Who is Treating my Child

When a child is admitted to a hospital, an avalanche of healthcare providers get involved. This creates considerable amount of confusion. Parents hear multiple references to “your child’s doctor“, presumably a single individual in-charge. At the same time, people identifying themselves as “Doctor X” turn out to be not that, and further inquiry reveals that they are consulting physicians, the admitting doctor, on-call doctor, or a resident.

The Attending

After a child is admitted to a hospital, they are assigned to a “prescriber” who is responsible for their overall care. In terms of training. that person is generally a physician or a nurse practitioner (NP). Other terms used for that person may be “the attending,” “psychiatrist,” or “primary doctor.” The term “attending” is probably the most reliable way to refer to the person-in-charge and will be used here as such.

A whole slew of healthcare providers may be working under the attending physician/NP with a direct role in diagnosing and treating a child. These include physician assistants, therapists, and psychiatrists-in-training (residents and fellows). How the responsibilities are distributed among these professionals vary from hospital to hospital, and it is always useful to inquire about the organizational structure.

Other commonly used terms:

Psychiatrist is a vague term which generally refers to a physician who had completed medical school and residency (specialty training) in general psychiatry. Many, but not all psychiatrists are “Board-certified psychiatrists” which means that they passed their “Boards” – an arduous test, after residency.

Child psychiatrists are physicians who completed residency training in general AND child/adolescent psychiatry. Again, they may or may not be “Board-certified.”

Unit Chief is a psychiatrist who treats patients but also is administratively in charge of an inpatient unit. A psychiatric unit may have several attendings, but only one unit chief.

The “admitting doctor/physician” is usually a different person who has shorter involvement at the point of hospital entry. The admitting doctors “hands off” the patient to the attending doctor in the hospital.

The attending physician may ask a consultant, e.g. a neurologist or a pediatrician, to weigh in on a complex case and make recommendations. Many hospitals employ nurse practitioners or physician assistance in this role.

The “covering doctor” (AKA doctor-on-call, medical officer, “night-float”) is responsible for urgent issues that may arise when the attending is not on duty, e.g. on weekends or overnight. The covering doctor may or may not be a psychiatrist, and they are generally unfamiliar with every particular patient. Many teaching hospitals have psychiatric trainees (residents and fellows) fill this role.

Minimum requirements for a physician to have a particular title:

Medical School

Licensed to practice medicine Residency Fellowship Board-certified, general psychiatry

Board-certified, child and adolescent psychiatry

Resident, incl. Chief Resident Yes varies by State current position
“Child Fellow” Yes Yes Yes current position
Psychiatrist Yes Yes Yes
Child psychiatrist Yes Yes Yes Yes
Board-certified psychiatrist Yes Yes Yes Yes Yes
Board-certified child psychiatrist Yes Yes Yes Yes Yes Yes

 Common titles of prescribers

MD, DO, and MBBS: These are physicians (not necessarily “psychiatrists” – see above) who completed a medical school and are licensed to practice medicine in the United States.

*  “MD” is the degree awarded by allopathic medical schools;

*  “DO” degrees are awarded by osteopathic medical schools;

* “MBBS” is a degree awarded by medical schools outside of the US.

NP is a nurse practitioner, or an advanced practice registered nurse(APRN), who are licensed to diagnose and treat patients with minimal or no supervision (depending on state).

PA is a physician assistant who practices medicine and surgery with some degree of supervision. In some hospitals, the term PA may refer to “psychiatric attendant” or psychiatric aide.

What is a PRN, and why is my child getting it???

The word PRN is thrown around casually by healthcare professionals as in “he was aggressive to staff, and the doctor gave him a PRN,” and “she took two PRNs for headache and went to sleep.”

P.R.N means pro re nata in Latin, or “as needed” medication. This is in contrast to the medication that is given on a scheduled basis. There are several situations where PRNs are used in a psychiatric hospital; some of these situations involve PRNs being given without explicit consent from the patient or the parent.

PRNs for aches, pains, and discomfort

When a child comes to the hospital, parents are often asked to give permission (consent) for several common medications which can be used as the need arises. Examples include, giving Tylenol or Motrin for headaches or cramps, Milk of Magnesia or Colace for stomach problems or constipation, Melatonin or Benadryl for insomnia, and Vistaril or Ativan for anxiety. There are numerous advantages to selecting PRNs early on (i.e. before they are needed): patients or parents can make an informed decision with the admitting doctor, take time to recall all the allergies and sensitivities that the patient may have, and what had worked in the past. This is also the time to discuss potential interactions and side effects of the PRNs.  The alternative is often rushed and haphazard. A parent may get a call at 3AM: “Your child has a headache and there is no consent for anything; what can we give him to help him get some rest?”

PRNs for behavioral emergencies

On occasion, parents are shocked to learn that their child received a medication that they did not explicitly consent to. This can take the following form: Dad gets a phone call from a nurse on the unit, who tells him that his daughter was threatening staff, was not responding to verbal de-escalation, became aggressive and violent, and then “the doctor ordered an injection of thorazine 50mg.” This is often upsetting and scary to parents and patients; families often imagine their child manhandled and “put down” with a tranquilizer. It may be reassuring to realize that these situations are likewise unpleasant and scary for the staff involved; the staff tries to avoid them at all cost for a number of reasons.

