Determining If Your Child Needs Counseling Services

Understanding The Different Levels Of Mental Health Services

Dealing With Insurance Providers

Initiating Treatment, Selecting An Outpatient Treatment Provider

Preparing Your Child For The Initial Individual Outpatient Therapy Session

What To Do If Your Child Refuses To Attend Treatment

What To Do If Your Child Is Experiencing A Psychiatric Emergency

If Your Child Needs Inpatient Treatment

Understanding Your Child’s Difficulties And Related Treatment Needs 

 If Your Child Is Prescribed Psychotropic Medications

The First Step In Your Child’s Treatment At Strength For Change

ARTICLES:

Unless other wise specified, all articles appearing on this web page have been written and copyrighted by Bernard Ivin.  If an article has been written by another author, his or her name will be referenced at the end of the article.

Determining If Your Child Needs Counseling Services 

Your child may be in need of counseling services if you or anyone in your child’s life (teachers, friends and/or family members) are concerned about ANY of the following symptoms:

• Difficulty concentrating
• Low energy - fatigue
• Sudden change in behavior, mood and/or attitude
• Unusual behavior
• Evidence of alcohol and/or drug involvement
• Academic, behavioral or social difficulties
• Failure to meet school, work and/or family responsibilities
• Extremes in emotion – anger, happiness, sadness, anxiety
• Police involvement
• Change in friends; isolation or withdrawal from friends
• Change in hygiene – poor hygiene
• Change in sleep habits
• Change in eating habits
• Evidence of an eating disorder – preoccupation with body image, binge eating, excessive exercise
• Oppositional behavior toward authority
• Expression of hopeless or suicidal/homicidal thoughts

 It is very difficult for parents to be objective about their own children. Many times they see their children through the eyes of unconditional love. If anyone in your child’s life ever approaches you to express concern about your child, it is important that you give him/her serious consideration. You can assume (once your defensiveness passes) that most people would feel anxious about telling a parent something negative about his/her child. If they do so, their concern for the child’s well-being is serious enough to override their apprehension about telling the parent. If you are ever approached by such a person, consider that individual an objective set of eyes that may very well be aware of something you are not yet able to recognize.  Top

Understanding The Different Levels Of Mental Health Services

In seeking mental health services for your child, you have several options available regarding the philosophy, frequency, intensity and duration of the treatment you choose. Listed in this section are the different levels of treatment in order of intensity (lowest to highest) and typical progression of care. If your child is not a danger to himself or others, I recommend individual outpatient therapy as your starting point. Individual outpatient therapy is the easiest treatment to access and it provides the most personalized care and least restrictive environment. It is important to note that if your child starts with individual outpatient therapy, the treatment provider, upon completing an assessment of your child’s difficulties, may refer you to a more intensive level of care if deemed necessary.

Mental health services can be provided by a variety of different professionals including psychiatrists (Medical Doctor, MD), nurse practitioners, psychologists, social workers, family therapists, alcohol and substance abuse counselors and/or a combination of all of the above. Psychiatrists are the only mental health professionals who can prescribe medication. Throughout the remainder of this handbook, the professionals mentioned above will be referred to as "treatment providers". 

Outpatient Treatment: Your child attends the treatment session and then returns home.

Individual Outpatient Therapy: Provided by a licensed treatment provider (psychologist, social worker or professional counselor). Approximate duration of treatment varies according to patient’s diagnosis and treatment needs. Typical treatment structure is one-on-one counseling, one session per week, one hour per session. I categorize individual outpatient therapy into two subtypes: Individual Talk Therapy – primary focus is the patient, primary treatment strategy is to have the patient talk out his/her problems and emotions, gain insight, problem solve and implement identified solutions. Multi-Strategy Therapy – focus of therapy includes the patient and his/her family members, treatment strategies may include individual talk therapy, group therapy, patient/family education, parent training, behavior modification, and skills training. Session structure often varies with regard to number of sessions per week, length of sessions, strategies for change and who is involved in the treatment along with the patient.

Intensive Outpatient Therapy: Provided by a community or privately operated mental health/substance abuse agency or hospital. Approximate duration and structure of treatment is 2-4 months, 4 days per week, 3-4 hours per day (after-school hours, 4-9 PM). Treatment typically includes a combination of individual, group and family counseling.

Partial Hospitalization: Provided by a community or privately operated mental health/substance abuse agency or hospital. Approximate duration and structure of treatment is 2-4 weeks, 4-5 days per week, 5-8 hours per day (8 AM - 4 PM). Treatment typically includes a combination of medical/psychiatric evaluations and monitoring, individual, group and family counseling and approximately 2-3 hours of academic education (coordinated with the patient’s school district).

Inpatient Treatment: Your child stays overnight in the hospital or treatment facility.

Emergency Hospitalization: Provided by a public or private hospital. Length of stay may vary from 2-10 days. Usually occurs following a psychiatric or substance abuse emergency during which an individual is at risk for harming himself/herself or others. The primary goal of hospitalization is to ensure the individual’s safety, stabilize acute physical and/or psychiatric symptoms and educate the patient and his/her family about the nature of the diagnosed condition. Treatment primarily includes medication, medical evaluations/monitoring, psychiatric evaluations/monitoring and patient and family education.

Intensive Inpatient Treatment: Provided by a publicly funded or privately operated inpatient treatment program. Approximate length of stay may be from 5-28 days depending on the treatment program. Usually occurs as a result of failed attempts at less intensive treatments (individual outpatient, intensive outpatient, partial hospitalization) or following an emergency psychiatric hospitalization. The primary goal is to educate and assist the individual in developing a long term plan and strategies for effectively coping with the diagnosed condition. Treatment primarily includes supervised living, academic education (coordinated with patient’s school district), medical evaluations/monitoring, psychiatric evaluations/monitoring, behavior modification and individual, group and family counseling.

Extended/Long-Term Treatment: Provided by a publicly funded or privately operated extended/long-term care program. Approximate length of stay may be from 2-18 months. Usually occurs as a result of failed attempt(s) at intensive inpatient treatment and/or when the nature and severity of the psychiatric disorder requires longer treatment. Treatment primarily includes supervised living, academic education (coordinated with patient’s school district), medical evaluations/monitoring, psychiatric evaluations/monitoring, behavior modification and one-on-one, group and family therapy. 

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Dealing With Insurance Providers

Mental health services can be expensive. While insurance can help offset the cost, it can also be a source of frustration and confusion. To determine which mental health services are available to you under your insurance coverage and to help prevent complications, delays and/or unexpected costs, it is crucial that you read your insurance policy carefully and/or speak to an insurance representative prior to contacting a potential treatment provider. Check your insurance card for a toll-free telephone number that will connect you with an insurance representative who can answer your questions.

There are typically three types of insurance coverage – traditional indemnity, preferred provider (PPO), and managed care (HMO).

Traditional Indemnity Plan: A traditional indemnity plan provides you with the most options. You can see a licensed treatment provider of your choice, pay the fee and submit the claim for reimbursement. The percentage of the fee you are reimbursed may range from 50% - 100% depending on your policy. Some policies require that you pay a deductible prior to being eligible for reimbursement.

