“Marie” had been helping her 10-year-old navigate an escalating pattern of acting out against himself and his family when things came to a head in one of his therapy sessions. He threatened to hurt himself, and “the provider advised us to take him to the emergency room,” says Marie, a 50-year-old writer in Pennsylvania who asked that we use a pseudonym to protect her son’s privacy.
It was the right call. Marie’s son ended up staying in the hospital for a week and then being discharged with a detailed plan for ongoing mental health care. Five years later, Marie says her son is doing well. In hindsight, she thinks she should have reached out for help sooner, and she wants to help other parents avoid making that mistake.
I talked with Marie and two experts in the field of child and adolescent mental health to put together a guide to help you know when and how to support a child who is struggling.
“The main thing to look for is any dramatic change in behavior or your child’s expressed affect,” says John Duffy, a clinical psychologist in the Chicago area who specializes in tweens, teens and families and is the author of Parenting The New Teen in the Age of Anxiety. Some things to watch out for:
- Spending more time in their room than usual
- Hanging out with a completely new set of friends
- Grades that plummet or skyrocket (the latter could be signs of perfectionism)
- Increased moodiness
- Less communication
- Eating or sleeping a lot more or a lot less than usual
“You know your child best; trust your gut,” says Katie Hurley, a licensed clinical social worker, who works with kids and teens in Los Angeles and is the author of The Depression Workbook for Teens. “What is your child or teen’s baseline? If you see those patterns changing, err on the side of caution. It’s better to give your child a support system than wait it out.”
In 25 years, Duffy says, she has never worked with a family that erred on the side of caution, pursued a psychological evaluation, and regretted it.
During a psychological evaluation, a trained mental health professional will meet with your child and assess their psychological strengths and challenges.
“It typically consists of interviews, tests and questionnaires,” Duffy says. A provider might conduct it all in one session, but Duffy prefers to meet several times. Once it is completed, you should receive a write up of the results along with any recommended treatment plan, which could include psychotherapy, medication or a combination of the two.
If you know of—or have a relationship with—a therapist, Duffy suggests starting there. Ask them to recommend therapists who specialize in evaluation work. If you don’t know any therapists, “school counselors and advisors tend to know people in the area,” Duffy says. “I always encourage parents to talk to them. They will have names and numbers and people they prefer over others.”
Hurley suggests reaching out to your parent network or pediatrician. If your school district does not have counseling services and you strike out with friends, check your county or municipality’s website for their behavioral health resources.
“A lot of places have community mental health centers staffed with licensed clinical social workers where you can get in for an evaluation,” Hurley says.
You or your teen can also call crisis hotlines where someone will listen to you confidentially and connect you with local support. If all else fails, reach out directly to a psychiatric hospital or hospital that has a psychiatric unit—even better if they have one specifically for children and teens.
“They will have resources at the ready,” Duffy says.
Make it part of a bigger conversation about the importance of mental health in general. Duffy recommends telling your child, “our job as your parents is to make sure you are healthy in every way. That’s why we encourage you to get exercise, and to go to school, and that’s why we bring you to the doctor. If you are having a hard time emotionally, we are responsible for that, too. This is just part of taking care of you.”
You can explain that you are doing the evaluation to figure out what their strengths are and whether they might benefit from help. Duffy’s suggested wording: “This is not about what’s wrong with you, but more about what’s working well and areas where the grown-ups around you can help make it better for you.”
Your child may actually tell you they are in crisis, Duffy says.
“This happens more and more these days, because kids know what anxiety is, they know what depression is, and they know what suicidal ideation is,” he says.
If your kid is telling you they are in trouble, listen and take action. Other signs that require emergency medical attention:
- Any suicidal ideation (evidence that your child is thinking about suicide), which can include comments, notes, and posts on social media.
- If your child is showing any violent inclination toward themselves or someone else, including talking about it.
- Evidence of self-harm, such as cutting. Kids may cut on their arms, but they also may choose places that are easily covered by clothing, such as the legs or back.
- Your child is clearly struggling but refuses to talk to you at all.
- Dramatic shifts in behavior that are negative.
“Call 911 right away,” Duffy says. “Don’t even wait to hear from their therapist if they have one, because it is a matter of immediate health and safety. I’ve worked with parents who have lost kids or whose kids have done dramatic harm to themselves, and that is devastating.”
