Outside Perception of Child Psychiatry

[JourneyAgent]

I was hoping to get a better sense of other medical field's and societal views of child psychiatry as a field.

I was in grand rounds on a pediatric rotation hearing a child psychiatrist give a talk, which was really good, and did not expect that the pediatricians were ready to ambush her with accusatory tone about the lack of scientific evidence for diagnostic criteria to indicate antipsychotics and amphetamines in controlling refractory psychotic disorders and ADHD.

I mean I understand skepticism about the diagnostic criteria we use. And I would hope everyone is hesitant to use these drugs in children....but I'm having a hard time understanding the level of emotionality and accusation leveled at the child psychiatrist as if nutrition and counseling were viable in children who had horrible functionality after exhausting other avenues of treatment.

I'm interested in the field because I've always loved peds.

What's it like to negotiate hostility from so many angles?

And for child psychiatrists...how do you feel about the known and unknown side effects of using these drugs in children?

Thanks for any input.

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[vistaril]

I was hoping to get a better sense of other medical field's and societal views of child psychiatry as a field.

I was in grand rounds on a pediatric rotation hearing a child psychiatrist give a talk, which was really good, and did not expect that the pediatricians were ready to ambush her with accusatory tone about the lack of scientific evidence for diagnostic criteria to indicate antipsychotics and amphetamines in controlling refractory psychotic disorders and ADHD.

I mean I understand skepticism about the diagnostic criteria we use. And I would hope everyone is hesitant to use these drugs in children....but I'm having a hard time understanding the level of emotionality and accusation leveled at the child psychiatrist as if nutrition and counseling were viable in children who had horrible functionality after exhausting other avenues of treatment.

I'm interested in the field because I've always loved peds.

What's it like to negotiate hostility from so many angles?

And for child psychiatrists...how do you feel about the known and unknown side effects of using these drugs in children?

Thanks for any input.

the outside perception of child psychiatry is similar to psychiatry as a whole(ie poor)......on the one hand people tend to respect people who work with children more in some cases. otoh, child psych is probably even less 'medical' in some ways than adult psych and the 'pediatric bipolar' stuff hasn't helped the rep within medicine for sure.

 

[wolfvgang22]

I was hoping to get a better sense of other medical field's and societal views of child psychiatry as a field.

I was in grand rounds on a pediatric rotation hearing a child psychiatrist give a talk, which was really good, and did not expect that the pediatricians were ready to ambush her with accusatory tone about the lack of scientific evidence for diagnostic criteria to indicate antipsychotics and amphetamines in controlling refractory psychotic disorders and ADHD.

I mean I understand skepticism about the diagnostic criteria we use. And I would hope everyone is hesitant to use these drugs in children....but I'm having a hard time understanding the level of emotionality and accusation leveled at the child psychiatrist as if nutrition and counseling were viable in children who had horrible functionality after exhausting other avenues of treatment.

I'm interested in the field because I've always loved peds.

What's it like to negotiate hostility from so many angles?

And for child psychiatrists...how do you feel about the known and unknown side effects of using these drugs in children?

Thanks for any input.

It's not that way every where. I haven't seen any hostility around here from pediatricians or any one who is not a Scientologist or anti-psychiatry person. A couple of my supervising attendings used to be pediatricians. Usually peds just want to help patients however they can, and that's why we have a 6 month long waiting list of referrals from pediatricians to our child psych clinics. I've usually received valuable cooperation from most pediatricians, psychologists, and other professionals.

Hostility toward Child Psych from any pediatricians complaining about haphazard diagnosis and treatment would be a little amusing to me, actually. As a fellow in child and adolescent psychiatry many of the patients we see are referred to us by pediatricians who diagnose kids with Bipolar Disorder at age 5 and then start certain antipsychotics and mood stabilizers not FDA approved for patients that young, on patients who have ADHD and Oppositional Defiant Disorder, not Bipolar Disorder. When they do diagnose ADHD, often their go-to drug is high dose Vyvanse, before trying any of the other stimulants. They can never tell me why Vyvanse is chosen as first line - I reckon because it's newer? Do they have samples laying around? We almost always end up discontinuing the Vyvanse when the patients come to us because the parents report it made the child even more irritable. The kids often gradually get better with more conservative medication and adding psychotherapy and parent training, which is key for ODD. I think we should probably try to collaborate with pediatricians even more, they have a lot to learn from us, and us them. I do not envy the much higher volume, generally lower pay, and wide variety of medical issues both mundane and urgent that many pediatricians see and treat!

