Child’s Play

Dr. Kenneth Azar, a mentor of mine at the old Georgia Regional Psychiatric Hospital in Augusta, Georgia, told me something once that has always stuck with me.

He told me that in the early years of his practice, when he was living and working out in Idaho, that he was one of a very small handful of psychiatrists who served the whole state. If an adult with psychosis needed to be stabilized, he would write orders for medications and restraints. If a probate court hearing came up and needed testimony from a psychiatrist about the need for further inpatient treatment versus release to outpatient follow up, he would oblige. If a child was mentally ill and needed to be assessed for depression or trauma or sexual abuse, he was called on. If a forensic case could not go forward without an evaluation by a mental health professional, he would get that call too. He was basically, in this early part of his career, a jack of all trades and a master of none.

Fast forward several decades, when Dr. Azar had been on the faculty of the Medical College of Georgia School of Medicine, Department of Psychiatry and Health Behavior for a few years. He was teaching me, and a steady stream of medical students, interns and residents, all about acute inpatient psychiatry. The North Unit, as we used to call our stomping grounds in those days, was the perfect backdrop for real world learning about mental illness, its diagnosis and treatment. No textbook could have ever provided the rich tapestry of mood disorders, psychosis, substance abuse, personality disorders and rapid-fire triage of mental disorders that this unit did. I probably learned more there, when I think about it now, than I did anywhere before or since in my long association with the field of psychiatry and mental health.

In those early days, I developed my love of the treatment of severe, chronic mental disorders such as bipolar disorder and schizophrenia. I have gravitated towards jobs and positions that allowed me to continue interacting with and caring for patients who have those disorders. Even on the days that I was stressed to the max, wondering how I was going to pull it all off and get the work done, I was happy in that element of chronic illness. I really did, and still do, enjoy learning more about the progression of illness over decades, how we treat it, and how we try to limit the debilitation that often comes from a lifetime of major illness that affects the brain.

Now, fast forward a few more years, past my own stints as associate faculty and mentor and teacher and lecturer to my current duties as the medical director of a busy mental health center, a clinician for four days a week during the daylight hours, and a phantom telepsychiatrist another two or three nights a week on top of that. I am still in my element, seeing chronic illness in some of my clinics that has allowed me to see how depression and psychosis and substance abuse can play out through the years and through multiple generations of the same family, all of whom I have treated.

The twist?

I am now, as Dr. Azar once was those many years ago in Idaho, a child psychiatrist by default.

Now, I did my four years of residency in general psychiatry, to be sure, including a rotating internship year and a chief residency year. I learned about psychiatry as a field, including the treatment of adults, children and adolescents, mood disorders, personality disorders, substance abuse and trauma. I am certified by the American Board of Psychiatry and Neurology. I am well trained, and I have decades of experience in systems as varied as local family counseling centers to Veterans Administration hospitals to state hospital systems to the private sector.

All that being said, I have never seen so many children with so many mental health problems in so many venues presenting with such severe disease.

Children do not scare me. I do not feel uncomfortable around children. I have helped raise three of my own, I have three grandchildren now, and hope to have more in the future!

Even so, there is something quite distressing and disconcerting to me about the fact that I, and many other psychiatric clinicians like me, must now, in 2014, see, evaluate and treat children as young as two-yes, TWO- who might present with symptoms as disparate as mild separation anxiety to florid psychosis. I am humbled by the fact that as I get older, I know what I do not know, and I am striving to increase my knowledge base daily so that I can provide the best care I know how to my charges, adult and child.

It breaks my heart when a child tells me stories of being bullied mercilessly by his peers because he is thin or fat or smart or talented or effeminate or likes to color his hair orange.

It makes me angry to hear stories of abandonment by fathers who are nothing more than biological and care not at all for the fragile lives they help bring into the world, leaving them to flounder with overwhelmed, poverty stricken mothers ignored by political systems that simply don’t care about them.

It makes me physically ill when I hear stories of sexual trauma, rape and molestation that go on for years, with other family members turning a blind eye or simply accepting that this is how it is.

It brings tears to my eyes when the little eight year old girl in front of me tells me that she attacked her teacher because “the voice of the bad man in my head told me that I should kill her”.

I never considered myself a child psychiatrist. That was not my first love clinically. I did not seek my Board certification in that specialty area. I never solicited patients who rode skateboards instead of cars and rocked Beats headphones and iPads instead of printed newspapers and transistor radios.

If I look at my schedule for the past week and read over the consults I’ve done in the emergency rooms all over the state of South Carolina in the past week, though, the picture is pretty clear.

I am a child psychiatrist whether I chose to be one or not. It’s a big part of my job and my professional life at this point, and with the shortage of child psychiatrists coming out of training programs around the country, I don’t see it changing anytime soon.

