What Parents Need to Know
About Choosing a Therapist for their Child
When a child is having emotional or behavioral problems, parents become not only concerned, but also may need to intervene. When lesser measures fail, the next step may be finding a child psychotherapist.
Many parents have no idea whom to turn to or how to assess the qualifications of such a professional. What can be expected during an evaluation. If therapy is needed, what is the therapeutic process?
In this post I will address those questions and provide information and guidelines to help you though a difficult time which, with the proper intervention, could turn into a great benefit for your child. I’m an adult and child psychiatrist who has been evaluating and treating children for five decades. I understand how difficult it is to face the reality that your child is in need of help and to find the right person to intervene. Let’s begin with an understanding of the various mental health professionals who evaluate and treat children and how their credentials differ.
A child psychiatrist is a medical doctor who has chosen to specialize in mental and emotional problems. In order to become a psychiatrist, a man or a woman must have graduated from medical school, likely spent a year as an intern, and then spent at least four years, full time, in adult and child residency training programs. Two or three of those years would be spent in an approved program working exclusively with children. Not every psychiatrist is a child psychiatrist. So when considering a physician for your child, ask specifically if the person has completed a residency in child psychiatry, in addition to the years of training in adult psychiatry.
Psychologists also treat children. They go through a lengthy graduate school program that can take five or more years to complete. After graduating with a PhD degree, psychologists spend a year or more in a clinical setting working with patients under supervision. After passing a licensing examination in their chosen state, they are ready to begin a practice and see patients. If you are considering a psychologist for your child, you should inquire about that person’s specific training and experience with children.
Social workers also treat children. They undergo two or more full time years of training in social work before becoming licensed to practice. As with child psychiatrists and psychologists, it is important to ask about the social worker’s training and experience in treating children.
Marriage and family counselors may work with children. As with all of the professionals mentioned above, experience in treating children and their families is critical.
If you live in a community where all of these professionals are available, knowledge of the individual’s reputation gained from friends or local professional organizations can be extremely helpful in making an appropriate choice.
Psychotherapy—Play therapy: In plain English, psychotherapy is talking therapy. When dealing with children, particularly young children, play is often utilized as a way of understanding the child’s inner world. Children naturally express themselves through play. So child therapists have toys, board games, puppets, blocks, etc. available for the child to use. The child reveals his or her inner world by the games they choose to play and the fantasies they express while playing. The child therapist will watch the play and participate when asked, form a comfortable working relationship with the child and often communicating information to the child by commenting on the content of the play. Unlike younger children, adolescents usually prefer to sit and use words as the major form of communication between therapist and patient.
Work with Parents: Parents play an essential role in the treatment of their child. Particularly with younger children, they provide information about the child’s difficulties and developmental information from birth onward to the chronological present. In addition, they bring the child to the therapy setting and are financially responsible for the treatment. With adolescents, their role is less prominent but just as important to the success of the treatment. In addition to assisting in the evaluation they provide emotional support and structure to the therapy by working with the therapist to maintain the treatment alliance during periods of resistance on the part of the adolescent. We will delve more deeply into all of these subjects later in this article.
Any experienced therapist who is worth his or her salt understands that he or she treats a child at the pleasure of the parents. Failure to maintain a respectful and cooperative relationship with the parents inevitably results in the end of the therapy.
Medication: Medication is useful, indeed, necessary in the treatment of many conditions in childhood. However, medication should be part of a comprehensive program which, following a thorough evaluation, may also include psychotherapy and work with the parents.
The Diagnostic Evaluation
Not every competent child therapist proceeds in exactly the same manner. But every experienced therapist recognizes these basic concepts and utilizes the following elements in a thorough evaluation.
The immaturity of the child’s mind does not allow him or her to understand the need for an evaluation or to participate in it with the same degree of comprehension or cooperation as an adult. Hence the need to involve parents in the evaluation procedure.
In reference to the question of why parents need to participate in the diagnostic process, it is important to recognize that children are not independent. They live with parents or other adults who control many aspects of their lives. Parents not only make the decision to bring their child for help, but also provide information about the present and past which the child cannot give because of a lack of knowledge and intellectual immaturity.
Since children are different at different ages, techniques and procedures will vary depending upon the developmental level of the child. For example, the evaluation of a five year old will differ significantly from the evaluation process with an adolescent.
Basic Components of a Child Psychiatric Evaluation:
I’ll now describe the child psychiatric evaluation from the parents view point and experience.
