- Email: [email protected]
Psychiatric Consultation to Schools on Remote Islands
SCHOOL CONSULTATION / INTERVENTION
1056-4993/01 $15.00 + .00
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS Ana E. Campo, MD
SETTING
The Florida Keys extend approximately 160 miles southwest of Miami, Florida. They are divided into three areas, Upper, Middle, and Lower Keys, with the Monroe county seat being Key West, Florida. To drive to the three schools in Key West takes approximately 3.5 to 4 hours. Although it is a beautiful commute down US 1, in the midst of blue ocean dotted by green islands, most school consultants do not make the drive there, because agencies do not pay for travel time and the consultant is therefore taking time from other clinical obligations. There is a paucity of psychiatrists working in rural areas: only 3% of child psychiatrists work in such communities. 2 The same need, however, applies to the Florida Keys as to more populated areas. For years there have been very few child psychiatrists in the Upper and Middle Keys, thus the children are seen by either primary care physicians or pediatricians. The children living in these Keys who require the care of a child psychiatrist travel to Miami. The population of Key West was approximately 27,522 in 1998, with 21 % being between the ages of 0 and 17. Of the 11,205 households in Key West, 36% report an income of less than $24,900. Most of the
From the Department of Psychiatry, University of Miami School of Medicine; and Bertha Abess Children's Center, Miami, Florida
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 •JANUARY 2001
161
162
CAMPO
population is white (67%); African Americans account for 12%, and Hispanics for 18%.7 THE SCHOOL CONSULTATION PROGRAM
The programs in Key West that serve severely emotionally disturbed children are operated by a coventure agreement between the Bertha Abess Children's Center (BACC) and the Monroe County Public School System. When the only child psychiatrist in Key West retired, there was no one to serve as a school consultant to the three Bertha Abess Children's Center programs in Key West. As a school consultant to the agency for more 10 years who had been consulting to the Upper Keys Schools for about 3 years, the executive director of the agency asked me to consult to the Key West programs. Given the length of the drive, they agreed to allow me to fly there on a monthly basis to see the children and their families. The BACC is a private Psychoeducational Day Treatment Program for Emotionally Handicapped and Severely Emotionally Disturbed Children. The public school systems provide the physical plant within the schools and the teachers, and the BACC provides the therapeutic aspects of the program, such as social workers who do the individual counseling, group therapy, or family interventions. The BACC contracts with individual child psychiatry practitioners who provide psychiatric consultation to the programs. There are a total of 48 programs in Miami and the Florida Keys. Of these programs, 30% are for emotionally handicapped students and 70% are for severely emotionally disturbed children. Six programs for severely emotionally disturbed students are in the Monroe County area, the Florida Keys. The BACC programs in Key West include an elementary, a middle, and a high school, serving approximately 20, 10, and 10 children, respectively. Eighty percent of these children are seen by me in some form of psychiatric consultation. School consultation models h ave been described as (1) client centered; that is, focused on the management of clients, patients, or students of the consultee; (2) work centered; that is, focused on working relations and organizational problems within a team; or (3) consultee centered, in which case the aim is to develop the professional skills of the consultee. 1 Kandler6 described a model of consultation that focused on client-centered issues and provided direct services such as evaluation, referral, and psychologic support for students who needed special programs; consultation with teachers; training of staff; and working with paren ts. In the programs where I consult, w e use all three forms of consultation. There is a multidisciplinary team consisting of a social worker, the teachers, and members of Family Services Planning Team who work with the particular student and myself. We need to maximize the effectiveness of the consultative process, since I am at the schools only once a month for 8 to 10 hours. I perform psychiatric evaluations,
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
163
psychopharmacologic management of patients, and staff education and participate in the multidisciplinary team meetings. Geographic Issues
The first challenge of the consultation process is for the consultant and the clients to get to the destination. I fly to the location, as driving is impractical. The children are bused from far-away islands and have to, in some instances, spend 1 to 1.5 hours on a school bus. Multiple complaints of misbehavior occur during these long rides. Sometimes, smaller children are placed in safety harnesses for their own protection. We work with parents in terms of the best time to administer medication, mainly stimulants, to help during the bus ride. By the time the children arrive at school, they are already tired, and the teachers must put extra effort into aiding them to get settled into the classroom routine. Authors working in rural areas have described the transportation difficulties and flexibility needed when working with populations in rural areas. 2 Child psychiatrists working in rural areas frequently encounter situations in which the telephone can be used as an effective way of communicating and also a therapeutic aid. 3 Some parents at times are not able to keep the follow-up appointments because they do not have money for transportation. In these cases, we telephone them while the child is seen at the school. A problem occurs when a child is absent from school on the day I am there. Because I will not be back for another month, if I do not renew the medication because I cannot see the child, his or her behavior might become a problem for the child, the family, and the school. This is a situation in which flexibility is required. Documenting the reasons for different clinical decisions becomes of utmost importance. If the pattern becomes repetitive, and it is clear the parent is being resistant, I must stop prescribing. If it is an occasional occurrence and telephone contact is available, then I wil prescribe. In these cases, the social workers in the program can also make home visits at a later date. Cultural Diversity Issues
