Dr. Schreier is the principal mental health professional appointed by
the Juvenile Court to evaluate Brandon, the 6-year-old charged with
assaulting the Bermudez infant in Richmond, California last year. Dr. Schreier
is the Chief of Psychiatry at Children's Hospital in nearby Oakland and has
been there for 19 years.
Question: Dr. Schreier, what is your particular expertise?
Schreier: I have various research and clinical interests, but particularly
cognitive and developmental disorders in very young children, including autism,
non-verbal learning disabilities, Tourette's syndrome and the conditions that
along with Tourettes, like obsessive-compulsive disorder (OCD), attention
deficit disorder (ADD), and severe behavior problems resulting from abuse. And
I am also very interested in the early childhood antecedents of criminal
behavior in adults in society, because studies tell us that between six to eight
percent of violent juveniles go on to commit 60% of adult crimes. I
don't work with adults at all except with families and their kids.
Question: How common is it to see anti-social, impulsive or violent young
children in your practice at Children's Hospital?
Schreier: We see a lot of violent, impulsive young children. In the weeks
before we evaluated Brandon, we had seen many children under the age of 7
who were exhibiting some violent behavior. We do see many more impulsive
children because that's part of the attention deficit disorder (ADD) syndrome.
We also see a fair smattering of manic-depressive kids who can also present
violent behavior. And we see a lot of abused kids, which I mentioned as a
particular concern we have here at Children's Hospital. We have a special
clinic that focuses just on abused kids, particularly kids traumatized by
neighborhood violence and large natural disasters. We did a study on kids
traumatized by the Oakland Hills fire, for example. So, we see a lot of kids
with bona fide disorders and/or kids suffering from abuse who present with
very violent behavior under the age of 5--unfortunately, we see a lot of
Question: How many do you see a year?
Schreier: Well, when the Brandon case hit the news and a reporter came to talk
me, I told her that I could certainly show her that we had calls for services
in the three months prior to the Brandon case of at least 15, 16, 17 kids up
to the age of 7 with really severe, violent behavior, and we couldn't pick
up all of those kids. So, in a year, maybe 80 kids like that will come into
Question: How are these kids referred to you?
Schreier: They're referred from the schools, by pediatricians, by the
social services, by foster care parents, by various clinics in the hospital.
Questions: Since you've been here for about 19 years, what kind of changes
have you seen with these kids?
Schreier: Well, I think the change that has occurred over time, in my opinion,
is that there is an inordinate amount of violence that has been perpetrated on
and violence that they've witnessed. We now see kids who have witnessed
traumatic situations and violent situations who are very severely
traumatized by it. And it seems, from where I sit, that we're seeing more
and more of those kids. We also have a heightened sensibility to the fact
that those kids need help early on, so that when the fire occurred in the
Oakland Hills or recently when there was a fire in one house in a
where a couple of kids died, we actually sent a team out to help the
neighbors deal with that.
Question: Do you see a lot of drug abuse in the families of these
Schreier: Drug abuse often leads to violence, sure. We had at one time
a group for grandmothers who were taking care of drug-exposed, intrauterine
-drug-exposed babies. And the parents of those kids would wander in and out
of the house and would create violent situations, would often rob from their
parents or rob from their own kids. These same kids were seriously traumatized
early on by the living situation when they were with their parent. So they
were very difficult for their grandparents to deal with. What we did was set
up a group--group supervision parenting for the grandparents of these at
times very difficult children.
Question: How about the socioeconomic background of these children? Is
that a factor?
Schreier: Since Children's Hospital has a clinic and because people know my
these various fields, I get referrals from all over northern California and the
San Francisco Bay Area, so its really hard to say. We see a fair amount of
Medicare patients--about 70% of the kids who come through the clinic--but
then the rest of them are middle-class, and we also see a smattering of
upper-middle class families with kids who have fairly heavy duty psychiatric
There's no doubt in my mind that kids who grow up in poor neighborhoods,
particularly ghetto neighborhoods, are exposed to much more violence than
kids in middle-class neighborhoods. If anything, with the flight of the middle
class to the suburbs and middle-class people sending their kids to private
schools, what we've seen is that these kids are increasingly in schools where
they are "ghetto-ized."
So these poor kids have, I think, more in the way of special needs because of
the neighborhoods they grow up in. And the various kinds of after-school
programs available for kids that used to help contain some of their
difficulties have disappeared. That includes music programs and sport programs
and art programs. If
you look at the highest time period for crime rate of these kids it is
3 and 6 p.m. And those used to be times when there were many after school
programs. The other thing is that the neighborhoods that these kids are
growing up in--with the increase of drug problems--are less and less safe
these kids witness violence. There are guns in the school, violence in the
school, violence in the streets and violence at home. When we do things like
go into the schools when a kid has been shot, it's really hard to find any
student who hasn't had first hand experience with somebody being violently
attacked in their presence.
Question: When you see a child in your clinic, what techniques do you use
to evaluate them?
Schreier: When we see kids where there's a lot of violence we try to do a
comprehensive exam. We need to get a really good sense of how that child
functions at home versus how he functions in school, for example. We send
questionnaires to the teachers as well as the parents. We often do a
battery of neuro-cognitive testing, and if there is any indication or
suggestion of bona fide brain damage as opposed to cognitive difficulties or
problems or learning disabilities, then they'll get a neurological workup and
an EEG. We're also very careful
these days to take a very thorough family history because the psychiatric
disorders that can lead to violence run in families. And then we evaluate the
child directly through play therapy, particularly if it is a very young kid.
