Childhood Manic-Depression_ US News & World Report [Fred A. Baughman Jr., MD:
----- Original Message ----- From: "VERACARE" [Fred A. Baughman Jr., MD:
"At 51/2, Hudson was in the midst of pediatric mania. DeLong recalls that Hudson couldn't calm down when they first met, and his words came out garbled and giddy. He was not as neurologically damaged or developmentally delayed as his older brother, but it's likely they share genetic predisposition to the illness. [Fred A. Baughman Jr., MD:
Now Hudson, too, takes a small pile of pills with his morning and evening glass of milk. In the beginning one of them was lithium. It had worked so well with Alex, Hudson was likely to benefit too." http://www.usnews.com/usnews/issue/021111/health/11kids.htm US NEWS & WORLD REPORT 11/11/02 The Demons of Childhood Young brains break. Then comes the broken care system BY MARIANNE SZEGEDY-MASZAK When Alex McAbee turned 7, many of the happy accomplishments of childhood were missing from his short, tortured life. Indeed, he had not even learned to read [Fred A. Baughman Jr., MD:
, nor had he doffed a corny cap and gown to graduate from kindergarten. Instead, his milestones included several expulsions from day care [Fred A. Baughman Jr., MD:
, one after he had given a child a concussion. Then there was that dreadful day he poked out the eye of his grandmother's puppy, and the day he chased his younger brother, Hudson, around the house with a butcher knife. Drinking gasoline, rubbing his feces on the walls-the list goes on. Then there were the routine travails, more than the family cares to count, when he would shriek and hurl his dinner against the wall simply because his hamburger was located in the wrong position on the plate. Or when he would just sit and scratch his face and gnaw on his own arm. His mother, Kelly Troyer, recognized that Alex desperately needed help, but she discovered that finding psychiatric care for children in Greenville, S.C., was not so easy. "I was at my wits' end," she recalls. "I went through hell trying to get him treatment." That road through hell is a familiar one for parents of children with emotional disorders. It begins at home and runs through the schools and into the offices of pediatricians, psychiatrists, psychologists, cardiologists, child neurologists, behavioral pediatricians, and social workers. All of these specialists could tell that there was something seriously wrong with Alex, but the problem was figuring out exactly what. Now 9, Alex has been diagnosed at various times as having autism, attention deficit disorder, bipolar disorder, and oppositional defiant disorder. Each diagnosis, of course, required different medicines [Fred A. Baughman Jr., MD:
. Many failed, and some actually exacerbated the problem. It is impossible to say just how often this kind of story is repeated in homes across the country. But with an estimated 20 percent of all U.S. children and adolescents having a diagnosable psychiatric disorder, and 13 percent [Fred A. Baughman Jr., MD:
of all adolescents experiencing "serious emotional disturbance," one can imagine that it is repeated in most communities every day. Indeed, the surgeon general's National Action Agenda in 2000 detailed a "public crisis in children's mental healthcare." Compounding the problem is the fact that today's children "are sicker, younger," says Richard Sarles, professor of child psychiatry at the University of Maryland and the president-elect of the American Academy of Child and Adolescent Psychiatry. Why? No one knows for certain. Certainly, budget cuts haven't helped. Hospital beds for children in psychiatric crisis are decreasing, and in most communities, long-term care is virtually nonexistent. Richard Harding, former president of the American Psychiatric Association and a child psychiatrist in Columbia, S.C., calls the national problem a "perfect storm, where budgets are cut, and inpatient facilities are closing, and more children than ever need help" But Kelly Troyer and her family were unaware of this in 1993 when Alex was born. All she knew after several months was that her sleepless, agitated second son wasn't acting right. And what she knows several years later is that the system that should have been there to help wasn't acting right either. [Fred A. Baughman Jr., MD:
Kelly Troyer sits in her van in the pickup line at the Pelham Road Elementary School, where Alex attends a special class with six other emotionally ill children. While he still clearly struggles-small setbacks can leave him tearful and frustrated-this has been a good year for Alex. After his diagnosis was finally nailed down, Alex began medication that has stabilized his symptoms. Both he and his younger brother, Hudson, are among an estimated 1 million children with bipolar disorder. [Fred A. Baughman Jr., MD:
Hudson, an impish, sparkling 7-year-old, is in a different school. The oldest brother, 12-year-old Brandon, is not only healthy but enrolled in a program for gifted and talented students. Alex emerges, a typical little boy lugging a giant backpack. He is, as a report from the Medical University of South Carolina states, "well groomed and quiet with very soft speech," but he also has the slightly haunted look of a child whose brain has exacted a terrible price with its unpredictability [Fred A. Baughman Jr., MD:
"How are you doing, honey?" asks Troyer. "Did you have a good day at school?" "I can read now," he announces proudly, as he searches for a book in his backpack [Fred A. Baughman Jr., MD:
. "We never thought that would be possible," says Troyer as she drives away from the school. "Given everything else we had to deal with." When Alex was a baby, he didn't sleep more than two hours a night and had problems eating and digesting food. When he was a year and a half, he began to hurt himself and other children at the day-care center, and he was kicked out. Troyer took him to the pediatrician, who "discounted everything I said." Alex, the doctor told her, was a normal kid, just colicky or in the midst of the terrible twos. All that was needed, suggested the pediatrician, was "different parenting skills." Troyer recalls: "I kept saying, you don't understand, this is a child who would rage and not sleep." Unfair as this appears, and maddening as it is for parents, Troyer's difficulties also reveal the complexities of diagnosing severe mental illness in children [Fred A. Baughman Jr., MD:
