How to Suspend a Kindergartner

How to Suspend a Kindergartner


And


The Value of Compassionate / Informed Provider Care

Kate Warden, PhD, MSCP and Ed Korber, PhD, FPPR

In our recent personal exchanges and discussions with allied colleagues, at work in our hospital and clinic settings, both here in NYS and across the nation… we have personally come to agree that the main advantage of having prescribing psychologists working within NYS lies in their ability to provide a more comprehensive, collaborative and integrated approach, to mental health care, by offering psychological assessment, therapies, and aspects of mental health related medication management within a single practice setting… allowing patients to access comprehensive treatments and care without needing to run a gauntlet of multiple providers. This is particularly beneficial for both financial and adequacy of care concerns especially in community populations with limited access to a medical providers, certainly for patients in rural communities within NYS or any of the many highly populated urban community enclaves where medical specialist care, amazingly, is for all practical purposes not present or more simply economically out of reach. A case in point … Dr. Wardens story of Malik or


“How to Suspend a Kindergartner”


Malik (name changed for privacy) is a handful on a good day. A sweet and very rambunctious five-year-old boy who comes into my office with his mother and two younger siblings in tow. He playfully explores the room, ignoring all instruction to sit in the chair provided for him. He opens all the drawers and touches everything before lying on the floor pretending to be a snake. His
mother sighs heavily and looks up at me, pleading for help managing this clearly hyperactive and curious young boy. While I entertain the boy with toys and tricks, mom vacillates between providing a developmental history and redirecting her son while also attending to the three-year-old and infant in her lap.

Mom shares that Malik is in kindergarten and being there only one month, the school is threatening to suspend him. She tells stories of having to pick him up early almost daily, and some days not even sending him because she is too tired to try to get him out of the house on time. The school reports an inability to sit still, difficulty responding appropriately to directions, touching other students, standing on his desk, running into the hallway, rolling around on the floor, dumping out materials, refusing to do school work, breaking things, running in the halls, running into other students. Even one on one, the teacher cannot get him to focus on any school work or even sitting in circle time.

After they leave my office, I call the school to gain their perspective, which is exactly as the mom relays. They have tried many different approaches with him but need a diagnosis to develop a formal Individualized Education Plan (IEP) or 504 Accommodation Plan. I diagnose him with Attention Deficit Hyperactivity Disorder and the school starts to work on a plan to help Malik succeed. Unfortunately, this plan can take several weeks if not months to develop, even with a diagnosis. In the meantime, the school tells me that they are considering removing him since he is “unsafe.”

Now the ethical dilemma. This child would likely do well in an environment that can meet all his needs including one on one attention from teachers and his parent, more physical activity, a well- balanced diet, good sleep, limited screen time. Unfortunately, our school system does not have the resources necessary to accommodate this and neither does this mother. Consultation with our psychiatry team confirms that a trial of a stimulant medication could be helpful to keep this kiddo in school.

I reach out to the nurse practitioner treating the child and recommended a low dose stimulant medication to see if it would help this child remain safely in school. The NP was not comfortable prescribing the medication. I provided numerous supports including recommended readings, treatment guidelines, scheduling weekly appointments to follow the child to monitor for efficacy and side effect profiles; however, nothing would make this NP comfortable. The pediatrician in the office would not cover the case. Our psychiatry team had a two month wait list. After the NP talked with one of the psychiatrists, who does not generally work with children and actually knew less about the use of psychiatric medications in pediatrics than I did, she was willing to prescribe for the child.

I provided the NP with specific instructions on pre-prescribing practices, important health considerations, how to counsel the patient and family on monitoring for side effects and efficacy, type of stimulant recommended and specific dose and schedule of dosing. Unfortunately, she provided the wrong dosing instructions so instead of giving the medication at breakfast and at lunch, it was written for breakfast and before bed. The mother gave the medication as instructed by the NP so he was not sleeping at night. I provided the mother with corrected information and I reached out to the NP to correct the instructions. The NP did not think it was appropriate that the school give the medication, despite the fact that the afternoon was when he had the most difficulty… so she did not provide a script for the school to administer it in the building.

