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.

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.

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).

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.

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.

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.

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.

Emotional development and temperament is a key component in the evaluation of every child. A child’s capacity to recognize his or her own mood state and to self-soothe or regulate negative affect should be investigated. Prevailing moods can be described by parents, as well as past suicidality, irritability, specific fears and anxieties, and conditions associated with the child’s happiness and pleasure. Whether the child can recognize when a mood is mild or severe, and what steps the child will take when anxious, sad, or when encountering change or disappointment provide insight into vital coping mechanisms. Circumstances which provoke aggression or anger and the child’s responses and capacity to accept input or direction from others may clarify intervention options such as parenting or behavioral treatments. These traits commonly exist along a spectrum, so that bullying, for example, may have started as assertiveness and progressed to exploitation or intimidation of others.

Assessment of the child’s moral development provides an important gauge of whether the child’s 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 religious and cultural/ethical views and practices and how those fit with those of the family also provide helpful information guiding potential treatment interventions. Similarly, the child’s ability to recognize the plight of others, to recognize impacts of decisions of others, to reconcile principles with mistakes the child makes, and to acknowledge and correct mistakes often provides clarity about the child’s strengths and limitations.

At any stage of the child’s development, children may experience trauma which has substantially impacted or even arrested development. Investigation of not only actual events (such as documented physical or sexual abuse), but of events perceived traumatic by the child and the vicissitudes of these events for the child and family shed important light on the child’s behaviors and patterns of relating to others. Identifying episodes of abuse (physical, sexual, verbal), the events surrounding the trauma, the child’s role in disclosing such abuse to others, and the reactions of adults to such disclosures are also important for the clinician to recognize and address.

Harmful behavior, toward self or others, should always be investigated. Past episodes of harmful comments or acts may reveal important developmental progressions or patterns that warrant intervention. Headbanging or self-injurious behaviors may reveal underlying sensory disturbances, sometimes seen in developmental disorders; thoughts or comments about death may reveal suicidality; and self-harmful acts such as self-mutilation or cutting may reveal primitive coping mechanisms (12), and may increase risk for subsequent psychopathology such as eating disorders (13). Harmful acts toward others, animals as well as people, may reveal safety or monitoring issues required to preserve the safety of others while other diagnostic or treatment interventions occur.

Parental variables may impact the child’s problems and warrant examination. First, family conflict, or differences in parenting style, may culminate in the child manifesting symptoms; however, the converse is equally true, in that disturbed behavior by a child may stress otherwise adequate parental coping skills or provoke conflict between parents. Parents may have grown up themselves with different parenting practices in their families of origin that they wish to employ, or avoid, and these influences are important to understand in assessing the consistencies and discrepancies within and between each parent’s style. In the face of a child’s distressing behaviors, parents may attempt a wide variety of approaches, some uncharacteristic of their usual parenting style, poorly conceived, and enacted at inopportune times (e.g., unenforceable threats during a tantrum); such responses may not improve the problem but do increase parental guilt and hopelessness. Accordingly, the clinician must be mindful that the approach parents ordinarily employ may not be described if it did not work with this child. Clarifying the evolution of the approaches parents have attempted for this child’s problems, and how these approaches may have differed from approaches employed with their other children, may help the clinician disentangle child and parent contributions to the current problem.

Second, parents may have problems with the child at particular developmental periods. Certain developmental stages may have particularly challenged the parent’s skills or coping responses, or may have reminded the parent of a painful time in his or her own childhood. Discussion with parents about how they navigated past difficulties with this child, their rationales for certain parenting practices, and their expectations (and fears) during this given developmental phase of the child often provide clues about potential parental contributions to the problem. Similarly, information about parents’ cultural, ethnic, education, occupation, and religious background may reveal not only sources of adversity or conflict between parents or family members, but sources of pride and resilience that inform interventions to enhance treatment adherence among parents and children.

Third, parental genetic contributions remain an important variable to consider, particularly since some parents perceive that the child’s psychopathology may be attributed to one or the other parent based on that parent’s personal or family history. Few if any common psychiatric disorders appear exclusively through genetic transmission alone, although increased vulnerabilities to various disorders are likely. In addition, the child’s experience of growing up with a parent who has struggled with depression, anxiety, psychosis, or substance abuse is likely to have an impact on the child, over and above any genetically transmitted vulnerability. Tactful but thorough investigation into psychopathology in each parent and among the extended family may suggest which disorders or general conditions (mood, anxiety) may be more probable. Patterns can also be visualized by constructing a genogram, particularly in complex families with multiple psychopathologies. Although unspoken during psychiatric evaluations, many parents fear that their other children may be destined to suffer psychopathology when one sibling manifests a disorder, so clarification of genetic contributions to expression of disorders can often be helpful in reducing unwarranted fear, guilt, and distress among parents.

Divorce, separation, and single-parent family circumstances may stress all family members, including the children. Even when parents part amicably, children may have difficulty with change from what has been familiar. Similarly, even in circumstances where parents and children experience reduced conflict after parents separate, children sometimes exhibit symptoms which coincide with marital changes. The child’s symptoms may reveal overwhelming stress or fear, but also may reveal efforts to reunite family members. In addition, children may exhibit symptoms months or years after separations as difficulty adjusting to new roles or environments occurs or as they enter a new developmental phase (14).

