Adolescent (not child) Psychiatry

[YES123]

Hi,
I am considering studying to become a psychiatrist and had a question regarding working with adolescents. I know that many folks go through CAP training and become a CAP psychiatrist, but I have also read that if one only wants to work with adults and adolescents one does not need to go through this extended training (although at times the added training may be helpful). Is this true? Also, if it is true and a regular Psychiatrist is permitted to work with adolescents what age must a patient be to be considered an adolescent and not a child. I know these are pretty specific questions but I would be most happy if someone could answer them for me.
Thanks!

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[Fastball32]

Hi,
If you were wanting to work exclusively with Adolescents, my recommendation is to go ahead and do the Child Fellowship and then work at a Private Practice to tailor specifically towards Adolescents, or find an inpatient unit with just Adolescents.
Although it's true you do not need a Child Fellowship to work with Children or Adolescents (which is common in underserved areas), the extra training in developmental psychiatry and family therapy I feel would be important.
If you were to look for jobs in a major city, most places with Children and Adolescent patients will require a psychiatrist trained in Child.
I too had a similar desire to work exclusively with Adolescents and young adults when i was a General Resident, but now that I am in a Child Fellowship, I believe that I am much more competent with treating Adolescents. Another thing to consider is that a lot of med checks in an Adolescent clinic have to deal with ADHD, which is bread and butter for a Child trained psychiatrist.
Diagnosing children and adolescent is often difficult because the classical presentations of most disorders occur in early adulthood.

 

[whopper]

You don't have to do child psychiatry to practice on children. That said, if you did, you'd be opening yourself up to liability and the odds would be dramatically higher that you'd be doing shoddy practice and not even know it because you might not know enough to know you weren't good. All things being equal I wouldn't trust a psychiatrist that didn't have chlid-training to treat a child unless that person just had several years experience doing in and spent a heck of a lot of CME time learning about it.

But there are places where only someone with general psychiatry training is THE ONLY ONE around and this doc may be forced to do his/her best for children in need of a psychiatrist and that would be better than none at all.

Adolescents are kind of an in-between. I do not have child psychiatry training via fellowship (only what I saw in residency) though I do see a few adolescent patients on the older end of the spectrum (e.g. age 16+). I only do so because for a large radius where the practice is, there are no child psychiatrists, and if I don't think I can handle it, I openly tell this to the parents and patient. I also encourage the patient and parents to look for a child psychiatrist and I'll provide treatment in the meantime because that is better than nothing and give a full disclaimer that I am not a child psychiatrist, nor expect my treatment to be on par with one.

There are some child psychiatrists that are about 40 minutes away from that practice, but they have waiting lists at 6+ months. Most of the adolescent patients I see, I have their parents get on the waiting list and I treat the adolescent during the wait.

And a point of clarification, while I am faculty and an attending in a university program, I'm talking about a practice I've been doing on the side in a different town, though I will likely have to leave that practice in a few months as part of my contract with the University.

 

[billypilgrim37]

And expect to be mocked, derided, and shunned by your colleagues who actually took the time to get properly trained to treat the population that you are not properly trained to treat. As whopper said, if you're the only game in town (or for a few towns over), that's one thing, but if there are legitimately folks around with training, don't be surprised if they spread the word that you don't know what you're doing, whether it's true or not.

There are of course exceptions. An addiction psychiatrist may be better off treating a 15 year old heroin addict than the average child psychiatrist, but maybe not.

 

[notdeadyet]

And expect to be mocked, derided, and shunned by your colleagues who actually took the time to get properly trained to treat the population that you are not properly trained to treat.

Aside from the ethics of treating a population you don't have the training to treat, I'd also be concerned about the legalities.

I know psychiatrists don't often get sued, but I personally wouldn't want to be on the stand justifying how I treated primarily youth but did not get fellowship trained in Child and Adolescents and my training was limited to Adult Psychiatry.

 

[YES123]

Hi,
OK, thanks for the responses. It seems that this is not something very much recommended. What, however, would you folks say if I only treated older adolescents (Whopper, I already know that you would discourage that, but how about other folks here)? I mean would I need to go through all the extra training just to treat somebody 16-17 years old? Also, when does someone become an adult for these matters? Is an 18 year old considered an adult?
Thanks!

 

[notdeadyet]

I mean would I need to go through all the extra training just to treat somebody 16-17 years old?

You get very little exposure to people 16-17 years old in an Adult Psychiatry residency.

Personally, if I knew that my practice was going to be primarily 18-19 year olds, I'd consider a CAP fellowship, as these teens have as much or more in common with kids as they do with adults.

 

[Fastball32]

One of my General Psychiatry classmates just started working in a rural town, about 40 minutes from a major city. Although he works in primarily an adult clinic, he is seeing quite a bit of Adolescents due to the shortage of Child Psychiatrists, particularly 16 and older. He often calls me about questions with treating teenagers, and most of his questions are related to medicine.
Most people who have completed a Child training will tell you that medicine is secondary, that diagnostic concerns such as family interactions, stressors, environment, etc are more important to properly assess the situation and then slowly introduce medicine if it is appropriate. I'll be the first to admit that medicine was most often the treatment of choice for treating adults when I was a General Resident, but my view is much different now for treating children and teenagers.
The general rule of thumb is that if the patient is still in high school, then the Child Psychiatrist should probably see them.
That being said, if you really enjoy older teenagers and young adults, then you will probably be a good psychiatrist for them. A lot of mild psychiatric symptomatology is treated by pediatricians and family physicians, so I would assume that an Adult Psychiatrist would still be better than primary care for psych issues.

 

[OldPsychDoc]

My group just asked me what ages I wanted to treat when I started. I'd done a pretty strong OP year in CAP, as well as a college health service stint as an elective, so I agreed to see 16 & 17 year olds as well as adults. I felt reasonably confident in that, and knew if push came to shove I could easily refer. It's only been 2-3% of my patients at most--mostly ADD, GAD, mild depression--and lots of adjustment crap in dysfunctional families to affirm my decision to stay out of CAP for the most part.

 

[billypilgrim37]

There are plenty of 16 and 17 year olds who are more similar to 25 year olds, and there are plenty of 16 and 17 year olds who are more similar to 13 year olds. So I think it's a bit of a generalization to talk about all of the older adolescents, as the earlier group will certainly do fine with an adult psychiatrist. Probably more important is making sure you're working with a therapist who is qualified to work with the younger folks and help you manage family issues.

 

[YES123]

Alright, thanks for answering my questions!