When To Refer For A Psychological Assessment

We expect to see fluctuations in a child’s daily functioning. Changes in schedule, lack of sleep, illness, and temperament can all impact everyday academic performance, a child’s mood, and their behavior.

To determine the appropriateness of a referral for a Psychological Assess- ment it is useful to look at the intensity and frequency of a problem. If a child is has been struggling all semester with their reading, or having fits daily for the last two weeks then the frequency criteria may be met. However, if the “fits” last for less than a minute, or the child’s reading skills are on grade level, then the intensity criteria may not be met. On the other hand, if the fits last for several minutes (or hours in some cases), or the child’s reading level is below grade placement, than both the frequency and intensity criteria are met.

When in doubt it is usually better to refer than wait for a problem to worsen. We always conduct an initial interview before initiating a full Psychological Assessment battery.

Key Issues in School Avoidance

Primary care physicians are often the first professionals to become aware that school avoidance is an issue for a child or adolescent. Many school avoidant children will complain that they fell ill, and parents will schedule them to see their physician. Assessing why a child is avoiding school can be a complex and difficult issue.

In the absence of an underlying physical cause, children avoid school for many reasons, ranging from a social phobia to truancy. Children may also avoid school because they are struggling academically, being bullied, or having conflict with teachers. Some children avoid school in order to obtain attention from parents, or spend more time in activities they prefer, such as video games. School avoidance has a negative impact on academic performance, and as the child or adolescent falls behind, the desire to avoid school can often intensify.

School avoidance should be treated as a symptom. The first step in addressing school avoidance is to understand the motivation behind the avoidant behavior. Is the child avoiding school to engage in more pleasurable activities, to avoid emotional distress, or manage some sort of unpleasantness such as a learning problem or bullying? In all cases the child should return to school as soon as possible while the underlying reasons for the school refusal are being evaluated. Support should be obtained from school administrators and counselors to facilitate the child’s or adolescent’s return to school. Temporary relief can sometimes be obtained by not having the child return directly to their classroom. Instead they may spend the day with a different teacher or in the counselors’

Self-Harm and Cutting

The incidence of self-harm, or “cutting” is on the rise among adolescents. Primary care physicians are in an ideal position to identify self- harming behaviors due to the presence of atypical wounds and scarring. Self-harm can occur anywhere on the body, but usually is expressed on the wrists, thighs, arms or chest. Self-harming behaviors may include burning with cigarettes or a lighter, scratching with any- thing sharp enough to pierce the skin, or cutting with a knife or razor.

Many adolescents will initially deny that they have engaged in self-harming behaviors because they do not want their parents to find out and because they are embarrassed. However, adolescents often communicate among them- selves about their cutting and there can be a contagion effect among communities and groups of adolescents. Adolescents who self- harm are typically in emotional distress and referral to a mental health professional is always warranted. Self-harming behaviors should not be ignored, and assurances from the adolescent that they will stop on their own are insufficient.

Self-harming behavior is not necessarily suicidal behavior. Adolescents who self-arm should be assured that they are not “crazy”, this is a common problem, and one that can be ad- dressed by a trained mental health provider. People who self-harm are not “looking for attention.” Often, they are introverted people who are trying to avoid drawing attention to them- selves. Frequently, they are experiencing in- tense emotional distress that is beyond their ability to express and cope with.

Parents often need immediate counseling and intervention when they learn their child is self- harming. They too need to be reassured that their child is not “crazy,” this is a common problem, and it is treatable. Advise parents to provide reassurance of love and support to their child. Parents should ensure that their child spends more time with, and receives supervision from, a trusted adult. They should avoid judging the child and assist them in finding resources. Encourage the parents to “vent” with someone other than their child. Parents should be encouraged to let their child express their emotions without passing judgment.

Individuals who self-harm often experience temporary relief fr0m their emotional pain, a sense of calmness, and a sense of control. Sometimes self-harm is self-punitive and relieves guilt. Some individuals experience a sense of control over their bodies when they cut or engage in other self-harming behaviors. Treatment involves acknowledging the problem and talking with a trusted adult. Over the course of therapy individuals who self- harm learn to identify their triggers, learn better ways to cope and self-soothe, and address underlying emotional issues. They replace self-harming behaviors with adaptive behaviors and appropriate expression of emotions.

