When you express a concern about a child’s development or behavior—she seems to be more anxious than other kids her age, or he’s struggling in school—the first advice you’re likely to hear is: “Wait.” Wait and see if she grows out of her fears. Wait and see if he catches up with his peers. Being advised to relax and wait can be very reassuring—kids do develop at uneven speeds. And sometimes it’s good advice. But sometimes it’s not. For every child who develops out of what seems to be a problem, another gets worse. And then there you are, telling a specialist that you’ve known something was wrong for a year or two but you were waiting to see if it would resolve itself. So how do you tell the difference between transient issues and enduring problems?
We say it all the time: Far too few children and adolescents with serious psychiatric and learning disorders are identified early, when intervention is most effective. But we also know that parents are keenly aware of mis- and over-diagnosis and unnecessary treatment for mental illness, as well as the cost of intervention in time and money. These factors, and the stigma still associated with these disorders, make the question “When should I wait to get care?” worth studying. We set out to find some answers.
“We as parents can be a little anxious,” CMI clinical psychologist Rachel Busman says, and keeping a child’s challenges in perspective requires a clear head. “If something is impairing, persisting, and interfering, those are key factors” in raising a quirk in development to the level of a problem that requires treatment. On the other hand, “if you live in Manhattan and have a snake phobia that doesn’t really impact your life that often,” she notes, maybe a strategy of watchful waiting is just what the doctor ordered (or didn’t).
Dr. Busman gives an example of a teenager who had experienced a panic attack at school severe enough that the teacher recommended he visit his pediatrician. “The primary care physician checked him out and medically he was fine,” she says, but he suggested the teen “get a psychiatric evaluation” to be safe. During the intake process, as the patient’s mother was learning about what it entailed, she asked if it was really necessary.
“It might have been an isolated incident,” Dr. Busman notes. “My sense is the mother was thinking, ‘Whoa! This was a one-time thing. Maybe we don’t need to go through all this.’ ” The family ended up deciding not to do an evaluation. Where they right?
“Most 15-year-olds don’t have panic attacks that require medical attention,” continues Dr. Busman. “However, that doesn’t mean that he’s going to now have panic disorder for the rest of his life.” But it does mean the family needs to be alert: “This involves waiting to see if he has another panic attack and if he’s engaging in any behavior with the purpose of avoiding panic. Avoiding going to the place where the panic attack occurred or taking extreme measures to stay calm are some examples.”
There are a number of situations and symptoms that make deciding whether to wait or not fairly straightforward. Some disorders are so serious—and responsive to early and immediate intervention—that consulting a mental health professional is imperative. When the communication deficits and social problems associated with autism are caught early, children have a better chance of improving and enjoying less restricted lives. When an eating disorder is identified before it becomes ingrained, it can literally save a young person’s life. And if there is a family history of a certain psychiatric illness, parents should naturally be more attuned to specific symptoms and the increased likelihood that a child will begin to develop the disorder.
Then there are life events that naturally cause changes in a child’s functioning as a part of a natural process of adaptation. Parental divorce, changing schools, a new sibling—these can all have troubling effects on a child’s behavior, though most often the symptoms will pass with time. In fact, the criteria for many child and adolescent psychiatric disorders require symptoms to be present for at least a period of weeks or months. Sometimes you need to watch and wait.
Thinking about development
How, and how long, you decide to monitor a situation depends on the age of a child and the specific concern, explains Matthew Cruger, a clinical psychologist and the director of the Child Mind Institute’s Learning and Development Center. When dealing with issues of learning and early development, he says, “most people wait as a rule of thumb,” and that’s okay. “If your child is presenting with some learning challenges, the obvious and natural thing to do is wait and see. It’s the rare family that is going to come in and say my child is 4, he’s not reading yet or he’s reading inconsistently, and I want an evaluation.”
Development in the early ages is uneven, Dr. Cruger continues. Milestones aren’t hard-and-fast rules, and a group of kids in the same age range can show a pretty wide variation in social development, learning, attentional skills, and emotional maturity. If delays, deficits, or unusual behavior persist, he says, that’s when parents might consult their child’s pediatrician, who has a more comprehensive understanding of the range of abilities and behaviors that are appropriate in a child’s age group. And if parents are still concerned, it’s natural to consult a specialist—someone who has insight into more of the particulars of the child’s situation.
Getting help for a child who is struggling doesn’t mean you’re a bad parent, or overreacting. “Parents are concerned that they will be seen as meddling or looking into something that isn’t important,” says Susan Schwartz, a learning specialist at Friends Seminary in New York. “But you have to make yourself as a parent feel comfortable.” And it can do a world of good for children whose problems with learning or anxiety are making school or play miserable. An intervention “allows them to understand that people can help them, provides ways to solve problems, and makes sure they don’t persist in developing bad habits,” she says. “These are foundational skills that are just crucial for a child to develop.”
