News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
Why a new, whole-family approach can make a difference for the smallest patients.
Lice, stomach flu and a swirl of family chaos. Joyce Harrison’s recent description of what’s routine drove home the scope of programs she heads for children age 0 to 5.
Harrison, one of only a small number of psychiatrists to specialize in that age group, oversees a new diagnostic clinic at the Hopkins Bayview campus and an even newer outpatient program—both often a last resort in reversing toddlers’ downhill trajectories. She described both in a recent Psychiatry seminar.
“We’d always assumed problems started at age 6, when troubled children appeared at school,” says Harrison. “But I’m seeing them much younger.” Of the young ones at the preschool clinic since its March opening, more than a third were age 3; two patients came at a year old. “Problems in this age group had been written off as bad behavior or poor parenting. Yes, the causes can be environmental. But, in many children, biology’s clearly at fault.”
Take Amy, born prematurely to a mother on cocaine.* She came to the clinic at age 3 because of violent behavior toward siblings and an unhealthy fecal
fascination. Amy has low muscle tone; she’s clumsy and speech-delayed. Her father suffers from anxiety disorders. Under stress from their own problems and the imbalance Amy brings, the parents argue frequently. The only time there’s calm, the mother explains, is well after midnight.
“Kids come to us because of behavior problems,” says Harrison. They’re aggressive, hyperactive; they can’t go out in public—the presentation is almost a stereotype. So Harrison must resort to detective work. “Everything is by inference in this age group,” she says. “You have to watch, interpret.” The Infant and Toddler Mental Status Exam and developmental screens she and her team employ involve rating play behavior, for example, or reactions to new situations. She routinely videotapes children in the programs’ playroom.
What underlies Amy’s behavior, roughly put, is wiring. She was born with a chemical exposure. Yet family problems all contribute. How, then, do you help this new person whose needs are so pressing?
Harrison realized early on that weekly therapeutic visits would change little. Also, sending children out for wait-listed speech and other evaluations means unacceptable delays. So she and Hopkins colleagues set up the Preschool Therapeutic Learning Center (PTLC), an intensive program that, unlike others, enfolds a child’s core family, three hours a day, five days a week. “About 90 percent of our parents have a psychopathology,” she explains, “and the siblings aren’t without problems.”
But whether diagnosing or treating, the team sees obstacles in the lack of valid diagnostic categories for preschoolers and the slim number of evidence-based treatment protocols (an exception: PATS, page 1). “There’s little precedent for what we do,” says Harrison. So their mainstay is considerable collective experience.
Harrison has ties to a trusted network: clinician-pioneers in early child psychiatry, Head Start experts, Maryland’s Early Childhood Mental Health Steering Committee, a study group for the American Academy of Child and Adolescent Psychiatry, and academics at the University of Maryland who’ve run a 20-year infant study program. “It’s taking a village to do right by these children,” Harrison says.
So a taxi was sent for Amy’s mother, father, baby brother and 5-year-old sister to bring them to the PTLC’s airy, sunlit playroom high in the west Mason Lord tower. It’s a low-stress environment, much like a preschool but more structured and more supervised. While Amy and her sister were in play (therapy) groups or seen singly by a therapist, their parents were registered for psychiatric or addiction services.
The first weeks were rocky. Often, one parent didn’t come. The baby was sick. Harrison’s discovery that Amy had lice got the family packed off in a taxi to the pharmacy and then home. Stomach flu kept them away for days. On their return, lice were rediscovered; the older sister threw up: It was back to the pharmacy in the taxi. With each day, however, the family became more resilient. “You could watch the parents’ attitude change,” says Harrison. “They see us all working to help their children and say, Wow, my child really has value. They realize problems can have a solution.” On Fridays, she says, the families don’t want to leave.
For information, call 410-550-0104.
*For privacy, Amy’s story is changed in kind but not spirit.
|THE BUBBLE TEST AND MORE|
We asked Dr. Harrison some specifics.
What are your feelings on medications for the 0-to-5s?
They’re absolutely a last resort. Less than 2 percent of our patients use them and then, only the few medications clinicians are comfortable with, like some stimulants and SSRIs. I’d rarely use the antipsychotic Risperdal (just approved for this group) and, then more for sedation and cognitive organization. Given preschoolers' amount of imaginative and fantasy thought, it's both difficult and rare to see psychosis!
What about bipolar disorder or depression?
I have an extremely high threshold for calling anything bipolar. I think it’s much overused in the young. That doesn’t mean it doesn’t exist. At this age, it’s characterized by grandiosity beyond what’s age-appropriate, sometimes hypersexuality and hyperactivity. You look for family history.
The main signs of depression in this age are withdrawal, a lack of pleasure. I find the bubble test helpful. Most kids are joyful around bubbles. If they don’t respond, they’re often depressed. They also withdraw, are a little irritable.
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