Psychological Testing and Diagnosis

Reading through the Diagnostic and Statistical Manual of Mental Disorders-IV it quickly becomes apparent that most of the diagnoses that we make for a child or adolescent are not dependent upon data obtained through psychological testing. Most DSM-IV diagnoses are based on history and symptoms. The most obvious exceptions are Learning Disabilities, cognitive processing disorders and Mental Retardation. In some cases, psychological testing is not required to make a diagnosis, but it is clearly indicated. For example, most clinicians recognize psychological testing can provide valuable information when there has been trauma at birth, developmental delay, a drug overdose, head injury, surgery, regression in development, or a serious medical illness.

Given that psychological testing is not needed to make a diagnosis, why is it so common for children referred for behavioral and emotional problems to undergo psychological testing? There are a number of very good reasons. In many cases testing can assist in clarifying a diagnosis. For example, depression and anxiety share many overlapping symptoms and behaviors. A brief battery of tests can assist in clarifying what the salient issues are. Testing is not decisive when making the diagnosis, but is undertaken to clarify the nature and extent of a particular problem. Psychological tests can be used to rule out other disorders and identify strengths and weaknesses. For example, a child suspected of having a Mood Disorder may be administered an IQ test, projective testing, and may be asked to complete a variety of questionnaires. The goal of this testing would be to ensure that there are no complicating factors such as a cognitive impairment or co-morbid condition, identify factors involved in the mood disorder (e.g., body image, self-esteem, peer issues), and to assess the seriousness of the mood disorder.

In some cases guidelines promulgated by professional organizations provide strong recommendations for obtaining information that can only be gathered through psychological testing. For example, the American Academy of Pediatrics makes the following recommendation when assessing for ADHD:

“In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorders or other neurodevelopmental disorders), and physical (e.g., tics, sleep apnea) conditions.”

As we learn more about disorders such as ADHD, Bipolar Disorder, and Asperger’s it is becoming very clear that most children with one of these diagnoses have other cognitive issues that affect their functioning. Impairments in long-term retrieval, working memory, and cognitive fluency can only be identified by psychological testing. Further, without proper assessment, appropriate accommodations and interventions cannot be identified. Children exhibiting behavior problems may have limited intellectual capacity, a learning disability, or a language delay. While a thorough Diagnostic Assessment can assist in identifying these issues, only a comprehensive psychological battery can rule out the presence of a learning disability, low intelligence, cognitive impairment, or language delay.

Explaining medication to children

Many of the children that we see in therapy will be prescribed medication for their behavioral and emotional difficulties. Sometimes we’ll be in agreement. At other times we may be dismayed that medication is being prescribed at all. We may also discover that some of the prescribing physicians we work with do not spend enough time discussing medication with the parents or child. As a result, prescriptions may not be filled, medication may be discontinued prematurely, or the child may refuse to take the medicine. Some children won’t refuse to take medication, they’ll just lie about it. All medications have side effects and not understanding the side effects of a particular medication may lead to side effects being ignored, missed, or their importance exaggerated. Prescribing psychotropic medications can be difficult, and multiple trials of different medications at different dosages may be required before a desirable result is obtained. Not understanding the process may contribute to both the parent and child becoming discouraged and prematurely discontinuing medication.

As child and family therapists it often falls on us to have a discussion with the child and parents about their medicine. Since we are not physicians we are at a decided disadvantage, but it is unlikely that we are going to see an increase in education about medication being provided by our medical colleagues. Therefore, it is extremely important that we remain current about medications so that we can have reasonably intelligent conversations with our clients about their medicine. I’d also recommend a cautious approach when reading about psychotropic medication on the internet. The internet has no filter and there is a tremendous amount of misinformation available.

When talking to parents and children about medication it is important to keep in mind that it is not our job to convince anyone to take medication, nor is it our job to discourage anyone from taking medication. It is ultimately the parent’s responsibility, in conjunction with their physician to make a determination about what medication, if any, should be prescribed. We can provide a path to understanding, and we can address issues of noncompliance.

When talking to parents and children about medication it is important to keep in mind that it is not our job to convince anyone to take medication, nor is it our job to discourage anyone from taking medication. It is ultimately the parent’s responsibility, in conjunction with their physician to make a determination about what medication, if any, should be prescribed. We can provide a path to understanding, and we can address issues of noncompliance.

The following suggestions are offered:

• Educate the child, in terms that they will understand, about their diagnosis. For example, with children who have ADHD, I compare their brain to a computer. “We know that you have a really good brain. And like a computer it comes preloaded with lots of programs. We know your programs for Spelling, Running, Talking, in fact most of your programs, are really good. But your program for paying attention, well that doesn’t work very well. So, your doctor is prescribing some medication to help that program work better.” Or for a child with depression I might say, “We know that people with even a great life, can feel depressed because of their brain chemistry. Your doctor wants you to take this medicine to change your brain chemistry, which might help you feel less grumpy and irritable. I don’t know if it will help. You’ll have to tell me
after you’ve taken it for a while.”

