After submitting an op ed about the health insurance industry published in today's Boston Globe
I learned about another story of possible mass abandonment of children by the health insurance industry. As with all of my stories, details have been changed to protect the patient's privacy.
Seven year old James was having frequent stomach aches. A full evaluation showed no medical explanation. His mother, Stephanie, was convinced it was "stress." A one hour visit Stephanie by herself revealed the cause. In a slow calm deliberate manner she told me a story of violence and terror.
Stephanie described multiple arrests of James' father for violence towards her, all witnessed by James. Yet now, two years after the latest event, the parents shared custody. James went between the home of his mother and father every other weekend. None of these traumas had ever been addressed in any way.
I told Stephanie I agreed that the stomach aches were indead a symptom of stress. But it was critical that we address not only the symptom, that is not only "what to do" about the stomach aches, but also the meaning of the symptom. I said that James had likely been traumatized by these events and that he continued to experience significant stress on a psychogical level as he traveled between these two homes. Therapy, where both James and his mother together could come to understand what had happened, was essential. Furthermore, the younger James was when he was given this opportunity, the more likely he would be able to get past it.
Mom agreed, and I gave her names of some excellent colleagues who accept their insurance. Later that afternoon, I called one of these colleagues to make sure that he had time. That was when the horror really began.
He said that he was not taking any new patients with this insurance for the following reason. He had received notification a few weeks earlier that this company was now outsourcing its mental health care to another company. All providers would have to get recredentialed, a long labor intensive process. This new company would lower the fee from $75 for a one hour session to $60. There were tighter restrictions on extending coverage beyond a set number of weeks.
This means that mental health practitioners all over Massachusetts are facing a heartbreaking decision. Doing therapy with children is much more than a 50 minute session. It involves speaking with teachers, talking to divorced parents at separate times on the phone, going to school meetings. None of this time is reimbursed. So being paid $60 per visit is impossible. One cannot earn a living with a practice of kids on this insurance. And effective treatment takes months to years, not weeks. Fighting with the insurance company over coverage for each visit is an untenable situation.
I had to call James' mother and tell her that with her insurance she would have difficulty finding a therapist, and that the people I recommended were not available at this time. She was reluctant to pursue therapy in the first place. The fact that I could not connect her with a person I trusted made her back away in full retreat.
Perhaps the worst part of this story is about all of my other patients who are in treatment with my colleague. If he makes the agonizing choice that he cannot afford to contract with this new insurance company, he will no longer be able to see those children.
Multiply this by hundreds of therapists seeing thousands of kids all over Massachusetts. This decision by the insurance company, with its unlimited power, could lead to abandonment of countless vulnerable children.
Senin, 25 Januari 2010
Minggu, 24 Januari 2010
A Pill to be Nice
This past week, a mother in my pediatric practice (details, as always, have been changed to protect my patients privacy) asked if I would increase the dose of her 13 year old daughter’s ADHD medication “so she would be nice all of the time.” She was perfectly serious, saying, “I know she’s capable of it, she can be so sweet.” When I told her that in my experience most 13 year old girls were not “always nice” to their parents, and that I might be worried about a child if she were, she became furious with me. She accused me of giving her daughter permission to be oppositional.
Later that day I opened the most recent issue of the Journal of Developmental and Behavioral Pediatrics. I found the following two page ad placed prominently on the inside cover.
“His ADHD symptoms can be disruptive, but there’s a great kid in there.
Now there’s a new way to help him out”Below this writing is a photograph of a big green monster, with the head removed to reveal a sweet, smiling boy inside.
I am not pleased with this ad. Research in developmental psychology and neuroscience clearly shows that recognizing the meaning of a child’s behavior leads to healthy emotional development. In this case, my patient is working on becoming her own person and so, to leave the comfort and security of her mother’s embrace, she must sometimes actively run in the opposite direction. While certainly her mother does not need to condone her behavior, understanding and respecting her feelings will go a long way in helping her negotiate this difficult developmental stage.
But with the powerful pharmaceutical industry running ads indicating that any unpleasant behavior can be eliminated by a pill, it’s no wonder I have a hard time getting my message across.
Later that day I opened the most recent issue of the Journal of Developmental and Behavioral Pediatrics. I found the following two page ad placed prominently on the inside cover.
“His ADHD symptoms can be disruptive, but there’s a great kid in there.
Now there’s a new way to help him out”Below this writing is a photograph of a big green monster, with the head removed to reveal a sweet, smiling boy inside.
