July/August 2006

Does my child need a therapist?
How to tell and what to expect

By Wendy Underhill

Little Alicia, age five, only eats white foods-macaroni, milk, rice. Brendan has had three bone fractures in four years, and owns more broken toys than whole ones. Claudia has nightmares. Daphne can't seem to make or keep a friend. Evan loses something between the kitchen and the carpool almost every day. Which of these children needs professional help?
When it comes to knowing if a child (say, your child) needs therapeutic help for mood or behavioral disorders, professionals agree on one answer: “It all depends.”

And there's agreement that dealing with childhood psychological disorders is a risky business. If you take action, you risk harm; and if you do nothing, you risk harm. What a choice!

Keeping in mind the specific complexities of any human being, the range of possible diagnoses, the ever-increasing knowledge about interconnections between biology, chemistry and mental health, and the myriad treatment options available, the only sane thing to do is to bone up on the When-Where-What-Who-How's of child-specific therapy, and make the best decisions you can. Herewith is a Cliff Notes version of what to expect and do when you enter the world of children's special needs.

• When. It's time to seek help when you've tried everything that common sense, parenting books, and trusted friends and family recommend. Understandably, parents are loath to admit that their offspring could be anything less than perfection incarnate. There's an active self-protective mechanism that allows parents to chalk difficulties up to “it's a stage she's going through” or “boys will be boys” or “the system needs to adjust to the kids, not the other way around.”

Given that hesitancy, the truism, “when parents think the child needs help, then the child does need help,” is probably true. That day may come only after a teacher suggests that an evaluation is in order, the child hurts him or herself, or a doctor sees something that raises a red flag.

Red flags tend to go up more readily for boys than girls, and that makes it appear as though boys have more psychological difficulties than girls. It ain't necessarily so. Girls often present psychological problems in quiet ways, such as avoiding friends, falling grades and new fears. Boys, on the other hand, tend to “act out” which gets everyone's attention. One set of problems is no better or worse than other; both can be helped by professionals.

If you're thinking of waiting, envision doing nothing until little Fabian enters adolescence with the same problems, newly compounded with hormones and semi-independence from home. Sooner is better.

• Where. When parents have a general idea that something isn't right, the next step is to seek a diagnosis. Often, public institutions are the first line of defense. Colorado provides “Early Childhood Connections,” a program throughout the state which helps identify and assess children, from newborns to age 3, with any special needs. The emphasis is on “any.” Any parent with any concerns can have their child screened for mental, physical, emotional and any other issues imaginable. The outcome might be reassurance that the child is on the appropriate trajectory, or that the child does have a problem, and can be connected to appropriate services in the community.

Babies born prematurely are particularly at risk for behavioral, learning, and emotional problems, even after the child has caught up physically. So care has to be taken from the onset to protect the fragile child. The Center for Family and Infant Interaction at the University of Colorado Health Sciences Center uses a Newborn Individualized Developmental Care and Assessment Program, an approach that has spread to 14 centers in the state.

Past the preschool years, public schools are mandated to offer screenings for a variety of learning and developmental problems. These are free to the parents and will provide lots of information and a proposed plan to deal with any issues that surface.

If you don't like or trust the outcomes of such a screening, seek a second opinion. Try a clinical psychologist who specializes in children for an evaluation; this person should be able to recognize what signs and symptoms (see sidebar) point to which kind of therapy. Especially if the issue is anxiety or depression, a clinical evaluation may be enough and treatment can begin promptly.

Such an assessment might also lead to a whole battery of quantitative tests that include academic, mental and emotional health, and speech, language, sensory, and neurological testing. These are usually offered at large institutions, such as Children's Hospital or the University of Denver, and the information is referred back to the psychologist or clinician. You may find that your child has a very high IQ but also very high distractability and mild dyslexia, for example. Oftentimes learning difficulties go hand in hand with emotional and behavioral issues. This kind of detailed, quantitative information can save time in treatment by getting the child to the right professional's office immediately, although it comes with a hefty price tag that insurance may or may not cover.

Colorado is also dotted with mental health centers. These vary greatly in the services they offer, but are uniform in knowing what is available in your area. Especially if cost is a factor (and it always is, when mental health issues surface), these centers may be your best resource.

