The problems began with bedtime. Like most toddlers, Cindy Freifeld’s daughter, Alexandra, liked to be tucked in before she fell asleep. But when she was around 3, the little girl started insisting that her mom say good night in a strangely specific way. “I had to say ‘I love you’ in a sing-song voice, three times in a row,” recalls Cindy, who lives in Huntington, New York. “She’d panic if I didn’t do it just right, with just the right pitch, and she’d make me start over. It could go on like that for almost an hour.” The habit was disconcerting and frustrating, but Cindy pushed her worry aside and tried to laugh it off with friends. “Everyone said it was normal and healthy for kids to crave routine, and as a first-time parent, I listened.”
But a year later, Alexandra’s insistence on having things just the way she wanted grew even more urgent. She started to arrange toys and other things—baby doll clothes, old cell phones, uneaten lollipops—in a particular order in her room, and she was so worried that friends would touch her things that she refused to have anyone over. “My husband kept saying, ‘She’s fine, she’s fine, it’s a stage,’ ” Cindy says. “But I’d walk past her room and see her lining up those little collections by herself, and I’d have this terrible gut feeling: No, my little girl is not at all fine.” Still, Cindy was frozen—unsure of what to do next.
When a child feels sick with a fever or a cough, parents don’t think twice about calling their doctor for advice. But time and again, the symptoms of pediatric mental illnesses like depression, anxiety, bipolar disorder, and disruptive mood dysregulation disorder (DMDD)—a relatively new diagnosis associated with constant irritability and frequent, extreme tantrums—are another story.
Just how prevalent and serious a problem is parental uncertainty? To find out, Parents teamed up with the Child Mind Institute to survey approximately 400 moms and dads across the country. Sixty-five percent said they would wait weeks or longer before seeking help if they noticed a mental-health symptom in their child. “In fact, the average window of time between when parents notice something is wrong with their child’s mood or behavior and when a child gets diagnosed is two years,” says Parents advisor Harold Koplewicz, M.D., a child psychiatrist and founding president of the Child Mind Institute.
The American Academy of Pediatrics (AAP) recently released updated guidelines that call for pediatricians to screen adolescents ages 12 and up for depression annually. But there is not enough evidence to support universal screening in younger kids. Depression symptoms are different in children than in teenagers; they often present as behavioral issues rather than emotional ones, says Nerissa S. Bauer, M.D., an AAP liaison who helped craft the guidelines. Plus, she adds, “Younger children may not have the words to express how they’re truly feeling.” This is part of what makes diagnosing mental-health disorders so challenging, and what makes parents’ input so crucial.
In our survey, the vast majority of parents told us that the reason they’d wait to see a doctor was because they wouldn’t want to overreact. But the truth is, it’s never an overreaction to seek help for your child—even if you ultimately find out that she’s fine. Mental illness is one of the most common pediatric health issues in America. “With few exceptions, adults who’ve struggled with mental illness recall their troubles starting early in childhood,” says Rahil Briggs, Psy.D., national director of HealthySteps at Zero to Three, in Washington, D.C. According to a research review by the AAP, 10 to 14 percent of kids under age 5 experience emotional problems serious enough to cause suffering.
In short: “Parents should be starting their detective work the moment they become concerned,” says Dr. Koplewicz.
So what’s in their way?
Seventy percent of respondents in our survey said they believe mental-health diagnoses carry a stigma, and only 36 percent said they would speak totally freely about a child’s diagnosis. As a society, we need to do better—and eliminate the fear that a child will be shamed or considered “crazy”—so that worried parents won’t hesitate to seek help, says Dr. Koplewicz. Early intervention is our best weapon against mental illness in childhood, and that’s because it works.
“The brain is at its most ‘plastic’ when children are very young, which means the things they learn over and over again at this age tend to stick, including strategies to help them manage stress,” says Dr. Briggs. Studies show that kids with mental disorders who receive treatment get better grades and are more resilient in the face of challenges than those who don’t.
