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Challenging Children: Getting Professional Help

Keep a Written Log of Your Child's Problem Behaviors
If you are uncertain about whether to seek professional help, keep a log of situations or behaviors you find challenging. Yes, it's time-consuming and hard to remember to do, but written records like these--and any notes you make during teacher conferences or other notes you receive from school--are useful when you begin the process of getting help.

If one parent thinks the other is overreacting, a notebook may help the couple decide whether the problems are isolated events or a trend. Moreover, if you do end up seeking help, professionals will find this information useful. If nothing else, it's a great history of your child.

Quick Tip
Keep a record of comments or situations that indicate difficulty. Include date, comment made, by whom, and situational details.

Obstacles to Getting Professional Help
If a parent is not ready to seek help, he or she will often rationalize or ignore comments and recommendations.

Guilt can be a major deterrent to seeking help. Some parents are hobbled by simply having waited so long. Fearing that they overlooked obvious signs and ignored others' warnings, they agonize over having used potentially damaging parenting techniques, worried that it is not too late. "If only we had responded sooner." Or "If only I had insisted when my spouse was reluctant to get outside help." Listen to your gut instinct. If you think the situation needs professional help, it probably does. At the very least, a professional perspective can provide direction. Don't let fear or guilt override your good judgment.

Some parents are so concerned that someone will blame them that they refuse to seek professional guidance. Instead, if they do anything at all, they read book after book on parenting difficult children, rather than combining this information with a professional's insights. Books can provide insight and information. A knowledgeable professional can guide you in using this information to help your child and family.

Some families get mired in the question of "how he got this way." "What did I (or my spouse) do to cause this?" is often the unspoken concern. It's as if, until they know for sure, one way or the other, they're stuck. Similarly, the fear that help will lead to the stigma of a label deters many families from turning to professionals. When the question of "why" sidetracks them or the issue of guilt or fault gets so big that a family can't get past it, individual or couples' counseling must be considered an essential part of the treatment package. You can't help your child until you help yourself.

"Diagnosis and Labels"
You may be leery of seeing a professional to "diagnose" your child. But don't kid yourself-everyone is diagnosing your child. You are, your mother-in-law is, and so is your child's teacher. Everyone's trying to figure out what is "wrong" with your challenging child. (Or what's wrong with you.) A diagnosis is a label, and a label can be a very scary thing. But whether a label gets attached to your child is not really the issue. It doesn't change the difficulty your child is having just getting through his daily life. If much of life is a struggle for you or for him, advice from a professional with relevant education and experience may be just what you need. When to Seek Professional Help
It's time to seek professional help when:

• Your child does not achieve developmental milestones on time according to standard measures.
• Your child's behavior results in his calling negative attention to himself on a regular basis. His behavior requires special attention from adults to ensure his or others' safety. Peers avoid your child.
• Your child's behavior results in his exclusion from a situation or program that he wants to participate in and is a good match for his skills and/or interests.
• Your child consistently behaves or talks angrily; he is reactive.
• Parenting this child is an overwhelming, exhausting, and sometimes painful experience that leaves you wondering, "Is it him or is it me?"
• Other adults with a frame of reference( frequent contact with the child, experience with other children the same age, expertise in child development or child behavior) suggest it.
• Any potentially harmful or life-threatening behaviors occur. These warrant immediate professional advice.

Education and Research
Sharon: Talk to your pediatrician. Some doctors may minimize the problem and a few too quickly resort to medication, but most are highly knowledgeable and will have good ideas about how to proceed. Because pediatricians have seen many challenging children, they are often an excellent first resource and may be part of an initial evaluation. They may suggest reading material or direct you to other professionals. You should also talk to teachers--not just your child's current teacher, but last year's, too. Talk to friends who are educators. All of these are potential resources for professional referrals.

Before getting an evaluation, and certainly before starting any recommended therapies or services, educate yourself as much as possible. You are about to become your child's case manager. You're going to decide which stranger to trust. You have to determine which of many options are right for you, your child, and your family.

READ! Read books whose titles seem to capture your child's traits. Check some of the books we recommend in our Resources section at the back of this book. Follow the suggestions in other books for further reading. Ask a librarian where to find books that might be relevant for your child's problems. While some do not give specific solutions, most provide direction regarding professional consultation. They can help clarify what information you need to know before proceeding. In addition, most help give parents perspective on the situation--and perspective is important.

