Honestly, why do some many Psychiatrists not like CAP

[DO_or_Die]

Between peds and child psych right now. I am torn, because I would only do psych to do CAP. All of the psychiatrist that I have met currently seem to dislike CAP with a passion, "because of the parents", etc. This is something about working with kids that has never bothered me as I view the parents as co-partners with me. Is it because the children are a product of their circumstances and can't realistically be helped by psychiatry without just giving them a new family or what, exactly? Is that extremely common. I feel like intervening in crisis and helping a kid change the trajectory of their lives would be extremely rewarding. Perhaps I am just naive as I don't have exposure to CAP yet and I have to decide very soon. Psych wins in terms of lifestyle and it's interesting enough, but I'm most satisfied working in peds albeit the pay and lifestyle is subpar. Very hard decision.

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[Bartelby]

I am one of those who loves psychiatry but didn't like CAP. For me it boils down to:

1- I'm not a kid person. I liked working with adolescents (and of course adults) but just found working with young kids a lot less interesting.

2- in many settings having to triangulate between parents and kids simply adds work/barriers/potential frustration.

Overall though CAP is a great field! For those who really enjoy working with kids (like you) I think it can be great, and I agree that #2 isn't a deal killer and that family work is an important and helpful skill. CAP psychiatrists are also the true generalists who know psychiatry from cradle to grave. If you think you are interested in it do some electives, talk to some CAP people, and don't let the negativity scare you off.

 

[Celexa]

Don't be scared off of CAP until you've been exposed to it and spoken to some actual child psychiatrists.

I'm also one of the people who strongly dislike CAP, and a big part of that is the parents. For example I had a teen patient in residency who definitely had their share of issues but also had a good head on their shoulders. Mom was WAY sicker and weaponized the child's issues into an excuse for why she couldn't seek out/didn't need help herself. It was uniquely infuriating to me in a way working directly with adult patients isn't. My colleagues who do CAP just seem be able to role with this type of situation in a way I'm not built for, and in turn they don't understand why I enjoy consult psychiatry so much. To each their own. I have huge respect for child psych and we desperately need more people to go into it.

That being said, it's fine to go into psych with a clear idea you want to do child but you should not go into psych if you actively dislike adult psychiatry--there is a LOT of work with adults between starting as an intern and child fellowship.

 

[TexasPhysician]

CAP can be very rewarding, but it has its issues like anything else.

1. You are essentially doing 2x the work. You interview two instead of one and sometimes the stories don’t mesh. Sometimes you see through who is minimizing or bending the truth. Sometimes you need a third perspective or more. This leads to additional time spent.

2. If you are taking insurance, finances for psychiatrists increase with volume more so than added time.

3. Some parents want what is best for them at the expense of their child.

4. Some children are currently or have been in absolutely terrible situations. You can’t snap your fingers and take the pain away.

 

[wolfvgang22]

I did CAP. I mostly enjoyed fellowship and working with kids and parents is rewarding. I didn't find it to be too much more work, but it is a bit more. And it is work worth doing! But most employers didn't want to pay me more to do it (less, actually) , and the good places to work seem to be in large cities at University, places I didn't want to move to. And for me pioneering CAP private practice in my town isn't something I am ready to do. I worry I would quickly be overwhelmed by the need here with few community resources. Also, Child Psych is as different from peds as Psych is different from IM.

 

[smalltownpsych]

Between peds and child psych right now. I am torn, because I would only do psych to do CAP. All of the psychiatrist that I have met currently seem to dislike CAP with a passion, "because of the parents", etc. This is something about working with kids that has never bothered me as I view the parents as co-partners with me. Is it because the children are a product of their circumstances and can't realistically be helped by psychiatry without just giving them a new family or what, exactly? Is that extremely common. I feel like intervening in crisis and helping a kid change the trajectory of their lives would be extremely rewarding. Perhaps I am just naive as I don't have exposure to CAP yet and I have to decide very soon. Psych wins in terms of lifestyle and it's interesting enough, but I'm most satisfied working in peds albeit the pay and lifestyle is subpar. Very hard decision.

Sometimes the family is clearly the cause, especially if there is actual abuse or neglect; however, for much of the work we do with kids the family is not the sole cause as opposed to being caught in a maladaptive pattern that can be the result of trying to parent a kid that is not in the normative range of functioning. Many in the field will default to blaming parents for the issue and the reality is that the patient has the family they have and splitting that is rarely a good plan. Learning to change the dysfunctional pattern and decrease the frustration on both sides that the family couldn’t “fix the problem” and their trying to help often makes it worse is the goal. From that perspective, we often achieve great success.

 

[Merovinge]

When I trained in adult it was a trendy thing to bash CAP for the folks who knew they were staying in the adult age range (or adult attendings when the CAP attendings weren't around). I think the idea is that peds specialties are less hardcore, less empiric, and for "softer" people. Of course if you talk to the random person off the street, people who take of kids are often thought as of the opposite, but I can at least understand where the sentiment comes from in the medical field.

If you already know you are for sure a peds person, those comments by adult psychiatrists are irrelevant. It would be like listening to a surgeon who mocks medical specialties.

You need to decide a few critical things: 1) will 3 years of adult psychiatry be a large drag on your life? If so, you can potentially look out for the few peds portal programs or just do gen peds. 2) do you prefer psychiatric management to general peds management. The fields certainly have cross over but the day to day does look quite a bit different. I was planning on CAP from day one of adult residency but I ended up loving adult psych. I think deep down inside I knew I liked the work more than primary care, so definitely time for some self reflection when making this decision.

 

[comp1]

For me it was really the extra work. I don't think there's another psych subspecialty where you do 2x the work and get like 1.2x the pay (if that). Forensic evals are insanely long, but you get paid commensurately. Good CL evals shouldn't take much longer than an outpatient intake (the patients often lack the ability to speak which can balance having to talk to the primary team) and get nice inpatient billing codes. Also, I didn't get the exact same feeling from child psych that I got from general peds, ie most patients get completely or a heck of a lot better in general peds. Most of these CAP kids had severe trauma that they'll be unpacking their whole lives or, more often, they had literal brain damage (often congenital or in utero) that we were trying to fix with psych meds that weren't approved for kids, but more importantly weren't actually approved for what we're trying to use them for at any age.

 

[Celexa]

When I trained in adult it was a trendy thing to bash CAP for the folks who knew they were staying in the adult age range (or adult attendings when the CAP attendings weren't around). I think the idea is that peds specialties are less hardcore, less empiric, and for "softer" people. Of course if you talk to the random person off the street, people who take of kids are often thought as of the opposite, but I can at least understand where the sentiment comes from in the medical field.

