The process of having a child evaluated by a psychiatrist or other mental health professional can certainly be complicated and confusing. Taking a child in for help is sometimes further complicated by a diagnosis that we do not understand or may disagree with. We address some of the most common questions asked by professionals working with children below. Click on the question to be directed to it.
Psychiatric evaluations should be reserved for children for whom adults have specific concerns about their behavior, emotions or functioning. Some people think that every child involved in the child welfare system should receive a psychiatric evaluation to see if he or she could benefit from mental health care. We strongly disagree. This is a waste of busy professionals’ time and the government’s money. Plus, as we’ll discuss later, they can lead to healthy children being labeled with psychiatric disorders.
Trust your instincts. As an adult familiar with the child, usually you need to trust your instincts when it comes to being concerned about a specific child. Parents, teachers, and caseworkers are often the first to recognize issues which should be addressed by mental health professionals. The reasons that adults think that a child may require an evaluation vary widely, but often include marked changes in the child’s eating, sleeping, or academic performance. Also, use of drugs or alcohol, unusual sexual activity, aggressive behavior, and general disobedience are common concerns.
If gentle conversations between the child and adults do not rectify these issues and they continue to persist for a period of time (6 months or more in most circumstances), a psychiatric evaluation may be warranted. If changes in the child’s mood or behavior are particularly precipitous, a psychiatric evaluation may be advised more quickly. Sudden, severe changes such as dropping grades or aggressive and dangerous behavior, could signal the need for a consult. A child who talks about hurting themselves or other people should receive a same-day or next-day urgent psychiatric evaluation or you may need to seek such an evaluation through a hospital emergency room.
When the child’s problems or symptoms are only related to school (classroom behavior, underperformance, etc.) educational screening with emphasis on learning problems should occur before referral to a medical, psychiatric, or psychological evaluator is made. These evaluations are usually available through the school district and are completed by social workers and psychologists who are specifically trained to asses for these disorders. Perceptual/information processing problems and learning disabilities can easily be missed and misdiagnosed in psychiatric or psychological evaluations if a child has not already been checked for them.
Psychiatric evaluations are different from psychological evaluations. Both may include assessment of a child’s behavioral and emotional issues, a diagnosis, and recommendations for treatment. Psychological evaluations often include some testing for intellectual and interpersonal functioning and are conducted by licensed psychologists, who usually have a PhD, PsyD, or EdD. in clinical or counseling psychology, or by licensed clinical social workers, (LCSW's), who have a master's degree in social work. Psychiatric evaluations are conducted by psychiatrists, medical doctors who have completed a residency program in psychiatry. They usually focus on determining if there is a psychiatric diagnosis that may be used to guide treatment for a child.
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Tell the psychiatrist in behaviorally-specific terms what the child has done that gave rise to concerns about their health. Tell them exactly what you have seen in the child in terms of symptoms or behaviors, (“s/he has not been eating much lately” or “s/he has been punching and kicking other children” as opposed to “s/he has been acting out” or “is resistant”), and how this is different from how the child usually acts. Tell them things like:
- How long this has been going on
- When it started
- How often it occurs
- How intense it is
- When does it occur
Don't presume a diagnosis. You may go to the psychiatrist with an idea that a child has a specific psychiatric disorder, let’s say ADHD. In this situation it is best to describe the behaviors and symptoms that led you to this conclusion, instead of telling the psychiatrist, “This child has ADHD.” Give the psychiatrist the opportunity to diagnose first, based on your description of the child’s behavior and the psychiatrist’s interaction with the child.
Psychiatrists will usually want to read other records about the child. These could include previous psychiatric evaluation notes, treatment/therapy summaries, results of medical or psychoeducational tests, and a list of past and current medications the child is taking (including dosages). Be sure to include information on over-the-counter drugs the child uses. Also, inform the doctor if you suspect, for any reason, that the child is using illegal drugs. Optimally, the psychiatrist should also be able to review records from other agencies or professionals who have worked with or assessed the child, including social workers, psychologists, nurses, physical or occupational therapists etc. Send this information ahead of time if possible.
In addition, the adult that brings the child to the appointment should be familiar with the child’s medical history. Be sure to know about known allergies to medications.
Some psychiatrists may not be used to the involved, often horrifying histories of children seen in the child welfare system. It is your job to provide some context to the child’s behavior, especially related to maltreatment history, separation from loved ones, and multiple moves and separations.
Be forthright with the psychiatrist about why the child has been referred for an evaluation. Sometimes child welfare professionals are asked to arrange psychiatric evaluations for children when there are no pressing emotional or behavioral problems for a child. For example, a judge may order a psychiatric evaluation to inform a legal decision the judge must make. In this case, inform the psychiatrist of the purpose of the evaluation and why it is being requested at this time. If you think the child is healthy and not experiencing psychiatric problems, be sure to share that information with the psychiatrist.
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The American Association of Child and Adolescent Psychiatry has published on the web its guidelines for what an evaluation of a child should involve. It's pretty extensive and the truth is, in our experience, psychiatric evaluations are rarely this involved in practice.
Psychiatric evaluations are different from "consultations." On the other extreme, child welfare professionals have told us on many occasions that a psychiatric evaluation for a child lasted 5, 10 or 15 minutes. This is not a proper evaluation. It might be called a consultation, but it is not an evaluation. Child welfare professionals sometimes call psychiatrists in crisis, asking that a child be seen now or as soon as possible. In these cases, you will not likely get a full evaluation, but a psychiatrist’s professional opinion based on limited information. This kind of consultation should not hold the same weight as a thoughtful, professional evaluation.