, especially when it is manifest at a very early age. The conundrum with mental disorders is linking a clinical presentation-wild and frightening behavior, for example-with a diagnosis and suitable treatment. "We have improving, but not perfect, diag- nostic schemes," says James Scully, the chair of the department of neuro- psychiatry and behavioral science at the University of South Carolina School of Medicine. Diagnosis is based on observation and clinical experience rather than some measure of underlying physiology or cell pathology [Fred A. Baughman Jr., MD:
, and "there is a huge range of 'normal.' We need to figure out if the child is experiencing a developmental process versus a developmental delay versus a real illness." When Troyer's marriage broke up in 1997, she moved with her three sons into her parents' house in Greenville. Eventually, her mother and the boys' grandmother, Cindy Troyer, quit work as a nurse in order to help Troyer with the children, and Troyer's father, Tom, became a father figure to the boys, playing basketball, teaching them carpentry, and providing essential male ballast to their lives. Alex continued to be impossible to control, and Troyer thought she might finally get help from the family pediatrician in Greenville. The pediatrician recommended the popular antidepressant Prozac. Yet "it made him about 100 times worse," recalls Troyer. Pediatricians and family practitioners prescribe over 85 percent of the psychiatric drugs today and, according to the surgeon general's report, two thirds of mental health visits are to primary-care physicians. "Clearly, half the patients I see have some kind of serious emotional problem," says pediatrician David Kaplan, chief of adolescent medicine at Children's Hospital in Denver. "Over the last five years I have been prescribing and managing more and more kids on psychotropic medication. It's a huge change in practice for us in adolescent medicine." And not for the better. Kaplan and other pediatricians point out that the combination of more difficult cases and few available child psychiatrists leads them to dole out medicine they are neither trained in nor comfortable with prescribing. Some pediatricians, like Kaplan, who are affiliated with large hospitals or academic institutions, can consult with the child psychiatrist down the hall when confronted with a vexing case. But most don't have that luxury. Before grim experience teaches them otherwise, desperate parents of mentally ill children assume that mental health services, like those for physical ailments, will proceed through some relatively predictable steps. The pediatrician refers you to a specialist, you get an appointment within a few weeks, the child is examined, medication is prescribed or a procedure is scheduled, and everything is reimbursed by insurance. This model goes terribly wrong from the start. According to the American Academy of Child and Adolescent Psychiatry, there is a "crisis in the workforce." Only 6,300 child psychiatrists practice nationally, whereas, according to the Council on Graduate Medical Education, the nation needs more than 30,000 to serve those in need. Also, more than 20 percent of child and adolescent psychiatry residency programs were unfilled in 1999, and the number of child and adolescent psychiatry residents did not increase at all in the '90s. One problem is that to become a child psychiatrist, a young doctor must complete a three-year residency in adult psychiatry plus an additional two-year fellowship in child psychiatry. At the end of all that education, child psychiatrists typically end up on the bottom of the pay scale compared with other specialists. The result is a massive maldistribution of services, with especially limited options for troubled children in rural or low-income areas.For example, there is less than 1 child psychiatrist per 100,000 young people in Mississippi, while there are nearly 20 per 100,000 in Massachusetts. Nebraska reported this year that it has barely enough mental health specialists to help children who are suicidal or in crisis. Even if there is access to a mental health provider, there is the other problem of paying for the care. Although almost half of all children have some sort of private insurance coverage, the vast majority of those with psychiatric disorders are covered only by specialized "behavioral health carve-outs." What this means is that insurance companies have split off mental health care from primary care. Rather than a physician simply authorizing services, a "reviewer" or "gatekeeper" working for the insurance company determines what care will be reimbursed, in effect determining both the quality and the nature of the care. A recent Rand Health Program study showed that eliminating gatekeepers would most likely not raise costs for HMOs, but insurers have lobbied hard against equal treatment for mental disorders. Many parents are stunned to learn that their insurance will not cover psychiatric medical care for what is clearly a seriously ill child. "If a child had cancer we would be infuriated if parents were made to beg for care," says child psychiatrist Harding. Kelly Troyer has what she calls "excellent private insurance" and secondary Medicaid as well. But even with that, Alex was refused treatment because the psychiatrist did not take Medicaid. When Troyer said that she had private insurance and would pay out of pocket, she was told that this, too, was impossible. Care and reimbursement problems are further complicated because children who are mentally ill typically have a whole range of other needs. Alex also needed speech therapy and help with his learning disabilities and auditory processing problems. In a perfect world, a child psychiatrist would monitor both the medication and these other therapists, teachers, even the child's pediatrician. A few communities are experimenting with ways to better coordinate all the services-what's called "continuum of care" or "wraparound" services--- |
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