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Ask the Mental Health Expert Archives 2001-2004

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Behavioral Evaluation

Q. My son is six years old and has several behavior issues. I took him to a psychologist who interviewed me and observed him for an hour, then diagnosed him with Tourettes, oppositional defiant disorder (ODD) and possible attention deficit hyperactivity disorder (ADHD).

I was then referred to a psychiatrist who saw us for about 30 minutes and prescribed Paxil for my son. I am an exhausted and terrified parent who isn't sure what the right thing to do is. Aren't there more extensive tests or evaluations that can be done before drug therapy is recommended?

A. I can appreciate why you feel exhausted and terrified--and confused. I can't tell you what problems your son actually has, or whether he got a thorough diagnostic evaluation. But there certainly are more comprehensive evaluations and testing procedures that can be done, and if you feel you've gotten short shrift, you may want to avail yourself of these options. (I will say, off the cuff, that a total of an hour and a half strikes me as a pretty short time frame in which to reach all these diagnostic and treatment conclusions).

With respect to the diagnosis of Tourette's Disorder (TD), I would recommend that you consult a pediatric neurologist or neuropsychiatrist for a second opinion. That's because there are different kinds of tic disorders, some of which are transient, and the diagnosis of TD may not apply. Many child psychiatrists also consider Oppositional Defiant Disorder to be an overly-broad term that may overlook other conditions, such as a mood disorder. Attention Deficit Hyperactivity Disorder (ADHD) also requires very careful assessment. It can sometimes be misapplied to children who are simply bored and restless, on the one hand; or to kids with bipolar disorder, on the other.

A comprehensive assessment involves not only an interview with the parent, but also a review of school-related information (often involving a discussion with teachers); an evaluation of the family environment (e.g., is it highly stressful?); an assessment of child-parent interactions; an interview with the child; and the use of various ADHD screening instruments, such as the Connors Parent Rating Scale. For more details on assessment, you may want to read the relevant chapters in Dr. Russell Barkley's classic text, Attention Deficit Hyperactivity Disorder (1990). It is geared toward professionals, but is clearly written.

I am not sure why Paxil was prescribed for your son, but since recent concerns have been raised about this medication in younger populations, I would also consider obtaining a second psychiatric opinion. Paxil is not an agent with FDA-approved labeling for any of the conditions diagnosed by the psychologist.

With all this in mind, is there a one-stop place you might consider for further assessment of your son? I would begin with the Department of Child Psychiatry at any medical school within driving distance. You can ask to speak with one of the attending faculty members, explain the situation to him or her, and ask for some referrals to an appropriate clinic or faculty member. You may also find useful information and support on two websites: that of CHADD (Children with Attention Deficit Disorders; http://www.chadd.org/) and the Learning Disabilities Association of America (http://www.ldanatl.org). I hope you are able to get a through assessment for your son very soon.

January 2004

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