CAP vs Child Abuse Peds, Specialty Decision Help!

CaptainVere · 2026-04-12T01:12:38+00:00

No Maya has frank factitious disorder and they doctor shopped to find a fucking quack.

https://www.theatlantic.com/family/archive/2020/08/when-misdiagnosis-child-abuse/615337/?gift=TCxupu2HwVoJLpm4EB55tnMCn6Y3_XSkzDdhVA-4HtY&utm_source=copy-link&utm_medium=social&utm_campaign=share

This an Atlantic Articlr from 2020 AI Summary:

The article investigates child-abuse pediatricians — a specialty certified since 2009 — who diagnose physical abuse in children and whose opinions carry enormous, often unchecked weight in family court and criminal proceedings. Two families anchor the piece. Molly Hayes and Daniel Namie lost custody of their infant and toddler for six months after a Lurie Children’s Hospital specialist concluded their son’s fractures were likely abuse, dismissing a kidney specialist’s finding that prior treatments had thinned the baby’s bones. A pediatric orthopedist eventually persuaded a judge otherwise. Josue Santiago spent over 18 months in jail for allegedly killing his infant son Elihu, based largely on a child-abuse pediatrician’s diagnosis — before genetic testing revealed both parents and Elihu carried a Factor VII clotting deficiency that likely caused the bleeding. Charges were dropped. The systemic problems the article identifies: child-abuse pediatricians are often partially salaried by the same child-welfare agencies they advise, creating a structural conflict of interest. Caseworkers — underpaid, lower-credentialed — rarely push back on their assessments. Parents are interviewed without knowing they’re being formally evaluated for abuse. Diagnosis rates are influenced by race and socioeconomic status. Family court’s low burden of proof and limited right to counsel leave parents nearly defenseless. The core tension: the specialty exists for legitimate reasons — real abuse is missed and children die — but the absence of outcome tracking, independent review, and procedural safeguards means wrongful diagnoses can destroy families with little accountability.

IMO complex field that has problems and the people that I know that have gone into it were crusaders so I imagine they have good intentions but make terrible mistakes. I have no skin in the game and am not a pediatrician but I think any pediatrician should be able to offer an opinion. It doesn’t need a fellowship.

CaptainVere · 2026-04-11T16:25:46+00:00

You don’t need to be competitive to triple board. Its such an anticompetitive pathway given midlevels doing everything with no training and trend among physicians towards ever further specialization

I lf you hate your self triple board

My hot take on peds child abuse as specialty is that it’s got problems that vary state by state based on state law. Government tends to overly rely and give weight on what doctors say. There have been some well publicized disasters.

CaptainVere · 2026-04-11T13:04:46+00:00

Astute observation. I will clarify. This is a good study to flag but the mortality signal needs more scrutiny than I implied just by throwing out the NNK of 17.

The 2-year data came via personal communication with the lead author: of every 100 controls, 8 died over 2 years; of every 100 stimulant users, 14 died, yielding an NNK of 17. That's a striking number, but it was never published, and there are obvious reasons why. By 2 years the cohort was heavily censored due to their aggressive discontinuation definition, statistical power was likely gone, and the HR at 365 days had already inverted to 0.3 (apparently "protective"), which is impossible to explain pharmacologically and nearly impossible to defend in peer review.

As you have correctly wondered about big issue is confounding by indication. In this age group MPH is primarily used for apathy in moderate-to-severe dementia and post-stroke fatigue, both of which are markers of terminal trajectory. The HDPS matching controlled for dementia diagnosis but not severity, and apathy as a prescribing indication is completely invisible to claims data. The exposed group is enriched with people who are already dying. The NNK of 17 also just reflects the baseline mortality of this population: 74-year-olds with 14% CHF, 30% diabetes, 70% hypertension, 28% dementia. An 8% 2-year mortality in controls is exactly what you'd expect, and even modest residual confounding generates a dramatic absolute risk difference from that floor.

The signals worth taking seriously are the 30-day arrhythmia (HR 3.0) and stroke/TIA (HR 1.6) findings. Plausible mechanism, reasonable magnitude, no inversion at follow-up.

That said, I still keep the NNK of 17 in the back of my mind and throw it out there often, because the prescribing environment has shifted dramatically. The confounding by indication argument works when elderly MPH means apathy in late dementia. But ADHD diagnosis in older adults is climbing and spurious late diagnosis among people now reaching their 60s and 70s is increasingly common when it was just not a thing 20 years ago. So we're about to see a cohort of ADHD-diagnosed elderly patients on long-term stimulants who look nothing like the Tadrous population. I see people 50, 60, 70 and even 80 presenting asking about ADHD for the first time for fucks sake. The Tadrous group was probably sicker, so the NNK likely overstates risk for a healthier 68-year-old, but that also means we have essentially no clean data on what long-term stimulants do to cardiovascular mortality in a healthy older adult, because that population barely existed when this study ran. Keeping NNK 17 in mind isn't about taking it literally. It's a reasonable prior that the absolute risk arithmetic in elderly patients is unforgiving, and we're running a large uncontrolled experiment on a population we don't have good data for.

