Thursday, August 27, 2009

Diagnosing Young Children

DISCLAIMER: I fully expect this to be a heated topic. Please leave comments and I will clarify/explain/consider any and all points made. I do believe that mental illness exists in young children. I DO NOT think it is all the fault of the parent. I DO think that we over use medication I DO NOT think medication is evil - I believe it can be useful and necessary. I DO think that medication should be a last resort with young children. I DO NOT believe that individual therapy should not be done with young children - it should be family therapy. These are all my opinions based on my experiences.

In my last job, I was a therapist for a community mental health center(CMHC). If you aren't familiar with that term (which I wasn't until I was employed at one!), a CMHCs came out of the Community Mental Health Act as a way to provide for people with mental illness and developmental disabilities in their communities - as opposed to institutions. I was a therapist and I mainly saw children who were under 7 yrs old. I lead a parenting support group/class and did all of the intake assessments for children under 5 yrs old. I also met weekly with an Infant Mental Health Consultant and ran a peer supervision/support group for working with young children. For a little more background about Infant Mental Health please read this post.

I've had a lot of experience with children - but this was my first time having a lot experience with children living with their biological parents. And, with my focus on young children, I quickly came to realize something:

There are a LOT of children receiving mental health services... children who do NOT have mental health issues.

"Wait, what?" you may be saying.

That's right - MANY of the children being treated at my agency did NOT have mental health issues in my (and many other therapists') opinion. What they did have was this - parents who did not understand appropriate child development and parenting techniques.

Now, before I go any further let me state this clearly:

Let me explain by starting with a typical intake assessment:

Mom walks in - she is probably about 24-30 years old. Not exceedingly young by many parenting standards. I have friends who are in that age range that are parenting. She probably has a high school education, and works at a blue collar job in the area. (It was mostly blue collar in that region).

Next, in walks the child - 4 years old and typically a boy. I averaged about 4 boys for every girl that I assessed.

Following the child, is at least one younger sibling. I rarely met with a child who was the younger child in a sibling group. There is an exception to that rule - but I'll get to that in a minute.

After gathering some basic info (name, birth date, address, etc) I'd ask for the "presenting problem" AKA "the reason you came here today". And here is the answer that I got about 98% of the time.

"Well, Bobby (child) just doesn't listen! He is all over the place, he never sits still, and gets into EVERYTHING. He is getting into trouble ALL THE TIME at preschool. He won't listen to anything that I tell him - he never picks up his toys and argues constantly. He fights with his baby brother/sister. If I tell him "no", he throws a HUGE FIT and gets really mad. He doesn't like going to bed at night and he is a terribly picky eater - its driving me CRAZY! I just don't know what else to do and I'm afraid that the school is going to kick him out and I'll loose my job."

Now, you are probably thinking one of two thoughts right now.
  1. That child obviously has ADHD/ODD /Bipolar/Intermittent Explosive Disorder/Major Depressive Disorder.

I could have diagnosed the child above with ANY of those disorders based strictly on the symptoms that the mother described: irritability, angry, frequently looses temper, refuses to obey requests, impatient, impulsive, aggressive, and sleeplessness.

OR you could be thinking

2. The child is FOUR YEARS OLD.

I tend to lean to the side of #2. In fact, I often wished that the DSM-VI would include "Four Year Old Child" as an official diagnosis. (And also "3 yr old Child", "2 year old Child", and "5 year old Child" for good measure)

I was assigned many a child who had been given those diagnoses above - including a two year old diagnosed with Bi Polar disorder. Let me assure you right now - that child did NOT have bi polar disorder. What that child, and almost all of the others who were receiving services at our agency DID have were parents who did not know or understand how to deal with the age appropriate behaviors of their children.

Now for the part where I explain why I am NOT blaming the parent for this lack of understanding.

Anyone who has given birth will likely be willing to testify to the fact that from the minute they announced that they were pregnant they started getting parenting advice. And, that the parenting advice varied from person to person. Many will tell you that they tried reading books on parenting - only to be confused at the variety of contradictions. One of my very good friends was ready to pull her hair out at the mere thought of figuring out how to potty train her daughter recently.

And unfortunately, in my opinion, society has done a great disservice to parents in the last 10- 15 years. We've talked about a lot of really great and important things in regards to raising happy and healthy children. Things like self esteem, creative expression, fostering individuality, and encouraging our children to think for themselves! But we've also forgotten to mention to parents that children need to be TAUGHT most of these things!

When I worked as a Nanny, I was in charge of the evening routine after my 4 year old charge. Prior to me, there had been a Nanny that did EVERYTHING for the little angel. Right down to spoon feeding her dinner while she watched TV. Boy did things change when I arrived - and the shock wasn't just to the child.

I had to teach and reinforce every step of the bedtime routine - from eating dinner at the table with me to washing her own hair and body in the bath tub to putting on her own PJs without assistance. I never used a raised voice or a sticker chart. She learned by me guiding, hinting and praising every step.

When I worked in an Preschool, I had to intervene in about 1,000 fights a week between children 3-5 years old. I could have simply stepped between the two screaming/crying children, sent them both to a corner, and then let them back out in 3-5 minutes when their time out was done. I could have seen a child hitting the other on the head with a toy, run over, yanked the offending child off the floor, put him in a time out, and given the other child a hug. I could have just yelled across the playroom every time I heard a child scream, "NO!" at a playmate.

