Initial Contact

Children are usually referred to psychiatrists by their parents or caregivers. Parents should be made aware that a collaborative approach to diagnosis and treatment is essential and that their children older than 3 years of age should be prepared for the diagnostic encounter. The initial contact is usually made over the telephone by the parent or referring agent. The importance of the impression made at that first contact cannot be underestimated. The initial intake staff member gathers identifying information and a brief history of the presenting complaint. Emergency situations must be dealt with at once and urgent situations within 24 hours. Table 5–1 lists situations, roughly in the order of frequency, that require immediate evaluation.

Sequence of Interviews

If the initial interview is prompted by a crisis, or if the family has come a long distance, the clinician should see the whole family together. Even if there is no crisis, some clinicians still favor interviewing the whole family first whereas others prefer interviewing the parents first, before interviewing the child or adolescent at a separate later interview. Even if the parents are separated or divorced, it is preferable to interview both parents, unless the tension between them would be unmanageable. Other clinicians prefer to interview an adolescent first, before interviewing the parents. In any case, the clinician should try to avoid having the child wait anxiously in the waiting room while lengthy parent interviews are conducted. At some point, the parents will need to be interviewed to obtain a detailed history (see “Interviewing Parents” section) and the family interviewed together to throw light on family dynamics (see “Interviewing Families” section).

Intake Questionnaires & Checklists

Important data can be collected even before the first interview. For example, the parent can complete a Child Behavior Checklist and a developmental history form. Teacher versions of the Child Behavior Checklist can also be obtained if the child’s behavior in school is an important issue. Previous mental health evaluations, psychological reports, medical records, and school records are also available in some cases. Thus, the clinician can focus during the parent interview on the developmental issues and symptom patterns that emerge from the preliminary data.

Purpose of the Parent Interview

The initial parent interview serves several purposes. Most important, it helps the clinician form an alliance with the parents, and it helps the parents prepare the child for the next interview. The clinician can use the parent interview to obtain a formal history of the child’s presenting problem, medical history, early development, school progress, and peer relations as well as information on the child’s recreational activities and interests, home and family environment, and family history. The clinician can also gather from this interview information about parent–child relations and communication, the parents’ child-rearing techniques and methods of discipline used, and the family’s values and aspirations. The clinician can gather information on the parents’ current marital relationship and its development and can ascertain how the parents understand the child’s problem and the kind of help they are seeking.

Sequence of the Parent Interview

The parent interview proceeds through four key stages: (1) inception, (2) reconnaissance, (3) detailed inquiry, and (4) termination.

Inception

The interviewer begins by greeting the parents in the waiting room and ushering them into the office, indicating where they should sit. The interviewer then tells the parents what he or she already knows and invites them to tell their story.

Reconnaissance

The interviewer should let the parents proceed at their own pace without interruption other than to facilitate the flow of associations or clarify issues. As the story unfolds, the interaction between them is observed. Do they support each other? Does one parent do most of the talking? Do they interrupt or contradict each other? Which issues evoke the most emotion from them? Do they express warmth, humor, coolness, detachment, remoteness, tension, irritation, or hostility? If one parent becomes upset, how does the other respond?

Detailed Inquiry

After the parents have finished their story, the areas listed in the next several sections are explored. These areas should be surveyed in a standard diagnostic inquiry, and particular areas should be explored in depth according to the diagnostic hypotheses triggered by the clinical pattern that is emerging.

The Problem

When did the problem first appear? Did its onset coincide with a physical or psychosocial stressor? How has the problem evolved? Is the problem persistent or intermittent? If intermittent, do exacerbations coincide with vicissitudes in physical health or the environment (e.g., family, school, peer relations)? What have the parents done about it? Are there any other problems in the child’s behavior at home, at school, with siblings, or with peers?

Referral

Who referred the parents? Why do they come now? How do they feel about it? Have they sought help before? If so, from whom, and how effective was the help? What kind of help do they expect now?

Medical History

Has the child had any significant physical illness, physical disability, surgery, accidents, or hospitalizations? If so, at what age, what was the duration, and did any adverse psychological reactions occur? Has the child sustained any head injuries or had seizures, syncope, headaches, eye symptoms, abdominal or limb pains, nausea or vomiting, or prolonged or frequent absences from school? Has the child had previous psychological disturbances? If so, what were the cause, treatment, and outcome? Is the child currently taking any medication? Does he or she have significant allergies?