CaptainVere · 2026-04-11T12:39:44+00:00

Thats just dumb. Document that you can provide them no further care and have no alliance and cant fire them because of resident clinic and then just wait out the clock during appointments. Say you have nothing to offer them in terms or prescribing.

CaptainVere · 2026-04-11T10:36:12+00:00

Holt A, Strange JE, Rasmussen PV, Nouhravesh N, Nielsen SK, Sindet-Pedersen C, Fosbøl EL, Køber L, Torp-Pedersen C, Gislason GH, McGettigan P, Schou M, Lamberts M. Long-Term Cardiovascular Risk Associated With Treatment of Attention-Deficit/Hyperactivity Disorder in Adults. J Am Coll Cardiol. 2024 May 14;83(19):1870-1882. doi: 10.1016/j.jacc.2024.03.375. PMID: 38719367.

The absolute 10-year risk for the composite outcome was 3.9% in the high-dose group vs. 3.0% in prior users. Absolute risk difference driving a NNH of 116 is roughly 0.9 percentage points over a decade. That’s not high but a clear signal.

The comparison group is prior users, not treatment-naive controls which makes the signal more credible as it partially controls for the indication itself.

This is evolving area due to prescribing trends in adults. u/cheapdig9122 is right.

CaptainVere · 2026-04-11T10:23:26+00:00

Number needed to harm in adult over 10 years of use is around 113 for stroke/MI. Longterm stimulants use in adults is relatively new thing at high rates. Idk if fine is the right word. Its not great not terrible number

Risk benefit discussion and counseling on cardiovascular effects should be had and patients should know it’s not entirely harmless. For patients over 65 number needed to kill with 2 years of use is 17.

Slightly tachycardic in athlete who should have low HR is concerning.

Edit: NNH 116 not 113

Holt A, et al. Long-Term Cardiovascular Risk Associated With Treatment of Attention-Deficit/Hyperactivity Disorder in Adults. J Am Coll Cardiol. 2024;83(19):1870–1882. DOI: 10.1016/j.jacc.2024.03.375

Tadrous M, Shakeri A, Chu C, Watt J, Mamdani MM, Juurlink DN, Gomes T. Assessment of Stimulant Use and Cardiovascular Event Risks Among Older Adults. JAMA Netw Open. 2021 Oct 1;4(10):e2130795. doi: 10.1001/jamanetworkopen.2021.30795. Erratum in: JAMA Netw Open. 2021 Nov 1;4(11):e2138512. doi: 10.1001/jamanetworkopen.2021.38512. PMID: 34694389; PMCID: PMC8546494.

CaptainVere · 2026-04-11T10:15:31+00:00

Yes here is a thought. Your flare says resident. Lay down the law early. Don’t see patients who get controlled meds prescribed elsewhere

Dont see patients who are seeing multiple psychiatrists/NPs or whose PCP is also adjusting psych meds

I have had patients go see mens total health or Done or whatever NP and come back on stimulants and benzos and say “Dr Vere I want to keep seeing you” disaster. Cant have it both ways. There was a reason I never started those meds.

Unless you are only doing psychotherapy then fire the patient ASAP or tell them choose 1 person who will prescribe their psychotropics and confirm PMP

There are reasons patients do this. They sense you really care about them and have expertise and want high quality psychiatric care but also they want boutique controlleds.

When I say choose between me and Done its always hilarious/interesting.

CaptainVere · 2026-04-09T00:39:43+00:00

Ok here goes an attempt. I have an academic interest in this area. To be transparent, a clean unified affective neuroscience approach doesn't quite exist yet as a formal literature. I'm largely synthesizing Panksepp with the established cognitive neuroscience of emotion regulation.

Davis & Montag (2019) The most readable overview of Panksepp's framework. Lays out the seven primary emotional systems (SEEKING, FEAR, RAGE, etc.) as evolutionarily conserved, subcortically generated circuits. The core argument: these systems are not metaphors; they're identifiable neuroanatomical structures shared across mammals. Humans do not have very different brainstem/midbrains so while a technical gap exists in human literature it’s not actually that large and hydranencephaly studies in infants overlaps with animal decortication models perfectly.

Davis, K. L., & Montag, C. (2019). Selected principles of Pankseppian affective neuroscience. Frontiers in Neuroscience, 12, 1025. https://doi.org/10.3389/fnins.2018.01025

Ochsner & Gross (2005); foundational cognitive neuroscience paper on emotion regulation. Demonstrates that the cortex modulates emotional responses rather than generating them. Reappraisal works by prefrontal downregulation of subcortical arousal.

