Whither Child Psychiatry?
The fact was that her 16-year-old son was incredibly psychotic. After months, or perhaps years, of smoldering paranoia, his mind had ignited into a full-fledged psychotic break. Unfortunately for this child, at the time of his emergency, 911 was busy. He got sick at a time of a horrendous shortage in psychiatric beds for children and adolescents across Massachusetts and much of New England. The well-intentioned solution when a psychiatric bed could not be found was to place him, along with four or five other psychiatric patients from the ER, on the pediatric floor so that he could be safe.
Safe, but without an inpatient psychiatrist, without a psychiatric social worker to support and educate this family in crisis, and with a pediatric nursing and housestaff who could handle complex chemotherapy protocols in seconds but who knew nothing about four-point restraints for assaultive patients.
I went to medical school to become a child psychiatrist, and in my one-on-one work with patients it feels intellectually and emotionally challenging and satisfying. But as a system, child psychiatry feels like a game of hot potato. And unfortunately, the potatoes are the patients.
Kids who present to the emergency room are probably the hottest hot potatoes. The exhausted PGY-2 or PGY-3 on call dreads them: they take time; you have to deal with their families; and they are really hard to place. If there is no psych bed, they may have to stay in the ER—usually a barren room with only a television to keep children amused. Or they can “board” on the pediatric floor and be followed by a consultation/liaison child psychiatry resident.
Once one is lucky enough to find an inpatient bed, the goal is quick stabilization as the insurance clock starts ticking. Only on the very best units can one expect thoughtful psychopharmacology evaluations or significant family work. The trick with this hot potato is finding aftercare. Residential placements, day treatment programs, even just plain old outpatient providers—these are all in painfully short supply and are the culprits responsible for “stuck kids,” children who stay in the hospital because there is nowhere for them to go. Some kids are at high risk of getting stuck, like those with autistic features or other developmental issues. But even the run-of-the-mill depressed patients can be an issue. I remember being told one depressed teenager would have to wait two months for an initial outpatient medication visit. I called to complain and was told Dr. So-and-so had an opening. Seemed great, until I learned Dr. So-and-so was actually a psychologist.
And of course, finding child psychiatrists who are willing to see really sick kids is particularly difficult. Wearying medication checks in the context of paltry reimbursements, unpaid ancillary work with schools and pediatricians, lack of community supports, and a threadbare inpatient safety net make outpatient work with these kids enough to make psychiatrists run. Not to mention that child psychiatry practice with private-paying parents and less-sick kids is feasible even for recent trainees in this economic climate, and seems to be the one “system” in which a psychiatrist can actually practice as he or she was trained: careful evaluations, long-term psychotherapy, measured medication management, family work, and school consultation.
For those who cannot pay out of pocket, though, the potato gets passed round and round as the system refuses to take hold.
There are some admirable efforts to address these issues. The recent Surgeon General’s report emphasizing children’s mental health needs is a step in the right direction. In Massachusetts a few new inpatient units have opened up. One unit where I work is focused on providing transitional care for “stuck” kids.
But these are really Band-Aid measures in a system that is largely broken. And it is broken at a time in our history of unprecedented economic growth and affluence. If ever we had the resources to fix the system, it is now.
I don’t see myself as victim here. On the contrary, I hope to be part of the solution. But I am also aware that at the crux of the solution lies a change in consensus, a shift in social contract from “each one for himself” to the belief that each one is actually part of a greater whole for which we all bear responsibility. Without such a shift, I fear, we may find ourselves in a two-tiered system in which an entire generation of have-not children is at risk. ▪
Dr. DeJong is APA’s member-in-training trustee.