Developmental History

What were the circumstances surrounding conception of the child (e.g., motivation, acceptance, convenience, emotional turmoil, reaction of in-laws)? What was the nature of the marital relationship during pregnancy? Did the parents have a sex preference? How was the mother’s physical and emotional health during pregnancy? Did she have toxemia, eclampsia, kidney disorder, hypertension, or febrile illness? Were any X-rays taken during pregnancy? Did she take prescribed or over-the-counter medications, tobacco, alcohol, or illicit drugs during pregnancy, and if so, how much and how often? Did she experience excessive nausea, vomiting, or vaginal bleeding during pregnancy? How was she prepared for labor?

Did the mother have a normal confinement? Was the child born at term? How long did labor last? What was the nature of the delivery? Did any complications occur? How soon did the mother see the infant after delivery? What were the mother’s initial thoughts on seeing the infant?

What was the infant’s birth weight, maturity, and physical condition? Was the infant in intensive care? If so, for how long? What was the method of feeding? How well did the infant gain weight as a neonate? Did the infant have problems with asphyxia, cyanosis, jaundice, convulsions, vomiting, rigidity, or respiratory disorder?

Was the child breastfed? If so, for how long? Was formula used? When were solids introduced? How well did the child gain weight? Did the child have problems with vomiting, diarrhea, constipation, colic, food allergies, or eczema? Did later conflicts over eating occur (e.g., refusal to eat, bulimia, hoarding)? What are the child’s current eating habits?

At what age (in months) did the child first hold his or her head erect, sit alone, stand, and walk alone? How is the child’s coordination (gross and fine)? Is the child right- or left-handed? Does the child have repetitive movements or mannerisms?

When did the child first use single words, two- and three-word phrases, and sentences? Did the child have trouble with faulty articulation or stammering? How mature is the child’s current language, vocabulary, and syntax? Is the child able to carry a conversation?

When did the child first learn to control his or her bladder and bowels? What method of training was used? How did the child respond to training (e.g., with resistance or acceptance)? Did the child regress during training? Has the child had problems with enuresis or encopresis?

Has the child had sleep problems in the past? What are the child’s current sleep habits (e.g., is the child a deep sleeper, restless, or insomniac)? Does the child have fears of the dark or of being alone? Does the child sleepwalk, rock head or body, have nightmares or night terrors, or resist going to bed?

Did the child display early sexual curiosity or sex play? Has the child received sex education? Has the child begun to menstruate, or have nocturnal emissions? Does the child masturbate? What is the child’s gender-role identification? Is he or she interested in the opposite sex? Has the child experienced any sexual trauma?

Educational Progress

What schools has the child attended? What grade is the child in now? Who are the child’s teachers? How is the child’s current academic performance? Does the child have any learning problems or any need for special education or tutoring? Does the child participate in school sports and activities?

How are the child’s relationships with peers and teachers? How does the child respond to school rules? What is the child’s capacity to concentrate? Does the child have problems with truancy, fear of going to school, or school refusal? Has the child bullied others or been the victim of bullying? What is the child’s attitude toward homework? Does the child exhibit any antisocial behavior at school? Does the child have any history of drug or alcohol use or abuse?

What are the child’s ambitions? Is the child involved in social and recreational activities?

Home Environment

Where is the home located? What is the neighborhood like? What are the neighbors like? How is the home laid out? What are the sleeping arrangements? Does the home have inside and outside spaces for play? Are the parents satisfied with the domestic arrangements?

What is the child’s typical weekday and weekend schedule, from rising to retiring?

Parent–Child Relationships

How was the child’s early temperament (i.e., easy or difficult)? Has this changed with age? What is the child’s general mood? What is the child’s capacity for affection, tolerance for frustration, and proneness to tantrums? Is the child aggressive, resentful, fearful, or timid; depressed; sociable; and accepting of limits, rules, and discipline? How does the child respond to punishment (i.e., by being stubborn or compliant)?

What methods do the parents use to set limits and discipline the child? Are these methods applied with consistency? How much time does the family spend together (i.e., father–child, mother–child, entire family)?

What are the child’s attitudes toward each parent (e.g., closeness, mutual understanding)? Do conflicts about dependence and independence exist between the child and parents?

Social Relationships

How are the child’s relationships with siblings and peers? Does the child tend to be a leader, a follower, or a protector? Is the child overly dependent?

