Are Child patient's easier to treat than Adults?

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ara96

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I'm seeing more and more kids who come in with the same diagnosis (ADHD) and seem to improve with medications. Whereas in adults, we have the whole constellation of symptoms (depression/anxiety with mix of borderline personalities) and everyone is always seeking a benzo. It seems to me that (with the little child exposure I've had) it just seems that it's not as emotionally draining as adult psych (at least from an outpatient perspective).

Is this the way it is in real practice? Keep in mind I'm just 3rd year resident who is just getting into the outpatient groove of things.

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I find child psychiatry less emotionally draining than adult psychiatry, but others will feel the opposite. It just depends on what fits you better. Personally I enjoy working with kids and their families but others hate it. By the way, outpatient child psych isn't just about managing ADHD. There are plenty of complicated children out there.
 
The difficult adults are the ones that act like children so that should tell you something. :arghh:
 
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I'm on an Irish training scheme, heading towards child psych. Have one year done with adults and 1 with children, plus one with children as a stand alone job.

For me, children are easier. Even with the surliest teenager on drugs, I feel a little empathy goes a long way. They expect less, and engage well with CBT, usually out of a desire to please. Sometimes I feel I do a lot of good, just by being an adult to talk to.

I find my local adult services are more medication oriented, and many of the patients have expectations beyond what we can humanly do (usually in the more affluent areas). I also find I feel less valued and more burnt out when working with adults.

I think it depends on who you are, but for me it's child psych all the way.
 
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If you are doing outpatient and seeing mostly ADHD, then yeah child will seem much easier. That is like comparing apples and oranges. You would need to compare it to doing outpatient and seeing soccer moms that are depressed and anxious. Just give antidepressants and some benzos...

Inpatient v inpatient I find the kids much harder. The ones that are Conduct, ODD, DMDD. The parents usually are a wreck and there is much more social work type issues involved. Much of it is behavior and personality, which is hard to treat and getting the parents to understand we can;t just "fix" them is hard.

My heart drops every time I see one of these kids roll up in our ED and I have to see them.
 
J ROD brings up an interesting issue.

Ireland only has about 4 inpatient units and we generally don't take the ODD type cases. We're underresourced and have to reserve inpatient care for psychosis and eating disorders. (The odd emerging EUPD comes in too). As a result, I can definitely say my stints in outpatients were more intense.

Lack of staff also meant I was a social worker, med manager, CBT therapist etc. And I still loved it.

Which is harder may well depend on where you are and what you like.
 
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Child is much more difficult and draining. Imagine yourself trying to do adult work but the entire time some other adult in denial about their own pathology constantly interferes with your treatment. The whole, "fix my kid" expectation is also a huge problem, and I blame us for creating it. It's not my job to, "fix" your child, and not every child has behavioral problems such as conduct disorder or ODD because of some deep-rooted depression they've managed to obscure all these years or some mystery trauma you never knew anything about. Sometimes, the kid just sucks and you're seeing the formation and eventual manifestation of a personality disorder.

I'm ok telling parents my honest impression of what I think is going on with their kid, whether they like it or not, which I always thought was kind of our job. Not everything can be fixed. The types of people who think they're going to charge in and save all of these innocent children and fix the problems of the world are in trouble.

ADHD is easy, and most of the time should remain with primary care, honestly. Go to an outpatient clinic and see an entire day full of adolescent females who cut and endorse ambiguous intermittent dysphoria with no identifiable etiology who never improve and tell me if you still want to do child psych.
 
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Working with kids keep me hip and young and in with the trends :laugh: even with difficult parents I would chose over Geri, Addiction, Personality any day as those tends to turn me into a pessimist
 
“The children now love luxury. They have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise.”
Socrates
 
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Haven't done it in years, but early experiences in training steered me towards adult for my field in Neuro. I always found it particularly disheartening to do a lengthy evaluation, make some great recommendations, and send the child right back into a chaotic and dysfunctional household with parents who would not follow through, perpetuating the problem. At least with adults, they usually just have themselves to blame for not following through, with some exceptions of course.
 
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I think that the question of whether or not child is "easier" than adult depends mostly on what you like to do. Those who choose adult may say things like "It's not the kids, it's their parents!" or conclude that most pediatric mental health problems stem from a dysfunctional family. While true in some cases, this is the exception rather than the rule, and is probably more likely to be the case on inpatient. I love working with kids and their families, so that's what I do. I have found most families to be generally supportive, provide a safe place for their child to live, and do a decent job of ensuring medication compliance. Also, for the most part parents tend to agree with my treatment recommendations. To me this is a lot better than working with the adult patient who has tried "everything" and says the only thing that works is Xanax and Adderall, or the chronically suicidal person with no job and no support system. A nice plus is that kids usually have shorter medication lists and fewer health problems, which simplifies things. I'm sure others could counter my arguments, but really it boils down to what makes you more excited to show up to work.
 
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Thank you all for the very helpful information. I am leaning towards applying. I was wondering, if one does not feel 100% confident in Adult psychiatry, should they wait out and finish 4th year to learn more, then apply after residency?

