Suffer the Little Children

We are all happy that with the arrival of three vaccines against COVID-19, the end of this long, stressful pandemic might finally be in sight. However, I read two articles recently that gave me pause. I wanted to share them with you .

The first, entitled Kids’ Mental Health is Still Pediatricians’ Greatest Concern, was in the Sunday, March 7, 2021 edition of the Augusta Chronicle. In it, Steven Shapiro, Chair, Department of Pediatrics, Abington Hospital, Philadelphia, PA, stated that “20% of calls are now to put kids on more medications for panic attacks and anxiety.” He was quite concerned that the uncertainty and anxiety spurred by the pandemic, coupled with a lack of social contact, may be having lasting effects on the mental health of children and teens. As we have all seen, children seem to be less likely to have serious physical illness from COVID-19, but the emotional toll of this ongoing pandemic may be affecting them more than we know. Vaccines are super and many of us have already had at least one dose, but they are not yet available for children. Moderna began testing its vaccine for young children just recently, so there is hope that this age group may soon be part of the more fully protected when a vaccine is deemed safe for them to take.

What kind of emotional affects does the pandemic have on kids? For one, they worry about somehow getting infected, then making their parents, grandparents, and teachers sick, according to Stephanie Ewing, Assistant Professor in Counseling and Family Treatment at Drexel University College of Nursing and Health Professions. Routine health appointments and follow up visits for well checks and vaccinations, among other things, fell drastically in the first few months after the pandemic was discovered and stay at home orders became more common. According to a November 2020 Blue Cross/Blue Shield report, vaccinations for measles and whooping cough fell 26% compared to the same time in 2019. On the positive side, there has been a decrease in the number of cases of strep throat, flu, and ear infections due to social distancing, says Jonathan Miller, a pediatrician at Nemours/Alfred duPont Hospital for Children. Dr. Miller also notes that children have been much more inactive, they have had an increase in screen time, and they have been home for a much longer period of time than pre-pandemic times. He wonders about the impact of these on overall wellbeing. There has been an increase in depression and anxiety symptoms in his practice as well, and he has shifted to a more proactive stance and an emphasis on preventative care when dealing with behavioral and mental health issues.

The second article, MUSC Doctor Says Pediatric Suicide , Suicide Attempts “unprecedented” Amid Pandemic, appeared in the Post and Courier on 2-19-21. It continued to look at the issues we’ve already outlined but went a step further to drill down on the issues of suicidal ideation, suicide attempts and completed suicides. It also made this issue much more real for me, as these doctors live and work on the South Carolina coast in the Charleston area.

Dr. Elizabeth Mack, Chief of Pediatric Critical Care at MUSC, says that the number of these suicidal kids has reached a crisis in Charleston during the pandemic. What they are seeing inside the pediatric intensive care unit is much higher than normal and unprecedented. “We’re seeing a twin pandemic in many different ways. The isolation is really amplifying the inequities that have been laid bare for us.”

What are some of the factors that are contributing to the rise in pediatric suicide attempts and suicides? Isolation, grief secondary to the loss of loved ones, and financial insecurity are just three. Delayed return to school, which of course may be rectified in the coming months for many students, has lead to increased anxiety and depression. Schools are also safety nets for kids who don’t have enough food, who get most of their social needs met there, who have better access to physical and mental health care in school, and who sometimes are rescued from various kinds of abuse when a teacher or counselor sees warning signs and investigates further. Even when they are in school, some children worry about getting infected with COVID-19 themselves. Plexiglass barriers, mask wearing and social distancing also lead to odd emotional reactions in some children.

What can we all do to help?

Parents, teachers and counselors can be as open as possible with kids, including sharing some of their own healthy emotional responses to the pandemic and how they dealt with them. Focusing on the future can be very helpful. All of us can be vigilant, and if a child acts or sounds or interacts differently than usual, taking them to their pediatrician is a good first step. One more potentially lifesaving thing we can all pay attention to? Gun safety.

Dr. Annie Andrews, Director of Advocacy in the Department of Pediatrics at MUSC, noted that pre-COVID-19, thirteen million children lived in homes with firearms present, and four million of these in homes where the firearms were not secured. Children in homes with guns are three times more likely to die from suicide. Eighty per cent of children who attempt suicide with a gun will die. Only 2% of those who attempt to kill themselves by ingestion/overdose will die. Gun safety means unloading, locking up, and separating ammunition from firearms. As many as five children a week have been brought to MUSC with self-inflicted gunshot wounds, either accidental or intentional, and many of these kids die.

As Dr. Andrews and others in these articles said, these data are still anecdotal, but more data will be forthcoming as we go forward. As I started this column by saying, we are very happy that one pandemic seems to be heading towards its latter stages. Unfortunately for our children and teens, another pandemic may just be beginning, and we will be wise to watch for it and confront it wherever it arises.

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.