Making the right diagnosis for a child experiencing emotional or behavioral problems can be difficult. The same symptoms can have very different causes in different kids. For example, trouble focusing could be a sign of ADHD in one child and a sign of anxiety in another. That’s why it’s important for a mental health professional to do a thorough, careful evaluation before giving a diagnosis. The goal is to get a complete picture of what’s going on with the child — not just the parts of the situation that parents see as problems.
When a mental health professional is evaluating a child, they should look at all of the information available. Your clinician will ask you questions about the child’s history to see if they can find patterns to their behavior. It’s also helpful for them to talk to the child’s teachers and other adults in their life. That’s because kids often behave very differently in different settings. Clinicians often use tools like questionnaires or structured interviews to gather information. In a structured interview, they ask the child a series of specific questions that are based on the way that mental health disorders commonly show up in kids.
When you’re choosing a clinician to diagnose your child, look for someone with training and experience diagnosing kids with challenges similar to your child’s. It’s a bad sign if a clinician tries to treat your child or put them on medication without a clear diagnosis. Understanding the cause of a child’s symptoms is an important part of effective treatment.
When a child is experiencing emotional or behavioral problems, there are no blood tests or scans that will tell you what’s wrong. Add to that the fact that children are often not able to tell you clearly what’s bothering them. We hear from many parents who are frustrated because they can’t understand why their child is acting out, or unhappy, or struggling in school.
The key to getting good help is getting a good picture of what’s happening. And that’s not always as simple as we would like. It can be difficult to sort through the many kinds of professionals who diagnose mental health and developmental problems. And if the clinician you see is in a hurry or unfamiliar with the kinds of issues your child is having, you may get a faulty or incomplete picture.
That’s why it’s important to know how to tell whether the clinician you’re seeing for a diagnosis, whether it’s your pediatrician or a mental health professional, is following best practices in determining what’s troubling your child.
For an effective diagnosis, a clinician needs to gather information on all aspects of your child’s emotional and behavioral functioning-not just the short list of things you find problematic. One of the most common causes of misdiagnosis is focusing only on the parents’ preconceptions about what’s wrong with the child.
The bigger picture of the child’s mood and behavior is essential because the root of the symptoms you’re concerned about might not be obvious. For instance, a child who seems angry or aggressive might actually be intensely anxious. A child who has trouble paying attention in school might not have, as is commonly assumed, ADHD, but instead be depressed or, again, anxious. (Anxiety, in fact, is often missed in children because it masquerades in such a wide range of behaviors.)
“Often the presenting symptoms can have many different causes,” explains Ron Steingard, MD, a child and adolescent psychiatrist at the Child Mind Institute. “A full, rigorous interview needs to cover all the potential contributors.”
Your clinician should ask questions not only about your child’s current mood and functioning, but about your child’s history, too. Knowing how your child’s behaviors have evolved and changed as he developed can make a big difference in understanding what’s bothering him now, and how to treat it.
“We need to think of diagnosis as a narrative, not just checking a series of boxes,” says Dr. Steingard, an expert in diagnosing children with complex problems. “We need to ask about all the things that have brought the child to this moment.”
For instance, he notes, take a child who is severely anxious about school at age 10. If he was already unusually anxious about, say, separating from his parents, at 3 or 4, you would suspect that he has a fundamental problem regulating his internal alarm system. You might treat him differently than a child whose became fearful only after he started school, who is more likely to have learned anxiety in response to problems there.
Another of the goals of detailed interviewing is to avoid the mistake of assuming that all of a child’s behaviors have a single source. This is particularly important because it’s very common for kids to have a number of overlapping challenges. Kids who have autism may also have ADHD. Children who have learning disabilities may also have developed depression or anxiety, which won’t go away automatically if they get help on the learning front.
Dr. Steingard gives the example of a child who was described by his parents as hyperactive and impulsive, and was treated with medication for ADHD. His parents noticed a robust response to the medication in his behavior at home. But, surprisingly, his teachers reported that his performance was less reliable and thereby less improved at school. What had been missed is that in addition to ADHD he was also experiencing serious anxiety. The stimulant medication didn’t fully resolve the symptoms at school because school was the focus of his anxiety, and that made it very hard for him to concentrate and settle down.
A clinician should also not depend solely on parents for information on a child’s functioning. Some children behave very differently in different settings, such as at home and at school. If a child’s symptoms are appearing only when he’s at home, or only at school, or only with one set of people, they may be interpreted quite differently than if they are occurring across several settings.
That’s why it’s important for a clinician to gather information from the child himself, parents, teachers, and other adults who have knowledge of him. Screening tools, in the form of questionnaires and rating scales, are often used to collect information from other sources.
There are many specialized diagnostic tools clinicians use to help get an objective take on a child’s behaviors and symptoms.
Some of these tools take the form of structured interviews, in which a clinician asks a set of specific questions about a child’s behavior. The questions are based on the criteria for psychiatric disorders as they appear in children. The answers are used to guide the clinician’s thinking in diagnosis.
Common tools that are structured interviews include something referred to as ADIS (Anxiety Disorders Interview Schedule), and the K-SADS (Kiddie Schedule for Affective Disorders and Schizophrenia).
Some of the tools used to aid in collecting information are rating scales, in which the child is rated numerically on a list of symptoms. For instance, BASC (Behavior Assessment System for Children) is a set of questions that are customized for parents, teachers, and the patient, to utilize multiple perspectives to help the clinician understand the patient’s behaviors and emotions, and indicate where further exploration is necessary.
For children who may have ADHD, tools commonly used include the SNAP (Swanson, Nolan and Pelham) rating scale for teachers and parents, which scores kids on how often each of a list of 18 symptoms occur.
A-DOS (the Autism Diagnostic Observation Schedule) is a set of tasks that involve interaction between the tester and the child which are designed to diagnose autism.
When looking for a mental health specialist to provide an evaluation for your child, you’ll want to be prepared with questions that will help you decide if a particular clinician is a good match for your needs:
What kind of training do you have?
Are you board certified and/or licensed?
How much experience do you have diagnosing children whose behaviors are similar to mine?
How do you arrive at a diagnosis?
Will you recommend treatment options and make referrals to other professionals if needed?