Introduction

Psychosocial treatments have been the bedrock for addressing child emotional and behavioral problems, and pharmacology is increasingly seen as a core treatment option for children and adolescents. This shift reflects historical trends in the development of medication therapy and the cultural shift that accompanies such advances. Psychopharmacology for children has a start date of 1930, associated with Charles Bradley’s 1937 study of Benzedrine on youth with emotional challenges. Much of the research from then until the 1980s extrapolated findings of adult studies on child use, and in the 1990s, pediatric psychopharmacology cemented itself as an independent field (Dulcan, 2016). Children can only meaningfully engage in treatment if it is tailored to their developmental and contextual situation. Cognitive ability, social connectivity, physical growth, and development all factor into this, along with the family context particularly, as the family is responsible for the treatment of the child (AACAP, 2019). Other contextual factors to consider include all child- and family-serving systems that the individual patient is interacting with. All of these considerations are no exception to psychopharmacological treatment.

Psychopharmacology practices vary based on place of practice. The overall rates of prescription of psychotropics to children and adolescents in the United States is higher than rates in Europe, and rates have considerable variance between countries (Bachmann et al., 2016). There are increases in prescription rates globally regarding three classes of medications: antidepressants, antipsychotics, and stimulants. With antidepressants, Bachmann et al. (2016) have noted increases from 2005-2012 in antidepressant prescriptions in the United States by 26.1%, in the United Kingdom by 54.4%, in Denmark by 60.5%, in the Netherlands by 17.6%, and Germany by 49.2%. During that same time frame, average rates of antipsychotic prescriptions increased between 32%-84% in those countries (Kalverdijk et al., 2017), and rates of stimulant prescriptions increased by an average of 14.6% from 2005-2012 in Western Europe, Asia, Australia, and North America (Ramen et al., 2018). There are trends of increased prescription rates worldwide, and it is hypothesized that this is related to an increase in people who are seeking psychiatric services. Additionally, systemic and structural factors play a role in how our society perceives human behavior and what is labeled an illness that requires treatment. By definition, psychiatric illness must cause functional impairment in the individual, but we cannot forget that functionality is determined by the social parameters that have been established by non-disabled individuals.

Across samples, stimulants tend to be the most prescribed medicine, followed by antidepressants and antipsychotics (Sultan et al., 2018). There have been concerns about over-prescription of medications for children (Olfson et al., 2010), but it appears that the patterns of prescribing coincide with the developmental onsets of common mental disorders in children and adolescents (Sultan et al., 2018). The data set pulled from the national prescriptions database indicates that 6.3 million youth were prescribed a stimulant, antidepressant, or antipsychotic (Sultan et al., 2018). A cohort study highlighted that in the US, children on Medicaid tend to be exposed to psychotropics at high rates and with higher rates of polypharmacy (Pennap et al., 2018).

Sultan and Olfson (2016) found that in the United States, there were sex differences in prescribing rates, with males being more likely to be prescribed a stimulant and with girls being more likely to be prescribed antidepressants. They also found no differences in rates of antipsychotic medications across sex. These differences may be linked to the overall prevalence of ADHD in males and mood disorders in females. Cook et. al., (2017) highlight disparities in psychotropic prescription rates between white children and black/Latinx children. Their findings show that medication use is lower among racial and ethnic minorities, and they point to a need to understand if minority youth are not offered or do not accept medication recommendations, despite having psychological impairment that could warrant such intervention.

Social policies and practices can also affect child and adolescent health and thus the need to diagnose and treat medical conditions. For example, the educational system has been developed in a way that conforms to the social expectations of adulthood. In the U.S., the need for two-income households is inevitable, and if parents are expected to be at work early in the morning, then children are expected to be at school before then. However, more and more evidence demonstrates that children and adolescents are not biologically equipped to conform with these social expectations. Evidence shows that there is a circadian delay that occurs in adolescence, which does not align with our current expectation that teenagers must wake up early to attend school. As is usually the case, decades of scientific discoveries and the subsequent development of scientific consensus must occur before policies and practices adapt to respect the human experience.

The Pathway to Pharmacological Intervention

The following sections will cover aspects of the psychiatric assessment used to determine the need for pharmacologic intervention, as well as considerations about treatment planning and the ethical concerns involved in consenting for medications.

The Psychiatric Assessment 

A psychiatric assessment by itself can be considered a comprehensive biopsychosocial assessment. There are some nuances to this that build upon the assessments that behavioral health clinicians perform. The psychiatric assessment will cover a psychiatric symptom screen and assessment; a review of the chief complaint; the history of present illness; a psychiatric review of systems; a review of the patient’s past psychiatric history, including any history of medication trials; substance abuse and chemical dependency history; suicidality and homicidality history; developmental and early childhood history; and family, school, social histories. During the evaluation, the physician will perform a mental status examination, physical evaluation, or assessment. With all of this data, the psychiatrist will present a formulation and diagnosis, then present treatment options which may or may not include a recommendation for a medication trial.

As you can see, many of these areas are covered in the clinician’s assessment. In the realm of collaborative documentation, where a masters-level clinician performs part of the overall evaluation, the physician can review the clinician’s initial assessment and ask follow-up or probing questions. There are two key tasks that only physicians can perform: the physical evaluation and pharmacological recommendations. They have the authority to state that treatment recommendations can be medically necessary.