I am not pleased with this ad. Research in developmental psychology and neuroscience clearly shows that recognizing the meaning of a child’s behavior leads to healthy emotional development. In this case, my patient is working on becoming her own person and so, to leave the comfort and security of her mother’s embrace, she must sometimes actively run in the opposite direction. While certainly her mother does not need to condone her behavior, understanding and respecting her feelings will go a long way in helping her negotiate this difficult developmental stage.
But with the powerful pharmaceutical industry running ads indicating that any unpleasant behavior can be eliminated by a pill, it’s no wonder I have a hard time getting my message across.
Senin, 18 Januari 2010
Medication for ADHD: Over-reliance is the Problem
At a panel discussion at the recent meetings of the American Psychoanalytic Association Esther Fine, PhD suggested that children might benefit from psychotherapy rather than medication to “understand the unconscious meaning of psychological symptoms.” It is statements like this that, in my opinion, give psychoanalysis a bad name.
Consider Sara, an eight-year-old girl in my pediatric practice(details have been changed to protect my patient's privacy). In third grade, she was unable to learn because she could not sit still, was extremely disorganized and would impulsively rush through her work. Many family members had a diagnosis of either ADHD or substance abuse, which may have been self-medicated ADHD. She had a dramatically positive response to medication. She mastered her math facts and began to enjoy going to school.
Yet at a follow-up visit about one year into her treatment, things were not going well. Her teacher reported that Sara was increasingly distracted. She suggested to her mother that she ask me to increase her medication dose. "Is anything else going on?" I asked. Sara looked directly at me and said, "I'm sad because I miss my Dad." I looked puzzled and turned to Mom, who then reluctantly told me that Sara's father was in jail for selling drugs, and that Sara had not seen him for several months.
I not only recommended psychotherapy, but explained that I could not in good conscience continue to prescribe medication unless both Sara and her mother were engaged in therapy. But my recomendation was certainly not aimed at helping her "understand her unconcious processes." It was aimed at validating her experience and offering her an opportunity to address the feeling of grief and rage around losing her father. My wish, in an ideal world, would have been for parent-child therapy, where the therapist could not only validate Sara's experience, but help her mother to understand why she did not recognize the impact of this event on Sara's emotional life.
This story is typical of many I hear on a daily basis. If we are going to help these kids, I believe it is important not to frame the discussion as therapy vs. drugs. Likely Sara has neurobiologically based ADHD in addition to significant environmental stress. Instead we should ask, "What can we do to validate the experience of both parent and child?" Limited access to quality mental health care and aggressive marketing by the pharmaceutical industry converge with a cultural acceptance of treating complex problems with medication. We need to support parents and children, not only on an individual level, but also in the form of improving access to high quality primary care and mental health care.
Consider Sara, an eight-year-old girl in my pediatric practice(details have been changed to protect my patient's privacy). In third grade, she was unable to learn because she could not sit still, was extremely disorganized and would impulsively rush through her work. Many family members had a diagnosis of either ADHD or substance abuse, which may have been self-medicated ADHD. She had a dramatically positive response to medication. She mastered her math facts and began to enjoy going to school.
Yet at a follow-up visit about one year into her treatment, things were not going well. Her teacher reported that Sara was increasingly distracted. She suggested to her mother that she ask me to increase her medication dose. "Is anything else going on?" I asked. Sara looked directly at me and said, "I'm sad because I miss my Dad." I looked puzzled and turned to Mom, who then reluctantly told me that Sara's father was in jail for selling drugs, and that Sara had not seen him for several months.
I not only recommended psychotherapy, but explained that I could not in good conscience continue to prescribe medication unless both Sara and her mother were engaged in therapy. But my recomendation was certainly not aimed at helping her "understand her unconcious processes." It was aimed at validating her experience and offering her an opportunity to address the feeling of grief and rage around losing her father. My wish, in an ideal world, would have been for parent-child therapy, where the therapist could not only validate Sara's experience, but help her mother to understand why she did not recognize the impact of this event on Sara's emotional life.
This story is typical of many I hear on a daily basis. If we are going to help these kids, I believe it is important not to frame the discussion as therapy vs. drugs. Likely Sara has neurobiologically based ADHD in addition to significant environmental stress. Instead we should ask, "What can we do to validate the experience of both parent and child?" Limited access to quality mental health care and aggressive marketing by the pharmaceutical industry converge with a cultural acceptance of treating complex problems with medication. We need to support parents and children, not only on an individual level, but also in the form of improving access to high quality primary care and mental health care.
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