Resources on the web: www.selfinjury.com


When Should I Refer to a Mental Health Professional?

If any of the following persists longer than two weeks:

  • Restlessness and agitation
  • Feelings of worthlessness and guilt
  • Lack of enthusiasm and motivation
  • Fatigue or lack of energy
  • Difficulty concentrating
  • Thoughts of death or suicide
  • Sadness or hopelessness
  • Irritability, anger, or hostility
  • Tearfulness or frequent crying
  • Withdrawal from friends and family
  • Loss of interest in activities
  • Changes in eating or sleeping habits

Immediate referral is warranted if someone is aggressive, suicidal, is abusing drugs or alcohol, or there has been an extreme change in behavior.

Using Games in Child Therapy

Imagine, Sophie returns to the waiting room and tells her mother how much fun she just had with her therapist. When asked what she just did in therapy Sophie reports that she played games. At that point, Sophie’s mother begins to wonder what she just paid for! Let me explain. Games are a wonderful way to engage children. Therapists use both traditional and therapeutic games to help children identify social and emotional skills, role-play these skills, problem solve, improve their attitude toward school, peers, and family, increase motivation for life tasks such as learning, and enhance creativity. Playing games teaches identification and expression of feelings, how to identify needs, how to formulate requests and demands, and how to listen and communicate effectively. Playing games can help children develop a sense of responsibility, a positive attitude, creative thinking, build self-esteem, appropriate assertiveness, self-confidence, a sense of self and self-identity, and conflict resolution skills. Gameplay encourages children who are fearful and reluctant to talk to become comfortable, and after a couple of sessions, the therapist can begin to draw the child into a conversation and therapeutic dialog.

The type of games a child chooses tells you something about their maturity, confidence, and personality. A nine-year-old child that picks Candy Land, for example, may be demonstrating social immaturity, may be communicating a lack of confidence, or low self-esteem. In psychotherapy, games can be used to resolve issues at an unconscious level and behavioral therapists and cognitive therapists use games didactically to provide learning opportunities, provide information, role play, and skills training. Many older children are reluctant to engage in the playroom and are either unable or unwilling to engage in a conversation with the therapist. One of the values of many therapeutic games is that they immediately create relevance. A game can inform the child what therapy is about, how therapy can be used, provide an immediate understanding of a problem, and how to address it. At the very least, the therapist has a tool, something concrete, observable, and real, to address the client’s issues.

In summary, gameplay orients the child toward therapeutic interactions, assists in building a relationship with the therapist, helps identify strengths, weaknesses, and issues, and provides opportunities to intervene. So, if you see Sophie’s mom, you can let her know that a lot of great work took place while they were playing those games!

Executive Functioning: A Crucial Component in Academic Success

Although the impact of executive functioning deficits on school success is profound, executive functioning deficits are often unrecognized by parents and teachers. Executive functioning is crucial for school success. Executive functioning is the conductor of our behavior. The conductor of an orchestra organizes various instruments to begin playing singularly or in combination, integrates the music by bringing in and fading certain actions, and controls the pace and intensity of the music. Executive functioning, as the conductor of our behavior, prepares the plan (music), directs and regulates behaviors and cognitive activities that will accomplish the plan, regulates self-control, monitors performance, and considers future outcomes.