The Florida Keys and Key West are a distinctly diverse population, not only ethnically and culturally but economically as well. Key West has the highest cost of living in the state of Florida, and it is the fourth most expensive housing market in the United States. The children served in our program are most frequently in the lower socioeconomic groups. They frequently come from chaotic families with multiple social, emotional, and psychiatric problems. Approximately 50% are white, 20% are African American, and 30% are Hispanic. The Hispanic group poses a special challenge. They often come from immigrant families of Hispanic origin and present with some of the
164
CAMPO
psychologic distress associated with immigration. It has been stated that the characteristics of the receiving community, including the presence of members of the same ethnic group and the attitudes of individuals toward the migrants, are equally important in determining the adaptation process of new immigrants. 5 Given that 67% of the population in Key West is white non-Hispanic, it was not surprising to find that none of the school staff (social workers and teachers) spoke Spanish. In this regard it has been helpful that I, as the consultant, am both an immigrant and Hispanic. Even though the children may acculturate and develop English-speaking skills faster then their parents, it has been shown that adolescents at most risk for psychologic distress are US-born Latinos from a low acculturation background who speak mainly Spanish and experience low family pride. 4 Additionally, others have demonstrated that the rates of mental illness in different ethnic groups are strongly correlated with lower socioeconomic status. Poverty for immigrant families is a significant risk factor for psychiatric disorder.11 For these reasons, it is important for programs serving these populations to have multilingual and multicultural staff members. With my presence as a Hispanic in the program, we have been able to engage the families into better compliance with treatment and with appointments. The ability to communicate in the same language and the ability to resonate with some of their plight about the immigration process contributed to narrowing the gap between the families and the psychiatrist. This comfort with the program continued even in my absence.
SCHOOL CONSULTATIONS RELATED TO HURRICANES
The Florida Keys as well as all of South Florida lie in the potential path of hurricanes. Since 1992, when Hurricane Andrew destroyed South Florida, there has been a heightened awareness of the weather patterns and storms. In a study done after Hurricane Andrew, we reported that children and adults experienced not only the trauma related to the event but a "process trauma" that occurs secondary to all the adversities related to the event, such as loss of property, relocation, and unemployment. Some of the symptoms experienced by the children were present not only in the high-impact zone but also in peripheral areas. 9 We saw reactions in the children related to the storm, such as sleep problems, nightmares, and anxiety reactions. In the subsequent months, as the media reported on other storms forming or approaching the mainland, we saw exacerbations of the symptoms in the children. Other authors have noted the helpfulness of the media in warning about storms and helping with evacuation proceedings, but at the same time they have been implicated in a stress response. 8
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
165
School Interventions
As a hurricane develops, the psychiatrist and the team, including the teachers, can help the children decrease their anxiety by developing a plan of action. This can include discussing evacuation procedures, favorite toys a child can take with them, securing their houses, and so forth. Holding meetings with parents to educate them about the importance of this plan for them and the children is important. The psychiatrist can help the members of the team identify the children's stress responses as well as parental post-traumatic responses and help them develop treatment interventions to have in place if a storm occurs. Group therapy and expressive art therapy have been helpful in allowing children to process their experience and lessen the traumatic response. After the storms we held group therapy sessions with the children. They drew pictures of what they imagined hurricanes to look like. Some of them drew the "eye of the storm" as an actual eye of an animal. Some drew pictures of the devastation left by the storm. One child drew a picture of tornadoes taking away children. After the children finished their drawings, we met to discuss them. They talked about the hardships their families were enduring, which gave them an opportunity to express their fears. In addition to the described special challenges that working in this area of the country present, several collaborative relationships are crucial. These are with the school and local community, with other physicians, and with the juvenile justice system. CONSULTATIVE COLLABORATION WITH SCHOOL PERSONNEL AND THE COMMUNITY
