It's Nobody's Fault (6 page)

Credentials
are
important. Parents owe it to themselves and their children to learn something about the training of the psychiatrist who is going to treat their child. Parents should look for someone trained and
board-certified in
child and adolescent psychiatry; this means that a physician has completed at least five years of training in general psychiatry and child and adolescent psychiatry as well as rotations in neurology and pediatrics or internal medicine, after which he passed an extensive written and oral exam in child and adolescent psychiatry. It is also useful to find out
where
the physician’s training took place. Like doctors, some hospitals have a better reputation than others. Parents who aren’t comfortable asking the psychiatrist about training and the reputation of a hospital may get the information from their child’s pediatrician.

Many parents like to interview child and adolescent psychiatrists before their children are evaluated. Spending time talking to the doctor can
satisfy parents in two important ways: first, you get a sense of the psychiatrist’s breadth of skills; and second, you get a feeling for how well the psychiatrist communicates. A child and adolescent psychiatrist, like all physicians, should speak to you in language you can understand. I have little patience with any caregiver whose attitude is, “This is far too technical for you to understand. Why don’t you let me, the expert, handle this?” Parents should be comfortable not only with what the psychiatrist has to say but also with how he says it.

There’s a good chance that parents faced with this kind of decision are venturing into new, uncharted territory, and they need to be informed and reassured every step of the way. One way to accomplish this is to ask the child and adolescent psychiatrist how he works right up front. Don’t be shy about asking questions: What is the procedure for making a diagnosis? Who will be involved? How many sessions will it take? The doctor should be able to give you an idea of the time and expense involved in the diagnostic evaluation.

It pays for parents to be as specific as possible about what is troubling their child. A description of a child’s symptoms—“My daughter follows me from room to room and won’t let me out of her sight,” a parent might say, or “My son refuses to go to school,” or “My child seems really depressed,” or “He has these terrible temper tantrums all the time”—followed by, “How do you think you might approach the problem?” should give you the lay of the land in short order. Sometimes it makes sense to be even more specific about a child’s disorder, asking such questions as:

“My son has tics. Have you ever treated Tourette syndrome?”

“Do you specialize in children with attentional problems?”

“My kid has a real language difficulty. Are you the right person for that?”

“Do you have experience with depression?”

“How many kids have you treated for schizophrenia?”

It’s not essential that a child and adolescent psychiatrist specialize in a certain disorder—in fact, many people feel that “generalists” are preferable—but it is advisable to find someone who has some track record with a specific disease. The more familiar a doctor is with a given disorder, the more likely he is to be proficient in treating it. There are many ways of treating a disorder once it has been diagnosed. Practice does make perfect.

Parents would do well also to find out in advance if a psychiatrist has
a particular therapeutic approach; that is, which kind of psychiatric treatment the doctor is likely to favor. Some child and adolescent psychiatrists rely exclusively on psychoanalysis or a specific type of psychotherapy. Others work only with medication. Most work with a combination of medication and psychotherapy. You shouldn’t expect a psychiatrist to be committed to a specific course of treatment in advance, of course, but it is not unreasonable to expect a straight answer to these kinds of questions, in terms that make sense. Treating a child with a brain disorder is very much a collaborative effort between doctor and parents; mothers and fathers need and deserve to know what’s going to happen between the psychiatrist and their child.

In my practice I am very much in favor of psychopharmacology—the use of medication as appropriate in the treatment of children’s brain disorders. While nearly all of my patients undergo some sort of behavioral therapy as well, medications are often a very important part of the treatment package I recommend. I strongly advise parents to choose a child and adolescent psychiatrist who keeps an open mind about medicating children and adolescents and who knows how to prescribe medicine when the diagnosis suggests that it is indicated. The best way to find this out is to come right out and ask: “Do you use medication in your work? Is there a role for psychotherapy as well? What is your general approach to treating a problem?” Parents who send their children to doctors who “don’t believe in giving drugs to children” are not giving them the chance for recovery that they require and deserve.

Child and adolescent psychiatrists should
listen
to parents as well as speak to them. It’s not always easy for a professional, any professional, to take the time to read clippings that parents tear out of magazines or listen to the latest miracle cure that Uncle Henry read about in last week’s Sunday supplement, but that’s part of a physician’s job. If you have something,
anything
, on your mind about the treatment that your child is receiving, the doctor should hear you out and respond accordingly. For example, if you’ve read about a new treatment for a child’s disorder and want to talk about it, the best response from a psychiatrist is: “If you’ll send me the information, I’ll read it and discuss it with you. I’ll tell you the pros and cons as I see them. I’ll explain why I agree or disagree.” Psychiatrists should be willing to discuss all aspects of a child’s case with his parents—provided that the discussions don’t violate doctor-patient confidentiality—without becoming defensive or annoyed. It comes with the territory.

Ever since I was a kid I’ve liked mysteries, especially detective stories. One of the things I’ve enjoyed most about being in medicine is being able to solve mysteries every day. As far as I’m concerned, when a child comes to me with a problem, I’m a detective. It’s my job to ferret out information and unravel the mystery, only instead of “Whodunit?” I’m faced with “What is it?” I’ve always been a firm believer in getting as much information about a patient as possible. The more information I have access to, the easier time I will have making a diagnosis.

