As a child and adolescent psychiatrist, I am routinely asked many questions by parents and other adults who care for children. I completely understand that it takes a parent a great deal of thought, concern, and courage just to seek help for a child who is struggling. Please know that for child psychiatrists, these questions are welcome and are never taken lightly or seen as a bother.
In this post, I will discuss questions that frequently arise during diagnosis and treatment. This is not meant to take the place of me sitting down with a family to discuss their concerns. Rather, I want to give you a bit of a behind-the-scenes look at how a child psychiatrist approaches a problem.
As a physician, my role at our agency is to ensure that everything is considered a possibility when it comes to what makes a child behave or feel in ways that create problems. This involves not only extensive training and experience but also a flexible approach that arrives at a view of the child that makes sense to all, especially to the caregiver who brings the child in.
Children are complicated beings, as complicated as you or me. It’s difficult enough to diagnose an adult, who can TELL you things that are important, but a child may lack the vocabulary, perspective, or self-awareness to explain what they are feeling. As a result, the evaluation process is as complex as the individual child being evaluated. Given that it’s your child going through this process, it is understandable that you may have questions about it. Let’s look at some of the questions that can come up.
Do I have to tell you everything all over again?
Yes (some would say, unfortunately), this is the case. When you first come to see me, I will read what is written in the record, since I’m never the first person to see a child. But there are questions, and even whole lines of questions and follow-up questions, that are sometimes not asked, and it falls on me to make sure a child’s history is as complete as possible. If I were bringing my child to a doctor, I would not feel good about the doctor just saying, “I read what my nurse heard about him, and I read what this other doctor said about him, so I’m good. I think his diagnosis is ______.”
So, I will ask a lot of questions. And what’s worse, my medical training directs me to consider the worst possible diagnosis and then actively work to rule it out, whether by asking more questions or recommending other examinations. I frequently tell people that if, for example, you go to a good neurologist with a headache, he will assume you have a brain tumor and actively work to rule that out. Chances are, you don’t have a brain tumor, but the neurologist would be doing you a disservice if he didn’t think of the worst diagnosis first.
I will also take some time with the child you are bringing in. What I do during that time depends on the problem's history and the child’s level of development. I will behave very differently when spending time with a 6-year-old child, a 10-year-old child, or an adolescent. But, regardless of their age, I will always talk with the child first, because they need to have a sense that this care and treatment is for them, and their benefit, not because I’m working in some sort of adult alliance with their caregivers.
Is It “Nature” or “Nurture” Causing My Child’s Problems?
You’ve probably heard the phrase “nature versus nurture.” It usually comes up when people are trying to understand the underlying “cause” of a child’s behavior. I put the word “cause” in quotation marks because life is never that simple. Most problems are not caused by just one thing.
Consider a motor vehicle crash. It is almost never due to a single factor. Speeding may play a role, but so might weather, lighting, road conditions, construction, mechanical issues, or the driver’s state of mind. Most significant events in life result from multiple interacting forces
Most of the time, behavior also reflects a combination of factors. A child’s genetics, brain development, relationships, school environment, life experiences, and stressors all interact. These influences shape how a child behaves, how they understand the world, and how they respond to what is happening around them. Our job as clinicians is to carefully explore all of these areas rather than settling on a single, simple explanation.
Some mental health conditions do have a hereditary or biological component. Mood disorders, anxiety disorders, psychotic disorders, and attention problems can run in families. Certain information-processing difficulties may relate to events before birth, including exposures to drugs or other complications during pregnancy. This is the “nature” side of the equation.
Other conditions are more clearly connected to a child’s early environment. Trauma-related disorders, including reactive attachment disorder, may develop in the context of significant early adversity, such as exposure to violence or sexual abuse, neglect, or repeated changes in primary caregivers. This reflects the “nurture” side.
In real life, however, these forces are not separate. They operate within the same child at the same time. Focusing only on “nature versus nurture” rarely brings us closer to helping a child feel or function better.
A more accurate (and more helpful) way to think about it may be:
How do both nature and nurture contribute to this child’s experience and behavior?
Is this a “behavioral” problem?
My response is usually, “Behavioral versus what?”
Everything is happening within one child, one brain, one person. There is no separate “behavioral part” of the brain.