EVALUATION PROCEDURES WITH YOUNG CHILDREN
Although the component parts are the same in the evaluation of younger children and adolescents, they are not utilized in the same manner because of the developmental differences between the two.
For children from birth through approximately age 11 or 12 year of age, the sequence of the evaluation is as follows: The concerned parent or guardian, after a thorough search to insure competence and experience, calls the child therapist for an appointment. Then the history is obtained from the parents in a series of two or three 45-minute sessions. After that, the child is interviewed individually at least twice. If needed, additional procedures such as psychological testing are obtained at this point. After assessing all of the relevant information, the therapist schedules a summary conference with the parents but not with the young child.
The initial contact, almost always in the form of a phone call, is very difficult for most parents - often the most difficult moment in the entire evaluation experience. That’s because the decision to seek professional help is almost always made with considerable apprehension, fear and misgiving.
For the parent who sees the child as both a responsibility and an extension of him or herself, the expected response at the other end of the phone is often anticipated to be criticism for real or imagined wrong doing. The very act of seeking help is often accompanied by considerable guilt. A warm telephone voice and a friendly inquiry into the reason for the call on the part of the therapist goes a long way to calm such concerns and will inevitably be the response of any competent therapist who understands the parent’s feelings and apprehensions.
In the evaluation of a young child, the therapist will explain the evaluation procedure and arrange for the initial visit with the parents. If at all possible, both parents should be present during the history-taking sessions, since both parents play a critical role in a child’s development.
The History is obtained from the parents because the child is not able to describe current problems or past experience in an organized manner. The information is gathered before seeing the child because it assists the diagnostician in understanding the child’s communications that are often in the form of play or incomplete verbalizations.
The diagnostician will first gather identifying information--names and ages of all the family members, home address and relevant phone numbers. Does anyone else live in the home, including very important family pets? This information sets the frame for the diagnostician’s thinking. For instance, the child’s experience may be very different if he or she lives with a single parent as opposed to two parents or with a biological parent and a stepparent.
Next the therapist will ask the parents to describe in their own words, in any manner that they choose, what are the problems or issues that have brought the parents to seek professional help. Once the parents have conveyed their concerns, in a clam neutral voice, the diagnostician will ask additional questions to clarify the issues and to determine when they began, when they were most severe, and what if anything has been done to try and deal with them. By this point you should be beginning to relax a bit because you are in the presence of someone who is kind, caring, and obviously trying to understand and help.
Following the description of parental concerns about the child, the diagnostician will take a developmental history. The developmental history traces the child’s life experience from birth to the chronological present and allows the diagnostician to compare this child’s experience against a large body of knowledge on normal and pathological developmental processes. In anticipation of this part of the evaluation, it is useful to bring baby books and other sources of information which will help you answer questions such as when did Johnny or Susie sit up, walk, say single words, etc.
The diagnostician will also want to gather some parental history since your experiences as a child and growing up affect the manner in which you parent hour child. The intent in gathering this information is not to turn you into a patient but to understand how your thoughts, feelings and interactions with your son or daughter affect the child’s development.
Diagnostic Interviews With the Child
The therapist will help you decide what to tell your child about the diagnostic interviews. The child should be told the truth about what is going to happen in words that he or she can understand. For children five and under they should be told about two days in advance. “Johnny, on Friday I’m going to take you to talk to a nice lady who talks to boys and girls about their worries. She has a nice office and there are toys there to play with. She’s not like Dr. Lewis (pediatrician) so she won’t be giving you any shots. I’ll be waiting for you outside in the waiting room.”
For elementary school aged children they should be given several days notice and given a similar explanation of what is to take place, gearing the language used to the child’s age and ability to understand. With a child of any age, the parent should be available to answer questions again, always truthfully, that Johnny or Susie may have about the coming appointment and the therapist.
A thorough diagnostic evaluation will include at least two diagnostic interviews with the child. This is necessary because the first interview is primarily spent observing and insuring that the child is comfortable in the playroom. The second interview may be quite different than the first. The child may be more spontaneous and revealing, and the therapist may choose to ask questions about the presenting symptoms and problems.
Once the child separates from the parent and is comfortable in the playroom, he or she will communicate through actions and words. An understanding of developmental theory and knowledge of the individual child allows the diagnostician to assess normality and pathology as the interview progresses. When the interview is over, parents should not ask questions about what took place but should listen to anything the child wishes to say about the experience.