.... Wut? I never encountered this attitude. I've always encountered (and share) the opinion re: CAP 'it's such a hard field, I'm so glad there are other people who are willing to do it'. I have great relationships with my CAP colleagues. Sounds like a localized toxic culture.

 

[FlowRate]

I just didn't want to to extra training and wasn't sold enough on CAP/geared toward a CAP fellowship application to need more disincentive than that.

Personally, I'd really only want to do CAP if the long term plan was cash private practice. In the right market, you can build some cool niches in that sort of setup, offer family therapy directly, take as much time as necessary to do a good assessment, etc. Unfortunately, as is also the case in adult psych, cash pay patients are not, on average, where the greatest need lies.

 

[Merovinge]

.... Wut? I never encountered this attitude. I've always encountered (and share) the opinion re: CAP 'it's such a hard field, I'm so glad there are other people who are willing to do it'. I have great relationships with my CAP colleagues. Sounds like a localized toxic culture.

I mean this is in the context of psychiatry. Not real toxicity like Ob/Gyn or surgical fields. Most of it was like "ha ha the parent's amirite, I would never sign up to deal with that", an occasional comment about how limited the research basis is in the field, or just how much they hated their time working with kids. I will say my program had a significant neuropsychiatry bent and those folks felt about CAP like my PhD physicist uncle feels about MDs (which is to say, that's what you do when you can't cut it in the big kid leagues). It certainly wasn't a scaring experience but I suspect this poster is hearing similar things to what I experienced first hand.

 

[comp1]

I mean this is in the context of psychiatry. Not real toxicity like Ob/Gyn or surgical fields. Most of it was like "ha ha the parent's amirite, I would never sign up to deal with that", an occasional comment about how limited the research basis is in the field, or just how much they hated their time working with kids. I will say my program had a significant neuropsychiatry bent and those folks felt about CAP like my PhD physicist uncle feels about MDs (which is to say, that's what you do when you can't cut it in the big boy leagues). It certainly wasn't a scaring experience but I suspect this poster is hearing similar things to what I experienced first hand.

It's always important to point out that any area of psychiatry is better than other fields of medicine.

 

[mistafab]

I can't speak broadly about all gen psych folks OP.

However, I don't hate CAP. It's just that people on the fence about Peds vs Psych->CAP love working with kids way more than I do. When you sum it up, all the extra work and stress is not worth it for someone like me.

 

[calvinhobbes]

CAP >>>>>>>> Peds. Trust me you won’t regret it lol.

 

[Stagg737]

I was on the CAP track in residency but dropped it and did not pursue fellowship. Things that turned me off of CAP included:

1. Dealing with parents (of course). Some are very loving and supportive and the kids have legit psych problems, but imo the majority of the kids I worked with in med school and residency probably would not have needed to see us at all if they had a stable home life with supportive parents who weren't train wrecks themselves. Plus, when parents are separate or divorced it can make figuring out how to go about treatment and absolute nightmare since the kids can't consent to anything themselves, which happened at least weekly on inpatient rotations.

1b. Kids can't consent and so you have to go through parents for everything. Want to change a med on a 17 yo? Can't do it if parents say no. Want kid to start therapy? Can't do it if parents won't let them. Want to get a kid OFF a med you think is causing problems but parents demand they be on it because "they need it"? Too bad. Think the parents are being abusive or not acting in the child's best interest, great! We can do something! And once the state intervenes weeks to months later maybe they'll agree with you, or not. Who knows!? Until then the kids can keep living with those problematics parents or maybe a dysfunctional foster family. Again, who knows!? Rarely, you'll see an emancipated minor who gets to make decisions for themselves, but I think I've only encountered this once, probably because many of the kids actually do better and don't need our help (or only a little help) once they're free from the disasters that caused the problem in the first place.

2. Moderate to severe ASD, ID, genetic disorders, etc. We're not going to fix these problems. The best we can do is educate and help provide therapeutic and behavioral interventions and maybe treat severe symptoms with meds. Good luck finding the resources for these kids in many places though, or families with the resources available to implement them. I see A TON of these patients come through the ER in their late teens and 20's because they've aged out of child psych. They're still often a mess, even the ones who did have great support and programs as kids, because in many places once they age out those resources evaporate. This is not just unique to CAP, but a fair amount of CAP patients fall into this umbrella. No thanks.

3. Kids are stupid. I say that in the most non-judgmental way possible. People in general can be stupid, but it's a natural state of children. They often can't communicate their needs or problems well or at all, and just figuring out what the CC is can be a lot of work. Several pediatricians and CAPs I've talked to joke around that they're basically veterinarians because their patients know something is wrong but can't tell you what. If you like that, awesome, but I like to talk to people who can at least tell me what's wrong at a very basic level. Obviously, this gets better as kids get older, but for kids under 12 yo or so it's frustrating.

4. Many problems are "behavioral" and may actually be somewhat normal developmental processes. A lot of kids are oppositional, defiant, or just exploring their identity and sometimes this is expressed in negative ways. That doesn't mean they need to be seeing us, but oftentimes parents, the schools, our "system" as a whole aren't flexible with this and demand we do something. Combine this with #3 and I don't particularly enjoy working with people who just want to be left alone to figure it out (with actual psychopathological depression or anxiety absent) while the system and parents are hounding you to "fix it".

4b. Socialization problems are common and have only been getting worse with COVID and increased reliance on technology. Is this a psych issue? Idk, I don't think it is as a whole and think it's more of a societal issue. Again, good luck fixing this one, imo it's only going to keep getting worse.

5. The foster system in general is awful and dealing with a large percentage of patients dependent on this system who have no choice but to be in it is depressing in itself.


Some of the above is true for Peds and CAP, some is true for gen psych as well. The thing that I hated about CAP was dealing with so many kids stuck in a system that probably does more harm than good for them and that those kids really don't have any choice about anything. I got tired of telling kids that I/we would do what we could to help knowing full well many of them were completely screwed. If I could see only child patients who come from caring and supportive families where I know there are actual resources available to help them succeed, then maybe I'd have continued down that path. I also don't really like outpatient much though, which is where that kind of practice would have actually been viable. So it became pretty obvious that it wasn't the path for me.

