How to tell if your child needs mental health services

By Amy Wang, The Oregonian, Jan. 12, 2013Teenage girl

A study of more than 6,000 U.S. teens and their parents, published last week in the journal JAMA Psychiatry, found that most adolescents who consider or try suicide have received some mental health treatment, according to The New York Times.

READ – “Study Questions Effectiveness of Therapy for Suicidal Teenagers,” The New York Times

READ – “Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents,” Matthew Nock, et al, JAMA Psychiatry, Jan. 9,2013 (PDF, 249KB)

Meanwhile, tragedies such as last month’s shootings in Clackamas Town Center and Newtown, Conn., have indicated that other young people who need mental health treatment never get it.

Here are tips on how to tell if your child needs mental health services from Chris Bouneff, executive director of NAMI Oregon, the state chapter of the National Alliance on Mental Illness; Cyndy Rutto, a psychiatric-mental health nurse-practitioner in private practice in Portland; and Sarah Mack, a certified parent coach with Skelton Thomason and Associates, a Portland educational consulting firm specializing in therapeutic programs for children and adolescents.

Trust your gut — After years of hearing from concerned parents, Rutto said, “I don’t think I’ve ever had a call that wasn’t appropriate.”

Know the signs — For school-age children, Rutto said, red flags include a sudden unexplained decline in academic performance, constant worrying, persistent nightmares and resistance to typical social activities.

Prolonged aggressive behavior — more than six months — and frequent unexplained tantrums are also cause for concern.

There are physical red flags, too: extreme anxiety presenting itself in the form of severe stomachaches, constant fidgeting, inability to sit still or pay attention for any length of time and invading others’ personal space.

Any child who threatens to kill himself or others should be evaluated, Rutto said.

Bouneff said parents should also take note of a child who starts having problems with daily life, such as becoming next to impossible to manage on outings.

The easiest thing for a parent to see, he said, is sudden inability to succeed at or progress in an area where a child once did fine.

Adolescence is a particularly important time to observe a child’s behavior, Bouneff said — mental health disorders start between ages 14 and 24 in about three-quarters of cases.

It’s normal for teens to be moody, but “a kid who’s locking themselves up and in the depths of despair for two or three days at a time, or for 50 percent of the time over a two-week period,” needs evaluation, Rutto said.

Other possible symptoms of teen mental illness, especially in combination, include significant changes in eating or sleeping patterns, hyperactivity, increased agitation or irritability, sexual acting out, obsession with body image that has no relationship to actual weight, excessive dieting or throwing up, self-injury or other self-destructive behavior, repeated threats to run away and criminal activity or opposition to authority.

Mack noted that parents should give behavior more weight than words during discussions of possible problems or treatment. “Sometimes your child will tell you they don’t want treatment, but their behavior is a cry for help,” she said.

See a pediatrician — Bouneff cautioned that pediatricians are often just the first stop. “Particularly in younger children, it’s really hard to tease out if there really is something going on,” he said. “Recognize that whatever your pediatrician’s able to tell you or refer you to … it may just be the beginning of the process.”

A knowledgeable pediatrician can refer parents to agencies that do screenings, which vary, Bouneff said. Some focus on sensory problems, while others focus on disorders such as ADHD.

Prepare for a marathon
— “Just because a screening indicates something, that’s not necessarily the diagnosis,” Bouneff said. “With children it’s very tricky to diagnose anything. … It can be a long series of observations and trial and error to see what a child is dealing with.”

“Kids are a moving target,” Rutto said. “You don’t want to jump right to a major diagnosis; in fact, it might be something less.” The best approach, she said, is “looking at the big picture but constantly reassessing as you’re going along.”

Rutto, Bouneff and Mack all stressed that mental health treatment takes time, including the time it takes to find the best-fitting practitioner and/or treatment.

Take notes — One thing NAMI Oregon teaches parents is how to document all the various doctor visits, Bouneff said. He also recommended that parents keep journals of children’s symptoms, writing down “things that are unusual, things that stand out, that cause you concern. Then that’s a good well of information when you do go see a clinician.”

Stay connected at school
— Educators are good at spotting symptoms because they see a lot of kids, Bouneff said. However, he added, some educators try to diagnose kids themselves, so parents must become advocates for their kids, including blocking attempts to prematurely label a child.

Be wary of medication
— “Pills are not the answer,” Rutto said. “No child should ever be on medications without being in therapy. Therapy is the thing that gives you tools for your tool box.”

If things get worse
— When standard outpatient therapy doesn’t work, families often begin looking for long-term treatment, and that’s when Mack meets them. Her company helps parents sort through the options, including wilderness and residential programs.

Skelton Thomason’s clients are typically between ages 12 and 26, with problems such as anxiety, depression, grief and loss, bullying, adoption and attachment disorder, substance abuse and gaming and Internet addiction.

Mack said the staff has 10 risk factors it uses to assess whether a young person is a suitable candidate for long-term treatment:

  •  No significant progress after at least six months of outpatient therapy.
  •  Escalating negative behavior.
  •  Behavior that has profound negative effects on family dynamics.
  •  Acting in a way that puts him/her at physical risk.
  •  Acting in a way that already has or could put him/her at legal risk.
  •  Attending school erratically, failing classes and/or showing changes in school performance.
  •  Changing friends or showing significant negative influence from friends
  •  Dropping out of activities that he/she once enjoyed.
  •  Exhibiting extreme behavior that is out of character.
  •  Experimenting with drugs and alcohol.

If parents aren’t ready to consider residential treatment or want to give a child another chance at home, Mack said, Skelton Thomason also offers coaching on developing rules, setting boundaries and determining expectations and consequences.

Practice self-care — Parents can’t do what’s best for their child if they themselves aren’t sound of mind, Mack said. “Surround yourself with supportive friends and family members who can provide assistance and objectivity while making a very emotional, important decision.”


  • Health insurers: If parents don’t know where to start, Mack suggests they call their insurer. That includes the Oregon Health Plan, which covers mental health services such as therapy, behavioral health day treatment and psychiatric health facilities.
  • NAMI Oregon: The state affiliate of the National Alliance on Mental Illness has phone and email helplines: 1-800-343-6264 and It offers classes and referrals to support groups and resources.