Managed Care Plan (HMO): A managed care plan requires you to see a treatment provider who is contracted with your insurance company (referred to as a "in-network" provider). With some policies you may need a referral from your primary care physician to initiate treatment. You pay a co-pay ranging from five to twenty-five dollars at the time of service. The treatment provider submits your claim to the insurance company and is paid the balance of the fee directly from the insurance company. Under the HMO plan, initial and ongoing sessions are subject to pre-authorization and review by your insurance provider.

Preferred Provider Plan (PPO): A preferred provider plan gives you the option of seeing either a contracted (in-network) treatment provider (at the cost of a co-pay) or a treatment provider of your choice. Under the PPO plan, if you choose to see a treatment provider that is "out-of-network", the fee reimbursement is typically lower then it would be with the traditional indemnity plan.

In speaking to your insurance representative, it may be helpful to ask the following questions (I recommend that you document all conversations, dates and names of contact personnel):

·         All Plans: What type of policy do I have? Traditional Indemnity? Preferred Provider (PPO)? Managed Care (HMO)?

·         All Plans: Are mental health services covered?

·         All Plans: Are both outpatient and inpatient treatment covered?

·         All Plans: Do I need a referral from my primary care physician? If so, what is the best procedure for obtaining one?

·         All Plans: Do I have to start with outpatient treatment prior to accessing inpatient treatment?

·         All Plans: If the parents or family members of the identified patient need to be seen separately, do specific rules apply? What are those rules? How does the treatment provider need to document those sessions in order for me to be reimbursed?

·         All Plans: What is the total amount the insurance will pay on a yearly or a per contract basis for mental health services (e.g., $5000, $10,000, etc.).

·         All Plans: If my child is covered by more than one insurance policy, do special rules apply? What are they? What are the steps I need to take in processing the claim and ensuring reimbursement?

·         All Plans: Is there anything else I need to know to ensure that I can obtain the type of treatment I am seeking, that my claims are processed expediently and properly and that I receive the correct reimbursement?

·         All Plans: What are the steps I need to follow in order to obtain the services that I am seeking?

·         Traditional Indemnity Plan: If I receive individual outpatient treatment, what credentials does the treatment provider need in order for me to receive reimbursement for the treatment?

·         Traditional Indemnity Plan: Is there a limit on how high the professional’s charge may be (e.g., $120, $250, etc. per session), what is the maximum fee for which I will be reimbursed?

·         Traditional Indemnity Plan: What is the percentage that I will be reimbursed?

·         Traditional Indemnity Plan: Do I have to pay a deductible prior to receiving reimbursement? If so, how much is my deductible (e.g., $500, $1000, etc.)

·         HMO Plan: Do I have to pay a co-payment? If so, how much is my co-payment?

·         HMO Plan: Are there out-of-network benefits (PPO option) available? How do I obtain those out-of-network benefits? How do those out-of-network benefits differ from in-network coverage? What is the percentage of reimbursement? Is there a deductible?

If you have an HMO plan, ask your insurance representative for a list of "in-network" providers. When selecting a treatment provider from a list of unknown names, it is strongly recommended that you conduct a telephone consultation (as outlined in section 4) prior to scheduling your first appointment.

If you are on public assistance and you have Medicaid as your insurance, follow the strategies outlined above for an HMO policy.

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Initiating Treatment, Selecting An Outpatient Treatment PROVIDER

A good starting point for obtaining counseling services for your child is to consult with your child’s pediatrician/primary care physician. Have the doctor do a physical examination to determine if a medical condition is causing or contributing to your child’s emotional/behavioral difficulties. Make sure that the physical exam is thorough and includes blood work and, if your child is middle school age or older, a urine drug screen. If your child’s symptoms are not related to a medical condition, then mental health or substance abuse treatment may be recommended. If you have an HMO insurance plan, ask your doctor to give you feedback on your list of "in-network" providers. If you have a traditional indemnity or PPO plan, ask your doctor to provide you with the names and phone numbers of at least two treatment providers that he/she thinks would be a good match for you and your child.

In addition to your doctor, I strongly recommend that you consult with your child’s guidance counselor or other member of the school counseling staff (guidance counselor, social worker, psychologist or student assistance coordinator). School counselors are accustomed to working with children experiencing difficulties and can be a great source of support and expertise in connecting you to a treatment provider in your area.

Selecting A Treatment Provider:

To help determine the probability of a good match between you and a potential treatment provider, it is crucial to conduct a telephone consultation and to ask a lot of questions. Consider your first telephone contact and first therapy session as a two-way interview. While the treatment provider assesses you and your child’s difficulties and treatment needs, you are assessing the treatment provider’s personality, treatment philosophy and skill level.

Ask the treatment provider the following questions:

·         Do you accept my insurance ____________________?

·         What are your fees?

·         What are your credentials? What is your professional license?

·         Do you have experience working with patients my child's age? How many do you have in your total caseload?

·         Do you have experience working with my child’s presenting difficulty? How many patients with my child’s difficulty have you treated?

·         What is your treatment philosophy?

·         Do you have any specialized training?

·         What is the average length of treatment for my child’s type of difficulty?

·         If my child does not want to come to therapy or is uncooperative with you, how will you handle that?

·         Do you communicate and work with school staff if necessary?

If you are still not sure, then ask:

·         What are your strengths as a treatment provider?

·         Is there anything else you think I need to know as a parent/guardian of a potential patient?

Since most of us do not have ample experience in directly questioning a professional about his/her expertise, it may feel uncomfortable asking these kinds of questions. I urge you to put aside your discomfort. Not asking questions and adequately assessing the compatibility between you and a potential treatment provider increases your risk of wasting your time, money and hope.

The type of responses you get to these questions may vary greatly. What often matters as much as the answers is the openness and sincerity with which they are given. From a credentials standpoint, you want a licensed treatment provider (or someone under the direct supervision of a licensed treatment provider) with both experience and specialized post-masters training.

In making a final decision about a treatment provider, ask yourself the following questions:

·         Did the treatment provider sound professional, knowledgeable, warm and considerate?

·         Was I comfortable speaking to this treatment provider?

·         Did the treatment provider welcome my questions? Did he/she answer the questions fully or did I have to probe for more thorough responses?

·         Was the treatment provider patient with me or did I feel rushed?

·         If you left a message on the treatment provider’s voice mail or answering service – Did the treatment provider return my call within a reasonable amount of time?

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Preparing Your Child For The Initial Individual Outpatient Therapy Session

If Your Child Is Asking For Help — Motivated To Attend:

Give your child as much information as possible regarding the treatment providers that are available. Encourage him/her to be part of the selection process. If your child is mature, socially skilled and assertive enough, have him/her participate in the initial telephone consultation described in section 4 of this booklet.

If Your Child Is Denying And/Or Resisting The Need For Help — Not Motivated To Attend:

Introduce the idea of seeking professional assistance to your child at a time when emotions are calm. If your child gets angry, denies the need or rejects the idea and you feel strongly that treatment is necessary, then proceed by researching and selecting a treatment provider on your own. Do not include your child in this process and do not keep him/her posted on your progress; to do so may create counterproductive conflict and stress.

Once you have made the initial appointment, inform your child about the appointment and your expectations for him/her to attend. If you anticipate a strong amount of resistance from your child, inform him/her of the appointment shortly before you need to leave your house to attend. Do not allow for a large gap of time between informing your child and leaving for the appointment. To do so may provide your child with the opportunity to argue, challenge and wear you down enough that you find it difficult to follow through with your decision.

