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Releases Packard
Children's News
Children's Fund
Update |
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Body and Mind
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Carl Feinstein, MD, Endowed Director of Child and Adolescent Psychiatry |
When Feinstein became Packard’s chief of child psychiatry in 2005, one of his first priorities was to further strengthen the Pediatric Psychiatry Consultation-Liaison Service, an innovative program that offers psychiatric counseling and treatment to children with a broad range of medical conditions, from leukemia to heart disease. Program staff members often are asked to coax a recalcitrant patient into accepting treatment, or to assess the long-term neurological effects of treating a major illness.
''I had a medically ill sister,'' recalls Feinstein, professor of psychiatry and behavioral sciences at Stanford. ''Therefore, I am an absolutely tenacious bulldog when it comes to meeting the psychiatric needs of medically ill children at Packard, both inpatient and outpatient.''
The Consultation-Liaison Service is just one of several outstanding mental health programs offered at Packard, including seven outpatient specialty clinics for children with specific behavioral and psychiatric conditions: depression, autism and developmental disorders, early life stress, bipolar disorders, anxiety, disruptive behavior disorders, and eating disorders.
''We are the busiest freestanding, non-publicly funded psychiatric clinical service in this area,'' Feinstein says. ''We’ll have about 10,000 patient visits this year, but we pride ourselves on giving individual attention to each family and each child.''
As an example, Feinstein points to Packard’s nationally recognized eating disorders program, which consists of an outpatient clinic and the Comprehensive Pediatric Care Unit, a 15-bed inpatient facility located at El Camino Hospital in Mountain View. Treating eating disorders, which he notes can be life-threatening, involves a team of child psychiatrists, psychologists, and specialists in adolescent medicine who evaluate the nutritional and pharmacologic needs of the child and develop a psychotherapy regimen tailored to patient and family.
This interdisciplinary approach to care also applies to clinical research, an important component of Packard’s child psychiatry program. Feinstein, for example, studies autism spectrum disorders, a group of illnesses that affect a child’s ability to communicate and interact with others. He and his colleagues are using cognitive, genetic, and neuroimaging techniques to find the underlying cause of these serious disorders, which affect an estimated 1 in 150 children.
Training new fellows in child psychiatry and psychology is another critical part of the program, Feinstein says. ''Our mission is to integrate research, clinical practice, and teaching. A lot of families actually work with our advanced students, who have a deserved reputation for being not only smart but very caring.''
The number one dream of the faculty, students, and staff of Child and Adolescent Psychiatry is to discover cures for these disorders, Feinstein says. ''Mental disorders often get swept under the rug, but 5 to 10 percent of children have pretty significant problems. We’ve made great progress treating these conditions, but there are still too many children and not enough answers.''
An estimated 1 in 50 children is at risk for bipolar disorder, a debilitating condition characterized by extreme mood swings. Formerly known as manic depression, bipolar disorder worsens as the child moves from adolescence into adulthood, says Kiki Chang, MD, director of Packard’s Pediatric Bipolar Disorders Clinic.
''It’s a very serious illness in its most severe form,'' says Chang, associate professor of psychiatry and behavioral sciences at Stanford. ''About 15 percent of people with bipolar die from suicide. It also leads to significant cardiovascular and substance abuse problems later in life--an economic burden that costs society billions of dollars per year.''
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Kiki Chang, MD |
Chang has been treating and studying young bipolar patients since he arrived at Packard in 1996. Today, he’s an internationally recognized authority on this enigmatic disease. ''The problem is that you have to be very experienced to tease out what’s normal childhood behavior and what’s a symptom of bipolar disorder,'' he says.
The disease is especially difficult to diagnose when the child is very young, adds Chang. ''When you see an adult with a manic episode, it’s pretty hard to confuse it with anything else. Their mind is racing, they can have grandiose, even psychotic, delusions and hallucinations, and they do very odd things. But with kids it’s not as obvious. In fact, manic episodes in young children often are confused with attention deficit hyperactivity disorder (ADHD), and in teenagers it’s even confused with normal adolescent behavior.''
