Clinical Assessment of Children and Adolescents: Content and Structure

Jeff Q. Bostic M.D.

Robert A. King M.D

The goal of the clinical psychiatric assessment of a child or adolescent is to identify the presence of psychopathology and to guide the planning of appropriate interventions, if indicated (1). The child (except as noted in identified sections, “child” will refer to “child and adolescent”) is evaluated in the context of his or her functioning in the family, the school, and with peers, with sensitivity to cultural or community influences. The clinical assessment seeks to detect any developmental aberrations and maladaptive psychodynamic patterns, while casting a wide net to identify the patient’s miscellaneous symptoms, as well as protective and resilience factors that may affect treatment outcomes. Many symptom constellations will respond to established treatments, so the clinician must prioritize intervention targets to devise a treatment plan that will address multiple problems, including comorbid disorders (2). A thoughtfully conducted interview provides the clinician with sufficient information to identify not only intervention targets, but those relevant environmental variables, such as family or school factors, which will influence adherence to any treatment efforts.

The purposes of clinical assessment of the child or adolescent vary, and outcome is often contingent on the alignment among the family’s, child’s, and clinician’s acknowledged goals in pursuing a given assessment. The most common purposes of psychiatric assessment are: 1) to determine if psychopathology is present, and if so, to establish target symptom priorities; 2) to determine what treatments, if any, might address the target symptoms; 3) to evaluate with the family and patient the relative benefits and risks of any proposed treatment. A given clinician’s assessment of a child or adolescent may focus on any (or all) stages of this process, such as clarification of diagnoses, or consultation regarding benefits or risks of treatment options. Less frequently, clinical assessment may occur for more circumscribed purposes, such as to determine safety issues or potential need for hospitalization; to consult regarding school placement or pedagogical interventions; to advise about custody decisions; to consult in a pediatric setting; to serve as a component of family or other modes of treatment; or for research purposes (3).

Distinctive Aspects of the Psychiatric Assessment of Children

The psychiatric assessment of the child differs from the assessment of adults in several respects. First, children rarely initiate psychiatric assessment or treatments themselves; rather, in most cases their parents or other adults provide the impetus for seeking treatment for the child. The child’s behavior may cause greater distress to these adults than it does to the child. In some situations, the adult’s expectations for the child may exceed the child’s abilities, or the adult’s own parenting or teaching style may be a poor fit with this child, yet these adults may seek means to alter the child to remedy this poor fit. On the other hand, children may not recognize their behaviors as problematic for others, or may not be receptive to changing these behaviors. Often these misbehaviors have “worked” by getting parents or teachers to avoid requesting the child to complete chores or tasks, or have culminated in others giving in to the child’s requests. Children also may attribute problems to others and be unable or unwilling to accept their personal contribution to an identified problem. The psychiatric assessment of children thus requires consideration of both adult and child contributions to the distressing behaviors for which evaluation is being sought. In addition, the assessment requires explicit attention to the child’s perceptions of the problems and what the child desires to change.

Second, the child and the clinician are at different developmental levels, such that they may essentially speak different languages. The school-age child may lack the maturity to abstract “patterns” from isolated events, while the adolescent may perceive the clinician’s questions as another inquisition resembling that of parents or school staff. Moreover, phase-specific developmental features may further impede communication. For example, young children may not trust unfamiliar adults, while adolescents may perceive the clinician as simply another adult imposing expectations or judgments.

Third, the child may function differently in different settings. The child may function relatively well in multiple domains (with family, at school or work, with peers), function poorly in only one domain, or may function poorly across multiple domains. This underlines the necessity of multiple informants (4), not only to discern accurately the child’s overall functioning, but also to identify the child’s areas of strength on which the clinician can build, and to identify others (peers or adults) effective with the child and potentially able to introduce or reinforce more adaptive skills or behaviors.

Fourth, the child’s presenting problems must be examined in a developmental context. The child may have a delay in skill development, such as delay in speaking or in areas of self-care, such as toileting. The child may not yet possess the skills necessary to interact appropriately with age-similar peers, and thus require interventions to introduce skills not yet present. The child’s problems may also emanate from an inability to select appropriate skills from an existing repertoire. A child with depression or anxiety may have the necessary skills, but not be able to apply them, causing distress. For example, a child may overgeneralize that all animals are dangerous, and fear going outside, or an adolescent may stalk or threaten a classmate when threatened with a breakup. Finally, the child’s problems may follow the loss of previously attained skills, often consequent to serious medical and psychiatric disorders, loss,
or trauma. For example, a medically hospitalized school-age child may transiently regress with immature behaviors or loss of bowel or bladder control; adolescents developing schizophrenia may lose previously effective interaction skills (Chapter 5.3).

