Advances and Achievements

September 1, 2004

With the increase in child and adolescent patients comes an increase in challenging cases. Dr. Schowalter introduces this Child and Adolescent Psychiatry Special Report and provides perspective on articles discussing approaches to initiating care with a teen-ager, collaborating with pediatricians and other clinical topics.

The four articles comprising this special report describe approaches to care that vary from the first session with an individual patient to the conceptualization of a mental health care delivery system for patients in primary care.

The number of child and adolescent psychiatric patients has increased greatly during the past generation. This is due to multiple reasons: better understanding of developmental psychopathology; better case-finding; and a real increase in illness. There are not enough child and adolescent psychiatrists to provide the necessary care. To this end, although the concept of training primary care clinicians to expand their provision of basic mental health care is not new, John V. Campo, M.D.'s, chronic care model, supplemented by a cadre of clinical researchers to test its effectiveness, is very exciting indeed.

I have been startled at times when, toward the end of long-term psychotherapy with an adolescent, they give a detailed and often accurate account and critique of our first session together. Richard David Brand, M.D., provides a lovely description of how one experienced clinician, with one type of practice, approaches an encounter that will set the tone for whether or not treatment begins and, if so, in what emotional atmosphere. Of course, the patient's developmental stage, type of psychopathology, support system and other variables prohibit the possibility of a cookie-cutter template for all adolescents; nonetheless, it is rare to find teachers with a fine eye for detail and the chutzpah to cite chapter and verse of specific interactions that work for them.

The article by Leo Bastiaens, M.D., focuses on the well-known problem of polypharmacy in the long-term care of treatment-resistant children. Although the issue is targeted from a residential care perspective, the excellent questions posed in the concluding paragraph are relevant for all patients who go through multiple clinicians. During my 27 years as a residency training director, I noticed that there was no end of pressures to add requirements to the curriculum, while it was almost impossible to drop a requirement. We see the same mind-set in the pressures to add, but not subtract, medications for patients who are not doing well. Because we have virtually no understanding of how multiple medications interact with one another, this practice requires change. I never maintain a previously prescribed medication unless I am willing to write a note that I am convinced of its efficacy based on personal findings or personally vetted data from others.

Finally, Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannario, Ph.D., describe a type of cognitive-behavioral therapy for sexually abused children that has been used for fewer than 10 years. Given the difficulties in treating this important population, this article provides a new approach that is being carefully studied and critiqued.

Psychiatric Times extends a warm thank you to Dr. Schowalter for his assistance in planning and reviewing this special report. Dr. Schowalter is the Albert J. Solnit Professor Emeritus and senior research scientist at the Yale University Child Study Center.