Joseph Strayhorn, M.D.: Child Psychiatry



Where I am, and how to reach me

My private office is at 903 Hanshaw Road, Ithaca, New York, 14850. My phone number there is 607-319-0880. My email address for patient-related matters is jstray@gmail.com.

The door that you enter from the outside faces Hanshaw Road. There is no sign on the entry door with my name; you go in the door with a sign saying “Hage Tailor.” This door is immediately to the left of the entry to the Heights Restaurant, and just to the right of the entry to Talbot's.

Once inside this door, walk up the stairs to the second floor; turn left and walk as far as you can down the hallway; the entrance to my office is at the end of that hall.



At this time...

I'm not taking on new patients. I'll revise this page when this changes. However, I am open to referrals for OPT, the Organization for Psychoeducational Tutoring. OPT offers an educational intervention which relies on the teaching and learning of psychological skills, lasting many hours, conducted by phone sessions. To read more about this, please see optskills.org.

I'm specializing in...

I'm specializing in children 10 years old and under. I'm interested in helping with all varieties of mental health issues. I try to avoid the “medication management only” role.

Insurance

I am “in network” for Aetna, Cigna, Excellus, Multiplan, and Pomco. If you have insurance for which I am a network provider, the filing of claims is done for you. You pay the co-pay, coinsurance, and amounts not covered by deductibles.

If you have insurance for which I'm not in network, you pay me directly and file your own claim to your health insurance company for reimbursement. Some insurance plans reimburse well for "out of network" providers; others reimburse poorly; others don't reimburse at all.

Biographical Information

I grew up in Tennessee. I got a bachelor's degree from Amherst College in 1970, and an M.D. from Northwestern University Medical School in 1974. Thence I went to Duke University Medical Center for a general psychiatry residency, which was completed in 1977, and a research training fellowship. After four years on the psychiatry faculty at Duke, I moved to Pittsburgh for a fellowship in Child and Adolescent Psychiatry, which was carried out between 1981 and 1983. I stayed at the University of Pittsburgh until 1990, as first an Assistant Professor and then Associate Professor in Psychiatry. In 1990 I began working for Allegheny General Hospital, in outpatient child psychiatry, and joined the faculty of what became Drexel University College of Medicine. In 1994, I went into private practice of psychiatry in Wexford, PA (a suburb of Pittsburgh), and continued this private practice until 2010. In the summer of 2010, I moved to Ithaca, New York, where I have been in private practice.

One of my first publications was a book, in 1977, entitled Talking it Out: A Guide to Effective Communication and Problem-Solving. This was a manual on how people could resolve conflicts in a peaceful and rational manner. My interest in teaching important psychological skills, through psychoeducational techniques, and my interest in conflict-resolution, persist to this day. In 1982 I finished writing a general textbook of psychiatry; an appendix to this book contained an inventory of psychological health skills, my first answer to the question, "What does someone need to learn to do, to become psychologically healthy?" In 1983 I published an article entitled "A diagnostic axis relevant to psychotherapy and preventive mental health," which refined this list of psychological skills. And in 1988, Guilford Press published my third book, The Competent Child: An Approach to Psychotherapy and Preventive Mental Health, which gave book length treatment to the basic ideas of psychoeducation that have informed my life's work. These ideas are that 1) we can list a set of psychological skills that constitute mental health; 2) we can list a set of ways of influencing someone to gain these skills; 3) the essence of what mental health practitioners need to do, and what society in general needs, is the use of influence in positive ways that promote the growth of psychological skills. Societies are as strong or weak as the collective psychological skills of their members. The skills that help people get over diagnosable psychiatric disorders, I argued, are the same skills that lead people to higher functioning and greater happiness and productivity.

In the 1980's I was principal investigator on a research project looking at ways of teaching psychological skills to low income preschoolers and their parents. By teaching parents to use conversation, "modeling stories" (i.e. stories that model psychological skills) and dramatic play with their preschoolers, we got a significant reduction in attention deficit and internalizing symptoms in the children, as rated by their teachers when they began school.

In the 1990's I continued work that I had done in the 80's concerning the relation of academic skills to psychological skills. I developed a manual for teaching reading, and did a research project testing this method with a randomized study. The reading instruction methods seemed to work well, and in addition, we found that children's adhd symptoms were greatly diminished in individual tutoring sessions as contrasted to classroom periods.

At the end of this project, I began to experiment with methods of delivering reading instruction by telephone. It appeared that telephone instruction in reading was quite feasible, useful, and effective; a report on this was published in 2005.

In the first decade of the 2000's, I formed my own publishing company, Psychological Skills Press, in order to publish manuals not only for instruction in reading, but also for instruction in psychological skills.