Approximately 40% of the children we work with in the Severely Emotionally Disturbed programs are either in foster care or under the supervision of the Department of Children and Families. Whenever there is a member of the Families Services Planning Team (FSPT) involved, we invite them to participate in our team meetings and direct consultations. This has fostered a good relationship among the school system, the BACC program, and the workers from FSPT and has helped ensure continuity of care for the patient. There is active collaboration between the BACC staff and the school personnel. The school nurses who dispense the medication at the elementary school have their clinic next to our program. When I am there on a monthly basis, we have an opportunity to review any medication changes and answer any questions about psychotropic actions and side effects. Periodically, I meet with the school assistant principals, specifically those who have the special education programs under their responsibility. This collaboration has been very effective, so that they feel free to contact me to help them resolve issues related to the program and to
166
CAMPO
families. Occasionally, they have asked me to call local physicians who are involved with the children in the program for clarification of medical issues. Example of Interventions with School Personnel
An assistant principal asked me to call a local physician who was involved with one of the children in the program to obtain clarification of a medical issue. The child was not responding to the prescribed medication. The mother had displayed some erratic and belligerent behavior in the assistant principal's office when called to come and pick up the child because of his uncontrollable behavior. The assistant principal asked me to talk to the family physician to see if there was a known problem with the mother and how this might be contributing to the child's behavior. I called the family physician and found that we had both been prescribing stimulant medication to the child, but it was the mother who had been taking it in an effort to self-medicate. Because the family physician had a longer relationship with the mother, she trusted him and allowed him to place her on the right medication. I continued treating the child. We agreed that we would communicate periodically and notify each other of any changes in medication regimens. I gave the feedback to the assistant principal, who was satisfied with the way the problem was handled and saw the effectiveness of the collaboration between the two physicians.
On several occasions, we have had children who have needed inpatient hospitalization. The assistant principals have called me because the children have become highly disruptive in school and can no longer be managed even within the program for severely emotionally disturbed students_. There is no inpatient unit for children in Key West, so I arrange for these children to be admitted into the inpatient facility of the University Hospital in Miami, where there is another BACC School/ Hospital program. This has proved beneficial to the patients because it ensures their safety, provides them treatment that otherwise would not be available, and offers them continuity of care. COLLABORATION WITH THE JUVENILE JUSTICE SYSTEM INVOLVING HIGH SCHOOL STUDENTS
As children enter their adolescent years, there is an increase of behavioral difficulties and delinquent behavior. The children we serve at the high school level have the risk factors that have been attributed to developing aggressive and delinquent behavior: poor family functioning, family aggregation of drug and alcohol abuse, psychiatric problems, poor parenting practices, and low socioeconomic status. 10 In Key West High School, many of the children are under the care of the juvenile justice system. They are living in shelters, have gone and come back to residential/juvenile treatment centers, and have probation officers. We try to work as closely as we can with the members of the Juvenile Justice System. We do not perform formal evaluations for
PSYCHIATRJC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
167
placement or competency for them, but both the Juvenile Justice workers and our program have benefited by our collaborative efforts. We notify them of the progress the child makes in our program. We frequently enlist their help in trying to enhance the patient's or the family's compliance with our treatment goals. Some of these children will only respond to treatment interventions if they know their court sentences will be affected by their degree of compliance with treatment. Example of Collaboration with the Juvenile Justice System In several cases, when an adolescent has been resistant to taking medication, the juvenile probation officers have met with us, and together we have worked to try to convince the adolescent of the advantages of taking the prescribed medication. One of the adolescents in the program was highly resistant to taking his medications, an antidepressant and a stimulant, while under house arrest for several crimes he had committed. We met with the probation officer and convinced the patient to take the medication for a trial period. The probation officer in turn reported favorably to the court, and the length of the time the patient was to spend under house arrest was decreased. Once the adolescent felt better while taking the medication, he continued taking his medication even after the court sanctions had been lifted. As with this case, there have been others in which we were able to collaborate effectively in such a way. Ultimately, the adolescents benefit as their behavior and symptoms improves with the better compliance to treatment. The community also benefits as the degree of delinquency diminishes.
