What About Problems With Diagnosis or Treatment?

Like all other areas of medicine, some psychiatric and learning disorders are harder to diagnose, and harder to treat, than others. Since there are no blood tests to determine if a child has ADHD or OCD, clinicians depend on measures of behavior. And many behaviors can point to a number of different underlying disorders. If a child is having trouble concentrating in school, for instance, he could have ADHD, but he could also be very anxious. Add to this the fact that some children have multiple disorders—autism and ADHD for instance, or anxiety and depression. All of this contributes to the fact that sometimes the first diagnosis you get is not accurate, and the first treatment is not always effective.

How do you know when it’s time to look for a second opinion, and/or pursue different treatment options?

When should I get a second opinion from another clinician?

  1. If you have poor communication with your clinician, leaving you feeling that you don’t understand the diagnosis or the treatment, or that he or she doesn’t listen to your concerns or answer your questions, you need to find an alternative. It’s important for your child that you and the professionals you engage are all part of a unified treatment team.
  2. If your child—especially your teenager—doesn’t have a comfortable relationship with his clinician, and good communication, it can seriously undermine his treatment. If he’s not willing or able to report his feelings and experiences, the clinician can’t effectively tailor the response.
  3. If the clinician doesn’t seem to have enough expertise and experience with the diagnosis and especially the specific treatment he or she has proposed, you may need to make a change. Behavioral therapies like exposure and response prevention (for OCD) or habit reversal (for Tourette’s) or dialectical behavioral therapy (for self-injury) are very precise, evidence-based treatment, and vague approximations don’t work. Similarly, medications are best prescribed by a clinician who has substantial experience with effective dosing, managing side effects, and adjusting over the long term.
  4. If the clinician proposes medication for your child without giving you a clear diagnosis, you should look elsewhere. Trying medications to see if they work, without a comprehensive evaluation, can lead to inappropriate and ineffective treatment. Response to medication is NOT a diagnostic tool, so someone is wrong if he says, “Let’s see if this works as it will confirm the diagnosis.”
  5. If your child is struggling and your clinician is adding one medication after another, it’s easy to lose track of what’s effective and what’s not. When kids are given medications to alleviate side effects of other medications, it may be time to get a second opinion.
  6. If your child isn’t responding to treatment, it may mean that the diagnosis was wrong, and you need to seek a new, broader evaluation. It could also mean that there are several disorders involved, and they need to be identified and treated separately.

When should I consider switching to different medication, or adding medication?

  1. If the medication your child is on is not alleviating his symptoms, the first step is to make sure that you’ve given it enough time to work—some kick in more quickly than others. You also want to make sure that your clinician has tried adjusting the dosage. Sometimes it takes time to get the dosage up to a clinically effective level. If you’ve done those things and you’re not seeing results that work for your child, it may be time to investigate other alternatives.
  2. If the medication your child is taking has side effects that are debilitating, the first thing to do is to make sure the dosage is appropriate. If that doesn’t solve the problem, you should look into other options.
  3. Adding medications is something clinicians should do with great care. It’s not unusual for children to take two or more medications, because it’s common for children to have several disorders: for instance, kids with ADHD may have anxiety or depression. You want an experienced clinician with clear expertise if you are combining medications, and it’s generally not a good idea to add medications to counter side effects of the first one.

What if my child resists the treatment, or the therapist?

  1. You may need to try several therapists before you find one with the right personality to bond with your child or teenager—someone with an active and engaging style that will give your child confidence in treatment.
  2. Sometimes when kids are dismissive or negative about the value of therapy it is a result of a mood disorder: the pervasive pessimism and lack of enthusiasm he’s feeling may extend to the possibility of working to get better. In that case the first step in treatment is getting him to identify his pessimism and recognize that it is part of his disorder, and that he can feel better.
  3. With anxiety and disruptive behavior disorders that can be appropriately treated with behavioral therapy, it is sometimes necessary to combine a course of medication to decrease your child’s symptoms enough to enable him to participate effectively in the therapy that can make a big difference in his life.
  4. It may also be useful to explore something called “motivational interviewing,” a treatment that’s usually applied to substance abuse. Motivational interviewing is based on meeting a patient where he is in terms of his own self-assessment, and working to help him understand how changing problem behaviors might benefit him.