And a little bit goes a long way, Schwartz continues. “Small changes have a major effect on self-concept, future learning, and on the ability to be flexible and problem solve.” You just need to recognize the issue of concern and go after it. “You don’t have to do the most extensive intervention. You can look at a child’s development in pieces—at a circumscribed area.”
There are many reasons a family would consider not addressing a mental health problem, both conscious and unconscious. First, anyone who tells you there are no costs associated with treatment is lying. And there are non-financial considerations governing the intensity of intervention. You have to understand that “you’re taking time away from other things,” Dr. Cruger says. And because of stigma in some families and the reluctance of certain professionals to give parents bad news, it can be difficult for families to get an honest assessment, resulting in passive inaction—the real problem.
The most important thing to understand for parents, says CMI pediatric psychopharmacologist Alan Ravitz, is that waiting is not a passive stance—waiting is an action. Should you wait? No, says Dr. Ravitz, if by waiting you also mean ignoring. “The real problem is when you identify something as nothing.”
“All of the things that people think their kids will grow out of, more often than not their kids don’t grow out of them,” Dr. Ravitz says. Persistent anxiety’s effect on development is a good example. The longer a child lives with it the likelier it is to shape his behavior in dysfunctional ways. “Some kids get over it,” says Dr. Ravitz. “But they get over it by developing through it, and the problem has an impact on the specific trajectory of development.” Down the road, a child who couldn’t sleep apart from his parents might no longer be afraid to sleep in his room at night by himself, “but now he’s afraid to go to sleepovers or he’s afraid to be identified as the kid in class with a birthday because he doesn’t want to be the center of attention.” And understandably, Dr. Ravitz concludes, “this may have an impact on his social development.”
Doing something doesn’t need to be doing a lot
Doing something doesn’t necessarily mean breaking the bank for expensive treatment or signing up for a lifetime of therapy. “It may not even be seeing a mental health professional,” says Dr. Ravitz. “It may not be psychotropic medications. It might be a conversation with a teacher.” The important thing is acknowledging concerns and monitoring how a child is doing.
Dr. Busman agrees. “There is a balance as to how to identify when something is problematic,” and in many cases finding that balance means talking to other people in a child’s life—starting with those who observe them in classrooms many hours a day.
“Parents should feel that they can talk to teachers,” Dr. Busman continues. You shouldn’t be wary about gathering information that will inform a decision—it’s what doctors do. “When we do an evaluation we always get collateral information,” she says. “It’s not like we don’t take what the parent says as reliable source of data, but we also talk to the child, we use rating scales, we talk to the school, other therapists, the pediatrician.”
Conversely, parents can consult mental health professionals as part of their approach to their concerns about a child. Even if there isn’t a diagnosis, says Dr. Busman, talking to a professional can sharpen the picture and provide tangible rewards. “We can certainly offer some strategies to ease difficulties even if isn’t a disorder,” she said, like cognitive behavioral therapy skills for coping with anxiety or mood or behavior problems, as well as helpful information about signs and symptoms.
Above all, don’t worry about making an appointment. Both Dr. Busman and Dr. Ravitz agree that there is no health downside to seeking help. “Good treatment is never harmful,” he says.
Whatever you do, remember that you’re making a choice. “It’s completely fine to say I want to wait,” Dr. Busman concludes, “but there’s a very big difference between saying, ‘Let’s see how things go, let’s talk in a year’ vs. saying ‘This is clearly a concern, I’m watchfully waiting.”
It all starts with your management and assessment of your own worries. “You have concerns about all sorts of things but you tell yourself that you’re worrying and that you have to take some time to see,” Dr. Cruger says. “So you have this conversation with yourself all the time.”
Getting on the same page
Dr. Cruger also notes that this conversation may be complicated by disagreement between parents as to what is or isn’t a “problem.” The difference between “Should I?” and “Should we?” can be significant, and is a major reason families wait to seek advice or care. But, like all waiting, it should have structure. “You say you have concerns about your child,” Dr. Cruger might tell one parent, “and you say there are no concerns about your child. Let’s say we’re going to agree that this is an area that needs to be monitored, and in 3 months we’re going to have a follow-up.”
Any plan you make for addressing a concern should have a follow-up built in, he says, a “definite point where you’re going to return and examine what you found out. Did things resolve themselves or is there still a problem?” This sort of structure makes it easier to reflect on yourselves and on the child, and can help you understand if “you’re putting things off, or you’re avoiding things in some way.”
But like Dr. Ravitz and Dr. Busman, Dr. Cruger sees no health downside to appropriate care. “There is zero doubt in our literature that the earlier the intervention the better the outcome,” he says. “And more intervention is better.”
The key takeaways for parents are that “waiting” is not a passive stance—waiting is an action, and it should be weighed against the pros and cons of getting an evaluation and possible treatment.. And trust your gut. “If you find yourself being constantly irritated by your child’s behavior, that could be the sign of a problem,” says Dr. Cruger. “You’re not supposed to find them seriously annoying all the time.” Or, to put it another way, think about everyone in the family before you act—and think before you wait.