Physical evaluation and assessment. This physical assessment is needed to understand the physiological baseline of the patient, as certain behaviors can be attributable to medical conditions; for instance, an overactive thyroid can lead to the appearance of anxiety. Patient health conditions have an influence on medication selection by the psychiatrist if indicated. If a patient with ADHD has cardiac problems, for example, a stimulant would be contraindicated. The prescriber will check height and weight, as well as do diagnostic testing to establish a baseline for organ-function monitoring. Lab work tends to track levels of glucose, triglycerides, A1C, WBC, creatinine, and lipid levels, among others, to help monitor any potential effects that may occur after starting a medication. For instance, if a child warrants starting on an antipsychotic medication, it is critical to have these baseline labs; the medications can have metabolic side effects and affect triglyceride and blood glucose levels. Although psychiatric assessments are comprehensive, there is new evidence demonstrating the need for additional factors to be considered and better incorporated into treatment planning. For example, the role of diet, sleep and exercise are well established regarding their effects on mental health. However, the current medical model does not fully support clinician’s ability to address these issues due to low reimbursement fees, which limits the time spent with patients. This is an important consideration for non-physician mental health providers, as we can support clients to be better informed and learn how to incorporate health-promoting behaviors into their daily lives. Most importantly, as non-prescribing mental health providers, we will encounter conversations with clients regarding their medications, so it is important to develop tools, understanding and collaborative approaches to skillfully support both the prescribing clinician and the client we serve.

Pharmacological recommendation. The physician understands the neurobiological aspects of pathology, and pharmacological treatment recommendations are based on these impairments in neuroconnectivity. At this point, it will be helpful to review one of the essential aspects of pharmacology, neurotransmission. Neurotransmitters are considered the chemical messengers in the body, and they help bridge the gap (synaptic cleft) between neurons throughout the body. There are two major functions of neurotransmitters: they either excite or inhibit neural signals. These neural signals are the hardware for human behavior, acting as the circuits and the electricity that powers the body. Neural signaling is the response to stimuli (both internal and external).

It can be helpful to recall the main neurotransmitters associated with psychiatry. GABA is largely responsible for processes related to relaxation, and it has an inhibitory function which can decrease anxiety and involuntary muscle contractions like those in seizures (Heldt, 2017). Glutamate is an excitatory transmitter, and it acts opposite to GABA. It can be helpful with learning and memory. Acetylcholine affects the parasympathetic nervous system including functions like arousal, lacrimation, and GI motility; it can also affect learning, memory, attention, and muscle contraction (Heldt, 2017). Dopamine plays a role in psychosis, motivation, reward, reinforcement, and motor control; low dopamine is related to Parkinson’s disease, for example (Heldt, 2017).

Serotonin is linked to sleep, appetite, mood, and memory; its influence can be seen with migraines, anxiety, and impulsivity (Heldt, 2017). Much of the body’s serotonin is located in the gut, so this may account for the GI distress experienced after the start of an SSRI (Heldt, 2017). Norepinephrine impacts concentration, alertness, vigilance, and it plays a role with the sympathetic aspect of the central nervous system, affecting blood pressure and heart rate, as well as other organs (Heldt, 2017). Histamine is responsible for things related to the sleep-wake cycle, and it can play a role with other hormonal functions (Heldt, 2017).

In addition to understanding these pathways, the prescriber will consider pharmacokinetics, or the “absorption, distribution, metabolism, and excretion” of a medication (Nnane, 2005). Knowing the mechanism of these processes is not as important as understanding that treating a child is different than treating an adult. Child body composition is vastly different, in terms of fat tissue, organ development, and excretion of the medication (Lu & Rosenbaum, 2014), which ultimately affects how the medication works in a child. Additionally, what may work for an adult in terms of medication type and/or dosage may not work for a child, largely based on the idea of pharmacokinetics (Lu & Rosenbaum, 2014). Another related term is pharmacodynamics, or how the medication affects the receptor it is targeting. With a constantly changing neural system as related to synaptic sculpting, medications need to be considered in terms of chronological age and maturation (Lu & Rosenbaum, 2014). Understanding pharmacokinetics and pharmacodynamics conceptually is helpful to a clinician when they provide basic psychoeducation to parents about how medications work and what influences their effectiveness.

Treatment Planning

Three categories of psychotropics receive the most attention with child psychopharmacology: stimulants, antidepressants, and antipsychotics (Sultan, 2018). While there are other classes of medications used, such as anticonvulsants for mood lability or benzodiazepines for panic disorder, most of the literature points to the use of stimulants, antidepressants, and antipsychotics as common practice. Sultan et. al (2018) confirms from their reviews of the child psychopharmacology literature that stimulant medications are established for the treatment of ADHD, antidepressants for the treatment of depression and anxiety, and antipsychotics for the treatment of psychosis, bipolar disorder, and clinical aggression in children with and without autism. Consult the Quick Reference to Psychotropic Medications for common medication classes, various preparations of the medications, and other helpful information.

Syndromes, not symptoms. Treatment planning involves targets for behaviors or symptoms in the hopes of reducing the effects of a given disorder. With psychopharmacology, targets are critical in treatment planning; however, medication intervention is not aimed at specific symptoms but the syndromes or clusters of problems. Take a medical example: someone that has a runny nose would not necessarily take an antibiotic. The runny nose can be due to hay fever or a cold (not excluding the possibility of a bacterial infection). An antibiotic can be used for a sinus infection, and the efficacy of the antibiotic can be measured by its effect on the runny nose. Let’s now take a psychiatric example. It would be hasty to prescribe a stimulant if the child complains of inattention. There are potential causes of this symptom that need to be accounted for- is this child suffering from anxiety or depression, which is causing racing or ruminative thoughts? The stimulant would be warranted to treat diagnosed ADHD only, and the indicator if the stimulant is working would be any decrease in inattention. There are some exemptions to this rule. For instance, if a child with autism spectrum disorder has externalizing problems, an antipsychotic can be prescribed to help with aggression. However, the antipsychotic is not treating autism itself. There may be comorbid issues to be ruled out with this autistic youth.

