Diagnostic Evaluation for Children and Adolescents: Introduction
Based on the diagnostic hypotheses (generated, tested, and refined during history taking), the mental status examination, and the observation of family interaction, the inquiry plan proceeds to physical examination and, if required, to laboratory testing, special investigations, consultations, and psychological testing.
Figure 7–1 summarizes the flow of clinical reasoning from history taking, mental status examination, the generation of diagnostic hypotheses, through physical examination and special investigations, the refinement of the clinical pattern, secondary diagnostic hypotheses, psychological testing, and the diagnostic conclusion, to the diagnostic formulation and treatment plan.
Child Mental Status Examination
The child mental status examination is a set of systematic observations and assessments that provide a detailed description of the child’s behavior during the diagnostic interview. Combined with the history and physical assessment, the mental status examination yields evidence that helps the clinician to refine, delete, or accept the diagnostic hypotheses generated during the diagnostic encounter (see Chapter 34), and to decide whether special investigations are needed in order to test particular diagnostic hypotheses. Thus, the mental status examination is an integral part of the inquiry plan. In accordance with the diagnostic hypotheses and the inquiry plan, the mental status examination may be brief or comprehensive, but it always incorporates both standard and discretionary probes.
The mental status examination of the adolescent is similar to that of the adult (see Chapter 4). However, the examination of children is sufficiently different to warrant separate discussion. Many of the observations required to complete the mental status examination are made in the course of the semistructured interview with the child (see Chapter 5). Other observations, such as the clinical tests that screen cognitive functions, are part of a standardized set of questions.
Table 7–1 lists the areas covered by the mental status examination. For the most part, the first five areas are noted as the interview proceeds, whereas the last five require special questions.
Note the following: height, weight, nutritional status; precocious or delayed physical maturation or secondary sexual characteristics; abnormalities of the skin, head, facies, neck, or general physique; personal hygiene and grooming; and style and appropriateness of dress.
Observe the following: general level of physical activity (e.g., hyperkinesis, hypokinesis, bradykinesis), in comparison with others of the same age; abnormalities of gait, balance, posture, tone, power, and fine and gross motor coordination; abnormal movements (e.g., tremor, twitching, shivering, tics, fidgeting, choreiform movements, athetoid movements, motor overflow); mannerisms, rituals, echopraxia, or stereotyped movements; motor impersistence; or pronounced startle response.
Listen for the following: accent; abnormality in pitch, tone, volume, phonation, or prosody (e.g., squawking, shouting, whispering, monotony, hoarseness, scanning, high-pitched voice); abnormality in the amount of speech (e.g., mute, impoverished, voluble, loquacious) or its tempo (e.g., slowed, accelerated); abnormal rhythm (e.g., stuttering); abnormal articulation (e.g., dyslalia); unusual or inappropriate use of words (e.g., idioglossia, profanity); echolalia; abnormal syntax; and impairment in expressive or receptive language (e.g., difficulty finding words).
Note the patient’s eye contact (e.g., eyes averted, unfocussed, staring). Is the child friendly and cooperative, or resistant, oppositional, shy, or withdrawn? Is he or she assertive, aggressive, impudent, sarcastic, cynical, fearful, clinging, inhibited, indifferent, clowning, invasive, coy, or seductive? Is the child a reliable informant?
In demeanor and conversation, does the patient show evidence of a persistent abnormality of mood or of poor emotional regulation? For example, is there evidence of anxiety, tension, rage, depression, elevation of mood, silliness, apathy, or anhedonia? Is the child emotionally labile, or conversely, does he or she exhibit a restricted range of affect? Which topics evoke the most intense emotion?
Cognitive screening tests do not replace formal psychological testing. They serve as rapid clinical screens to determine whether formal testing is required. The following areas should be tested: attention, orientation, memory (immediate, recent, remote), judgment, abstraction, and intelligence (see Panels I–VI). Do not proceed with the tests described in the accompanying panels unless the patient has demonstrated a basic familiarity with numbers, letters, and words (see Table 7–2).