Watching them play, we can oftten determine how amenable the child is to
Question: How about pharmacological therapy?
Schreier: There are a number of children, as I mentioned before, who have
behavior based on true psychiatric illness. So, ADD kids with impulsivity, who
often have oppositional or conduct disorder and who usually also have
deficits, are at very high risk for developing antisocial behavior in
adolescence and adulthood. Those kids need very special attention, more
than you can give in a clinic. They often need special day programs or
programs that are focused on kids with ADD and impulsivity and behavior
problems. Those kids can respond with medication, but in the context of the
program including medication. We see manic-depressive kids who we've treated
very successfully with medication when they present with violent behavior.
Question: What kind of staff and resources do you have at the
Schreier: I have a staff of 18, inclusing psychologists, Ph.D. students in
psychology in training and various people at the clinic who help do
evaluations. If we need the particular expertise of a psychiatrist around a
diagnosis or if medication is
needed, then I am directly involved or we hire another person.
Question: Do you, yourself, do therapy with children in the clinic?
Schreier: Yes, I do have a small therapy caseload, but I'm mainly involved in
consultation and pharmacological interventions, at this point.
Question: Are there specific risk factors that help identify potentially
violent or anti-social behavior in young children?
Schreier: Well, there's a spectrum including everything from a kid with a
temperament who's negative in mood and intense and very active to kids with
very severe agressive behavior, some associated with bipolar disorder and
severe attention deficit disorder. Some temperamental behavior is simply
related to unusual things going on in the family--like divorce and
separation. With intervention in the family, kids like that can do well.
Then there are the cases who come to me after they have already been through a
lot and have not been identified early enough. These kids are much more
difficult to treat. They are the traumatized kids, who will be exhibiting very
So there are these antecedent risk factors, which I would call endogenous and
exogenous. It is very important that somebody doing an evaluation look for
these antecedents because in some ways they are predictive and in many ways
they're quite treatable. Thirty percent of the kids in the California Youth
Authority--essentially in youth prison-- have post-traumatic stress
disorder and another 50% of them have symptoms of PTSD. So we
recommend early diagnosis and treatment of kids who have been traumatized.
Interventions, even if they're group interventions, can be quite effective if
they happen early.
Question: How long do you usually work with a troubled child?
Schreier: It varies all over the place. I mean, from weeks to
years. Some of these kids cannot respond unless you keep them in long-term
Question. What is the prognosis for these kids? What kind of success have
Scheier: We've had tremendous success with picking up kids early on who have
bona fide psychiatric illnesses, which are quite treatable. I just
published a paper about a juvenile with various risk factors, with
very aggressive behavior, who responded to a vary low dose of a drug called
Respargon. So there are various forms of treatment that can be quite helpful or
at least get the kid to the point where they would be amenable to therapy so
they can calm down and be in
Question: Is there family involvement in the therapy?
Schreier: Almost always.
Question: Is it a requirement?
Schreier: The family needs to be willing to be involved--absolutely. It helps
enormously, I can tell you from the literature that family education,
parenting classes are very, very successful. We don't do those kinds of
classes at Children's Hospital per se, but we work on more dynamic or
interactional, interpersonal issues with family's so they're very similar to
parenting classes, but much more individualized.
Question: In terms of the outside resources, lets say the child has
completed therapy and they still need some sort of support--what's
Schreier: Very hard to get. I mean, if the kid is really tearing up in
sometimes you can get mental health to pay for a day treatment program or
residential program. Some are quite good, some of them not so good and
they're not enough of them and we need more subtle levels in between
because they're just these kinds of gross steps, if you will. There
should be more on school onsite programs than we have now.
Question: Do you think that's going to change?
Schreier: Well, they reduced the classroom size at long last and somebody told
they're starting to put in afterschool programs again in Oakland, but I
think they're going to end up building jails faster than they're going to
build good schools.
Question: Who pays for therapy and intervention?
Schreier: In my case, the hospital, we suffer a huge deficit because when you
population of 70% Medicare, it doesn't come close to handling cost.
this case the hospital has some funds that they're willing to put into our
deficit every year. Insurance for mental health services of this type
which are very long term is almost non-existent. And the idea that we have
to call in every three sessions or five sessions to ask for more and there's
always somebody skeptical and often that person doesn't really know very
much about these kids or their problems is really just an outrage.
Question: Do you have any recommendations for parents, teachers or others
who see troubling behavior
Schreier: Well, you should push and seek advice early--do not accept a
pediatrician's or a teacher's or a neighbor's suggestion of, "Don't worry,
he'll grow out of it, don't worry, there's nothing you can do about." If a
parent is worried, they should really seek professional advice from a qualified
person who's seen a lot of kids, who knows whether any one of these conditions
is a serious predictive risk factor of violence or other aggressive anti-social
Question: What are the serious signs?
Schreier: Well, the most obvious is tantrums that go beyond the "terrible
who are having tantrums at 4, that's a cause for concern. Its just a sign,
doesn't by itself say that all those kids are going to be in trouble, but a
tantrum may be oppositional behavior that suggests a serious problem: hurting
animals, hurting other children, not considering the feelings of others.
Oppositional behavior, major tantrums, stealing, lying, all that kind of
stuff--these are signs that should never be ignored.