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.