Maybe We Have Too Many Child Psychiatrists?

 

 

http://www.madinamerica.com/2016/06/many-foster-kids-are-still-being-prescribed-antipsychotic-drugs/#/more-78187

 

If child psychiatrists spend their time prescribing medication, and if foster children are over medicated, then it stands to reason that child psychiatrists are exacerbating the problem and then the so-called shortage of child psychiatrists, might, in fact, be a good thing. It is true that foster children are not only treated by child psychiatrists, as these medications may be prescribed by pediatricians, neurologists, primary care physicians or nurse practitioners, it is still true, that if child psychiatrists stop prescribing these medications, then these other providers would not feel comfortable prescribing them. The use of these medications for behavioral management is simply inhumane because of the metabolic and cognitive side effects. There, I have said it again, as I will again, as this has got to stop.

 

Child Psychiatry Shortage: Impact?

“There are only about 8,500 child psychiatrists in America, not nearly enough for the estimated 15 million kids who need one, the American Academy of Child and Adolescent Psychiatry says. On the local level, the shortfall becomes more pronounced. No individual state meets the AACAP’s standard of 47 child psychiatrists for every 100,000 children 17 or younger — or one for every 2,127 kids. In Wyoming, there is one child psychiatrist for 22,960 children, and in Texas the ratio is one per 12,122. Only Washington D.C., enjoys what the group calls “sufficient supply,” with one child psychiatrist for every 1,797 children.”

 

The mantra that there are not enough child psychiatrists in the US, as stated above, comes from the American Academy of Child and Adolescent Psychiatry. A group that I respect and often attend their professional meetings. Yet, I question this assertion. Child Psychiatrists, by and large, prescribe medication, and as such, they help some children, while, at the same time, they, as a profession, are guilty of over-prescribing medication to children who could benefit more from behavioral and/or psychological interventions. So, it is not clear to me that the problem is physician supply, but rather I see the problem as the need to re-define the job of the child psychiatrist. If the child psychiatrist were in charge of systems of care for children, we would not need more child psychiatrists, but rather we would need to change the training of child psychiatrists to include leadership skills to improve the health and welfare of children and their families. If we do not train child psychiatrists to take the aerial view of the profession, and we continue to train them to take a piecemeal view of children, then training more child psychiatrists will not help. We need to learn how to be thought leaders, and as such, we need to learn how to execute our ideas into a major overhaul of mental health for children which includes wellness centers, home visits, and family interventions. Medication can be a piece of this, but, it is only one of many pieces. This is the message that we need to get out to policy makers. Incentivizing child psychiatry by loan repayment programs or higher salaries are not the answer. The field needs to change its focus. There, I have said it again.

 

 

Achievement Gap

https://en.wikipedia.org/wiki/Achievement_gap_in_the_United_States

 

White privilege, in academic measures, leads to higher school performance than minority children, creating, what experts call the “achievement gap.” Although many factors contribute to this gap, the increase in stressors, be it poverty, domestic violence, childhood neglect and abuse, make it difficult for children to learn, and to have a supportive learning environment. Further, minorities tend to go to schools with fewer resources to support their education. Given that, what is the role of the child psychiatrist? How can he/she advocate for these kids? Providing mental health care at these schools is one answer. If these schools were staffed with mental health professionals who were trained to help children cope with their environments, could their school performance improve? I bet so, but studies are needed to prove this hypothesis. Plus, what about the funding? Well, if we assume that kids with lower achievement are more likely to drop out, and therefore have fewer employment opportunities, and be more likely to end up in the correctional system, then keeping these kids in school could pay off in the long run. My solution: have every parent sign a consent for mental health treatment, at school, if the need arises and is deemed necessary by school personnel. That way, as soon as symptoms are identified, intervention could be immediate. There, I have solved the problem. Of course not, but I think that is a good first step.

NSSID

 

 

 

http://capmh.biomedcentral.com/articles/10.1186/s13034-015-0062-7

DSM 5 has added Non-suicidal Self Injury Disorder (NSSID) as a new diagnosis for those who cut on themselves without the intention of dying. Should I rant about this? Of course. Cutting behavior is a symptom of psychic distress, not a diagnosis, per se. The issue is what is the meaning of the cutting? Self-soothing? Attention-seeking? Feelings of helplessness in that there are few other options, or feelings of empowerment because now the person has turned passive feelings of despair into active feelings of anger? As with all symptoms, the puzzle begins, with the task of the professional to try to understand the broader context of this behavior. The act of cutting does not communicate the essence of the patient’s struggle, only that some sort of struggle is going on. This is the difference between a symptom and a diagnosis. A diagnosis is an answer and a symptom starts the questioning. As with so much of psychiatry these days, the confusion between symptom and diagnosis is disturbing. Once a diagnosis is made, questioning often stops, and treatment begins. With NSSID, this should start the inquiry, and not lead to quick labeling and a certainty of a mental illness which underlies the behavior. Mental distress does not equal mental illness. DSM 5 gets that all wrong. End of rant, at least for now.