In the twenty-first century, I’ve written about 18 books published by Psychological Skills Press. One of the important ones is called Exercises for Psychological Skills. The main idea of this is that a major way to improve mental health is by practicing certain exercises. Just as we get better in tennis, dancing, mathematics, or typing by practicing certain exercises until we can do them quite competently, the same is true for mental health. It is possible to construct psychological skill workouts analogous to physical fitness workouts. The exercises have names like the celebrations exercise, the conflict-resolution role play, the reflections exercise, the social conversation role play, the tones of approval exercise, brainstorming options, the twelve-thought exercise, and so forth.

I've also written stories that model psychological skills, since observing positive examples of psychological functioning is a very important method of influence. I've been gratified to have children enjoy reading or hearing or acting out these stories, published in Illustrated Stories that Model Psychological Skills, Plays that Model Psychological Skills, and Programmed Readings for Psychological Skills. In 2001 I recorded a CD of songs that model psychological skills, called Spirit of Nonviolence.

Statistics and research methods have been a hobby during all this time. I wrote some "statistical case puzzles" for the Joural of the American Academy of Child and Adolescent Psychiatry, an article on estimating the errors in data sets for the American Statistician, and a bunch of teaching materials used in teaching AP statistics to homeschoolers by internet. I taught a course in empirical research methods at Carnegie Mellon University.

In the 1990's I became a homeschooling parent; this post afforded me great joy and satisfaction. In 2009 my daughter Jillian and I collaborated on a couple of research articles that were great fun to carry out. In one of them, we looked at data from a large survey to see if there was evidence that martial arts training enhanced or worsened children's psychological skills. The effect size we found was zero, to about three decimal places -- that is, martial arts training didn't appear to help or hurt.

During all of this time, my primary professional activity has been seeing patients, trying to solve clinical problems, trying to help children, adolescents, and adults get over difficulties and attain higher functioning. All the research and writing I've done has been triggered and informed by my contact with people who have allowed me to try to help them solve problems. I've studied and used various forms of psychotherapy; I've been most influenced by the cognitive-behavioral school. I've also been using biofeedback since the late 1970's.

Attitude Toward Medication

The profession of psychiatry has increasingly become one in which using psychopharmacology is the major job description, and all the psychoeducational and psychotherapeutic work is delegated to psychologists or social workers. While I understand the economics of this, I don't do things this way. I think that one major advantage of a child psychiatrist being heavily involved in the nonpharmacological work is that the increased contact with the child and family helps in decisions about medication.

I have treated many children with medication over the past three decades, and for many of them, I have seen improvements that I do not believe would have been possible to obtain without medication.

The medication for children that I feel is one of the safest is also one of the most maligned: methylphenidate, a.k.a. Ritalin. There are some children who cannot participate in learning-based or psychotherapeutic interventions, who can do so with the help of "stimulant" medication such as methylphenidate. One of the favorable aspects of methylphenidate is its short half life, so that withdrawal from the drug can take place every day. For children with fairly severe ADHD (attention deficit hyperactivity disorder) symptoms, methylphenidate can make a vast difference in the quality of life, and for family interaction.

I tend to be much more conservative about the use of antidepressants than most of my colleagues. The problem with the older tricyclic antidepressants was their lethality in overdose, and their cardiac side effects. The problems with the serotonin reuptake inhibitors (SSRI's) are that first, the evidence of really good efficacy for depression in children is not particularly robust, and second, there is good evidence that the longer you take these medications, the more psychological side effects (anxiety, irritability, depression) you are likely to encounter when withdrawing from them. I have seen adults who have taken the SSRI's for years, who have found it extremely difficult or impossible to get off them. For this reason I like to try really hard with nonpharmacological techniques before using antidepressants, as a general rule.

The SSRI's are probably more efficacious as antianxiety agents than they are as antidepressants. They can sometimes be quite useful in situations where anxiety is greatly disrupting life. But my attitude is that when I prescribe them for anxiety, a race starts: can we use nonpharmacological antianxiety techniques fast enough to help the child get off the medications before becoming dependent upon them? The nonpharmacological techniques for anxiety are quite efficacious, for those people who have the self-discipline and support to be able to use them.

The atypical antipsychotic drugs are often prescribed for aggression and disruptive behavior in children, in the absence of psychosis. But this drug class is also associated with dependence and withdrawal problems; with tardive dyskinesia, a drug-induced disorder of involuntary movements that can be very disabling; and with metabolic effects that can increase the risk of diabetes and cardiovascular disease. One of the scariest possibilities that has been raised is the possibility of withdrawal psychosis -- that after having been on antipsychotic drugs for a long enough time, gradual changes in brain receptors can occur that manifest in psychotic symptoms when the drug is withdrawn. For all these reasons, I try to keep the duration of treatment with these drugs as short as possible when I use them at all, and to use nonpharmacological techniques as vigorously as possible.

There is much more that could be said about specific drugs for specific problems. But my general attitude is that with some exceptions, I like to see if psychoeducational methods can allow the medications to be withdrawn as soon as possible. I try to have the threshold for prescribing in proportion to my judgment of the riskiness of the drug. I do not like to prescribe most drugs without some sort of "exit strategy" planned from the beginning.

