It's Nobody's Fault

by Harold Koplewicz

  “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.

  THE EVALUATION

  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 t
he 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.

  THE DIAGNOSIS

  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.

  Parents have a right to a full explanation of the recommended treatment. If there is to be medication involved, you should be made aware of what the drug is supposed to do and what the side effects might be. If you ask the question, “What will happen to my child if I do nothing?” you should get a straight answer. If a child needs behavioral therapy in addition to the medicine, parents should be told what the therapy will entail and how they can help. It is in the best interests of everyone—psychiatrist, parents, and child—for parents to be directly involved in a child’s treatment, and by that I don’t just mean giving him a pill twice a day. If a child needs a special diet, his mom and dad make changes in the kitchen and supervise his meals. When he needs physical therapy, his folks make sure he follows the regimen strictly. It should be the same with behavioral therapy.

  Here’s how I might put it to parents of a child in therapy. “As far as I’m concerned, you two are both co-therapists here. I can prescribe the medicine, and my psychologist colleague can work with your daughter for an hour a week, but we can’t watch her all the time. Even on school days you’re with her eight waking hours every day. You’re in charge of making sure that things are different at home. I want to give you some strategies to try and things you can do to make the therapy more effective. With your help the therapeutic process will go a lot faster.” Most parents gladly rise to the challenge and welcome the opportunity to be involved. (The role of parents is discussed further in Chapter 4.)

  Mothers and fathers should be given an idea of how long any treatment is expected to last and how its success or failure will be determined. What are the goals of the treatment? When and how will we know if they have been reached? If you’re told, “Oh, the therapy is going to take at least three years. We won’t really know anything until then,” you should demand a more specific description of the treatment and ask the therapist to describe some short-term goals. It is not unreasonable to ask a therapist for a progress report every three months. Some treatments do take years—I’m not disputing that—but three years is far too long to go without seeing substantial improvement. For a child, even six months is too long to wait. A child with a brain disorder cannot afford to waste time.

  Parents who are dissatisfied with the progress that their child is making may find it necessary to find another doctor, or at least get a second opinion. If you’re uncomfortable questioning the judgment of your child’s doctor, you should know that in medicine this sort of thing is done all the time when a treatment doesn’t seem to be working. You should tell the treating psychiatrist about the second evaluation and ask him to participate by giving a summary of the child’s treatment and progress to the second physician. Sometimes the second doctor agrees with the first, but sometimes what is called for is a fresh approach.

  I believe that parents should look for a psychiatrist whose reaction will define short-term goals and set limits, as in: “Listen, I expect the treatment to be finished in six months. We’re going to give your child medication, and I’ll want to see him once a week every week for four weeks. I may want him to see a psychologist for some behavioral therapy. If everything goes well, we’ll switch to an appointment once a month. At the end of six months I expect to see a marked improvement. [Here the psychiatrist will get specific about symptoms.] If at the end of six months we haven’t accomplished what we set out to do, we’ll reevaluate and possibly take another tack.”

  A CHILD’S FIRST VISIT

  Generally speaking, children aren’t thrilled at the prospect of going to the doctor, any doctor. Most parents prepare them well in advance of the visit. Others go the other way, relying instead on the element of surprise. Very young children faced with a visit to a child and adolescent psychiatrist’s office may well think nothing of it. In fact, once they have been reassured that they won’t have to get an injection, they’re usually just fine about the whole thing. Older kids, who may have preconceived notions about psychiatry or who fear that they’ll be labeled “weird” or “crazy” if the word gets out to their friends, may have more problems with the first visit.

  I believe that a child should be prepared, however casually, for his first visit to a psychiatrist. Tricking a child to get him into a doctor’s office only adds to the problem by getting the doctor and patient off to a bad start. Kids should have at least a general idea of what they’re getting into. In presenting the notion of seeing a psychiatrist to a child, I often suggest that instead of focusing on the child’s problem, parents would do well to make it a family matter.

  Here’s how the conversation might go: “You know what? When one of us in this family has a problem, we all have a problem. We’re a family. That’s the good part about being a kid. If something is bothering you, we all try to find a way to make it better. If you had a rash, we would put some calamine lotion on it, right? If it still didn’t go away, we would go to see Dr. Smith, your pediatrician. If the rash still didn’t go away, Dr. Smith would send us to see a skin specialist. I’m your mommy, and it’s my job to do everything I can to make you feel happy.

  “Your dad and I can see that you haven’t been very happy lately. You�
�ve been crying and upset all the time and fighting with your friends. I don’t think you’ve been having fun in school either. Miss Jones says you seem sad in class. Your dad and I want you to feel better, so we’re going to take you to see a special kind of doctor. His name is Dr. Koplewicz.”

  “What kind of doctor?” the child will ask at this point.

  “He’s a child psychiatrist,” the mother might say. “He’s the kind of doctor who takes care of children who are sad or upset about something. If kids are having trouble in school or fighting with their friends, he can help them. We’ve met Dr. Koplewicz already, and he seems very nice and smart. He told us that he’s talked to a lot of kids who feel the same way you do. We’re all going to see him together. He’s going to help you and help us so that we can get over this and you can start feeling happy again.”

  “A psychiatrist!” an older child might say. “Psychiatrists are for people who are crazy. I’m not crazy!”

  “No, of course, you’re not crazy,” the parent might say in response. “Anyone who says that people who go to psychiatrists are crazy is wrong. People sometimes say silly things. They don’t mean it. They just don’t know any better. Child psychiatrists like Dr. Koplewicz help kids who have thinking problems or feeling problems.”

  I’m not saying that all conversations will go as smoothly as this one. Imaginary dialogues with imaginary children always go wonderfully well. Real-life kids are so unpredictable! However, it has been my experience that in this, as in all things, children take their cues from their parents. If Mom and Dad are straightforward and upbeat about a visit to a psychiatrist—and they certainly should be—children will follow their lead.

  CHAPTER 4