There are times too when a prescriber uses an off-label use of a medication; one of the more common of these being the choice of Seroquel, an antipsychotic, as a sleep aid. It is critical to understand risks, benefits, side effects, and targets of the medications, as well as have an understanding that medication has a particular role in treatment; it is not the sole modality or rationale for treatment. As non-prescribers, we can also meaningfully assist in the overall treatment for youth and their families by incorporating our training in ecological treatment models. With that, we can assess what needs to be treated in the child themselves as opposed to what can be addressed by shifting the child-serving systems interacting with that youth, including the family and the school setting.

Ethics

While there may be professional differences between the physician and the clinician, there are similarities in ethical approaches to care. From the physician point of view, there is an emphasis on beneficence, non-maleficence, and autonomy. Regarding beneficence, the physician is obligated to promote optimal well-being and development of the child, and this may be communicated to the patient in terms of the benefits of starting a trial of medication. Conversely, the physician will operate from the position of non-maleficence, or what is commonly known as the “do no harm” principle. Regarding medication treatment, this principle is communicated through discussion of the side-effects of medication and the risks associated with starting a trial of medication. For instance, the physician would need to present the risks of starting an antipsychotic medication for psychosis (e.g., metabolic side effects) and the benefits of the medication (e.g., decrease in hallucination) and allow the child’s family to make an informed decision based on the information provided. Additionally, non-maleficence plays a role in the importance of prescribers performing a thorough psychiatric assessment that clearly defines whether the symptoms are causing dysfunction and distress to the child, ensuring that we are not treating developmentally normal and expected behaviors that have not been accepted and welcomed in the child’s environment.

Consent can only be considered valid if the child and caregivers are able to make an informed decision about their care without external pressures. Informed consent requires three components:

1. Information-sharing: knowing the risks, benefits, and side effects of treatment, as well as alternatives to the proposed treatment.

2. Voluntariness: making a free decision without coercion.

3. Capacity for decision-making: sometimes legally referred to as competence, being able to comprehend information and reasoning and appreciating the significance of one’s choices.

Assent involves the agreement of someone who is not able to give legal consent, such as children under 18. It is important to note that studies indicate that 14 year olds have similar ability to adults in making complex decisions; however, laws governing age of consent for children vary from state to state.

Oftentimes, a child may refuse to take medications. It is important to consider the function of the refusal behavior. Is it in the presence of oppositionality? Is it related to side effects? Is it related to undesirable physiological states (e.g., “I feel like a zombie”)? Or is it that they disagree with the diagnosis and adult-determined presence of a condition that needs medical treatment? Refusals may happen if the child is not aware of the ongoing benefit, or maybe it has reached its benefit, and the child does not feel the need to take it anymore. Refusals that are in line with a desire to discontinue medication should be discussed with their prescriber to ensure necessary tapering schedules to limit adverse effects of abrupt discontinuation. The medication is seen in the context of treatment, so it is helpful to reiterate that there is some medical necessity; if there is no longer the feeling that it is medically necessary, the family should talk to their provider.

Interdisciplinary Roles of the Behavioral Health Practitioner

Bentley and Walsh (2006) outline seven potential roles for social workers who have clients receiving medication management service. The collaborator role supports the physician and the recommendations made in efforts to maximize the intervention. The consultant role appropriately screens clients for the need for medication evaluations, makes referrals to prescribing clinicians, and monitors the process of medication management. The counselor role acts as a guide for the client to problem-solve around decisions regarding their medication treatment. The advocate role positions the social worker as a support for the client and family to either receive services, to advocate the client position within clinical decision making or to link to supplemental resources in the context of medication management (e.g., prescription discounts with pharmacies). The monitor role acts like the collaborator role; however, it is more in regard to monitoring side effects and helping the client work through any side effects as indicated. The educator role provides information to families about medication treatments and further addresses questions related to risks, benefits, or side effects. Lastly, the researcher role uses single subject or case study designs to convey how the intervention has impacted the client, hoping to contribute to the knowledge base about medication interventions. In practice, one provider may assume multiple roles.

Regardless of role, it is important to have a baseline understanding of how the psychiatric assessment unfolds; the decision-making process of the physician; the collaboration strategies with the physician, the patient, and their family; and ultimately, the considerations with consent for treatment transition.

How to Talk to Families about Medication

Consider how medication fits into the whole treatment plan for the child. After the clinical formulation, recommendations cover various domains such as social activities, education supports, supportive psychotherapies, and medication therapies. When talking with the family, discuss how medication is not the sole focus of the treatment plan and how it may affect other domains. Ensure that the child is on a predictable schedule and that it is easy to take the medication; this is meant to limit defiance and forgetfulness. As a behavioral clinician, it is important to remind the family that the psychosocial work is the context for the therapeutic relationship and that medication issues fall in the realm of the medical provider.

Another aspect to consider is how medication works. There have been previous paradigms of medications addressing a “chemical imbalance,” and this explanation lacks the current state of the evidence about psychopharmacology and neural functioning. Additionally, this type of explanation may lead to negative labeling. Consider working with a child and saying that they have a chemical imbalance in their brain. How would they react? They may personalize their problems; they may think that their brain is “broken” or not working right, or they may think that if they are imbalanced, that the rest of their body is imbalanced too. For a child with ADHD, it may be easiest to compare the brain to a computer, where the computer has a lot of wires, buttons, and electricity. Medication can be seen as a way to help the computer run as effectively as it can. Or it can prevent having too many apps running in the background, where it can interfere with what we need the computer to do right now.