 

[PikminOC]

Cap is like dealing with three patients. The kid and the two parents

 

[Stagg737]

A much shorter answer, there are few main decision points we all make when figuring out what we want to do with the two biggest being:

1. Do you want to cut (surgery) or not?
2. Do you like to treat kids or not?

Maybe add in: Do you like talking to people/touching people or not? Asking why so many psychiatrists don't like CAP is like asking why so many physicians don't like surgery. For most it's just obvious after minimal exposure and is usually a pretty hard 'yes' or 'no' answer.

 

[MedMan80]

There's negatives and positives, CAP is better funded in many places and hence longer lengths of stay etc. The adult world, especially for SMI is much less coddling, ever had a patient age out of an adolescent unit and end up on an Adult unit? Not a fun place to be.

 

[docksan]

I've lost count of how many of my young adult patients were diagnosed with *everything* as kids and it's almost always due to parents wanting to overtreat and children not knowing a way to verbally communicate their symptoms so they act them out.

I can't do a specialty where I know what to do and have two people who might have their own demons to fight projecting them onto their child.

 

[clozareal]

I love CAP and do mostly CAP. I think it should be called child, adolescent, and parent psychiatry. I'm extremely intrigued by family systems and attachment theory.

There's a spectrum of difficulty with clinical work. Residency clinics tend to skew CAP patients that are trainwrecks and parents who also have a ton of issues themselves. This is less the case in insurance based and cash practices. The parents I work with in my private practice are for the most part highly motivated, great historians, and want guidance on how to help their kid. There's a lot of intergenerational transmission of trauma and maladaptive attachment patterns to undo in the parents though. It's a skill to learn and it does take practice. I believe if you can intervene appropriately with the parents early enough in the child's life, you can stop development of psychopathology from being passed downwards for many future generations.

I think that the notion that if a kid has behavioral symptoms, it's always and entirely the parent's fault is not true and perpetuates the stigma around children and their families who are dealing with psychopathology. I see motivated and good enough parents all the time with children who have symptoms. Of course if the parent has psychopathology themselves, the kid is at higher risk of having symptoms and also having a poorer prognosis. Are some parents exhausting and push boundaries? Of course! But so are adult patients. If this is the case, I make the parents see me (without the kid) frequently to address their concerns and provide a holding environment for them rather than their kids. I find that the parents with the most complaints typically don't want to put in the work and drop off my panel. More difficult = more time with me. More messages between appointments = more frequent appointments.

In adults with psychopathology, you still have to deal with with the parents but they are instead internalized objects and the maladaptive patterns have set in more firmly (i.e., more treatment resistant) if their symptomatology started in childhood.

Here are some things I like about child and adolescent psychiatry:

• ADHD has one of the most highly effective treatments in all of psychiatry. It's extremely satisfying to treat. In my experience, they're much more likely to respond to treatment than adults with ADHD are.
• Children respond much more readily to medications (and placebo) as well as psychotherapy. I can't tell you how easy it is to start the first SSRI and the kid remits completely from their anxiety/depression.
• Small interventions in parenting practices makes a huge difference in the child's symptoms. For example: Parent-Child Interaction Therapy has an extremely high effect size (d = 1.65) even if they drop out of treatment early (4 sessions).
• There's much less clinical history to gather in a 7 year old than a 55 year old who has had so much more life history to go through.
• With the clinical history, the parents often are good historians and have less distorted views about what is going on themselves. With the patient population I work with, they reliably bring the patient to the office/visit, follow-up on recommendations, and are great collaborators in working to improve their kid. I strongly encourage that collaboration and if they don't, then I make room for other parents who are.
• Much more objective findings from parents than subjective symptoms since kids often struggle to report symptoms. These are things that are much more readily measurable and identified and thus you can see the effects of intervention more clearly.
• I've saved marriages, improved the quality of life of the whole family, helped teachers, and made it easier for the kid to reach closer to their full potential with treatment that has large downstream effects.
• Kids are cute and funny.
• Less treatment resistance in this patient population. Adults come to me having tried many medications and they are much more hopeless about treatment than kids/parents are.
• I don't like addiction and personality disorders, which are less frequent in the pediatric population.
• You can take on a smaller caseload: one hour visits are common in CAP and so are 2-3 hour intakes. This is not the case with pediatrics where you have 15 minute well visit checks.
• You see children grow up and go through exciting life phases like prom, graduation, their first boyfriend/girlfriend, their first heartbreak, learning how to do things, picking a college.
• The short supply and high demand means that you are a hot commodity. I know very few CAP who take insurance. It's nice to feel needed and to have a niche. You can also charge more than with adults only.
• Some of these disorders have a large genetic component to it so there's already a referral source of treating siblings.
• It's made me a better parent.

Some things I don't like about CAP:

• Inpatient, emergency, intensive outpatient programs, partial hospitalization programs, residential treatment facilities, boarding schools, basically anything more acute. It's not in my personality to treat this. It's sadder for kids who get separated from parents which can relieve the symptoms acutely but they're going right back to that same environment. It doesn't help them develop a secure attachment when they also get separated and see how much better it is.
• Trauma, child abuse, severe bullying.
• Parent maltreatment and unwillingness to participate in care.
• Severe eating disorders. The ecosyntonic cognitive rigidity is so inflexible that it's tough for me to work against the patient.
• Custody issues, co-parenting difficulties, strong disagreements between the parents.
• Recurrent self-injurious behaviors and suicidal ideation in those who are really young.

In the end, it's about fit. You should talk to more CAPs and get more exposure to determine whether that's right for you.

 

[allantois]

I don't care that parents are paying for the appointment - I will not tell them what they want to hear. I will not start their kids on meds they don't need. You can imagine, I don't get along with parents very well. On a separate topic, there are psychologists out there who will write all sorts of nonsense reports for these parents for a few k.

 

[annoyedpsychiatrist]

because usually the issue isnt the kids, its the parents, and the parents are wanting you to fix their kid who has issues 2/2 to bad parenting skills. Plus sometimes I wonder for these kids being treated for ADHD, how often the parents take the kids meds.

 

[wolfvgang22]

I love CAP and do mostly CAP. I think it should be called child, adolescent, and parent psychiatry. I'm extremely intrigued by family systems and attachment theory.

There's a spectrum of difficulty with clinical work. Residency clinics tend to skew CAP patients that are trainwrecks and parents who also have a ton of issues themselves. This is less the case in insurance based and cash practices. The parents I work with in my private practice are for the most part highly motivated, great historians, and want guidance on how to help their kid. There's a lot of intergenerational transmission of trauma and maladaptive attachment patterns to undo in the parents though. It's a skill to learn but it does take practice. I believe if you can intervene appropriately with the parents early enough in the child's life, you can stop development of psychopathology from being passed downwards for many future generations.