Full depressive episodes usually do not appear until after puberty, Chang says, and are often treated with the wrong medications. ''We see a lot of children who are prescribed antidepressants and then have resulting mixed episodes, which are episodes of mania and depression at the same time,'' he explains. ''They’re very uncomfortable, and we think it’s very bad for the brain. So antidepressants are at the top of our no-no list for kids with bipolar disorder.''
To understand the biological causes of the disease, Chang is conducting genetic and neuroimaging studies with patients and families at the Pediatric Bipolar Disorders Clinic. ''We think there’s a process in which the child’s brain slowly changes before a full-blown manic episode occurs,'' he says. ''Stress and other environmental factors trigger subsequent episodes, and it gradually becomes harder and harder to treat.''
Research suggests that children with depression and/or ADHD who have a strong family history of bipolar disorder are at higher risk. ''For these kids, we’re really interested in intervening early and preventing that first manic episode from happening,'' Chang notes. ''We have a large study now looking at several genes and how they interact with brain functioning to see if we can predict which children are likely to develop bipolar disorder.''
But heredity is only part of the story: ''Environment is also a player in causing bipolar disorder, so if we can lessen the stress in a child’s environment, say at school or at home, we think we can improve their functioning.'' Chang recently launched a new study on family-focused therapy, which is designed to improve the way young patients interact with siblings and parents. ''We want to give kids more power over their own moods by recognizing and avoiding the stressors that trigger manic episodes,'' he says.
Chang points out that not all high-risk children will indeed progress in their illness. ''Many children with a bipolar parent will not develop bipolar disorder,'' Chang says. ''That’s why we’re doing magnetic resonance imaging of patients, siblings, and parents to look inside the brain and see if we can find some physical clues as to whether a child is likely to become bipolar.''
Chang’s lab also has conducted clinical trials of a promising drug called Depakote, commonly used to treat bipolar disorder, but which might also be useful in prevention. He hopes to obtain additional funding to expand the study and test other medications that could actually prevent bipolar disorder from developing in high-risk children.
''All of our research will take more time and money,'' he says. ''But it’s worth it, because anyone who has worked with children with bipolar disorder realizes that unless it’s detected early and treated correctly, it will completely derail all areas of their functioning, educational and social development, and personal growth.''
When Sharon Williams was an undergraduate at Pomona College, she enrolled in a class that would ultimately change her life. ''I took a neuropsychology course that seemed like the perfect combination of my interests: understanding the biology of the brain and the psychology of human behavior and emotion,'' she recalls.
In 1995, after earning a PhD in clinical psychology from the University of Cincinnati, she came to Packard Children’s for a two-year postdoctoral fellowship in child psychology. Today, she is director of the fellowship program.
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Sharon Williams, PhD |
''I really enjoy teaching and mentoring up-and-coming psychologists in a state-of-the-art practice,'' says Williams, an associate professor of psychiatry and behavioral sciences at Stanford. ''They get to see cases here that they wouldn’t usually see. Many people come to Packard with children who don’t fit neatly into one diagnosis, or with kids who have been given different diagnoses by multiple providers over the years, and they’re coming to us to ask what is really going on.''
Williams is also director of Outpatient Child Psychiatry, with responsibility for Packard’s seven outpatient specialty clinics. ''Because we have psychiatrists and psychologists, we can conduct initial evaluations as well as provide ongoing individual and family therapy, psychopharmacology, and psychological testing to inform treatment and recommend appropriate school placement,'' she says.
As a clinical researcher, Williams focuses on the cognitive and psychological effects of medical illness, specifically pediatric cancer patients who have undergone bone marrow transplants. She points out that because of advances in pediatric medicine, a child who may have died from a serious illness 30 years ago can survive today, but may face unknown long-term effects.
''Once you get children through the acute phase of cancer and into remission, you have to consider what cognitive or emotional damage resulted from that experience,'' she explains. ''We didn’t have to deal with that question years ago, but now that we know that children can survive, we have to look at the quality of that survival.''
Of particular concern for bone marrow transplant patients is the long-term impact of cancer treatment on memory, attention, and executive functioning--the ability to organize, plan, and sequence various tasks.