Suggestions for informing your resistant child about your expectations for him/her to participate in therapy.

·         Sit down with your child (both parents whenever possible) in a private and comfortable place.

·         Use a calm, respectful but assertive and directive tone of voice.

·         Explain to him/her exactly what is about to take place. Provide as much detail as your child is receptive to hearing regarding the time of the appointment, the treatment provider you have selected, the location of the provider’s office and what he/she can expect during the first meeting.

·         Take full ownership and responsibility for your decision to seek professional help. A good strategy is to say, "Today we are going to meet with a counselor…I have decided to make the appointment because I am concerned about what is happening in our family…(Be concrete and specific) We have had five "fights" in the last three weeks…" If you must place your concerns directly on your child’s behavior, say, "I am concerned because your grades have dropped from B’s to C’s…you seem real angry, you yell and curse at me and your brother…You were suspended from school and you keep telling me you don’t care about school or our family…" Conclude with your expectation for cooperation by saying, "I really need and expect you to cooperate…"

·         Avoid blaming comments, "You are going to the counselor because you are doing terrible in school…" Avoid sounding angry or frustrated. To do so will put your child in even a greater defensive state and intensify the resistance and stress of the moment.

·         Decide on and tell your child the exact number of sessions you are going to require him/her to participate in. Set the number of sessions at an amount you think your child can accept. The benefit of providing your child with a "light at the end of the tunnel" is that it usually helps take some of the edge off of his/her resistance and helps get him/her through the front door of the treatment provider’s office. Once there, it becomes the treatment provider’s responsibility to make a connection with your child that will hopefully lead to your child deciding to voluntarily participate beyond the required number of sessions. If your child does not choose to participate voluntarily beyond the required number of sessions, my experience has been that forcing him/her to do so will have little to no benefit. In fact, it may make things worse by further straining and damaging the relationship between you and your child. If your child participates in no more than the required number of sessions, at the very least the treatment provider will have had the opportunity to complete an assessment and report back to you his/her findings and strategies for addressing your child’s difficulties through means other than individual outpatient therapy.

·         Inform your child of the following principles he/she can expect in meeting with a treatment provider: Say, "You will be asked questions about school, family, friends, areas of interest and how you are feeling. You do not have to talk about anything you do not want to. If the treatment provider asks you a question that you are not comfortable with, you do not have to answer it. What you discuss with the treatment provider will be confidential with the exception of behavior that might be of danger to you or someone else (includes substance abuse). The main goal of your first meeting (and the first several sessions) is for the treatment provider to get to know you and what’s going on with our family". If your child seems receptive, educate him/her as much as possible about the counseling process. The only exception to this is in situations concerning substance abuse treatment. If your concern is substance abuse please read the recommendations below being sure to follow the prescribed precautions.

WHEN THERE IS A SUBSTANCE ABUSE CONCERN: If your primary concern with your child is substance abuse, you can probably expect a very high level of denial, resistance and anger from your child when informing him/her of your plan to take him/her to a counselor. Be prepared to handle and not allow your child’s resistance to deter you from your planned course of action. If you are a single parent and you do not have the support of your child’s other parent, you may want to ask another adult family member to assist and accompany you to your first treatment session.

If you have selected a treatment provider that is qualified and trained in the treatment of substance abuse (it is highly recommended that you do), you can expect that a drug and alcohol urine screen will be collected during the initial meeting. To prepare your child for the first meeting, follow the strategies outlined in the IF YOUR CHILD IS DENYING AND/OR RESISTING THE NEED FOR HELP section of this handbook, with the exception of the following precaution: Do not let your child know that a drug and alcohol urine screen will be part of the evaluation process. This is crucial because young people today have methods for passing drug tests even if they have been using substances. It may also intensify your child’s resistance to attending and participating in the counseling session. If your child specifically asks if he/she is going to be tested or evaluated for substance abuse, tell him/her that the first session is part of a comprehensive assessment that includes a substance abuse evaluation and that a urine test might be included. Stress to your child that there is nothing that can be discovered through the assessment that you are not prepared for and ready to deal with by being understanding and supportive.

It is important to note that if your child undergoes a drug and alcohol urine screen and it returns negative, it does not conclusively mean that your child is not using drugs or alcohol or that his/her current difficulties are not being caused or compounded by his/her use.

Facts parents need to know about drug testing:

·         Young people today have methods for adulterating and passing drug tests even if they are using drugs and/or alcohol.

·         Drug-testing standards vary greatly. "Zero cut-off" means that any level of a substance in the body will be detected by the test. Most drug tests do not have a zero cut off limit, which means that even if the test comes back negative your child could have a level of drug within his/her system that was not detected by the test. Many physicians do not use a zero cut off test. Their cut-off level might be high relative to typical adolescent drug use patterns. For this reason it is important to know the cut-off level of the drug test being administered. Whenever possible, request that a zero cut-off drug test be administered.

·         Many drugs (cocaine, ecstasy, ketamine, LSD, PCP) have a very short half-life in the body, which means that they may be undetectable by a drug test within hours (3-6) after they are last consumed.

·         Drug tests only test for specified drugs. If your child is using a drug not specifically being tested for, then the drug test result will be negative.

 Because of the numerous variables that impact on the results of a drug test, no one test should be considered 100% conclusive regarding an individual’s substance involvement. It is recommended that the drug test be administered as part of a comprehensive mental health/substance abuse evaluation facilitated by a professional trained in the treatment of substance abuse. A professional trained in substance abuse can advise parents on the probability of substance involvement beyond that indicated by the drug test results.

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What To Do If Your Child Refuses To Attend Treatment

If your child is experiencing a psychiatric emergency and refuses to go for help, see section 7 of this handbook.

 If your child is experiencing mild-moderate emotional difficulties (sadness, anxiety, shyness, social or academic difficulties) but can still meet his/her responsibilities, and refuses to attend treatment, do not try to force him/her to attend. Your best strategy is to be patient, continue providing love and understanding and repeatedly educate your child about the treatment process and its potential benefits. If you maintain your supportive position and your child becomes uncomfortable enough with how he/she feels, there is a good chance that he/she will eventually volunteer to participate in treatment. If your child does not take you up on your offer, then perhaps he/she does not feel as badly as you might think or is deriving some type of benefit from their emotional upset. In the latter case it might be helpful to discuss that possibility with your child.

If your child is involved in destructive and/or illegal behaviors (including substance abuse) and refuses to enter or participate in treatment, you may need to consider taking a "tough love" approach in motivating him/her to do so. Tough love is a parenting philosophy that stresses the accountability of the child to behave in a healthy and responsible way and the accountability of the parent to provide consistent and appropriate punishment for destructive behaviors. The way it works is, when your child is involved in destructive and/or illegal behaviors, you consequence (punish) him/her by imposing logical consequences and/or by allowing natural consequences to occur. Logical consequences are punishments that have a logical link to the behavior that is being disciplined. Logical consequences can include punishments as severe as reporting your child to the police, withholding non-essential support (materials and privileges outside of those necessary for survival - allowances, car, TV or computer in room, rides to friends’ houses) and/or making alternative living arrangements for your child. Natural consequences are punishments imposed by society (school suspension, police arrest, etc.). In addition to punishing destructive behaviors, you simultaneously provide logical rewards and encouragement for your child to enter treatment. 

