“Why Is It Impossible to Find a Psychiatrist?”

Over the weekend, I received calls from two old friends, both requesting advice about how to navigate the mental health care system during a crisis with their child. One child is preschool aged and has been “tantruming” for 75% of his waking hours for most of the past year, and now has been getting suddenly worse. He screams and writhes around on the floor most of the time. The other is a teen who cut herself with a razor and told her parents she hears voices and wants to die. These are serious situations in need of psychiatric opinions.

Their families live in different states and have different resources, but they ended up having very similar experiences when trying to get mental health services for their children. After exhausting the knowledge and resources of primary care providers, they needed a specialist. But then neither family could get an appointment with a psychiatrist, even with the assistance of their primary doctor. They offered to pay out of pocket, or do anything necessary to facilitate getting the child seen, and both families were told that nothing was available for many weeks. 

They faced the impossibly difficult decision of considering hospitalizing the child just to get the expert opinion. One family opted for hospitalization, where their child was locked in (and they were locked out), and although the child was placed on psychiatric drugs to stabilize symptoms, the parents still never directly spoke with a psychiatrist to hear advice or even education about what brought on the symptoms in the first place. They left the hospital without securing an outpatient appointment, and just hours after they got the child home, it was clear that the treatment wasn’t working and there was no one to call.

“Why has it become so impossible to access mental health care services?” was the question both families asked. 

I wish I fully understood the answer to that question. It seems many factors have contributed to the growing state of impossible access to psychiatric services. Foremost among them, there just aren’t enough psychiatrists. Filling psychiatric residencies is nearly impossible; it’s not a prestigious or high paying medical specialty. And then as the public raises awareness and encourages those in need to seek out psychiatric help, the need is increasing and no new providers are available to meet the increased need.

I don’t see access to care in psychiatry being resolved by training more doctors. My own premed, medical school, and then residency training spanned (a standard) twelve years. We can’t wait more than a decade for a solution. Physician’s assistants (PA’s) and psychiatric nurse practitioners (NP’s) can be trained more quickly and can therefor meet some of that need, but even then, psychiatrists have a great deal more specialized training and seeing a PA or an NP isn’t always interchangeable. Even primary care physicians, trained in a wide array of medical care, often say they lack specialized knowledge to feel competent in treating serious mental disorders.

I have concluded that psychiatry is going to have to change. Psychiatric physicians are going to have to alter the age old model for delivering mental health care. We cannot just work faster and see patients in 3-minute time slots to fill this need. We are going to have to be innovative and work in teams with our fellow professionals (PA’s, NP’s, and primary care doctors). Not every family has the ability to call a psychiatrist friend for advice, but everyone deserves basic access. Psychiatry is going to have to find a way to address the need. 

Here are ways to expand access now:

1.    Psychiatrists can provide case consultation services to primary care physicians to help them stabilize and manage complex cases.
2.    Psychiatrists can offer one time clinical “second opinion consultation ” services to aid in diagnosis and treatment planning, and them allow other professionals to manage care long term.
3.    Psychiatrists can work closely with well-trained physician extenders in their outpatient clinics.
4.    Psychiatrists can offer educational and support services to the public, and to other providers.
5.    Psychiatrists can coordinate medication refill services for stable patients with primary care, so that unstable patients can be seen in open/available time slots in the psychiatric clinic.

There are probably many other ways to expand access as well. Share your suggestions in the comments section below.

Have Overprotective Parents Really Ruined a Generation of Kids, or Is It All Hype?

Are we really a generation of helicoptering, overparenting, overprotective, crippling-our-kids-by-doing-everything-for-them, parents? Are we running behind all our toddlers while they climb up playground slides, pressing preschools to give them Ivy League resume building skills, and guarding them against any opportunity to develop autonomy or self-effectiveness? Do we only care about college, and do we measure our success by whether our kids get accepted to Harvard or Stanford? 

As I write this, my kids are not overscheduled and no adult is hovering to keep them safe. 2 kids are at a traditional summer camp where they are hiking and making crafts, singing songs and swimming, all while supervised by a group of teenaged camp counselors. They have no electronics, no email, and no cell phones and they don’t much care. If I’m lucky, I’ll get a scrawled letter or two by the end of the week. A third child has been running in and out of the house sopping wet this morning with a friend, lobbying for a sleepover, giggling at pop culture references, all after eating an impressively large pancake for breakfast. Nothing here seems much different than my own upbringing, except perhaps the latchkey kid part. But even those still exist in my neighborhood.

Articles and books tell me how my peers (and I?) are parenting from conception and I think, “Is this a real thing?” Is some author, somewhere living in a world where constant helicoptering, overscheduling, intruding, and otherwise invasive parental behavior is not only present, but is commonplace? Because I’m a parent, and truly, my life is not like this. I did not drive frantically across the city on the day I found out I was expecting a child to register for the best preschool. I don’t write my children’s homework essays or do their science fair projects or lash out at teachers when my child gets a bad grade or a note in his or her communication log alerting me to a discipline problem. And save for a few difficult parents (or more often, a few isolated misunderstandings or profoundly bad days) I don’t see other parents in my community behaving this way either. 

So this leaves me wondering, am I just blessed to live in a better community? Or has the whole narrative about how our generation of parents is helicoptering just been overblown? Perhaps much of what has been written is dramatized, highlighting the worst examples and adding quite a lot of embellishment. But why?

