While many child mental health professional stress the importance of obtaining information from multiple sources (child, mother, father, teachers, etc.), it is less clear what exactly one should DO with this information.  This dilemma is highlighted in circumstances where the reports from different informants paint a very different picture of the same child. 

In a recently accepted paper that will appear in an upcoming edition of the Journal of Child and Adolescent Psychopharmacology, we examined this issue in a community sample of Dutch children (Rettew et al., in press).  One major finding from the study was just how common discrepant reports were between parents and teachers.  Indeed, they were the rule rather than the exception. For example, among children rated by mothers as having clinical levels of aggression or rule-breaking behavior, teachers reported clear problems in only 22% and 12% of the time, respectively.  Agreement for attention problems was somewhat better. 

Disagreement was also found to be related to specific variables.  Problems reported at home but not at school were found to be related to parental stress, child temperament, and gender. 

When encountering such a clinical picture, the instinctual response is often to try and figure out who is “correct” and move on from there.  Alternatively, there may be great utility to explore the range of possibilities for informant disagreement. 

1. The child may actually be different in different settings.   Understanding why, for example, a child is disruptive at home but not at school can offer important clues as to environmental changes that could be incorporated more widely.
2. An informant’s own difficulties might be influencing judgment.  A parent who is depressed, for example, might have more trouble tolerating typical boisterous behavior, leading to needless conflicts that might be avoided if the parent is treated.
3. The presence of intentional misreporting can affect treatment too.  Simply discounting a parent who under-reports on his or her child to avoid medication treatment, for example, is unlikely to solve the problem downstream.  It is often better to discuss the issue head on to avoid future problems.

For those interested in further information, there will be a Department of Psychiatry Grand Rounds on this topic on Friday November 11, at 10:30am in the Davis Auditorium at Fletcher Allen Health Care in Burlington.

Reference

Rettew D, et al.  When Parents and Teachers Don’t Agree:  The TRAILS Study.  J of Child and Adolescent Psychopharmacology, in press.

by David Rettew, MD

When many people think about child psychiatric treatment, what comes into their mind is medications.  While it is true that many medications can be an important part of a patient’s overall treatment plan, other areas also need to be considered towards providing comprehensive family-based care.

In training medical students and residents, we often urge them to think about five different areas that may require further assessment and intervention. 

1. Child Psychotherapy and Counseling.  Research shows that certain types of psychotherapy can be extremely effective for child emotional behavioral problems.  The evidence is particularly strong for Cognitive-Behavioral Therapy and its offshoots (Trauma-Based CBT, Dialetical Behavior Therapy).  The challenge if often finding one.  See resources contained in this site.
2. Parental Guidance and Treatment.  Kids don’t come with instruction manuals, and the job of being a parent is even tougher for children with emotional behavioral problems.  Plus, it is well known that most psychiatric conditions run in families, meaning that the parent may be struggling with the exact same thing as the child.  Ask parents if they are struggling and could use advice and help them access their own care if needed.  If you are a family practice physician, you are in the perfect position to implement some of this treatment for the whole family. Consider using screening instruments to make this important aspect of a child’s care more efficient.
3. School.  Children spend a huge portion of their life at school.  The school shapes them and they shape their experience at school.  Many children benefit if their treatment continues into the school setting either informally or through specific plans such as IEPs or 504s.  Sometimes physicians and their offices need to advocate for further testing, accommodations, and school based interventions.  These efforts can definitely pay off and make school a much more enjoyable and rewarding place to be.
4. Environmental Changes.  Assessing and getting involved in particular aspects of the family environment can be offer clues about overall family functioning and provide important targets for interventions.  A few important areas to assess and encourage are the following.
   1. Sleep and bedtime.  When is bedtime?  Where do you go to sleep?  A regular routine that provides a quiet sleeping environment and enough hours can make a big difference.
   2. Nutrition.  Do you eat breakfast every day?  What do you have?  What are the rules for snacking?  Some basic guidelines on nutrition can help not only concentration and energy but also deal with other major public health problems such as child obesity.
   3. Media usage.  The average teen uses media up to 8 hours a day.  Knowing both the quality and quantity of media usage (cell phones, television, video games) and helping parents set appropriate limits can enable children to make the most of their time while not exposing them to media that can exacerbate aggression or anxiety.
5. Medications.  In conjunction with these other types of interventions, medications can be another useful aspect of treatment.  Patients and families need to be aware of the potential benefits and adverse affects and be well informed of the limits of treatment.

Giving attention to these five areas will keep the treatment balanced and comprehensive, thereby maximizing the chance for success and the opportunity for children not only to improve but to thrive.