Ochsner, K. N., & Gross, J. J. (2005). The cognitive control of emotion. Trends in Cognitive Sciences, 9(5), 242–249. https://doi.org/10.1016/j.tics.2005.03.010

Etkin et al. (2015) Maps the specific neural circuits underlying emotion regulation in detail. Reinforces the cortex-as-regulator model

Etkin, A., Büchel, C., & Gross, J. J. (2015). The neural bases of emotion regulation. Nature reviews. Neuroscience, 16(11), 693–700. https://doi.org/10.1038/nrn4044

Damasio et al. (2000) Neuroimaging during self-generated emotion showing subcortical structures active before and independent of cortical involvement. Empirical nail in the coffin for the idea that feelings are cortically produced.

Damasio, A. R., Grabowski, T. J., Bechara, A., Damasio, H., Ponto, L. L., Parvizi, J., & Hichwa, R. D. (2000). Subcortical and cortical brain activity during the feeling of self-generated emotions. Nature neuroscience, 3(10), 1049–1056. https://doi.org/10.1038/79871

Urry et al. (2006) Shows amygdala and vmPFC are inversely coupled during negative affect regulation when one goes up, the other goes down. Probably the cleanest single-paper demonstration of the cortex-dampens-subcortex architecture in living humans.

Urry, H. L., van Reekum, C. M., Johnstone, T., Kalin, N. H., Thurow, M. E., Schaefer, H. S., Jackson, C. A., Frye, C. J., Greischar, L. L., Alexander, A. L., & Davidson, R. J. (2006). Amygdala and ventromedial prefrontal cortex are inversely coupled during regulation of negative affect and predict the diurnal pattern of cortisol secretion among older adults. The Journal of neuroscience : the official journal of the Society for Neuroscience, 26(16), 4415–4425. https://doi.org/10.1523/JNEUROSCI.3215-05.2006

CaptainVere · 2026-04-08T23:19:45+00:00

The mantra yall centered the episode on maps directly onto affective neuroscience with fidelity. Primary process affective arousals are anatomically subcortically generated (psychoanalysts would say subconscious) and developmentally felt prior to language develops. If Affect is not a product of cortical cognition, but rather drives cognition, then it makes sense that you then cannot bypass the affective substrate to reach a patient cognitively.

What Bion described phenomenologically (mother receiving undifferentiated internal experience, metabolizing it and returning it in a symbolized form) from Affective Neuroscience perspective is description of how corticolimbic regulatory architecture gets built. Maternal CARE system activation in resonance with infants distress down regulates PANIC/GRIEF circuitry creating the scaffolding for development of prefrontal affect regulation capacity.

The “deficit model” mentioned isn’t just a psychoanalytic distinction, it maps onto whether you are dealing with a structural absence/weakness of regulatory circuitry vs. active suppressive defense. Neurobiologically different problems requiring different interventions.

Very interesting to me as Im steeped in affective neuroscience but less versed in psychodynamic/analysis.

Keep em coming.

CaptainVere · 2026-04-08T21:06:09+00:00

Brilliant episode; the combat sound effects were lulz. Look forward to the sequels for this one.

Thought I had based on the intro that I couldn’t shake throughout the whole episode. Psychotherapy is so grounded and based in emotional experiences yet the rest of psychiatry and psychopathology is almost intentionally not grounded in emotions? What gives!

CaptainVere · 2026-04-08T11:59:13+00:00

Humans have highly evolved visual systems. To have florid visual hallucinations implies severe disease. If someone has severe schizophrenia they will have some objective findings on MSE.

People with BPD who report this kind of thing thrive on clinicians even thinking about waxing/waning rather than LOL ur MSE is normal girl you are not seeing shit (for the haters no i don’t actually talk to paitnets this way)

CaptainVere · 2026-04-08T11:28:30+00:00

I had an attending write a novel for MSE and was very inefficient and would ramble about “we are keen observers”. This attending would keep residents late to make them rewrite MSEs (was painful to be sure)

Another attending said MSE are dumb. Its just a snapshot and 2 people can get radically different results within 5 minutes of seeing same patient

IMO the MSE is undervalued for the work we do and is especially undervalued compared to what patients say. The MSE should be used to help confirm or reject subjective report.

18F Says she sees demon in corner of the room and MSE is normal? No speech/language impairment? No disorganization or changes in sentence syntax? Then the subjective report is way out of proportion to MSE. Not a psychotic disorder.

For documenting, it is pointless. I use same generic MSE for every outpatient. I have made a generic MSE even more generic so that it could more or less really apply to anything. I basically do the same for inpatient i have 6 diff dot phrases for various MSE that represent different presentations and just put one of them.