I think that the notion that if a kid has behavioral symptoms, it's always and entirely the parent's fault is not true and perpetuates the stigma around children and their families who are dealing with psychopathology. I see motivated and good enough parents all the time with children who have symptoms. Of course if the parent has psychopathology themselves, the kid is at higher risk of having symptoms and also having a poorer prognosis. Are some parents exhausting and push boundaries? Of course! But so are adult patients. If this is the case, I make the parents see me (without the kid) frequently to address their concerns and provide a holding environment for them rather than their kids. I find that the parents with the most complaints typically don't want to put in the work and drop off my panel. More difficult = more time with me. More messages between appointments = more frequent appointments.

In adults with psychopathology, you still have to deal with with the parents but they are instead internalized objects and the maladaptive patterns have set in more firmly (i.e., more treatment resistant) if their symptomatology started in childhood.

Here are some things I like about child and adolescent psychiatry:

• ADHD has one of the most highly effective treatments in all of psychiatry. It's extremely satisfying to treat. In my experience, they're much more likely to respond to treatment than adults with ADHD are.
• Children respond much more readily to medications (and placebo) as well as psychotherapy. I can't tell you how easy it is to start the first SSRI and the kid remits completely from their anxiety/depression.
• Small interventions in parenting practices makes a huge difference in the child's symptoms. For example: Parent-Child Interaction Therapy has an extremely high effect size (d = 1.65) even if they drop out of treatment early (4 sessions).
• There's much less clinical history to gather in a 7 year old than a 55 year old who has had so much more life history to go through.
• With the clinical history, the parents often are good historians and have less distorted views about what is going on themselves. With the patient population I work with, they reliably bring the patient to the office/visit, follow-up on recommendations, and are great collaborators in working to improve their kid. I strongly encourage that collaboration and if they don't, then I make room for other parents who are.
• Much more objective findings from parents than subjective symptoms since kids often struggle to report symptoms. These are things that are much more readily measurable and identified and thus you can see the effects of intervention more clearly.
• I've saved marriages, improved the quality of life of the whole family, helped teachers, and made it easier for the kid to reach closer to their full potential with treatment that has large downstream effects.
• Kids are cute and funny.
• Less treatment resistance in this patient population. Adults come to me having tried many medications and they are much more hopeless about treatment than kids/parents are.
• I don't like addiction and personality disorders, which are less frequent in the pediatric population.
• You can take on a smaller caseload: one hour visits are common in CAP and so are 2-3 hour intakes. This is not the case with pediatrics where you have 15 minute well visit checks.
• You see children grow up and go through exciting life phases like prom, graduation, their first boyfriend/girlfriend, their first heartbreak, learning how to do things, picking a college.
• The short supply and high demand means that you are a hot commodity. I know very few CAP who take insurance. It's nice to feel needed and to have a niche. You can also charge more than with adults only.
• Some of these disorders have a large genetic component to it so there's already a referral source of treating siblings.
• It's made me a better parent.

Some things I don't like about CAP:

• Inpatient, emergency, intensive outpatient programs, partial hospitalization programs, residential treatment facilities, boarding schools, basically anything more acute. It's not in my personality to treat this. It's sadder for kids who get separated from parents which can relieve the symptoms acutely but they're going right back to that same environment. It doesn't help them develop a secure attachment when they also get separated and see how much better it is.
• Trauma, child abuse, severe bullying.
• Parent maltreatment and unwillingness to participate in care.
• Severe eating disorders. The ecosyntonic cognitive rigidity is so inflexible that it's tough for me to work against the patient.
• Custody issues, co-parenting difficulties, strong disagreements between the parents.
• Recurrent self-injurious behaviors and suicidal ideation in those who are really young.

In the end, it's about fit. You should talk to more CAPs and get more exposure to determine whether that's right for you.

Fantastic post, I wish I had the clarity of thought to put it so eloquently.

 

[Merovinge]

I love CAP and do mostly CAP. I think it should be called child, adolescent, and parent psychiatry. I'm extremely intrigued by family systems and attachment theory.

There's a spectrum of difficulty with clinical work. Residency clinics tend to skew CAP patients that are trainwrecks and parents who also have a ton of issues themselves. This is less the case in insurance based and cash practices. The parents I work with in my private practice are for the most part highly motivated, great historians, and want guidance on how to help their kid. There's a lot of intergenerational transmission of trauma and maladaptive attachment patterns to undo in the parents though. It's a skill to learn but it does take practice. I believe if you can intervene appropriately with the parents early enough in the child's life, you can stop development of psychopathology from being passed downwards for many future generations.

I think that the notion that if a kid has behavioral symptoms, it's always and entirely the parent's fault is not true and perpetuates the stigma around children and their families who are dealing with psychopathology. I see motivated and good enough parents all the time with children who have symptoms. Of course if the parent has psychopathology themselves, the kid is at higher risk of having symptoms and also having a poorer prognosis. Are some parents exhausting and push boundaries? Of course! But so are adult patients. If this is the case, I make the parents see me (without the kid) frequently to address their concerns and provide a holding environment for them rather than their kids. I find that the parents with the most complaints typically don't want to put in the work and drop off my panel. More difficult = more time with me. More messages between appointments = more frequent appointments.

In adults with psychopathology, you still have to deal with with the parents but they are instead internalized objects and the maladaptive patterns have set in more firmly (i.e., more treatment resistant) if their symptomatology started in childhood.

Here are some things I like about child and adolescent psychiatry:

• ADHD has one of the most highly effective treatments in all of psychiatry. It's extremely satisfying to treat. In my experience, they're much more likely to respond to treatment than adults with ADHD are.
• Children respond much more readily to medications (and placebo) as well as psychotherapy. I can't tell you how easy it is to start the first SSRI and the kid remits completely from their anxiety/depression.
• Small interventions in parenting practices makes a huge difference in the child's symptoms. For example: Parent-Child Interaction Therapy has an extremely high effect size (d = 1.65) even if they drop out of treatment early (4 sessions).
• There's much less clinical history to gather in a 7 year old than a 55 year old who has had so much more life history to go through.
• With the clinical history, the parents often are good historians and have less distorted views about what is going on themselves. With the patient population I work with, they reliably bring the patient to the office/visit, follow-up on recommendations, and are great collaborators in working to improve their kid. I strongly encourage that collaboration and if they don't, then I make room for other parents who are.
• Much more objective findings from parents than subjective symptoms since kids often struggle to report symptoms. These are things that are much more readily measurable and identified and thus you can see the effects of intervention more clearly.
• I've saved marriages, improved the quality of life of the whole family, helped teachers, and made it easier for the kid to reach closer to their full potential with treatment that has large downstream effects.
• Kids are cute and funny.
• Less treatment resistance in this patient population. Adults come to me having tried many medications and they are much more hopeless about treatment than kids/parents are.
• I don't like addiction and personality disorders, which are less frequent in the pediatric population.
• You can take on a smaller caseload: one hour visits are common in CAP and so are 2-3 hour intakes. This is not the case with pediatrics where you have 15 minute well visit checks.
• You see children grow up and go through exciting life phases like prom, graduation, their first boyfriend/girlfriend, their first heartbreak, learning how to do things, picking a college.
• The short supply and high demand means that you are a hot commodity. I know very few CAP who take insurance. It's nice to feel needed and to have a niche. You can also charge more than with adults only.
• Some of these disorders have a large genetic component to it so there's already a referral source of treating siblings.
• It's made me a better parent.

