▪ Classification and Assessment

PRINCIPLES OF CLASSIFICATION

Classification helps us be better observers and formulate hypotheses and principles. Shared approaches to classification help us communicate more effectively and develop better theories. In psychiatry, and indeed in medicine in general, the process of giving a label may be associated with some sense of relief on the part of the patient or the patient’s parents; unfortunately, this often reflects a mistaken belief that having a label implies having an explanation. Like all human constructions, classification schemes can be abused or ill-used. There is no single “right” way to classify disorders in childhood. Systems vary, depending on the purpose of classification and what is being classified. Official diagnostic systems, such as the World Health Organization’s International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV-TR), are generally categorically oriented, but dimensional approaches can be quite useful as well for clinical purposes. To be useful, classification schemes must be used readily and reliably, must provide adequate descriptions of disorders (so they can be reliability differentiated from each other), and must be useful across the range of age and severity. Deviant behavior itself does not necessarily constitute a disorder unless it is a manifestation of dysfunction within the individual person (e.g., conflicts over political beliefs do not constitute a mental disorder). Although it is often assumed that mental disorders must have a biological basis, this need not be the case; for example, maladaptive, enduring personality patterns can readily be classified as disorders. As with any classification, the approach chosen inevitably involves certain tradeoffs. Whereas the ICD-10 approach provides separate guidelines for research and clinical work, the DSM-IV approach provides one set of guidelines for both purposes.

Models of Classification

Various approaches to classification can be used (Table 3.1), These are not necessarily incompatible with each other. For example, a continuous variable such as IQ or blood pressure can be used to define levels of severity (e.g., of mental retardation) or disorder (hypertension).

The issue of which model works best depends on the specific situation. For example, structured rating scales and diagnostic interviews have been developed for many disorders. In addition a series of well-designed, psychometrically sound structured interviews “keyed” to
DSM-IV diagnostic concepts has been developed; these are particularly use for epidemiologic studies and screening purposes (see Angold, Costello, & Egger, 2007) for a review. Another approach has focused on more global assessments of psychopathology with derivation of more basic “factors” (e.g., internalizing vs. externalizing disorders on the Child Behavior Checklist; Achenbach, 1991). Such instruments have both research and clinical utility and may have importance for screening but do not usually translate straightforwardly into DSM-type diagnoses. As discussed later, there are major issues depending on the nature of the instrument and the informant—parents, teachers, peers, and the children themselves can, and often do, exhibit sometimes radically different perspectives.

TABLE 3.1 APPROACHES TO CLASSIFICATION

Categorical approaches

Presence or absence of disorder Examples: autism, appendicitis

Dimensional approaches

Assess dimensions of function or dysfunction

Examples: intelligence, hypertension

Ideographic approaches

Focus on the individual person

Examples: individualized education plan

Developmental issues are of great importance in classifying disorders in children and adolescents (and occasionally adults). Disorders such as autism and mental retardation have their origin during specific times of development, and other disorders, such as Tourette’s disorder, may be preceded by other developmental problems. In other cases, preexisting disorders may complicate the diagnosis of other conditions (e.g., a child with mental retardation who goes on to develop schizophrenia in adolescence). For some conditions, diagnostic guidelines have a strong developmental orientation, but for others, the deviant nature of the symptoms predominates.

Theoretically based classification systems tended to be more common in the past. For example, Anna Freud had a model of classification based on her psychoanalytically informed understanding of child development. Theoretically based classification systems tend to be most useful for clinicians working with that specific theoretical framework; they may be much less useful for clinicians who do not share the same orientation. For several decades, the official classification systems have focused less on such theories and more on a theoretical, phonologically based approach. The latter approach is based on clinical experience, and concepts derived in this way have proven enduring even when the theory they originally were based on proved wrong (e.g., Langdon Down provided an enduring description of the condition we now understand is caused by trisomy of chromosome 21, but his original theory for this, which was based on racial stereotypes, did not).

