Child Psychiatry Emergency Care: Dr. Laura Prager

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This week on Brain Waves I feature an interview with Laura Prager, M.D., co-author of Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness. Due to technical issues this interview will be presented in text form. As Director of the Child Psychiatry Emergency Service at Massachusetts General Hospital, Dr. Prager provides a fascinating window into the plight of mentally ill children and their parents, and the quick thinking and courage needed to provide them the best acute medical treatment possible in one of the best hospitals in an imperfect national psychiatric system.

Read Dr. Prager’s introduction to Suicide by Security Blanket

BKS: Dr. Prager, thank you for appearing on Brain Waves. Several stories in your book depict adults (parents, teachers etc.) too wrapped in their personal concerns or beliefs to attend adequately to kids’ mental health needs-in “Cornered and Contaminated,” the parents are too busy “saving the world” to take proper care of their son’s developing OCD. Moreover, some of your stories imply that parents behavior can contribute notably to kids’ mental health issues-in “Children Come With Parents,” the divorced parents are so at odds that their son’s mental health deteriorates. These apparent facts seem like they would be difficult for involved parents to accept. Is an intent of your reports on these instances to be a sort of “wake up call” for parents reading to behave more attentively to kids mental health needs?

LP: Actually, I have two goals.  First, as you noted, I want parents to pay attention to their kids’ needs. Parents can become very involved in their own lives and assume or hope that their kids will manage.  These parents need a wake-up call: kids need supervision, and they need consistent care and support.  However, many parents don’t realize how important they are, how much what they say and do can influence their kids.  So, the second reminder is that “children learn what they live.”  If parents fight, kids learn that fighting can be a way in which two adults relate.  Parents are the most important role models for their kids and they need to think about that before they engage in behaviors they do not want their kids to imitate.

BKS: It seems to me that the most treacherous threats to mental health you encounter are cultural stigma and discrimination. In “A Wounded Son”, Bhanu’s peers bully him into near suicidality because he acts reclusive and uses childlike mannerisms. In “It’s Just a Cold” a mother is so resistant to accepting that her daughter has a mental illness that she sneaks out of the ED with her and flees. In “Suicide by Security Blanket” a suicidal child’s depression is completely ignored by his mother, who responds to his diagnosis as if it is a threat to her dignity. Have you thought about what might be done to address the threats of discrimination and stigma? Do you think in-school mental health education programs might help?

LP: Yes, I have thought a lot about these issues, and yes, I am in favor of in-school mental health education.  In the city in which I live, there is a program in the public schools called Understanding Our Differences.   This nationally-recognized (but not implemented) program brings children and adults with various types of disabilities-for example, diabetes, blindness, deafness, learning disabilities,  and autism spectrum disorder– into the schools to meet with fourth grade students, with the goal of increasing the students awareness and understanding of differences.  I served as a classroom volunteer for this program when my children were in elementary school and I think it’s terrific.  At present, only one of the disabilities includes children with mental health issues.   It would be even better if the organization that runs this program could develop curricula that embrace other forms of psychiatric illness common in children such as Attention Deficit Disorder, Mood Disorders, or Anxiety Disorders.  Teaching young children about such problems helps to even the playing field (so to speak) and reduces prejudice and fear.  Such programs should continue to target elementary school students; by the time you get to high school, it’s more difficult to change existing thought processes.

BKS: You also recount numerous instances of having to work around insurance barriers to provide care for kids’ mental illnesses. You see this despite the passage of the federal mental health parity act in 2008. What do you think it will take to make insurance companies step in line?

LP: We need national healthcare with mental health parity.

BKS: Another story (“Do You See What I See”) imputes a young patient’s psychotic delirium to an overdose of medication as prescribed by her doctors. You explain that the doctor’s prescriptions seemed initially reasonable, given their knowledge. Alas, knowledge with today’s diagnostic tools is so often hard to come by. And, the therapies available all carry their own potentially dangerous side effects, especially when misapplied. What would you say should the priorities be in neuropsychiatric research to improve this situation?

LP: I don’t think I’m really qualified to answer this question.

BKS: As you illustrate, the few hours (at a time) you are usually able to spend with kids who come to your ED is usually not enough to get them well. But you give an instance of a success: in “the Astronomer”, you tell the story of how with an hour of conversation, the child, the mother, and the doctor all cooperated to apparently turn the kid’s life around. Such a great outcome must be extremely gratifying for you and your personnel to experience. I am very curious; about what proportion of the time do you get an outcome that good?

LP: Almost never-which is why we included the story.   It’s the exception that proves the rule.