In the era of 24-hour news cycles, parents hear about every rare disease, every child abduction, and every fluke head injury, so perhaps many parents have a heightened sense of danger. Maybe we should be letting our kids walk to and from elementary schools alone. Maybe we should let them play in the park unsupervised while we work our shifts at McDonalds. Parents these days may be fearful, and restricting previously “normal” activities for children.

But isn’t the sensationalized fear of our “helicopter” parenting culture just the next in a series of overreactions and overdramatizations in the world of child-rearing? Now we should be afraid of being afraid?

Parenting is about facilitating growth. In some instances, developing kids need parental oversight and protection. In other instances, kids benefit from exploration, independent discovery, and self-driven problem solving. But as the pendulum begins to swing away from “overdoing” and toward backing off, let us parents not forget that our role is all about being mindful and making sound, sane, in the moment decisions based on what is best for our children, in their given stage of development, to support the shaping of each child’s skillset for emotional health and lifelong independent adulthood. And no simple soundbyte captures our job fully.

When Best Friends Move Away

Goodbyes can be painful, especially for children. I’m reminded of this today because my daughter’s good friend is moving away over the summer, and both girls are heartbroken. They have known for months that the friend would be moving, her parent taking a new job in a far away city. But having information did not help them understand what they could do to make the transition easier.

Kids move to new cities. They transfer schools. Or they may even just move to a neighborhood in the same school district, but lose the opportunity to see one another often at the neighborhood playground.

Without experience, kids may not know how to cope with such change.

Supporting children while they manage these little goodbyes early on helps them develop a toolbox for managing the much bigger goodbyes that come later: loss and grief that are such normal occurrences in all our lives. 

1.    Plan ahead
Planning for a coming goodbye can help kids strategize. When will the friend be leaving? Where is s/he going to live? How will they keep in touch? What activities or plans would they like to make together while they have the time together?
2.    Talk about it
Parents should encourage kids to talk about their sadness or fear. Kids are likely to experience some intense emotions, and will benefit from discussing them with an adult they trust. Sorting through emotions about a friend’s move build emotional skill and resilience for coping with change and loss.
3.    Spend extra time together
Arranging opportunities to spend time together before a move or a change of school can help kids cope with the loss in smaller chunks. Rather than a flood of grief, kids can break it into smaller bits. Also, spending extra time with a friend who is going away helps build a sustainable bond that can survive the time and distance to come.
4.    Exchange a special gift
Kids often instinctively ask to make something for a friend when they’ll be parting ways, but if not, parents might suggest doing so. Making a special gift or writing a letter as a memento can give kids something to hold in their hands and use as a transitional object when they part company.
5.    Stay connected
In the current era of technology, it’s easy to stay connected with anyone. Cell phones, texting, email, FaceTime, Instagram, and a myriad of other options allow kids to continue to interact with special friends in real time. And it’s always fun to send and receive an old-fashioned letter or postcard by mail, in lieu of technology. Either way, teaching kids to stay in contact with far away friends will benefit them now, and in transitions later.

Childhood Disorders In A Forest Gump World

Last night I watched Forest Gump with my family and I was struck by the contrast between the lives of the main character, Forest, and his best friend/best girl, Jenny. While Forest has cognitive and social delays, and has an estimated IQ of 75, Jenny is a biologically normal, healthy girl from a troubled family. We might expect Forest to be the one in the movie, then, with the tragic life. Forest is different, physically and cognitively. His legs are in braces and his back is “crooked, like a question mark.” He is called “simple” and he often fails to comprehend life’s challenges. He relies on others, from his mother to his circle of friends, to insulate him from the harsh realities of life. 

Jenny is developmentally normal. She is bright and compassionate, aware of the social expectations and dangers of others around her. She seems to have a better chance at a normal life.

But there is more to the story of these 2 people’s lives than the destiny created by their biology. Forest lives in a loving home with a parent who would go to any length to provide him with a normal life. She wants him to have every opportunity a “normal” child would have. His mother is loving, kind, and encouraging. She continuously reminds her son that he can do anything he is determined to do, and Forest lives this out time and again by having the courage to try just about anything. By contrast, Jenny’s home is impoverished and abusive. Her father is shown raging at her with a bottle of liquor in his hand, and the audience is led to assume he may be sexually abusive toward her. Jenny’s life becomes tragic while her disabled friend thrives in parallel. She suffers with shame and a life a sexual acting out and substance use.

This movie portrays accurately what treatment professionals, researchers, and educators still seem to get wrong: life outcomes are more affected by the presence or absence of a loving, nurturing environment than simply by underlying neurobiology in the brain.

Whether a child suffers from an Autism spectrum disorder, dyslexia, anxiety, or any host of other cognitive or mental health issues that onset in childhood, when the child is steeped in an environment of support and encouragement, s/he can live a life of difference rather than one of disability. If, however, a child is bullied or abused in the home (kids with developmental disabilities and mental health problems are at higher risk for abuse), the risk for long term emotional and behavioral problems is heightened.

We’ve come a long way toward supporting kids who are on different developmental paths. Inclusion programs in school, education and support for parents, but we need a paradigm shift in the treatment world. Clinicians need to believe, and teach families, that all kids can achieve good outcomes and have good lives. While medical treatments have steadily increased and improved for decades, we can’t lose sight of the underlying source of our worst outcomes: unhealthy environments.

Treatments in mental health must teach families and communities how to encourage and support those with mental health and neurocognitive disorders to live full and healthy lives of independence and contribution, not disability and alienation.