As a non-prescribing mental health provider, you can help advocate for your patients by encouraging them to call their physicians and also offering to communicate their concerns directly. When you communicate with the prescribing physician or other providers, ensure that you objectively describe the information; for example, you may describe the behaviors you observe during your clinical encounters with the child and family, or you may describe the side effects that the patient is expressing during your visits. It is ultimately the physician’s or prescriber’s decision that determines the next steps for medication adjustments.

Stigma about Medication. Communities and cultures may have perspectives that do not view medication as an appropriate intervention. Some will rely on folk medicine or other types of healing practices relative to their culture. In the western perspective, this can be characterized by Complementary or Integrative approaches to medicine (NCCIH, 2018). Complementary practices are those that are not mainstream but used together with conventional medicine, whereas alternative practices are considered those that replace conventional medicine approaches, typically seen in the form of use of natural products like herbs or use of or mind-body practices like acupuncture, yoga, or tai chi (NCCIH, 2018). Related by complementary or alternative medicine by association only, integrative health relates to treating the whole person for instance, as opposed to one system in the body (NCCIH, 2018). This often is supported by coordination between different practitioners (e.g., an internist with a psychologist or clinical social worker in an obesity clinic). Regardless of approach, it is critical that options be discussed with the medical provider, as there are mixed or varying results in studies about natural products for particular medical conditions (NCCIH, 2018). Psychopharmacology as part of a treatment plan needs to occur within a culturally competent framework. This translates to understanding the family views of medication, presenting the proposed medication treatment in the midst of information about the alternative treatments or other remedies they may better understand through their culture. Transparency in communication builds the trust that is needed for the therapeutic alliance.

Clinical Dialogues: Psychopharmacology with Dr. LaToya Floyd, MD

Sean E. Snyder, LCSW: To start, Dr. Floyd, your impact goes way beyond your brief introductory paragraph. To our readers, I had the pleasure of working with Dr. Floyd, and she was instrumental in my development as a clinician. In a way, this book is a product of her influence on me, so I want to start by saying thank you. Ok, now to business.

With child psychiatry, it’s a very scarce resource. There’s a lot of training involved which may or may not be a barrier. What’s it like knowing that you’re a scarce resource and that there may not be many reinforcements waiting in the child psychiatry pipeline? What’s it like being at your clinic, having a full caseload, feeling like there are not enough hours in the day, being that scarce resource?

LaToya Floyd, MD: I think that there’s a realization that it’s under-resourced in general; then in certain areas, it’s even more so. If you’re outside an academic setting or if you find yourself in rural America, you may feel under-resourced. If you are in areas that may be well-resourced, such as the coastal areas, sometimes you’re under-resourced because of the population that we work with, namely youth and families that are economically disadvantaged and probably on public insurance (which affects reimbursement rates, which may scare off clinicians with loads of medical school debt). So, there’s the big perspective of seeing the more structural limitations and the economic underpinnings of it.

On a more individual, personal level, it takes trying to scale back and understand where your proficiency is, so you can be the best provider for the people in front of you. So, for me, I focus on school-aged children, and I do a lot of trauma work. I think that if you can identify what you do where you have some proficiency or competency, or dare I say even mastery, then you’re able to be more efficient at what you do. When you get that sweet spot where you’ve honed your practice, you will be in a better position to serve a larger group of people.

The other thing is it’s trying to consider that a treatment team should be like a pack; psychiatry really shouldn’t be practiced alone. You should have an interdisciplinary team and be connected to well-trained therapists like I had when I was in Philadelphia. You should work with your amazing team and the system infrastructure to affect change, whether it’s an in-home team or a family-based team. Otherwise, as a psychiatrist, you’re stuck with pharmacology, and at that point, if all you have is a hammer, then everything becomes a nail. So, if a child is acting out and this child has an intellectual disability, someone may choose to get them Abilify (and you may argue that it’s FDA approved for irritability associated with autism), but you may not actually pull back to look at the entire problem. There’s a skill set in the family, or there’s a misunderstanding about the condition, and this actually could be figured out with psychoeducation. So, I think it’s wherever you are, wherever your practices are. It’s knowing what your proficiency is, and it’s showing where your reach is, and not relying solely on medication to be the bridge between what the family needs and what you can do.

Snyder: So that kind of dovetails nicely with the idea of engagement. With some clinics, a youth needs to see a non-physician clinician first, and the clinician refers to you, or you may get direct referrals from pediatricians or schools. So, what’s it like when families finally get to you. How do you engage families in the first session?

Floyd: The first session I define what I do. I tell parents who I am, that I’m a medical doctor, and if it’s a young child, I talk about the fact I’m not a doctor that is going to give you a shot. I talked about the fact that I work with healing, and I think that the first thing is setting that tone. And it’s listening, listening to what the family has been through. Sometimes, by the time families have gotten to me, there’s been contact with multiple providers, multiple prescribers, multiple settings like acute inpatient hospitalization or partial hospitalization.

For me, I like to start with what their experience has been like, what they’re hoping to get out of the first meeting with me, what other clinicians have done that’s been super helpful, and what other clinicians have done that has not been helpful. I think during that first moment or that first appointment, it’s about understanding what got them in that chair today and what they’re hoping for. Anybody can prescribe Concerta; I think it’s trying to figure out what brings them to the point that they need some help with their child.

