I recognize the tentativeness and worry in the caller's voice. I've heard it a thousand times. "I'm worried about my son," the caller says to me. She goes on to describe his symptoms and the reason for her concern. The cause of her tone, at least in part, is the haunting question - "Should I be worried about my child? Parents are often unsure when a problem is serious enough to seek professional help. Presented below are four questions that I ask myself when trying to determine whether or not a child needs professional help.

My first point of concern with any mental health issue is one's ability to function. I ask the question, "How much does the thing that is concerning the parent inhibit the child's ability to do the things he needs and wants to do?" If the answer is "minimally" or "not at all," then the problem may not warrant professional help. Suppose you are afraid of snakes - "ophidiophobia" or technically "Specific Phobia - animal subtype." This phobia is classifiable as a mental health disorder, but so what. If you can get out of bed, go to work, do your family business, sleep OK and eat OK, then so what if you have a diagnosis? With children, I'm most concerned when their issues are creating noticeable problems with siblings, parents,teachers, or peers, or in specific environments (home, school, church,etc.). When this is not the case and they are able to do what needs to be done during the week, counseling may be unnecessary.

A second question I ask when I'm trying to help a parent decide if counseling is necessary is: "Is there a presenting issue that is almost always serious for children?" Some situations and problems are nearly always difficult for children. Other issues present significant challenges that, if not dealt with in childhood, can become serious problems later in life. Some issues that always concern me include difficulties with close family members including death, abandonment, imprisonment, or serious health issues (i.e. cancer, heart-attack, stroke, life-threatening injury), difficulties involving peers including fighting, threats, and bullying, as well as delinquent behavior.

Also of concern to me are serious health concerns involving the child, physical or sexual abuse, uncontrolled emotions including anger, depression, or suicidal behaviors, and traumatic events (i.e. traffic accident, abduction, natural disaster). While none of these situations always spell disaster for a child, they are issues that are difficult even for adults and professional help may be necessary to help the child work through his thoughts and concerns related to these situations.

A third question is closely related to the second: "Does this child present any of the three symptoms known as the 'terrible triad?'" These three symptoms are almost always signs of serious disturbance. The terrible triad is frequently the result of trauma, especially physical and sexual abuse. This triad includes fire setting, cruelty to animals, and bed-wetting beyond successful completion of bladder control. When any or all three of these behaviors are present, an assessment and clinical intervention is imperative.

A fourth question I ask is: "Does the parent need help and/or reassurance?" Sometimes a visit to a counselor is helpful in that it teaches parents skills that will help them work with their child given the situation in which they find themselves. It may also involve assuring parents that they are doing the right thing. In cases like these, talking to a counselor can be as helpful for the parent as it is for the child!

If you have answered these four questions and think you need professional help for your child, finding a therapist is your next challenge. Whatever you do, don't use the phone book. Ask for referrals from people you trust. Like any profession, there are good counselors and bad ones and I would never trust my child with someone I looked up in the yellow pages.

You will want a counselor who is licensed and who specializes with children the age of your child. You will also want one who specializes, or at least has experience, in working with children who have the same presenting issues as your child. I'll address ideas for finding a therapist more in the next column, but answer to the four questions in this article can help you decide if your child needs to see a therapist at all.

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