In taking a tough love approach, ideally you want to communicate with your child in a non-emotional, assertive yet loving and respectful way. The goal of your communication style is to keep the focus on your child’s behavior and not to get drawn into an argument that shifts the focus to you, your parent-child relationship or past unresolved conflicts.

With tough love, as with any disciplinary approach, you need to be patient. There is rarely any one consequence administered at any one time that is going to make the difference. You will only impact on your child by being consistent with your approach over an extended period of time. The following are examples of a tough love response to a child involved in ongoing destructive and/or illegal behaviors.

·         Child is being verbally abusive towards you, breaking curfew and refusing to follow house rules. You say: "You are being verbally abusive toward me…you have come home late the past two nights…you have stopped doing school work…at this time you will not receive your allowance and I will not drive you over to your friend’s house…you can receive those privileges back when you are able to talk to me about what is going on and improve your attitude and behaviors…"

·         Child gets arrested for drinking and driving. Your response is to not hire an attorney to get him/her out of trouble. You explain to your child that if he is going to break the law he has to be prepared to pay the price for it. You allow your child to experience whatever "natural" consequences result from his/her behavior.

·         You find drugs in your child’s room and confront him/her with it. Child gets angry, pushes you and runs out of the house. Your response is to call the police, report your child for drug possession and assault.

·         Child is misbehaving in all of the above ways, you want the child to enter treatment. Your response is to follow through with all of the predetermined consequences. Say to your child, "I don’t want things to be this way…if you continue to behave the way you are I will have to continue to hold you accountable…if you go for treatment and show me that you are trying to work at it, we can wipe the slate clean…you can have back all of the privileges you once had…what do you want to do?"

·         Child continues to be involved in unhealthy, destructive or illegal behaviors and refuses to enter or participate in treatment despite all of the consequences that have been imposed. You continue to set and follow through with consequences that match the severity of your child destructive and/or illegal behavior.

·         One severe consequence is to make alternative living arrangements for your child. You say to your child: "Things continue to get worse…this is not good for either of us…perhaps it would be better if you lived with someone else…here are your options…go to treatment for help in changing your behaviors or plan on living somewhere else by the end of next month."

·         Another serious consequence is to work with the police and court system in generating a court order for treatment against your child. To find out more about how to obtain a court order, read Section 8 of this handbook. When reading Section 8, please be aware that the court order is explained in the context of seeking inpatient treatment, but, that it can be used to force a child into any one of the various levels of care (individual outpatient, intensive outpatient, inpatient, etc.)

 What makes the tough love approach difficult to institute is that it goes against most parents’ natural instinct to protect their child from perceived harm and to avoid the interpersonal pressure inherent in saying no or imposing a consequence. Generally speaking, in some ways it is easier to yell, argue, nag or try to guilt our children into compliance than it is to hold them accountable and impose a consequence that often initially escalates their agitation and anger. Ultimately however, research and my own clinical experience suggest that children (particularly those with behavioral difficulties) learn and are more influenced by our actions in response to their behavior than by our words or emotions. With this principle in mind we move from trying to convince them to change, to giving them leadership and good reasons (logical and natural consequences) to change. For additional information and support in implementing a tough love approach with your child, contact the tough love support program at (800) 333-1069 or visit www.toughlove.org.

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What To Do If Your Child Is Experiencing A Psychiatric Emergency

If your child is experiencing a psychiatric emergency (danger to self and/or others, experiencing delusions, hallucinations, disorganized thoughts and/or exhibiting unusual behaviors) take your child to your local hospital emergency room immediately. If your child is already under the care of a treatment provider, you may want to call the treatment provider first and ask for any special instructions that he/she would like you to follow. If you can not contact your child’s treatment provider immediately, then proceed to the hospital and try to contact him/her later. If your child is emotionally or physically out of control or has harmed him/herself or someone else, call 911 for assistance.

If Your Child Is Uncooperative In Going To The Hospital

Community resources that may be able to help you transport your child to the hospital:

Psychiatric Screening Center: All counties have a psychiatric screening center (see appendix A). The centers are located in designated county hospitals. Some centers serve more than one county. They are staffed by mental health professionals known as "screeners". The role of the screener is to both protect an individual from self-harm in cases of a psychiatric emergency and to advocate for an individual’s right against involuntary hospitalization. Screeners intervene in situations when an individual appears to be experiencing a psychiatric emergency but is refusing medical assistance.

In cases when an individual appears to be having a psychiatric emergency, but is uncooperative in going to the hospital, many screening centers have a "mobile unit" that they deploy to the individual’s location. The mobile unit consists of 1-3 screeners accompanied by members of the local police department. Upon their arrival they evaluate the individual’s mental status. If they believe that a psychiatric emergency exists and that the individual is of danger to him/herself or others, then they exercise their legal authority to have the police bring the individual to the hospital against his/her will. Some screening centers (Morris, Passaic and Warren County) do not deploy their mobile unit in situations involving a minor (any person under the age of 18). If you live in such a county, you may need to get assistance from your local police department (read the Local Police Department section below).

In cases when an individual is already at the hospital and has been recommended for emergency inpatient admission, but refuses to comply, the screening center deploys a screener to the hospital in which the individual is being held. Upon arrival the screener conducts an independent mental health evaluation to determine and make the final decision on whether or not involuntary hospitalization is necessary. Most of the time the screener is in agreement with the hospital evaluation. However, on occasion the hospital is overruled and the individual is released.

Local Police Department: While all counties have a Psychiatric Screening Centers that you can contact in cases of a psychiatric emergency, some screening centers (Morris, Passaic and Warren County) do not deploy their mobile unit in situations involving a minor (any person under the age of 18). If your child is a minor and you live in such a county, you will need to contact your local police department for assistance. In psychiatric emergencies, police departments have the authority to assist parents in transporting a minor to the hospital. Police departments seem to vary in their level of sophistication in dealing with individuals (particularly minors) experiencing a psychiatric and/or substance abuse emergency. When involving your local police department, be prepared for all possible personalities, styles and protocols in how they intervene with your child. Regardless of their approach, remember that the important thing is that your child gets to the hospital where he/she can be further evaluated and treated.

What to do if your child refuses to go to the hospital:

 If you attempt to take your child to the hospital and he/she is uncooperative, contact your county’s screening center for assistance. During your initial telephone contact with the screening center, be prepared to answer questions regarding your child’s current condition and related psychiatric history. Tell them the exact reason you believe your child needs to go to the hospital. Ask them to please intervene. If they inform you that they will be sending their mobile unit to assist, ask them how long it will take for them to arrive and for instructions on what to do until they get there. If for any reason the screening center is unable to deploy it’s mobile unit, then contact your local police department for assistance. If the screening center tells you they can’t intervene because in their clinical judgement your situation does not constitute a psychiatric emergency, ask them to advise you on how to access and utilize other community resources that can help.