Further complicating this developmental context are developmental differences in presentation of mental illnesses. DSM-IV-TR diagnoses were primarily defined among adult samples. Although some disorders, such as obsessive-compulsive disorder look quite similar in children and adults, other disorders, such as major depression or bipolar disorder present notably differently in younger patients as compared to adults (Chapter 5.4.2). Hence, extrapolating the DSM-IV-TR criteria to children and adolescents can often be difficult or invalid. For example, in major depression, school-age children may be less likely than adults to manifest self-accusatory feelings and more likely to manifest somatic symptoms. Discerning “categories” of mental disorders in children is thus much more difficult, since numbers of symptoms in children predict psychosocial function (5). Efforts to consider where a particular child fits on the depressed mood axis, the inattention spectrum, and the impulsive axis, for example, may ultimately prove fruitful for prioritizing intervention targets.

Finally, an underestimated but critical facet of the psychiatric assessment of children is the necessity for forming alliances with the multiple parties, including among the clinician and the child, the parent, and outside agencies. A breach or rupture in any of these relationships can dramatically impair treatment efforts. Careful attention is required to establish effective alliances not only with the child, but with those adults who can serve as resources in facilitating the child’s progress. It is during the assessment phase that efforts must begin to identify and align the agendas of these various treatment “partners” to enhance any intervention efforts. Parental permission should be obtained to contact and elicit information and collaboration from the various relevant parties who may have important information or who play an important role in the child’s progress; such contacts include step- and noncustodial parents, teachers (by phone and via school records and requested rating scales), and primary medical care providers. Following the initial evaluation, followup contacts with parents living apart from the child, school staff, and other health providers can often help clarify obstacles to treatment and can help invest others in the child’s improvement.

Content of the Clinical Interview

Core contents of the clinical assessment of children and adolescents are common across purposes; these components are summarized in Table 4.2.2.1. They illuminate the need for a consistent, thorough assessment of the multiple variables that may contribute to the child’s presentation, and the importance of synthesizing the input from multiple informants to derive an accurate picture of each child’s unique predicament.

Reason for Referral

Clarity about who actually initiated this referral, their motivations, and what changes they seek is essential to the success of any evaluation. While parents may schedule an evaluation, opening questions about who suggested it, who recognized a need for an evaluation, or who is most uncomfortable with the child’s behavior may all help clarify the impetus for the evaluation. More important, clarifying the circumstances and concerned individuals driving the evaluation request may
reveal the expectations of relevant parties and their willingness to implement treatment recommendations. For example, a parent may indicate the school or a grandparent identified distressing behaviors in the child. The parent may be required to obtain an evaluation for the child to return to school. The expectations of these various parties may in fact be in conflict and must be reconciled if effective treatments are to be implemented and for adherence to occur. For example, the school may seek to have parents manage the child differently, or to consider medication treatments, while the parents may be wishing for the evaluation to validate their current parenting efforts, or for diagnoses or recommendations which would yield additional school services. Similarly, grandparents may wish for different parenting approaches, while the parents may seek confirmation that their current approach is appropriate.

TABLE 4.2.2.1 CONTENT COMPONENTS OF THE PSYCHIATRIC ASSESSMENT OF CHILDREN AND ADOLESCENTS

Content Component	Primary Informant	Additional Resources
Reason for referral	Usually parent, 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/treatment(s)	Child, parent, clinicians	Mental health records
Child’s development (includes psychomotor, cognitive, interpersonal, emotional, moral, trauma), harm (to self and others) development	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 (sports, music); cognitive, school, neuropsychological testing
Child’s media diet	Parent; child; caregivers; siblings	Media diary; “Tivo” records; DVD/CD collections; magazine subscriptions
Environmental supports	Parent; child; adults familiar to child	Activity schedules (scouting, teams); afterschool/summer programs; mentorships/Big Brother or Sister relationships
Mental status exam	Child	Mini-Mental Status Examination

History of Problem(s)

The evolution of the child’s problem should be elicited by the clinician mindful of the pain most parents encounter while recounting the deterioration or anguish of their child. To minimize this distress, and to obtain a full description, clinicians should provide parents some opportunity to chronicle this history in their own words. Moreover, the more treatments that can be framed within the parents’ own description and understanding, by using the parents’ words or concepts, the greater the probability parents will feel heard and collaborate in treatment. Parents diverge widely in terms of their own experience with and views of psychiatry, how they understand people’s behaviors, and in their acceptance of alternatives to their current responses. Attention throughout the interview to these parent variables allows the clinician to explain behaviors and select interventions in terms acceptable to these particular parents.