Is the child able to win or lose at games? What are the child’s favorite games?

Does the child exhibit any antisocial behavior? How are the child’s relationships with authority figures?

Family Background

What is each parent’s age, occupation, and physical and mental health? What is each parent’s drug and alcohol intake? What are the age, health, and occupations of both sets of grandparents? What are each parent’s family, educational, and occupational backgrounds? Pay particular attention to the emotional climate of each parent’s family of origin, the relationship between the parents and their parents, the parents’ schooling, and their occupational histories. What is the family history of psychiatric disorders, mental retardation, learning problems, substance abuse, antisocial behavior, or physical illness?

Were the parents married previously? How did they meet, and what was their courtship like? Were they both accepted by their respective in-laws? What were the early years of marriage like (e.g., sexual adjustment, division of labor, management of money, method of settling interparental disputes)? Is there a history of competition, unfulfilled needs, hostility, abuse, or separations? How effective is each parent’s parenting ability? What is their capacity for affection? What is their motivation for childcare and childrearing?

How old is each of the child’s siblings? What is the current health of each sibling? How does each sibling do in school or in his or her occupation? What is each sibling’s overall personality? How does each sibling relate to the child?

What is the family’s ethnic or sociocultural background? Is there a relative emphasis on conformity or independence, authority or freedom, warmth or coolness, control or expression? What are the family’s religious, moral and esthetic values? Does the family put an emphasis on education, piety, money, success, prestige, or gender differentiation?

How involved is the family in school activities, religious organizations, cultural bodies, and civic affairs?

Termination

At the end of the parent interview (usually one or two 2-hour interviews), the information gathered is summarized. The parents should be invited to add anything they think is important and to correct any misinformation. The interviewer should then tell them when he or she wants to see the child and the family again.

Purpose of the Infant Evaluation

The psychiatric evaluation of infants and their parents is designed to yield information concerning the following: the nature and development of the problem perceived by the parents; the child’s developmental history; the parent’s history (e.g., early relationships, prior experience with children, knowledge of child development, marital relationship, and medical and psychiatric history); parent–child interaction; infant development and attachment; and the parents’ perception of the infant.

Information on these matters is gathered by interviewing the parent, observing the infant, observing the interaction between parent and infant, and if necessary, conducting standardized assessments.

Interviewing the Infant’s Parents

Infants and their parents are usually referred by a pediatrician because of disturbances in regulation (e.g., insomnia, excessive crying, feeding problems, head banging), social disturbances (e.g., interactional apathy or negativism, traumatic separation, excessive separation anxiety), psychophysiologic disturbances (e.g., failure to thrive, vomiting), or developmental delay.

It is debatable whether, at the first interview, the parents should be interviewed alone or together with the infant. The infant’s presence is likely to generate historical information from the parents that might otherwise be missed. However, a number of interviews will be required, observation of parent–child interactions will always be necessary, and the aim of the interview will not be achieved unless a working alliance is formed.

The interview begins with introductory questions about family structure and dates of birth and quickly proceeds to a history of the problem. The following questions could be asked: When did the problem begin? How has it evolved? What is the problem now? What have the parents done about it? How do they account for it? Why do they come for help now? What do they want from the clinician?

Next, the clinician elicits the infant’s developmental history, including the circumstances surrounding, and the reaction of both parents to, conception, pregnancy, delivery, and early infant care. The child’s medical history will also be gathered.

As the alliance deepens, the clinician elicits information about the parents’ relationships with their own parents and siblings, their prior experience of childcare, their knowledge of child development, their preconceptions about being a parent, and their expectations about the baby (and whether these expectations have been borne out). The history and current status of the marital relationship will also be explored. If other individuals provide a significant amount of the infant’s care, they should also be interviewed.

The clinician seeks to identify critical dynamic sequences of behavioral interaction (e.g., the mother becomes anxious, disorganized, and angry if the baby refuses to eat), looking for connections between present emotional interactions and past significant relationships and events.

Observing the Parent–Infant Interaction

During the interview, parents should be encouraged to attend to the infant’s needs, for example, consoling, changing, or feeding the infant, if necessary. Parents will also be asked to play with the child. Parent–child dyads can then be observed with regard to the quality of attachment, the vigilance of the parents concerning the infant’s safety, the parents’ attunement to and effectiveness in responding to the infant’s need states, the quality of parent–child play, parental teaching ability, parental control, the affective tone of the interaction, and infant temperament. The clinician should remember that he or she is observing only brief samples of dyadic behavior. By seeking a working alliance and putting the parents at ease, the clinician can try to ensure that the samples of behavior observed are representative.