So I’d like to start there. I think in forming a therapeutic alliance, I tell parents, “It has to be a good fit. I’m not a cardiologist. If you hate me, and you don’t talk to me, then I can’t help you. I can’t just put a stethoscope there and say, ‘Yes, I hear a heart murmur. No, I didn’t hear anything.’” There’s this need to have a working relationship, and I think that a relationship is important overall, and say if the treatment is stagnant or things aren’t moving along. Sometimes it’s looking back at the relationship and realizing, “Is this a population I can work with, is this family I can serve? “As a provider, I’m always keeping my eye on what my treatment goal is and what the family is hoping to obtain from being with me; sometimes when those two things are out of sync, that’s when you see a slowdown in therapeutic traction.

Snyder: Fit is so critical because the work of a psychiatrist is interpersonal. I’m thinking of different types of presentations that come to doctors; some may just be seeking medication treatment from the start. And as a provider, you don’t jump right into medication, right, you want to treat the whole person as part of an ecosystem. And the reality is, their hope is different than what you think is best for them. Specifically with that example, when the parent leads with questions pressing you for medication, what’s your initial reaction? As a non-physician, I get reactions when the youth get disappointed that I can’t give them medications. So, I’m wondering for you as a physician, what’s that reaction like; is it “Here we go again…” or some other visceral countertransference reaction?

Floyd: That’s a good place to start, your reaction to the client. I think it’s recognizing what is happening to you in the process as you are meeting with families. Once you recognize what’s yours and what’s the patient’s, it’s easier to bridge. For instance, if somebody says, I need Xanax, that’s a hard place to kind of be at. Is this person really suffering or am I writing off this person because of my personal reaction to a statement like “I need Xanax.” So, for me, it’s again defining what the presenting problem is, what the diagnosis is. So you have to suspend that reaction to really see. Is it an anxiety disorder or a trauma-related disorder? And let’s just say it’s a trauma-related disorder. And then I may be thinking, maybe they want Xanax because that’s where they’re at with their mental health literacy (Xanax is probably more talked about than SSRIs in our popular imagination). So, it’s talking to the patient saying this is actually what evidence-based treatment is for anxiety; it would be an SSRI right now. And some patient education is needed too, to help them understand that what they asked for is really addictive.

And the other thing is, try not to make assumptions. That’s really hard. So, if you can check the prescriber inventory to see what the patient is prescribed, or if you can check with the pharmacy that they commonly use, try to ground yourself in some truth about this individual. Really ask yourself, “Is this really a med-seeking individual?” This is an important question to ask ourselves because we are in the midst of a crisis with opioid use and deaths. Somebody that prescribed something very short term (opiates) directly or indirectly created a longer-term problem for a lot of people. From here, I need to kind of position this person for more appropriate care or help this person in a different way. As a healthcare provider, I have to consider: have I created a more nosocomial issue? What if we do create dependency?

I think in that situation, the first and most important thing is acknowledging your own experience of what’s going on. What’s really important for people to realize is, for psychiatrists, you’re the instrument. Like a surgeon that has their scalpels, we do our work with ourselves. Your instrument has to be calibrated, and if you’re feeling this way about the person, you’re not calibrated; you’re not in the moment to use your best self. So, if you are feeling some reaction towards the patient, don’t suppress them. Find supervision, talk about them, think about them. Think about what interaction that brings, and then it’s trying to ground yourself to let your logical brain kick in. If you balance the logical brain and the emotional brain, much like wise mind in DBT, you’ll likely be able to make a good decision.

Snyder: That is such a great analogy. We are the instruments, and we need to be sharpened or calibrated. Otherwise, we become dull, and from my Eagle Scout days, dull knives lead to injuries, and dull knives make for longer, less efficient work. And frankly, less fulfilling work!

Floyd: Right, and consider other aspects of care: with a treatment plan, do you actually believe in them? Or are they laborious and formulaic, and they become actually just box-checking drudgery? A treatment plan doesn’t have to be 9 million goals, it could be 1) diagnosis: trauma 2) decrease hyper-vigilance and 3) will work PRACTICE skills. It can be very simple. It could be the end of a note, but it’s having the patient agree this is the treatment plan, and this is something their provider believes in. If that patient (I’m still talking about the Xanax-seeking patient) at that time doesn’t agree, then they aren’t a good fit. And then it’s making a referral, but it seemed very clear documentation of “This is what I thought. I thought it was trauma. It actually wasn’t depression. Treatment recommendations were to bring down the hyper-vigilance, I recommended the TF-CBT, and the patient refuses fees to do that. I recommended other pharmacological options, and the patient refused to do that. At this point, we had decided that a referral for another provider would be appropriate.” So, in all of what I just said, I’m not saying kick the can down the road. I would say to that patient, “I think that you need help, I think you need to come off Xanax. This isn’t a problem that is going to go away on its own or by taking more of it.” It’s just being true to what you can do, what you can practice, and knowing your scope.

Snyder: It’s really thinking with the end in mind, and being empathetic with someone doesn’t mean just giving them what they want. For example, with parents, it may seem unfair to the child that they can’t have ice cream for dinner, but as a parent, you know what is in the best interest of your child to grow up healthy. The big picture approach also has to recognize that here is what we can do now, here is what we can do later if this doesn’t work…here are the people in your world. We need to get on board and help support you…And I’m stuck on the idea that you are your instrument in psychiatry, probably because we talk about self-care so much. That calibration metaphor can translate a lot differently to non-physician clinicians, that we are the instruments, that we need to make sure that we have our countertransference calibrated.