Is there evidence of abnormal tempo, with flight of ideas or acceleration, slowing, or poverty of thought processes? Does the stream of thought lack clear goal direction, with vagueness, incoherence, circumstantiality, tangential thinking, derailment, or clang associations? Is the normal continuity of associations disrupted by perseveration, circumlocution, circumstantiality, distractibility, or blocking? Is there evidence of impairment in logical or metaphorical thinking, for example, in a blurring of conceptual boundaries or abnormally concrete thinking?
From the history given by the parents, the intake questionnaires and checklists, and free discussion with the child, the clinician will have generated hypotheses that can be tested by direct probes concerning clinical phenomenology. The following symptoms may not be routinely checked unless there are good hypothetico-deductive reasons for doing so: anxiety, separation anxiety, school refusal, panic attacks, phobias, obsessions, compulsions, impulsions, delusions, hallucinations, ideas of reference, ideas of influence, thought alienation, thought-broadcasting, depersonalization, déjà vu, derealization, suicidal ideation, impulses to injure the self or others, preoccupation with somatic functioning, somatic symptoms, stealing, fire setting, truancy, and fighting. In contrast, suicidal ideation, self-injury, assaultive impulses, substance abuse, physical or sexual abuse, risk taking, and antisocial behavior must always be inquired about when diagnostic evaluations are undertaken with adolescents.
The child’s fantasy is elicited through play, drawing, and storytelling. By his or her unobtrusive interest, the clinician can facilitate the child’s fantasy and encourage the child to express it. Table 7–3 lists a variety of techniques that can be used to elicit fantasy.
After the child has drawn a person, ask him or her the following types of questions: |
| Is that person a man or a woman, a boy or a girl? |
| How old is he/she? |
| What is he/she doing in that picture? |
| What is he/she thinking about? |
| How does he/she feel about it? |
| What makes him/her happy? |
| What makes him/her sad? |
| What makes him/her mad? |
| What makes him/her scared? |
| What does he/she need most? |
| What’s the best/worst thing about him/her? |
| Tell me about his/her family? |
| What will he/she do next? |
| Use the Kinetic Family Drawing test: |
| a. Ask the child to draw his or her family doing something together. |
| b. Note who the child puts in the family; the proximity of the figures; the coherence of or separations between group members; the relative importance and power of the family members; and their apparent emotions, attachments, rivalries, and so on. |
| c. Ask the child to explain the drawing, saying what the family members are doing, thinking, and feeling, and what the outcome will be. Base your questions, in part, on discretionary probes derived from the dynamic hypotheses you have generated. |
| Ask the child to draw “something nice” and “something nasty.” Consider using the following questions as icebreakers: |
| What would you do if you had a million dollars? |
| If you had three wishes, what would they be? |
| If you were wrecked on a desert island, who (and what) would you like to have with you? |
| Ask the child to tell you about (good/bad) dreams he or she has had recently. |
| Ask the child for the earliest thing he or she can remember, and for his or her earliest memory about his or her family. |
Is the child aware that he or she has a problem? If so, how is the problem conceptualized? Does the child want help for the problem?
Semistructured playroom interviews with children 7–12 years of age have been found to have a test–retest reliability of 0.84 and an interrater reliability of 0.74, with regard to the detection of abnormality. However, interviewers who are unaware of the parents’ perception of the child’s problems tend to underestimate abnormality in comparison with parent reports of child behavior.
In order to compensate for the potential unreliability of unstructured or semistructured interviewing, a number of structured interviews have been introduced. As a rule, these interviews are too cumbersome for everyday clinical work; however, they are widely used to standardize subject selection in research studies. Arguably, semistructured and structured interviewing complement each other: The semistructured interview yields information mainly about the child’s perception of self and environment, whereas the structured interview focuses on symptomatology. When reliable diagnostic categorization is the overriding consideration, structured interviews such as those described in this section are clearly preferable. It should be remembered, however, that with children younger than 10–12 years of age, the reliability of direct questions concerning symptomatology is affected by the fact that children are limited in their capacity to be objective about themselves. Furthermore, emotionally disturbed preadolescents tire if exposed to long, tedious interviews and may become careless in their answers. Table 7–4 provides more detailed information on these instruments.