Some things I don't like about CAP:

• Inpatient, emergency, intensive outpatient programs, partial hospitalization programs, residential treatment facilities, boarding schools, basically anything more acute. It's not in my personality to treat this. It's sadder for kids who get separated from parents which can relieve the symptoms acutely but they're going right back to that same environment. It doesn't help them develop a secure attachment when they also get separated and see how much better it is.
• Trauma, child abuse, severe bullying.
• Parent maltreatment and unwillingness to participate in care.
• Severe eating disorders. The ecosyntonic cognitive rigidity is so inflexible that it's tough for me to work against the patient.
• Custody issues, co-parenting difficulties, strong disagreements between the parents.
• Recurrent self-injurious behaviors and suicidal ideation in those who are really young.

In the end, it's about fit. You should talk to more CAPs and get more exposure to determine whether that's right for you.

Great post and agree with almost all of the things you like.

I actually like dealing with trauma/severe bullying as being able to just provide basic support for a child who does not have it is such a wonderful way to spend part of one's day. Similarly, budding PD issues are an opportunity to help someone find a different path rather than neurons that are already set in their personality disordered way.

I will say that parental maltreatment/custody issues are the absolute worse, I do everything I can to stay away from that as well.

 

[Cavafy]

I'm a PGY-3 and struggling with whether or not to enter the Match for CAP fellowship. I enjoy working with children and adults equally. I find working with adults more intellectually interesting, working with kids is more emotionally fulfilling to me. I'm not going to get granular. To me the Pros/Cons and other factors are as follows:

Pro:
-CAP can make a bigger difference in the world than adult psychiatry; this is huge for me

Cons:
-Patient work-flow is more tedious and time-consuming (what with getting collateral, CPS reporting, documenting ADHD, etc.)
-Coordinating care with other providers, like therapists, is more important in CAP than in adult
-Starting a fellowship as a "newbie" and spending an extra year in training is not appealing
-Containing work within tight, high-walled boundaries is essential to me

Other Factors:
-I don't believe that CAP pays more; in fact, I'm convinced that I can make at least as much in adult because the real money is in outpatient follow-ups, and these are faster in adults than in children when done properly
-Even if one can find a truly better paying CAP job, it really takes about 15 years to make up a modest improvement in pay for CAP vs. adult, given the 1 year delay in obtaining attending pay (must factor in the time value of money to calculate this correctly)
-I've seen no difference in pay for inpatient CAP vs. inpatient adult for graduates from my program(s)--CAP jobs actually paid a little less
-Locums has hidden costs that people have to understand: there is huge value in a 401k with matching contributions when invested intelligently that Locums cannot match; 401k and backdoor Roth IRA are the true potential wealth creation vehicles for most physicians, and physicians just don't know how to use them smartly.

So for me, it's a feeling that CAP is more important work, but it's a harder and more time-consuming job that requires a 25% increase in time spend in training, doing difficult work, while 4th year of residency is pretty much a cakewalk in my program.

I would love to hear how others weigh in on these factors. I'm interested in frontal lobe reasoning, not the "I just love kids" responses, haha. I love kids, too, but I'm thinking about the JOB, not the "interest in subject matter" perspective--I already said they are equal for me. Any responses would be greatly appreciated!

 

[whopper]

My problem is I like talking to adults better, but also where I did my general psych training the CAP rotation attending wasn't very good. It turned me off. Had I had better instruction I would've likely been more open to considering it.

 

[Merovinge]

I'm a PGY-3 and struggling with whether or not to enter the Match for CAP fellowship. I enjoy working with children and adults equally. I find working with adults more intellectually interesting, working with kids is more emotionally fulfilling to me. I'm not going to get granular. To me the Pros/Cons and other factors are as follows:

Pro:
-CAP can make a bigger difference in the world than adult psychiatry; this is huge for me

Cons:
-Patient work-flow is more tedious and time-consuming (what with getting collateral, CPS reporting, documenting ADHD, etc.)
-Coordinating care with other providers, like therapists, is more important in CAP than in adult
-Starting a fellowship as a "newbie" and spending an extra year in training is not appealing
-Containing work within tight, high-walled boundaries is essential to me

Other Factors:
-I don't believe that CAP pays more; in fact, I'm convinced that I can make at least as much in adult because the real money is in outpatient follow-ups, and these are faster in adults than in children when done properly
-Even if one can find a truly better paying CAP job, it really takes about 15 years to make up a modest improvement in pay for CAP vs. adult, given the 1 year delay in obtaining attending pay (must factor in the time value of money to calculate this correctly)
-I've seen no difference in pay for inpatient CAP vs. inpatient adult for graduates from my program(s)--CAP jobs actually paid a little less
-Locums has hidden costs that people have to understand: there is huge value in a 401k with matching contributions when invested intelligently that Locums cannot match; 401k and backdoor Roth IRA are the true potential wealth creation vehicles for most physicians, and physicians just don't know how to use them smartly.

So for me, it's a feeling that CAP is more important work, but it's a harder and more time-consuming job that requires a 25% increase in time spend in training, doing difficult work, while 4th year of residency is pretty much a cakewalk in my program.

I would love to hear how others weigh in on these factors. I'm interested in frontal lobe reasoning, not the "I just love kids" responses, haha. I love kids, too, but I'm thinking about the JOB, not the "interest in subject matter" perspective--I already said they are equal for me. Any responses would be greatly appreciated!

I'm not sure you are thinking about the bolded part correctly. Yes I get around 12k match/year BUT I can only put the 22.5k in myself, making the max of that account at 34.5k. 1099 folks can do a self-employed 401k with employee/employer contribution and get almost double the money tax deferred. Backdoor roth is obviously independent of employed vs 1099.