CONCLUSIONS
The position of consulting to the Key West BACC school programs has been a rewarding experience. The Executive Director of the program had the excellent vision of hiring a school consultant and especially in flying her there. If it were not for this collaboration, the children, their parents, and their educators would not be receiving the services they need. Collegial relationships with members of all disciplines helped. We have all benefited from our collaboration, but most importantly, we have enhanced the quality of life of our patients.
References 1. Caplan G: The Theory and Practice of Mental Health Consultation. New York, Basic Books, 1970 2. Cook AO, Copans SA, Schetky OH: Psychiatric treatment of children and adolescents in rural communities. Myths and realities. Child Adolesc Psychiatr Clin North Am 7:673-690, 1998 3. Copans S, Racusin R: Rural child psychiatry. Journal of the American Academy of Child Psychiatry 22:184-190, 1983 4. Gil AG, Vega WA: Two different worlds: Acculturation stress and adaptation among
168
5. 6.
7. 8. 9.
10. 11.
CAMPO
Cuban and Nicaraguan families. Journal of Social and Personal Relationships 13:435456, 1996 Guarnaccia PJ, Lopez S: The mental health and adjustment of immigrant and refugee children. Child Adolesc Psychiatr Clin North Am 7: 537-553, 1998 Kandler HO: Comprehensive mental health consultation in high schools. In Berkovitz IH, Seliger J (eds): Expanding Mental Health Interventions in Schools. Dubuque, Iowa, Kendall-Hunt, 1985 Key West Chamber of Commerce, Key West, Florida, 1998 Pfefferbaum B: Caring for children affected by disaster. Child Adolesc Psychiatr Clin North Am 7:579-595, 1998 Shaw JA, Applegate B, Tanner S, et al: Psychological effects of hurricane Andrew on an elementary school population. J Am Acad Child Adolesc Psychiatry 34:9, 1995 Steiner H, Cauffman E: Juvenile justice delinquency and psychiatry. Child Adolesc Psychiatr Clin North Am 7:653-672, 1998 Vega WA, Rumbault RG: Ethnic minorities and mental health. Annual Review of Sociology 17:351- 383, 1991
Address reprint requests to Ana E. Campo, MD 4330 Surrey Drive Coconut Grove, FL 33133
1056-4993/01 $15.00 + .00
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS Ana E. Campo, MD
SETTING
The Florida Keys extend approximately 160 miles southwest of Miami, Florida. They are divided into three areas, Upper, Middle, and Lower Keys, with the Monroe county seat being Key West, Florida. To drive to the three schools in Key West takes approximately 3.5 to 4 hours. Although it is a beautiful commute down US 1, in the midst of blue ocean dotted by green islands, most school consultants do not make the drive there, because agencies do not pay for travel time and the consultant is therefore taking time from other clinical obligations. There is a paucity of psychiatrists working in rural areas: only 3% of child psychiatrists work in such communities. 2 The same need, however, applies to the Florida Keys as to more populated areas. For years there have been very few child psychiatrists in the Upper and Middle Keys, thus the children are seen by either primary care physicians or pediatricians. The children living in these Keys who require the care of a child psychiatrist travel to Miami. The population of Key West was approximately 27,522 in 1998, with 21 % being between the ages of 0 and 17. Of the 11,205 households in Key West, 36% report an income of less than $24,900. Most of the
From the Department of Psychiatry, University of Miami School of Medicine; and Bertha Abess Children's Center, Miami, Florida
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 •JANUARY 2001
161
162
CAMPO
population is white (67%); African Americans account for 12%, and Hispanics for 18%.7 THE SCHOOL CONSULTATION PROGRAM
The programs in Key West that serve severely emotionally disturbed children are operated by a coventure agreement between the Bertha Abess Children's Center (BACC) and the Monroe County Public School System. When the only child psychiatrist in Key West retired, there was no one to serve as a school consultant to the three Bertha Abess Children's Center programs in Key West. As a school consultant to the agency for more 10 years who had been consulting to the Upper Keys Schools for about 3 years, the executive director of the agency asked me to consult to the Key West programs. Given the length of the drive, they agreed to allow me to fly there on a monthly basis to see the children and their families. The BACC is a private Psychoeducational Day Treatment Program for Emotionally Handicapped and Severely Emotionally Disturbed Children. The public school systems provide the physical plant within the schools and the teachers, and the BACC provides the therapeutic aspects of the program, such as social workers who do the individual counseling, group therapy, or family interventions. The BACC contracts with individual child psychiatry practitioners who provide psychiatric consultation to the programs. There are a total of 48 programs in Miami and the Florida Keys. Of these programs, 30% are for emotionally handicapped students and 70% are for severely emotionally disturbed children. Six programs for severely emotionally disturbed students are in the Monroe County area, the Florida Keys. The BACC programs in Key West include an elementary, a middle, and a high school, serving approximately 20, 10, and 10 children, respectively. Eighty percent of these children are seen by me in some form of psychiatric consultation. School consultation models h ave been described as (1) client centered; that is, focused on the management of clients, patients, or students of the consultee; (2) work centered; that is, focused on working relations and organizational problems within a team; or (3) consultee centered, in which case the aim is to develop the professional skills of the consultee. 