playing on the floor, as with talking with current and past treating clinicians, used to be the standard of care for child psychiatric assessment. These steps were the basic building blocks of understanding what was going on with the child. Now, it seems, that child psychiatrists are trained to look at symptoms which are amenable to psychopharmacological intervention. This means that the context, such as the school setting, or the family environment, is less important to understanding the nature of the presenting problem.
James, our mutual patient, six-years old, is by all reports suffering from “terrible anxiety.” This might trigger the need for a medication such as Prozac, yet, upon further history taking, it seems that his parents are under a lot of stress, and as such, it might make more sense to help the parents be less anxious and that might calm down James. Further, James is having trouble at school, especially on the playground. I am going to do a school visit to see how James navigates his social milieu. Maybe if James could find a way to have friends at school then maybe he will not need medication to calm him down. Friends tend to relieve a lot of anxiety, both for kids and adults. On the other hand, maybe James needs medication to calm down so that he can make friends. This is a judgment call, but a judgment that will be better made after a school visit.
Understanding, explaining and treating children is the job of a child psychiatrist. Understanding comes from deep history taking and sharply honed assessment skills. Seeing a child in multiple environments is key to thinking about a child in a comprehensive manner. The consultation room narrows the field, as children can behave so differently with one authority figure, as opposed to the challenge of peer relationships. These are basic concepts, yet lost in the present day of rushed assessments and low-thresholds for medicating kids. Consequently, psychologists like Stacy are appreciative of my 1980s, pre-Prozac, training. Again, it is nice to be appreciated for my assessment skills; it is sad that those skills, at least among child psychiatrists, seem to be going the way of the typewriter.
Shirah Vollmer MD 
Jon said
The first step in the scientific method is to play. Sadly this has been misunderstood for far too long. Too long have people been taught and regurgitate “make a hypothesis” as what should be done first. However, a good scientist cannot. One cannot make an intelligent guess – after all that is what a hypothesis is – without something one has tried to understand. The best initial understanding comes from playing around.
Usually playing is used metaphorically, but in the case of a child psychiatrist, it is literal. How wonderful! Without this actual play, a child psychiatrist is forced to make unintelligent guesses. Sadly, there is one standard unintelligent guess as a course of action – medication. The child psychiatrist becomes the one-tool workman. To anyone whose only tool is a hammer, the world looks like a bunch of nails. I applaud those who do not treat children in need of psychiatric care as nails. While this approach is more time consuming and more expensive, it is the correct approach in a just world.
Shirah said
Well said! Play is certainly the “work” of childhood, and hence understanding and preserving play sets the stage for later contributions to our world. As you say, science is lost without a playful mind. Preserving play is the struggle of so many adults, such that some adults who become parents then rob their children of play because, as I see it, play becomes something they dismiss in order not to feel the void in their own lives. Having said that, psychiatrists should certainly carry the banner of the importance of play, both with ideas, and in actuality when it comes to working with kids. Sometimes, as all of us who have lived a few decades know, old ideas may be old, but sometimes they are still useful.
Shelly said
I appreciate all that child and adolescent psychiatrists do. One question: why can’t child/adolescent psychologists do the school assessments? In all the time our child has been in school (he’s now in 12th grade) and among all the therapists, psychiatrists, and psychologists….not one of them has visited the school nor even stepped out of their offices to observe him.
Shirah said
School assessment, like so many professional endeavors, are not well defined activities. Hence, the skill set to do a good school evaluation is not clear. Child psychiatrists, generally speaking, are receiving little training or encouragement in school consultation work. If school assessment is not part of their training, they are unlikely to offer this to their clientele. As you know, this makes me very sad.