Floyd: Right, you are the instrument; you’re also the intervention. Your detection and care after identifying the problem are from your brain! So, if you are tired, or if this is not the population that you can work with, or if this isn’t a great time in your own life, or you just have too many trauma patients right now, or you’re just doing too much, that’s going to impact your clinical work. It’s actually going to change your view of your patients and yourself.

Snyder: It is hard not to personalize when you can be so many things in a therapeutic relationship. So, here’s my pitch for spiritual self-care. Clinicians! Make sure to check in with your worldview, your view of your patients, your value systems. We can have personal missions drift over time. Ok, so last couple of questions for the engagement portion of our talk. Let’s focus on the family. We’re looking at the family as a system, caregiver, and child. And the family is situated in systems, and the child is developing. So, there are a lot of moving parts. I want to pull apart those systems to focus just on the child. So, what’s it like to engage with a child?

Floyd: Oh, that’s the best part. I think that for me, it’s engagement around play. That’s something that’s come back into my life in this new kind of practice and engaging in its ability to find out if there is play and what comes with it like reciprocity, seeing how the child responds to praise, trying to see if it can get a little bit of frustration. I’m not pushing for a meltdown but setting expectations to see if the kid can actually meet them in the office. So, whether I have an expectation like “it’s clean up,” or “if you’ve been respectful, you can have a sticker,” or “I have a treasure box in my office, let’s see how you behave during our visit. Setting the expectations early and trying to see how the child kind of responds in that moment is where I start.

For me, the engagement in that first session with the child is about the kid feeling comfortable with me at that moment. And so, the first interview or the first visit, the parent and the child initially come in together. I introduce myself; I tell them what I do, I let them know no shots, and after this introduction, I ask if anybody has any questions that they really need to know, got to know right now before we go on. And even though I say no shots, kids will ask me, “No shots, right?” and parents will ask me, “Is it really going to be over an hour?” After that, I ask the hardest question of the day, “So somebody’s going to come with me to my office, and we’re going to get to know each other a little bit. Who wants to go first?” And I kind of watch what happens with the parent and the child at that moment. If it’s the parent, then the parent in that way is able to speak freely about the child. I find it really hard when parents and adults have non-developmentally appropriate conversations in front of the child about their behavior. It’s trying to interrupt blaming behavior and so that the parent can speak freely without the child internalizing a working model that their parent doesn’t love them. So, I let the parents talk freely alone, and they’re not expecting that.

And then I have my time with the kids, I’ll do my play activity, and then we all come back together and get the general feedback of “what did you think?” And then I tell them what I would need from them, whether it’s labs or additional releases or whatever. I have a shorter appointment for follow up to check in, see if I’m a good fit, see if the treatment plan is feasible and appropriate.

And it’s just helping them on their journey. And I have to look at it as a family journey. If a parent has other issues, for instance, I’ve had parents with their own substance use issues or have their own trauma, sometimes I need to have a parent-only session to pare those things out. Again, these are the things that do not necessarily need to happen in front of a seven-year-old at that first visit. I feel a sense of responsibility to give them an opportunity because they have carried a lot of things for a long time.

Snyder: I think you’re getting at when the child’s therapy ends up becoming the parents’ therapy. So, engage with them, set clear boundaries of who we’re here to support in this child’s appointment and help the parent out in their own sessions or ensure that they have their own clinician for their own long-term care.

Floyd: Right, and it doesn’t mean I won’t have parent-only sessions. I have a parent right now that is very triggered by something their child did and that person needs their own treatment to deal with that trauma trigger that they’ve experienced from their child. But when we are here for your child’s treatment, I’m here to kind of talk with you about how that’s changed your lens, how you discipline, and how you parent. But that adult’s own individual work can’t be the focus of my sessions with your kiddos, because we need to address the child’s stuff and how to parent them through it. I have to make a strong partnership.

Snyder: Right, it’s coming at it on how the trauma affects their relationship to their child; it won’t be exposure therapy or cognitive processing about the event itself.

Our readers will have hopefully looked at the assessment chapter and may know some things about the biopsychosocial approach. And in the pharmacology chapter above, we will see what a psychiatric evaluation is. In your own words, what makes it different doing an evaluation as a physician?

Floyd: So as a physician, we understand the biologic, neurophysiological, and medical aspects of a presenting issue and of pathology. I may find out something about the child’s medical history and how it pertains to developmental ranges. When you think about differential diagnosis too, you need to rule out any medical condition that could explain the presentation or if substances are contributing to the presentation. Our medical knowledge then allows us to take a deeper dive into the psychosocial and environmental factors of the child’s presenting issue.

As an example, I have a girl with a developmental issue. She has presented to the hospital here 12 times, and I was asked to do an Emergency Department consult (which I rarely do these days). I read up on her history in her chart, and when I saw her, she looked dysmorphic. To me, that changed my entire overview of what everybody else says, of what was put in her chart. So instead of just starting her on something for impulse-control or mood lability, I wrote for a workup that included genetic and neuropsychiatric testing. We found out that the child’s IQ is 56, and she does have a heritable genetic disease. Her behavior was getting her referred to delinquency court, and this comprehensive work up I did with her changed her placement options. She could go for treatment, as opposed to being shipped off to a juvenile correctional facility. Some of her externalizing behaviors were related to her emotional and intellectual maturity. So as a psychiatrist, I may take on more of the biological aspects than a psychologist, and I have more psychological insight than a pediatrician because of my training. I focus a lot of my time making sure that the other domains are cared for, like education, physical health, physical health things. So, for those physical health things, I’ll call their pediatricians, because I want their thyroid function to be followed by an endocrinologist and the pediatrician can help with monitoring other things.