A wide variety of cognitive skills must be utilized to ensure efficient and successful executive functioning. In a school environment these skills include:

· Working memory and recall – holding facts in mind while manipulating information, accessing facts stored in long-term memory

· Activation, arousal, and effort – getting started, paying attention, finishing work

· Controlling emotions – ability to tolerate frustration, thinking before acting or speaking

· Internalizing language – using “self-talk” to control one’s behavior and direct future actions

· Complex problem solving – taking an issue apart, analyzing the pieces, reconstituting and organizing it into new ideas

Children with attentional and learning problems and children on the Autism Spectrum often exhibit deficits in executive functioning. Therefore, a thorough psychological assessment needs to assess executive functioning. The first step is taking a good history from the parents and reviewing academic records. A variety of standardized questionnaires, completed by the student, teachers, and parents are helpful. Assessment of cognitive and intellectual abilities provides insight into the various aspects of executive functioning such as problem-solving, working memory, and cognitive efficiency. Utilizing several methods to collect data and assess skills enables the evaluator to provide the most useful recommendations to address executive functioning challenges.

Teens and Suicide Risk

Studies have suggested that that parents and teens may underestimate the risk of suicidality in their community. In my practice, parents are often surprised when I disclose to them that their child has had suicidal thoughts. Many parents still seem willing to overlook problematic behavior and excuse it as adolescent angst or identity issues. Failure to adequately recognize teen depression and suicidality is a serious issue. According to one study suicide is the third leading cause of death among teens.

Risk Factors

Risk factors for teen suicide are well known. They include the use of illegal drugs and alcohol, relationship issues, and depression. Adolescents struggling with sexual orientation issues are at especially high risk. One survey found that 28% of gay and bisexual males and 20% of gay and bisexual females had made suicide attempts. One should not underestimate familial factors. A family history of depression or bipolar disorder should always be treated as a red flag, especially when accompanied by other warning signs.

Screening for Suicide Risk

Dramatic changes are clearly the most obvious indicators that something is amiss. This may include changes in personality, aggression (both verbal and physical), break up with a romantic partner, school avoidance, or withdrawal from groups and activities. Sometimes changes are more gradual, like changes in peer affiliation, a decline in grades, and reducing participation in extracurricular activates. Other warning signs include changes in sleep or appetite, trouble concentrating, disorganized and confused thinking, writing notes, songs, or poems about death or suicide, talking about and joking about suicide, and reduced quality of homework.

Actions to Take 

Talk about it! Do not be afraid to use the word suicide. Making an empathic connection is reassuring to teens. Ask if the individual has made a plan. Alert the parents. They must maintain close proximity to their child and remove all dangerous items from the household, including medication. Obviously, don’t minimize the adolescent’s distress. Remind the teen that their behaviors and decisions will have a lifelong impact on their family. Refer the adolescent to a mental health professional right away.

Is My Child’s Anxiety Normal?

Parents often ask “Is my child’s anxiety normal?” Because all children have worries from time to time this can be a difficult question to answer. In fact, Anxiety Disorders in children can go undetected by parents for quite some time. One in eight children experiences an anxiety disorder that necessitates treatment. Normal anxiety is often associated with a specific event. Perhaps the child has seen a scary movie, is concerned about a peer conflict, or is afraid that they have failed a test. When the child cannot control their worry, or their fears interfere with normal childhood activities, they need to be evaluated for an anxiety disorder. Typically “giving in” to the anxiety leads to an increasing spiral of anxiety and avoidant behavior.

Symptoms and behaviors that indicate anxiety may include restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. The child may exhibit behavioral difficulties such as school refusal, resistance to new activities, separation difficulties, difficulty playing alone, difficulty sleeping alone, or the emergence of specific fears.

Fortunately, psychological treatment (such as play therapy) of anxiety in children has been proven to be quite successful. Many children can benefit from psychotherapy and do not require medication, a significant concern for many parents. Simply educating parents and children about the nature of anxiety and then teaching ways to identify, assess, and change anxious thinking can help the parent and child immensely. Teaching a child to recognize the physiological symptoms of anxiety and to combat them with relaxation techniques is quite helpful. Children can easily learn how to use positive self-talk to deal with recurring worry and stress. Parents may also need to be educated on the best ways to aid their child with these anxiety disorders.

Self-Help Books for Children and Adolescents

  • Sometimes I Get Sad (But Now I Know What Makes Me Happy)
  • What to Do When You Dread Your Bed
  • When I Feel Afraid
  • My Medication Workbook
  • Becoming a Superhero: A book for children who have experienced trauma
  • Brain Bullies: Standing Up to Anxiety & Worry 

Does Play Therapy Work?

