Wednesday, September 14, 2011

Why I Am Happy That I Am Not a Child Psychiatrist

My hat goes off to kiddy shrinks.  It's a tough field, full of issues we don't see in adult psychiatry.  
Our comment section often buzzes with talk about the over-diagnosis of bipolar disorder in children and the ethics of giving psychotropic medications to children.  The Shrink Rappers never comment on these things.  Why?  Because we don't treat children.  I have no idea if the children being treated are mis-diagnosed, over-diagnosed, wrongly-diagnosed, or if the increase in treatment represents a good thing---- perhaps children who would have suffered terribly now are feeling better due to the option of medications.  I've certainly had adult patients tell me their children were treated with medications, the children have often eventually stopped the medications and emerged as productive adults.  Would they have outgrown their issues anyway.  Or did the treatment they received switch them from a bad place to a good place and enable them to carry on in a more adaptive way?  Ugh, my crystal ball is on back-order at Amazon!  

Why I'm Happy I'm Not A Child Psychiatrist:

  • Two extra years of training (and being on overnight call)
  • No extra pay.
  • "Normal" or "well" children often display behaviors that look a lot like those of "ill" children.  Ever witnessed a temper tantrum? 
  • Children often can't verbalize their feelings and they are inferred from behaviors. 
  • Children are often subjected to the treatment, with all it's options for distress-- whether it be that therapy displaces soccer or that Risperdal causes sluggishness-- without the same open dialogue and choice that adults get.
  • Children are often treated based on the distress of other people.
  • Some illnesses in children are defined by the arbitrary standards of societal expectations.  There would be fewer hyperactive children if we didn't expect boys to sit still for long periods of time.
  • It's very hard to differentiate a "phase" that will be outgrown from "pathology."  This is especially true in teenagers where some angst and rebellion are part of some people's journey.
  • There are times when treatment is based on the reports of others (such as parents) and there is no guarantee that such reports are accurate or that the parent's expectations are reasonable/realistic, and parents can be quite demanding about the need for treatment and medications.
  • It can be difficult dealing with the troubled parents of troubled children.
  • Expanding on that, parents sometimes get angry and remove their children from treatment if it is suggested that they are part of the problem.
  • I don't like treating people who don't want help and children are sometimes in treatment at the request of their parents, schools, or other agencies.  True for adults as well, but not in my office.


rob lindeman said...

I'm glad you're not a child psychiatrist either, Dinah.

Since I'm hung up on how we will be viewed by future generations, how about the view of child psychiatry from 100 years in the future?

I'm going to guess that first, some of the stigma of childhood MI will be mitigated by the fact that virtually every child will carry a diagnosis. [Think this is raving lunacy? Who would have imagined that "50% of all Americans would suffer an episode of MI" at some point during their lives?]

Then I suspect that an impudent child will suggest out loud that the emperor has no clothes and the tide will be begin to turn.

Finally, the jaws of future readers of our history will drop in disbelief at this folly. Perhaps they will be kinder to us than we are to Walter Freeman and Egaz Moniz (at least the latter got a Nobel Prize for the Frontal Lobotomy!) I doubt it though.

Anticipating your replies, let us stipulate that many children's 'lives were saved' by psychiatric drugs. If so, it happened at an incomprehensibly horrible cost, including other lives lost.

aek said...

I think that adults are also often treated because of the distress (or fears) of others. But overall, I steered clear of caring for this population because their distress was distressing to me. Same reason I avoided burn patients. I have an incredibly difficult time inflicting pain or discomfort on another being, even when the intent and result is beneficial (debriding wounds, moving painful joints, keeping a body part immobilized - eg c-spine collars and trauma patients on hard backboards, etc.), but especially when the being isn't able to understand the reason for the infliction of pain or that it will be temporary and that relief is on the way.

Power to the peds folks!

aek said...

Whoa, Rob!

I have to ask (and you sure don't have to answer), but have you been personally harmed at the hands of a psychiatrist or mental illness treater? You are coming across to this n=1 as wounded, and if so, I'm so sorry.