What to do if you want your child admitted into the hospital for emergency hospitalization treatment:

If at the hospital you want your child admitted for emergency hospitalization treatment, communicate your request directly to the evaluating clinician. Tell him/her exactly what your child is doing that makes you believe emergency hospitalization treatment is necessary. Make sure you highlight behaviors that indicate your child may be a danger to him/herself or others. If it appears that the hospital is reluctant to admit your child, ask to fill out a request/application for hospitalization form. Doing so will document your concerns and thus force the hospital to give even greater consideration to your request. Be aware, however, that no matter how strongly and effectively you communicate your request, the hospital can choose not to admit your child for emergency hospitalization.

What to expect at the hospital:

Be prepared to provide the hospital with all pertinent insurance, demographic and medical information. If your child is already involved in some form of psychiatric treatment, remember to bring the treatment provider’s telephone number. The hospital might want to contact your child’s treatment provider and factor his/her clinical judgement into their evaluation. In preparation for going to the emergency room, remember to bring your child’s insurance card and any other information you think you might need to answer the intake questions.

Be prepared for a potentially very (very) long wait. Depending on how busy the hospital is, the recommendation of the evaluator and your child’s level of cooperation, your emergency room stay can be anywhere from two to twelve hours. If your child is recommended for inpatient psychiatric treatment, then he/she will be moved from the emergency room to another unit in the hospital or another hospital that has the appropriate type of psychiatric treatment available. In preparation for your potentially long day, it’s a good idea to bring some type of busy work (reading materials, crossword puzzles, letter writing, etc.) with you to pass the time. While your state of mind may not be conducive to busy work, emotionally it may be a good idea to force yourself.

Be prepared for a potentially stressful and emotionally draining experience. Depending on the quality of care you receive at the hospital, the length of time you’re there, the evaluation results, and your child’s emotional state and behavior throughout the process, you may experience an intense roller-coaster ride of fear, sadness, frustration, anger, rage, disappointment and guilt. In preparation for the potential roller coaster of emotion, it may be helpful to have a supportive family member or friend accompany you. Periodically focus on your breathing, step outside to take a walk, and assure yourself that you are strong and that you will endure and handle all possible outcomes.

If Your Child Needs Inpatient Treatment

A Quick Review Of Inpatient Treatment Options

Your child stays overnight in the hospital or treatment facility.

Emergency Hospitalization: Provided by a public or private hospital. Approximate length of stay may be from 2-10 days. Usually occurs following a psychiatric or substance abuse emergency during which an individual is at risk for harming oneself or others. The primary goal of hospitalization is to ensure the individual’s safety, stabilize acute physical and/or psychiatric symptoms and educate the patient and his/her family about the nature of the diagnosed condition. Treatment primarily includes medication, medical evaluations/monitoring, psychiatric evaluations/monitoring and patient and family education.

Intensive Inpatient Treatment: Provided by a publicly funded or privately operated inpatient treatment program. Approximate length of stay may be from 5-28 days depending on the treatment program. Usually occurs as a result of failed attempts at less intensive treatments (individual outpatient, intensive outpatient, partial hospitalization) or following an emergency psychiatric hospitalization. The primary goal is to educate and assist the individual in developing a long term plan and strategies for effectively coping with the diagnosed condition. Treatment primarily includes supervised living, academic education (coordinated with patient’s school district), medical evaluations/monitoring, psychiatric evaluations/monitoring, behavior modification and individual, group and family counseling.

Extended/Long-Term Treatment: Provided by a publicly funded or privately operated extended/long-term care program. Approximate length of stay may be from 2-18 months. Usually occurs as a result of failed attempt(s) at intensive inpatient treatment and/or when the nature and severity of the psychiatric disorder requires longer treatment. Treatment primarily includes supervised living, academic education (coordinated with patient’s school district), medical evaluations/monitoring, psychiatric evaluations/monitoring, behavior modification and one-on-one, group and family therapy.

If Your Child Is Experiencing Ongoing Psychiatric Or Substance Abuse Difficulties And You Are Considering Inpatient Treatment:

Inpatient treatment may be appropriate for ongoing psychiatric or substance abuse difficulties when an individual is experiencing life impairment and/or has had previous treatment attempts that failed to improve his/her condition. The decision to place an individual in inpatient treatment is a serious one that is subject to strict insurance guidelines and mental health legislature. It is not easy to have someone placed in inpatient treatment against his/her will. Inpatient treatment is most often utilized as the last line of treatment for ongoing psychiatric or substance abuse difficulties typically administered after prior treatment attempts have failed. There are exceptions to this protocol. If an individual is suicidal or homicidal or if there are other serious potentially self-injurious symptoms (including severe drug addiction or dangerously low body weight due to an eating disorder), inpatient treatment may be used as the first line of treatment.

If you have the financial means to pay for inpatient treatment, you can choose to have your child admitted into a private facility without the approval or guidelines of your insurance provider. In such cases it is important not to resort to inpatient treatment too quickly out of fear, anger or frustration. The risk is that you will utilize this powerful treatment tool at a time when your child’s level of impairment and treatment readiness might not warrant it. In the process you would be expending a limited resource (the cost of inpatient treatment is often so great that even financially secure individuals would have difficulty paying for it multiple times) that will perhaps then not be available to you at a time when it could have the greatest therapeutic impact. To research available private programs, speak to your child’s treatment provider, primary physician and/or school counselor.

If you have to depend on your insurance provider to pay for inpatient treatment, you will have to follow their protocol and guidelines for determining when inpatient care is appropriate and which facility to use. Since insurance companies and policies vary so greatly, you will need to speak to your insurance representative to determine how to proceed in getting your child inpatient treatment. If your insurance provider denies your request for inpatient treatment and you believe that it is necessary to your child’s well being, I strongly urge you to be assertive in advocating for your child. Request to speak to a supervisor and inquire about how to appeal the initial denial of services. Be diligent in asking the names of the insurance representatives to whom you speak, documenting your correspondence and following through with the necessary procedures.

If your child is a minor and is uncooperative in being placed in an inpatient treatment program the treatment facility you choose may be able to assist you in getting your child to agree to the proposed inpatient admission. In selecting a program and scheduling an admission date, inform the admission counselor of your child’s anticipated resistance. Ask them to advise you on how you should proceed in getting your child to their facility, how they will handle your child’s resistance and how you can best support them in doing so. Admission counselors have a lot of experience in working with resistant admissions. Through the use of "therapeutic leveraging" techniques, they have a good chance of being able to convince your child to enter their program. However, if your child refuses to agree to the inpatient admission, you will not be able to force your child into treatment. In such cases you may choose to seek an involuntary commitment or court order that mandates that your child enter into inpatient treatment.

If your child is of adult age (18 years or older) and is uncooperative in being placed in an inpatient treatment program you can follow the same strategies outlined above, for a minor that is resistant. However, be aware that treatment facilities are typically less effective in persuading adults into treatment than minors. To give yourself the best chance with an adult child, you may need to utilize other resources. One option is to seek the services of a private therapist who can facilitate a formal "intervention". A formal intervention involves planning and preparing for a meeting during which you and other family members and friends "confront" your child. You prepare for the meeting by working with a therapist who assists you in communicating in the least threatening and most powerful way. Without your child’s prior awareness, he/she is brought to the meeting during which time everyone expresses their concern and encourages your child to get "help". At the conclusion of the meeting, you attempt to immediately take your child to a treatment facility that you have pre-selected and scheduled an admission with. If your child refuses, you cannot force him/her into treatment against his/her will. In such cases you may choose to seek an involuntary commitment or court order that mandates that your child enter into inpatient treatment.