It is often assumed that classification systems are developed to approximate some ideal diagnostic system in which the cause could be directly related to clinical condition. This is not, in fact, the case, in that no single ideal system is waiting to be discovered and that cause need not be included in classification systems. Different etiologic factors may result in rather similar conditions, and the same etiologic factor may be associated with a range of clinical conditions. Aspects of intervention may be more directly related to the clinical condition than to the cause. Remedial services for children with mental retardation are, for example, much more likely to be oriented around aspects of developmental level than around the precise origin of the specific mental retardation syndrome. With a few exceptions (e.g., reactive attachment or posttraumatic stress disorders in the DSM-IV), etiologic factors are not generally included in official diagnostic systems.

Clearly, contextual factors are particularly important in understanding childhood psychopathology. Thus, variables such as family, school, or cultural setting can serve as major modifiers of clinical presentation. For example, a child who had attentional difficulties because of an inappropriate school placement should not have a diagnosis of attention-deficit disorder. Contextual variables are particularly problematic in disorders of infancy and early childhood in which child and parent variables often interact with each other. Cultural differences may also be important and may interact in complex ways with child vulnerability and family variables.

Finally, it is important to emphasize that disorders, not children, are classified. This may seem a subtle point, but it is not. There are potential negative effects (and positive ones) related to labeling. Clearly, it is children, and not labels, who need help, and it is not appropriate to equate people with their problems (e.g., the use of the word “autistics” to describe children with autism is just as inappropriate as would be the term “pneumatics” to refer to individuals with pneumonia). Labels can have some social stigma or other untoward effects or may be associated with more realistic expectations on the part of parents and teachers and provision of potentially more appropriate services.

Research Issues

As official classification systems have become more complex and sophisticated, issues of reliability and validity have assumed increasing importance. For example, both the DSM-IV and the ICD-10 use results of large national or international field trials in providing definitions of disorders. Categorical and dimensional approaches to classification share certain statistical concerns including validity and reliability. Validity refers to the extent to which the diagnostic category captures the phenomena it purports to (e.g., does the diagnostic category have some meaning relative to course and treatment or family history or associated conditions?). Reliability refers to the ability of different individuals to use the diagnostic approach in the same way. As with validity, various kinds of reliability are identified, and these are impacted by various factors such as the theoretical bias of the clinician. In providing diagnostic criteria and descriptions, there is often a trade-off between the level of detail of a definition and its reliability.

Various statistical methods can be used to study patterns of relationships among specific variables or symptoms and syndrome (e.g., studies that use checklists or behavioral reports can use such techniques in an attempt to evaluate clinical groupings). These methods are most useful for the more common disorders. Such approaches can be used to evaluate the stability of specific dimensions or profiles, and use of dimensional techniques of assessment can be helpful in this regard.

Multiaxial Classification and Comorbidity

In working with children, the ability to use a multiaxial approach is very helpful. This can help clinicians be aware of many areas relevant to diagnosis. Thus, putting developmental disorders on a separate axis is intended to remind clinicians to look for such disorders on a regular basis. On the other hand, the distinction of what disorders are “developmental” can be problematic. Enuresis, for example, has strong developmental correlates but is generally included as a psychiatric rather than a developmental disorder.

One of the major benefits of a multiaxial system is that certain conditions are particularly likely to be overlooked (e.g., the child with a conduct disorder who also has learning problems). The presence of multiple disorders does, however, raise another problem—that of comorbidity. Having one problem may increase the risk for other difficulties. Particularly in the area of intellectual disability, there has often been a tendency to underestimate the presence of other problems. This difficulty, known as diagnostic overshadowing, can be very problematic because rates of psychiatric problems of specific types in individuals with mild mental retardation may be four- to fivefold increased! There are significant differences in ways
in which diagnostic systems such as the DSM and ICD deal with comorbidity; on balance, the DSM tends to encourage multiple diagnoses, but the ICD system provides a single category for a child with what DSM might refer to as two conditions. The issue of comorbidity is a particularly complicated one for childhood-onset disorders given the importance of developmental factors and the potential for one condition or problem to contribute to others in complex ways. Potentially, an understanding of comorbidity might truly enrich our understanding of psychopathology; on the other hand, it can sometimes be trivial. For example, a child with autism should not receive an additional diagnosis of stereotypy-habit disorder because stereotyped movements are a diagnostic feature of autism. On the other hand, conduct disorder with depression does appear to be a more frequent and relevant combination with its own specific ICD code.

