A physician of How I evaluate
I start every new patient with a full evaluation, usually about an hour. For a child or teen, I want time with the parents and time with the young person alone. Kids tell me things they will not say in front of their parents, and parents tell me things they do not want to say in front of their kids. Both halves matter.
Before the visit I ask for whatever already exists: report cards, teacher comments, prior testing, previous medication trials and what happened on each one. I read it. A rating scale is useful data, but I do not diagnose from a questionnaire. I want to know when the problem started, what it looks like at home versus school versus with friends, how the child sleeps, and what else is going on in the family. A nine-year-old who cannot sit still in class may have ADHD. He may also be anxious, not sleeping, struggling with a reading disorder, or reacting to something at home. The treatment for each of those is different, so the diagnosis has to be right first.
With adults, the same rule applies. I want the history, not just the symptom list. Many of the young adults I see have never been in a psychiatrist's office and are not sure they should be. Part of my job in the first visit is to say clearly whether I think there is a diagnosis, what it is, and what I think it is not.
How I decide on medication
Medication is one tool, not the plan. When I recommend it, I explain why, what I expect it to do, what it will not do, and how we will know if it is working. I give the FDA-approved options first and say so when I am recommending something off-label and why.
For children I start low and move slowly, and I measure. If we are treating ADHD, I want teacher feedback at follow-up, not just a parent's impression from the weekend. If we are treating depression or anxiety, I use the same rating scale at each visit so we can see the trend. I watch weight, sleep, appetite and blood pressure where the medication calls for it.
I also say when I think medication is not the right answer. Some problems are better treated with therapy, a change in sleep, a school accommodation, or time. Parents sometimes expect a child psychiatrist to prescribe at the first visit. I do not, unless the situation calls for it.
How I think about therapy
For most of what I treat in children and teens, therapy is either the first treatment or an equal partner to medication. Cognitive behavioral therapy has the strongest evidence for anxiety and depression in young people, and parent training in behavior management is the first-line treatment for ADHD in preschool-age children. I will tell you which kind of therapy fits, and I coordinate with the therapist so we are not working at cross purposes. If a patient is already seeing a therapist they trust, I want to keep that relationship intact and work alongside it.
Interventional options
I am a medication and evaluation psychiatrist, and most of my patients are young. When an adult patient has depression that has not responded to several adequate medication trials, I refer within Stedfast Psychiatry for Deep TMS, which is FDA-cleared for depression in adults, or for Spravato (esketamine), which is FDA-approved for treatment-resistant depression in adults. I stay involved in the medication plan while those treatments are under way.
What a follow-up looks like
After a new medication start, I usually see a patient within two to four weeks, then monthly until things are stable, then less often. Follow-ups are shorter than the first visit, but they are not refill appointments. We go over the rating scale, side effects, school or work, sleep, and anything that has changed. With teens, I still ask for a few minutes alone. With younger children, I check in with the school when I can.
I also plan ahead. Transitions are where care breaks down: the move from elementary to middle school, the start of college, the first job. I try to see those coming and adjust before the first bad semester rather than after it.
What I expect from patients and parents
Honesty, including about missed doses and about substance use. Bring the forms I ask for. If something is not working, tell me before you stop a medication on your own; some should not be stopped abruptly. For parents of teens, I ask that you let your child have a relationship with me that is theirs. I will always tell you about safety concerns. I will not report back every detail of a conversation, because if I do, the conversation stops.
Telehealth
I see patients in person at the Stedfast Psychiatry office in Lexington and by video across South Carolina, including patients connected to the Goose Creek, Bluffton and Hilton Head Island offices. I have practiced telepsychiatry for years and I am comfortable with it. For a first evaluation of a young child, I prefer in person when it is practical. For follow-ups, and for teens and adults, video works well, and it removes the drive and the missed school day. If I need vital signs, we arrange them locally.
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