The only financial reason to do CAP is for cash pay practice. I know around 10 cash pay CAP in my region and they both fill easier/more consistently and charge more the adult cash pay folks. I'm sure folks like Splik are an outlier, but if you want to do cash pay outpatient AND you enjoy child/adolescent, it's a no-brainer financially. I love my PHP/IOP work presently but my colleague who is a year behind me in training makes more working 20-25 hours a week then I make working 35 hours/week.

 

[comp1]

Technically an employer can contribute to a 401k all the way up to the same as someone who is self-employed. It's just not very often that they do, unfortunately.

 

[clozareal]

I'm a PGY-3 and struggling with whether or not to enter the Match for CAP fellowship. I enjoy working with children and adults equally. I find working with adults more intellectually interesting, working with kids is more emotionally fulfilling to me. I'm not going to get granular.

You can always do a mix of adult and child. You can find the right fit for you. Some of my CAP colleagues do 1 day a week of CAP, some don't see anyone younger than 12, it can be all up to you if you find or create the right job for you. In terms of therapy, I enjoy adult > parents > teens > children > couples > family.

To me the Pros/Cons and other factors are as follows:

Pro:
-CAP can make a bigger difference in the world than adult psychiatry; this is huge for me

Cons:
-Patient work-flow is more tedious and time-consuming (what with getting collateral, CPS reporting, documenting ADHD, etc.)

I don't do much CPS reporting these days. I've written one in the past year. How is documenting ADHD different than documenting any other DSM criterion disorder? I get collateral from therapists for my adult patients just as much as I do with kids unless I'm doing both which I prefer. You're right in that you do have to have more structure (half the appointment with the kid, half with the parent for example).

-Coordinating care with other providers, like therapists, is more important in CAP than in adult

Why?

-Starting a fellowship as a "newbie" and spending an extra year in training is not appealing

You're not completely a newbie though. You have a working understanding of psychiatric nosology and psychopharmacology and can apply that to a different age group with a few minor changes. But you're right for the most part. It's a fellowship because you do learn some new skillsets like working with parents, family systems, communication skills in how to interview children and parents, how to utilize play as part of the diagnostic interview or therapeutic modality, learning how to observe more clinical signs rather than subjective history, understanding of school systems, learning developmental stages and what is normal and isn't at certain age groups, and legal considerations.

-Containing work within tight, high-walled boundaries is essential to me

This will be the case with any clinical practice.

Other Factors:
-I don't believe that CAP pays more; in fact, I'm convinced that I can make at least as much in adult because the real money is in outpatient follow-ups, and these are faster in adults than in children when done properly

In my area, CMHC pays 10% more and cash outpatient pays 50% more. If you want to do 10-15 med mgmt evals and see as many patients as possible with an insurance based practice, that can make more than CAP but you'll have to think about your own sanity. Doing 4-6 visits per hour is exhausting albeit completely possible.

-Even if one can find a truly better paying CAP job, it really takes about 15 years to make up a modest improvement in pay for CAP vs. adult, given the 1 year delay in obtaining attending pay (must factor in the time value of money to calculate this correctly)

If a fellow salary is between $50-75k and a first year attending salary is $250-300k, that means it's a difference of $175-250k for fast trackers. If you get paid 10% more, then it'll take you 7-10 years to make up the difference, not 15 years. Even less if you get paid more. The variation within adult psychiatry is also huge (I've seen anywhere from $150k-400k).

-I've seen no difference in pay for inpatient CAP vs. inpatient adult for graduates from my program(s)--CAP jobs actually paid a little less

I haven't seen that much of a difference either for inpatient. Good thing I'm not doing inpatient work.

So for me, it's a feeling that CAP is more important work, but it's a harder and more time-consuming job that requires a 25% increase in time spend in training, doing difficult work, while 4th year of residency is pretty much a cakewalk in my program.

The best way to make money in CAP is to do outpatient private practice since there are very few providers, many parents will pay whatever $$$ to get the best opportunities for their kids whereas they won't pay that much for their own care, and you can screen heavily for the most motivated patients who fit your practice style best. In my area, an insurance-based practice for CAP is not the standard of care. Cash is.

Yes, it's more training. That's why people don't want to do it.

For appointments, I don't think it has to be more work. It can be especially at the beginning when you’re getting to know the family. However, it’s more the case that it's a different type of work. You’ll have to work with multiple people (parents and kids) so there’s more dynamics to manage though. It can be more time but for me, I bill for work with kids and then work with parents if it’s a separate appointment. I’d rather spend more time working with one family system than seeing the equivalent of 2-3 different patients.

I'm not trying to convince you that CAP is better. It's not for many people. What I want to do is counter the anti-parent stigma in this forum and in psychiatry in general. You would think from this forum that all parents hate their kids, want to damage them as much as possible, and hate doctors who are trying to poison their kids with drugs. Most parents are trying to do the best they can to raise their kids and they get sensitive when they feel like they've failed when their kid needs to see a psychiatrist. I find meaning in helping parents process and work through that guilt and try to equip them with more tools to help their child feel better.

I also want to give a perspective of why I enjoy my job as a CAP since it seems like a rarity that people enjoy their work these days.

 

[G Sheb]

I liked working with kids.
The administrative burden though was just too much to bear.

 

[drechie]

You can always do a mix of adult and child. You can find the right fit for you. Some of my CAP colleagues do 1 day a week of CAP, some don't see anyone younger than 12, it can be all up to you if you find or create the right job for you. In terms of therapy, I enjoy adult > parents > teens > children > couples > family.

I don't do much CPS reporting these days. I've written one in the past year. How is documenting ADHD different than documenting any other DSM criterion disorder? I get collateral from therapists for my adult patients just as much as I do with kids unless I'm doing both which I prefer. You're right in that you do have to have more structure (half the appointment with the kid, half with the parent for example).

Why?


You're not completely a newbie though. You have a working understanding of psychiatric nosology and psychopharmacology and can apply that to a different age group with a few minor changes. But you're right for the most part. It's a fellowship because you do learn some new skillsets like working with parents, family systems, communication skills in how to interview children and parents, how to utilize play as part of the diagnostic interview or therapeutic modality, learning how to observe more clinical signs rather than subjective history, understanding of school systems, learning developmental stages and what is normal and isn't at certain age groups, and legal considerations.


This will be the case with any clinical practice.