• Monitor the family’s attitudes about medication. If the child is getting teased by a sibling, or Dad is telling Mom, within earshot of the child, that they just need to “get it together,” cooperation from the child can diminish.

• Be realistic, especially with teens and pre-teens. Nobody wants to be perceived as defective and medication, as well as being taken to a therapist or psychiatrist, can imply that the child has been found to be inferior or defective in some way. Be realistic and understanding of the adolescent’s concerns. Understanding that the adolescent has all of the control in this situation can go a long way to breaking down resistance.

• Don’t exaggerate the benefits of medication. It is likely that the child will have to continue to work hard in therapy, at school, and at home to overcome their challenges. Parents may also need some help being realistic about the medication. Of course, if the child does have a dramatic response to the medicine join in on the celebration and then step back and see if the
dramatic effect really lasts.

• In families where there is a history of substance abuse there may be great concern about taking a psychoactive drug. Elementary school children may not understand the difference between the drug they are being prescribed and the drugs they are being warned about in the substance abuse prevention program at their school. Again, it is important to use language appropriate to the child. With parents I’ll often discuss the incidence of substance abuse among adolescents with mental health problems who did not receive treatment. With an adolescent it may be important to discuss the difference between self-medicating and treatment. Self-medication offers more reward in the short-term, while treatment aims toward long term benefit. Additionally, self-medication typically exacerbates existing problems.

• Use proper names. For example, children with ADHD should not be told their medicine is a vitamin pill. Educate all children, regardless of age, about their diagnosis. Left to their own devices young children have a limited vocabulary for evaluating themselves: fast or slow, smart or stupid, good or bad. Children with behavioral problems are prone to self-esteem issues and understanding why they are having their difficulties can alleviate some of these esteem issues. Additionally, we want to help children avoid externalizing blame for their difficulties onto others. By owning their challenges children and adolescents are in a better position to accept help, support, and work on overcoming their difficulties.

I have also developed a workbook for children being prescribed medication. It is available on my website, and on Amazon. Check out this cool widget for a sneak peek.

Eleven Warning Signs of Mental Illness in Children & Adolescents

The “Action Signs” Project is a new tool kit to help identify children with mental health disorders. Approximately fifty percent of serious mental health conditions manifest themselves by the age of fourteen and as many as one in ten youngsters has a serious mental health condition that impairs their functioning in either home or school or in the community.  Family practice doctors and pediatricians are in an ideal position to identify these children, and the eleven signs identified in The “Action Signs” Project can be extremely useful.

The “Action Signs” Project  tool kit that was recently released by the REACH institute and was funded by The Substance Abuse and Mental Health Services Administration. The authors of the tool kit spent the last ten years sifting through studies and interviewed more than 6,000 families and children in an effort to identify the most efficient and simplest method for identifying the most serious mental health disorders.

The researchers identified eleven signs that require immediate action. They include severe mood swings that cause problems in relationships, intense worries or fears that get in the way of daily activities, sadness that lasts more than two weeks, or sudden and overwhelming fear brought on for no apparent reason.

Dr. Peter Jensen, a Mayo professor of psychiatry, was the principal investigator on this study. He noted that there is frequently a disconnect that occurs between what a child says and how a parent interprets that message.  For example, four to five percent of parents respond “yes” when asked if their child has “ever talked about wanting to kill himself or made a plan to do so?”  But then, when a follow up question is asked, “Has he seen anyone for that,’ they’ll say ‘no’ two out of three times,” Jensen said in an interview with Minnesota Public Radio.  Jensen said part of the problem is that parents don’t always recognize when the threats or behaviors their children display aren’t normal.

The 11 action steps listed in The “Action Signs” Project are designed to make these situations very clear. For example a child who has severe Attention Deficit/Hyperactivity Disorder is described in these 17 words: “extreme difficulty in concentrating or staying still that puts you in physical danger or causes school failure”.

It should be noted that that the eleven action signs won’t be able to identify every child with a mental health problem. The developers of the tool kit suggest the tool kit will identify at least half of the children who are currently undiagnosed.

These are the eleven signs:

  • Feeling very sad or withdrawn for more than two weeks.
  • Seriously trying to harm or kill yourself, or making plans to do so.
  • Sudden overwhelming fear for no reason, sometimes with a racing heart or fast breathing.
  • Involvement in many fights, using a weapon, or wanting to badly hurt others.
  • Severe out-of-control behavior that can hurt yourself or others.
  • Not eating, throwing up, or using laxatives to make yourself lose weight.
  • Intense worries or fears that get in the way of your daily activities.
  • Extreme difficulty in concentrating or staying still that puts you in physical danger or causes school failure.
  • Repeated use of drugs or alcohol.
  • Severe mood swings that cause problems in relationships.