1 Kandler6 described a model of consultation that focused on client-centered issues and provided direct services such as evaluation, referral, and psychologic support for students who needed special programs; consultation with teachers; training of staff; and working with paren ts. In the programs where I consult, w e use all three forms of consultation. There is a multidisciplinary team consisting of a social worker, the teachers, and members of Family Services Planning Team who work with the particular student and myself. We need to maximize the effectiveness of the consultative process, since I am at the schools only once a month for 8 to 10 hours. I perform psychiatric evaluations,
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
163
psychopharmacologic management of patients, and staff education and participate in the multidisciplinary team meetings. Geographic Issues
The first challenge of the consultation process is for the consultant and the clients to get to the destination. I fly to the location, as driving is impractical. The children are bused from far-away islands and have to, in some instances, spend 1 to 1.5 hours on a school bus. Multiple complaints of misbehavior occur during these long rides. Sometimes, smaller children are placed in safety harnesses for their own protection. We work with parents in terms of the best time to administer medication, mainly stimulants, to help during the bus ride. By the time the children arrive at school, they are already tired, and the teachers must put extra effort into aiding them to get settled into the classroom routine. Authors working in rural areas have described the transportation difficulties and flexibility needed when working with populations in rural areas. 2 Child psychiatrists working in rural areas frequently encounter situations in which the telephone can be used as an effective way of communicating and also a therapeutic aid. 3 Some parents at times are not able to keep the follow-up appointments because they do not have money for transportation. In these cases, we telephone them while the child is seen at the school. A problem occurs when a child is absent from school on the day I am there. Because I will not be back for another month, if I do not renew the medication because I cannot see the child, his or her behavior might become a problem for the child, the family, and the school. This is a situation in which flexibility is required. Documenting the reasons for different clinical decisions becomes of utmost importance. If the pattern becomes repetitive, and it is clear the parent is being resistant, I must stop prescribing. If it is an occasional occurrence and telephone contact is available, then I wil prescribe. In these cases, the social workers in the program can also make home visits at a later date. Cultural Diversity Issues
The Florida Keys and Key West are a distinctly diverse population, not only ethnically and culturally but economically as well. Key West has the highest cost of living in the state of Florida, and it is the fourth most expensive housing market in the United States. The children served in our program are most frequently in the lower socioeconomic groups. They frequently come from chaotic families with multiple social, emotional, and psychiatric problems. Approximately 50% are white, 20% are African American, and 30% are Hispanic. The Hispanic group poses a special challenge. They often come from immigrant families of Hispanic origin and present with some of the
164
CAMPO
psychologic distress associated with immigration. It has been stated that the characteristics of the receiving community, including the presence of members of the same ethnic group and the attitudes of individuals toward the migrants, are equally important in determining the adaptation process of new immigrants. 5 Given that 67% of the population in Key West is white non-Hispanic, it was not surprising to find that none of the school staff (social workers and teachers) spoke Spanish. In this regard it has been helpful that I, as the consultant, am both an immigrant and Hispanic. Even though the children may acculturate and develop English-speaking skills faster then their parents, it has been shown that adolescents at most risk for psychologic distress are US-born Latinos from a low acculturation background who speak mainly Spanish and experience low family pride. 4 Additionally, others have demonstrated that the rates of mental illness in different ethnic groups are strongly correlated with lower socioeconomic status. Poverty for immigrant families is a significant risk factor for psychiatric disorder.11 For these reasons, it is important for programs serving these populations to have multilingual and multicultural staff members. With my presence as a Hispanic in the program, we have been able to engage the families into better compliance with treatment and with appointments. The ability to communicate in the same language and the ability to resonate with some of their plight about the immigration process contributed to narrowing the gap between the families and the psychiatrist. This comfort with the program continued even in my absence.