In my area, CMHC pays 10% more and cash outpatient pays 50% more. If you want to do 10-15 med mgmt evals and see as many patients as possible with an insurance based practice, that can make more than CAP but you'll have to think about your own sanity. Doing 4-6 visits per hour is exhausting albeit completely possible.


If a fellow salary is between $50-75k and a first year attending salary is $250-300k, that means it's a difference of $175-250k for fast trackers. If you get paid 10% more, then it'll take you 7-10 years to make up the difference, not 15 years. Even less if you get paid more. The variation within adult psychiatry is also huge (I've seen anywhere from $150k-400k).


I haven't seen that much of a difference either for inpatient. Good thing I'm not doing inpatient work.


The best way to make money in CAP is to do outpatient private practice since there are very few providers, many parents will pay whatever $$$ to get the best opportunities for their kids whereas they won't pay that much for their own care, and you can screen heavily for the most motivated patients who fit your practice style best. In my area, an insurance-based practice for CAP is not the standard of care. Cash is.

Yes, it's more training. That's why people don't want to do it.

For appointments, I don't think it has to be more work. It can be especially at the beginning when you’re getting to know the family. However, it’s more the case that it's a different type of work. You’ll have to work with multiple people (parents and kids) so there’s more dynamics to manage though. It can be more time but for me, I bill for work with kids and then work with parents if it’s a separate appointment. I’d rather spend more time working with one family system than seeing the equivalent of 2-3 different patients.

I'm not trying to convince you that CAP is better. It's not for many people. What I want to do is counter the anti-parent stigma in this forum and in psychiatry in general. You would think from this forum that all parents hate their kids, want to damage them as much as possible, and hate doctors who are trying to poison their kids with drugs. Most parents are trying to do the best they can to raise their kids and they get sensitive when they feel like they've failed when their kid needs to see a psychiatrist. I find meaning in the process of helping parents process and work through that guilt and try to equip them with more tools to help their child feel better.

I also want to give a perspective of why I enjoy my job as a CAP since it seems like a rarity that people enjoy their work these days.

Can I PM you?

 

[clozareal]

Can I PM you?

Sure

 

[samac]

Triple board sounds like it could be a fit for you

 

[dl2dp2]

CAP >>>>>>>> Peds. Trust me you won’t regret it lol.

This 1000%

I know CAP who clear 1M a year on clinical work only. No such experience with peds. Yes, in a rare sitch peds can make that much by running a very large operation, but overwhelmingly they are overworked and underpaid vs. CAP.

 

[TexasPhysician]

Triple board sounds like it could be a fit for you

I’m one of many that believe triple board is a waste of time. I’ve met many that did it, and all of them gave up doing gen peds. Child psych pays much more, higher demand, and less call on average. Outside of rare instances, practices don’t want you doing both. You are worth more doing child psych or they are peds focused.

 

[milesed]

I went into med school planning on Peds, then hated the rotation. The attendings, residents and nurses all seemed unhappy and I did not like seeing many of our patients dying on the hem-onc service and the horrible staff we had to deal with on NICU. I did like the outpatient peds clinic.

I loved adult psyc and my med school had no CAP fellowship so went to another med school for an "away rotation" for 4 weeks in my 4th year. I came back and also did 4 weeks of developmental peds to be certain of my choice to go into CAP. I loved the CAP patients, staff and most families I encountered.

I love my job. I get to know the kids very well, follow them as they grow up into the adults they were meant to be (mostly). I've been at it for 22 years now and am seeing kids of former patients now. A lot of what others have said is true. They families can be very hard to deal with, there are always multiple versions of the "problem" and it's sometimes not the identified patient. I work in a CMHC so see the most difficult patients, but like having so much room for improvement. If I had wanted easy, I would've done Dermatology.

 

[Merovinge]

I’m one of many that believe triple board is a waste of time. I’ve met many that did it, and all of them gave up doing gen peds. Child psych pays much more, higher demand, and less call on average. Outside of rare instances, practices don’t want you doing both. You are worth more doing child psych or they are peds focused.

Many of the triple boarders I met are bad@ss academic attendings who are very committed to kids and their health. I loved working with them. That said, they all did just practice CAP, so it depends if you want to put yourself through a bunch of extra hoops just for that extra education. If you wake up with a lust for everything pediatric medicine wise and don't mind working 80 hour weeks in residency because it might make you a better doctor for 1 kid who's life you might save, then by all means go for it and keep on being a bad@ss.

 

[TexasPhysician]

Many of the triple boarders I met are bad@ss academic attendings who are very committed to kids and their health. I loved working with them. That said, they all did just practice CAP, so it depends if you want to put yourself through a bunch of extra hoops just for that extra education. If you wake up with a lust for everything pediatric medicine wise and don't mind working 80 hour weeks in residency because it might make you a better doctor for 1 kid who's life you might save, then by all means go for it and keep on being a bad@ss.

Training more triple boarders is the primary job market.

Being CAP and doing all of my primary care months in peds, you can certainly make the argument that triple boards would better prepare you for peds psych C&L life. Most won’t go into CAP C&L though.

Triple board comes at the expense of adult psych knowledge. You could argue that this could negatively affect your skills in late adolescent/young adult psych population.

Cramming a 3 year residency into 5 years of psych training will negatively affect your psych knowledge and maybe your mental health. Unless you are dead set on this path, don’t do it. More regret it than recommend it.

 

[Merovinge]

Training more triple boarders is the primary job market.

Being CAP and doing all of my primary care months in peds, you can certainly make the argument that triple boards would better prepare you for peds psych C&L life. Most won’t go into CAP C&L though.

Triple board comes at the expense of adult psych knowledge. You could argue that this could negatively affect your skills in late adolescent/young adult psych population.

Cramming a 3 year residency into 5 years of psych training will negatively affect your psych knowledge and maybe your mental health. Unless you are dead set on this path, don’t do it. More regret it than recommend it.

Yes one I knew did Peds C/L. Another did some outpatient peds embedded clinic and helped with gen peds phone a CAP line. One did exclusively OP CAP but was very will regarded for their knowledge base. Generally speaking if you want to be in academics there is a lot of street cred for being a triple boarder interacting with other areas of peds.

None of the attendings I met felt deficient in their psych knowledge. None regretted their training. None trained triple boarders.

I absolutely don't think it's for everyone (it's certainly not for me) but I would not dissuade anyone who was passionate about this option.

 

[TexasPhysician]

Yes one I knew did Peds C/L. Another did some outpatient peds embedded clinic and helped with gen peds phone a CAP line. One did exclusively OP CAP but was very will regarded for their knowledge base. Generally speaking if you want to be in academics there is a lot of street cred for being a triple boarder interacting with other areas of peds.