Skepticism about diagnostic criteria, treatment protocols, and so on is important and should be encouraged, but high expressed emotion and "accusing" a speaker ambush-style at a grand rounds probably isn't very helpful to anybody.

I do worry a lot about using antipsychotics in children. I worry about EPS, NMS, tardive dyskinesia, inducing metabolic problems that go along with increased appetite and weight gain, worsening lipid profiles, and so on. But, like you said, by the time we get the child by referral and are using these medications, other alternatives have been exhausted or are unavailable, or the patients daily functioning without the medication would lead to even worse outcomes, more quickly. We resort to the medications because we believe the benefits outweigh the very real risks. That is why medications go through FDA approval.

 

[TexasPhysician]

If you stick around long enough, you will witness every field insult or accuse every other field of something. Welcome to medicine.

 

[vistaril]

If you stick around long enough, you will witness every field insult or accuse every other field of something. Welcome to medicine.

true....but the nature of the criticism is very different.

 

[billypilgrim37]

And for child psychiatrists...how do you feel about the known and unknown side effects of using these drugs in children?

I feel that they are sometimes estimated to be much less than the known and unknown side effects of NOT using these drugs in children. If someone isn't doing a good job balancing these two things, then they aren't doing a good job. Our children's hospital more or less clamors for more education from our psychiatry department, so some of it is just going to be hospital specific. If you're in an area where every grumpy kid gets risperdal, then their criticism is spot on.

And some criticisms are easy and lazy. You have to be effective at handling it, but that doesn't have to mean you have to come home and believe it to be meritorious. The "criteria" for ADHD have very little to do with problems around ADHD diagnosis (it does however explain some aspects of problems with epidemiologic research, but that's a different ball game). If someone is complaining about ADHD criteria, that's like saying you don't like the fries at McDonald's because the bathrooms are dirty. Just because it's true doesn't mean it has much to do with the argument.

 

[michaelrack]

. When they do diagnose ADHD, often their go-to drug is high dose Vyvanse, before trying any of the other stimulants. They can never tell me why Vyvanse is chosen as first line - I reckon because it's newer?.

Personally, when I start a stimulant (usually for narcolepsy), I will start off with generic ritalin.... a cheap option.

Vyvanse may be a medicolegally safer option; theoretically there is less abuse potential because it is a prodrug. I am not sure if it is actually safer. I do like its long half life, but I rarely prescribe it because of its cost.

 

[TexasPhysician]

Personally, when I start a stimulant (usually for narcolepsy), I will start off with generic ritalin.... a cheap option.

Vyvanse may be a medicolegally safer option; theoretically there is less abuse potential because it is a prodrug. I am not sure if it is actually safer. I do like its long half life, but I rarely prescribe it because of its cost.

Exactly. With patients that have an abuse history, I prefer Vyvanse.

 

[TexasPhysician]

true....but the nature of the criticism is very different.

Criticism is real and everywhere.

EM - why don't they cure someone instead of admitting everyone?

Surgery - cause more harm than good by cutting on everyone.

Cardiology - 23 y/o with chest pain. Must stent them.

Pain Management - creates addicts.

I've seen all of the above come true, but that doesn't mean they are bad fields that aren't effective at their job. Just because one psychiatrist can't defend his ADHD prescribing, doesn't mean ADHD doesn't exist. Every field has downsides. Do the best you can, always be learning and listening, and ignore the ramblings from other fields.

 

[JourneyAgent]

Thanks all. The talk was about the decision making process of how children, their parents, and their pediatricians decide to seek a child psychiatrist. She had an interesting introduction followed by cases she had encountered with different outcomes and different assimilation processes of a pediatric psychiatric diagnoses. It had a good amount of cultural psychiatry content.

I think it was just 2 very vocal, hollistically-minded--whatever that means--pediatricians who were against these particular diagnoses in children. We don't have a child psychiatrist at my hospital or clinics--the speaker was a guest from the NYC metro area. We have a pediatric neurologist who does the ADHD cases that the pediatricians aren't comfortable with. I'm not sure how they handle other more severe problems of different sorts. There's children's hospital very close by. I rotate there next.