Financially, it seems like it would also be lucrative to be boarded in another specialty.
 
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Thank you all for the very helpful information. I am leaning towards applying. I was wondering, if one does not feel 100% confident in Adult psychiatry, should they wait out and finish 4th year to learn more, then apply after residency?

Financially, it seems like it would also be lucrative to be boarded in another specialty.


Your first question is difficult to answer. I think most of us don't feel 100% confident in adult psychiatry when graduating. You haven't mastered the specialty by the time you graduate from residency, and a lot of the, "real learning" starts as an attending. A better perspective would be to ask one's self, "Do I feel competent and confident enough in myself to know how to handle the things I don't know?". If your answer for adult psych is, "no", then give yourself another year. I know many of my colleagues highly valued that fourth year of general psych, as typically things don't, "come together" until some point in your third year (depending on how your program is structured), especially with psychotherapy training. That fourth year is a good time to hone your skills and build confidence.

As far as being boarded in another specialty, I'm not sure what you mean. Do you mean a subspecialty such as child? If so, then no, child doesn't really get you more money than adult. In fact, you may lose money since child cases tend to be more time consuming. If you mean another specialty as in internal medicine, surgery, radiology, etc., then yes -- they're much more lucrative.
 
If so, then no, child doesn't really get you more money than adult. In fact, you may lose money since child cases tend to be more time consuming.
I have never seen a place where child paid less than adult, but I've definitely seen the other way around. Child has a bigger supply-demand deficit and therefore sometimes makes more money.
 
I have never seen a place where child paid less than adult, but I've definitely seen the other way around. Child has a bigger supply-demand deficit and therefore sometimes makes more money.

Child work can be more time consuming and has a fair amount of unbillable work. Therefore your, "pay per hour worked" can be less than adult. Don't just look at the annual revenue or income potential. Pay more attention to the value of your time.

Of course you can negate this by choosing to just be a ****ty child psychiatrist and simply throw pills at whatever symptoms parents tell you about. Which is where most of us eventually end up after getting burned out.


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Thanks for the wider perpsective. One thing to note, I don't enjoy therapy (psychodynamic or cognitive) one bit. I much prefer medication management. That kind of sways me more to the C&A side.
 
Don't just look at the annual revenue or income potential. Pay more attention to the value of your time.
I'm not sure why you assume I don't already know these things. The salaries I know of, while limited, are still as I stated before, and this is not a product of child needing more unbillable time per patient.
 
Thanks for the wider perpsective. One thing to note, I don't enjoy therapy (psychodynamic or cognitive) one bit. I much prefer medication management. That kind of sways me more to the C&A side.
This does not make any sense. at all. please don't do child psychiatry.
 
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I don't enjoy therapy (psychodynamic or cognitive) one bit. I much prefer medication management

The preponderance of child psych will be symptoms secondary to problems in living and environment/family, socialization/social skills. No pills for that.

Most of the suspected ADHD referrals/consults you get will not be actually be so, and symptoms will likely be attributable to the above factors.
 
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This does not make any sense. at all. please don't do child psychiatry.

What? why is that?

I do enjoy supportive psychotherapy and I have seen medication make significant difference (with behavioral interventions thanks to the efforts of our case managers who go to schools) in these children.
 
What? why is that?

I do enjoy supportive psychotherapy and I have seen medication make significant difference (with behavioral interventions thanks to the efforts of our case managers who go to schools) in these children.

In my opinion, doing child psych well involves therapy. Even in higher socioeconomic areas, 99% need therapy added.

Not necessarily hour long sessions, but I add CBT techniques, PCIT, HRT, etc into appointments with significant benefits.
 
OP, if you want to do hardcore med management then adult psychiatry will be more your thing. The vast majority of child/adolescent psych patients are on one, maybe two, psychotropics (or at least should be). Or none, even. Majority will need therapy, as above posters have mentioned, and only for a minority will medication be the answer.
 
My job right now is all outpatient child/adolescent work, and I strictly do evals and meds, no formal therapy. If a kid needs therapy and isn't already getting it, then I make that recommendation and refer out. I'm under no pressure to give meds to kids when I don't think they're warranted; there are plenty of kids that would benefit from meds that I'm staying full anyway.

I will slip in some psychotherapy pieces into visits, but with only 30 minutes once per month, there's no formal psychotherapy taking place with me. I know nearly all my kids need real therapy, but I don't have to be the one to provide it (and if I did, then I'd have less room for the other kids I treat).

I don't know how common this job set up is, but it certainly exists in at least 2 places.
 
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My job right now is all outpatient child/adolescent work, and I strictly do evals and meds, no formal therapy. If a kid needs therapy and isn't already getting it, then I make that recommendation and refer out. I'm under no pressure to give meds to kids when I don't think they're warranted; there are plenty of kids that would benefit from meds that I'm staying full anyway.

I will slip in some psychotherapy pieces into visits, but with only 30 minutes once per month, there's no formal psychotherapy taking place with me. I know nearly all my kids need real therapy, but I don't have to be the one to provide it (and if I did, then I'd have less room for the other kids I treat).

