In Part 5 of a Parents’ Guide, I addressed the question of how a therapist can get off to a good start with a child, and not scare him/her away. In this sixth post I consider the question of a psychological evaluation and the recommendations that follow from it.
Parents reach out asking for help with their child. They share their presenting concerns. I gather a careful history of the family and the child’s development. When relevant, I speak with the pediatrician, school staff and others. I meet with the child and usually with the child and her family.
Learning about a child and her family channels this process, and from it flows an evaluation, formally called a diagnostic evaluation. Usually after several meetings, I will meet with you to review the results of the assessment. But as a parent you wisely ask, “What does that really mean?”
In this post I will first respond to this excellent and thoughtful question with some clarifying perspectives about the differences between medical and psychological diagnoses. Second, I will offer some reflections on the range of treatment recommendations that may follow from such an evaluation.
Perspectives on the Evaluation
Parents are wisely advised to recognize the essential distinction between medical and psychological diagnostic evaluations. Suppose you have a sore, red and inflamed throat. Your PCP looks at your throat and tests for strep: the results come back positive, and you are prescribed antibiotics. In physical medicine diagnoses rely on recognizing and identifying illnesses based on symptom presentations and test results. Deductive reasoning informs a differential diagnosis, i.e. differentiating between two or more conditions that share similar signs or symptoms – in this case a sore throat. Bacterial or viral infections can both cause a sore throat. If a bacterial infection causes your sore throat, your PCP prescribes antibiotics: if it is viral, she won’t prescribe antibiotics and will suggest that you ride it out. In the case of a sore throat, as in many common medical conditions, the pathophysiology and treatment for your illness is well defined and understood.
There are no such understandings of the aetiological causes of mental health disorders (aetiology means finding the cause). In mental health the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V) is widely recognized as the industry’s classificatory standard for mental health disorders. Each of the diagnostic classifications is based on symptom patterns for a particular state of mind and/or associated behaviors. For example, major depression is diagnosed based on showing five or more of the following symptoms:
- depressed mood most of the day
- markedly diminished interest or pleasure
- loss or increased appetite with associated weight loss or gain
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive inappropriate guilt
- diminished ability to think or concentrate, or indecisiveness
- recurrent thoughts of death, recurrent suicidal ideation
In mental health a diagnosis of depression means identifying a cluster of descriptive symptoms that are associated with a depressed state of mind. These symptoms in themselves tell us nothing about the underlying aetiology or sources of the depression. Returning to the example of a sore throat, suppose that all you know is that a person’s throat is sore, red and inflamed, but there is no way of determining whether the cause is bacterial or viral. By analogy, that is where we are in mental health. Symptomatically we recognize depression, but the causes cannot be readily defined, and there are no sure fire treatments.
As parents you should not expect a diagnostic evaluation to explain the causes of your child’s psychological difficulties, but instead think of it as the beginning of a process, i.e that you and your child are setting out on a shared exploration with the mission of achieving reflective understandings and working through fraught and often unsettling conflicts and tensions. Here is what is reasonable to expect of a psychological diagnostic evaluation.
- First, the evaluating therapist should offer insights and perspectives regarding the presenting concerns and your child’s state of mind that are clarifying and thoughtful and that ring true to you. If the process is meaningful, you might think to yourself, “Yes, that makes sense. I actually hadn’t thought of it quite that way.”
- Second, you should have the sense that the perspectives offered are grounded in and grow out of shared exchanges that have unfolded between you and the therapist. You should come away with a feeling of resonance with the process and that the diagnostic representations make sense.
- Third, you should feel completely free to ask a lot of questions and not feel constrained from challenging the perspectives that are offered.
- Fourth, trusting your instincts is vitally important. If it doesn’t feel right, don’t discount your own views in deference to the so-called expert’s authority and status.
Reflections on Treatment Recommendations
There are several common recommendations that grow out of a diagnostic evaluation of your child’s mental health difficulties. But what does this mean practically? Here are the most likely types of recommendations.
- Psychotherapy. The most common recommendation is ongoing psychotherapy. Once a week is a minimum frequency, because every other week dilutes the process. It becomes more like a check-in than an ongoing therapy. This is particularly so because of children’s sense of time: for a child a week can feel like a month. If the problems are more pressing and urgent, more frequent meetings may be in order. I have seen children more intensively up to 4 times a week. That may seem like an eye-rolling number, but for some children it is a game changer.
- Meetings with you as parents. Initial meetings with you as parents are essential in the diagnostic process of getting to know a child and her family. Thereafter, the frequency of our meetings depends on the specific circumstances. When there are lots of tensions at home and you are struggling with how to respond, meeting at least once a week makes sense. These meetings are useful in exploring how to think about and respond to the challenges at home around things like compliance and relational conflicts. If there is less urgency, meeting with you can be less frequent (once every two weeks, once a month – it all depends). Sharing perspectives, brainstorming together – me learning what is going on at home, you hearing my reflections about your child – provide valuable opportunities in working together on our shared mission.
- Family Meetings. Family meetings, of course including your child, can be of great value. This depends on what we together think will contribute most effectively to addressing the problems.
- Psychotropic Medications. Unless there are pressing indications for medicating a child, it is far better to first give psychotherapy a chance to work. When a child has a place to express and focus her feelings and has the experience of being listened to and taken in, the turbulences at home and at school tend to become attenuated and lessen in frequency and intensity. However, if behaviors and conflicts reach a threshold of dysregulated intensity, the feelings are acute and there are rising levels of distress and psychological suffering, a psychopharm consultation may well be in order. Bottom line – it shouldn’t be the first step.
- Neuropsychological Testing. Especially when a child is experiencing difficulties in school, testing may make sense. Typically issues of attention and impulsive behavior, avoiding school work, problems in processing certain kinds of information, difficulties with organizing and planning, problems in reading social cues, etc. – these kinds of presenting concerns may signal the need to have a thorough look at cognitive processing. Under these circumstances neuropsychological testing may be in order.
- Other Kinds of Supports and Interventions. For some children, special additional interventions may be worthy of consideration – such as independent educational plans under Massachusetts Chapter 766 law, coaching, tutoring, exploring the possibility of a therapeutic residential and/or school placement, etc.
In the next post I am going to consider the actual meetings with children and the central role of play in the therapeutic process with children.
I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you? What are your questions? I will do my best to respond in a timely way. Please don’t dismiss my requests. I really mean what I am saying! Please offer your thoughts and questions.