I agree with your overarching premise that we are medicalizing a large part of the normal range of childhood behaviors, but I don't think that's specific to children. In the US at least, given our faulty healthcare messaging via corporate marketing, every conceivable segment of the population is being sold medical treatments (reimbursable/billable goods and services) for largely non-medical conditions of living.

Until our society surgically excises (sorry, I couldn't resist the metaphor) health CARE from business/industry, I don't see medicalization going away. It's a marketing and sales strategy. It's effective, and it leads to corporate profits in the private insurance, medical device, pharma and provider sectors. It also has created artificial dependencies on healthcare providers (DTC marketing mantra, "ask you doctor if x is right for you").

None of those entities gives a whiff of concern about stigma and its devastating effects. No profession has taken steps to divorce itself from those industries, either. (Medicine, nursing, the licensed therapies, pharmacy, etc).

There isn't any organized movement to help launch people into health management independence. The traditional supports of school recess, gym classes, home economics, health classes and extracurricular organizations that dealt with home life - scouts, 4-h, etc., have largely been abandoned. Arguably, those were also community builders.

This is such a multifactorial, incredibly complex confounder laden area, that I can't imagine that we should or can lay the entire blame on psychiatry.

Anonymous said...

Interesting. Curious if you're drawing a distinction between children and adolescents?

Anonymous said...

If being forced to sit still is the cause of larger numbers of boys having ADHD than girls, why wasn't it just as prevalent in the '50s and '60s, when schools were even more restrictive about sitting in your seat and not fidgeting? Kids don't get beaten today for not paying attention. I agree with the crowd that thinks attention deficit is just as prevalent in girls, but they tend to be inattentive as opposed to hyperactive, so they bother their teachers less. Why call the shrink for a girl who just does poorly on her spelling?

Liz said...

ditto, ditto and more ditto....and, as a new-ish blogger in your field, thatnks for the inspiration of your blog. i will send my readers your way....and would welcome your feedback:

Anonymous said...

I always say that I would not treat children unless the family would agree to family therapy or couples counseling. I also say I couldn't treat children because what I saw in training and as a paralegal guardian ad litem was that the most medication was given to the children who had been the most neglected, abused and lived in their parents chaos. I am strongly maternal and might "disappear" some parents (please somebody take this seriously--I will NOT apologize--look up "hyperbole" in the dictionary) but then I would be in prison unable to help anyone....

rob lindeman said...

"[T]he most medication was given to the children who had been the most neglected, abused and lived in their parents chaos."

This too has been my experience.

I'm reminded of a fable, told about the Parisian Police, who, chasing a bad guy into a building, discover they don't have enough men to surround the building and cover all the doors. So they decide to surround the building next door, which was smaller and had fewer doors.

As the large building with the criminal is to the smaller building that is easier to surround, so is social pathology to childhood "mental illness".

The former problem is hard and the latter problem is (relatively) easy. So why not re-name the problem and prescribe a drug?

Carrie said...

I guess I am unique in that I don't think I saw a single child on one of the heavy hitting psych meds over the past year in my NP clinical, and I only saw a very small handful on ADHD meds.

There are a LOT of instances where the patient (child or adult) is a product of the dysfunction around them - but therapy in those instances can help them learn how to cope with that and how not to let it control their lives. I think that's valuable - and parents need not be present if they are disagreeable to change.

There's also a subset that I think it's important not to forget about. There are kids who know they need help but their parents won't let them - either out of fear of stigma or some other fear. There are also kids who stay silent or make suicide pacts with other kids, and so on. The memory of my own high school friends who did that is not lost on me. One of them eventually got help and felt so much better once on meds. The other never did and I saw the struggle for years after that.

I really think there are two places where meds can be helpful, but with adolescents - I don't think smaller children should be placed on them. #1. If an adolescent is so extremely troubled that they are in danger of dropping out (or being kicked out) of school or are so troubled that they can't even remotely participate in therapy. And #2. After giving therapy a very good shot first, but still having significant symptoms.

With the little ones, I think SO much bad behavior, etc is a product of their environment. Children act out for all kinds of reasons. The sad thing is that the ones who are treated the worst often cannot be removed from their situation. This is what I saw when I did one day in the peds inpatient psych unit 7 years ago in nursing clinical. The kids were just like regular kids in the unit, but then we learned more about what brought them there, it was eye opening.