I think also with that lens comes trying to understand if you’re really, really with pharmacology. You have to think about what’s medical and what’s not. If you’re talking about ODD, sure a medication could help with comorbid impulsivity, but your treatment plans should really be thinking about parent management training. So yes, in an evaluation, a psychiatrist can act as the gatekeeper of what is actually under the purview of medication versus what is more of a behavioral or psychosocial intervention that is indicated.

Snyder: Of course, we can’t medicate a parent-child interaction or a family systems issue! The relationships need work.

Floyd: For sure, and I do take “guardianship” of the physical part of it. So, in my formulation, I will note that they live in a food desert, I know that the neighborhood is dangerous, and they cannot exercise. That there are so many things that need to be considered to support the health and development of this child. And considering the presentation, I have to then reconcile what can be done in twice-weekly therapy for a month and what needs to happen outside of therapy to see if I can get more traction. Do I introduce a mentor? How do I take care of the welfare of a child knowing that all of these things influence their physical, emotional, and spiritual development?

Snyder: What you’re describing is really looking at the child in a positive way, meaning less about pathology and more from the lens of just health and wellness. Right. Sure, maybe there is some neuroconnectivity issue that medication can assist with, but what about health promotion, looking at, physical health and wellness, social health and wellness, emotional health and wellness. So, it sounds like from your perspective, it’s asking, “How can I look through this lens of wellness for this child and touch on all these domains of their life?”

Floyd: Of course, that’s why we become physicians, to help people live healthier lives across the different parts of their life; domains of health and wellness are all connected to each other. And some of those questions we have to ask are along the lines like “Are you going to the dentist? Do you eat lunch? Are you going to bed on time?” For me, there are so many other pillars of health that have to be there, whether you think about a pillars of health approach, or whether you think of Maslow’s hierarchy. Wherever you conceptualize it, you can’t just take your piece of the child and go with it. You can’t shortchange a family by being a lone wolf in caring for them; there are plenty of other factors in this child’s life.

Snyder: That’s the developmental systems approach in a nutshell. There are multiple systems at play that produce the presenting problem, and they occur within a particular developmental window. The response to such problems requires systems of care and systems of wellness, the pillars of health you mention.

Floyd: Right, don’t feel you have to manage it yourself. I made it a part of my practice just to work with pediatricians, and some out there actually enjoy working with different populations. That peer network is an amazing resource. I have somebody I can call if something doesn’t look right, so I don’t just ignore something or overlook it because it makes me uncomfortable.

Snyder: At the end of the day, it’s always about patient care and considering what’s the best thing for this patient.

Across all of what we talked about, you touched at times about intervention and a lot of different ways you address things like considering different domains and what to do. So now, I want to target intervention in the more pointed way that you do in your evaluation. What’s running through your mind as you do your formulation? You get to your diagnosis, then you think, what treatment recommendations do I make? Are there common things that you recommend or approaches you take to recommendations?

Floyd: There can be two camps with recommendations. So, when I was a resident, I had my treatment recommendations like this is what I’m doing for depression: we’re hitting sleep, we’re looking at food logs. In my mind, I would check yes, this is what we’re doing, an antecedent consequence logic, an if/then. So, in some ways, yes, you should always have your standard of care things, and you should always have ways to track what you’re doing, like if it’s the CPSS-5 for trauma symptoms or something simple like the PHQ9. Or do something like the CRAFFT. Track if there’s adherence or therapy interfering behaviors.

Then on the other side, there is a bit more of an open approach. It recognizes that if we start with something, we need to be open to feedback. There’s another part of an intervention that tries to figure out how this time can be different for this child. It’s really just thinking about what is going to get this on a developmental trajectory that can promote health and wellness.

Snyder: So, on one end, it’s pushing the trajectory in one direction with the intervention, then the other approach is trying to re-integrate aspects of the child’s life that were thrown into discontinuity before or after the onset of illness. It’s organizing it so it can be self-corrective, as opposed to the physician-directed correction.

Floyd: And when I talk to families about interventions, I take their temperature and ask them, is our meeting today as you expected? Did you get all your questions answered? I’m very honest with them again. Some of the kids may have been seen by other people, and I tell them that I have to learn about their family. I have to catch up on it. So, it’s acknowledging that I’m not up to speed because this was our first visit, and I need to bring you back. And it’s setting up a few appointments out because I really need to know what I’m treating to actually treat it. I can’t usually get it in one visit; otherwise, I would be relying solely on biases like case history or biases about what has worked for me as a provider. And I try to see them within two weeks and check in with them between visits to see if they have a therapist. And when I have follow-up appointments, it’s good to have your battery of inventories to help track things so you can have an honest conversation. So, on this Ohio scale, you presented initially as really high, and now it’s actually in the middle, we’re actually moving. And sometimes that’s enough to change the parent’s lens of therapy and lens of the child. I don’t want to set up the expectation that if you do this, all of your problems will go away. I It’s holding up the idea that behavior change takes time and that a lot of outside things can influence change, for instance, a pandemic, parent stress, the change in the marking period where the child gets a new teacher.

Snyder: It’s transparency and collaboration. It’s having the working hypothesis, sharing it with the family, working through potential treatments. Like you said, this isn’t just a matter of doing an EKG where there’s a firm reading and there’s a corresponding treatment. When we treat emotional and behavioral problems, we are seeing that kids change across time, seeing the presentation change across time as it is influenced by the environment.