Talkin’ To A School District!

A school district “community health and safety advisory committee” wants me to talk about childhood anxiety disorders? Oh yes, sign me up. Why does this excite me? I feel that I have a public health mission to educate school professionals about childhood suffering, helping them to understand when they should intervene. I want to talk about the warning signs and then, most importantly, I want to talk about the referral process so that the administrators understand that depending on who they refer to, the child will get vastly different interventions. I also want them to understand the issues surrounding medicating or not medicating school-age children. In particular, I want to emphasize the role of the school personnel in aiding the assessment and treatment of children with anxiety disorders. This will no doubt bring up the issue of the school refusal kids. How does the school help if the child does not make it to school? Does providing online support help or hinder these kids? Hinder, will be my response, in that the school needs to provide a safe place for that child at school so that if the anxiety erupts, the child can stay at school, but go to a counselor who can give this child some comfort and support. Anxiety disorders are internalizing disorders meaning that unlike ADHD where the student typically disrupts learning, with anxiety, children tend to suffer quietly. As such, it is helpful if school personnel can try to attend to the child who is NOT demanding attention, but yet is lonely or lost on the playground. I have dreamed that both public and private schools could target these quietly  suffering children for intervention, as this gives so much  hope for helping these children live more fulfilling lives. Helping a lonely child, a lost child, develop connections such that they enjoy and look forward to school is a game-changer. As we all know, the future is in our children. These  children growing up will take charge of our world, and we hope, they will bring it to new and exciting places. We owe it to them to help them enjoy their childhoods, as part of  enlightened self-interest, since we want them to take care of us one day. I am on a very important mission. Wish me luck.

Mood Meds For Kids

 

 

Friday morning I venture off to Reiss-Davis to talk about mood meds in kids, and actually, more broadly speaking, medicines for the child’s mind. This is a three-hour presentation to non-medical colleagues about the positives and negatives of treating children with medication. My first objective is to emphasize the need for a thorough evaluation, meaning a minimum of three hours, consisting of a history from the parents, an interview with the child and a feedback session. Although this three-hour evaluation is hardly ever done before placing a child on medication, I will say that it should be done and we, as professionals who care deeply about children, should insist on. My next objective is to separate out the notion that making a diagnosis does not mean treating with medication. Although this is obvious, in today’s world, the expectation from a psychiatrist is a prescription, as opposed to non-medical types of intervention such as psychotherapy or new school placement. I will then launch into the details of medicating children, with particular emphasis on the notion that this is a two-parent consent process, such that the job of the psychiatrist is to create consensus and without this, the child will feel confused and split between his parents. The last part of my presentation will be reviewing the various categories of medication, reinforcing the notion that the decision to medicate, in children and adults, is based on a risk/benefit analysis. In the end, medicating patients is a challenge of clinical judgment, knowing that close monitoring is essential, since each patient is different, and as such, we never know what will happen. As I conclude, I will feel like I have removed the curtain of psychiatry, because my message is we are guessing when we medicate children or adults, but with children the stakes are higher and the meaning of the medication runs deeper. By that I mean that a child’s brain is developing so we must be aware that we in no way want to inhibit that brain from its developmental course. In adults, we obviously do not have to worry about that. Further though, on a psychological level, children who receive medication might also receive the message that their brains are defective, and hence the impact on the developing self-esteem is something we need to think long and hard about. So, I will end my talk with more questions than answers, reminding my audience that I trained before Prozac so I bear witness to how we now have tools to help kids that we did not have in the past, and for some children, they are very fortunate to be born in this era, but for other children, they would have been better off to be born before 1991.

How Does Child Psychiatry Ruin Lives?