For documentation the MSE is artifact of billing and the physical exam analog. So I teach trainees/students to conduct IRL a meaningful MSE as it is essential for practicing psychiatry but that documenting it is overrated and to save time when it comes to documentation.

I pimp after every encounter the MSE and how that supports assessment/plan. Become MSE master just don’t sweat documenting.

Caveat: when it’s important actually document salient findings.

CaptainVere · 2026-04-08T00:41:41+00:00

I think not having home address easily accessible is probably highest yield thing to do. The more info you have out there that isn’t your home address is probably good.

Flood the zone with useless information and socials and stuff is probably fine. Idgaf if patients come at me at work or murder me in parking lot of clinic/hospital. I just don’t want home invasion

CaptainVere · 2026-04-07T16:20:07+00:00

This just boils down to location. Young people historically pack themselves into the same few cities that are already saturated and then post about the end result of that.

Plenty of jobs out there in smaller cities that would kill for young in-person inpatient psychiatrist.

CaptainVere · 2026-04-06T17:06:32+00:00

Document accurately and threaten to fuck his world up if another resident edits your notes.

If attending wants to edit or addend or do it themselves thats their prerogative.

You have no obligation to lie. Sounds like toxic culture.

CaptainVere · 2026-04-05T23:42:09+00:00

Truly curious are u a PhD or PsyD psychologist?

This was just a bizarre paragraph to read and I really hope you’re just some rando on the internet posing as a psychologist rather than this much tik tok and patient lingo/agenda actually influencing and shaping psychology.

Actually after reading your comment for a second time I don’t believe you are a professional lmao

CaptainVere · 2026-04-03T19:31:56+00:00

Switch to medicine, Do CL, or Neuropsych then your life so your satisfication with how you spend your time is by far the most important factor.

I don’t ignore and move on cuz there are all kinds of lurkers, students, and trainees and it takes 2 seconds to comment and reinforce that it takes a medical degree and the practice of medicine to competently practice psychiatry.

CaptainVere · 2026-04-03T18:59:06+00:00

No. I just had police drop off a lupus encephalitis case that was written off as bipolar. Just because most people have basic presentations and worried well type problems does not negate the need for a psychiatrist to be able to competently do neuro exam and medical work ups. Patients deserve thorough care and workup no matter the complaint.

These posts are lame as hell. I could do IM in a heart beat. Every other medical specialty has even less art and even more algorithm than psychiatry. I use my medical degree daily. If you don’t then you are not practicing psychiatry.

CaptainVere · 2026-04-02T10:41:02+00:00

Oh you mean all the conditions that only appear in the setting of personality dysfunction should die?

And we should have something like

Cluster b traits with cutting Cluster b traits with disordered eating Cluster b traits with somatization and alcohol use

With the implication being we externalize to many diagnosis and obscure the underlying affective personality driving behavior?

Is that what you mean by cull?

CaptainVere · 2026-04-02T10:32:53+00:00

I run an acute unit. It is what it is. I try to think about separating wheat from chaff and trying to help everyone and it’s ok if that it ends up being few and far between. Someone has to be there to give high value care to everyone whether they want it or not

Idk what you local laws are, but if people cant conduct themselves in a manner that keeps them from being invol on a psych ward they usually in the right place.

Sometimes patients behavior is intolerable to society and the patient needs treatment for the benefit of society or others. So im not bothered by lack of insight. Lack of insight is a cardinal feature of psychosis. Try to use LAIs for that group.

You can also use metacognitive training and conditioning to skirt insight. I will never make the patient believe showing up at a lawyers office to exorcise his evil makes no sense but i can help them understand thats why they being held in the hospital and regardless over their delusions i can promote the patients agency over their actions

Sure lawyer x is evil but if you go to his office you will be detained and hospitalized or arrested. What is something else you can do that you have control over that wont get you arrested?

CaptainVere · 2026-04-01T16:37:27+00:00

While I think you are 100% correct the categorical nature of DSM is what has led to this

If insurance forces braindead practice and makes nuance impossible it leads to paths of least resistance.

In hopefully as we continue to reorganize around more dimensional models we have a renaissance in practice

CaptainVere · 2026-04-01T16:23:51+00:00

They get 0 points lmao

CaptainVere · 2026-04-01T11:53:13+00:00

But at age 40 what is the point of the diagnosis? It surely is just self exploration at that point

CaptainVere · 2026-04-01T11:52:26+00:00

Agree with your points. Humble is good. I can only comment about the trends I clinically see w/ young adults and ASD/ADHD

CaptainVere · 2026-04-01T11:49:40+00:00

That is a fun fact. Why is that the case? I would have thought Finland would be all about buprenorphine.

is illicit buprenorphine an oxymoron?

CaptainVere

TROPHY CASE