Hurley warns parents not to sleep on any serious concerns. “That’s not a risk that anybody should be willing to take,” she says.
“There are definitely points where parents tend to say, ‘Oh, it’s nothing,’” Marie says. “We tend to minimize our children’s mental health issues, because we place the blame on ourselves.” But Hurley points out that it is well understood now that “we are in the midst of a mental health crisis in our country and you are not going to be judged.”
Duffy helps parents work through stigma by framing your actions as being the best parenting you can do in this situation.
“I’m using all of the tools at my disposal to make sure that my child is emotionally well and healthy,” he says. “I’m going to turn to the experts because this is not my field of expertise, and I don’t want my child to suffer.”
It’s helpful, he adds, to think of this as no different than seeing an endocrinologist to help a child who has diabetes.
“What you will find—if you are willing to talk about your experience a little bit—is a lot more people saying, ‘Yeah, this is happening with my kid, too,’” Duffy says. “I am finding that people are being more and more open about it, and they are finding way more community support when they are open about it.”
If you have a child who is currently receiving mental health care or seems to be struggling, Marie recommends doing some homework so you are prepared to help them if an emergency arises.
“Just like if my child has a broken arm, I know I take them to the emergency room and get them a cast,” Marie says. “If my child starts saying they want to die or they want me to die, who do I call?”
If you think your child may need mental health services at some point, Marie recommends putting together a toolkit by researching the laws in your state and knowing what will happen if your child gets evaluated or admitted. A good place to start is your city or county behavioral health department.
“In Pennsylvania—and I think a lot of states have similar things—there are specific mental health diagnoses for children that qualify them for medical assistance and programs that are supportive for families and paid for by medical assistance,” Marie says. “The application process can be onerous and confusing, and that’s where advocates, non-profits and regulatory agencies come in handy. You may be entitled to some benefits that can make your life easier for the time that you are dealing with it.”
When parents are unsure about what hospitalization might mean for their child, Duffy encourages them to reach out to a psychiatric hospital and discuss possible incidents. You don’t have to give your name, just ask what would merit hospitalization and what would happen if you brought your child in. Ask whether you would have access to your child or whether they could release themselves, depending on their age. You can also talk these scenarios through with your child’s therapist, who should be well-versed in the laws of your state.
“There is no situation in which you are powerless,” Duffy says. “In my experience with the psychiatric community, their goal is not to strip you of your power; their goal is to release a child who is healthy and ready to be released from their care.”
If your child is hospitalized for a psychiatric emergency, they should not be discharged without a detailed plan for the ongoing care they will receive.
“From an inpatient setting, a lot of young people often transition to an intensive outpatient setting (IOP) or a partial hospitalization program (PHP), where they receive daily care in a structured setting,” says Duffy. “If that is not an option or the care team doesn’t think it is necessary, ongoing care will probably include regular visits with a psychotherapist and/or psychiatrist.
“If you are not offered a plan going forward, you should demand it,” says Marie. For her family, her son’s continuing care included short-term medication, as well as therapy for the whole family.
A follow-up plan should also include communication with your kids’ school, says Cheryl Eskin, a marriage and family therapist and programming director of Teen Line in L.A. That way, professionals at the school can help your child if they need to take a mental health break in the middle of the day and so they can also be on the lookout for any signs of concern.
“After a few months of the family therapy, things started looking up,” Marie says. Within the first year, she began to feel hope that her son’s condition would improve. Now, five years out, life is more or less back to normal for the family. And she takes great comfort in knowing that “intervening in that crisis situation was the best thing to do, because he needed support that I was not able to give him.”
The National Suicide Prevention Lifeline (1-800-273-8255) answers calls 24/7, is confidential and can connect you and your family to local, professional support.
There are several hotlines nationwide staffed by teens who are trained in peer support. One of the biggest is Teen Line. Others include Safe Place, The Trevor Project, which supports LGBTQ youth in mental health crisis, and the Jed Foundation.
Mental Health First Aid is a program that trains adults and kids 12 and older about how to recognize when someone is in a mental health crisis and get them help.
The QPR Institute offers a technique to draw someone out who is expressing suicidal thoughts.