Psychiatrists want to help people. Child Psychiatrists want to help children and their families. Many times there are remarkable and heart-warming stories of intelligent guidance and warmth which saves children and families from lives of suffering and despair. This is a story of the opposite. A story, so scary to me, that I feel compelled to write about it as a cautionary tale. To preëmpt my critics, let me start by saying there are many sides to a story and cause and effect cannot be determined. I float in a world of theories and ideas which prove serious consideration resulting in different approaches to treatment. I do not work in a world of certainty or clear scientific evidence. With that in mind, let me tell you the fictionalized story of Joey, age 25, Caucasian, who grew up in a middle class area of San Diego. Joey is the youngest of four children. His three older siblings, by his report were “easy” and he was “difficult”, or so his mother told him. At 6, his mother took him to an academic medical center, trying to figure out why he was “so difficult.” Academic child psychiatrists diagnosed him with “atypical autism” and off he went, at age 6 on a continual journey of psychotropic medications including Straterra, Wellbutrin, and stimulants. Joey reports that being on these medications not only did not help him, but made him feel defective and disabled. Despite those negative feelings Joey got into a good college and did well, until he hit a disappointment, a break-up of a loving relationship, and by his account this triggered his childhood feelings of being seen as “disturbed” and so he, although never having used addictive drugs before, spiraled down into the world of heroin and cocaine. Yes, all of that could have happened without a mental health diagnosis, without being misunderstood as a child with a mental illness, as opposed to a child with a bad temper. Yes, all of that could have happened secondary to parents who felt inadequate to raise him and made him feel very inferior to his three older siblings, even if they had never sought a psychiatric evaluation and treatment. My point, however, is to illustrate that in this fictional tale, it is plausible that the medical team made Joey’s life worse.

What would have happened, I wonder, if the child psychiatrist had said that Joey is a wonderful kid, outlining his strengths, who needs help with anger management? What would have happened if the child psychiatrist would have guided this family towards a more positive parenting model where Joey was seen as a child who could go on to great things, as opposed to seeing Joey as a person who would forever be disabled and crippled by his limitations? Joey’s story, with all of the uncertainties associated with it, makes me cry. I cry because whether this applies to Joey or other adults out there, growing up with a label that suggests they are limited in their abilities, when in fact, they have enormous potential, I feel the tragedy of what our profession has done to their lives. Yes, I have diagnosed many children as autistic, but my bar is low, as it should be. The label, and I understand it gets very needed services, has the hazard of diminishing the self-empowerment of that child. It has the potential to take a capable person, perhaps with some rough edges, and make them feel small and helpless. Children, and adults, need understanding to flourish in this complicated and demanding world. Psychiatric labels oftentimes limits that understanding and that alone can have dire consequences. Add to that the journey of psychotropic medications which flows from that diagnosis, leads to an identity confusion that can cripple the budding adult. Joey was not crippled by his biology, I suspect, but he was crippled by his psychiatric journey. Tragic, unnecessary.  and it has to stop.

Head-Meds For Kids…Or..Medicine for the Child’s Mind?

 

May 6, 2016,  I am booked. Geez, that is advanced planning. Three hours, I have, to discuss medicating kids to mental health professionals dedicated to working with children. As usual, I expect to gain far more than I give, as this audience are folks who have spent years fine-tuning their skills to work with disadvantaged youth who struggle with coping with their circumstances. Nature and nurture will be discussed heavily, as the decision to medicate a child is never easy, simple, or straight-forward. The decision is made after a thorough history, but whose history? The parents, the child, another clinician, or all of the above? Yet, my first order of business is generating a title. I have a series of lectures which begin with Medicines for the…fill in the blank. Originally, I kept a similar title for all of my talks as a way of picturing my book on psychopharmacology for the lay public. Each talk was a chapter in my book, such that “Medicines for the Mind” was the large title and then there was “Medicines for the Female Mind”, “Medicines for the Old Mind,” and “Medicines for the Child’s Mind.” Yet, as the book has receded in my task list, and, as a patient once said to me, “you want to know about my head meds,” I began to think about changing my title. My next lecture on adult psychopharmacology will be entitled “Head Meds” but for my “kiddy talk” I will stick with “Medicines for the Child’s Mind.” I want to emphasize that the complexity of working with children is that their minds evolve as time goes on, such that all practitioners are made humble in that we never know whether we had an impact or maturation finally kicked in. I suppose the same is true of parenting. Parents take credit for “how well their children turned out,” when, in fact, it could very well be that their brain was developing in a non-linear fashion such that the child surprisingly became a responsible adult. Oh, so we return to nature vs. nurture, in which I will say that if the child does well it is nurture, and if he does not, it is nature. I hope I will get a laugh.

