This is tricky ground. You don't want to overreact to a possibility that remains unlikely, and very low-rate events are difficult to manage. The likelihood of something terrible happening may be very low, but the magnitude of the event, if it were to happen, is so huge that one must consider intervening. It's easy to misdiagnose or overdiagnose the everyday problems of children (e.g., anxiety, depression, hyperactivity), but a professional can be especially useful here if he or she uses systematic measures to assess child functioning and danger. Getting such a professional opinion will either allay worries or speed entrance into a program that can make a change.
Another factor to take into account is that parents, teachers, and other adults tend to detect and respond to a child's externalizing problems—those that disrupt the environment, such as oppositional, aggressive, and anti-social behavior—more readily than to internalizing ones like depression and anxiety. The most common clinical concern in psychiatry and psychology raised by this tendency is the overdiagnosis of hyperactivity. It's easy to point to an active boy and say, "That child is hyperactive. Go get treatment and start medicating." Systematic ways of measuring behavior reveal that many such children do not meet the criteria for the diagnosis.
So pay special attention to what might be outward signs of internalizing problems.
First, has there been any change in behavior? A behavior may take on significance and become a problem because it represents a break from the usual pattern. Two different preadolescents might mope, tend to stay in their room, and not want to be with friends. This may be pretty much how one child acts and has always acted, which is also, by the way, kind of like the way his dad acts. For the other child, who is usually actively involved in things and pretty cheerful (when not giving the usual attitude, of course), moping and standoffishness mark a notable change. In the case of this latter child, a parent should be more alert to the possibility of depression. The change marks the behavior as clearly not a matter of temperament or enduring personality style but as something else.
Second, is the child showing signs of stress that coincide with exposure to an event or stressor? Here I'm talking about, for instance, exposure to a disaster (anything from the grand scale, like a hurricane, down to something in the household, like a fire), domestic violence, death of a relative, peer bullying, sexual abuse, or even exposure to violent TV, be it CSI or news footage. The child may show lack of sleep, nightmares, anxiety, clinginess, or impairment as noted above. Many of the effects are transient, depending on the child and the nature of the event. If they do not go away or lessen after a few weeks (depending on the child and severity of the exposure to the event), consider seeking help.
When in doubt, pediatricians, psychologists, and child psychiatrists are the first line of inquiry about how a child is doing. Pediatricians do not specialize in social, emotional, or behavioral problems and psychiatric disorders; their primary training is in medicine and physical health. But a large percentage of children (up to 40 percent) who are brought to them have psychological problems. Thus, pediatricians very often serve as parents' first contact with specialists who can treat such problems or make referrals to mental health professionals. Psychologists and child psychiatrists are trained to provide systematic evaluation, meaning that they use various standard psychological measures to see how the child is doing in many areas of social, emotional, cognitive, and behavioral functioning. And they're trained to look at different contexts—how the child is doing at home, in school, in peer relations—and assess any signs of trouble requiring follow-up.
In a subsequent piece, we'll talk about the next logical step in this process: how to decide on the approach and the particular professionals best suited to helping your child. You need to be a critical consumer of mental-health services, as critical as you'd be when buying a car or a house, and we'll offer some suggestions about how to equip yourself to face that challenge.
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