But I didn't. Instead, I would get down on both children's level and ask them each to tell me what happened. Then, we would come up with some solutions. Lastly, (and most importantly in my book) I would have the children "rewind" the situation and do it over - helping them with the words when they didn't know how to tell their friend "nicely" that they didn't want to play with them. Then the children would each go their ways... for about 5 minutes before at least one of them would get into a similar altercation with another child and we would do it ALL OVER AGAIN.

Adults need to be involved and to teach their children these tiny little steps!

But popular parenting techniques today focus on giving children "choices" and reasoning with them - letting them make their own decisions. This article which was talked about on the Early Ed Watch blog hit the nail on the head for me - today's parenting trends have produced a generation of passive parents.

Parents who think that by letting their children "make their own choices" that they will automatically choose correctly! But what really happens is that by the time a child is 4 years old - the parent has an "out of control" child and is at their wits end. And because the child has not learned about rules and consequences at home - they also are becoming less able to function in school and in public. Parents are then getting phone calls from school and threatening looks from their bosses as they run to another parent/child meeting.

Schools were generally no help to this epidemic either - since they routinely told parents that their child "could NOT come back to school until they were on medication". Which, I informed many a parent, is AGAINST THE LAW. But it terrified the parent who was on the brink of loosing the job that fed her children.

Which is how they ended up in my office - generally looking for a diagnosis... and medication preferably. Very few wanted to engage in regular therapy - the same companies that produce those magic pills that lower our blood pressure without us needing to ever loose weight or exercise have also created many pills to stop your child from acting up without the parents ever having to change their parenting strategy!

So here was the Catch-22 that I was put in every time I did an assessment like the one I described above:

  1. I could tell the parent that their child did NOT have a mental health issue and therefore did not qualify for services at my agency. But then what? The parent leaves, even MORE desperate and hopeless than when they came into my office. The child gets kicked out of daycare (at best) or the parent begins to resort to even harsher and more punitive methods of trying to control their child and puts the child at high risk of developing a real mental health issue or being abused(at worst).
  2. Or I could give the child a diagnosis and get the family engaged in therapy (even though they usually wanted to skip straight to the meds) and hope that they would start to see results fast enough.

I usually went with #2 again - but almost never gave a child a diagnosis like the ones above. Thanks to all those pharmaceutical commercials, 20/20 specials and a whole lot of other sources of misinformation in the media, most parents have too many preconceived notions about ADHD, Depression, Bipolar etc. Most believe it is a disease like cancer - something that they can hope to treat with medication but otherwise do very little to change. In my opinion, it becomes a label and an excuse.

Let me introduce you to some diagnoses that you probably haven't heard about on TV:

Adjustment Disorder - generally given to a child who exhibits the behaviors described above, followed with the parent telling me this all started after they moved to a new house/divorced their spouse/child started a new school/birth of a new baby etc.

Disruptive Behavior Disorder - given to a child who exhibits the behaviors described above in addition to some more severe issues such as a child who has already been kicked out of school.

And my favorite: Disorder of infancy, childhood, or adolescence NOS - basically means, "I believe that there is SOMETHING happening here and that you and your child need help to make things right again".

Many therapists hesitate to use it - it is seen as a "cop out" diagnosis.

I disagree. I think it is a chance for the therapist to work with a child and their parents, siblings, extended family and school - without saddling the child with a label that may stick for a lifetime.

THOUGHTS? Feel free to leave a comment! :)


  1. I did a practicum in a children's mental health office and was amazed at how little work was done with families. The parents would drop the kid off, they would "get therapy" and then the parents would pick them up. In all the kids I worked with, I tried my hardest to meet with the parents, bring them in, ask them questions.

    There was this wonderful program for kids under 6 where a parent member was required to participate and play with the child in a reflective manner and then the therapist would talk with everyone about it. So much more effective than sending the kid in to be babysat while the parent got a break (that's what it seemed like was happening).

    And the over-medication...don't get me started.

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  3. I had multiple therapists that we tried with our eldest son who had some issues. He was ultimately diagnosed as having Aspergers and bunches of other things as a teen) I wasn't looking for meds, truly I wasn't. I was looknig for ideas, strategies etc. What I got was one of 2 things:

    1. The therapist would applaud everthing we did and tell us we should run a parenting group. I wasn't there to feel validated and it is hard to want to run a parenting group when what you are doing isn't working!

    2. The therapist would not share information or meet with us regarding out son. We would be shut out of the process.

    I also agree that so many times our society has created an artificial idea of how children should behave, regardless if they are adopted, or biological. Great post!

  4. The good news is that these parents were with it enough to seek help. Hopefully it gave you a chance to work with them! It's sad that I child needs to be diagnosed, but if you sent them off anyway, a less caring therapist might get them.

    I grew up in an environment where my behavior was a direct reflection on my mother, and while I wasn't punished, the emotional angst she went through was punishment enough.

    It wasn't until I was in my mid 30's, that I've realized my childhood behavior was normal, and her visits to therapists to help her figure out where she went wrong with us, was her illness, not mine.


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