Guest Editorial: Virginia Tech: How as pediatricians we can respond

May 1, 2007

A discussion of the tragedy at Virginia Tech

Dr. Michael Jellinek has recently joined the editorial board of Contemporary Pediatrics. He is both a pediatrician and a child and adolescent psychiatrist. We are confident that Dr. Jellinek's expertise will add an important perspective for our readers. His editorial in this issue is a welcome illustration.

The overall prevalence of emotional disorders in children is roughly 10%, and these violent events are rare and sporadic. Emotional disorders emerge at different ages, subside and then reappear, and vary widely. Preventing a massive school shooting is like looking for a needle in a haystack, and we do not know how to predict such violent outbursts. We must also be sensitive to the dangers of labeling, stigma, and discrimination. Yet there is much work we could do.

We should be ready to hear the concerns of parents and teachers, as well as to screen children for psychosocial functioning the same as we routinely do for growth, vision, diabetes, anemia, lead poisoning, etc. If we are open to listening, we will hear about a broad range of emotional problems. When we think of potential for violence, we must start at infancy by focusing on child abuse and neglect. Throughout childhood, focus on exposure to domestic violence, bullying in school, and violent behavior the child may have toward others. For adolescence, focus on areas like depression, substance use, attraction to gang activity, explicit violent behavior, antisocial acts, impulsive risk-taking behavior, psychotic thinking, and head injury.

Sometimes these issues will be obvious because of parental or school complaint. Some will present indirectly as school failure, disobedience, persistent social isolation, or other psychosocial dysfunction. Most could be identified through the use of a psychosocial screening questionnaire. We should face our reluctance to recognize many of these problems because of our limited training, feeling inadequate to the task, or the many barriers in accessing the mental health services our patients need. Some pediatricians have focused on their own postgraduate medical education and/or begun to place mental health providers such as social workers in their offices. Others have advocated through their local chapter of the American Academy of Pediatrics for statewide programs to provide better access for mental health services.

2. Advocate for better mental health services and medical reimbursement.

We need more attention to psychosocial problems. This will require better reimbursement for both pediatricians and mental health professionals, as well as a broader range of services. Virtually no state and only a few insurers pay for psychosocial screening. For-profit managed care has distanced pediatricians from their mental health colleagues, and there are too few child and adolescent psychiatrists to follow even the most narrowly defined group of severely at-risk children. Quite simply, children's mental health services are underfunded.

3. Take responsibility to coordinate care for those at high risk of violence.

Accountability for helping a troubled child or adolescent crosses medical, family, social agency, school, and community settings. Currently, a teenager with potentially violent behavior is a hot potato no one wants to hold. Everyone faces a tight budget, and the multiple agencies involved likely have little incentive to coordinate efforts. The pediatricians, for our part, may not know or have access to mental health services, and are not reimbursed for the hours of time it may take to advocate for coordinated care. Too often the outcome for the patient is little care, dropping out of school, or entering the punitive juvenile justice system. Sometimes, especially early on, a pediatrician's ownership and advocacy can make a real difference.

Of course, there is much more to be done beyond the pediatrician's office as well.

Schools have a key role to play in recognition of emotionally troubled students, in providing a safer culture, and should serve as a community resource well into the evening. In addition, state agencies have cherished autonomy rather than coordination. We have to face difficult ethical dilemmas that on one hand stigmatize mental illness, yet on the other grant civil liberties that allow easy access to guns and little requirement for treatment or medication.

Pediatricians alone cannot solve these many long-standing challenges. However, we have a path. After grieving the tragic loss of life at Virginia Tech, we should emerge with a renewed mission to improve the recognition and treatment of our patients' emotional disorders.