As the parent describes the history of the problem, the clinician attends to the context in which the behavior emerged and occurs, changes in frequency and intensity of the behaviors, and the current progression of the problem. Since parents are rarely familiar with medical history taking, they usually will not detail the history as a clinician would. Permitting the parents to tell their own version of the problem for at least several minutes is usually necessary to allow them to articulate the problem or to discern what truly most concerns them, to feel heard or understood by the clinician, and to begin to feel allied with the clinician.

The clinician ultimately needs to inquire directly about specific instances of the child’s problematic behaviors, parental responses to these behaviors, and the child’s response to current parental interventions.

Since any given symptom (anxiety, inattention, arguing, theft, hallucinations) may have quite different meanings, functions, and clinical implications in different children, it is important not to jump immediately from symptom to diagnosis. The clinician may need to inquire directly about the functions of the problem behavior, including any secondary gains for the behavior (tantrums diminish parental expectations of chore completion, complaining of headaches every morning decreases time spent in a painful school class, running away causes parents to unite in efforts to find the child). Identifying specific antecedents and precipitants of the problem behavior and its consequences, both for the child and for others (including the family or classroom) may provide valuable insights into the functions of the problem behavior. In addition, the clinician should clarify the impact of the problem on the patient’s quality of life, with particular attention as to whether the problem is specific to one functional domain or whether the behavior pervades multiple or all areas of the child’s functioning, such as home, school, and with peers.

Problem behaviors may reflect an underlying disorder within the child, but may also reveal a problem within the child’s environment (6). For example, a particular teacher, peer, or adult may contribute to the child’s distress, although it is the child’s symptom that is being labeled as the problem behavior. Perhaps most commonly, the fit between the child and a particular teacher, peer, or adult may culminate in expression or exacerbation of the child’s symptoms. Accordingly, even when the child’s symptoms occur pervasively across multiple domains of life (home, school/work, peers), attention to changes in school circumstances and peer and adult/parent networks may clarify forces fueling the symptoms.

Past Problems

Significant past problems, which have impaired the child, should be identified, as this provides a historical context for understanding the current problem. It is especially important to understand whether a problem has been persistent since early childhood, is intermittent, or represents a deterioration from a previously better level of functioning. (If the latter, the inquiry naturally leads to the questions of what events and circumstances have accompanied this deterioration). Identification of significant past problems which have interfered substantially with functioning at home, school, or with peers can also be facilitated through the use of screening instruments (see Chapter 4.2.3).

Comorbid Problems

Parents usually do not organize their descriptions of their child’s difficulties according to DSM criteria. Rather, they describe the symptoms that appear most prominently in their child. As they do so, the clinician begins thinking implicitly about what diagnostic categories (or other means of conceptualizing the symptoms syndromically) might apply. Symptom constellations may be described by a parent in such a way as to suggest one particular diagnostic category, particularly when parents have heard from other parents, books, or Internet resources about potential diagnoses. However, it is important to recall that psychiatric symptoms are often diagnostically equivocal in that they may often overlap between various disorders, so consideration of disorders that may share similar symptoms should be considered. For example, inattention may occur in children with ADHD, but also among children with bipolar disorder, posttraumatic stress disorder or other anxiety disorders, or autism spectrum disorders, as well as in children who may be preoccupied with obsessions that distract them from focusing on what others are discussing.

Comorbidity is extremely common in childhood psychiatric disorders. Hence, clinicians should inquire about evidence of disorders often seen in tandem. For example, bipolar disorder in children is often associated with previous attention deficit hyperactivity disorder. Similarly, when depressed, many children will manifest symptoms of inattention, oppositionality, or irritability. Screening instruments can be useful to provide comprehensive information about less conspicuous conditions. This may be particularly important in detecting internalizing disorders, such as anxiety or mood disorders, which may be difficult for children to articulate, or which may be less troublesome or apparent to adults than disruptive externalizing disorders.

Substance Use History

Some symptom patterns, such as substance use, are particularly worrisome, both in terms of the direct hazards they pose to the child’s development and as markers for a broader constellation of risk behaviors (7). Hence, it is particularly important to inquire regarding the child’s exposure to and use of substances, including tobacco, alcohol, and illicit substances and how they may contribute to current symptoms. Previous exposures (including prenatal), contexts surrounding use, and effects of substances may impact treatment. Some children identify specific reasons for taking certain substances, while others proceed through many substances with diverse motives for taking or continuing use of these agents. For example, some children perceive that substances temporarily alleviate some of their symptoms (anxiety, depression) and so “self-medicate.” In such cases, clarifying what impact these substances have on symptoms can clarify symptom priorities of the child, as well as possible intervention points more likely to be embraced by the child.

