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.

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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 go 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 those kids.

Question: How many do you see a year?

Schreier: Well, when the Brandon case hit the news and a reporter came to talk with 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 the clinic.

Question: How are these kids referred to you?

Schreier: They're referred from the schools, by pediatricians, by the department of 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 these kids 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 neighborhood 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 children?

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 own 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 work in 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 problems.

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 between 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 so 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 fairly 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 interventions.

Question: How about pharmacological therapy?

Schreier: There are a number of children, as I mentioned before, who have violent behavior based on true psychiatric illness. So, ADD kids with impulsivity, who often have oppositional or conduct disorder and who usually also have neurocognitive 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 total 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 clinic?

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 difficult 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 aggressive behavior.

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 therapy.

Question. What is the prognosis for these kids? What kind of success have you had?

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 therapy.

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 available?

Schreier: Very hard to get. I mean, if the kid is really tearing up in school 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 me 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 treat a population of 70% Medicare, it doesn't come close to handling cost. In 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 behavior.

Question: What are the serious signs?

Schreier: Well, the most obvious is tantrums that go beyond the "terrible twos." Kids who are having tantrums at 4, that's a cause for concern. Its just a sign, it 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.