• What. Now that you've had an assessment, evaluation or battery of screening tests for little Grace, does she have attention deficit/hyperactivity disorder (ADHD)? Obsessive-compulsive disorder? Attachment disorder? Sensory integration disorder? Something on the autism spectrum? Dyslexia? Oppositional disorder? Perhaps a hearing deficit? A mood disorder? Post traumatic stress? Some of these are psychological issues, and some are learning differences or deficits. More to the point, they often come in two's or three's, not singly.

• Who. With overlapping diagnoses, parents may be on a long and winding road through many professionals' offices. Don't be surprised to end up with a team of professionals that might include a psychiatrist, a therapist for the parents, another for the child, and perhaps an occupational or speech therapist as well.

Ideally, parents are part of that team. Some say that if the child has a problem, it's the parents who need the work. And yet, research is uncovering the biological bases of more and more disorders every year. Parents are, at the very least, almost certain to play a part in their child's treatment. If parents are facing battles of their own with grief, mental illness, substance abuse, severe financial stress or other problems, they may not be as active as they'd like on behalf of their children. In these cases, it may fall to child care providers, teachers, or others in the community to work with and for that child.
As for the lead therapist of a working team, what should a parent look for? Compassion, a broad-based view of children's psychological needs, and someone who “clicks” with your Harry. Of those, compassion comes first. Seek someone who is kind and understanding about the difficult path your child has been on. If the therapist approaches you as if your child is a bundle of pathologies, think twice. Instead, look for a “first, do no harm” approach, with a person who sees the excellent qualities Harry brings, as well as the struggles he faces.

Then make sure he or she has a broad set of skills, and the flexibility to recognize that when one approach isn't working it's time to move to plan B, C or D. There is no one right road, regardless of how many parenting gurus suggest otherwise.
As for “clicking,” a therapist has to have a relationship with the child. Chemistry counts, and if after a handful of sessions your child is still uncommunicative, don't lose time before trying a new therapist. (Consider that it is the parents' job to get the child to the first appointment; after that, it's the therapist's job to create a bond.)

• How. After getting a diagnosis and choosing a therapeutic team, you'll be offered a bushel of ways to treat childhood behavioral, emotional, and learning disorders. Step one in almost all cases is pretty basic: diet, rest, and regulation. In fact, some say that the three best things you can do for a child with depression is give him or her a protein-rich breakfast, an hour of aerobic exercise daily and fish oil, which has a palliative effect on mood disorders. In general, though, if a child leads a chaotic life with questionable nutrition and inadequate sleep, disorders are hard to treat.

And the therapy itself? Young children will play with puppets, dolls, other toys or games, and from this play the therapist learns about their world. When difficult issues surface in play (Mom and Dad fighting, for instance) the therapist will guide the play to a resolution more satisfactory than having the child get pummeled in the process. The play becomes the conduit for offering new perspectives, coping strategies, and even concrete techniques such as deep breathing to ward off anxiety.
If your Jenna won't go alone, Mom and Dad may go along, too. If that doesn't work, then the parents might go without Jenna, and receive coaching on how to set up a household, schedule and expectations that work.

Another option: family therapy. Here, the idea is that the child who presents “problems” in the family constellation isn't operating in a vacuum. Instead, Kai is performing his role, as are all the other family members. Perhaps a sibling has the role of “good child,” the mother has the role of the family's emotional barometer, and the father has the role of playmate and conciliator. With family therapy, all (or at least most) of the family attend sessions together, and it's the interactions between them that are the focus, and breaking out of those roles may be the goal. Family therapy takes the pressure off Kai, a potentially huge relief.

Yet another option: group therapy. If it's a group of 10-year-olds who tell little Louis that they don't like him because he grabs and interrupts, he may hear it more clearly than if a caring adult gives the same message. And, the group provides an opportunity to practice nascent social skills.

Still more: there is a surprising body of research indicating that Eye Movement Desensitization and Reprocessing (EMDR) can help, especially with children who are suffering from past traumas. In practice, this looks like the child following an object that the therapist moves rapidly before his or her eyes. Any form of activity that bounces attention quickly back and forth from the right to the left side of the brain helps “unstick” traumatic memories that are impeding daily life or growth.