I begin to gather data even before I see a new patient. When parents call for an appointment, I ask them to pull together reports from teachers, guidance counselors, and any physicians or mental health professionals the child has seen and send them to my office in advance. I ask both parents and child to fill out a questionnaire. The parents answer questions about themselves, their families, and their child; the child, assisted by his parents if necessary, provides information about himself. The child’s questionnaire includes a “self-rating scale,” which identifies the presence of various symptoms by asking for responses to nearly a hundred questions. The questionnaire addresses, among many other subjects, such physical symptoms as headaches, dizziness, chest pains, muscle soreness, numbness, and difficulty breathing; behavior patterns, such as overeating, shouting, throwing things, or having to repeat the same action over and over again; anxieties, such as worries about talking to other people, eating in public, or being watched; and delusions, such as irrational thoughts and ideas not shared by others.

And finally, I ask for the results of a recent physical examination conducted by a child’s pediatrician and any cognitive and psychological evaluations a child might have undergone. By the time I meet a child for the first time, a picture of the little boy or girl has already begun to form in my head.

When a family comes to my office for the first time, I spend the first part of the session with the whole group, parents and child, explaining, first of all, what a child and adolescent psychiatrist does. “I help kids who are having problems with their behavior, their feelings, or their thinking” is how I usually put it. During this period I start a discussion of why the youngster has come to see me, making sure to ask the child
directly: “Why are you here? What kind of problem do you have? Is it a thinking, feeling, or behaving problem?” Even if the child isn’t verbal or responsive, the question has been asked, and the child has been given an opportunity, in his parents’ presence, to express himself. Then I ask the parents what
they
think the problem is, and the child hears the answer. As much as possible I try to make everyone acknowledge that there is a problem and to define, however loosely, what it is.

I go on to say to parents and child that the talks I have with children are
private.
I tell parents that there are things that children and adolescents talk to me about that parents are not entitled to know. I’m quite direct with the child too, even if he’s very young: “You are the patient,” I say. “I will blow the whistle on you if you are going to hurt yourself or someone else, but otherwise everything you tell me about yourself is private. I may tell you what your parents say about you, but I won’t tell Mom and Dad what you say unless you give me your permission.” This policy occasionally is a source of frustration and irritation to parents, and I sympathize with the adults’ desire for full disclosure when it comes to their kids. Still, patient-doctor confidentiality is essential, even when the patient is in kindergarten. A child has to feel he can trust his psychiatrist; it’s the only way he’ll feel comfortable enough to talk openly to him.

This group meeting should be reassuring to parents as well as the child. As a father myself, I would not want to leave my child alone with a psychiatrist until I had observed their interaction, at least for a few minutes. I would want to be secure in the knowledge that the doctor I’ve chosen knows how to relate to my child.

The ground rules having been set, I then ask the child to leave for a little while so that I can talk to his mother and father. I assure the youngster that after I talk to his parents, he’ll get his chance to spend some time alone with me too. How the child leaves my office is important. Does he leave easily? Does she protest or cry? Does he become physically aggressive? Once he’s gone, does he sit patiently in the waiting area, or does he keep interrupting and banging on the door? Does she disrupt the secretary or the physicians and patients in the other offices? I’m watchful for any clues that will help me solve the mystery.

When I am alone with the parents, the second stage of the information-gathering process may begin: taking the
history.
When I take a history, I ask questions about the development of the child’s disorder, covering every detail about the child and his extended family. There’s an
old cliché about the game of baseball that comes to mind: pitching is 90 percent of the game. In my line of work taking the history is 90 percent of the game. Exploring the details of a child’s behavior—especially his developmental milestones (described in
Chapter 1
)—and investigating the psychiatric histories of his mother and father, his grandparents, his aunts and uncles, and his siblings help to give me a very clear picture of the child.

I also use this time to put parents at their ease about the diagnostic process. Parents need time to describe fully and clearly what is bothering them about their child’s behavior, and I want them to feel confident that their message is getting across, without feeling rushed by the clock or restricted by the presence of their child. During this encounter, as I take a detailed history from the child’s mother and father, there is sometimes a “language barrier” between psychiatrist and parent that needs to be overcome. Words don’t always mean the same thing to everyone. The word
depression
is used a lot, but it doesn’t often mean “clinical depression”—a psychiatric disorder.
Anxiety
is another frequently used word, but it can be used to refer to any of a hundred different emotions, none of which necessarily indicates an anxiety disorder. Encouraging parents to be very specific is a vital part of taking a history. Parents who come prepared with details make the process go more smoothly.

After I’ve taken a history from the parents, I excuse the parents and ask the child to come back into the room. “It’s time for Harry and me to have a private talk,” I might say. Then I ask the child specific questions about his symptoms, ruling out various disorders and narrowing down the possibilities. I ask about his life at home and at school, about his worries, his eating habits, his sleep patterns. All the while I’m observing how the child behaves. Mood, eye contact, motor activity, use of language, comfort level—all are important factors as I evaluate a child’s mental status. By the time I have finished talking to the child, I have usually confirmed my diagnosis, and I am ready to call the parents back into the room to talk about treatment.

If medication will be part of the treatment I recommend, I’ll check the child’s height, weight, blood pressure, and pulse and order blood tests, which rule out anemia and infection and tell me something about his kidney, thyroid, and liver function. Depending on which medication is to be used, I may ask for an electrocardiogram.

Another cliché is appropriate here, but it has nothing to do with baseball. It’s strictly medical:
diagnosis drives treatment.
Parents should keep those words in the forefront of their minds as they seek help for their troubled children. In real estate, the saying goes, the three most important criteria are location, location, and location. In child and adolescent psychiatry they are diagnosis, diagnosis, and diagnosis. Before a child and adolescent psychiatrist recommends a course of treatment, he should give parents a diagnosis. Parents are entitled to know what’s wrong with their child and how the psychiatrist plans to proceed before agreeing to any course of treatment.