LETTERS TO THE EDITOR Cure for Overhospitali~ation?
REFERENCES
Darnton, N. (1989), Committed youth, Newsweek. July 31:66-72. Patterson, G. R. (1976), LivingWith Children-Revised. Champaign, IL: Research Press.
To the Editor:
Have you been reading the recent articles about the growth of the psychiatric hospital industry andthe waymany patients aresupposedly •'turfedout" whentheirinsurance expires (Darnton, 1989)? Haveyou noted themonthly f~s for thisservice-s-between $12,000 and$20,OOO? Do you worry that these charges will lead to the defunding of psychiatric care for children and adolescents? Whatfollows is a proposal to putthe mental health careof children andadolescents on II different footing. Suppose that when a psychiatric provider initiates care with a conductdisordered patient that he/she has to agree to treatthe patient and his/her family for 2 years for a fixedprearranged sum. Funding would be determined aftera thorough diagnostic evaluation of treatment needs and would vary from case to case, Additionally, treatment would be subject to periodic case reviews to establish treatment efficacy. This proposal would be consonant with the view that conduct disorders require long-term care and would allow clinicians to employ various treatment strategies, besides hospitalization, which have already beenexperimented with, such as (1) partial hospitalization, (2) in-home treatment, (3) parent training-a la Gerald Patterson (1976), (4) case coordination and management, (5) in-school treatment, and (6) vocational training and job placement. Sucha program would limit (a) potential abuse of hospitalization, (b) so-called "walletectomies" where brief, high-cost treatment is provided without therapeutic benefit, and (c) nonproductive therapies. At the same time, research studies could compare the results of various packages of care and offer incentives to hospitals and providers, andpatients and theirfamilies, to use programs that havebeen proven to be efficacious. At the end of the 2-year program, if the care system could show that the behavior disorder had improved or remitted for the money budgeted, then the family would receive a rebate on their health insurance, and the provider would be targeted as a "favored" provider. Additional 1 or 2 yearextensions of the agreement couldbe negotiated as well, depending on the efficacy of the provider'S treatment and the motivation of the patient and his/herfamily for continued treatment. Thisplan would recognize the following clinical realities which are not built into the current fee-for-service system:
Tourettes and School Refusal To the Editor:
1. Long-term treatment at some level is usually indicated for the treatment of behavior disorders. 2. Motivation from parents and children, as well as providers, is needed for a successful outcome. 3. The "businessof psychiatry" should be dictated by the efficacy of treatment. 4. The profit motive in care should not only provide an incentive to the providers of care, but also the recipients. 5. If we do not develop a packaged approach to the treatment of these disorders, we willbe at the whimof funding agencies who are looking to cut costs, and treatment modalities which may address one component of care (like parent troubles), and leave others (likegroup and academic skills) untouched. The netresult would be that treatment would be successful, but the patient would fail.
Kim J. Masters, M.D. Asheville, North Carolina
School refusal in children or adolescents has not been specifically associated withTourette'ssyndrome (TS), although somecasereports havebeensuggestive, Severe school phobia wasnoted in a malecousin of a patient with TS by Comings and Comings (1987), and Linet (1985) reported "relatively subtle separation anxiety difficulties such as reluctance to sleepover at friends' homes" (p. 614) in an l l-yearold boy with TS who later developed school phobia after treatment with plmozide. Rather thanconsidering an existing association in some childand adolescent patients between TS and anxiety disorders, Mikkelson et al, (1981) and Linet (1985) argued that the treatment of TS with haloperidol may precipitate school avoidance and school phobia. Three cases seen at this Unit and diagnosed by psychiatrists using DSM-/ll criteria support an association between TS and schoolavoidance. These young males developed school refusalwithanxiety, were initially referred and diagnosed with this problem, and were later diagnosed withTS. Case 1: A 12-year-old boy was referred with a 2.year history of inability to attend school. He described acute episodes of anxiety suggestive of panic attacks and said part of his worry about going to school was his frequent need to go to the toilet and embarrassment about this. During assessment, involuntary, though at timescontrolled, repetitive rapidandpurposeless movements, mainly of his pelvis,were observed. Thesemovements had begunat the same time as his panic attacks. Upon questioning, the parents alsodescribed repetitive coughing and sniffing witha history of about2 years. No family history of tics or anxiety disorder could be elicited and EEG and CT scan investigations proved normal. Birth and early development were unremarkable. A report of a psychiatric interview held 1 year previously at another center stated the mother had said, " ... he sniffs all the time and this drives us up the wall." Sniffing was also recorded as present in that psychiatric interview. Following a second psychiatric consultation, a diagnosis of anxiety disorder with panic attacks was made and treatment commenced with alprazolam, A subsequent referral wasmade for residential treatment and only following this third psychiatric assessment was a diagnosis of TS made. The patient was admitted to a residential adolescent unit and haloperidol (:~.5 mg/day) prescribed. There wasan almost complete cessation of tics, and panic attacks did not recur. The patient was discharged after approximately 4 months of residential treatment including milieu and family therapy as well as attendance at school. After returning home he maintained satisfactory school attendance and there were no further episodes of anxiety, although continuation of haloperidol was needed to control the tics. These improvements were maintained at an additional 12month follow up. Case 2: A 14-year-old boy was referred because of aggressive behavior toward his mother and refusal to attend school. He was frequently telephoning his mother anxiously from schoolasking to come home. Diagnoses of separation anxiety disorder and conduct disorder were made and the boy was admitted to residential treatment, where he proved difficult to manage at times because of defiance. After discharge, and following further school refusal, he confessed to his mother that his reluctance to attend school had beendue to teasing by
149
REFERENCES
Darnton, N. (1989), Committed youth, Newsweek. July 31:66-72. Patterson, G. R. (1976), LivingWith Children-Revised. Champaign, IL: Research Press.
