Children’s Mental Health — The Doctors are In

Circa 2010

When your child or teenager demonstrates emotional or behavioral challenges, the task of finding the appropriate mental health professional can be daunting. When your teenage daughter has just confessed that she has been taking diet pills and laxatives to lose weight, you might feel a little like Dorothy, unexpectedly thrown by a tornado into the strange world of Oz. Maybe your nine-year-old son is still sleeping in your room and pretends to be sick every Monday morning to get out of going to school. Perhaps your seven-year-old is having trouble learning to read and is getting in trouble for talking too much in class. If any one of these scenarios seems all too familiar, know that you are not alone: it is estimated that one in five children in the United States battles with a diagnosable mental disorder at some point in his or her development.

So what can be done to help your child? The first step is to decide to seek out professional aid. It is estimated that half of all children in the United States who have a diagnosable mental illness go untreated. Lack of treatment can put a child or teenager at risk of falling behind in his educational, emotional or psychological development.

Once you have made the decision to seek treatment for your child, knowing where to turn is often the next biggest stumbling block. Dorothy had the Scarecrow, the Cowardly Lion and the Tin Man at her side early in her journey. Two easily accessible allies when you begin your own journey toward the mental health of your child are your child’s school counselor and primary care doctor. These professionals can often suggest an initial treatment or refer you to a mental health expert who can best help your child.

Once you receive referrals, sorting out the qualifications from the alphabet soup of titles can be daunting. Should you take your child to an MFT, LCSW, PsyD, PhD, or an MD? The table at the conclusion of this article describes the training of each type of mental health professional, but all of these practitioners can provide psychotherapy to patients. Only psychiatrists, however, can prescribe medication. Some mental health disciplines have national board certification procedures as well, and most states have licensure requirements for each type of medical professional. Your state medical board website can help you verify licensure status and possibly board certification before you move forward.

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Treatment for emotional and behavioral problems in children and teens involves a variety of psychotherapies or medications. There is a wide range of psychotherapies to consider, including counseling, group therapy and educational therapy, play therapy, cognitive behavioral therapy and psychoanalysis. It is generally advisable to try non-medication interventions first, although some conditions or emergency situations might call for medication as the most suitable first line of treatment. Ask your pediatrician or school counselor at the outset of the referral if your child’s situation merits medication. If psychotherapy is failing to yield timely progress, for example, ask the therapist if a referral for an evaluation for medication might be warranted.

When it comes to prescribing medication for your child, the professional with the most expertise is a Child and Adolescent Psychiatrist (CAP). Unfortunately, however, CAPs are in short supply in the United States. It is estimated that, while there are only 7500 CAPs in the nation, there are 15 million children and teens who require treatment in this field. Even in big cities, it might take months to secure an appointment with a CAP. Because of this shortage of Child and Adolescent Psychiatrists, about two thirds of all medication prescriptions for mental health diagnoses for children and teens are prescribed by non-CAPs: pediatricians, general psychiatrists, family practitioners, neurologists, and other physicians. Here are some tips on getting to a specialist for medication treatment:

1. If your current non-CAP prescriber is not able to achieve sufficient reduction in symptoms, or if your child’s side effects are becoming unmanageable, ask your prescriber for a referral to a CAP.

2. Visit, the website for the American Academy of Child and Adolescent Psychiatry, and click on the link for Child and Adolescent Psychiatrist Finder (found under “Quick Links”) to identify a CAP near you.

3. Check your insurance provider’s website and search for CAPs in your area who are covered under your plan.

4. If no CAPs are listed within 50 miles of your home, contact your insurance company and request that it pay for treatment with a CAP outside of its network.

