My other three children occasionally pop their heads in the room, and it takes every ounce of patience I can muster not to snap at them to leave me alone. They are scared. They’ve witnessed their brother’s episodes before, and they want their mother to reassure them that everything will be all right.
Only I don’t know that it will be.
My son is a sweet, fun-loving boy who loves jokes, reading and parkour. But he has a long list of mental health problems and skill deficits that make it nearly impossible for him to control his emotions. He suffers from extreme anxiety and depression, and he’s attempted suicide twice. He’s a bit like Bruce Banner. Kind and mild-mannered ordinarily, but you wouldn’t like him when he’s angry.
Though he was making a lot of progress earlier this year, the pandemic has made it very difficult for us to get my son the treatment he needs. His Intensive Outpatient Program transitioned to telehealth, but my son couldn’t concentrate on the Zoom sessions, so the IOP team quickly discharged him. I found him another therapist who was available for in-person sessions, but he had a five-week wait. Even after we got in, it wasn’t enough. My son was flailing in a mental health system that was simply not designed to help kids like him.
To be clear, while the pandemic has made it particularly difficult for us to access competent care, my son’s mental health problems affected him before the coronavirus, and I’m sure they’ll continue once it’s over. Both now and in the post-coronavirus future, we need the help of mental health professionals who understand kids like him.
Better options for behaviorally challenged kids
I’ve taken my son to countless therapists and psychiatrists. I’ve read more than a dozen parenting books and tried all of their suggestions. I can’t count the number of times a professional has told me that if I just did what they told me to do, my son’s behavior would improve. But it never worked.
“I think you’re bumping up against the limits of their training,” says Ross W. Greene, a psychologist and the author of “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children.” “Most mental health clinicians are trained in behavioral models of therapy. That’s how I was trained in graduate school.
“I’ll tell you what I would’ve said, years ago, if you’d come to me and told me that the rewards and punishments weren’t working. I’d have said, ‘You must not be doing it right.’ And that’s very frustrating to the parents because it turns out, we were wrong about that,” he added. “Those models assume that kids do well if they want to. We want parents and educators and therapists to change their lenses. The most important theme of our model is that kids do well if they can.”
Greene says that explosive kids have lagging skills and unsolved problems, and it’s our job to teach them the skills they need to solve those problems. He recommends doing this collaboratively, allowing the child to share their own ideas for solving their problems. For example, my son frequently throws a tantrum before bed. Working through Greene’s method with him, I learned that he feels pent-up energy in the evenings and needs to exercise for a while right after dinner.
Anisha Patel-Dunn, a psychiatrist and chief medical officer at LifeStance Health in Lafayette, Calif., says clinicians serving explosive children must work closely with the parents, especially if they are treating kids via telehealth. “Young children are becoming more facile with virtual formats, but their attention spans are understandably short, so visits often include time with the child, and time with parents and caregivers.”
Trevor Dahle, clinical director for Havenwood Academy, a residential treatment center for girls with reactive attachment disorder in Cedar City, Utah, says clinicians should work almost entirely with the parents if telehealth is the only option.
“While telehealth may be better than nothing in many situations, children simply lack the verbal skills to communicate adequately just through talking,” he says. “That is why play therapy rooms and sand trays are the most common means of providing therapy for kids.”
All three of the experts I spoke with said clinicians must treat the whole family, and they must do so with empathy. Many people are quick to blame parents for their children’s behavior problems. I know there are people who think my son’s angry outbursts are my fault. But the truth is, most parents don’t have the skills to treat explosive behaviors on their own.
A struggling mental health system
The demand for mental health services far exceeds the supply, meaning families often have long wait times for care. A 2019 study found as many as 1 in 6 children in the United States may have a diagnosable mental health condition. But according to a 2018 study, there are about 8,300 child and adolescent psychiatrists in the United States, and an estimated need for more than 40,000. This may leave parents relying on pediatricians, who are not trained specialists in psychology, for psychiatric care, including drugs.
There are also financial barriers to treatment, including families who don’t have insurance and others whose plans cover only a small fraction of the cost of care. In fact, many mental health providers no longer join insurance networks because of the low rates of reimbursement they offer.
Indeed, some families are forced to use inpatient psychiatric hospitalization as a stopgap measure for kids who need immediate care but can’t access it from an outpatient provider. My family is one of them.
Last month, after a particularly explosive episode in which my son punched, kicked, threw furniture and threatened suicide, my husband and I made the heartbreaking decision to admit him to a psychiatric hospital. I hated every minute of the 10 days he was there. Ten days during which his childhood was put on hold so that he could participate in a structured, therapeutic program. I am certain that if we’d been able to access appropriate mental health care in our community, he could’ve spent those 10 days at home.
We don’t even know how much money this hospitalization will cost us yet. The total bill is many thousands of dollars, and the hospital is out of network with our insurance. So like many American families, we will simply wait to see if we have to come up with an impossible sum or a slightly more manageable one.
What needs to change
This all left me wondering what must happen to provide these kids, and their families, a chance for a better outcome. Here is a list of recommendations from Greene, Patel-Dunn and Dahle.
· Train more clinicians in treatments for children with serious mental illness and explosive behavior problems, especially methods that emphasize family therapy and support for parents.
· Insurance providers should offer free, annual mental health screenings to all kids. This may also help reduce the stigma surrounding mental health struggles. Additionally, they should treat mental health care as truly equal to medical care by covering the full length of care and reimbursing providers at market rates.
· Increase local initiatives that provide education and counseling to struggling families, including partnerships between schools, physicians and mental health providers.
· Traditional models of care that separate medical, mental health and substance abuse treatment are problematic. Instead, mental and physical health care should both be easily accessed in the same place, through the same funding streams, with information-sharing capabilities.
· Telehealth is a great option for serving kids who might not otherwise be able to access treatment, especially during the pandemic. But if a child is having difficulty connecting with their therapist virtually because of age-related communication issues, clinicians should explore safe options for seeing the child face-to-face.
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