In summary, classification in child and adolescent psychiatry has multiple meanings and functions. Complications for classification of child and adolescent disorders are myriad: The child is often not the person complaining, different kinds of data may be used in making a diagnosis, developmental factors may have a major impact on the expression of disorders, and certain features (e.g., beliefs in fantasy figures) are normative at certain ages but not at others. Additional complications are posed by the unintended, but no less real, uses to which diagnostic concepts are put, such as their inclusion in legislation and their use as mandates for services in educational programs or for purposes of insurance reimbursement for services. Different kinds and levels of classification are needed for different purposes. Advances in diagnosis and classification since 1980 have significantly advanced the field, but important work remains to be done. The ability, over the next decade, to identify more clearly endophenotypes or intermediate endophenotypes may advance the already impressive potential for relating genetic and neurobiological features to disorders.

ASSESSMENT

The child or adolescent should be evaluated in the context of her or his functioning within the family, school, peer, cultural, and community settings with a goal of identifying specific forms or psychopathology and developing an appropriate treatment plan if one is needed. Depending on the clinical situation, the examiner may need to prioritize areas for assessment and intervention (e.g., the presence of suicidal thoughts or psychotic symptoms suggests immediate intervention needs).

Occasionally, an assessment is needed for a very specific purpose (e.g., custody assessments or evaluation of psychiatric problems of a child hospitalized on a pediatric ward). More typically, the assessment process is much broader and less focused, which requires the examiner to take a broad view, taking into account presenting complaints (of child, parents, teachers, and others), the child’s history and level of development, and family and cultural factors.

There are several major ways in which the assessment of a child or adolescent differs from the psychiatric assessment of an adult. Typically, the child is not the person complaining of the problem; more typically, parents or sometimes schools have initiated a referral. The child may or may not be as troubled by the problem. Sometimes the problem arises more in the context of the family rather than in either child or parent. The assessment also depending on the child’s chronological age and developmental level (e.g., the approach to a preschool child will often involve play or games; a school-age child may prefer some combination or discussion and activities; and an interview of adolescent may be more like that of the adult, although even in this situation, there will be some differences).

It is important that the child understand, at whatever level he or she can, the purpose of the assessment and that, as appropriate, the clinician conduct interviews in a way designed to facilitate discussion. Unlike adults, children can function very differently depending on the setting. A child who is having real trouble sitting still in school may be well behaved and popular on the playground. As a result, it is typical that multiple sources provide information (e.g., child, parent(s), school, and others); consequently, a major task for the clinician becomes the reconciliation of views when they diverge. Also, as a result of this process, the clinician
needs to form a working relationship with multiple parties while maintaining, as appropriate, the child and family’s confidentiality. This process, just by itself, can be quite revealing about the nature and extent of the difficulties and development of a treatment plan. In contrast to interviews with adults, developmental issues can loom large either as presenting complaints (e.g., continued bedwetting, delayed speech) or as important considerations in the assessment itself (e.g., a child with autism who is not verbal). For younger, typically developing children, it is important that the clinician have an awareness of normative cognitive processes and common childhood fears, beliefs, and fantasies. In some instances, skills can be lost (e.g., a child who is hospitalized and begins to wet the bed again or an adolescent who becomes psychotic and whose self-care skills diminish).

A final set of problems arises from the limitations of current diagnostic approaches. The categories included with DSM or ICD were usually developed from work with adults. Developmental considerations have not always been given central importance. For some conditions, this makes little difference, but for others, it can be a major complication (e.g., there may be differences in how major depression is experienced in children, with more somatic complaints and less overt self-deprecation) As discussed earlier in this chapter, there are important and legitimate tensions around issues of syndrome boundaries, problems of comorbidity, and diagnostic overshadowing.

The assessment should, of course, be tailored to the circumstances of the individual case, but several key components should be considered (Table 3.2) with the aim of identifying the variables relevant to the child’s presentation.