The neurologist does an amazing physical and history. And as I was discussing with her a senior elective she tried to convince me neurology is what I should go into and was mildly disparaging of psychiatry as a career.

I think my department lacks strength and respect outside of its addiction service.

I don't think there are lazy diagnoses here. I'm not sure why they are wary of child psychiatry. It's a predominantly African-American community with a wide selection of immigrant populations. Many different types of Muslims and other highly religious cultures. A psychiatric diagnoses might have an extra layer of stigma is many of these contexts. But I didn't expect that to be manifested in the physician culture.

So the talk was very apropos.

Thank you for your thoughts.

 

[JourneyAgent]

Criticism is real and everywhere.

EM - why don't they cure someone instead of admitting everyone?

Surgery - cause more harm than good by cutting on everyone.

Cardiology - 23 y/o with chest pain. Must stent them.

Pain Management - creates addicts.

I've seen all of the above come true, but that doesn't mean they are bad fields that aren't effective at their job. Just because one psychiatrist can't defend his ADHD prescribing, doesn't mean ADHD doesn't exist. Every field has downsides. Do the best you can, always be learning and listening, and ignore the ramblings from other fields.

I don't think she couldn't have defended herself. She did to a small extent. But her talk went over time. And she was a guest and I think she didn't feel it was the place argue. She discussed how she tries to avoid medications that aren't absolutely necessary.

 

[vistaril]

Criticism is real and everywhere.


Surgery - cause more harm than good by cutting on everyone.

Cardiology - 23 y/o with chest pain. Must stent them.

sure, in some cases there is a tendency for other providers to wonder if a certain person really needs a surgery or stent.......but nobody questions the MASSIVE benefit and overall good of fields like surgery and cardiology anymore than people question the importance of air and water. The criticisms surgeons and cardiologists experience are completely different than those psychiatrists experience. The fact is, and this helps us somewhat, many people inside medicine don't have a lot of anger/hostility towards psychiatry as a field because they either don't take us all that seriously or dont consider us 'one of them'. And that's not neccessarily a bad thing

 

[michaelrack]

please forgive me for going off on a tangent. Cardiology is very helpful when treating acute coronary syndromes.
Invasive cardiac procedures (stenting) can improve quality of life when it comes to chronic CAD, but don't improve survival. Risk factor modification (especially smoking cessation) is critical when it comes to chronic CAD. So when it comes to chronic CAD, psychiatrists (working with a good pcp) can be more helpful to a patient than a cardiologist.
Get them to a cath lab asap, though, if they are having an MI.

 

[wolfvgang22]

Exactly. With patients that have an abuse history, I prefer Vyvanse.

Yeah, I don't have that problem with little kids much.

 

[DOC PENGUIN]

If you stick around long enough, you will witness every field insult or accuse every other field of something. Welcome to medicine.

Medicine Vs Surgery (Whats with adjusting medication, if your pateints don't comply!, Whats it like not knowing a patient at all/Killing one every week) Is much much worse. While, vistiral is not wrong. THe public perception is not THAT poor.

 

[DOC PENGUIN]

Criticism is real and everywhere.


Surgery - cause more harm than good by cutting on everyone.

Cardiology - 23 y/o with chest pain. Must stent them.

sure, in some cases there is a tendency for other providers to wonder if a certain person really needs a surgery or stent.......but nobody questions the MASSIVE benefit and overall good of fields like surgery and cardiology anymore than people question the importance of air and water. The criticisms surgeons and cardiologists experience are completely different than those psychiatrists experience. The fact is, and this helps us somewhat, many people inside medicine don't have a lot of anger/hostility towards psychiatry as a field because they either don't take us all that seriously or dont consider us 'one of them'. And that's not neccessarily a bad thing

Why do you imply there are no "MASSIVE" benefits in psychiatric treatment? Its seems like you live in a pretty stable town. Good for you.

 

[Armadillos]

The pediatrician vs child psych thing must vary by town, I know here the C&A faculty have been lamenting the fact that a decent number of pediatricians in town are diagnosing kids with tons of psych disorders based almost entirely on 5 minute questionnaires the parents filled out in the waiting room.

 

[michaelrack]

Yeah, I don't have that problem with little kids much.

So you don't treat that many teenagers???