Anonymous said...

My experience was not like Carrie's. Many of the children I observed in a child psych ward were heavily drugged. Some were drooling. It was incredibly sad.

Very little attention was paid to the children unless they were "acting out" as they call it. There was nothing on the walls, no decorations, nothing to indicate that this was a place for children. But the worst part is that the place with the exception of a child who was freaking out was for the most part eerily quiet. That's when you know everybody is drugged out of their minds. What place full children is quiet? It should be a bunch of wiggling, busy, noisy, playful children.

I was blown away by the differences in how children in a regular children's hospital are treated. In a regular hospital they are showered with attention and given a present anytime a painful procedure is performed, a parent can stay by their bedside and comfort them. When the lights go out they don't have to be alone. The hospital is brightly decorated and looks like a place for children.

I cannot imagine the trauma children in child psych wards experience. They go to bed alone in a strange place and no one hugs them goodnight. They have no idea what is going to happen to them. It must be terrifying. They have their blood taken and aren't comforted or even given so much as a sticker afterwards, at least they weren't at the place I observed. It's hard enough to be in one of those places as an adult. I cannot imagine the nightmares this leaves children with.

Most of them came from extremely screwed up environments. For those who didn't, I doubt seriously if their parents had observed what went on there would have allowed their children to be admitted.

It broke my heart to see what was being done to those children who had every reason in the world to feel sad.

Dinah said...

Liz : Thank you.

Anon: The sub-specialty fellowship training is in Child and Adolescent Psychiatry. It's a two year fellowship after residency training in adult psychiatry. The residents in adult training do spend a few months doing child psychiatry, so it's not totally foreign to us, but I don't feel qualified to treat children or younger adolescents. I do see older (18 and up) adolescents.

Anon: heartbreaking story of a horrible inpatient unit. Add it to my reasons why I'm glad I'm not a child psychiatrist. Even in places with decorations on the walls, many of the children have horrendous stories and have been the victims of awful family discord and often psychiatrists have little to offer to 'fix' what really calls for a loving, stable family to repair.

Somehow, this called to mind an OB rotation I did as a medical student-in one hospital, everyone had a partner there for the births, in another, the partners were only allowed in the labor room if they had completed a Lamaze class and had a certificate, that hospital had no anesthesiologists and the mothers were not offered was striking how different an experience it was.

Carrie said...

Dinah - interesting description of the OB ward. In the NICU, we just watch the differences in parenting, even when they've never had a child at home. Lots of things to see and observe, really. Hopefully a chance to have a positive impact in many situations, and I feel like that is the case much of the time. There are sometimes where we'll never make a difference at all in the family situations or parenting. That's usually demoralizing.

Re: the child psych inpatient unit that I saw, it was brightly decorated with lots of different types of therapists (art, music, and so on) that kept the kids pretty busy. I didn't really see a single kid who was upset to be there. A few were upset when disciplined, but the extent of that was pretty much just time out. This is why I was really blown away when reading their charts and learning what brought them there. It was horrifying. They probably did better in the hospital because they had actual authoritative figures in their lives. Many of them came in, were discharged, and bounced back as the situation at home deteriorated again. Many of the kids really did do bad things at home - kill animals, torture their siblings, etc - but you'd never have known that seeing them in that unit.

The rest of the hospital was horrible - the setting is beautiful, but it was just pretty much awful. I spent time with an all women's unit, a dual diagnosis unit, and a geriatric unit. I spent a very very brief amount of time just touring the adolescent unit, but that was about 5 minutes.

Since I did clinical there, the child psych unit has been closed and the hospital has come under totally new and much better administration. My best friend took a job there at the start of the summer as a chaplain - she loves it, and from what she has described, it is run in a much better way than what I saw when there. I met my best friend in a bioethics program, and she's the most grounded person I know - so I don't doubt a bit of what she says. When she was applying for the job, I was horrified - but it has changed so much since I was there.

The thing I took away from the child psych unit was that it truly was the first time in anything pediatric related where I felt absolutely no hope whatsoever. The kids were totally fine in the unit - but they all returned home to the same family situations unfortunately. Nothing anyone could do to change or fix that. That is what truly broke my heart.