The short answer is, “Yes!” During the past two decades, there has been a significant increase in research on play therapy and its efficacy is well demonstrated. A 10-year study completed by Play Therapy UK found positive change occurred for 74% to 83% of children participating in play therapy. Play therapy is a structured approach with a strong theoretical basis, that capitalizes on a child’s inclination to play. The Association for Play Therapy defines play therapy as “the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.”

The first use of play in therapy dates to the early 1900s. Play therapy differs from regular play in that it encourages children to use their play to address their challenges. In play therapy, toys and games are the language used to express thoughts and feelings. Facilitated by the relationship with the therapist play therapy helps children learn more adaptive behaviors. Some of the benefits of play therapy include enhanced communication skills, learning to express feelings, modification of behavior, improved problem-solving skills, and improved relations with peers and family members. By providing “a safe psychological distance” from their challenges and conflicts play therapy gives children an opportunity to express their thoughts and feelings in a way that is consistent with their development.

Play therapy works by allowing children to confront their problems and challenges in a supportive setting in a developmentally appropriate way. There are many strategies for working with children in play therapy. Often children are able to discover their own strategies for dealing with their challenges. In other situations, the therapist provides play therapy structured, or semi-structured, activities that promote social and emotional competence.

Children as young as three-years-old can benefit from play therapy and it is often utilized up to early adolescence. Play therapy is recommended as the primary, and first intervention for a variety of childhood issues such as depression, anxiety, and oppositional-defiant disorder. It can also be a useful adjunct for children experiencing medical illness, ADHD, autism, and academic difficulties. Play therapy is useful for children experiencing life stressors such as divorce, abuse, neglect, death, or natural disaster.

Play therapy sessions are typically 30-45 minutes. Children may attend as few as 6-8 sessions, or weekly sessions for a year, or longer. While parents are typically not included in these sessions many child therapists meet separately with parents to provide feedback, support, and parent training.

Kids in the Mix

There are an increasing number of children coming into our practice with overlapping conditions. These children have been diagnosed with ADHD, Bipolar Disorder, Learning Disability, Tourette’s, and/or Asperger’s. Many of these children also experience depression, anxiety, and obsessive thoughts and compulsive behaviors. Often they are defiant and oppositional. No single diagnosis seems to apply to these children, so we say they are in the “syndrome mix.”

Assessment and treatment of these children cannot be accomplished by any single provider. These children require a multi-disciplinary assessment and multi-modal intervention. A complete evaluation may include the following: psychological (which would likely include educational and neuropsychological tests), medical, neurological, and psychiatric evaluations. Many of these children also need to be evaluated by speech and language, physical, and occupational therapists. Treatment will most likely include psychotherapy, medication management, and educational interventions. Many of these children also require language therapy, social skills training, physical therapy, and occupational therapy. The most successful kids are those whose parents are willing to take an active case management and advocacy role. Providers can help by supporting and counseling these parents.

Most children in the “syndrome mix” experience deficits in executive functioning. Most definitions suggest executive functioning is the ability to formulate a plan, initiate the plan, and carry it through to the end. Executive functioning is sometimes compared to the conductor of an orchestra. Almost every human endeavor requires executive functioning. A short list of the regulatory functions carried out by executive functioning includes: perceiving, initiating, inhibiting, modulating/adjusting, gauging, shifting, manipulating, organizing, storing, retrieving, pacing, time sense, focusing attention, focusing effort, sustaining attention, stopping, anticipating, time management, monitoring, and correcting. Deficits in executive functioning will impair most aspects of daily life, from getting out of bed, to completing homework, to responding to a simple command.

A proper assessment and treatment plan will evaluate various aspects of executive functioning. Parents, teachers, and others may need to continue to assist the individual with various aspects of executive function well into adulthood. An excellent resource is the book Kids In The Mix of ADHD, LD, Asperger’s, Tourette’s, Bipolar, and More! By Martin L. Kutscher, MD.