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.

Peekaboo, the ER Sees You!

Peekaboo, I see you!

Any of you who have children have played this game over and over with your young ones. At a certain age, they love to pull a blanket over their heads, or better yet, to have you hide behind that same blanket, and then squeal with joy when you emerge. It’s always as if you went far, far away and then miraculously returned to be with them again, much to their delight. The repetitive interaction teaches your child that you are always there, that if you appear to be gone that you will return and that you are a constant in their lives. They learn that you are there for them, and that you will keep them safe.

In mental health, we try to see and evaluate children in many contexts. We see them for who they are in a family unit, in their school environment, with their friends and in other social settings. In pre-COVID-19 times, we might have seen a child in the office, with input by a therapist, nurse and child psychiatrist. We might have had a school based therapist see the child in his or her natural environment in the classroom, the lunchroom, or the playground. We most likely would have wanted to get collateral information from other family members, several teachers, court systems, pediatricians, probation officers, or anyone else who might know something about that particular child and their presenting problem.

Since the pandemic began and lockdowns of various types began to be commonplace last spring, a lot of this normal information gathering has been curtailed. Clinics are closed and onsite, face to face interaction with mental health professionals is severely curtailed. School based therapists have been deprived of their most fertile diagnostic and therapeutic ground, the school itself, because so many children have been placed in virtual learning environments, often from home. If mental health providers cannot see the kids, they cannot do an adequate assessment and provide timely treatment. The result is the very real possibility that more depression, academic failure, physical, mental, or sexual abuse or neglect may be happening but never seen. Where do children and their parents turn when care is needed, but normal avenues of assistance are cut off?

The CDC tells us in their Morbidity and Mortality Weekly Report (MMWR) for the week of November 13, 2020, that emergency departments are often the first point of care for children’s mental health emergencies. As a community telepsychiatrist who has seen folks in the emergency rooms of South Carolina for the last ten years, I can attest to the truth of that statement. An interesting point here: during the first few months of the pandemic last spring, ER visits for all sorts of problems for adults and children actually went down, not up, at least at first. Why? Everyone was so afraid that they would contract COVID-19 at the ER that they stayed away, even if they had legitimate emergency health issues that needed to be attended to right away. Starting in April 2020, the CDC tells us, the proportion of children’s mental health related visits among all pediatric ER visits increased and remained high through October. Compared with 2019, the proportion of mental health related visits for children aged 5-11 and 12-17 years increased 24% and 31%, respectively.

We know that the coronavirus pandemic has had a negative effect on the mental health of children. If other services as outlined above are not available, children end up in ERs. These resources are invaluable when the going gets tough and there is no other option, but by virtue of their very nature, rapid assessment and evaluation of the sickest among us and triage to admission or discharge to further outpatient assessment, it is impossible for ER staffs to do a really thorough assessment of a child with serious mental health needs, even with telemedicine and other services there to assist.

Monitoring indicators of children’s mental health, the CDC tells us, promoting coping and resilience, and expanding access to services to support children’s mental health are absolutely critical during the COVID-19 pandemic. With the launch of vaccinations and continued use of masks, handwashing and physical distancing, we will get through this pandemic and back to some semblance of normal. In the meantime, we must not let even one child who needs us slip through the cracks and suffer from mental illness that can be assessed, diagnosed and treated.

Peekaboo, we see you.

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?

IMG_4775

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

Childless

ImageApril 20, 1965.

A day like any other day, I suppose, but not for my parents. 

I was seven years old, and I remember nothing of it. Nothing at all. 

Isn’t that odd? An event that could change the dynamics of my entire family forever would not even be a part of my conscious mind as I moved forward in time every April 20th after that? Odd, but true. I don’t know exactly how it happened, how it affected my folks, how they processed it, who was there with them and for them. 

She didn’t even have a name. Infant daughter of…was all the simple gravestone says. She rests in the bright middle Georgia sunshine at my father’s feet, no doubt where she would have spent many happy hours if he’d lived longer. If she’d lived at all.

I often wonder what she would have been like. Dainty and feminine? Rough and tumble? Smart and searching? Ready to change the world? Loving, caring, feeling, giving? The apple of her older sibling’s eye, I’m sure of that. Someone to be protected by a bragging, proud brother, I’m sure. Someone to be a protector too, somehow, for a brother who even now needs a buffer between him and the big, wide, harsh world some days when it gets to be just a little too much. 

I might have done that for her. She might have done that for me. 

How sad for a gravestone to have but one date inscribed on it. One date. Birth and death all at once. No dash. 

 

Oh, I don’t know. Thank you for asking. 

Maybe because we just passed through another Memorial Day with its row upon row of white crosses and the thousands of kids that lie there, motherless in the ground. 

Maybe because of what my grandmother said to me, in her grief, as she waited, slumped over in the parlor before my father’s funeral. “It’s not right. No parent should have to outlive their own child.” 

Maybe it’s because one of my friends has been dealing with a very sick child. “She’s never been this sick.” The quietly frantic pleading and praying and busyness that goes with that, with the knowledge that you will do anything, everything in your power to make sure that child gets well and lives. There is no higher calling for a parent than to be totally focused on the need of their offspring, until whatever is assaulting them is totally annihilated. 

Maybe it’s because she came to see me the other day, wrapped in grief so raw, so tangible, so real that you could see it in the bathrobe, pajamas and house slippers she wore to my office. It didn’t matter one whit to her what she wore that day. I didn’t matter that her red, tear-stained face hadn’t seen eye shadow or rouge or powder in days, maybe weeks. None of that mattered.