Previous Treatment(s)

Chronological assessment of past treatment efforts may reveal seasonal patterns, or escalation of a disorder, or may identify past strategies effective with this child which might be useful or adaptable for the current problem. In addition, past treatment history may suggest which treatment modalities have been tolerable (or not) to this patient (and family), signaling adherence issues or approaches that will be important in this case. Previous treatments including medications employed, counseling, hospitalizations, or alternative treatments may all provide useful information about the evolution of a child’s problems.

Developmental History

The developmental history is a detailed accounting of the child’s development from birth forward. This history includes bodily function regulation, psychomotor development, language development, cognitive growth, social development, emotional regulation, moral development, and exposure to trauma. Parents vary widely in their recollection of precise timing of developmental milestones. However, comparisons with other siblings or children, comparative recollections by different adults, and review of earlier videotapes of the child by the parents may improve the reliability and completeness of parent reports regarding the sequence of the child’s growth.

Bodily, or basic, functions include sleeping, eating, and toileting. The child’s development in regulating sleep, eating, and toileting may reveal episodes of difficulty. Similarly, previously attained skills may suddenly be lost, sometimes signaling the importance of emotional events at particular times and association with regression. Eating behavior has become complicated as the availability of various types of food, and times to eat, have increased. While hunger remains a risk factor for psychopathology (8), obesity particularly has become more common among younger people, and markedly increases both physical and mental illness 9, 10.

Psychomotor development includes milestones such as standing, walking, throwing, running, hopping, skipping, and playing sports or musical instruments whose timing may reveal uneven periods in development. Inquiry as to how the child enjoys or fares at sports may suggest treatment options through nonverbal modalities. Fine motor and gross motor skills may not be congruent and graphomotor (handwriting skills) may be an area in which some children need classroom accommodation. The ease of toileting, and persisting difficulties with bedwetting or soiling, should be investigated. In addition, medical history from parents may clarify periods when the child could not employ skills or became frustrated in attempting preferred activities.

Cognitive development usually begins with the child’s verbal and attentional skills. The history of the child’s language development (including higher order social language, prosody, and conversational rules) is important in identifying pervasive developmental disorders. The child’s progression in preschool and school often reveal cognitive weaknesses, which may contribute to the current problem, or potential strengths to be harnessed to ameliorate the current problem. Specific inquiry concerning reading, writing, and math skill progression may reveal global difficulties or uneven skills in development. History by grade level can be helpful in discerning environmental changes that ameliorated or exacerbated symptoms. Report cards, behavioral concerns, absences, and retentions can be important in understanding the evolution of the child’s development. It is important to bear in mind that adequate progress in school requires more than adequate innate cognitive abilities. It is also reflects the child’s motivation, freedom from distraction, attitudes toward authority, capacity for peer relations, tolerance for frustration and delayed gratification, and degree of parental support for learning.

Interpersonal development assesses how the child interacts with others, particularly family members and other children and adults. Early interactions, especially with parents, provide important information about this child’s unique temperament and comfort around others and the environment. Early aloofness, disinterest in others, absence of interactive play with parents or attention to objects pointed out by parents may be early markers of pervasive developmental disorder. The child’s (and parents’) reactions to significant changes in the social environment of the home are often important precipitants for the child’s symptoms, particularly births/deaths of family members, marital changes (separations or conflicts, divorce, remarriages), and changes in caretaking arrangements (parent returning to work, or custody/visitation changes).

Exploring the child’s compliance with family rules and expectations, the consequences for noncompliance, and the child’s reaction to parental interventions in response to noncompliance often provide opportunities for behavioral interventions to diminish symptom expression. It is important to identify parents’ style of limit setting in a variety of areas. For school-age children these concern hygiene; sleep; diet; TV, Internet, and video game use; and the expression of aggression. For adolescents, it is additionally important to know what sort of expectations parents do or do not set regarding curfew, dress, leisure activities, and choice of friends. Effective parental monitoring of an adolescent’s activities, whereabouts, and peers is an important determinant of problem behaviors and usually reflects not only parents’ efforts at active, close surveillance, but also a close parent–child relationship that encourages open communication and child disclosure (11).

The child’s interactions with peers and adults outside the family are also important. How the child interacts with other children and preferences in play activities and friends (gender, age, interests) are important data for assessing the child’s social skills and interest in relating to others. Stability of relationships, numbers of friends, types of activities shared, and expectations of peers (“plays with me when I want,” “plays what I want to play,” “helps me out if I need it,” etc.) often reveal sources of difficulty or persistent maladaptive clashes where only the names of the antagonists change.

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