Preface
Working with troubled children and families is invigorating, rewarding, fascinating, frustrating, and confusing. Child and adolescent psychiatry is a discipline that can seem overwhelming at first. There are parents, schools, protective services, primary care physicians and many others providers with whom to collaborate. There are the complexities of the diagnostic interview with a child, which may require an enormous amount of creativity to help this child feel comfortable enough to engage, let alone communicate to you the personal information required for psychiatric understanding. It is a field that pulls at your most basic emotions-——such as the wish to “adopt” your patients, over-identification with the vulnerability of the child patient, and wanting to undo the actions of “incompetent" parents. We are mandated reporters, which may necessitate “turning in” parents to authorities. We are the professional experts called on by schools, courts, and social service agencies to make decisions that have a profound effect on the child and family, including decisions about hospitalization, custody, placement, and even incarceration. We undertake the intense work of supporting dying children and grieving parents. We are called on to answer complex developmental and behavioral questions from parents, pediatricians, other professionals, and the media. These are the tasks of learning the art and science of child and adolescent psychiatry.
I vividly recall a child interview during my residency I was called to the emergency department to evaluate a 10-year-old child who had been referred by the school because she had threatened to kill her teacher. My job, as delineated in a short memo from the school principal, was to attest to her safety, determine if the legal system or mental health system should be involved, and plan for her ongoing education if I was unable to ensure that she would be completely safe at school. So, shouldering that heavy burden, I entered the room to investigate these matters. There, sitting sullenly, was a 10(appearing 16-) African American girl who was with an emergency department “sitter” (the school had sent her alone by ambulance, and her mother was at work and couldn’t take off or she would lose her job, according to the social worker who had done an initial intake history). I introduced myself and began to launch into the history and mental status exam when, in sudden realization, I stopped short. The girl was not answering my questions. She had turned her back on me and was totally and utterly silent. Was she psychotic, angry, oppositional, dissociating? I asked “are you hearing voices?” to which I received a curt you f—ing moron just get out of hare!” Actually, that was a tempting proposition at that point, but I had my job to do. I sat a good long while thinking. Finally, I reached over for some play doh (Which was there for monitored play) and began to squish at it and offered her some, which she finally picked up and squished as Well. Finally, at my wit’s end, I said the obvious. “Well, What to do? I guess you don’t want to be here and you are stuck with a psychiatrist who is supposed to figure out if you are safe. ‘What do you suggest we do?” She gazed at me for the first time, looking incredulous. “What do you mean, what do I suggest? You are the shrink! You can read my mind. You tell me!” I-admitted that, actually, 1 could not read her mind (I wasn’t completely sure that she knew that) and that I did not know what to do——but I would like to hear her side of the story o what happened at school. To my utter amazement, she told me. She told of living in a scary neighborhood where only the tough survive—_and she was a survivor. She told me she was not very smart. (which was actually not at all true) and of the indignities foisted on her by her teacher when she did not know an answer. guess I just couldn’t take it anymore,” was her final statement.
The girl was admitted to the children’s psychiatric inpatient unit, Where I was rotating. I was her doctor. I learned many things from her (and from the fabulous supervision I received around her care). I learned that children are not just miniature adults even though (as in her case) they may look like it. I learned that engaging with a child uses many modalities. I learned that what is asked by schools and others may be impossible to do or, even more importantly, may not even be the right questions to ask. I learned that children know honesty when they see they know when they are being manipulated. I learned that building rapport with both the child or adolescent and his or her caregiver (either one alone will not do) is the essence of any treatment. I learned that there are no books to address the must-know practicalities of child and adolescent psychiatric care. I could learn the Diagnostic and Statistical Manual (DSM). I could learn about psychopharmacology, epidemiology, and components of a workup. But I longed for “how to” guide that would provide helpful advice in my work with complicated patients, situations, and dilemmas.
The Practical Guide series is just that—-a series of manuals that provide practical, user friendly, and engaging material that may be used in clinical practice. I chose to Write this manual on child and adolescent psychiatry because, as a former trainee, as a clinician educator, and now as a training director for child and adolescent psychiatry residents, these are the gems that I have accumulated. This is the advice I now attempt to impart to residents. This manual serves as an organization of the pearls of clinical practice in child and adolescent psychiatry—-from mnemonics to recall diagnostic criteria to clinical vignettes to important tips for working with children and systems. This is a manual that may be used by child and adolescent psychiatry residents and many more—medical students, psychiatry residents, other mental health professionals, and even more seasoned practitioners.
Working with children and families with psychiatric disabilities is, in my mind, the most fascinating, needed, and rewarding of all careers. I hope this manual conveys my love and dedication to children, to my profession, and to teaching_ This manual does not take the place of textbooks, journals literature reviews, intensive supervision, or clinical experience. However, I do hope that this book will-find its way into the pockets of and be useful to all clinicians who embark on the crucial mission of treating children who are suffering from psychiatric disorders.