SCHOOL CONSULTATIONS RELATED TO HURRICANES
The Florida Keys as well as all of South Florida lie in the potential path of hurricanes. Since 1992, when Hurricane Andrew destroyed South Florida, there has been a heightened awareness of the weather patterns and storms. In a study done after Hurricane Andrew, we reported that children and adults experienced not only the trauma related to the event but a "process trauma" that occurs secondary to all the adversities related to the event, such as loss of property, relocation, and unemployment. Some of the symptoms experienced by the children were present not only in the high-impact zone but also in peripheral areas. 9 We saw reactions in the children related to the storm, such as sleep problems, nightmares, and anxiety reactions. In the subsequent months, as the media reported on other storms forming or approaching the mainland, we saw exacerbations of the symptoms in the children. Other authors have noted the helpfulness of the media in warning about storms and helping with evacuation proceedings, but at the same time they have been implicated in a stress response. 8
PSYCHIATRIC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
165
School Interventions
As a hurricane develops, the psychiatrist and the team, including the teachers, can help the children decrease their anxiety by developing a plan of action. This can include discussing evacuation procedures, favorite toys a child can take with them, securing their houses, and so forth. Holding meetings with parents to educate them about the importance of this plan for them and the children is important. The psychiatrist can help the members of the team identify the children's stress responses as well as parental post-traumatic responses and help them develop treatment interventions to have in place if a storm occurs. Group therapy and expressive art therapy have been helpful in allowing children to process their experience and lessen the traumatic response. After the storms we held group therapy sessions with the children. They drew pictures of what they imagined hurricanes to look like. Some of them drew the "eye of the storm" as an actual eye of an animal. Some drew pictures of the devastation left by the storm. One child drew a picture of tornadoes taking away children. After the children finished their drawings, we met to discuss them. They talked about the hardships their families were enduring, which gave them an opportunity to express their fears. In addition to the described special challenges that working in this area of the country present, several collaborative relationships are crucial. These are with the school and local community, with other physicians, and with the juvenile justice system. CONSULTATIVE COLLABORATION WITH SCHOOL PERSONNEL AND THE COMMUNITY
Approximately 40% of the children we work with in the Severely Emotionally Disturbed programs are either in foster care or under the supervision of the Department of Children and Families. Whenever there is a member of the Families Services Planning Team (FSPT) involved, we invite them to participate in our team meetings and direct consultations. This has fostered a good relationship among the school system, the BACC program, and the workers from FSPT and has helped ensure continuity of care for the patient. There is active collaboration between the BACC staff and the school personnel. The school nurses who dispense the medication at the elementary school have their clinic next to our program. When I am there on a monthly basis, we have an opportunity to review any medication changes and answer any questions about psychotropic actions and side effects. Periodically, I meet with the school assistant principals, specifically those who have the special education programs under their responsibility. This collaboration has been very effective, so that they feel free to contact me to help them resolve issues related to the program and to
166
CAMPO
families. Occasionally, they have asked me to call local physicians who are involved with the children in the program for clarification of medical issues. Example of Interventions with School Personnel
An assistant principal asked me to call a local physician who was involved with one of the children in the program to obtain clarification of a medical issue. The child was not responding to the prescribed medication. The mother had displayed some erratic and belligerent behavior in the assistant principal's office when called to come and pick up the child because of his uncontrollable behavior. The assistant principal asked me to talk to the family physician to see if there was a known problem with the mother and how this might be contributing to the child's behavior. I called the family physician and found that we had both been prescribing stimulant medication to the child, but it was the mother who had been taking it in an effort to self-medicate. Because the family physician had a longer relationship with the mother, she trusted him and allowed him to place her on the right medication. I continued treating the child. We agreed that we would communicate periodically and notify each other of any changes in medication regimens. I gave the feedback to the assistant principal, who was satisfied with the way the problem was handled and saw the effectiveness of the collaboration between the two physicians.