Dr. Psychobabble said...

I'm doing an inpatient child psychiatry rotation right now with adolescent boys. I agree with all of your comments above, and have encountered each and every one of them. On this rotation, in particular, my biggest frustration is "the child is okay, the parents are sick" conundrum. It's incredibly difficult to help parents understand that they may be responsible for most of the pathology they see in their children. And the most frustrating part is when the kid is absolutely, completely, 100% normal and happy while on inpatient, but rapidly "decompensates" when they get home. Many times I wish we could hospitalize the parents...

rob lindeman said...

Dr. Psychobabble's choice of words captured my attention:

"It's incredibly difficult to help parents understand that they may be responsible for most of the pathology they see in their children" (italics added)

Why weasel out of saying all of the pathology? Or does Dr. P believe these kids actually have something wrong with their brains independent of the psychological damage inflicted by their parents and/or environments?

"Many times I wish we could hospitalize the parents..."

I know she's kidding, but Dr. P kids about something we all know to be true: psychiatric hospitalization is incarceration and it is punitive. Too often, it satisfies a human need to punish people we don't like, in this case bad parents.

wv = pliseade; a bit of doggerel designed to alleviate the stress of an inpatient rotation

Anonymous said...

I think the point Rob makes about it being punitive is very important. I personally think people should be concerned that children are adjusting to the psych hospital environment. But, children learn quickly and I guarantee you many if not most see this as a very punitive experience.

I remember one little girl (and there were a dozen and one other stories just like hers) who had done nothing wrong except have the bad luck to have a screwed up mother and father. She ends up in foster care shuffled around from place to place and she can't even cry or have a fit because someone will forcibly medicate her. So, she sits quietly throughout the psych hospital stay being "good." Oh, look how well she's adjusting everyone says. Give me a break.

I sat down beside her and colored with her and she looked up at me at one point and said, "Can I come live with you? I promise I will be good." I wanted to tell her you have every right to have a screaming fit after what you've been through, but of course I couldn't tell her that or they would rush in to give her a sedative. So, all I could was sit there and think in my head forgive society for subjecting children to this.

Adjusting to an insane environment is not a sign of success. The children should be allowed to have tantrums after what they've been through. Sadly, in the psych hospital tantrums are not allowed.

C said...

I don't read putting the parents in the hospital as punitive. I read it more as they are the ones that need the help, not the kid. Helping the parents helps the kid... There are many times where the patient is really not the real patient at all - but those around them unable to deal with them for whatever reason. Maybe that's just me.

rob lindeman said...

Thing about what you're saying, C.

I don't know if you live in the U.S., so forgive me if you already know the following:

"All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws."

14th amendment to the United States Constitution, Section 1

wv = poxystin OTC topical antibiotic, sold for about a week until the pharmaceutical company went bust.

C said...

Rob - it's me, Carrie. First off, you all are reading way too much into that comment. It's a statement that when kids are brought in, many times it's not them that need the help so much as their parents. We've all seen it time and time again. I'm not saying we should lock them all up. It's the same as saying you should need a license before having a child. People say it all the time and nobody is proposing that government actually require a license to do so.

rob lindeman said...

That's a relief, Carrie. My response to Kendra (Dr. Psychobabble) was meant to point out that we say parents ought to be locked up, but we half mean it!!! Sometimes more than half. That's an attitude we ought to be aware of, and should make an effort to squelch.

wv = enwan; Multinational cowpowation fow whom Paul Kwugman used to wowk.

Anonymous said...

To me it doesn't really matter if it's meant to be punitive or not, what matters is the impact of the experience on the patient.

I've spent many, many hours observing and talking with children on inpatient child psych wards and I can guarantee you most feel that they must have done something wrong to end up there, even when in many cases they have done nothing wrong.

Psych hospitals operate on a reward-punishment system. If you're "bad" which is defined as "acting out" then you get a shot in your butt or you are deprived of going outside for fresh air, etc. If you're "good" which is defined as not acting out, then you may get some fresh air and maybe no shots in your butt. It's not rocket science to realize why these children "adjust" to the psych hospital environment. They adjust to all sorts of situations they shouldn't have to adjust to.