An involuntary commitment is when an individual (minor or adult age) is forced by the mental health system to enter inpatient care against his/her will. It is very difficult to have a person "committed". Your best chance of doing so occurs when there is a psychiatric emergency in which your child is overtly expressing thoughts of suicide or homicide, appears psychotic and or is engaging in potentially dangerous behaviors. If your child is experiencing a psychiatric emergency, follow the instructions outlined in Section 7. In addition, inform the evaluating mental health professional that you believe your child is in need of inpatient care and should be involuntarily committed. Another process by which an individual can be involuntarily committed is when a treating psychiatrist determines that inpatient treatment is the most appropriate level of care. In such cases your treatment provider should work with you in making the necessary arrangements for hospitalization and inpatient placement.

A court order for treatment is when an individual (minor or adult age) is mandated by the criminal justice system to enter treatment or face more serious legal consequences. If you want to generate a court order for treatment to be imposed on your child, you will need to follow a "tough love" parenting philosophy. When your child is involved in criminal activity including substance abuse, you notify the police in order to initiate your child’s involvement with the criminal justice system. Once your child is involved in the criminal justice system, you work collaboratively with the judge and/or probation officer assigned to your child’s case. By informing and/or keeping them abreast of your child’s criminal behavior and asking them for help, you will increase the likelihood that the judge and probation officer will impose a court order for treatment (possibly inpatient care).

If you are attempting to generate a court order for treatment and your child is a minor, find some reassurance in knowing that the juvenile justice system is set up to rehabilitate rather than punish. Juvenile records are typically expunged at the age of 21. By getting your child involved with the juvenile justice system, you will be providing him/her with a level of consequences that are mild in comparison to the consequences that may occur as a result of his/her disruptive, dangerous and/or substance abusing behaviors when he/she is older. In the process you will be taking advantage of a window of opportunity that only exists until your child’s eighteenth birthday and can possibly give you the leverage needed to motivate him/her to enter and participate in treatment.

If you are attempting to generate a court order for treatment and your child is an adult (18 years or older), the decision to do so will be a very difficult one. The adult criminal justice system is more punitive than the juvenile system. You will have to decide between the lesser of two evils: let your child act out and risk major life catastrophes or death; or generate legal consequence that may result in incarceration and/or a permanent criminal record but could motivate or force your child to get help.

 Once you have a plan and are ready to try to get your child into inpatient care, contact the treatment facility you are considering and proceed as follows:

·         Ask to speak to an intake/admissions counselor.

·         Begin by providing all the necessary insurance information and ask if they accept your coverage.

·         Be prepared to spend several minutes on the telephone answering intake questions concerning demographic information and the history and current status of your child’s difficulties.

·         Ask for their admission criteria and if they will contact your insurance provider to determine treatment eligibility and ongoing case management.

·         Ask how any outstanding bills at the end of treatment will be handled. Who would be responsible – you or your insurance company?

·         Ask how they handle patients who resist admission.

·         Ask if they have counselors in your area that can assist you with an "intervention".

·         Ask what the average length of inpatient stay is and what are the typical aftercare options.

·         If your child is from age 18-21, ask on which unit your child will be placed, adolescent or adult.

·         Schedule your child’s intake. Ask that the intake process be explained to you thoroughly. Ask what you need to bring including any necessary paperwork and personal items your child will need during his/her stay.

·         In getting your child to the treatment facility, follow the strategies outlined in section 6. In some cases with minors you may not want to inform your child of your plans until you are in the car driving to the treatment facility.

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UNDERSTANDING YOUR CHILD’S DIFFICULTIES AND RELATED TREATMENT NEEDS

Regardless of the treatment provider you choose or the level of care to be provided, effective treatment should begin with a comprehensive initial assessment/evaluation of your child’s difficulties and related treatment needs. The length of time it takes for an initial assessment varies from 2-5 hours (conducted over 1-5 sessions), depending on the treatment provider’s professional training and/or treatment philosophy. The goal of the assessment is to determine what is causing and/or maintaining your child’s difficulties and how to effectively intervene. In order to have a comprehensive understanding of your child’s difficulties, many treatment providers will want to get input from other caretakers, school officials and other agencies or treatment providers working with your child. A treatment provider will need your written consent in order to speak to anyone outside of you and your child.

At the conclusion of the assessment, your treatment provider should report to you what he/she thinks is going on with your child, if there is a diagnosable psychiatric disorder and the best course of treatment. A child’s emotional, behavioral and/or social difficulties can be explained many different ways. Remember that it is possible to get varying opinions from different professionals.

Different Diagnoses And Their Implication For Treatment:

Generally, I explain a child’s emotional, behavioral and/or relationship difficulties in one of two ways: difficulties caused and maintained by a life stressor or difficulties caused and maintained by a psychiatric disorder.

Difficulties caused and maintained by a life-stressor can be linked to a specific environmental trigger including developmental/physical changes, conflict with family or friends, parents’ divorce, illness or death of a family member and/or some other negative life event. A child experiencing difficulties caused and maintained by a life stressor typically responds well to individual outpatient therapy and the experience of being listened to, understood and emotionally supported. Even if therapy is not provided, there is a good chance that the child’s difficulties will stabilize and improve as the child matures and/or the life stressor passes.

Difficulties caused and maintained by a psychiatric disorder appear to be independent of a life stressor even though several might be occurring in an individual’s life. A child experiencing difficulties caused and maintained by a psychiatric disorder, may or may not respond to individual outpatient therapy. The less motivated a child is to acknowledging and working on his/her life difficulties, the less likely individual outpatient therapy will be effective. Treatment often needs to be supplemented by other therapies including family education, family therapy, parent/child management training, group therapy, self-help programs and medication. Having an accurate diagnosis is essential to developing and implementing the most effective treatment plan possible. An inaccurate diagnosis can result in ineffective treatment and, in the worst-case scenario, an intensification of symptoms. If treatment is not provided, there is a good chance that the child’s difficulties will continue to intensify and cause ongoing relationship, school and general life impairment.

The following are categories of disorders for which children and teenagers commonly need treatment: 

·         Mood Disorders

·         Anxiety Disorders

·         Disruptive Behavior Disorders

·         Eating Disorders

·         Substance Abuse Disorders

·         Thought Disorders

·         Personality Disorders

The table below identifies specific disorders within each category and the most effective treatments as prescribed by a variety of mental health researchers. It is intended to provide you with a general overview that can serve as a starting point for accessing additional information from your child’s treatment provider and other credible sources.

Please keep in mind that the table below does not provide a complete list of effective treatments; rather, only treatments backed by consistent research evidence are presented. There are many treatments without consistent research evidence that are considered worthwhile by treatment providers and may be selected as a primary treatment for your child. If you ever have any questions or concerns about the type of treatment that your child is receiving, speak to your child’s treatment provider about it. I believe a skilled and effective treatment provider will welcome your inquiry and be willing and able to explain his/her rationale for the treatment being administered.

When it is indicated that there is no consistent evidence of an effective treatment or medication, it does not mean that no treatment exists for a disorder, but rather, that no one treatment has produced consistent positive research findings. In such cases, treatments commonly used with some degree of effectiveness are indicated.