On several occasions, we have had children who have needed inpatient hospitalization. The assistant principals have called me because the children have become highly disruptive in school and can no longer be managed even within the program for severely emotionally disturbed students_. There is no inpatient unit for children in Key West, so I arrange for these children to be admitted into the inpatient facility of the University Hospital in Miami, where there is another BACC School/ Hospital program. This has proved beneficial to the patients because it ensures their safety, provides them treatment that otherwise would not be available, and offers them continuity of care. COLLABORATION WITH THE JUVENILE JUSTICE SYSTEM INVOLVING HIGH SCHOOL STUDENTS
As children enter their adolescent years, there is an increase of behavioral difficulties and delinquent behavior. The children we serve at the high school level have the risk factors that have been attributed to developing aggressive and delinquent behavior: poor family functioning, family aggregation of drug and alcohol abuse, psychiatric problems, poor parenting practices, and low socioeconomic status. 10 In Key West High School, many of the children are under the care of the juvenile justice system. They are living in shelters, have gone and come back to residential/juvenile treatment centers, and have probation officers. We try to work as closely as we can with the members of the Juvenile Justice System. We do not perform formal evaluations for
PSYCHIATRJC CONSULTATION TO SCHOOLS ON REMOTE ISLANDS
167
placement or competency for them, but both the Juvenile Justice workers and our program have benefited by our collaborative efforts. We notify them of the progress the child makes in our program. We frequently enlist their help in trying to enhance the patient's or the family's compliance with our treatment goals. Some of these children will only respond to treatment interventions if they know their court sentences will be affected by their degree of compliance with treatment. Example of Collaboration with the Juvenile Justice System In several cases, when an adolescent has been resistant to taking medication, the juvenile probation officers have met with us, and together we have worked to try to convince the adolescent of the advantages of taking the prescribed medication. One of the adolescents in the program was highly resistant to taking his medications, an antidepressant and a stimulant, while under house arrest for several crimes he had committed. We met with the probation officer and convinced the patient to take the medication for a trial period. The probation officer in turn reported favorably to the court, and the length of the time the patient was to spend under house arrest was decreased. Once the adolescent felt better while taking the medication, he continued taking his medication even after the court sanctions had been lifted. As with this case, there have been others in which we were able to collaborate effectively in such a way. Ultimately, the adolescents benefit as their behavior and symptoms improves with the better compliance to treatment. The community also benefits as the degree of delinquency diminishes.
CONCLUSIONS
The position of consulting to the Key West BACC school programs has been a rewarding experience. The Executive Director of the program had the excellent vision of hiring a school consultant and especially in flying her there. If it were not for this collaboration, the children, their parents, and their educators would not be receiving the services they need. Collegial relationships with members of all disciplines helped. We have all benefited from our collaboration, but most importantly, we have enhanced the quality of life of our patients.
References 1. Caplan G: The Theory and Practice of Mental Health Consultation. New York, Basic Books, 1970 2. Cook AO, Copans SA, Schetky OH: Psychiatric treatment of children and adolescents in rural communities. Myths and realities. Child Adolesc Psychiatr Clin North Am 7:673-690, 1998 3. Copans S, Racusin R: Rural child psychiatry. Journal of the American Academy of Child Psychiatry 22:184-190, 1983 4. Gil AG, Vega WA: Two different worlds: Acculturation stress and adaptation among
168
5. 6.
7. 8. 9.
10. 11.
CAMPO
Cuban and Nicaraguan families. Journal of Social and Personal Relationships 13:435456, 1996 Guarnaccia PJ, Lopez S: The mental health and adjustment of immigrant and refugee children. Child Adolesc Psychiatr Clin North Am 7: 537-553, 1998 Kandler HO: Comprehensive mental health consultation in high schools. In Berkovitz IH, Seliger J (eds): Expanding Mental Health Interventions in Schools. Dubuque, Iowa, Kendall-Hunt, 1985 Key West Chamber of Commerce, Key West, Florida, 1998 Pfefferbaum B: Caring for children affected by disaster. Child Adolesc Psychiatr Clin North Am 7:579-595, 1998 Shaw JA, Applegate B, Tanner S, et al: Psychological effects of hurricane Andrew on an elementary school population. J Am Acad Child Adolesc Psychiatry 34:9, 1995 Steiner H, Cauffman E: Juvenile justice delinquency and psychiatry. Child Adolesc Psychiatr Clin North Am 7:653-672, 1998 Vega WA, Rumbault RG: Ethnic minorities and mental health. Annual Review of Sociology 17:351- 383, 1991
Address reprint requests to Ana E. Campo, MD 4330 Surrey Drive Coconut Grove, FL 33133