Shirah Vollmer MD

The Musings of Dr. Vollmer

Why Don’t Pediatricians Refer to Child Psychiatrists?

Posted by Dr. Vollmer on February 27, 2012

Neal, thirty-two, a long-term patient of mine is concerned about his five-year old daughter who is having behavior problems in kindergarten. He and his wife are told by the school that she is uncooperative at school and that she needs to be “evaluated.” Neal and Sophie, his wife, take Chelsea, his daughter to Dr. Firth, their highly regarded Westside pediatrician. Dr. Firth, hearing the concerns from the parents, advises Neal and Sophie to take Chelsea to an occupational therapist. The occupational therapist evaluates Chelsea and she tells Neal and Sophie to take Chelsea to an optometrist because she seems to be having “balance issues”. My heart is having palpitations. “Maybe you should consult a child development specialist or a child psychiatrist,” I suggest, hoping that Neal does not feel that I am dismissing Dr. Firth. “Well, I know you see kids,” he says, “but my wife and I associate you with medication and there is no way that we want to put Chelsea on medication.” Again, I pause in distress. “Chelsea needs an evaluation, so it is no way clear whether medication in on the table or not. First thing is first.” I say, reminded that in these days, people only think of child psychiatrists as “medication doctors” and they forget that their expertise is also in assessment. I think about Dr. Firth. Why did he refer Chelsea to an occupational therapist when the report from the teachers was that she was having behavior problems. Should I call the pediatrician and ask him? Of course, I could not do that without both Neal and Sophie’s permission. Why did Dr. Firth not think of referring Chelsea to a child psychiatrist? I really wish I knew the answer to that question. My hunch is that Dr. Firth has a professional relationship with this particular occupational therapist and that he is not aware of the variety of professionals who do  mental health assessments for children, even though he is a well established pediatrician. On the one hand, if what I am suspecting is true, it is unbelievable. On the other hand, if what I am suspecting is true, then Child Psychiatrists have done a poor job of marketing their talents. Maybe both are true.

6 Responses to “Why Don’t Pediatricians Refer to Child Psychiatrists?”

  1. Shirah, personally I find it almost impossible to believe that any “well established” pediatrician is out of the loop when it comes to child psychiatrist/psychologist referrals. What I don’t find hard to believe is that, while a pediatrician may have a professional relationship with an occupational therapist, he or she might feel that, with a mental health referral, they may be insulting the parents parenting skills and they (the parents) may just move on to another pediatrician. There is still stigma associated with mental health issues and struggles in our culture…..just putting an additional possible slant on the situation in addition to your ideas.

  2. Thank you Eleanor for your comment. I think your point is very well taken. Going to an occupational therapist may indeed be less stigmatizing than a child psychiatrist. From my point of view, child psychiatrists are puzzle masters and we explore the various possibilities that underly behavioral issues in children. However, as you say, this is not purely a detective game. This pursuit involves dealing with the anxieties in the parents that something is not “right” with their child. Again, I would like to think that if something is not “right” it is better to find this out sooner rather than later. Having an odyssey of misdiagnosis seems a recipe which would get the parents angry at the pediatrician, but maybe this is long-term versus short-term thinking. Also, I think the stigma is perpetuated by the pediatrician if the pediatrician does not frame the referral to a child psychiatrist in the appropriate, nonjudgmental way. Finally, as I often say in my blog, child psychiatrists are also to blame, as we could be doing a lot more to spread the word that we are master diagnosticians, so coming early will hopefully set your child out on a better path of development. Thanks again for chiming in.

  3. Shelly said

    You’re right, it does seem odd that the pediatrician would refer to an occupational therapist. I also agree with ELeanor that the referral to a child psychiatrist would be stigmatizing and the pediatrician might have feared losing patients. But why not refer to a developmental psychologist or some other paraprofessional before the hard-core psychiatrist (sorry Shirah, the stigma thing still is alive and kicking) to assess if the child has some learning issues?

    • Thanks, Shelly. Yes, understanding referral process is something that I am particularly interested in. The patient is often at the mercy of the referring physician, so they have no idea what path they are being led down, unless they get a second opinion, which in the case of children, often creates unnecessary delays. My next post will be about a situation involving an adult referral so stay tuned as this topic continues.

  4. jo said

    Wow, if I were in your shoes, I think I’d get really tired of being associated with ‘medicine’ treatments only. I know the stereotype exists, but it seems unfair. Thanks for your post.

    • Hi Jo,
      Thanks for your comment and thanks for your understanding. Maybe we are moving away from psychiatrist as “drug doctor” and into psychiatrist as thoughtful with an array of tools. I certainly hope so.

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