Who initiated this referral, their motivations, and what changes they seek is vital. Expectations of various parties may collide and must be reconciled for effective treatments to be implemented. For example, the school may seek changes in parental discipline, while parents may expect the evaluation to yield additional school services.

Parents often experience intense pain while recounting the deterioration or anguish of their child. Clinicians should provide parents an opportunity to describe the evolution of the problem, attending to the context in which symptoms emerged and occur, changes in frequency and intensity of symptoms, and their current progression. The clinician should inquire directly about the functions of problem behaviours, including secondary gains (e.g. tantrums diminish chore requirements, etc.). The clinician should clarify whether symptoms are specific to one functional domain or whether they pervade multiple areas of the child’s functioning at home, school, and with peers.

Significant past symptoms impairing the child should be identified. It is especially important to understand whether symptoms have been persistent since early childhood, are intermittent, or represent deterioration from a previously better level of functioning.

Clinicians should inquire about disorders often seen in tandem. For example, bipolar disorder in children is often associated with previous attention deficit hyperactivity disorder.⁽³⁾ Screening instruments (such as those selectively available free of cost at websites such as www.schoolpsychiatry.org) can be useful to provide comprehensive information about less conspicuous symptoms.

Clinicians should inquire about the child’s exposure to and use of tobacco, alcohol, and illicit substances. Children may perceive that substances alleviate their distress (e.g. anxiety, depression) and ‘self-medicate.’ Clarifying impacts of substances on symptoms may yield intervention points attractive to the child.

Chronological assessment of past treatments may reveal strategies adaptable to the current problem. Past treatment history may suggest treatment modalities (in)tolerable to this patient (and family). Medication trials, counselling, hospitalizations, or alternative treatments should be explored.

Parents may vary in their recollection of their child’s attainment of developmental milestones. Review of earlier videotapes of the child may improve the reliability and completeness of reports regarding the sequence of the child’s growth.

The child’s development regulating sleep, eating, and toileting should be investigated. Attained skills may suddenly be lost, sometimes signalling the importance of emotional events at particular times. Eating behaviour has become complicated as both hunger and obesity increase risks of psychopathology.^(4,5)

Psychomotor development includes standing, walking, running, throwing, hopping, and playing sports or musical instruments. How the child fares at sports may clarify psychomotor skills. Fine motor and gross motor skills may not be congruent.

Cognitive development refers to the child’s acquisition of thinking skills. Specific inquiry concerning speech development, reading, writing, and math skill progression may reveal global or specific difficulties.

Interpersonal development refers to how the child interacts with others, particularly family members and other children and adults.
Stability of relationships, numbers of friends, types of activities shared, and expectations of peers often reveal sources of difficulty or maladaptive patterns.

Emotional development and temperament reveal the child’s capacity to recognize his or her own mood state and to self-soothe or regulate negative affect. Prevailing moods can be described by parents, who may also detail past suicidality, irritability, specific fears and anxieties, and conditions associated with the child’s happiness and pleasure.

The child’s moral development indicates whether conscience or moral values are too lax, too harsh, overly focused on particular areas, or uneven and out of proportion to daily events. The child’s ability to recognize impacts of decisions on others, and to acknowledge and correct mistakes provides clarity about the child’s strengths and limitations. The child’s religious and cultural/ethical views and practices also shape this area, and may guide treatment interventions.

Trauma may impact or even arrest development. Investigation of actual events (such as documented abuse), but also of events perceived traumatic by the child and family may shed important light on the child’s behaviours and patterns of relating to others. Events surrounding the trauma, disclosures to others, and reactions of adults are also important for the clinician to recognize and address.

Harmful behaviour, towards self or others, may reveal important developmental progressions that warrant intervention. Head-banging may reveal sensory disturbances, thoughts or comments about death may reveal suicidality, and self-harmful acts such as self-mutilation or cutting may reveal primitive coping mechanisms.⁽⁶⁾ Harmful acts towards animals or people may indicate needs for monitoring while other diagnostic or treatment interventions occur.

Few psychiatric disorders appear transmitted exclusively genetically. Many parents fear that their other child may be destined to suffer psychopathology when a family member manifests a disorder, so clarification of contributions to expression of disorders can reduce unwarranted fear, guilt, and distress. Please refer to Chapter 6.3.8 for more information on assessment of family functioning.

Divorce, separation, and single-parent family circumstances may stress all family members. Even when parents part amicably, children may attempt to reunite family members. Children may exhibit symptoms even years after separations as they enter different developmental phases.⁽⁷⁾

Adoption may be a positive event for the child, and adoption warrant tactful attention by the clinician, including age at adoption of the child and biological parents, the involvement with biological parents, the child’s understanding of the adoption, and how the adoption is discussed at home.

Pregnancy complications, birth difficulties, hospital stays, and medical illnesses requiring treatments (e.g. asthma, diabetes) should be investigated, as they increase the child’s risk for psychopathology.⁽⁸⁾ Inquiry into emergency room visits or surgeries can shed light on the child’s fears, or parental over/underprotectiveness. Allergies should be ascertained, as well as responses or side effects to medications, including naturopathic or homeopathic agents.

Interests, hobbies, and talents of the child should be obtained from the child and parents. Parents may have aspirations the child does not share, or the child may have fantasies beyond apparent abilities. In most cases, though, the child will have some identifiable interests or abilities that serve as potential points of connection with peers and adults (including clinicians).

Children are exposed to television, music, videos, electronic games, cell phones, e-mail and instant messaging, personal digital assistants, etc. It is important to clarify which media the child uses, how much time each day is spent with these various media, and what consequences these media have on the child (e.g. in response to watching action TV show the child becomes more violent versus has developed interest in Asian food through watching cooking programmes).⁽⁹⁾ The degree of parental awareness and appropriate limit-setting regarding TV, video games, and instant messaging may warrant intervention.