Nancy Rappaport

The meaning of psychotropic medications for children, adolescents, and their families.

Despite the dramatic increase in the use of &atric psychopharmacology Uensen et al., 1999), there is a surprising paucity of discussion about the psychological meanings of medication to both children and parents. Shapiro (1996) presents some clinical examples that explore the meaning of medication. He points out that in the early years of pediatric psychopharmacology, there was an artificial polarization between doctors who were alleged to have a primarily biological view and those who very reluctantly used medication secondary to a largely psychodynamic formulation. Shapiro encourages clinicians to maintain a rigorous standard of care that is attuned to developmental and temperamental issues when considering medication for children. Bastiens (1995) advocates that clinicians pay attention to the efficacy and side effects of medication, as well as to whether parents are comfortable giving medication and children are comfortable receiving it. Clinicians’ attention to the wishes, fantasies, and fears of children and their families will enhance the therapeutic relationship.

Traumatic Stress and Posttraumatic Stress Disorder in Youth: Recent Research Findings on Clinical Impact, Assessment, and Treatment

Childhood trauma can have a profound effect on adolescent development, with a lifelong impact on physical and mental health and development. Through a review of current research on the impact of traumatic stress on adolescence, this article provides a framework for adolescent health professionals in pediatrics and primary care to understand and assess the sequelae of traumatic stress, as well as up-to-date recommendations for evidence-based treatment. We first review empirical evidence for critical windows of neurobiological impact of traumatic stress, and then we discuss the connection between these neurobiological effects and posttraumatic syndromes, including posttraumatic stress disorder, depression, aggressive behavior, and psychosis. This article concludes by considering the implications of this current research for clinical assessment and treatment in pediatric and primary care settings.

Psychiatric Consultation to School-Based Health Centers: Lessons Learned in an Emerging Field

Child and adolescent psychiatrists are increasingly likely to be included in school-based health clinics (SBHCs), which are an effective vehicle to meet the many health care needs of students, particularly adolescents. SBHC services are often more accessible to students than traditional community mental health services because SBHCs decrease stigma, increase efficiency by providing services where the students are available, and support more comprehensive, coordinated services within the school community. Adding psychiatrists to the interdisciplinary staff of SBHCs requires moving beyond a traditional school consultative role. Psychiatrists can expand the range of services offered by SBHCs by supervising and participating in SBHC assessment, therapy, and psychopharmacology and also by providing insight into the complex situations that arise within a school setting. The development of SBHCs (particularly in poor urban areas), was prompted by concern that adolescent health care needs were largely unmet (Santelli et al., 1996). The number of SBHCs in the United States has increased dramatically from 2 in 1970 to more than 1,200 by 2000 (Berkovitz, 1999). Initial financial support for SBHCs came from foundations. Subsequent funding has been from local grants, state block grants (departments of public health), and federal support (through Medicaid reimbursement) (Weist and Schlitt, 1998). Most clinics offer a broad spectrum of services that are usually provided by nurses and social workers and supervised by physicians. These services include assessment and referral, diagnosis and treatment of minor injuries, sports physical examinations, nutrition education, family planning, and mental health counseling. Initial studies of SBHCs demonstrated that students use the clinics frequently. Prior to the availability of SBHCs, many high-risk students rarely used “regular” sources of health care such as annual doctor visits. Instead, they relied on spo

Psychopharmacology in the School Setting: Therapeutic Challenges in an Adolescent with Attention Deficit Hyperactivity Disorder, Possible Bipolar Disorder, and Other Comorbidity

IN COMMUNITIES IN WHICH child and adolescent psychiatric consultation is available to schools, the psychiatrist-consultant is often beset with a variety of challenging clinical issues. As the awareness and recognition of childhood psychopathology in schools has grown, teachers are frequently asked to manage children with disruptive behavior and other symptoms in their classrooms. The child and adolescent psychiatrist-consultant is thus often called upon to help with “behavioral management” of these youth. However, although one of the more powerful and effective therapeutic tools is pharmacotherapy, many parents are unwilling to accept recommendations for medication for their children. John, whose case is described below, illustrates some of these challenges and dilemmas.