She shared her grief with me. She shared what it must have been like for my own mother on April 20, 1965, and every April 20th after that-every day after that. In her brokenness, she still got out of her house, trudged the distance to my office, and tried to help me understand what she was going through. 

Like so many patient encounters, this one was good for both patient and doctor. This one showed me how very real the connection between us is, the tiny thread of communication that persists even through the darkest hours, the most blinding pain, the most raw, aching, devastating grief. I felt it, but I could not put it into words. 

I didn’t have to.

Sometimes it’s best for the doctor just to be present and say nothing. She did it for both of us. I just sat there with her, feeling it, letting her feel it, knowing that eventually, it will get better. It will never go away, no never, never, never, but it will get better. She was not convinced. 

She looked up at me and made direct eye contact once in that session, only once, and summarized her grief.

“There is no pain, I mean no pain in this world, that is worse than this pain.”

At that moment, I believed her. 

 

Suffer the Little Children

Image

It is hard to see a child in pain.

I have seen quite a few children in the emergency departments of South Carolina in the past three years, more than I could have imagined just a while ago.

Now, in the interest of full disclosure, I am not a child psychiatrist by trade. Like any general psychiatrist, my training at the Medical College of Georgia Department of Psychiatry and Health Behavior, now at Georgia Regents University, provided me with didactic and clinical training in a variety of sub-specialties in my field, including affective disorders, substance abuse, and the disorders that children may suffer from. Most hospitals that I work in now, desperate for help with children who come in sick and in need of assistance, grant me and others like me privileges to evaluate these kids, simply because they do not have any other choice. There are very few trained child psychiatrists in the United States per capita, and they can pretty much command their price and practice where and how they wish.

That being said, I have been scrambling in the past three and a half years to find my sea legs and get into the rhythm of seeing children and their families in emergency departments and in the clinics of my own home mental health center. It is a different rhythm all together, rewarding when done right but extremely taxing and challenging and physically and emotionally exhausting at times.

In the ED, children come in for various reasons including depression and anxiety, acting out in school, danger to themselves (yes, I have seen children as young as four years old who were actively suicidal and had a specific potentially lethal plan to kill themselves), and for the aftermath of sexual or physical abuse or the effects of other trauma that they have lived through. Witness the recent graphic pictures of children being pulled from the rubble of a school monstrously devastated by a killer 200 mph tornado.

Before I go any further, let me make one thing abundantly clear. Children are resilient. Wonderfully and fearfully resilient. I think this is why we still exist as a species today.

One of the things that bothers me tremendously about seeing kids in the EDs and clinics today is the fact that parents have lost their way. Yes, I am now turning this post about children on its head and speaking about their parents. Indulge me, please.

Parents bring their children in for evaluation, sometimes as young as two years old-two years old, mind you!- because the nursery school can’t handle their outbursts towards other toddlers. Elementary schools tell parents that their child will not be admitted back into the classroom “until you see a psychiatrist and get him put on some medication to control him”. Some children are refusing to get out of bed in the morning, refusing to get dressed and go to school, causing their parents great anxiety because “I just can’t make him do anything”. Some parents are resorting to the old taking away of privileges tactic, retrieving in-bedroom game consoles, televisions, computers, and even smartphones.

Wait. Stop. Hold on.

These parents tell me that their children are out of control, that they need to be medicated, that they “are ADHD and bipolar”, that they are SICK, when actually they are suffering from one thing and one thing only.

A profound lack of discipline in the home and at school.

Parents do not feel that they make the rules any more. There can be no house rules. There can be no punishments, behavioral or corporal or otherwise, because Little Johnny has the Department of Social Services on speed dial on his $600 iPhone and will call them if his parents lift a finger to keep order in their own home.

Teachers are hamstrung, overwhelmed by sheer numbers of children in their classrooms and piles of lesson plans and paperwork designed to leave no child behind, all the while leaving good teachers behind who can no longer stomach the profession they once loved.

My friends, I see a lot of kids in the EDs of South Carolina these days. Granted, some of them need real psychiatric help. Some of them are severely depressed. Some of them have been sexually and physically and emotionally traumatized beyond your wildest imaginings. Some of them truly hear voices and see dead people. I see these kids and I evaluate them and I recommend the treatments they need.

Others are victims, yes, I said victims, of a system that has lost its way. A system that no longer lets parents be parents and set the rules in their household that lead to a healthy, happy functional family. A system that has taken away control of the classroom from the teachers and placed it in the hands of bureaucratic suits who have never had chalk dust on their hands, much less come up with creative ways to engage a classroom of seven year olds for a day. A system that tells us that little children are ill, sick, infested with the seeds of diseases and syndromes like Intermittent Explosive Disorder, when in fact, they are having tantrums and need to be disciplined by strong parents who love them.

I am appalled dear readers, absolutely appalled, that in this age of technology and enlightenment we are too stupid, too afraid or too threatened to call normal behavior by its rightful name and deal with it. I am appalled that we are trying to turn normal, sometimes troubled children who have briefly lost their way into psychiatric patients with diagnoses that will follow them for the rest of their lives.

I fear for our own sanity and wellbeing, and that of our children and grandchildren, if we do not start to , as Vernon Howard said, “Learn to see things as they really are, not as we imagine they are”.