TABLE 1 – CATEGORIES OF DISORDERS & THEIR TREATMENT

MOOD DISORDERS

 ANXIETY DISORDERS

DISRUPTIVE BEHAVIOR DISORDERS

EATING DISORDERS

SUBSTANCE ABUSE

THOUGHT DISORDERS

PERSONALITY DISORDERS*

*References supporting the above table appear in the back of this handbook.

Please note that there are a number of disorders that are resistant to individual talk therapy (as defined in section 2 of this handbook). With disorders that are considered biological in nature and/or characterized by a child’s unwillingness to acknowledge life difficulties, a lack of motivation for change, blaming others for one’s life difficulties and/or a resistance to participating in therapy, the focus of treatment becomes the family dynamics and parenting style. The hope is to assist parents and family members in creating a home environment that serves to reduce stress, teach healthy coping strategies and motivate the child to work on changing maladaptive patterns of thoughts, emotions and behaviors.

If you bring your child to a treatment provider with the hope that he/she will be "fixed", it can feel invalidating and frustrating to hear that the focus of treatment will need to be on your family dynamics or parenting style. The recommendation may seem to imply that you are in some way the cause of your child’s difficulties. If you are given the recommendation of parent training or some other family focused intervention, please understand that it is not an indictment of your parenting but rather a reflection of the nature of your child’s difficulties and the limitations of standard individual outpatient therapy. Traditional "instinctive parenting" needs to be supplemented by parenting strategies and skills specific to your child’s difficulty.

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 IF YOUR CHILD IS PRESCRIBED PSYCHOTROPIC MEDICATIONS

The information in this section is taken from non-copyrighted material on the Mental Health Institute Web Page.

While medication rarely should be the only strategy used, in some cases it may be a key component to effective treatment. If your child’s treatment provider believes that your child could benefit from medication, he/she will refer you to a psychiatrist or your primary care physician. Medications can only be recommended and prescribed by a medical doctor (MD). The decision to accept a doctor’s recommendation for medication can be difficult. Issues to be considered are the age of your child, severity of emotional and/or behavioral difficulties, level of life impairment, your child’s degree of cooperation and the potential benefit versus risk of the medication. As parents you will want to ask your child’s doctor many questions, research the medication(s) being recommended and carefully think over your final decision.

If you decide to place your child on medication, learn everything you can about it. Know which side effects are tolerable and which are life threatening. Have your child monitored regularly by the prescribing physician. Contact your doctor whenever you have any concerns about the presence of side effects or the medication’s effectiveness. Listed below is information describing the several major categories of psychotropic medications. It is intended to provide you with a general overview that can serve as a starting point for understanding and accessing additional information from your child’s treating physician/psychiatrist and other authoritative resources.

There are several major categories of psychotropic medications: stimulants, antidepressants, anti-anxiety agents, anti-psychotics and mood stabilizers. For medications approved by the FDA for use in children, dosages depend on body weight and age.

Stimulant Medications: There are four stimulant medications that are approved for use in the treatment of Attention Deficit Hyperactivity Disorder (ADHD), the most common behavioral disorder of childhood. These medications have all been extensively studied and are specifically labeled for pediatric use. Children with ADHD exhibit such symptoms as short attention span, excessive activity, and impulsivity that often causes substantial behavioral, social and academic impairment. Stimulant medication should be prescribed only after a careful evaluation is performed to establish the diagnosis of ADHD and to rule out other disorders or conditions. Medication treatment should be administered and monitored in the context of the overall needs of the child and family, and consideration should be given to combining it with behavioral therapy. If the child is of school age, collaboration with teachers is essential.

Antidepressant and Anti-anxiety Medications: These medications follow the stimulant medications in prevalence among children and adolescents. They are used for depression, a disorder recognized only in the last twenty years as a problem for children, and for anxiety disorders, including Obsessive-Compulsive Disorder (OCD). The medications most widely prescribed for these disorders are the Selective Serotonin Reuptake Inhibitors (the SSRIs). In the human brain, there are many "neurotransmitters" that affect the way we think, feel and act. Three of these neurotransmitters that antidepressants influence are serotonin, dopamine, and norepinephrine. SSRIs affect mainly serotonin and have been found to be effective in treating depression and anxiety without as many side effects as some other antidepressants.

Anti-psychotic Medications: These medications are used to treat children with schizophrenia, bipolar disorder, autism, Tourette's syndrome and severe conduct disorders. Some of the older anti-psychotic medications have specific indications and dosage guidelines for children. Some of the newer "atypical" anti-psychotics, that have fewer side effects, are also being used for children. Such use requires close monitoring for side effects.

Mood Stabilizing Medications: These medications are used to treat bipolar disorder (manic-depressive illness). However, because there is very limited data on the safety and efficacy of most mood stabilizers in youth, treatment of children and adolescents is based mainly on experience with adults. The most typically used mood stabilizers are lithium and valproate (Depakote), which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes in adults. Research on the effectiveness of these and other medications in children and adolescents with bipolar disorder is ongoing. In addition, studies are investigating various forms of psychotherapy, including cognitive-behavioral therapy, to compliment medication treatment for this illness in young people. Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat co-occurring ADHD or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.

 The following Medications Table (Table 2) below shows many of the commonly prescribed medications for children with mood, anxiety (including Obsessive Compulsive Disorder), disruptive behavior and thought disorders. It is intended to provide you with some psychopharmacological terminology that can help you access additional information from your treating medical doctor. It is important to note that it is common practice for doctors to prescribe medications to patients outside the approved age group (see section below titled "What Does Off Label Mean"). The reason for this is that physician experience and judgement is ahead of the research process. If your child is prescribed a medication that has not been approved for his/her age group, do not assume that the physician made an error in his/her selection. Instead, speak to the physician and find out the appropriateness and potential benefit of the medication plan being recommended.

TABLE 2 - MEDICATIONS

STIMULANT MEDICATIONS

ANTI-DEPRESSANT AND ANTI-ANXIETY MEDICATIONS

ANTI-PSYCHOTIC MEDICATIONS

MOOD STABILIZING MEDICATIONS

When your child is being evaluated and considered for psychotropic medication, it is essential that you provide the doctor with a thorough history of your child's medical problems, any medications your child is taking, including over-the-counter medications or vitamin and herbal supplements, and any allergic reactions your child has suffered. If a medication is prescribed for your child, there are certain questions you should ask. It will be helpful to take notes as it is easy to forget exactly what the doctor says.

·         What is the name of the medication and how will it help my child? Is the medicine available in both brand name and generic versions, and is it all right to use the less expensive (generic) medication? What is the name of the generic version? Is it all right to switch among brands, or between brand name and generic forms?

·         What is the proper dosage for my child? Is the dose likely to change as he/she grows?

·         What if my child has a problem with the pill or capsule? Is it available in a chewable tablet or liquid form?

·         How many times a day must the medication be given? Should it be taken with meals, or on an empty stomach? Should the school give the medication during the day?

·         How long must my child take this medication? If it is discontinued, should it be done all at once or slowly?

·         Will my child be monitored while on this medication and, if so, by whom?

·         Should my child have any laboratory tests before taking this medication? Will it be necessary to have blood levels checked or have other laboratory tests during the time my child is taking this medication?