Most of these children need a stable, loving home not antipsychotics.

wv = nouloo. Out with the old toilet, and in with the new.


C said...


Actually the psych hospital I wrote about above doesn't allow for that kind of thing - there are no shots or anything of the sort for children or adults if they "misbehave".

You all have blinders on and paint everything with the same brush.

It's tiring.

rob lindeman said...


I'll have to back Leslie up here. I was medical supervisor of a 15-bed in-patient child-psyche unit for about 3 years. The place was well-lit, there was fairly diverting stuff to do, and the staff were reasonably even-keeled kind people. However, the criteria for discharge were based entirely on rewards and punishments for behaviors, good and bad. It's hard to imagine an adult behaving normally in a strange, scary environment; how much more so for a scared, vulnerable child! Children have a limited repertoire for manifesting psychological stress: messed up eating, toileting, sleeping, and acting out. My sense of this particular unit is that these signals were not well read by the staff.

My n = 1 psyche unit experience suggests that these units punished children rather than treating them.

BTW, virtually every child was on a CNS stimulant and Abilify.

wv = chingn; what I'd be doingn if I were a bell.

Anonymous said...

Carrie, it is good to know that some psych hospitals at least do not give IM antipsychotics to patients when they misbehave. You can only imagine how terrifying this would be to a child.

Granted, I've only observed inside 5 psych hospitals but all 5 I did observe operated with the reward-punishment system. If the reward is fresh air, then it's logical that patients would believe they must be bad to not be allowed outside. Of course the staff did not see what they did as punishment for misbehavior they saw it as symptom management I guess, but most of the patients saw it as punishment which is the important part. Screaming, in particular, is a big no-no.

The last thing most of these children need is one more message that they must have been bad to deserve what is happening to them.


C said...

I wouldn't be one of the staff who would so mistakenly believe what I was seeing as I was there to observe as a student and had very minimal interaction with the staff. I don't know why I'm bothering to explain this anyway since you're all set in what you believe. But the place wasn't run that way - I spent a lot of time talking with the kids, and I was not on a side against them, as I am sure I can see staff being. These children came from some absolutely horrendous living situations - some of the worst I've ever heard. It seemed like many of them were happy to be somewhere where they could predict their next meal and had people who acted predictably around them. They weren't being molested and abused as they were in their home situations. You think their home life is less punishing than where they were? Yes, they were expected to behave in certain ways, but I never saw any of them get in trouble for yelling other than a time out to settle down, same as any child. No hitting or violence against staff or each other was tolerated.

But since I'm viewed as one of the staff who "wouldn't know any better" and clearly these children were being tortured, I guess I'm done with this subject.

Anonymous said...

Carrie, I'm certainly not meaning to imply that the psych hospital you were at tortured children. The hospital where you were sounds a lot better than the ones I have been inside of. I don't even believe that the hospitals where I observed and talked with patients intentionally created trauma, although I do believe it was often the unintended result. I think the staff meant well and were trying to help. They weren't mean people. The shots I did see given were pretty rare even where I was, mostly they were pretty sedated from the multiple oral psychiatric meds they were on. The reward punishment thing was more having to earn the right to go outside or other privileges.

I do think, though, that the reward punishment thing is confusing to children in psych hospitals. They're told they are sick and can't help it, yet they are expected to be good and control their behavior. It's sort of a confused message. I wish I had seen more children pitch a fit without consequences, because I think many of them desperately needed to pitch a fit after what they had been through.

I also wish I had seen the same comforting and doting on children that I saw happening in regular childrens hospitals. I just didn't see it and if anyone needs to be doted on and loved on it's these kids.

Every single time my little sister had something done in the childrens hospital where she practically grew up the nurses loved on her and gave her presents and if she demanded three flavors of jello off they went to find it. They understood that she was ill and scared and was hurting. Where are the hugs and the presents and the three types of jello for children in psych hospitals who are also scared and hurting? It would have been kind of nice to see at least a sticker or a lollipop on occasion after a blood draw. Maybe the hospitals I was in were just particularly bad. I hope they were the exception rather than the rule.


Dinah said...

