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When to Seek a Mental Health Referral
By Barbara Keith Walter, PhD, MPH and Dennis Clements, MD, PhD, MPH

Mental health disorders are more common in children and adolescents than many people realize. Studies show that at least one in five children and adolescents have a mental health disorder. At least one in 10, or about six million, has a serious emotional disturbance.

When is a child displaying enough concerns with emotions, behavior, development, or school performance to warrant a referral to a mental health specialist?

Like adults, children and adolescents can have developmental, learning, or mental health disorders that interfere with the way they think, feel, behave, and learn.

When untreated, mental health disorders can persist into adulthood and can be very costly to individuals, families, communities, and the health care system. Untreated disorders can lead to school failure, family conflicts, substance abuse, violence, crime, and suicide.

Unfortunately, there are many barriers that make it difficult for people with mental health disorders to receive appropriate care, including:

Lack of health insurance, insurance restrictions, and other financial barriers
Complex and fragmented mental health service delivery systems
Perceived stigma that discourages families from seeking care
Lack of culturally appropriate care
Lack of available mental health professionals with expertise in treating children and adolescents

Signs of a Problem
The American Academy of Child and Adolescent Psychiatry (AACAP Facts for Families, No. 24, July 2004, or http://www.aacap.org/publications/factsfam/whenhelp.htm) has described the following signs which may indicate a problem that requires further evaluation from a qualified mental health professional:

Younger Children (Ages 5 to 10)

Marked fall in school performance
Poor grades in school despite trying very hard
Severe worry or anxiety, as shown by regular refusal to go to school, go to sleep, or take part in activities that are normal for the child’s age
Hyperactivity, fidgeting, or constant movement beyond regular playing
Persistent nightmares
Persistent disobedience or aggression (longer than six months) and provocative opposition to authority figures
Frequent, unexplained temper tantrums
Pre-Adolescents and Adolescents (Ages 11 to 18)

Marked change in school performance
Inability to cope with problems and daily activities
Marked changes in sleeping or eating habits
Frequent physical complaints
Sexual acting out
Depression shown by sustained prolonged negative mood and attitude, often accompanied by poor appetite, difficulty sleeping, or thoughts of death
Abuse of alcohol or drugs
Intense fear of becoming obese with no relationship to actual body weight; purging food or restricting eating
Persistent nightmares
Threats of self-harm or harm to others
Self-injury or self-destructive behavior
Frequent outbursts of anger, aggression
Threats to run away
Aggressive or non-aggressive consistent violation of rights of others; opposition to authority, truancy, thefts, or vandalism
Strange thoughts, beliefs, feelings, or unusual behaviors

When considering whether your child or adolescent would benefit from seeing a mental health professional, it is important to not just focus on individual signs and symptoms, but to look at the intensity, frequency, and persistence of the presenting symptoms and the degree to which they interfere with the child’s functioning.

However, it is also very important to be aware that you should seek an urgent evaluation if you believe that your child is at immediate risk of harm to themselves or others or there has been an acute deterioration of thinking, emotions, or behavior that could place the child at risk for harm to self or others.

Where to Go for Help
Once you have decided to seek help for your child or family, it is often confusing to know where to start.

Parents often find it helpful to discuss their concerns with a family member, friend, teacher, school counselor, church leader, or primary health care provider.

The variety of mental health practitioners can also be confusing, and your insurance may have a specific network of providers from which you must choose or services you might need a referral or prior authorization to use with your insurance benefits.

In addition, in many communities, there is a shortage of specialists trained in the identification, diagnosis, and treatment of childhood mental disorders.

Parents should try to find a mental health professional with advanced training and experience with the evaluation and treatment of children, adolescents, and families. However, it is also very important to find a good match between your child, your family, and the mental health professional.

There are a variety of mental health professionals who can evaluate and treat children and adolescents with mental disorders, including child and adolescent psychiatrists, developmental and behavioral pediatricians, pediatric neurologists, clinical or pediatric psychologists, clinical social workers, psychiatric nurses, pastoral counselors, and a variety of other types of licensed counselors and therapists.

All of these professionals have training in the evaluation and treatment of children and adolescents, but the nature and extent of their training varies.

Parents should always ask about the professional’s training and experience. While some physicians, nurses, and social workers are trained in administering some tests as part of their assessment, psychologists typically receive specialized training in administering and interpreting developmental, psychological, and educational tests.

And in most states only physicians, such as child and adolescent psychiatrists, developmental and behavioral pediatricians, and pediatric neurologists, can prescribe and monitor medication.

Barbara Keith Walter, PhD, MPH, is a pediatric psychologist who is an assistant clinical professor of medical psychology in the Department of Psychiatry & Behavioral Sciences at Duke University Medical Center and the clinical coordinator of the Behavior, Development, and Mental Health Team at Duke Children's Primary Care. Dennis Clements, MD, PhD, MPH, is the chief medical officer of Duke Children's Hospital. For information, visit www.dukehealth.org

The information presented on this site is intended solely as a general educational aid, and is neither medical nor healthcare advice for any individual problem, nor a substitute for medical or other professional advice and services from a qualified healthcare provider familiar with your unique circumstances. Always seek the advice of your physician or other qualified healthcare professional regarding any medical condition and before starting any new treatment.

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