We recognize that something may be wrong because of behavior. A child might have public outbursts, hit a sibling, send inappropriate texts, bully others, or withdraw completely. A change in a child’s usual behavior is what alerts us about a problem, but we would be doing the child a disservice if we focused only on the behavior and not on the visible signal that something deeper is going on.
Rather than labeling a problem as simply “behavioral,” we work to understand what is driving the behavior. Is it anxiety? Depression? Attention difficulties? Trauma? A learning disorder? Family stress?
Behavior is the signal. Our task is to understand the source.
Shouldn’t you be asking for a neuropsychological evaluation to arrive at a diagnosis?
Not as a rule.
A neuropsychological evaluation is a detailed, standardized assessment of how a child’s brain is functioning. It usually involves several hours of structured testing to measure areas such as attention, memory, language, problem-solving, processing speed, learning style, and sometimes social understanding.
There are situations where this type of assessment is especially helpful. For example, a neuropsychological evaluation may be appropriate when a child’s prior psychoeducational testing (often done through the school system) shows unusual results. In these cases, more in-depth, specialized testing can provide a more accurate picture.
Neuropsychologists have also developed expertise in using standardized tools to assess for autism spectrum disorders, and a comprehensive neuropsychological evaluation can be an important part of making that diagnosis.
It is important to remember, however, that when it comes to making a complete psychiatric diagnosis, standardized testing alone is not enough. The instruments used in neuropsychological testing measure specific skills and abilities, but they do not replace a thorough clinical assessment by a child and adolescent psychiatrist. A psychiatric evaluation focuses not only on test performance and rating scales but also on emotional functioning, behavior across settings, developmental history, family dynamics, medical factors, and how symptoms affect daily life.
Aren’t you supposed to do a genetic test to find out what medication would be best for my child?
The short answer is no, not usually.
You may have heard about genetic, or pharmacogenetic, testing that claims to help match a child to the right psychiatric medication. While this type of testing can provide useful information in certain situations, it does not typically tell us which medication will work best. Here is why.
The liver is the organ responsible for removing foreign chemicals from the bloodstream. It does so with the aid of a number of enzymes that help to inactivate substances and eventually excrete them. Genetic testing examines the presence (or absence) of certain enzymes and provides a doctor with clues as to why a particular child develops side effects when others do not, as this child may be lacking one or more of the necessary enzymes. Genetic testing can also help us figure out why a child is not responding to a particular medication, as that child’s liver may be much more efficient than others at clearing the medication from the bloodstream.
I use these tests sparingly when confronted with unusual responses, using clinical judgement first and foremost.
Is this medication going to make my child into a “zombie”?
Any medication decision requires a careful discussion about why it is being recommended, what benefits are expected, and what side effects are possible.
No physician can predict with certainty how any individual will respond. However, if a parent feels their child “does not look right” or seems dulled, slowed, or unlike themselves, that concern alone is reason to reassess treatment promptly.
“Zombie-like” behavior is not an acceptable outcome. If medication interferes with a child’s personality, vitality, or functioning, it should be adjusted or discontinued.
The goal of treatment is improvement, but this should happen without any change in a child’s personality or traits that make that child your child.
What happens if I do not agree with your diagnosis and plan for treatment?
The first step is discussion.
Additional information may have emerged. Symptoms may look different over time. Parents may see things at home that were not fully evident during the evaluation.
Parents are understandably cautious about medication. My role is to explain the reasoning behind a diagnosis and any recommended treatment, including benefits and risks. Ongoing care requires listening carefully to parents’ observations and concerns.
It is not our role to push medication (no matter what the internet says). And if a parent wishes to seek another opinion, that request will be respected.
A Final Word to Parents and Caregivers
If you have read this far, it likely means you are thinking deeply about your child’s well-being. That alone matters.
Child psychiatry is not about labeling children or reducing them to diagnoses. It is about understanding the whole child in the context of their biology, development, relationships, and experiences. It is about identifying what is getting in the way and helping remove obstacles so a child can thrive.
Most importantly, you are not alone in this process. Thoughtful evaluation, open conversation, and careful collaboration between families and clinicians can lead to meaningful progress. Children are remarkably resilient, and with the right support, they can grow, adapt, and succeed in ways that may not feel possible at the start.
Asking questions is a sign of advocacy and love. We welcome them.