To the Editor:
Have you been reading the recent articles about the growth of the psychiatric hospital industry andthe waymany patients aresupposedly •'turfedout" whentheirinsurance expires (Darnton, 1989)? Haveyou noted themonthly f~s for thisservice-s-between $12,000 and$20,OOO? Do you worry that these charges will lead to the defunding of psychiatric care for children and adolescents? Whatfollows is a proposal to putthe mental health careof children andadolescents on II different footing. Suppose that when a psychiatric provider initiates care with a conductdisordered patient that he/she has to agree to treatthe patient and his/her family for 2 years for a fixedprearranged sum. Funding would be determined aftera thorough diagnostic evaluation of treatment needs and would vary from case to case, Additionally, treatment would be subject to periodic case reviews to establish treatment efficacy. This proposal would be consonant with the view that conduct disorders require long-term care and would allow clinicians to employ various treatment strategies, besides hospitalization, which have already beenexperimented with, such as (1) partial hospitalization, (2) in-home treatment, (3) parent training-a la Gerald Patterson (1976), (4) case coordination and management, (5) in-school treatment, and (6) vocational training and job placement. Sucha program would limit (a) potential abuse of hospitalization, (b) so-called "walletectomies" where brief, high-cost treatment is provided without therapeutic benefit, and (c) nonproductive therapies. At the same time, research studies could compare the results of various packages of care and offer incentives to hospitals and providers, andpatients and theirfamilies, to use programs that havebeen proven to be efficacious. At the end of the 2-year program, if the care system could show that the behavior disorder had improved or remitted for the money budgeted, then the family would receive a rebate on their health insurance, and the provider would be targeted as a "favored" provider. Additional 1 or 2 yearextensions of the agreement couldbe negotiated as well, depending on the efficacy of the provider'S treatment and the motivation of the patient and his/herfamily for continued treatment. Thisplan would recognize the following clinical realities which are not built into the current fee-for-service system:
Tourettes and School Refusal To the Editor:
1. Long-term treatment at some level is usually indicated for the treatment of behavior disorders. 2. Motivation from parents and children, as well as providers, is needed for a successful outcome. 3. The "businessof psychiatry" should be dictated by the efficacy of treatment. 4. The profit motive in care should not only provide an incentive to the providers of care, but also the recipients. 5. If we do not develop a packaged approach to the treatment of these disorders, we willbe at the whimof funding agencies who are looking to cut costs, and treatment modalities which may address one component of care (like parent troubles), and leave others (likegroup and academic skills) untouched. The netresult would be that treatment would be successful, but the patient would fail.
Kim J. Masters, M.D. Asheville, North Carolina
School refusal in children or adolescents has not been specifically associated withTourette'ssyndrome (TS), although somecasereports havebeensuggestive, Severe school phobia wasnoted in a malecousin of a patient with TS by Comings and Comings (1987), and Linet (1985) reported "relatively subtle separation anxiety difficulties such as reluctance to sleepover at friends' homes" (p. 614) in an l l-yearold boy with TS who later developed school phobia after treatment with plmozide. Rather thanconsidering an existing association in some childand adolescent patients between TS and anxiety disorders, Mikkelson et al, (1981) and Linet (1985) argued that the treatment of TS with haloperidol may precipitate school avoidance and school phobia. Three cases seen at this Unit and diagnosed by psychiatrists using DSM-/ll criteria support an association between TS and schoolavoidance. These young males developed school refusalwithanxiety, were initially referred and diagnosed with this problem, and were later diagnosed withTS. Case 1: A 12-year-old boy was referred with a 2.year history of inability to attend school. He described acute episodes of anxiety suggestive of panic attacks and said part of his worry about going to school was his frequent need to go to the toilet and embarrassment about this. During assessment, involuntary, though at timescontrolled, repetitive rapidandpurposeless movements, mainly of his pelvis,were observed. Thesemovements had begunat the same time as his panic attacks. Upon questioning, the parents alsodescribed repetitive coughing and sniffing witha history of about2 years. No family history of tics or anxiety disorder could be elicited and EEG and CT scan investigations proved normal. Birth and early development were unremarkable. A report of a psychiatric interview held 1 year previously at another center stated the mother had said, " ... he sniffs all the time and this drives us up the wall." Sniffing was also recorded as present in that psychiatric interview. Following a second psychiatric consultation, a diagnosis of anxiety disorder with panic attacks was made and treatment commenced with alprazolam, A subsequent referral wasmade for residential treatment and only following this third psychiatric assessment was a diagnosis of TS made. The patient was admitted to a residential adolescent unit and haloperidol (:~.5 mg/day) prescribed. There wasan almost complete cessation of tics, and panic attacks did not recur. The patient was discharged after approximately 4 months of residential treatment including milieu and family therapy as well as attendance at school. After returning home he maintained satisfactory school attendance and there were no further episodes of anxiety, although continuation of haloperidol was needed to control the tics. These improvements were maintained at an additional 12month follow up. Case 2: A 14-year-old boy was referred because of aggressive behavior toward his mother and refusal to attend school. He was frequently telephoning his mother anxiously from schoolasking to come home. Diagnoses of separation anxiety disorder and conduct disorder were made and the boy was admitted to residential treatment, where he proved difficult to manage at times because of defiance. After discharge, and following further school refusal, he confessed to his mother that his reluctance to attend school had beendue to teasing by
149