''One key issue is the age of the child,'' Williams notes. ''Some research suggests that children who receive transplants at younger ages have more cognitive deficits than older children. What does the illness or treatment disrupt in the developing brain of a young child that impairs their functioning years later?''
To find out, she and her co-workers are collecting cognitive, genetic, and neuroimaging data from a dozen transplant patients ages 5 through 14. ''For children for whom the cognitive and imaging data show negative findings, we can go back and evaluate their treatment regimen,'' she says. Williams is also conducting exploratory work with genetics. For that study, she is comparing saliva samples from patients and their parents to examine which genes are transmitted and thereby influence the cognitive outcome for patients.
Williams also conducts psychological testing and follow-up exams for children with traumatic head injuries. ''Children with moderate-to-severe head injuries can have difficulties with attention, concentration, memory, executive function, and intellectual functioning,'' she says. ''We find that once children recover physically, if no one has assessed them, they often have persistent difficulties in school with attention and concentration and remembering what they have learned.''
A diagnosis of a disease or a head injury can be very traumatic for the child and the family, she adds. ''Helping them get back on track so the kids can be kids and the household is together again is very rewarding.''
Working with troubled children and adolescents can be tremendously challenging. For psychiatrist and pediatrician Shashank V. Joshi, MD, FAAP, the key is to communicate sincerely with patients and family members alike.
''Even in a busy pediatric clinic, you have to be aware that a child or parent is observing and evaluating you from the moment they walk into your office,'' says Joshi, an assistant professor of psychiatry and pediatrics at Stanford. ''Are you asking thoughtful questions? Are you attentive to the child’s emotional state? Does your tone of voice convey empathy, respect, and understanding for their situation?''
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Shashank V. Joshi, MD, FAAP |
As director of Packard’s program in Child and Adolescent Psychiatry Training, Joshi prepares fellows, residents, and medical students to deliver compassionate care for children and adolescents with complex emotional illnesses.
''In our training program, we try to model the idea that, while one family’s child or teen might be the last patient of the day for you, you are likely the one and only doctor for them that day,'' says Joshi. ''You have to be genuinely there for each family and every child.''
The training program at Packard Children’s is one of the largest in the country, and draws from a broad range of disciplines, including developmental psychology, genetics, and the neurosciences. This collaborative effort was enhanced three years ago when Joshi helped to establish the Neuropsychopharmacology (NPP) clinic at Packard, with seed funding from the Harman Endowment and the Lucile Packard Foundation for Children’s Health.
''The idea was to create a clinical setting where advanced trainees in child neurology and child psychiatry could work together with patients who have chronic neurological and psychiatric illnesses,'' Joshi explains. ''For example, an 11-year-old with autism and epilepsy--who also has an anxiety disorder.''
The NPP clinic is one of only a handful of formal pediatric neuroscience collaboration clinics in the country, and was created because many neurologists do not feel confident treating children with psychiatric disorders, and vice versa for psychiatrists. ''A neurologist, for example, may not feel comfortable managing depression, and a psychiatrist might be uneasy about prescribing certain psychotropic medications with potential neurological side effects,'' Joshi notes. ''But mind and brain are two sides of the same coin. To consider it as strictly dichotomous doesn’t help the doctor see the whole picture and really does the patient a disservice.''
The NPP clinic has served more than 100 families from throughout California and has a four-month waiting list for new patients. ''The set-up allows child neurology and child psychiatry fellows to spend time with their patients and really explain the nature of the illness and answer questions,'' Joshi says. ''We aim to meet the needs of the family through pharmacotherapy (medication management), but we’re also asking if they’re getting the appropriate behavioral therapy and the appropriate services at school. Our role as advocates for these children is a crucial part of the training mission as well.''
Joshi also directs Packard’s School Mental Health Services, which gives child psychiatry fellows the opportunity to work with local schools and counsel students in nearby communities. ''One of my areas of research focuses on the treatment alliance not only between the doctor and patient, but also with the parent and with the teacher,'' he says. ''A strong treatment alliance can help ensure that patients adhere to their treatment regimen. Through better communication among these three important adult entities in the child’s life, we hope to improve health outcomes and overall well being.''
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