Do Child Psychiatrists Still Play With Kids?

I have a new job-a volunteer job, that is! On July 12, 2012, I will begin teaching “Clinical Practicum,” which is a six month child psychotherapy course to first year child psychiatry fellows at UCLA. I will have seven students with varying degrees of interest in doing child psychotherapy. “Can I give my students articles to read?” I ask, my new boss. “You can do whatever you want,” she tells me with a smile. I am excited to walk into an environment in which psychopharmacology is the dominant modality, with the hope, that maybe, just maybe, I can remind my students, budding professionals, that listening and explaining are still valuable skills. Maybe, I can encourage play. By that I mean, maybe I can inspire them to play with their patients as a way of getting to know them.

I have a goal, but my question to myself is how best to achieve that goal. We can read and discuss articles. I can talk about my clinical experience, by disguising identifying features in order to preserve privacy.  If I choose that path, should I pick one patient and go into depth about his treatment, or should I discuss vignettes of multiple patients? I can have them bring in their clinical experience, and we can have a group supervision group where we share ideas about how to get into the inner workings of both the child and his/her family. If I have the child psychiatry fellow bring in a case, then should I divide up the 26 weeks among seven fellows so that everyone has an equal opportunity? Should I limit the class to the treatment of pre-pubertal kids, since treating adolescence is a very different skill set? The best path is not clear to me.

I need to connect with them in a way which expands their experience, but does not seem “outdated.”  I fear that they will see the idea that one must  spend a lot of time with a child and his family before plunking down a diagnosis  as “unrealistic.” To help them see that understanding and explaining is a journey contradicts the notion that parents need immediate answers to their concerns about their child. On the other hand, this is a University, so a multiplicity of ideas should be embraced by both students and faculty. I hope that my exploration of different ways to approach this class will be in line with my goal that different approaches all have value. The more one learns, the more tools one can draw upon. This is a simple notion, but even in the most open minded families, I mean institutions, this idea gets lost. Am I too grandiose to think that I can bring back a discussion of family dynamics to a scene which is so heavily based in neurobiology? Or, do I need that grandiosity to enter into this adventure? As always, I welcome your thoughts.

Child Psychiatry Rant….

  Dr. X,  A notable child psychoanalyst, from a notable academic institution says “I am OK with putting kids on Risperdal, because if it controls his symptoms, then I can do my work better.” My rage explodes internally. Putting kids on Risperdal is a major decision. There are long-term side effects which range from increasing cardiovascular risk factors to permanent movement disorders. There is no way that a self-respecting child psychiatrist can be carefree about prescribing atypical antipsychotics. Sure, some kids really need it so that they can stay in school and achieve academic and social success. Sure, some kids can go on Risperdal for short-term treatment, thus mitigating the long-term concern. Still, prescribing these medications come with serious consideration,  which we, as child psychiatrists, need to join to say that we are focused on both short-term gain and long-term pain. Getting a child better is one thing, but we must also be concerned for the future of that child. We must think about prevention as well as symptom relief. Sometimes, I feel lonely in that regard, but I also remind myself that speakers often posture; they say things they don’t believe, to be both provocative and interesting. I bet that was true for Dr. X. It worked.

Prozac Wonders

   Emily, seven years old, has had a life characterized by social, emotional and academic struggles. She has no friends; she never has. A previous physician diagnosed her with autism, but she wanted to make friends, she had a good imagination and she understood social cues, so that seemed unlikely. She tantrums often; she has very little frustration tolerance. She seems smart when you talk to her, but academically she does not sit long enough to finish her work. Her attention span is very short, although stimulants make her more agitated and uncomfortable.   Emily does not seem anxious; she does not report any worries or concerns. Yet, her mom wondered, maybe she is so anxious that she cannot focus; maybe if she were calmer she could learn better and pay better attention to her friends.

   Emily’s mom, Shayna, made a good argument that Emily might benefit from a medication that reduces her anxiety, so, with a bit of uncertainty, we, meaning Shayna, Tom-Emily’s dad, and I, agreed to give Prozac a go. 1.25 mg of Prozac for little Emily, where the typical adult dose is 20 mg, and the typical child dose is 5 mg. Starting low seemed right given that Emily had such a bad reaction to the stimulants. Emily took to Prozac like a dehydrated plant takes to water. Within weeks, she was learning better at school, more affectionate at home, and beginning to make friends. Her tantrums stopped. A placebo, one wonders. It is hard to see how a placebo acts in a child. Emily knows she is taking medication, but she does not understand what it is for-at least she can’t tell me that. Maybe Shayna is seeing things differently because she wants the medication to work so badly. Maybe, but her teachers also report dramatic improvements. My theory is that Shayna was spot on. Emily, for reasons probably relating to an immature nervous system, was anxious trying to learn and she was anxious trying to make friends. Treating her anxiety with medication, opened the world to Emily, at least so far, that is true.