Adoption may be a positive event for the child and for the adoptive parents, and the circumstances of the adoption warrant tactful attention by the clinician, including age of the child and biological parents, the degree of ongoing contact with or interest in biological parents, the child’s understanding of the adoption and attitudes about the biological and the
adoptive parents, and how the adoption is discussed at home. In addition, adoptive parent expectations and feelings about the adoption, particularly as their child now undergoes a psychiatric evaluation, may reveal underlying parental fears, guilt, or disappointments.

However the family system is currently configured, the clinician should inquire about how the family system functions, with whom the child spends time, and the nature of the relationships between the various household members and the child. Boundaries and alliances, conflicts, and the child’s affinities or resentments of other family members should be determined. Family communication and problemsolving, including how issues of disagreement are handled, should be assessed. The emotional tone of families vary widely from constricted to overly expressive and dramatic, and should be examined both by observation of family interactions during the interview, as well as by direct inquiry. Clarification of family stressors that are chronic family stressors (family member illness or disability) or acute (sudden illness, job loss/change, financial or legal difficulties) may identify determinants of the child’s current problems as well as potential targets for intervention.

Medical conditions experienced by the child should be identified beginning with conception (as well as any difficulties the mother had in conceiving or the use of assisted reproductive technologies). Pregnancy complications, birth difficulties, extended hospital stays, and medical illnesses requiring recurrent or ongoing treatments (asthma, diabetes) should be investigated, since these appear to increase the child’s risk for psychopathology (15). In addition, inquiry into hospitalizations, emergency room visits, or surgeries can help shed light on the child’s fears, or parental over/underprotectiveness. Allergies, particularly to medications, should be ascertained, as well as responses or side effects to previous medications, especially psychotropics, and including naturopathic or homeopathic agents.

Age of menarche and stage of pubertal development should be inquired about when relevant. If the child’s weight and/or stature is out of the normal range for age (as plotted on a standard growth chart), a detailed review of the child’s growth history and eating habits should be made.

Accidents or illnesses with a potential for central nervous system impact, such as lead exposure, seizures, head trauma, loss of consciousness, deserve specific inquiry.

In addition to clarifying the child’s problems, the evaluation simultaneously elicits the child’s areas of strength so that interventions can build on these existing strengths and assets rather than focusing exclusively on areas of weakness.

Interests, hobbies, and talents of the child should be obtained from both the child and the parents, since these accounts may not match or may even be in conflict.

Parents may have aspirations for their children that 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 the therapist) and may serve to facilitate therapy. Exploration of the child’s interests, including newly emerging ones, may allow the interviewer to anchor recommendations or treatment metaphors to language or subjects familiar to or valued by the patient. Similarly, the child’s and parents’ accounts of time spent in an activity (10 years of ballet and modern dance) or perceived fruits of the child’s labor (“I won trophies twice,” vs. “I’ve lost most games I’ve played in”) illuminate what effect the activity has had on the child, including pride or disappointment, as well as the parents’ and the child’s own expectations.

In an information-processing society, children are exposed to immense doses of media, including television, music, videos, electronic games, cell phones, e-mail and instant messaging, and personal digital assistants. These media, which may provide exposure of the child to much violent and sexually provocative material, may have positive or negative effects. 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 shows the child becomes more violent vs. has developed interest in Asian food through watching cooking programs, or listening to an MP3 player at school serves to distract the child from classroom instruction vs. helps the child calm down on the bus or ignore other disruptions) (16). E-mail, instant messaging, chatrooms, and bulletin boards such as MySpace or Facebook, can be used to multiple ends, which may be adaptive (maintaining friendships with camp friends), problematic (bullying, harassment, or dangerous exhibitionism), or both (permitting a socially anxious child to maintain a modicum of electronic social contacts, but at the cost of avoiding more face-to-face relationships) (17). Evidence suggests that frequent watching of television during childhood is associated with violent behaviors decades later (18). As with other aspects of parental monitoring, the degree of parental awareness and appropriate limit setting regarding TV, video games, and instant messaging is important to determine, in part as an indicator of parental structure and expectations. As with other of the child’s interests, preferred television show, favorite movies, favored musicians or bands provide a common language to examine topics, as well as clues about the child’s aspirations and behavioral self-expectations (“[Music idol] swears at adults all the time, so why can’t I?”) (19). Asking a child to describe an episode of a favorite TV show or movie also provides a convenient picture of the quality of the child’s social language and grasp of others’ motives and feelings.

Although many children must contend with moves or changes in the family constellation, other environmental supports and buffers often provide stability and even sanctuary and warrant investigation. Adults other than the parents (such as grandparents and other relatives, coaches, teachers) may play significant, ongoing roles in the lives of children, while community involvements, such as church groups, athletic team participation, outdoor clubs, musical ensembles, or even preferred places to convene may provide opportunities for intervention or support in natural settings on a regular basis.

The mental status examination is an essential part of any psychiatric interview, as it provides direct information about how the child presents and interacts with the clinician. The mental status examination includes a clinical description of the child’s appearance, mood, sensorium, apparent intelligence,
and thought content and process. Although often conceptualized as a separate component that is distinct from the history-taking interview, in reality much of the mental status examination takes place implicitly as the clinician interacts and observes the child during the child and family interviews. Although some components of the exam will require specific inquiry or examination (such as orientation, memory, fund of knowledge, and mental contents), most will be noted as the clinician organizes his or her ongoing observations of the child according to the elements of the mental status exam. A format for the child mental status examination is provided in Table 4.2.2.2.