And last but not least, there are psychotropic medications to treat many conditions: anxiety, compulsiveness, attention deficit/hyperactivity disorder, or depression. Many parents are reluctant to use them for understandable reasons: they believe using psychotropic drugs may set up a pattern of medicating problems away, they fear dulling little Maria's personality, or they may cause metabolic changes that effect growth. Recent news about a link between anti-depressants and higher rates of suicide, the abuse of ADHD drugs among older teens, and the overuse of sleeping medications for children all scare parents away. So, choosing to medicate isn't always straightforward, and probably the child's pediatrician isn't the right person to make that call. Ask for a referral to a child psychiatrist.

While thinking about whether to medicate or not to medicate, note that there is risk if you choose not to. If you don't medicate, the child suffers from the presenting problem and very likely social problems that are an outgrowth, and which can become ingrained patterns that are hard to shift later. Parent after parent says, “I wanted to do everything I could to avoid using medications, but once we finally went that route, life was bearable for Nate for the very first time. Medication has been a lifesaver.” Expect that it will take time to get the right drug and dosage, and that when the child grows, your doctor will need to reformulate the prescription again, and again. Note, too, that medication is rarely a solution all on its own; it works best in conjunction with some kind of “talk” therapy and modifications to the home and school expectations and environment.

Whatever treatment is pursued, you'll want to know when recovery has begun. “Recovery” can be a tricky word; if parents hold on to the glowing expectations they've carried since Omar's birth, recovery may be hard to achieve. If, on the other hand, recovery means that life gets easier for him, then recovery is eminently achievable. The best sign that you're on the right track? Friendships improve. When your child brings home friends who represent the best, not the worst, in him or herself, you're on the road forward.

Red Flags
If you see these behaviors in your child, consider seeking help:

• explosive behavior
• self-abuse (hitting, biting, hair pulling, cutting)
• violence against others
• withdrawal
• changes from your child's usual behavior
• nightmares
• difficulty sleeping
• unreasonable defiance
• unexplained behavioral problems
• excessive shyness
• newly developed fears
• repetitive behaviors such as handwashing
• difficulty making and keeping friends
• lack of empathy
• attachment difficulties
• cruelty to animals

Say “no” to stigmas

Even when parents recognize that their child is experiencing problems in school, with friends, or at home, parents may try to avoid screening and say, “I don't want my kid labeled.” (There may be a subtext of “I don't want myself labeled as the parent of a problem child” underlying this viewpoint, too.) There's good reason to worry for the children; lots of research indicates that teachers and others treat children according to their expectations; if they've been told that the child has “oppositional disorder,” they may take a geared-for-struggle stance, for instance. And children tend to live up (or down) to those expectations.

As for relationships with peers, you don't have to go far to find stories of children who have been embarrassed by being labeled a “special education student,” a broad category that includes children with anything from mild dyslexia to severe developmental disabilities. Classmates do notice who goes to the office to receive medication, who gets pulled out of class for “special” help, who gets to have an extended time for test taking, all common (and appropriate) ways that children are accommodated. They notice, and they may be unkind about it.

In other words, stigma is alive and well in relation to mental illness and every form of special needs. Having agreed that stigma is a persistent hindrance to seeking treatment, experts say parents simply have to face it and proceed to treatment anyway. That begins with accepting for themselves and their children that mental disorders are no different than diabetes or any other disorder: unpleasant and long term, but treatable. Then parents (and children as they grow older) may find themselves becoming advocates for people with mental or emotional disorders, spreading the word that stigma is perhaps the most treatable part of a child's special needs. “Just Say No to Stigma” could be the rallying cry.

Child Therapy Resources, local and beyond

For more information, see the following:

• www.aacap.org, The American Academy of Child and Adolescent Psychiatry
• www.emdr.com, the website for the EMDR Institute
• www.mhacolorado.org, The Mental Health Association of Colorado
• www.thechildrenshospital.org/public/cs
• A Parent's Guide to Developmental Delays: Recognizing and Coping with Missed Milestones in Speech, Movement, Learning, and Other Areas by Laurie LeComer (Perigree, 2006)
• Think for Yourself: A Kids' Guide to Solving Life's Dilemmas and Other Sticky Problems by Cynthia McGregor (Lobster Press, 2003)
• Your Child in the Balance: An Insider's Guide for Parents to the Psychiatric Medicine Dilemma by Kevin T. Kalikow, MD (CDS Books, 2006).