Topher, a 10-year-old boy with no psychiatric history, is admitted to the inpatient child and adolescent psychiatry unit due to suicidal and homicidal ideation linked to bullying at school. “They were rude and called me names,” he tells you. Topher placed people on a “death list,” stating he did not plan to kill them but needed to express his anger. The school suspended him, triggering guilt and thoughts of self-harm. 

Child psychiatrists’ roles extend beyond traditional medical practice. They are guides, educators, advocates, and problem solvers for families as external forces overshadow patient care and treatment planning. Advocacy can be a daunting process, and while we work toward an ideal, we recognize that it is not always achievable. This article will help child and adolescent psychiatrists and related professionals to envision and labor toward that ideal using targeted education and collaboration to improve patient care. 

Strategic role of the child and ­adolescent psychiatrist 

Further history reveals Topher’s exposure to parental alcoholism, recent relocation to a new town, and COVID-19 disruptions. Still, he wants help and has good family support. Topher complies with unit rules and participates in milieu activities, interacting well with peers without aggression. The evening before discharge, a school shooting in a neighboring state alarms Topher’s parents and school. The next morning, his parents request continued hospitalization so that Topher can start on medication to prevent any aggression. 

Clinicians must often navigate community circumstances not directly related to the patient. For instance, during the COVID-19 pandemic, clinicians had to work with schools to address family fears, particularly around gun violence, in returning to in-person classes (Sanchez C et al, Am J Emerg Med 2020;38(10):2169–2178; Schmidt CJ et al, J Behav Med 2019;42(4):706–723). In Topher’s case, we must respect parental concerns in the context of community strife while ensuring that Topher receives care appropriate to his specific circumstances. 

Mobilize an interdisciplinary team

You shift from your usual child psychiatry role into an advocacy role, assembling the inpatient unit interdisciplinary treatment team—nurses, therapists, and social workers—and discussing options for addressing the fears of Topher’s parents.  

Share the burden of complex clinical cases, whether inpatient or outpatient. Make time to think about the nuances of your patient’s situation from multiple perspectives to create a patient-centered treatment plan. In outpatient settings, the team may consist of parents, therapists, school personnel, and a psychiatrist. 

• Restate the barrier: All team members are aware of the community’s concern that Topher’s recent threats suggest he might harm people if he is released.
• Summarize the case: The team highlights Topher’s challenges, your interventions, and Topher’s progress.
• Discuss diverse viewpoints: The team discusses Topher’s clinician interactions, engagement in groups, and peer interactions. This gives everyone a nuanced understanding of Topher’s readiness for discharge.
• Review the alternative plan: The team examines the option of prolonged hospitalization and finds no clinical justification to delay ­Topher’s discharge.
• Distribute tasks: Specific team members ensure care continuity, placing supportive phone calls to Topher’s family and broader support system, and social workers coordinate with outpatient and aftercare services.

The patient’s support system 

Engage with a patient’s family to: 

• Listen to concerns: You regularly speak with Topher’s parents over the phone, acknowledging their fears and ensuring they feel heard, eg, “I know you are concerned that Topher might hurt someone. Help me understand what you are seeing and hearing from him and how that might indicate that there is some danger.”
• Summarize the treatment course: The team sets out their professional assessment that Topher does not pose a risk to others and supports their assessment with detailed observations of his interactions with staff and peers: “We thought this through carefully using well-studied guidelines about risk and safety, and here is why we think that Topher is safe to leave and why it would be best for him.”
• Clarify the role of psychiatric treatment: Inform Topher’s parents and school support staff that Topher is demonstrating no symptoms requiring medication at this point. Explain that during his time on the inpatient unit, the focus was on supportive therapy and strategies for coping with stress and anxiety, particularly regarding his school ­environment.
• Define treatment objectives: To make sure all members of Topher’s care team are on the same page (including his parents and his school), you suggest a key goal: ensuring ­Topher feels safe and accepted upon returning to school. This includes building a supportive network of teachers and students around him.
• Discuss the outpatient plan: You recommend scheduling regular sessions with a therapist who will coordinate with school counselors to monitor Topher’s adjustment, and regular check-ins by your outpatient liaison with the parents to reassess Topher’s needs and progress.
• Acknowledge and address issues stemming from outside factors: You help Topher’s parents learn how ­distress can arise even when individuals are not physically close to an incident (Shultz JM et al, Curr Psychiatry Rep 2014;16(9):469). 

Navigating community challenges  

Topher’s mother shares that her neighbors are pushing back against the family, saying “anything could happen” with Topher, and the school is debating Topher’s return to classes. You decide to add Topher’s outpatient therapist and a school representative to the multidisciplinary team.

In cases with greater community implications, clinicians can collaborate with other people in the patient’s life to hear their concerns and clarify the roles of all the people involved. This can serve as a useful platform to educate and solidify partnerships between inpatient and outpatient clinicians, and between outpatient providers and schools. 

Tips for implementation

• Early work with school personnel: Focus on building a supportive environment and specific accommodations. You communicate with the school counselor and provide a letter discussing the team’s recommendations.
• Community reintegration: Consider community outreach to foster a supportive neighborhood environment. The team’s outpatient liaison explores case management to help the family navigate community challenges. 
• Continuous evaluation: Keep the plan dynamic with scheduled reviews to ensure that the approach remains responsive to evolving needs. You recommend Topher and his parents regularly communicate with your outpatient liaison post-­discharge.

Bear in mind that it’s not always easy to engage schools, you don’t often have community interface personnel, and you might have trouble getting kids back to clinic as soon as you’d like. Sometimes phone calls need to substitute for meetings, warm handoffs, and check-ins. Still, if you consider the approaches set forth here, you can often find avenues for improving communication and care. 

The multidisciplinary team, which now includes the vice-principal, advocates for Topher’s return while addressing strategies to combat bullying and provide parent support (Hardaway C et al, J Youth Adolesc 2016;45(7):1309–1322). The team recommends:

• Antibullying strategies: Teachers and students should receive training on empathy and inclusivity, establishing clear antibullying policies, and a confidential reporting system. 
• Mentorship programs: Social groups centering on shared interests can help build a social network.
• Family care coordinator following discharge: Engaging a coordinator can help navigate challenges in the community and school.

School advocacy might include urging the school to convene a student study team to offer more resources and options for managing bullying, and school-based antibullying programs such as www.tinyurl.com/bdftyzks.

Three months later, Topher’s parents contact you to thank you and your team. Topher has teachers who are watching out for him and classmates who include him in activities. Topher feels safe and valued. 

Education 

Help healthcare professionals in training to learn these principles by including them in advocacy efforts. They can offer perspectives that challenge assumptions and remind us to reassess biases that influence decision making. Mentors also add depth, offering valuable frameworks for navigating challenging situations, especially when the team is stuck. Collaborative learning experiences reinforce our sensitivity to the complex ways patients communicate distress and help us practice identifying and addressing barriers to care.

Carlat Verdict 

Depending on your setting and resources, good advocacy could be good care, or it could be an ideal to strive for. Either way, Topher’s case demonstrates several aspects of clinical advocacy. Clinicians in similar circumstances can take steps to mobilize an interdisciplinary team, engage the family, navigate community challenges (eg, the patient’s return to school), and leverage mentorship and collective learning. Child psychiatrists have a pivotal role as guardians of evidence-based care in a patient’s journey through the labyrinth of challenging circumstances, particularly in the face of complex and intense dynamics involving the child’s family and community.