Internet Research
Do some research on the Internet. If your child has been recommended for testing for something like ADHD, or depression, anxiety, or autism, search the Internet by typing in a keyword, such as autism, and check out the sites that crop up. Bookmark whatever looks like it could be useful because you may want to go back to those sites after the testing has been done. Be sure to use multiple search engines to ensure broad coverage of the Internet's resources. The best sites provide linkages to other sites for further information. Many also provide lists of recommended books, some of which have ratings that may or may not be useful for your situation. Often a keyword search will lead you to organizations or support associations for parents of children with behavior problems. These can be very useful.

Internet sites come and go so don't rely solely on the following list. Try www.conductdisorders.com for conduct disorder (CD) and obsessive-compulsive disorder (OCD). Try www.autism.org for autism. Government sites, located by typing in "National Institute for Mental Health," can provide information on behavior disorders, current research, and sources for further help. The site for the National Depressive and Manic Depressive Association (www.ndmda.org) can provide information on childhood depression and bipolar disorder. Try www.chadd.com, the site for Children and Adults with Attention-Deficit/Hyperactivity Disorder.

The information you gather in this early phase will help define the problem. Equally important, it will help you develop a list of questions to ask a professional, such as the following:

• Does this behavior warrant a diagnosis?
• How will this affect my child at school?
• What types of services have proved successful?
• Who can best deliver these services?
• What steps do I take first?

Often it helps to draw up a list of questions even before you begin your research and revise it according to what you learn. Sometimes, once you begin the process, there's so much new information you can't figure out what you need to know. A list of questions keeps you focused on the kind of information you originally thought important. As you read and speak to others, you can modify the list. Choosing Whom to See
Jan: More than anything, I wanted to ensure we had the "right" person to do the testing. I didn't want to end up skeptical about the validity of any diagnosis.

After six weeks of gathering recommendations, I called the parent of another child in my daughter's class. Her son had ADHD. I wished I'd called her sooner. It was a relief to talk to a parent who was further along in this process. She gave me the names of the psychologist who had tested her son as well as a therapist her son was seeing.

Since we were increasingly concerned about Theodore's eroding self-esteem, I called the therapist. She strongly urged that we get testing results first to better understand what we were dealing with. Only after that should we bring him to see her.

This was my introduction to the concept of "sequencing interventions." Sequencing interventions means doing treatments or getting professional assistance in a sequence instead of all together. If you do everything at once, you won't know what's working and what isn't. Gradually I learned how important this is for using professional assistance wisely--and not overwhelming either my child or my pocketbook.

We narrowed the names I'd received down to a highly recommended neuropsychologist. When I called him, I reached him directly and had the chance to ask questions about how he tested for attention deficit disorder. Reputation, sterling recommendations from more than one person, and direct contact were the important factors in my decision. Then my gut instinct took over. I felt I could trust that this person knew what he was doing.

Seeking Other Parents with Children Like Yours

• Ask teachers for names of parents you might talk with.(They might want to get that parent's permission first.)
• Ask neighbors or relatives for more names.
• Find a local support group where parents can share their experiences dealing with their challenging child.

Getting a Formal Assessment or Evaluation
Sharon: When you reach the point where you want professional help, think in terms of getting a formal "assessment" or evaluation to help you understand what is happening with your child. Many people can administer tests; fewer have the ability to interpret the scores using their experience to understand your child. While technicians may be adequate for administering a test, the best assessors learn as much from talking with the child, family, and teachers, and by observing how a child "gets" to the answer, as they do from the scores themselves.

The trick is finding the "right" professional to evaluate your child--the one in whom you'll have confidence that their evaluation of your child rings true. To find that person (or persons), you have to do research and gather recommendations. It's a good sign when you get the same name from several, disparate sources. Interview qualified candidates for a comfortable fit. That doesn't necessarily mean you'll agree with everything they tell you--or that you'll like the conclusions they'll reach. The important thing is to find someone whose experience and judgment will help you better understand your child.

To find the professional who is right for you, some of the questions you should ask include:

• What is your particular area of expertise?
• What are your qualifications?
• What are you licensed to do?
• Do you specialize in evaluating children?
• What's involved in an evaluation?
• Do you provide specific recommendations as part of your evaluation?
• How many sessions will it take?
• What is the cost?

In addition to these questions about qualifications, costs, etc., you should also prepare a list of questions about what they--or any other expert you may see--might be able to do for you and your child.