Attitude Toward Measurement

For any intervention, psychoeducational or psychotherapeutic or pharmacologic, a major question is not "does it work on the average in a research sample," but "does it work for this child?" For that reason, it's important to do lots of measurements of psychological health or psychological skills, and to record those measurements. It is so easy to forget how well or poorly a child was doing before some intervention was begun, particularly when several different interventions are tried at different times. If you're a parent, you don't want to find yourself in the situation of trying to remember, "Are things better now than they were before?" without some good documentation of the answer.

There are several ways to measure psychological skills and mental health functioning. One is by rating scales and questionnaires, filled out by parents, teachers, or the child him/herself. Another is by performance tests: how well can the child perform in academic tests, how well can the child pay attention on a test of sustained attention, how well can the child role-play a certain social situation, etc.

It's also important to measure factors other than the child's mental health. A parent's mental health status can greatly affect the child. Conflict between the parents is a very important factor impinging upon the child -- parents who want the child mental health professional to ignore parental conflict and fix the child without trying to fix parental conflict are often making a very big mistake. Family stress factors, the behaviors of siblings, family support systems ... the more of the variables that affect mental health can be measured and understood, the better.

One of the benefits of measuring lots of things is that one can "mine" the data of many patients to try to figure out what is most helpful for children with a certain type of problem. In this way, good clinical practice and good research practice facilitate each other.

Research

I ask all my patients' families if they would be willing to consent to “observational” research. The research protocol and the consent forms are reviewed by an independent Institutional Review Board. Unlike experimental research, where treatments are often randomly assigned and placebos are often used, observational research involves giving whatever treatments are predicted to work best, and trying hard to measure what happens. A subset of observational research is looking at the relationship of various measures to one another, and otherwise trying to answer the question, “How do we best measure whatever is most important for us to improve?” The whole enterprise of mental health treatment is built upon the foundation of outcome measurement, and this foundation, in my opinion, remains in great need of further strengthening. Another subset of our observational research involves trying to determine how much “psychoeducational tutoring” helps.

Psychoeducational Tutoring

Much of what helps people get over psychological difficulties is new learning. For example, someone with anger control problems learns ways of responding calmly and rationally to provocations, and drills and practices those desirable responses. Someone with anxiety learns not to exaggerate the "awfulness" of what will take place, and drills and practices responding courageously to the previously feared situations. Children with defiant behavior learn patterns of kind and cooperative behavior, and practice them. Practice in imagination, or fantasy rehearsal, is a very effective method of practicing these skills. Much of this new learning can be carried out by educational techniques: reading instruction manuals and doing standard exercises with hypothetical situations. Since 1999 I have trained and employed "psychoeducational tutors" who are often college students, to read manuals and do exercises with children and adolescents. My daughter, Jillian Strayhorn, is now executive director of our nonprofit organization dedicated to psychoeducational tutoring. In order to accumulate sufficient time on task, tutoring sessions are delivered for a half hour, six days a week. The way to have such frequent sessions without putting impossible transportation burdens on parents is to conduct the sessions by phone. We've been gratified to find that very positive relationships can develop through phone tasks and chats. This method allows greatly increased learning time at at vastly less expensive rate than a professional would cost. For more on this, and to look at excerpts from the manuals, you can go to optskills.org.

Attitude Toward Other Biological But Nonpharmacological Interventions

In the area of "alternative" treatments, "many are called but few are chosen" to be very helpful. A large number of promising candidates for nutrients or various practices are proposed with a great deal of excitement but that don't seem to prove very useful upon further examination. (The same thing is also probably true for drugs.)

That having been said, however, there are some biological nonpharmacological interventions that have clearly stood the test of careful research. One is helping the child to get enough hours of sleep; a related one is helping the child to stay in a regular sleep rhythm. Good sleep habits improve mood, behavior, and learning. Exercise has proven antidepressant effects, perhaps mediated by the positive effect of exercise on sleep. Bright light is a tested treatment for seasonal affective and for delayed sleep phase problems (i.e. having your internal clock set to fall asleep and wake up too late). Omega 3 fatty acids have had positive effects on irritability and emotional lability. For some children, the elimination of food dyes from diet has a replicable positive effect on behavior (or, we should say, the food dyes themselves have a replicable negative effect). The food dye hypothesis has been around for a long time; it has recently received some greater experimental support. Lead, from paint chips or paint dust or other sources, is a very powerful neurotoxin and eliminating any ingestion of this element is of paramount importance. There is accumulating evidence that pesticides and herbicides may play a role in children's behavioral and emotional problems.

Other "nutraceutical" treatments seem promising according to one or two studies. For example, n-acetylcysteine, an amino acid derivative, produced a positive effect on hair-pulling in one study, and on maintaining abstinence from marijuana in another.

My attitude is to try to stay tuned to the literature for interventions that seem to be very low in potential side effects, that may turn out for some people to have very positive therapeutic effects.