Floyd: Yeah, so I think being honest about what we’re working toward after the first visit. Again, my lens is I’m trying to get you back on to your “psychological growth chart” and that is an evolving process. This didn’t happen overnight, nor is it going to be fixed overnight or after one visit. I also remind them that our meeting is one aspect of getting them back on the right track. I’ll recommend school supports, or mentorship, or prosocial activities, and therapy, and oh yeah, medication if that is appropriate.

Snyder: Considering environmental influence and developmental time, a child won’t be frozen in time until the next visit; they are continuously developing day after day. I’ve referenced this elsewhere, with newborns, they grow so rapidly on a physical level, and so they have to adjust to walking or crawling every day because their body is different from the day before. Emotionally, too, when we look at children, the way they were yesterday is different than today, and there can be some general growing pains, and sometimes, there are cumulative effects of those pains. This kid is having an ongoing narrative being written in real-time.

Floyd: Of course, like say you have a very depressed kid, and they come in, they think you’re going to fix it in one day because that’s the narrative, the depression has to be corrected so that child doesn’t leave feeling hopeless. But what I can do when I close that session out with a family is that there is the possibility of the future being different. That’s where I end with the family, it’s thinking: how can I help this child and family to open possibilities for a narrative of health and wellness, in which they feel empowered, energized, and content with their quality of life? No feeling is final, so we need to be open to the idea that things could be different. And to go back to the beginning of this interview, that condition of possibility needs a clinician that listens, that has a sense of boundaries, transparency, a spirit of collaboration. We are the instrument and the intervention, so we need to make sure we are calibrated to make the best impact that we can.

References

American Academy of Child & Adolescent Psychiatry. (2016, May). AACAP Code of Ethical Principles. Retrieved from https://www.aacap.org/aacap/ Member_Resources/Ethics/Foundation/AACAP_Code_of_Ethical_Principles.aspx

Bachmann, C. J., Aagaard, L., Burcu, M., Glaeske, G., Kalverdijk, L. J., Petersen, I., . . . Hoffmann, F. In Bachmann, Christian J. (Ed.), Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012. https://doi.org/10.1016/j.euroneuro.2016.02.001

Bentley, K. & Walsh, J. (2006). The social worker and psychotropic medication: toward effective collaboration with mental health clients, families and providers. Thompson Publishers.

Bradley C. (1937). The behavior of children receiving Benzedrine. American journal of orthopsychiatry, 94:577–585.

Cook, B. L., Carson, N. J., Kafali, E. N., Valentine, A., Rueda, J. D., Coe-Odess, S., & Busch, S. (2017). Examining psychotropic medication use among youth in the U.S. by race/ethnicity and psychological impairment. General hospital psychiatry, 45, 32–39. https://doi.org/10.1016/j.genhosppsych.2016.12.004

Heldt, J. P. (2017). Memorable psychopharmacology. CreateSpace Independent Publishing Platform.

Kalverdijk, L. J., Bachmann, C. J., Aagaard, L., Burcu, M., Glaeske, G., Hoffmann, F., . . . Zito, J. M. (2017). A multi-national comparison of antipsychotic drug use in children and adolescents, 2005–2012. Child and adolescent psychiatry and mental health, 11(1). https://doi.org/10.1186/s13034-017-0192-1

Lu, H., & Rosenbaum, S. (2014). Developmental pharmacokinetics in pediatric populations. Journal of pediatric pharmacology and therapeutics, 19(4), 262–276. https://doi.org/10.5863/1551-6776-19.4.262

National Center for Complementary and Integrative Health. (n.d.). Complementary, alternative, or integrative health: What’s in a name? Retrieved June 08, 2020, from https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name

Nnane, I. (2005). PHARMACOKINETICS | Absorption, Distribution, and Elimination. Encyclopedia of analytical science, 126-133. https://doi.org/10.1016/b0-12-369397-7/00458-1

Olfson, M., Crystal, S., Huang, C., & Gerhard, T. (2010). Trends in antipsychotic drug use by very young, privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry, 49(1), 13–23. https://doi.org/10.1016/j.jaac.2009.09.003

Pennap, D., Zito, J. M., Santosh, P. J., Tom, S. E., Onukwugha, E., & Magder, L. S. (2018). Patterns of early mental health diagnosis and medication treatment in a medicaid-insured birth cohort. JAMA pediatrics, 172(6), 576. https://doi.org/10.1001/jamapediatrics.2018.0240

Raman, S. R., Man, K., Bahmanyar, S., Berard, A., Bilder, S., Boukhris, T., Bushnell, G., Crystal, S., Furu, K., KaoYang, Y. H., Karlstad, Ø., Kieler, H., Kubota, K., Lai, E. C., Martikainen, J. E., Maura, G., Moore, N., Montero, D., Nakamura, H., Neumann, A., … Wong, I. (2018). Trends in attention-deficit hyperactivity disorder medication use: a retrospective observational study using population-based databases. The Lancet. psychiatry, 5(10), 824–835. https://doi.org/10.1016/S2215-0366(18)30293-1

Sultan, R. S., Correll, C. U., Schoenbaum, M., King, M., Walkup, J. T., & Olfson, M. (2018, April). National patterns of commonly prescribed psychotropic medications to young people. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905871/

Sultan, R. S., & Olfson, M.(2016). 4.12 national rates of psychotropic medication use in pediatric populations. Elsevier Inc. https://doi.org/10.1016/j.jaac.2016.09.207