It was with much distress that I read the recent New York Times front page article by Benedict Carey about the heart wrenching plight of the Serpico family in their journey to get proper psychiatric treatment for their two sons. As a child and adolescent psychiatrist who has served children and families for more than 30 years, trained many child psychiatrists, and served as President of the American Academy of Child & Adolescent Psychiatry (2001-2003), I am deeply disturbed by the current psycho-pharmacologic practice of psychiatry.
Over the past decade, there have been amazing advances in medicine that have pushed the profession in the direction of utilizing more evidence-based practices. This is easy to see in most specialties, such as cardiovascular medicine, where implementing the latest surgical best practices results in proven, tangible positive outcomes. Unfortunately, it is not that clear cut in the field of psychiatry.
Every other medical specialty claims an organ of interest – cardiologists have their heart, nephrologists have their kidneys, hepatologists have their livers, yet the brain remains a medical orphan.
In the “mental health” field we treat diseases of the brain, yet we shy away from claiming the brain as our organ of interest. The brain is the only organ that cannot be transplanted, nor can a person survive without it. People actually survive with mechanical hearts while awaiting heart transplants. The idea that a child can go into an inpatient unit with emotional and behavioral problems and simply be treated in five days with reckless medication trials, without any diagnostic tests that guide an understanding of the genesis of the problems, is preposterous. There is no evidence-based science to support such treatment. The “health” (misnomer?) insurance industry has been the driver of such treatments, and, unfortunately, psychiatry has capitulated instead of pushing back and advocating for appropriate time to evaluate, diagnose, and properly treat our patients. I do not think there is a nephrologist in the world that would accept fewer dialysis sessions for a patient in renal failure, or a cardiologist who would deny critical diagnostic testing simply because the insurance company decided they would not pay for it. Medical necessity should drive assessments—not the insurance industry.
Most inpatient units fail to do any psychological testing. They typically do no testing to probe for language and communication problems, learning disabilities, or other cognitive challenges that may be at the root of the problem. Children with early traumatic experiences are not being diagnosed appropriately; instead behaviors associated with such trauma are targeted for treatment with medications. If the diagnosis is incorrect, then so is the treatment intervention.
Medicating children to address episodes of challenging behaviors is destined to fail. Without an understanding of what is driving the behavior, how can we ever help find a solution? Functional behavior analyses would help to clarify this, but most inpatient stays do not allow enough time— let alone resources – to complete such an analysis. If we want to truly address these issues and find real solutions, we must advocate for adequate time to conduct proper bio-psycho-social evaluations, examining historical information about myriad aspects of the family’s life, probing the family and personal medical histories, and considering the social ecosystems that have impacted the developing brain of the child. Simply treating the behaviors with psychotropic medications and sending children home in five to seven days results in what we see as revolving door admissions that only further traumatize children and increase frustration and hopelessness in their families. The costs—in hard dollars, opportunity costs, and emotional costs—far outweigh any short-term behavioral benefits.
The brain of a developing child presents a complex set of challenges. Research proves that environment is constantly impacting a child’s brain development in ways that we are still trying to understand. The Adverse Childhood Events (ACEs) study by Kaiser Permanente has finally infiltrated the mainstream of the medical profession. For the first time, there is credible, scientific evidence that increasing numbers of ACEs impact the total health of individuals, leading to increased chronic illnesses, earlier mortality, and greater dependence on tax payer dollars.
Judicious use of psychotropic medications has a place in treating some brain disorders that have been properly assessed and diagnosed (depression, anxiety, Tourette’s, schizophrenia, attention deficit hyperactivity disorder, and complex partial seizure disorder to name a few). However, medication cannot treat the family environment, parental neglect, physical and sexual abuse, exposure to violence at home and/or in the neighborhood, parental mental illness, and substance abuse, all critical elements in understanding and diagnosing emotional and behavioral disorders, which often have a trauma substrate. Quickie checklists filled out in a waiting room cannot replace a thorough clinical evaluation. The era of checklist medicine is doing our patients a disservice. It simply does not work!
Psychiatry provides interventions that treat the brain, our most precious organ. It’s time for the profession to stand up and begin working more aggressively with the insurance companies to research our current practices and determine the long-term impacts of the widespread use of psychotropic medications as a first line intervention in the treatment of behavioral and emotional brain disorders. Research proves it takes time for the brain to make changes—and for families, it really means changing several brains in order to make behavioral changes. Quick fixes clearly have not created a lasting solution. It’s time we find a new approach—one that goes back to the basics of medicine. We took an oath to, “first do no harm,” and right now we’re failing these children and families. We should not focus our attention on dollars and cents or add to the complex trauma so many children who are hospitalized have experienced in their young lives—they deserve better.
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