Instrument | Target Age (years) | Time Needed (minutes) | Reliability |
|---|---|---|---|
Diagnostic Interview for Children & Adolescents (DICA) | 6–17 | 60–90 | Interrater and test–retest reliabilities are acceptable Parent–child agreement: 0–0.87 on specific items (k = 0.76–1.00 for anxiety and conduct disorders) |
Diagnostic Interview Schedule for Children (DISC) | 9–17 | 60–90 | Interrater reliability: 0.94–1 for symptoms Test-retest reliability for parents: .9 (symptoms), 0.76 (syndromes); for children aged 14–18: 0.8 (symptoms), 0.36 (syndromes) Parent–child agreement: 0.27 (greatest for disruptive symptoms, less for depression or anxiety) |
Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) | 6–18 | 180 | Interrater reliability: .65-.96 (syndromes) Test-retest reliability: variable, 0.09–0.89 (symptoms), 0.24–0.7 (syndromes) Parent-child agreement: 0.08–1.00 (symptoms) |
Child Assessment Schedule (CAS) | 7–17 | 45–75 | Interrater reliability: 0.73 (for content, less for diagnosis); higher for hyperactivity and aggression (0.8), less for anxiety (0.6) |
Interview Schedule for Children (ISC) | 8–17 | 90–120 | Interrater reliability: 0.64–1.0 Parent–child agreement: 0.2–0.95 (symptoms), 0.32–0.86 (syndromes), lowest for subjective symptoms |
Child & Adolescent Psychiatric Assessment (CAPA) | 8–18 | 90–120 | Not available |
DICA is a semistructured interview that uses a modular technique, organized by diagnostic syndrome. Parent, child, and adolescent versions are available. Clinical judgment is required at several decision points; otherwise, lay interviewers can administer DICA. A computerized version is available for recording and scoring results. DICA has reasonable validity comparing pediatric and psychiatric referrals (especially in academic and relationship problems).
DISC is a highly structured interview that is organized by topic, in a manner close to a natural free-flowing interview. It is mainly epidemiologic in purpose. Parent and child versions are available, and clinical judgment is not required. DISC has reasonable validity comparing pediatric and psychiatric referrals. Diagnoses are generated by computer algorithm.
K-SADS is a semistructured instrument that has been used extensively in child psychiatry research. Parent, child, and epidemiologic versions are available. Clinical judgment is required. The same clinician interviews the parent and the child and attempts to resolve discrepancies in their reports. This interview was originally developed to identify children with affective disorder. It now emphasizes affective, anxiety, and schizophrenic disorders. It is scored manually, and diagnosis is reached from summary ratings. Pilot validity data come from follow-up, treatment change, and biological correlate studies.
CAS is a semistructured interview that has been used with both children and adolescents. Parent and child versions are available. Interviewer training is required. Interview items are grouped by topic (e.g., school, peers, family), not syndrome. CAS does not cover posttraumatic stress disorder, dissociative disorder, or adolescent schizophrenia. Its pilot validity was estimated by comparing inpatients, outpatients, and normal subjects.
ISC was designed originally for a longitudinal study of depressed children and may be most useful for the diagnosis of depression. Parent and child versions are available. ISC requires clinical skill, judgment, and training.
CAPA is intended for use in both clinical and epidemiologic settings. Parent and child versions are available. It starts with an unstructured discussion and proceeds to a systematic inquiry into a broad range of symptoms for which an extensive glossary is available. It contains psychosocial and family functioning sections. Lay or clinician interviewers can administer it, and it is scored by computer algorithm.
Physical Examination, Laboratory Testing, & Special Investigations
Usually, a physical examination has already been completed by the child’s pediatrician. If not, the clinician should refer the family to the primary physician. In some circumstances, however, it is important that the child psychiatrist complete the physical examination. Table 7–5
Related posts:
Psychodynamic and Social Interventions
Delirium, Dementia, and Amnestic Syndromes
Factitious Disorders and Malingering
Posttraumatic Stress Disorder and Acute Stress Disorder
Anxiety Disorders in Children and Adolescents
Psychological Reactions to Acute & Chronic Systemic Illness in Pediatric Patients
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