I don't know how common this job set up is, but it certainly exists in at least 2 places.

There are far more therapists than psychiatrists.
 
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My job right now is all outpatient child/adolescent work, and I strictly do evals and meds, no formal therapy. If a kid needs therapy and isn't already getting it, then I make that recommendation and refer out.

I will slip in some psychotherapy pieces into visits, but with only 30 minutes once per month, there's no formal psychotherapy taking place with me. I know nearly all my kids need real therapy, but I don't have to be the one to provide it (and if I did, then I'd have less room for the other kids I treat).

I'm not saying we replace formal therapy, but what do you do for 30 minutes? After a thorough eval, I generally know the diagnosis. FU's include monitoring labs, looking for SE's, titrating meds, etc., but if strictly med management, 15 min would be plenty of time.

I spend at least 15 min of each visit going over CBT strategies, recognizing negative thoughts, parenting strategies, reinforcing therapist goals, etc.
 
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I'm not saying we replace formal therapy, but what do you do for 30 minutes? After a thorough eval, I generally know the diagnosis. FU's include monitoring labs, looking for SE's, titrating meds, etc., but if strictly med management, 15 min would be plenty of time.

I spend at least 15 min of each visit going over CBT strategies, recognizing negative thoughts, parenting strategies, reinforcing therapist goals, etc.
I'm not doing anything different, but 15 minutes of therapy stuff once per month is not therapy. So if someone doesn't like doing formal therapy, they still might like this format. You certainly don't get into things the same way like this as you would with weekly hour sessions.
 
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I'm not doing anything different, but 15 minutes of therapy stuff once per month is not therapy. So if someone doesn't like doing formal therapy, they still might like this format. You certainly don't get into things the same way like this as you would with weekly hour sessions.

While not usually sufficient in itself, I find this level of therapy to still be quite useful with dedicated parents and adolescents. You must agree as you are keeping your appts 30 min long. What do you call it if not therapy? I agree that it shouldn't replace full-time therapy. We have a LPC on site, and I certainly refer to the LPC for 1-3x weekly therapy.
 
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What do you call it if not therapy?
I call it therapy for billing purposes and because I don't know what else to call it. But I don't think it feels the same as doing real therapy, so again for someone who doesn't like doing therapy, this may still be acceptable.
 
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I call it therapy for billing purposes and because I don't know what else to call it. But I don't think it feels the same as doing real therapy, so again for someone who doesn't like doing therapy, this may still be acceptable.

I get your point, but "real" therapy doesn't just mean therapy every week for 45-60 minutes. You can most definitely do 15 minutes of med management as well as 15 minutes of CBT/IPT/supportive and call it therapy.
 
I get your point, but "real" therapy doesn't just mean therapy every week for 45-60 minutes. You can most definitely do 15 minutes of med management as well as 15 minutes of CBT/IPT/supportive and call it therapy.

The implementation of behavior change techniques or positive regard/reflection is not "doing therapy." I've actually never head of therapy being described/conceptualized as a verb.
 
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The implementation of behavior change techniques or positive regard/reflection is not "doing therapy." I've actually never head of therapy being described/conceptualized as a verb.

You don't therapize your patients?
 
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Child work can be more time consuming and has a fair amount of unbillable work. Therefore your, "pay per hour worked" can be less than adult. Don't just look at the annual revenue or income potential. Pay more attention to the value of your time.

Of course you can negate this by choosing to just be a ****ty child psychiatrist and simply throw pills at whatever symptoms parents tell you about. Which is where most of us eventually end up after getting burned out.

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This has not been my experience working in outpatient and inpatient child mental health settings. It takes being organized but if you schedule 30 minute family meetings after a 15 minute med check you can bill for both. If I spend 20 minutes talking to a school I'll do it after a brief med review bill a time based 99233 for coordination of care. Really not much I can think of that I have to do that I can't bill for at all. More significantly, my institution is willing to pay me a bit more for seeing about 20% fewer patients because they want to keep their child services running and the supply of child psychiatrists is low.
 
The thing about kids is that they aren't always demanding to be medicated with Benzo's and they have less medications in general so you don't have to obsess over polypharmacy and whatnot.

I just hate dealing with those rotten parents.
 
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If you are a C&A certified, can you choose just to treat child patient's? Or do most jobs require you to treat adults too?
 
I only see kids in my practice. Some jobs may ask you to see patients of all ages. But there are plenty of others out there for someone who wants to practice strictly C&A.
 
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parents demand klonopin for their kids y'know...
This is a new low. Glad I haven't seen this (yet). I have seen parents diverting their kids' stimulants...
 
This is a new low. Glad I haven't seen this (yet). I have seen parents diverting their kids' stimulants...

Parents will demand all sorts of medication for their child, often times as a substitute for the parent actually taking an active role in the non-pharmacologic interventions that would likely lead to improvement. Those pathological adults you abhor have kids, who end up in your office. You cannot escape them.
 
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