The morning dose was working for Malik, though suboptimally. He was sitting for longer periods of time, not running out of the class and was somewhat quieter. However, this mild positive effect wore off just about lunchtime and he struggled significantly with appropriate behavior in the afternoons. He was sent home early almost every day and now the school insisted that he only have half a day of instruction, routinely sending him home at noon everyday. Mom pleaded for more help, she could not get rest at home with the new baby with Malik home everyday at noon. She was giving him his noon medication at home but it was not working well enough, resulting in an incident when he hurt the baby by accident with his wild behaviors.

I reached out to the NP, hoping I could appeal to her good nature and receive a higher dose, and a dose given at noon at the school. She stated that this case was too difficult for her to manage and she would only write one more 30 day supply but then he had to be treated by psychiatry. We managed to schedule him for an appointment with psychiatry in one month with hopes for a cancellation. Unfortunately, in that time, Malik was suspended from kindergarten for 45 days for throwing scissors. 

Now Malik had a reputation for aggression and other students and teachers were afraid of him but once he was placed on the correct dose and dosing schedule of stimulant medication, Malik was a very well behaved and attentive child. He was still rambunctious and curious but able to sit for 20-30 minutes at a time and start learning his numbers and letters. When he returned to school, it was after the winter break and he had lost the majority of the first four months of schooling. He was behind his peers and started to feel frustrated. We were finally able to get him an IEP at school and he received appropriate accommodations to help him succeed. He was sleeping better, behaved better for his mother, and with the establishment of appropriate medication and ongoing psychological intervention started to participate appropriately in school.

Now Malik is in the 1st grade and excels in school. He received Student of the Month last month and he came to my office with his certificate. His mother beamed with pride at his accomplishments and we reflected on his journey. They worked hard to eliminate processed, sugary foods, got him into a sports program, and limited screen time. He tells me excitedly about his Lego creations that he never used to be able to tolerate and now spends free time building animals instead of glued to a video game.

I often wonder if we could have avoided a kindergarten suspension and subsequent heartache if we could have treated Malik adequately sooner. Thankfully, there were no long lasting effects that we can see; however, that’s not always the case. With my knowledge and clinical skill, I could have easily written this prescription for this family and avoided inaccurate and harmful dosing instructions. We could have avoided putting a practitioner in an uncomfortable position and wasting a psychiatry appointment that could have been used for a more complicated case seeing as the psychiatry resident simply prescribed exactly what I requested. I also wonder how it is possible that someone with much less education in psychiatry and psychiatric medication than myself has the ability to write prescriptions, and do so incorrectly! Properly trained and supported psychologists are capable of writing psychiatric medication prescription and can alleviate a huge gap in psychiatric care for hundreds of thousands of Americans, especially those specially trained in specific populations such as pediatrics, geriatrics, addiction, and those with developmental disabilities.

Experience has taught us that cases like that of Malik are more common than we might think and that some changes of our professions scope, involving already existing advanced APA accredited specialty training, could more readerly lead to improved better coordinated access to timely care when it counts.

And Yes… we both agree that the key benefits of prescribing psychologists are:

Increased accessibility to mental health care:
By allowing psychologists to prescribe medication, more individuals can access needed treatment,
especially in areas with a shortage of psychiatrists. 

Specialized knowledge:
Psychologists with prescribing authority undergo additional training in psychopharmacology, ensuring they are well-equipped to manage medication effectively. 

Improved patient experience:
Patients can receive both therapy and medication from a single provider, simplifying their treatment
process and fostering a stronger therapeutic relationship. 

Holistic treatment approach:
Psychologists with prescribing privileges can better tailor medication management to a patient's specific needs and psychological profile while reducing the burden of other collaborative Primary care Providers with limited or no training in Mental health issues

Potential for earlier intervention:
Psychologists can identify when medication might be necessary earlier in the treatment process,
potentially leading to faster symptom improvement. 

Cost-effective care:
By providing both therapy and medication, patients may need fewer appointments overall, potentially reducing healthcare costs. 

Always remembering that the best of care in NYS requires our personal persistence in professional
growth and sharing of experience in collaboration with our like minded allied colleagues.


About the authors:


Kate Warden, PhD, MSCP
Licensed Psychologist
Assistant Program Director - MVHS, Inc. Psychiatry Residency Program
Director of Behavioral Medicine - MVHS, Inc. Family Medicine Residency Program
Mohawk Valley Health System
ph. 315-734-3583
fax 315-801-4302
kwarden@mvhealthsystem.org

Ed Korber, PhD, FPPR
Licensed Psychologist
NYS Office of Mental Health
ph. 516-884-5572
Korber@me.com