 

[billypilgrim37]

There's not much difference in price anymore between generics and other stimulants given restrictions on materials for manufacturing stimulants. The only time I use short-acting stimulants for anybody is in kids under 6 or as an afternoon augmentation strategy. Also for very old people, but I don't see very old people any more.

I have rarely started Vyvanse (it's fourth on my personal algorithm, after Concerta, AdXR, FocXR, and then Vyvanse). It's expensive and it has about as low an abuse potential as Concerta. If you're worried about abuse, then a more responsible person should be overseeing the administration of the medication. If there's no responsible person available to do so, I wouldn't be prescribing the stimulants anyway.

Diversion for "cognitive enhancement" is a bigger issue than outright abuse nowadays. Vyvanse is the same as any other long acting stimulant in that regard.

 

[heyjack70]

I think it was just 2 very vocal, hollistically-minded--whatever that means--pediatricians who were against these particular diagnoses in children. We don't have a child psychiatrist at my hospital or clinics--the speaker was a guest from the NYC metro area. We have a pediatric neurologist who does the ADHD cases that the pediatricians aren't comfortable with. I'm not sure how they handle other more severe problems of different sorts. There's children's hospital very close by. I rotate there next.

I think you found your answer.

I think there are individuals who are either blinded to the reality that psychiatric treatment is beneficial for some reason (like a psychologist who can't practice medicine wants the meds to not work, so is adamantly against them for no legitimate reason), or they are seeing a population that does not have serious mental illness. I could easily argue against meds if my population of patients consisted entirely of employed, affluent, worried well neurotic patients. Either way, the militant attitudes against meds or psychiatry specifically are usually not backed with any decent evidence outside of emotions.

Pediatric bipolar overdiagnosis not withstanding.

 

[vistaril]

There's not much difference in price anymore between generics and other stimulants given restrictions on materials for manufacturing stimulants. The only time I use short-acting stimulants for anybody is in kids under 6 or as an afternoon augmentation strategy. Also for very old people, but I don't see very old people any more.

I have rarely started Vyvanse (it's fourth on my personal algorithm, after Concerta, AdXR, FocXR, and then Vyvanse). It's expensive and it has about as low an abuse potential as Concerta. If you're worried about abuse, then a more responsible person should be overseeing the administration of the medication. If there's no responsible person available to do so, I wouldn't be prescribing the stimulants anyway.

Diversion for "cognitive enhancement" is a bigger issue than outright abuse nowadays. Vyvanse is the same as any other long acting stimulant in that regard.

around here, the cost difference between the stimulant I mostly write(adderall) is about 2 to 2.3x as much....it seems like my patients are telling me they can get the dose I would write of adderall for like 50-60 bucks cash pay and the equivalent ER dosing for like 130-140.....

more importantly(since all many pts care about is their copay if they have insurance), the xr is generally a higher tier copay. Meaning it may be a 35 dollar copay rather than a 10 or 15 dollar copay.

Adderall(either the IR or XR) is my 1st line med for this. I should add I don't see any people under 18 though, so most of these are people in the very late teens or college/grad students.

 

[vistaril]

around here, the cost difference between the stimulant I mostly write(adderall) is about 2 to 2.3x as much....it seems like my patients are telling me they can get the dose I would write of adderall for like 50-60 bucks cash pay and the equivalent ER dosing for like 130-140.....

i should add thats with extensive shopping around....often times just calling a pharmacy and asking for the price will priduce prices of > 240 dollars. Some independent pharms in particular use an AWP that is about a million% profit margin. I always tell my cash pay patients to call at least 5 places, with wal mart being one.

 

[billypilgrim37]

One nice thing about kids is that they have insurance most of the time.

Sent from my DROID RAZR using SDN Mobile

 

[JourneyAgent]

I appreciate the widened perspective.

Our population is the urban poor. Lot's of pediatric HIV patients. Lots of chaos and violence in the environment. A corrupt and dysfunctional public school system. Poor health care delivery systems. The works.

In terms of the cultural psychiatry issues, there's an active counter culture of alternative medicine that is also complicated by an Afro-centric/religious/historical mistrust of medical institutions and perhaps an added layer of stigma against mental illness, although I don't have the experience to say. Our physicians reflect this. And in addition we have a lot of Muslim docs and many immigrant physicians--I'm not sure how that effects diagnosis and child psychiatry referral, but I suspect that views of psychiatry might even be lower elsewhere than here.