Of course, it’s easy to understand why a parent’s instinct might be to downplay her child’s upsetting behavior. Little kids are notorious for rollercoaster moods, from weekend meltdowns over torn hot-dog buns to morning tantrums about getting dressed or brushing their teeth. And doctors agree that for the most part, these emotional episodes can be chalked up to an immature prefrontal cortex—the part of the brain that helps kids think rationally and temper their emotions. “Almost by definition, a 5-year-old has strong feelings about all sorts of things,” says Dr. Briggs.
But while every kid has bad days, the life of a child with a budding mental-health disorder often feels like one long, bumpy ride—for him and for you. “I encourage parents to look out for the two D’s: distress and dysfunction. Is their child unhappy or agitated very often? Is it usually hard for him to get through a normal childhood ritual, like a school morning or a birthday party?” says Dr. Briggs. A worrisome behavior might not be constant—a child may seem well-adjusted at home but not at school or day care, or vice versa—but it is often chronic.
Ultimately, it took a difficult, dramatic moment for Cindy to come to grips with the fact that Alexandra was truly unwell. One day, as sort of a test, she decided to see if her daughter could allow her favorite cousin into her room. But when the boy came toward her door, Alexandra didn’t just protest—she rolled on the floor and screamed as if she were in pain. “Any last denial inside me just fell away,” says Cindy. “I started crying right along with her. It was clear that my daughter was in agony. She—we—needed help.”
Cindy scoured the Internet for clues about Alexandra’s symptoms and landed on a website about obsessive compulsive disorder (OCD). Her daughter fit the description of this anxiety disorder to a T. Quickly, Cindy found a nearby specialist who diagnosed Alexandra and started to treat her with cognitive behavioral therapy. Within six months, she was better at relaxing and articulating her worries to her parents. “It took a huge weight off to understand why she was behaving the way she was and to know she could get better,” says Cindy.
Unfortunately, for many parents, the real challenge begins when they start the process of seeking a diagnosis and treatment. Mental-health message boards are full of frustrated parents struggling to find a specialist within driving distance who accepts their insurance. Only 8,300 or so child psychiatrists practice in America, compared with almost 58,000 general pediatricians (and there’s a shortage of those too). But the effort to locate an expert pays off: “Learning that good help is out there, and that it works, changed our lives,” says Cindy.
If you have concerns about your child’s mental health, start by discussing them with your pediatrician. The next step is to find a psychiatrist, psychologist, developmental-behavioral pediatrician, or in some cases a highly recommended licensed clinical social worker, who regularly treats patients with your child’s specific condition. We suggest the websites of the American Academy of Child & Adolescent Psychiatrists and the American Psychological Association as good jumping-off points that allow you to search by state. Steer clear of experts and coaches who have neither medical nor mental health training.
How will you know if you’ve truly found “the one”? The first conversation can tell you a lot. “Ask if her treatment will be guided by recent, peer-reviewed research,” suggests Carol Weitzman, M.D., professor of pediatrics at Yale University. You’ll know you’re in capable hands if the clinician’s answer is yes and she can cite examples. And remember that parents know their kid better than anyone; if your child isn’t opening up with a provider after a few visits or you sense little progress after several months, it’s time to look for a new doctor.
The right treatment carried out by the right doctor can yield a powerful, lasting effect—and in less time than you might think. “Interventions that would take three years to make an impact in a teen or an adult might take four to six sessions in a young child,” says Dr. Briggs.
Alexandra is proof of this. She still gets anxious if the friend she always sits next to on the bus is absent, but these days Alexandra will later joke to her mom that she was in “butterfly” mode—a reference to an Arnold Lobel book that her therapist recommended about monarchs who do the exact same thing every day. She still gets nervous about playmates entering her room, but now she can explain the situation. “I have worries,” she’ll say. “But I’m working on them.”
Cindy realizes that her daughter might have to deal with anxiety for a long time—possibly forever. “But since she began treatment, I can see that above all, she’s a bright, silly little girl,” says Cindy. “I know that she’s going to be okay.”
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