So all the people with all the experience on child psych units who have the sense that these children are treated badly or improperly:
Is it a sense, or have you asked a reasonable number of these children questions such as: Did you get anything out of being in the hospital? Do you feel any better at the end of your stay then you did at the beginning? Did the stay in the hospital help you? Did you learn anything about yourself that might help you in the future? Do you feel better or worse on medications? If you asked these questions, please do publish your results.

Anonymous said...

I would love to do that study, but I don't think Eli Lilly would give me a grant.


rob lindeman said...

Children innocent of crimes are incarcerated against their will ["FOR THEIR OWN GOOD!" the chorus chants in reply!]

Whether they feel better for having had their right to liberty infringed upon is irrelevant.

And pace my long-time blogosphere friend Carrie, the contrast between the outside world and the inside too is no justification for incarcerating children and drugging them against their wills. If that were so, we (whoever we are) would be within our rights to relocate everbody from a bad location to a better one.

Free societies don't do this to their citizens.

Zoe Brain said...

I sat down beside her and colored with her and she looked up at me at one point and said, "Can I come live with you? I promise I will be good."

I could never be a child psychiatrist. To be effective, there must be some distance.

I cried when I read that. Had I been in that situation, I would have broken down, which would not do the patient any good.

I take comfort in the fact that I've met many people who suffered dreadfully when young (like an Intersex girl I know sold at the age of 3 to a pedophile ring...) who, while damaged, are healing. They're often not just functional but actually happy too.

Unknown said...

"Children are often treated based on the distress of other people."
Oh my goodness, yes. And the behaviors which distress others the MOST don't respond to medication, like ODD and Conduct Disorder Symptoms. As a therapist for children, all the points you bring up really do make it difficult, and I empathize with our psychiatrist, who has to actually decide to prescribe or not prescribe. And the behaviors related to disorders which one would most want to diagnose early for preventative measures, such as positive symptoms of schizophrenia, look so much like OTHER behaviors that most of the time the ethical answer is "wait and see" rather than diagnosis. And its very hard not to be perceived as judge and jury of their families when one points out their role in their child's "abnormal" behavior. The more I learn about children, the more I learn that there are so many caveats within the childhood experience that I can't really say what's "abnormal" unless its REALLY obvious (such as a 10 year old eating her feces, that's pinpoint-able). Aggression against peers and animals, nightmares, emotional displays and breakdowns at unusual times- its all par for the course for children and it is socialization, which decreases these behaviors, not labeling or medicating.

And for our children who really are super severe and need medical interventions to rule out medical conditions, like a consultation with a neurologist and an MRI, we can't get their state insurance to cover these things without moving heaven and earth. So instead of being able to rule out a medical condition or TBI as a cause for bizarre behaviors (despite a history of physical abuse and injury which indicates possible blunt force trauma to the head) we are stuck working with Disruptive Behavior Disorder NOS when we KNOW there is something more serious going on. But if their Medi-Cal doesn't cover it, they must not have it, right??? And if we can't navigate these things, what hope do the families of severely impaired children have for advocating for their children?
Additionally many of our children are manifesting their parent's symptoms- I know there is no criteria in the DSM for "Shared Depression Disorder" or "Shared Antisocial Disorder" but there should be.

I could keep on going about this for a WHILE so I will stop now before I work myself into a lather. Working with children can be very frustrating.

Anonymous said...

It may appear I'm rather late joining this conversation! However, I still felt moved to make a comment- knowing that I will be in Child Psychiatry for another 4.5months.

From my observations, many children I've come across happened to be the products of their environment/families and very few are genetically predisposed to being classic ADHD with some ASD sprinkled on top.

I can think of about 4 children quite quickly who have very troubling mothers. Two are going through a divorce,one still treats her 13 year old like the child was 2 (openly caressing and kissing the child at the child's beck and call) and another got defensive when she realized her son showed her up to be over-medicating him despite proper instruction! (And of course, doctor was blamed!)
I find I'm dealing with more than one patient at every review. And oh how my patience gets tested.

To not make matters worse, there are the 'scanners.' Mothers who are evaluating your ability, looks, charm, etc since 'you look too young to be a doctor' and they don't like feeling below par. Competitiveness when I'm providing a service to help them...wonderful!

Oh how I miss Geriatric Psychiatry.