The underlying principle is that in an emergency, a consent from parents or the patient is desirable but not required. The best way to mitigate this, is to try to anticipate most common emergencies and plan ahead: most emergencies in a psychiatric hospital involve behavioral dysregulation, i.e. becoming a danger to self or others. Parents can and should discuss it on admission or at any time after that. For many parents this is highly unpleasant; nobody  wants to talk about a situation (no matter how rare or unlikely) where their child is at their worst. Others imagine that discussing emergency plan which involves injectable medication makes staff “trigger-happy,” and more likely to reach for the needle, when something does not go their way; this is false. Behavioral de-escalation plan should be a part of every patient’s plan of ttreatment, and parents, who know their child the best, could offer ideas as to what to do first. For example, for some children being able to write or color, or punch a pillow may be soothing. Staff would try these, and a number of other verbal techniques that they are trained at; nurses will reach for the needle only if the child 1) continues to be danger to self or others despite non-pharmacological interventions, and 2) unable to take similar medication by mouth.

What PRNs are used in behavioral emergencies

Hydroxyzine (brand names: Vistaril or Atarax) is an anti-histamine medication (similar to Benadryl), and, thus fairly sedating. It also relieves anxiety by acting on the serotonin system. It is a very safe medication, but is not available as injection (can only be given by mouth). It is often ordered as a PRN for mild agitation or anxiety.

Benadryl (generic name: diphenhydramine) is an anti-histamine medication that can be given by mouth or injected intramuscularly (IM). It is fairly sedating, but it also has “anti-cholinergic” effects. This means that at higher doses it causes the “fight-or-flight” response of the sympathetic system: increased heart rate, slowed bodily functions (leading to constipation, urinary retention), and at its worst, confusion and delirium. Despite this, it is considered a very safe medication in young people.

Thorazine, or chlorpromazine, is an anti-psychotic medication. It can be injected or given by mouth; it promotes sedation and also alleviates psychosis, which can contribute to severity of the behavioral emergency in some patients. It has anti-cholinergic effects, similar to Benadryl. As all antipsychotics, it can cause abnormal movements (e.g. a dystonic reaction). However, when it comes to emergency use of anti-psychotics in children, thorazine is generally preferred to other anti-psychotics, because the risk of a dystonic reaction is the lowest.

Haldol, or haloperidol, is another anti-psychotic medication, arguably more potent than thorazine when it comes to treating acute psychosis. It has a higher risk of a dystonic reaction, and, in an emergency, it should be given with another medication that treats dystonia (Benadryl, Cogentin, or Ativan)

Ativan (lorazepam) is benzodiazepine medication that quickly treats severe anxiety; it is also sedating and often used as sleeping-aid. Thus, it is often classified as anxiolytic-hypnotic. It is relatively safe when used in an emergency situations. Rarely, some children (particularly those with autism or developmental disabilities) may have a “paradoxical reaction” to Ativan, i.e. becoming more agitated, anxious, or aggressive.

Supporting your child after hospitalization

Parents are often unsure about how to relate to their children after they come home. This is particularly true if the hospitalization resulted from some significant life-changing event, like a suicide attempt.  During a family session where we were discussing discharge plan for a 16-year-old teenager who was struggling with low self-esteem and suicidal thoughts, a father asked bluntly “Am i suppose to kiss her ass now?”

For some parents, child’s hospitalization is a rude introduction to mental illness  which can leave them feeling shell-shocked. For others, it’s yet another setback in a long struggle with their child’s chronic illness. For all parents child’s illness creates a sense of sinking apprehension: “what am I doing wrong??”

The father who captured the dilemma so nicely, felt blindsided when it emerged that his occasional comments about his daughter’s weight were very hurtful and exacerbated her underlying depression. Resentment persisted when he would enforce house rules and curfew.

The short answer I gave the father was a categorical “No.” His daughter will continue to go to school, and should be expected to do her homework, clean her room, and turn in her cell phone at 10pm. Her life is not all rosy, but she is neither an invalid, nor royalty.

Supporting your son or daughter with mental illness does not mean relaxing common sense rules, compromising on safety, or giving in to more demands. Rather it means 1) improving communication and staying 2) rational, 3) supportive and 4)  consistent. The specifics of implementing these principles vary from child to child, but at their core, these principles are the foundation of good parenting. It’s worthwhile to deliberately think about and discuss each one within the family as well as with treating professionals.

For the young teenager coming home after a week in the hospital, we discussed treatment recommendations, safety plan, her needs and responsibilities, as well as the needs and responsibilities of the parents. We asked the parents to put themselves in her shoes, and to try to imagine what it’s like to be an adolescent who on one hand is wrestling for independence, and on the other, needs warmth, love and support. This is true for all teenagers. In her particular case, the struggle with weight, body image, and depression provided additional challenges.

Supporting your child after hospitalization refers to being “tuned-in” to the particularities of their age, development, strengths, and struggles. Being tuned-in does not mean avoiding the topic of illness or dysfunction, or pretending that everything is normal. It means being increasingly sensitive and available. In most cases, saying something like:

“I know this is a very painful/uncomfortable area for you. Let’s talk about what I/you can do to make it better”

could open a dialogue. Underlying this statement are the first three principles of parenting outlined above. Checking in with your child regularly and consistently with this attitude takes care of the 4th.

Our patient told us that she is not willing to get into discussion about her weight or body image with her parents at this time. One area she thought that her parents COULD help her, was by not having soda in the fridge which would help her cut out liquid calories. We all agreed on treatment recommendations (therapy and medication), and a safety plan.

Parents have an important role in their children’s lives, long after they learn to brush their teeth and feed themselves. After a psychiatric hospitalization, the balance of their needs, abilities, strengths and struggles is particularly tenuous. Attending to the basic principles of good parenting will help in the most complex or difficult situations facing your child and your family.