I’m writing this column at the beginning of March, and I’ve been thinking a lot this week about that old aphorism, March comes in like a lion and goes out like a lamb. And I’m greatly troubled about the beast of violence against children and that perpetrated by children. The effect of our inadequate care for emotionally troubled kids is roaring again.

When a 6-year-old first grader shoots and kills his classmate, it makes national news for a while. There’s much wringing of hands and gnashing of teeth, but little really changes. The same week we were shocked by this news, ABC’s "Nightline" had a series on how psychiatrically ill and emotionally disturbed children and adolescents are being confined in the criminal justice system. This is no news to us in psychiatry, as we have been aware of this trend for years. Perhaps its lack of newness takes some of the edge off our own emotional response.

A number of years ago one of my uncles, who at the time was the pharmacist at the Leavenworth Penitentiary in Kansas, told me that 50 percent of the inmates there were taking major psychotropic medications. He believed that probably another 25 percent needed them, but they couldn’t find a psychiatrist even willing to come out and evaluate these individuals, much less manage their ongoing care. We shudder when Ted Koppel says that 20 percent of adolescents in California juvenile detention centers have major psychiatric illnesses, but it’s really not news to us, and little changes when these stories are aired.

The Surgeon General in his December 1999 Report on Mental Health stated what most of us already know. Millions of children and adolescents each year are afflicted with major psychiatric illnesses, and 50 percent receive no treatment from anyone. Data from the American Academy of Child and Adolescent Psychiatry affirm this and indicate that only 20 percent of children are seen by a child psychiatrist.

How can this be? One reason is because there are not nearly enough child psychiatrists in the United States. It’s unfortunate, but not surprising, that the politics of health care reform has influenced the federal government’s own projections about physician workforce needs. Every study released by the Graduate Medical Education National Advisory Council (GMENAC) up until the primary care revolution in the 1990s said that child psychiatry was among the specialties with the greatest shortages. Estimates were that about 30,000 child psychiatrists were needed to provide adequate care for the mental health needs of our children. Since we have only about 6,000 child psychiatrists at the moment, you can see how far we are from having an adequate workforce to provide the needed care.

But, when the Clinton health care reform plan got up a head of steam in the early 90s and the emphasis was on primary care medicine, child psychiatry disappeared from the federal government’s estimates of shortage specialties. What an ironic and tragic turn of events that is, since these workforce projections influence federal funding decisions.

Also, early this March many of us read the report in the Journal of the American Medical Association that showed that the use of stimulants in children tripled between 1991 and 1995, and the use of antidepressants more than doubled. This study should provide even more impetus to us to look at how treatment decisions for these children are being made. In a Newsweek article in the beginning of March commenting on the JAMA article, Joe Coyle, chair of psychiatry at Harvard, and Steve Hyman, director of the National Institute of Mental Health, both expressed concern about this dramatic increase in prescribing in very young children.

And the concern is well taken from my point of view. Some might argue that this vast increase in medication use in children reflects better case finding and better evaluation of children. I wish I felt confident that that was true. But I know that we have not had any major influx of child psychiatrists in the last 10 years, and I know how difficult it is to even get an appointment with a child psychiatrist, so I wonder who’s making these diagnoses and making recommendations for treatment. I know they’re not likely child psychiatrists.

When the average physician’s visit is six or seven minutes in length, and you know that certainly is not an overestimate if you have taken your children to the pediatrician lately, I worry about the thoroughness of the evaluations. I recently heard a story about a psychologist who had assessed an adolescent as potentially having depression and who had scheduled a 15-minute evaluation with a general psychiatrist to make a determination about whether medication was indicated.

Unfortunately, too many factors come together to produce these ongoing tragedies, both the few that make the news and the millions more that don’t. One, we don’t have enough well-trained people to take care of the needs of our children and adolescents. Further, funding for needed services for our most troubled children and adolescents is sorely lacking. This has meant that some of our most disturbed children and adolescents, just as with adults, end up being placed in the criminal justice system rather than in the mental health system where they belong.

Further, the influence of managed care, which has emphasized medications as a "quick fix" for many problems, has pervaded all of medicine and has clearly exerted an inappropriate influence on tilting people toward medications as a routine first-choice intervention for complicated problems that often require sophisticated psychosocial interventions. Please don’t misunderstand me. I’m not opposed to psychiatric medications, even their appropriate use in children or adolescents. What I am opposed to is the trend in recent years to view medications as the cure-all without attention to the antecedents or the psychological and social aspects of emotional disturbances in children and adolescents—or adults either for that matter.

Medicating people or locking them up are after-the-fact responses to severe disturbances and violent behavior in children. I have never heard any public discourse outside of psychiatry that reflects on the crucial role of parenting and child development before the age of 6 in modulating aggressive behavior. We know that children learn to deal with aggression in important and fundamental ways during the first years of life.

But where is the political discourse on primary prevention with parenting education and with school-based programs to deal with helping children and adolescents to cope with anger? Where is our adequate funding for secondary prevention so that those children who have problems and their parents can seek and receive the needed treatment? I don’t see such a discussion going on anywhere, and that is the real tragedy to me.

The problems of violence and serious emotional disturbances in children will not disappear, I believe, no matter what we do. But we can make a significant change in the epidemiology of these problems with appropriate interventions throughout childhood. We need to commit ourselves to making this the highest priority for our country, and we need to speak with decision makers in all walks of life at every level of society about the fundamental origins of these problems and resources we know are necessary to address them. Otherwise, I fear, this lion will continue to roar.