What Should You Look for in a Diagnosis?

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 veteran child and adolescent psychiatrist. “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 their behaviors have evolved and changed as they developed can make a big difference in understanding what’s bothering them 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 they were already unusually anxious about, say, separating from their parents, at 3 or 4, you would suspect that they have a fundamental problem regulating their internal alarm system. You might treat them differently than a child whose became fearful only after they 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 their parents as hyperactive and impulsive, and was treated with medication for ADHD. Their parents noticed a robust response to the medication in their behavior at home. But, surprisingly, their teachers reported that their performance was less improved at school. What had been missed is that in addition to ADHD they were also experiencing serious anxiety. The stimulant medication didn’t fully resolve the symptoms at school because school was the focus of their anxiety, and that made it very hard for them 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 they’re 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, parents, teachers, and other adults who have knowledge of them. 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?

One final thing to be wary about is accepting treatment from a clinician who offers to write a prescription without offering a diagnosis or explanation for your child’s behavior.

Just as a headache can be caused by many different things, worrisome behavior or moods can be symptoms of a range of psychiatric and developmental disorders. It’s a mistake to try medications to see if they work on the symptoms without a serious effort to understand the causes.

This happens, in particular, when a child is hard to manage. Putting a child who’s out of control on medication may be necessary, but it shouldn’t be done in lieu of careful diagnosis, especially since behavioral therapy is surprisingly effective for many children with disruptive behavior.