Case Study: The Internet as a Developmental Tool in an Adolescent Boy With Psychosis

The Internet has become an increasingly important part of teen culture; however, there still remains little in the medical/psychiatric literature pertaining to the impact of the Internet on adolescent development. Despite the potential problems associated with communication online, the Internet offers a variety of positive opportunities for teens. In this report, we present a case study that illustrates the Internet as a helpful tool in a 15-year-old adolescent boy with a history of chronic neurological illness accompanied by refractory psychosis. Although the case emphasizes some of the ways in which the Internet may have a positive impact on adolescent development, further research is indicated to evaluate the contexts in which the Internet serves healthy developmental processes and those in which its influence is potentially deleterious.

Under the Gun: Threat Assessment in Schools

Physicians can aid schools in assessing threats of violence and treating students whose aggressive behavior may pose a threat to others. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

From zero to a hundred in a split second: understanding aggression in an eight-year-old child

Xavier is an eight-year-old American boy of Italian ancestry in a second-grade inclusion classroom at a public elementary school. He carries diagnoses of a severe language-based learning disorder (LD) and attention-deficit/hyperactivity disorder (ADHD). He lives with his mother, twin sister, and older teenage brother; his parents are in the process of divorcing. The Office of Special Education referred Xavier to a child psychiatrist (NR) for evaluation due to its increasing concerns about both his academic progress and his level of impulsivity and aggressive behavior (biting, head butting, kicking, throwing chairs, and running unsupervised down the street outside the school). Although many of these behaviors are not new, this referral was prompted by increasing concerns about safety. The evaluation included record reviews, interviews with parents and school personnel, and a classroom observation of Xavier. Several examples will illustrate the behavioral challenges that Xavier presents. During recess, Xavier was trying to explain to a teacher that his ball had gone over the

The Opioid Crisis and Schools—A Commentary

Ms. Brown, a high school teacher, notices that a student is nodding off in class and no longer turns in homework on time. She asks the student in private if he is all right. He tells her that last month he had a wisdom tooth extraction and started taking prescribed pain medication. When the teacher asks if she can talk with the school nurse, he discloses that his parents are not aware that he has continued to take pain medication, which he is now getting from a friend. Ms. Brown is unclear what to do, especially because the student has just turned 18. Adolescents have an increased susceptibility for substance use due to a number of risk factors, ranging from genetic heritability, peer influences, adverse childhood experiences, and a low perceived risk of harm.1-4 Around 1.3 million, or 5.1% of adolescents ages 12 to 17 need treatment for a substance use problem. Unfortunately, only 6.3% of those who needed treatment in 2015 were able to access specialized care.5 Many of these adolescents are actively using substances and struggling in school. According to the Youth Risk Behavior Survey, 21.7% of high school students have been offered, sold, or given an illegal drug on school premises in the last 12 months.6 The use of prescription opioids for nonmedical purposes has been increasing, with 12.4% of students endorsing a lifetime nonmedical use of these drugs.7 Approximately 20% of 12th grade students describe heroin as either ‘‘fairly easy’’ or ‘‘very easy’’ to obtain.3 Given the ongoing opioid crisis, school personnel should have an understanding of reasons for opioid use, signs of active use, existing screening tools, and how to respond effectively. A common misconception is that teenagers are only ‘‘experimenting’’ when they use substances. However,

Safety Assessment in Schools: Beyond Risk: The Role of Child Psychiatrists and Other Mental Health Professionals

This article presents an overview of a comprehensive school safety assessment approach for students whose behavior raises concern about their potential for targeted violence. Case vignettes highlight the features of 2 youngsters who exemplify those seen, the comprehensive nature of the assessment, and the kind of recommendations that enhance a students safety, connection, well-being; engage families; and share responsibility of assessing safety with the school.

School Safety and the Partnership Between Psychiatrists and School Personnel

Concerns the risks from agitated, potentially violent students who may bring weapons to school. Language: en