The next several sections describe specific observations about the parent–child interaction that the clinician can make during the infant evaluation.

Attachment

How close is each dyad? Are they, for example, detached or clinging, or able to separate sufficiently to allow the infant to explore? Does the infant seek body or eye contact with the parent? Does contact with the parent reassure the child, or is the infant inconsolable? Does the infant explore the surroundings recklessly, confidently, cautiously, or not at all? Does the infant get pleasure from the exploration? How does he or she respond to separation? How does the parent feel about it?

Protection

Is the parent vigilant, overprotective, or careless in regard to the infant’s reckless, cautious, or confident exploration? Or does the parent strike a good balance, given the infant’s apparent temperament? How does the parent feel about the infant’s exploration?

Regulation of Need States

Is the parent attuned to the infant’s needs concerning hunger, discomfort, pain, or stimulation? Does the parent know when to stimulate the infant, when to back off, and when and how to console the infant? Does the parent make effective use of eye contact, soothing voice, smiling, facial movement, wrapping, touching, holding, rocking, nursing, and dorsal patting or rubbing in stimulating or consoling the infant? How does the infant respond to the parent’s ministrations?

Play

Do parent and infant play together in a manner appropriate to the infant’s developmental level? Do parent and infant enjoy the playful interaction?

Teaching

If the infant is old enough, ask the parent to teach him or her to stack blocks or solve a puzzle. Does the parent make effective use of modeling and language? Does the infant imitate the parent? Does the parent allow the infant sufficient opportunity for trial and error to solve a problem independently?

Control

Does each parent maintain calm, confident control of the infant, or is the parent helpless, passive, inconsistent, disorganized, explosive, punitive, or overly controlling? How effectively does the parent communicate in words? How does the infant respond? In response to the parent’s attempts to control his or her behavior, is the infant heedless, provocative, negativistic, passive, disorganized, or biddable?

Emotion

What is the affective tone of the interaction? Is the infant generally happy, angry, sad, neutral, affectively “empty,” or unresponsive? What is each parent’s emotional state? Are the members of the dyads attuned to each other? If the infant becomes upset, is he or she able to regain equanimity in a reasonable time?

Temperament

Temperament refers to relatively enduring characteristics of the infant’s behavioral response to the internal and external environments. Despite limitations in the duration and representativeness of the behavioral sample elicited, the clinician may be able to make observations concerning the infant’s activity level, tendency to approach or withdraw from people, adaptability to new situations, affective intensity, mood, persistence with tasks or play, sensory threshold, and distractibility.

Standardized Testing

Through standardized testing, the clinician can explore hypotheses generated from the history and observation of parent–infant interaction. Tests are available, for example, with regard to infant psychomotor development, parent–infant interaction, infant attachment, quality of the home environment, infant temperament, and the parent’s working model of the infant. Although some of these tests are best regarded as research instruments, several may have clinical utility. Furthermore, parents can be involved in the data-gathering process of many of these tests, with potentially great educational benefit.

Developmental Level

Tests of infant development have only modest predictive validity with regard to tested intelligence in later childhood. There is increasing evidence that intellectual development is characterized by individual differences and discontinuity rather than a smooth progression. Early infant development tests must be applied too soon to tap those elements of intelligence (e.g., language-based cognitive skills) that are highly responsive to the home environment. Nevertheless, if the infant tests very low in some or all developmental domains, the clinician should be concerned.

Brazelton Neonatal Behavioral Assessment Scale

The Brazelton Neonatal Behavioral Assessment Scale (NBAS) was designed for use with the full-term neonate, but it has also been modified to apply to high-risk infants. The NBAS is usually administered 3 and 9 days after birth. It surveys reflexes and behavioral responses in such a way as to yield a profile of social interactiveness, state control, motoric behavior, and physiologic response to stress. It has modest predictive power with regard to later developmental measures.

Bayley Scales of Infant Development (2–30 Months)

The Bayley Scales assess development in three domains: mental (perception, memory, problem solving, communication), psychomotor (gross and fine motor), and behavior (the affective responses of the infant). This test uses a structured play approach.

Infant Muller Scales of Early Learning (0–38 Months)