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Many parents are reluctant to consider medication for their children, perhaps due to an abundance of media reports about children being overmedicated or inappropriately medicated. After the Food and Drug Administration released a warning that antidepressants could increase suicidal thinking in children and teenagers, prescription rates for antidepressants dropped and, ironically, the rates of suicide completion increased. It seems a reasonable truth, then, that wisdom lies in a safe middle ground between over-medication and no medication at all. If depressed suicidal teens are not responding to psychotherapy alone, they may best be served by a combination of anti-depressant medications and frequent psychotherapy. Here are some easy guidelines to follow in determining when medication for a childhood mental health disorder should be considered:

1. Your child’s agitation, aggression, recklessness or poor impulse control has put the child, family members, or others at risk of imminent physical harm. In such situations, hospitalization should also be considered.

2. The symptoms of your child’s mental health disorder impede his or her ability to meet developmental milestones (e.g., academic progress, behavior commensurate with intelligence level, healthy familial relationships, an ability to make and keep friends).

3. Psychotherapies show little or no evidence of successful treatment but medication treatments show robust evidence of successful treatment (e.g., psychosis).

4. Non-medication interventions, such as psychotherapy, have failed to yield results. Additionally, medication treatments have been proven to be effective instead of, or in concert with, psychotherapies.

In addition to psychotherapy and medication, a variety of other interventions exists to get kids back on the road to mental health. This range includes therapeutic and special education schools, speech and language therapy, and occupational therapy. When multiple professionals are involved in the care of your child, it is often helpful for them to communicate and work in concert with one another.

Once a sound treatment plan is in place, your child or teen can get back on track to grow and reach his or her full potential. With help from the right wizard or a good witch (and a few other new friends), your family can effectively ease back onto the road to a place like home.

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PSYCHIATRIST: A physician with a doctor of medicine (MD) degree or osteopathic (DO) degree, with at least four subsequent years of specialized study and training in psychiatry. Child and Adolescent Psychiatrists (CAPS) specializing in treatment of children and teenagers complete a two-year fellowship in child psychiatry and are then eligible to receive a subspecialty board certification in child and adolescent psychiatry.

PSYCHOLOGIST: Might have a master’s degree (MA or MS) in psychology or a doctoral degree (PhD, PsyD, or EdD) in clinical, educational, counseling, or research psychology. Most states license psychologists to practice psychology. Psychologists can provide psychological testing, evaluations, treat emotional and behavioral problems and mental disorders, and provide psychotherapy.

SOCIAL WORKER: Possesses a bachelor’s degree (BA, BS, or BSW), a master’s degree (MA, MS, MSW, or MSSW), or doctoral degree (DSW or PhD). In most states, social workers take an examination to be licensed to practice social work (LCSW or LICSW). The type of license depends on the social worker’s level of education and practical experience. Social workers provide various services including assessment and treatment of psychiatric illnesses, case management, hospital discharge planning, and psychotherapy.

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PSYCHIATRIC/MENTAL HEALTH NURSE: Psychiatric and mental health nurses may have various degrees ranging from associate’s to bachelor’s (BSN) to master’s (MSN or APRN) to doctoral (DNSc, PhD). Depending on their level of education and licensing, nurses provide a broad range of psychiatric and medical services, including the assessment and treatment of psychiatric illnesses, case management, and psychotherapy. In some states, some psychiatric nurses may also prescribe and monitor medication.

LICENSED PROFESSIONAL CONSELORS: Licensed Professional Counselors have a master’s degree (MA or MFT or MFCC) in psychology, counseling or a similar discipline, and typically have two years of post-graduate experience. They may provide services that include diagnosis and counseling (individual, family/group or both) and have a license issued in their state. They may also be certified by the National Academy of Certified Clinical Mental Health Counselors.

PSYCHOANALYSTS: Any of the above providers who have completed their licensing requirements are eligible to pursue further training in psychoanalysis. Psychoanalysis involves frequent patient-professional visits (on the order of three or more times per week) and can take the form of play therapy for younger children and lying on the couch for teenagers and adults. Psychoanalysis training takes five to 10 years and also offers a subspecialty training in child and adolescent treatment, which can require an additional two to four years of education. Accreditation and certification of psychoanalytic training are overseen by the International Psychoanalytic Association and the American Psychoanalytic Association.

by David Coffey, MD

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