None of the attendings I met felt deficient in their psych knowledge. None regretted their training. None trained triple boarders.

I absolutely don't think it's for everyone (it's certainly not for me) but I would not dissuade anyone who was passionate about this option.

Beware that even in academics it can be seen as a negative to those that do it. Some academic centers require all peds faculty and those with peds boards regardless of department to take peds call on the floor. I’ve seen triple board folk purposefully drop their peds board cert and stop doing peds work to avoid that call.

 

[clozareal]

I considered triple boarding during medical school but decided against it because I wanted more psychiatry than medicine. There's only 14 programs in the country and seemed harder to match into than just general psychiatry residency. I'm glad I didn't do it because I got into a residency program that was the best fit for me.

The reason why I wanted to do it was to treat medically complex patients. In actuality, I'm doing that now and enjoy it. Perhaps I may be more comfortable with more medical conditions but I felt as though I got enough elective time and education during my intern medicine/neuro rotations to feel comfortable with it. I collaborate heavily with PCPs and other specialists as a way around this.

I do treat side effects of the medications that I use, such as treating hypertension if I cause it with stimulants, using cholesterol-lowering medications or antidiabetics for metabolic side effects, using thyroid supplementation for lithium-induced hypothyroidism, basic antiacne medication for lithium-induced acne, bowel regimens for anticholinergic agents, mild topical steroids for drug rashes, etc but basically things that an NP can do in a medical urgent care. I've been getting more education on obesity medicine and I'm starting to use GLP-1 agonists more often. I probably order more lab tests than most psychiatrists, such as getting testosterone levels, AM cortisol, MRI scans, ferritin levels, sleep apnea testing, etc if it's indicated on review of systems/exam whereas my colleagues will just say "go to your PCP" which patients invariably don't do or the PCP doesn't want to do these tests.

If I had a pediatrics board would I feel more comfortable using more? Perhaps but I do think I'm doing enough to feel satisfied that my comprehensive medical education didn't go to waste for the most part. I feel like people tend to get good at one and all right with the other two areas. Even now my geriatric psychiatry knowledge feels dwindling as I'm seeing mostly CAP.

 

[calvinhobbes]

Beware that even in academics it can be seen as a negative to those that do it. Some academic centers require all peds faculty and those with peds boards regardless of department to take peds call on the floor. I’ve seen triple board folk purposefully drop their peds board cert and stop doing peds work to avoid that call.

That’s crazy haha. No wonder triple boarders do CAP primarily.

 

[calvinhobbes]

OP, there is also the Post Pediatric Portal Program pathway if you’re interested later on, where you do 3 years of general pediatric residency, and then 3 years of combined general psych/CAP residency/fellowship and become board eligible in psychiatry. I knew people who went this route and some practice primarily adult psych, or CAP, or both, very little end up doing pure peds though. Something to think about! I’m in Texas currently and work with some of these grads, they’re great.

Child and Adolescent Psychiatry Training

www.aacap.org

Post Pediatric Portal Programs

www.aacap.org

 

[calvnandhobbs68]

Training more triple boarders is the primary job market.

Being CAP and doing all of my primary care months in peds, you can certainly make the argument that triple boards would better prepare you for peds psych C&L life. Most won’t go into CAP C&L though.

Triple board comes at the expense of adult psych knowledge. You could argue that this could negatively affect your skills in late adolescent/young adult psych population.

Cramming a 3 year residency into 5 years of psych training will negatively affect your psych knowledge and maybe your mental health. Unless you are dead set on this path, don’t do it. More regret it than recommend it.

So this isn’t totally unique, peds neuro does essentially the exact same pathway (which is really the only mainstream pathway to do peds neuro). It is rough, you’re basically just doing the required rotations for pediatrics, so you don’t get any electives or anything. Same thing about ultimate career outcome, they typically just end up doing child neurology. I'm not sure I would describe doing a triple board program or PPP program as "negatively impacting psych knowledge" though, it's just not the most efficient way to get there.

 

[calvinhobbes]

So this isn’t totally unique, peds neuro does essentially the exact same pathway (which is really the only mainstream pathway to do peds neuro). It is rough, you’re basically just doing the required rotations for pediatrics, so you don’t get any electives or anything. Same thing about ultimate career outcome, they typically just end up doing child neurology. I'm not sure I would describe doing a triple board program or PPP program as "negatively impacting psych knowledge" though, it's just not the most efficient way to get there.

Not to mention peds neuro does a *lot* of adult neuro and depending on the program, they are basically a neuro resident and take the same calls, do stroke service, etc lol.

 

[allantois]

Can I just add that ADHD is an absolute nightmare to treat these days

 

[rjs2131]

Can I just add that ADHD is an absolute nightmare to treat these days

Is it though? I’m CAP in PP and yes, the shortage is annoying but (and maybe this is just the area I’m in + luck) ADHD is absolutely one of the most satisfying things to treat. I’ve had several where it has been life-changing to find the right treatment. I also enjoy all of the associated therapy to help patients with better habits and organization/productivity. Nowhere near being a nightmare from my perspective!

 

[MedMan80]

Is it though? I’m CAP in PP and yes, the shortage is annoying but (and maybe this is just the area I’m in + luck) ADHD is absolutely one of the most satisfying things to treat. I’ve had several where it has been life-changing to find the right treatment. I also enjoy all of the associated therapy to help patients with better habits and organization/productivity. Nowhere near being a nightmare from my perspective!

Concerta is candy mon'

 

[Mad Jack]

Now that I'm no longer in CAP and am working with very sick adults, I've got to say- it is 100% the family dynamics. Most kids don't end up with mental illness for no reason, and when the dysfunction is coming from inside the house, as it were... Well let's just say it can become quite stressful to provide meaningful care when you can't change the environment. Yet parents expect you to "fix" their child while often making no changes themselves, and then blaming you if progress doesn't occur.

 

[clozareal]

Is it though? I’m CAP in PP and yes, the shortage is annoying but (and maybe this is just the area I’m in + luck) ADHD is absolutely one of the most satisfying things to treat. I’ve had several where it has been life-changing to find the right treatment. I also enjoy all of the associated therapy to help patients with better habits and organization/productivity. Nowhere near being a nightmare from my perspective!

It's so much easier and satisfying to treat it as CAP compared to adults who come in their 40s for an ADHD evaluation with questionable developmental history prior to age 12 ("I was never a good student" says almost everyone).