My take on this state of affairs?

I will never stop learning to be a resource to my patients, especially the small ones. I will never stop growing professionally. I will always pay special attention to the stories that the children tell me, because after all, they are our future.

I know that by seeing children who suffer from mental illness and trying my best to help, I can change the world, one little child at a time.

Is there really any more awesome reason to get up and go to work in the morning?

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Two of my grandchildren, when they were first learning to use an iPad mini.

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11 thoughts on “Child’s Play

  1. Hi Greg–First a point & then a question. There a TOO FEW psychiatrists in general,irregardless of their subspecialty-adult,adolescent,or child. How do you assess a 2 yr old for psych problems & what does psychosis look like with a 2-3 year old child? Also,there are far too few psychiatric beds available.

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  2. Greg,

    Reading this just now brought back memories of my psych rotation in nursing school. Georgia Mental Health Institute in downtown Atlanta (don’t even know if it is still there). I was assigned to the children’s section, along with about six others student nurses. My patient was a five-year-old little boy named Stevie. He was delusional & I think diagnosed schizophrenic. But what I remember most was how he constantly kept waiting & looking for his mom to come. Every day. It broke my heart b/c we knew she would not be coming. He had been pretty much abandoned by her. Dad no where around. This little guy was pretty much alone in the world. His mind would wander down streets & avenues that I had no idea how to follow. But I tried to show him that he mattered. That there were people who cared for him. I have often thought about him over all these years. Wondered if he made it in this dark world. If someone was able to help him see his true worth. Guess I’ll never know.

    Thank you for what you do. It is vital to these little patients. You may not have planned on child psychiatry as your field. Sometimes our plans are not God’s plans. He is sending these young & troubled patients to the best doc around.

    🙂
    M

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  3. Vivid post, Greg. I wonder why severe mental disorders among children seem so prevalent these days. Is there really more disease? Or is it because we’re more aware of how these disorders manifest and have more/different diagnostic categories? And there I go, right down the sociological rabbit hole! More to the point, my prayer is that you know that you’re making a difference in many tender lives.

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  4. I transcribe for a large children’s hospital and see a lot of sad things, from failed transplants to genetic disorders to psychiatric issues. One clinical report that sticks with me because I just cannot wrap my head around it was of a 4-year-old boy whose father tried to end his and his son’s life with an overdose of morphine, ketamine and another drug I can’t remember via injection in the neck. Both of them were found and treated and recovered, and the little one was being monitored for mental and developmental issues. At the end of the mental status examination section of the report, the clinician dictated “he [the patient] misses his daddy.” I cried for the rest of my shift that night, but found a new respect for those mental health professionals who willingly tackle such things with hope in their hearts.

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  5. Yes, there are too few by far.
    AS for the two year olds, I have seen a lot of parents bring their little ones in when they are really only being toddlers. The trick then is to help some of the parents learn about normal development and behaviors that are expected in children of that age, and teach them some parenting skills that make them feel more comfortable with their child’s behaviors.

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  6. Meredith,

    I truly think that it’s both.

    I see many more kids with psychosis, substance abuse, all at a much younger age than when I started my training. Broken families, absent fathers, and substance abusing parents also add to the problem, as does a very sluggish economy and lack of jobs, especially in the very poor areas of the state of South Carolina where I see a lot of these kids.

    G

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  7. Carol,

    That says it all, doesn’t it?

    I have heard horrendous stories from children who have been horribly abused, then turn around and ask to see their parents.

    It is a very strong bond, even in the face of such events.

    Bless you for YOUR work, because you are at risk of vicarious trauma just from hearing about these things that others are seeing first hand.

    Take care of yourself too!

    G

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  8. I think revulsion is cumulative in all of us, Doc, but most often silently so. For some, it reaches a critical mass that tips us into despair–either from prolonged, unrelenting stress or an inciting event of unusual potency. From that point on, there’s no full recovery, no going home again. Unfortunately, there’s also no “revulsion meter” I know of. No way to accurately predict when or how the tipping point will be reached. The point is not to get to that point. Things being what they are today, the “new normal” puts everyone in healthcare at increased risk– those who have remained in the trenches the longest, most of all. I know you know this, and I know you’re doing what you can to protect yourself, but as the years go by, luck plays a very large part. I just don’t want to read your name on the casualty list. I’d much rather see it here, or on a book jacket, or a faculty roster. All three would be great– a grand slam. Best Always, Chester

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  9. Alright then, I’ll be a blue-nosed gopher, Hoppy…I mean Doc. Keep your powder dry and shoot low, they’re ridin’ Shetlands. Carp the day, etc.

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