We're mainly known for producing PCP's and surgeons for underserved communities. A weak psychiatry department in combination with these other factors, I think, creates a permissive environment for disparaging of the field.

 

[michaelrack]

For a patient doing relatively well on ritalin, what would be the cheapest long-acting formulation to switch them to??

thanks

 

[billypilgrim37]

Goodrx.com is an amazing resource I just recently became aware of. When last I checked drugstore.com prices there wasn't a big difference in price between say ritalin and concerta, but it appears now that it's back to being pretty disparate (with Ritalin being really cheap again). I still don't think the short acting are good choices for ADHD if they can be avoided.

Sent from my DROID RAZR using SDN Mobile

 

[NJWxMan]

Eeek...some major inaccuracies being thrown around in here.

1) ADHD in children has probably some of the absolute best psychiatric literature out there. The MTA is an excellent study. Diagnosis is and criteria are pretty clean cut. Medication certainly improves this condition and there is no data to support otherwise.

2) Studies show that drug abusers are not more likely to abuse a short acting stimulant. There's no indication to use Concerta in this situation, especially if you are treating appropriately.

3) Anyone can throw Concerta at a child and hope that it works. Why is Concerta so popular? Avoid embarrassing the child and to avoid dumping more work on the school nurse.
In fact, studies show that stimulants work only as blood levels are rising. Concerta produces a steady state in the blood which been found to be less helpful.

4) Society has a much higher regard for child psychiatrists, but I think that it's for the wrong reasons. People picture this scenario in which we simply talk to kids and fix their problems. We obviously don't do that necessarily (although we'd like to).

5) Pediatricians love child psychiatrists. We help clean up some really difficult family situations and at least take some of the pressure off of the pediatrician. In fact, I have met many pediatricians that will state that they "always wanted to go into child psychiatry."

 

[wolfvgang22]

So you don't treat that many teenagers???

Sorry, I didn't say that. If you read my original post you would see I had been talking about the example of young children being misdiagnosed and then given the wrong treatment. Perhaps I should have been more clear. I didn't mention adolescents, though perhaps I should have.

Also, I think billypilgrim37 and NJWx are absolutely correct. Eloquently put!

 

[billypilgrim37]

2) Studies show that drug abusers are not more likely to abuse a short acting stimulant. There's no indication to use Concerta in this situation, especially if you are treating appropriately.

The AACAP substance abuse committee would say otherwise.

If you define abuse as "taking it when you aren't supposed to," (i.e. studying for MCAT), then this is true. If you define abuse as taking it to get high, it is not true. They aren't the same.

 

[billypilgrim37]

3) Anyone can throw Concerta at a child and hope that it works. Why is Concerta so popular? Avoid embarrassing the child and to avoid dumping more work on the school nurse. In fact, studies show that stimulants work only as blood levels are rising. Concerta produces a steady state in the blood which been found to be less helpful.

Studies conducted prior to OROS (other "long-acting technologies were vastly inferior) demonstrated higher peaks (not "rising") correlated with better outcomes. Follow-up studies have not continued to support this. Adherence to treatment is a huge problem for various practical reasons. "Embarrassing" the child means child may refuse to take it, "dumping more work" on the school nurse means dosing is as reliable as you'd like. Add that in to the narrow windows involved with dosing an preventing yoyo-ing while at school, and it's a challenge. Never mind the fact that ADHD is one of the most genetically transmissible diseases in psychiatry (i.e., parents likely to have organizational problems as well) and getting families to adhere to regimens with 2-3x daily dosing is a challenge.

Long-acting stimulants are simply the standard of care in ADHD for kids over 6.

 

[vistaril]

5) Pediatricians love child psychiatrists. We help clean up some really difficult family situations and at least take some of the pressure off of the pediatrician. In fact, I have met many pediatricians that will state that they "always wanted to go into child psychiatry."

ummm...so why didn't they?

 

[Armadillos]

ummm...so why didn't they?

I know a pediatrician who was planning on doing child psych in medschool, but really, really hated adult medicine and adult psych, so were thinking about just doing peds instead so they wouldn't have to deal with residency. Their adviser correctly convinced them that it was only a couple years and that they should do psych. First week of psych internship some agitated drug seeking guy threw an object at her and she said screw this, Im doing peds.

I dont think she regrets doing peds , but admits it might have been kind of short sighted to change fields just to avoid the residency.