Typically, the assessment begins with a review of the reasons for referral. This helps clarify the nature of the presenting problem(s), the “pool” of individuals relevant to contributing to the assessment process, and expectations (overt or covert) for what the assessment will provide. The history can be obtained from relevant persons and perspectives (e.g., child, parents, siblings, other family members, school personnel). The examiner should be alert to the context or circumstance in which problem behavior emerges. In some fundamental way, the examiner tries to assemble, and constantly revise, a narrative with first attention paid to the “facts” as they present themselves (the who, what, where, and when of the narrative) with an eventual formulation (the why). The clinician should be alert to important clues about what sets off or maintains problem behaviors. Problems can arise for many reasons, including psychiatric difficulties in the child but also because of some environmental circumstance. A history of previous treatment should be included if relevant. At some time, the examiner will also wish to obtain a developmental history to help clarify any potential developmental difficulties contributing to current problems and any long-standing issues that may shed light on current problems (e.g., the child’s temperament; see Chapter 2).

A review of the past history should put current problems in an historical context (e.g., is this a new problem, an exacerbation of an old one, or some new problem that arises in the context of some other difficulty?). As noted earlier in this chapter, this last issue, of comorbidity, presents particular challenges for diagnostic systems and clinicians alike. Children (and parents) typically have not studied the DSM-IV, and clinical presentations usually include a range of difficulties. Accordingly, an important part of the assessment reflects the clinician’s judgment, based on history and presentation, of how the presenting symptoms can be placed in a broader context. For example, although attentional problems are a hallmark of attentiondeficit disorder (Chapter 8), they can also be seen in children with anxiety, autism spectrum disorders, stress, depression, or bipolar disorder or may arise because of some environmental factor (e.g., a child placed in an inappropriate classroom setting).

The medical history should include attention to the pregnancy, labor, and delivery. Sometimes parental expectations of the child even before birth may be relevant. Complications during delivery or the neonatal period should be noted as should any relevant medical conditions, hospitalizations, surgeries, and so forth. Response to medications and allergies to medications should be elicited. The clinician should be alert to any factors in the history that might contribute to current difficulties (e.g., a mother who drank during the pregnancy, putting the child at risk for fetal alcohol syndrome or a child with a history of significant prematurity who might be at risk for learning difficulties). Any sensory vulnerabilities should be noted (e.g., a child
with recurrent ear infections who might present with language delay). The medical history should include a review of any significant accidents or injuries and any potential sequelae.

TABLE 3.2 CONTENT COMPONENTS OF THE PSYCHIATRIC ASSESSMENT OF CHILDREN AND ADOLESCENTS

Content Component	Primary Informant	Additional Resources
Reason for referral	Usually parent or guardian; sometimes school or legal agency	Letter from school or other agency seeking evaluation
History of problem(s)	Child and parent	Referral source; contact from primary care provider
Past problems	Child and parent	Structured interviews; screening scales
Comorbid symptoms	Child and parent	Structured interviews; screening scales
Substance use	Child, parent	Laboratory screening (as relevant)
Previous assessment or treatment(s)	Child, parent, clinicians	Mental health records
Child’s development, including psychomotor, cognitive, interpersonal, emotional, moral, trauma, harm (to self and others)	Parents, school staff	School records, including special education evaluations; home video (as relevant)
Family history	Parent	Genogram
Medical history	Parent, health care provider(s)	Review of symptoms checklist; laboratory tests (as relevant)
Child’s strengths	Parent, child, teachers, coaches, peers	Activity video (e.g., sports, music); cognitive, school, neuropsychological testing
Child’s media diet	Parent, child, caregivers, siblings	Media diary; “Tivo” records; DVD or CD collections; magazine subscriptions
Environmental supports	Parent, child, adults familiar to child	Activity schedules (scouting, teams); after-school or summer programs; mentorships such as Big Brother or Big Sister relationships
Mental status exam	Child	Mini-Mental Status Examination
Reprinted with permission from Bostic, J., & King, R. A. (2007). Clinical assessment of children and adolescents: Content and structure. In A. Martin & F. Volkmar (Eds.), Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th edition, pp. 324 . Philadelphia: Lippincott Williams & Wilkins.

Family history should include a review of the parents’ own histories of developmental or psychiatric problems, parenting styles, marital style, and methods for conflict resolution. Relevant cultural, ethnic, religious, or other information should be noted. Recent, or enduring, stresses and, for that matter, supports should be noted. Family moves can be disruptive of peer relationships and stressful for parents and children alike. Sometimes the death of a familiar figure (e.g., a grandparent) significantly changes child care patterns. If parents are divorced or if there has been chronic or sporadic marital conflict, it is important that the examiner
attend to parental perceptions of how these have impacted the child. If a child is adopted, the history, to the extent available, of the child before the adoption is relevant. The child’s understanding of the adoption should also be obtained. The clinician should be clear about the family constellation and inquire about other individuals present. A genogram can be helpful in this process.