·         Should my child avoid certain foods, other medications, or activities while using this medication?

·         Are there possible side effects? If I notice a side effect—such as unusual sleepiness, agitation, fatigue, and hand tremors—should I notify the doctor at once?

·         What if my child misses a dose? Spits it up?

·         How well established and accepted is the use of this medication in children or adolescents?

You may think of other questions. Don't be afraid to ask. When you have the prescription filled, be sure the pharmacist gives you a flyer describing the medication, how it should be taken, and any possible side effects it may have. The label on the medication will have a lot of information. Read the label carefully before giving the medication to your child. The label will give the name of the pharmacy, its telephone number, the name of the medication, the dosage, and when it should be taken. It will also tell you how many times the medication can be refilled.

If you want to learn more about your child's medication, you will find helpful books at your public library, or the reference librarian can show you how to look up the medication in the Physicians' Desk Reference (PDR). Of course you can also access information from the Internet; however, much care is required in distinguishing fact from opinion.

WHAT DOES "OFF-LABEL" MEAN?

Based on clinical experience and medication knowledge, a physician may prescribe to young children a medication that has been approved by the U.S. Food and Drug Administration (FDA) for use in adults or older children. This use of the medication is called "off-label." Most medications prescribed for child mental disorders, including many of the newer medications that are proving helpful, are prescribed off-label because only a few of them have been systematically studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement that "safety and efficacy have not been established in pediatric patients." The FDA has been urging that products be appropriately studied in children and has offered incentives to drug manufacturers to carry out such testing. The National Institutes of Health and the FDA are examining the issue of pharmacological research in children and are developing new research approaches.

HELPING YOUR CHILD TAKE MEDICATION SAFELY

·         Be sure the doctor knows all medications—including over-the-counter medications and herbal and vitamin supplements—that your child takes.

·         Read the label before opening the bottle. Make sure you are giving the proper dosage. If the medication is liquid, use a special measure—a cup, a medicine dropper, or a syringe. Often a measure comes with the medicine. If not, ask your pharmacist which measure is most suitable to use with the medication your child is taking.

·         Always use child-resistant caps and store all medications in a safe place.

·         Never decide to increase or decrease the dosage or stop the medication without consulting the doctor.

·         Don't give medication prescribed for one child to another child, even if both appear to have the same problem.

·         Keep a chart and mark it each time the child takes the medication. It is easy to forget.

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THE FIRST STEP IN YOUR CHILD’S TREATMENT AT STRENGTH FOR CHANGE:

Children are brought in for treatment for many reasons.  The most common of which are the following:

• School difficulties including academic underachievement and/or disciplinary problems
• Emotional difficulties including depression, anxiety and anger
• Behavioral difficulties including disobeying rules, illegal behavior, substance involvement and/or aggression or violence towards others
•  Other difficulties - social difficulties, low self-esteem, poor body image, impulse control disorders
  

The most common causes of these difficulties are the following:

 Mood Regulation Disorders – depression, anxiety

1. Attention/Behavior Regulation Disorders – ADHD, Oppositional Defiant Disorder
2. Learning Disabilities
3. Substance Abuse or Addictions
4. Personality Traits/Disorders
5. Life Stressors
6. Medical Conditions
7. Other Psychiatric Disorders

Your child’s treatment at Strength for Change will begin with a comprehensive mental health assessment.  The goals of the assessment are to determine what is causing your child’s difficulties and to develop a trusting and collaborative relationship with your child.  Both goals are crucial to successfully treating your child.  The specific cause of the difficulties determines the most appropriate (effective) treatment plan to implement.  The trusting and collaborative relationship enables your therapist to encourage and influence your child to cooperate with the implementation of the treatment plan.  Failure in one or both of these goals will greatly diminish the likelihood of a successful treatment outcome. 

During the assessment stage, your therapist will obtain information about your child using multiple instruments including many of the following: 

q       Semi-Structured Life History Interview:

q       Symptom Interview

q       Depression, Anxiety & Symptom Questionnaires

q       Amen Mood Behavior Questionnaire

q       Personality Interview and/or Questionnaire

q       Parent Intake Packet

q       Parent Symptom Questionnaire

q       School Behavioral Checklist (Parent needs to sign release of information)

q       School Contact/Feedback – Prior Treatment Provider Contact/Feedback

The reason we use so many assessment instruments is because we want to obtain a large pool of data thereby increasing our capacity to cross-reference information and improve the accuracy of our analysis.  Parents fill out several forms including a parent intake packet that provides us with detailed information regarding their child’s life and symptom history.  

ANSWERS TO QUESTIONS YOU MIGHT HAVE ABOUT THE ASSESSMENT STAGE:

1. Why do you meet with the child (and not the parent) first?

Many children feel a high level of anxiety and/or distrust (believing that the parent(s) and therapist are in cahoots) about attending therapy.  Rather than risk feeding their negative feelings by having closed door meetings with their parent(s), we meet with the children first so that we can (as quickly as possible) put their minds at ease and start developing a positive rapport.

2. How will you know what is really going on with my child if he/she is not telling you the truth?

We are aware that the information reported by your child may not match the facts about what is really going on.  This is why we will not make any clinical judgments based solely on what your child reports.  As part of your child’s intake, you will fill out a lengthy and detailed intake packet and sign releases (if you choose) enabling us to contact your child’s school and others involved in your child’s care.  It is the combination of information from several relevant sources (including the most important source – you) that will enable us to understand your child and his/her treatment needs. 

Even if your child presents information that is inaccurate, the information is helpful in that it provides insight to your child’s level of honesty, life prospective, communication style, level of self-awareness, readiness for therapy and other key treatment factors.

3. Why does it take 3-8 sessions?

If our only goal for the assessment stage was to obtain the information necessary for an accurate diagnosis, we could get through all the assessment questions in 1-2 sessions.  Because we also have the second goal of developing a collaborative and trusting working relationship with your child, the format we use takes longer because of its’ emphasis on interacting with your child in way that creates a positive rapport.  The format reflects over 20 years of clinical experience working with children. 

We can always understand why a parent would be eager for us to move quickly from the assessment to the treatment stage of therapy.  In response, we must emphasis that successfully achieving the two goals of the assessment stage is just as relevant (if not more so) to a successful treatment outcome as any skill or strategy that is taught during the treatment stage.   

4. When will I find out what is going on with my child?

The assessment stage will conclude with you coming in for an hour and a half long assessment review session.  Your therapist will report to you the assessment findings including a diagnosis (if applicable) and individualized treatment plan.  Your child's treatment plan will reflect his/her individual needs along with research-based treatment recommendations.

Following the assessment review session, if you agree with our assessment findings and individualized treatment plan, we will begin the treatment stage of therapy.  During the treatment stage, our primary focus will be to assist your child (or you and other family members) in developing the skills and strategies necessary to overcome the presenting life difficulties.  

As you wait for the assessment stage to be completed, you may want to get a jump-start on learning about the nature of your child’s difficulties and some of the skills and strategies that your therapist might present to you.  Below is a bibliography of several books that we have found to be helpful to parents.  Please read over the list and, either, select the title that best addresses the difficulties your child is having or ask your therapist for a recommendation.  The more educated you become about your child’s difficulties, the more effective parent and advocate you can be for your child.