• Will your services result in a diagnosis?
• Are you able to attend meetings to discuss the findings and make recommendations to educators?
• Will the evaluation highlight my child's learning style and strengths as well as any disabilities?
• Do you recommend additional services?
• Do you provide any of the therapeutic services that may be necessary?
• What can we expect to see in the way of change as a result of these services?

Once you are in someone's office, it's easy to become sidetracked and leave without asking important questions. Make sure whomever you see sets aside enough time to address all of your concerns. That often means forwarding your list of questions before the meeting. How to Find the Right Professional

• Consult your pediatrician.
• Call support group(s). Locate support groups on the Internet; then look for a local chapter in the telephone book. Or call the national organization for recommendations in your area.
• Call local mental health agencies. Start with your city or county health service. Ask them for names of private agencies as well.
• Do research--read books; seek information on the Internet.
• Survey professionals. Look for overlapping referrals:
  • From your pediatrician
  • From school
  • From friends and knowledgeable acquaintances
• Interview professionals you might want to use.
• Trust your gut instincts. The professional (or professionals) you choose has to "feel right" or you may not have confidence that the diagnosis is correct, especially if you don't like it. If it doesn't feel right, you will be far less likely to follow the specialist's recommendations for treatment.

Sharon: Any diagnosis should be the result of a thorough evaluation, not a judgment or pronouncement at the end of a single appointment. It's a process, based on a great deal of information supplied by the child and parent, and gathered by the specialist(s). The evaluation process results in a differential diagnosis, that is, a determination not only of what your child's diagnosis is, but, just as importantly, what it is not. Through an extensive review of information, combined with parent and child interviews and observations, an experienced professional makes an assessment, or diagnosis. It is this thorough process that drives decisions regarding treatment. If one professional doesn't handle all aspects of a complete evaluation, seek referrals for those who can augment what has been done. It can be lengthy and inconvenient but it is invaluable.

 

Assessment or Evaluation Components
Component	Reason
Family Evaluation (with a social worker or other specialist)	To determine what family dynamics, if any, may be contributing to the child's problem; suggest having a family behavioral modification
Psychosocial and school assessment (teacher or guidance counselor contact)	To assess child's peer functioning; determine academic and behavioral performance at school
Psychological testing (with a psychologist)	A broad group of tests that assess the child's emotional and cognitive (thinking) functioning
Neuropsychological testing (with a psychologist)	Extensive and specific tests to evaluate a child's thinking or information-processing abilities
Structured parent interviews	Detailed questions about your child's history
Medical assessment (pediatrician)	Physical examination and laboratory studies as indicated; suggested prior to using medications and when there are concerns about a medical contribution to the child's problem
Medication evaluation	Thorough history of the child and his or her current and past emotional and behavioral problems; review of above

This table represents potential assessments for children with behavioral and emotional disorders. The evaluation process varies greatly dependent on the region of the country, the type of practice, and the circumstances of the child.

Adapted from "Table 2. Elements of the Psychopharmacology Evaluation Process," in Straight Talk about Psychiatric Medications for Kids by Timothy E. Wilens, M.D. (New York: Guilford Press, 1999), p. 56. As important as the evaluation and diagnosis are, they are the beginning, not the end, of the process. Armed with this information, parents still need to understand what it means to have pervasive developmental disorder (PDD) or an anxiety disorder, or any of the other names given to the problems children may have. What does this label tell you about your child's needs? What can you expect in your child's future development? What services are available to help you address your child's needs? How can you locate those services? How can you evaluate the service and the person who delivers it when you do find it? While having received a diagnosis may feel like a stopping point, it is the time to take action--whether your child has a formal diagnosis or not.

Sequencing Professional Help
In general, the following sequence should help you make decisions about who to see first:

1. Deal immediately with serious worries about your child's life, safety, and control of your own behavior. Ask yourself:
   • Am I afraid my child may hurt himself or others? If so, get help now.
   • Is my child losing touch with reality, seeing or hearing things that aren't there, or experiencing an abrupt halt in development (such as sudden loss of language, sudden appearance of head-banging, etc.)?
   • Am I afraid I may harm my child?
2. If you receive a recommendation that medication might help, investigate that next.
3. Focus on behaviors that drive you crazy--specifically those that adversely affect daily routines. If things have deteriorated too far, family or individual therapy may be necessary.
4. Consider auxiliary services recommended such as occupational therapy, speech and language services, or physical therapies.
5. Depending on the child's need and family priorities, consider family or individual therapy, social-skills training, couples therapy, and education counseling. Evaluate each child on an individual basis.