Additional Information and Procedures
The need to collect diagnostic information from psychological and educational testing or from medical procedures can only be determined after the presenting problems have been described during the history-taking and diagnostic interviews. Since ancillary procedures subject the child to anxiety-producing situations and may involve additional expense, they would only be ordered, with the parents permission, when the information they provide is essential to obtaining a clear diagnostic impression.
Formulating the Diagnostic Impression and Treatment Plan
Once the necessary data are collected, the hard work for the diagnostician begins. Although the process of formulating a diagnostic impression begins with the initial contact, it cannot be completed in a responsible manner without a thorough consideration of all the data from the history, interviews, and ancillary procedures. This happens over several hours or days of deep thought. Once the diagnosis is formulated various treatment possibilities must be considered that take into account the diagnosis and the realities of the child’s life.
The Summary Conference
Following the completion of the evaluation of a young child, a conference is held with the parents during which the findings are presented in detail. The child is not present because he or she would not be able to fully understand the concepts being presented and might experience unnecessary anxiety from exposure to the information itself or parental comments and reactions to it. In preparing for the summary conference, the diagnostician organizes the findings and considers how he or she can present the findings to the parents in a manner that insures clarity. An organized presentation, usually from prepared notes, indicates to the parents that their concerns have been taken seriously and were thoroughly considered. Such an approach is important for the therapist as well as the parents because the decision to accept the treatment recommendations will be made by the parents, not the child or the therapist. In addition to serving its diagnostic function, the evaluation period allows the parents time to form a relationship with the person—at first a stranger—to whom they may entrust the care of their child.
EVALUATION PROCEDURES WITH ADOLESCENTS
The diagnostic process with an adolescent differs from a younger child because of the developmental differences between the two. In conducting an evaluation of an adolescent, the diagnostician will take into consideration the following developmental concepts:
For all these reasons, the sequence of the evaluation differs from the one used with younger children.
The Initial Telephone Contact
As with the young child, the initial telephone contact is usually made by a parent. After listening to the parent’s concerns and outlining the diagnostic process, the clinician should attempt to schedule the diagnostic interviews directly with the adolescent, thus underscoring the diagnostician’s respect for the adolescent as a maturing individual. Parents are often relieved by this suggestion because of the anticipation of a battle with the adolescent over agreeing to see the clinician.
However, parents do need to tell the adolescent to expect a phone call and its purpose. In my clinical experience, most adolescents will respond positively and schedule an appointment that is convenient for them after the clinician, in a friendly voice, explains that his parents have concerns but the therapist wants to hear from the adolescent first. If all efforts fail, and more than one phone call may be necessary before the adolescent agrees to meet, then the appointment is scheduled by the parents who have the responsibility of setting a limit and bringing the adolescent to meet the clinician.
Both parents and adolescent are informed that the details of what the adolescence conveys to the diagnostician will be strictly confidential and will not be revealed to the parents. However, the adolescent is free to ask any questions about what the parents have told the therapist. They will be answered honestly and openly. At first, some parents are uncomfortable with this arrangement. But as they come to understand the developmental reasons behind the diagnostician’s reasons for proceeding in this manner, the discomfort diminishes or disappears.
The diagnostic interviews with the adolescent are held before the parental history taking sessions. Two or three sessions are usually sufficient for the diagnostician to gain an understanding of the adolescent. But in some instances, several more may be required. Without a working relationship with the adolescent, any future efforts at treatment are likely to fail. Early adolescents, aged 12-14, may be interested in playing. But almost all adolescents will sit and talk just like adults.
In addition to attempting to gain an understanding of existing symptoms and problems, the diagnostician will obtain a developmental history from the adolescent as well as the parents.
The adolescent is informed that after meeting with his or her parents and obtaining whatever additional information is necessary, the diagnostician will present his findings first to the adolescent alone and as soon as possible afterwards, to the parents in a separate session.
Parent History-Taking Interviews
The history-taking interviews with the parents follow and serve the same functions as they do with younger children. If required, addition data are obtained from ancillary procedures such as psychological tests and pediatric and school records.
Diagnostic and Treatment Formulations
Then comes the job for the therapist of organizing the data for presentation, not only to the parents, but also to the adolescent. Two sets of notes are organized because, although the same information is given to both parents and adolescent, the choice of words may be quite different.
Treatment recommendations should be detailed and specific, tailored to the child’s problems and individual circumstances. All of the information gathered through the diagnostic interviews, psychological testing and other sources of information should be utilized to explain to the adolescent and parents how a diagnosis was arrived at and how this relates to the treatment recommendations made.