Growing Up Alone

Continuing on the topic of needing a “mother,” a person who is passionate and hopeful for your existence, I am thinking about those children out there, who for a variety of reasons lack that passionate advocate. It is my feeling that for some children, that passionate advocate is the key person who takes a hedonistic child and turns him into a productive and giving human being. Without that advocate, the child becoming an adult could be lost in a drifting world, where there is little future planning, and life is very self-centered, mostly as a means to survival. In other words, some children lack the imagination to see themselves as a powerful force who can bring change into the world, and with a passionate push, that child gets the confidence to grow, both personally and professionally. This is the tale as old as time. A supportive mother, friend, and/or wife, gives the child, friend, and/or husband the push to apply for a new job, move to a new city, or take on more responsibility, and in so doing confidence grows. Without the push, stagnation sets in.

Vince, fifty-four, comes to mind. He grew up with a mom who was always “busy” doing “charity things” and a father who was never home, and who years later confessed to having a girlfriend and another family. Vince was not good at school, but he managed to go through college, but dropped out when school got too hard for him. At thirty-five, Vince marries Cory, a thirty-year old female, who openly says  she is “desperate to have a family.” Cory encourages Vince to start a business in commercial real estate. Vince is scared, but Cory is a strong advocate that Vince can handle it, so with Cory’s encouragement, Vince starts and eventually grows a very successful business. What if Vince never met Cory? I would wonder if Vince would have remained a drifter. Vince is grateful to Cory, but he has a difficult time admitting it, because it makes him feel “small”. With time, though, Vince develops the courage to tell Cory how much he appreciates her push, and how now he is living a life he never dreamed he could. Vince opened himself to Cory’s ideas because he loved her, and he wanted to make her happy. Cory was able to push Vince because she saw potential in him that he did not see in himself. This is an example of how change happens, and sad lives become happy ones. Is it the “love cure”? Yes, the “love cure” with a “push”.

Teaching Child Psychiatric Assessment

A child comes into the Emergency Room because the parents are worried about their behavior. The adult psychiatry resident, not schooled in child development, is called to make an assessment, to triage this patient. Send them home, admit them, call for help, these are the choices. My task today, in one hour, so nearly an impossible task, is to teach psychiatry residents how to begin to triage these children and adolescents. Given that I do a three-hour assessment, and the reality for these residents is that they have, at most, one hour to make this decision, I need to help them pare down my three hours, such that they distill the most important clinical issues. Clearly, this is an inverse situation, in that I, with more experience, could do one-hour assessments, and these residents, in order to learn, should be given three hours, but alas, that is not the current reality.

I will begin by helping them think about where the presenting problem lies?

Emotional?

Cognitive?

Physical?

Behavioral?

Behavioral disorders are the most acute, since those issues can lead to immediate self-destruction or harm to others. We all worry, I will tell them, about seeing the next school shooter, and somehow, tragically, missing the acuity of the situation. At the same time, we know that we will let children and adolescents out of the emergency room, only to find out later, that violence ensued. Our tools are flawed. Our ability to predict, hopelessly fallible.

Next, I will talk about how to get a history, by thinking about the child in four domains.

Family Situation

School Functioning

Community Functioning

Cultural Issues

Returning to the reason for landing in the Emergency Room, the major questions are “why now” and “says who?’ Pre-pubertal children can usually, but of course, not always, return to the care of their parents, but post-pubertal adolescents are much more challenging because they have the means to independently cause destruction. On the other hand, if the parents are part of the problem, or if there is any suspicion of abuse, then the Psychiatry Resident is charged with contacting the authorities, with the possible outcome that the child will land in an emergency foster care situation. The dance between being sympathetic and suspicious of the parents begins. Likewise, this same dance with the child begins as well. Is the child a victim of his circumstances or are the parents victimized by this child, or is it some combination? Eventually, after the data is obtained, both by direct interview and record review, the resident is charged with making a diagnostic formulation and treatment recommendations. Finally, these ideas need to be conveyed to the parents in a way which minimizes defensiveness, as talking to a parent about psychiatric issues in their child is a very delicate conversation. As complicated as all this is, the most challenging issue will be finding outpatient referrals. Child psychiatrists are in short supply, and as such, most families have tremendous difficulties finding good care. Further, the good care that is available is not always well-known to those that work in emergency rooms.

At the conclusion of my lecture, as most of my teaching goes, there is usually a heavy feeling associated with the uncertainties in our field, which is tied together with huge responsibilities, leading to an uncomfortable sense of fear and uneasiness in the provider. I will joke about how this uneasiness might be correlated with the shortage of child psychiatrists. Maybe though, this is no joke.