Depending on the child’s age and level of maturity, other issues may merit review. If the child is approaching adolescence or if adolescence is already well established, it is important to inquire about pubertal development. In some situations (e.g., feeding or eating problems), measures of height and weight can be very relevant. The child’s use or exposure to alcohol, cigarettes, or illegal substances should also be reviewed. Media-related issues (broadly defined) may also be worth exploration (e.g., how does the child spend his or her time? What is the level of supervision?). The identification of favorite activities can also help inform the clinical interview with the child (e.g., by giving the examiner some obvious places to begin a discussion).

It is helpful for clinicians to have a general conceptual model to follow during the assessment. This aids both the assessment process itself and the written summary that should follow. It is important that the child or adolescent (and family members) understand exactly what is involved in a psychiatric assessment. Unlike a usual office visit to the pediatrician, a visit to a psychiatrist or other mental health professional is fraught with psychological “baggage” that may interfere with the assessment process. Accordingly, clarity and transparency on the part of the interviewer can be extremely helpful.

Often, parents may come for an initial interview without the child. This allows for both a review of the presenting problem and child’s history and a chance for parents to convey their own concerns, expectations, and misconceptions. It can also provide an opportunity for talking with the parents about exactly what they will tell their child before she or he comes to the assessment.

The child may have major misconceptions about what is involved in speaking with a psychiatrist. She may worry that the parents are going to hospitalize her or send her away or that the assessment is a form of punishment. The child may be burdened with some secret—or not so secret—fear. It is helpful if parents can openly discuss their hopes for the meeting and indicate, if it is appropriate, what they know about what will happen and who the child will see. Depending on the context, other family members (siblings, parents) or child care workers (day care providers) or teachers and school personnel may be involved and may have their own, sometimes major, misconceptions about what will take place and what can be accomplished.

For younger children, information from the parents (e.g., about the child’s favorite activities, TV shows, or games) may serve as an “ice breaker” for the clinician. Any special needs of the child should be discussed along with confidentiality issues.

Often, the initial parent interview focuses both on the question of how (did we get here?) but also of “Why now?” Parents should be helped to elaborate, in their own words, their understanding of how the child’s difficulties have evolved over time. If there are major differences in perception (e.g., between the mother and father or between a parent and teacher), it is important that everyone have a chance to voice their own perspectives.

In addition to areas of weakness or vulnerability, the clinician should be alert to areas of strength and potential resources for the child. The latter may take the form of people who have special relationships with the child. Similarly, cultural or social resources should be noted (e.g., the presence of a supportive religious or ethnic community can be very relevant).

A host of factors can complicate the valuation process. These can include problems in the parents (e.g., highly divergent expectations or perspectives on the problem). Sometimes, sadly, often in custody situations, the child can become a “target” of parental struggle. As with the child, the specific developmental and personality issues of the parents may color the assessment process.

The clinician should be very sensitive to the potential for parents to feel embarrassed or ashamed (i.e., that they have failed in some way because their child has some problem or need). The clinician should be actively listening to parental concerns and to how these concerns are colored by the parents’ own history. Some important aspects of the topics for parent and child interviewing are summarized in Appendix 1.

The Mental Status Examination

The mental status examination (MSE) is a key component of the assessment. It gives a perspective based on direct interaction as to how the child presents him- or herself. The MSE should be informative and descriptive. The MSE should include a description of how the child presents him- or herself (well organized, tidy, or studiously the reverse). How easy is it to engage the child? How cooperative is she or he? How does she act and interact with the clinician? What is her or his speech like? Are there concerns about mood or thought process disturbance? Although usually written up as a separate section from this history, the MSE is usually highly dependent on observations made throughout the assessment. Some aspects of the MSE require specific inquiry (orientation, memory, fund of knowledge, and so forth), but others can be collected continuously throughout the assessment. Table 3.3 provides an overview of components of the MSE. Depending on the results of initial examination, other assessments (e.g., of cognition, speech-communication functioning, academic skills, or learning problems) may require specific investigation.

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