The Intake

Aah, the intake.  What is the intake? Well, it’s like an interrogation of sorts, and, if you have a suspected bipolar child, a child with schizotypal symptoms, a bipolar child with psychotic features, or a child who is clearly in need of some kind of stabilization, prepare yourself.  The intake experience can be a rough ride, and not the good kind.

So far, I’ve done at least ten intakes, and each one has had a different flavor thanks to the practitioner asking the questions as well as the context of the intake.  If you’re in an emergency setting in a crisis, then your intake will most likely be different than if a social worker from the county is at your house doing an intake so that you can receive services.  What sorts of questions will you be asked? The easy ones usually come first.  Your child’s age, date of birth, gender, their name, their grade, the name of their school, and where they are in the birth order of their siblings.  Are you the legal guardian, are there any custodial or legal issues pending?  There are other questions, too.  Is your child pregnant, sexually active, or gay?  Is s/he currently engaged in a relationship with a girlfriend or a boyfriend? They will ask this of a 9 year-old child so be prepared to feel shocked at the notion of your little child having sex with another 9 year-old and getting pregnant.  It happens.  So, they ask.  They will ask about any pertinent health conditions and any STIs your child might have.  In the intakes I do now, I play those cards for them in a very polite manner:

“Grace is not involved in any relationships with anyone–gay or straight.  She is not pregnant.  She has never been pregnant.  She has never had an STI.  She is not currently and has never been sexually active.  She has never been sexually abused.”

I have found that the clinician expresses relief because they don’t relish asking those questions of an 11 year-old, but they must.  In some cases, it’s relevant, and it’s always important.

Next, we move on to current family climate.  Have there been any recent changes like a divorce, a significant loss, a job change, or the like?  Has the child been abused? Is there any trauma in the child’s past or on-going traumatic situations? This is important because if a child is exhibiting psychotic features, then that’s often due to trauma.  Know this.  They will be assessing you the entire time.  Your mannerisms, your language, how you speak, what you say, your affect, and your tone.  What you say and what you don’t say can discredit you or help you.  It’s part of the intake process whether we like it or not.

Next up, your family history.  You might have a very “clean” family history–no Axis I or Axis II disorders (refer to The Lingo).  Family history, however, is exceedingly important when a clinician is assessing for Bipolar Disorder or schizotypal disorders in general because they are rare and tend to run in families.  Sifting through the family history is almost as important as the presenting behavior of the child when it comes to getting a solid diagnosis.  The current medical establishment is very reluctant to consider a Bipolar Disorder diagnosis for a young child especially if there is no family history.  Bipolar Disorder-NOS has been overly diagnosed in recent years, and clinicians have now become overly cautious in their diagnostic practices to the exclusion of those children who are truly bipolar.  Sad, but true.  So, be prepared to air out your family’s dirty laundry.  All of it.

Can it be a humiliating process? That depends upon the person doing the intake.  It can be a very positive and affirming experience if you have a compassionate and respectful practitioner.  It can also be a very victimizing and shaming experiencing rife with judgment if the clinician is unkind and suspicious.  I’ve had both experiences because I have a very “colorful” family history, and my own history is less than ideal.  Mental illness runs in my family.  Inevitably, I have been asked, “So, what are YOU being treated for?” My answer? “I am not being treated for anything relevant to my daughter’s condition.  I’m healthy.”  I’ve finally learned what to say…after a lot of intakes.  If you have any abuse in your past and you are private and reticent to share, then I’ll be blunt with you.  You must get over it.  Learn to speak, share, and open up about your family’s past and present because it might make the difference between an accurate diagnosis and your child falling through the cracks of an overly burdened mental healthcare system.

Of course, the most important part of the intake is accurately describing your child’s behaviors and state of mind.  If you’ve been keeping mood charts, writing details down, recording statements your child has made, then now is the time to share this with the clinician.  If you have not been doing those things, then start doing it.

You will be asked a range of questions:

  • When did you begin noticing these behaviors? (If your child is schizotypal (having psychotic features) in nature, then s/he may have always been “that way” before the mood disorder emerged.  That’s extremely important to note.)
  • How would you characterize your child before your child started behaving this way? (They are looking for a baseline to compare presenting and emerging behaviors to.)
  • Discuss the nature of the behaviors that you see.  (Now is the time to discuss mood.  Is your child hypomanic? When? For how long? Does your child behave in a certain way BEFORE the hypomania–i.e. headaches, flat affect, confusion, is there an intermittent moodiness that precedes the mood shift from depression before the hypomania/mania, Is your child depressed? Characterize that depression.  Be as specific as possible.  Things that might seem inconsequential to you can be very significant to a clinician.)
  • Has your child been in therapy?
  • Is your child receiving any services or on an IEP?

Bring all of your documentation with you to every intake.  I carry an accordion folder with all appropriate paperwork, particularly paperwork related to diagnoses and treatment plans, with me to every meeting I attend–even when I go to the ER.  You’ll never know what’s needed.  The good news is that once you’ve been to the ER (and you will if you’ve got a kid with an Axis I disorder), your second visit goes much more quickly because your first intake is already on file with the hospital.  They know us on sight at our local Behavioral Health Emergency Room.  We were just there a few days ago when Grace stabbed herself with a fork.  We know our way around quite well now.

The most necessary component of the intake is a sense of humor.  You must maintain your sense of humor, or you will crack.  There’s a reason I’ve done over ten intakes within 5 months.  My child is enormously unstable and currently exhibiting emerging schizotypal features.  I was told today that I need to remove all sharps from my kitchen and switch to plastic spoons and forks–no knives.  I have a safety plan on my fridge.  If I don’t find humor in this…somewhere…I’ll lose it.

This is why Nadia, the therapist on duty at the ER, winked at me when we brought Grace in for evaluation on Friday night–“Long time, no see!” she shouted as the security guard ushered us in.  She had done our original intake when Grace was hospitalized for five days in August.  There are allies to be found in the strangest of places, and a familiar face in the middle of a crisis looks like an angel to me.  Those Behavioral Health ER security guards, who used to look like mean bouncers, now look like huggable bears.  I recognize them on sight and smile at ’em.

The best part about the intake is that you learn to speak up and advocate not only for your child but for yourself.  You learn how to operate with eloquence under pressure, and, aside from wartime, how much more pressure will you know? Try speaking succinctly after just watching your child pull out her hair and stab herself while screaming that three men are chasing her with guns.

“Tell me about your family history and your daughter’s behavior.”

You also learn the true meaning of stress.  My definition of stress is quickly changing.  Traffic? A bounced check? Bad hair? An autistic meltdown? Meh.  I could be at the ER doing another intake.  There’s a lot to be learned from the intake process.  Each one is different.  You’ll walk away from each one knowing your child a little better, feeling more confident, and knowing your own boundaries better, too.  You’ll have a better sense of how to read a clinician and their bedside manner, how to tailor your speech to meet that bedside manner, and how to advocate most effectively to get the needs of your child met.  And, isn’t that what you’re doing that intake for in the first place?

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