As described above, two summary conferences are held: the first with the adolescent alone, the second with his or her parents. This sequence conveys a strong message of respect for the adolescent and increases the chances that he or she may accept the recommendations made. It also permits the adolescent to know, in advance, what the parents will be told and allows time for discussion of any concerns that the adolescent may have about the information that will be conveyed to the parents.
The parent conference is held as quickly afterward as possible, ideally on the same day. Adolescent and parents are asked to discuss the recommendations together and arrive at a course of action.
Obviously these guidelines may need to be altered from time to time depending on circumstances, diagnosis, and other factors. For instance, a clinician would operate differently in a true emergency (rare in child psychiatry, but not in adolescent psychiatry) or in the evaluation of a severely retarded or psychotic youngster.
In all instances, common sense, a thorough understanding of the developmental process, and sensitivity and empathy to both parents and adolescents should determine the professional’s interaction with all of the individuals involved in the diagnostic process.
In nearly all instances, it is wise for parents and adolescent to discuss and consider the diagnosticians recommendations over a few days. This is a wise course because very frequently additional questions arise which need to be answered. And both parents and adolescent need to consider the effect of a decision to proceed with treatment on finances and schedules.
When approached in the manner described, the completed evaluation should give the patient and parents a clear understanding of the problems and reasons for the treatment recommendations. Further, during the time that adolescent and parents have spent with the diagnostician, a relationship of mutual respect and understanding should have been established. This forms the basis of a therapeutic alliance if the family decides to accept the recommendations for treatment.
THE RELATIONSHIP BETWEEN DIAGNOSIS AND TREATMENT RECOMMENDATIONS
The Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, is the only diagnostic manual that is used by all mental health professionals. It contains detailed descriptions of what symptoms and conditions need to be present before the diagnostician can make a diagnosis. In this section I’ll utilize diagnoses from the Manual that vary in severity and relate them to the kind of therapeutic interventions that might be suggested by the diagnostician, thus conveying to parents some sense of the range of diagnostic possibilities and the usual treatment recommendations for them.
In all diagnoses involving their children, parents need to be active participants in the treatment process by working with mental health professionals in supportive roles and as partners, and often participants, in the treatment process.
Pervasive Developmental Disorders: These are severe pathological conditions in which there are significant problems with social interaction, peer relationships, language development and restricted repetitive and stereotyped patterns of behavior, interests, and activities. Autistic Disorder and Asperger’s Disorder are examples of pervasive developmental disorders.
The treatment for these conditions may involve hospitalization, outpatient treatment on an ongoing basis and the use of medication, educational interventions and other similar techniques. There are no known cures for these conditions, but treatment can be very helpful in diminishing their severity.
Attention-Deficit and Disruptive Behavior Disorders: These conditions are usually treated with medications and psychotherapy. In extreme circumstances, short-term hospitalization may be required. A thorough diagnostic evaluation that considers psychological causes should be completed before a child is placed on medication for Attention-Deficit/Hyperactivity Disorder since both the diagnosis of this condition and the use of medication to control behavior may be excessive.
Elimination Disorders: such as encopresis (soiling) and eneuresis (bed wetting) are treated with parental guidance techniques, psychotherapy for the child and medication. Causes range from failure of parents to provide consistent toilet training expectations (most frequent) to organic causation.
Learning Disorders: difficulties with reading, math or writing may be organic, or psychological in nature. Identification of problems in central nervous system functioning and/or psychologically based factors will lead to interventions such as tutoring and appropriate classroom placement. Early detection and treatment is particularly important for the child’s development and self-esteem.
Psychotic Disorders and Severe Mood Disorders: Disorders such as Schizophrenia and Major Depressive Disorder or Bipolar Disorder usually do not occur before adolescence. Schizophrenia is an organic disease of unknown etiology that occurs in all cultures. It is treated, but not cured, with medication, psychotherapy and hospitalization. The successful treatment and management of mood disorders with medication and psychotherapy is now possible. In severe cases, intervals of hospitalization may be required.
So there you have it, basic information about who is qualified to evaluate your child for mental and emotional problems and what you can expect when you take your child, and yourself, to a qualified professional. As I mentioned at the beginning of the book, not every professional will follow the procedures as I outlined them but every competent professional will explore each of the major areas mentioned and engage you and your child with expertise, empathy and understanding.
The evaluation and treatment processes are not easy, even more so for the parent than the child, but a competent diagnostician and clinician can make a profound difference in the healthy development of your child if parent and clinician can forge a therapeutic relationship in the best interests of the child.