There have been many reports in the press recently about families with
children who have developmental, emotional and/or behavioral difficulties.
These articles help other parents recognize that they are not alone with
their angst and frustrations. Among the many issues addressed in these
reports are that psychiatrists and other mental health professionals are
unsure as to how best treat children with complex disorders, and whether
the use of several psychotropic medications simultaneously are indicated.
Unfortunately, much too often parents are faced with a dilemma as to
how to proceed because, to quote one parent, “they hear an alphabet soup
of labels that seem to change as often as a child’s shoe size.” Most often
categorizing a child with a standard diagnostic label does not do justice
the child or the family in trying to determine the best therapeutic course
follow. Too many of us have been led to believe that if we only made the
“right” diagnosis we could find the “right” medication or combination of
medications for the child. A current example is the ubiquity with which the
diagnosis of bipolar disorder is made in children with a variety of
and/or mood symptoms. These children are often very quickly prescribed
mood stabilizers. This approach has many pitfalls.
So what are parents to do when faced with complex behavioral and/or
emotional situations with their children? Whenever parents bring their
children to mental health professionals, the parents will feel frightened,
anxious, puzzled; they may not even be able to know what questions to
ask, especially if they are worried or if it’s their first contact with a
In such a state, how can parents judge the value of the professional’s
With the helpful guidelines that follow.
If, from the very first contact, the mental health professional enters into a collaborative relationship with the parents – that professional and parent will work jointly to determine the best course to follow for the child- the parents should feel assured they are in good hands.
Parents should see evidence that the mental health professional will be assessing five eneral areas of the child’s behavior.
First, the professional needs to understand how the parents view the child’s symptoms. This includes how the child’s symptoms affect the family and how do family interactions affect the child. Second, the professional needs to assess how the child experiences his or her symptoms. It’s critical to the treatment to understand how the child interacts with people around him or her: with the parents, siblings, relatives, other children, other
significant adults, and in school; as well as, how others interact with him or her. In other
words the parents and professional together try to understand how the child’s
social development has proceeded.
In addition to an assessment of the child’s emotional and social development, the
child’s sensory, motor, and cognitive development need to be evaluated. This
includes understanding the nature of the child’s responses to sensory stimuli
(appropriate, under-reactive, over-reactive); fine motor and gross motor development;
language development; memory; fund of knowledge; ability to understand social
situations; and changes in school performance.
With these assessments accomplished, the professional in collaboration with
the parents is ready to come up with a diagnosis. By that I do not mean simply
a specific label, such as ADHD or bipolar or depression, based on the number
and frequency of particular symptoms. Rather I mean, as those of us who
work intensively with children and their families use the term, “diagnosis,” in
a broad sense, how do we understand the child’s symptoms in terms of his or her
current state of development, his emerging personality pattern, and with his
particular family structure.
In trying to understand the child, we try to ascertain whether the problem concerns mainly the child’s feelings (is it mainly depression or anxiety)? Or does the problem relate mainly to the child’s sensory, motor, and/or cognitive development with emotional reactions secondary to those problems? Or is the problem is mainly what’s called an “externalizing” kind of problem?
In other words, does the child express his problems primarily through action rather than through expressing subjective distressful feelings, particularly with words? Whether there is a problem with the child’s ability to differentiate his or her fantasy life from the rest of his experience? Whether the child experiences a conflict within him or herself or does he or she only feel a conflict with other people? Whether there is a mixture that is hard to tease apart?
And, how do the child’s problems impact on and interact with the family’s feelings and functions?
And here’s the most important guideline. Parents need to remember that a diagnostic assessment is always a “work in progress.” As time and treatment evolve, both parents and mental health professionals always need to be sensitive and allow for modifications and changes in direction.
Only after such a comprehensive evaluation can one understand the adaptive and maladaptive patterns in the child and family and implement a treatment plan which always has to include supportive work with the parents. Together, parent and professional have to decide the specifics that are best for the child at “this” particular time. The possibilities include psychotherapy, a variety of remediation interventions, special classes or schools, pharmacotherapy, or some combination of these and other modalities of treatment. The comprehensive approach I am describing requires time and adequate resources.
Unfortunately, in today’s climate of limited insurance benefits and the ascendance
of the psychopharmacological revolution, too many of our children visit a child
psychiatrist once or twice and are quickly diagnosed to have a “disorder,” resulting
in the “need” for powerful psychotropic medications. Certainly some children require
psychotropic medications and/or mood stabilizers. However, without an adequate
comprehensive evaluation and without comprehensive ongoing care, families and
children may enter into the “alphabet soup” maze where one diagnostic label after
another is followed by a trial of one medication after another. And more than ever,
the climate of the nation’s health care complex is short shifting health care for our
children. We should be mindful and be attentive to just how our children are cared for.
Leon Hoffman, MD
Chief Psychiatrist, West End Day School, NYC
Board Certified Child and Adolescent Psychiatrist, Certified Child and
Leon Hoffman, MD
Director, Pacella Parent Child Center of
The NY Psychoanalytic Institute & Society
167 East 67th Street
NY NY 10021