A quality evaluation is characterized by using multiple sources (the child, caregivers, teachers, child welfare workers, etc.) to assess a child’s circumstances over a period of an hour or two. Optimally, the child would be seen by the evaluator on at least two occasions for an hour each before completing the evaluation. Due to agency and insurance-imposed constraints, however, it has become common practice to conduct evaluations in one session lasting an hour or less.
Evaluations typically begin by the psychiatrist asking the child, “Has anyone told you why you are coming to see me today?” After the client has a chance to tell his or her story, the doctor continues by asking questions in order to identify a cluster of symptoms that match a psychiatric disorder. The psychiatrist tries to get a robust sense of all the individual symptoms and their specific meaning. This includes doing a mental status examination and gathering information about the client’s biological, psychological, and social circumstances. In order to gain full understanding of the situation, the psychiatrist might ask the same questions to family members and other professionals. The doctor may decide to use standardized tests or measures to help obtain a basis for diagnosis. In many circumstances, though, tests are not available, feasible, or appropriate to the child’s situation.
Additionally, some evaluations may entail a physical examination, psychoeducational testing, and medical tests including electroencephalogram (EEG) or electrocardiogram (EKG).
Just to be clear, a psychiatric evaluation is usually focused on determining a psychiatric diagnosis that may be used to guide interventions for a child. If you want other information, you may consider a different type of evaluation.
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We have heard complaints from child welfare professionals that every psychiatric evaluation (and every psychological evaluation for that matter) results in the child being given a psychiatric diagnosis. Psychiatrists in Missouri have told us that in order to get paid by insurance companies or Medicaid, they must provide a diagnosis for every child seen, even if the physician believes that the child is healthy. Is that the way it should be? No. Is it true? The Division of Medical Services at the Department of Social Services told us that is true to a point. Psychiatrists need to provide some diagnostic information, but they are not required to diagnose a major mental or personality disorder in order to get paid for an evaluation. They can use what are called “V codes” for other conditions that may be a focus of clinical attention. Most relevant for child welfare, there are V codes related to physical or sexual abuse, neglect, and for relational issues within the child's family.
There are reasons why mental health providers should try to make sure that children do not receive unwarranted psychiatric diagnoses. Child welfare records tend to have long lives. A child who received a diagnosis of conduct disorder five years ago can still be viewed as conduct disordered when someone reads that record today. These diagnoses can pile up over time when the child remains in the system and comes into contact with more mental health professionals. It can become hard to find placements for these children because of these labels they have been assigned through the years. This can be especially problematic in finding adoptive families for children. We all should work to make sure that a child’s behavior warrants the diagnoses they have been assigned by mental health professionals.
If you are concerned that a healthy child is going to be labeled with a psychiatric disorder as a result of a psychiatric evaluation, discuss this concern with the psychiatrist. You may even suggest that the psychiatrist include a V code instead of labeling the child with a major mental disorder in the absence of evidence that the child meets criteria for such a disorder.
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A number of things might be happening. Consider two possibilities: the psychiatrist may be wrong and the psychiatrist may be right. He or she may have some specific insight that could lead to an accurate diagnosis that does not seem immediately right to you. The shorter the evaluation, the more likely it is that the diagnosis is wrong. In some cases, the foster parent, child welfare professional or other adult knows a child really well, understands the diagnostic label the psychiatrist is using, and is convinced the label does not fit the child. In these cases, the adult has a responsibility to provide this opinion to the psychiatrist.
Most psychiatrists will welcome this opinion. Good psychiatric practice entails continually re-evaluating diagnoses and treatment decisions. Communicate with the child’s clinician and give them your concerns in a positive, non-combative way. Build a collaborative relationship by asking them to help you understand why this child has been assigned a specific diagnosis or prescribed certain drugs. If any of these reasons seem incongruent with the child’s problems or situations, tell the psychiatrist. It is entirely possible that they have gotten incomplete information from the child or previous reports. If you fail to inform the psychiatrist, the child may be medicated unnecessarily or put on the wrong medications. Asking the psychiatrist to help you understand the rationale for the child’s course of treatment is a technique which both ensures that complete information is used in making decisions and prevents defensiveness on the part of the physician.
In some cases, the psychiatrist may challenge your opinion. We have heard that psychiatrists have even asked child welfare professionals, “Where did you get your medical degree?” While this may be a sign of an arrogant doctor, it may also signal that you didn’t approach the situation tactfully. Either way, the point you need to convey to the psychiatrist is that you are asking about the diagnosis because you want to ensure that it is accurate so that the child can receive the best possible treatment.
To best ensure the accuracy of any diagnosis, caseworkers and caregivers should accompany the child to their initial evaluation whenever possible. When you schedule the appointment with the evaluator, let them know you will be coming. Make sure that the clinician receives complete and correct information from both the child and the records provided to them. Be cognizant of the fact that your presence will make the meeting longer and tell the clinician that you do not want to take up any more time than is absolutely necessary - you are just there to fill in gaps in information and to be sure that you understand any decisions the doctor makes. Don’t leave until you understand what, if any diagnoses have been assigned, and for what reasons.
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Child welfare professionals have special responsibilities to document medical information in the child’s case record and to provide certain information to caregivers, parents, lawyers, judges and others. If a child is evaluated by a psychiatrist, the child welfare professional needs to receive some documentation of the evaluation signed by the psychiatrist. This documentation should include:
- Multiaxial diagnostic information
- Justification of diagnoses
- Sources of material used in the evaluation
- Total amount of time spent on the evaluation
- Treatment recommendations, if any
- Recommendations for additional assessments
Feel free to provide this list to the physician and specify the date the report is needed, and the address to which it is to be sent.
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