Use of Multiple Informants

No single informant or technique can give a full description of a child. Children themselves, teachers, parents, other relatives, community members, and clinicians each have their own point of view and opportunities for observation. Lack of agreement between parents and teachers or between two parents often results from genuine variations in the behavior of children in different settings and with different people. Ideally, both parents should be interviewed, even if they are not living together, because their cooperation will enhance the likelihood of successful treatment, and each parent has a unique perspective on the child’s development and environment. A telephone interview may be substituted if a parent is not available in person.

History From Parents

The elements of a complete history from the parents or caregivers are outlined in Table 2–1. The construction of a time line, including symptoms, life events, and changes in the family and environment, can help organize a complex history.

An important element in the developmental history is the child’s temperament, or “style” of behavior. Children can be rated on each of the nine dimensions listed in Table 2–2. The goodness of fit between the child’s temperament and the parents’ temperament, expectations, and child-rearing skills significantly affects developmental course and outcome. In addition, certain trait clusters (Table 2–3) have predictive value. Both difficult and slow-to-warm-up children are at risk for emotional and behavior problems, whereas easy children are relatively protected.

Patient Interview

During the patient interview, the child provides his or her view of the history and his or her current symptoms, strengths, and concerns while the clinician makes observations. Children and adolescents often report their anxiety and depression, clandestine conduct problems, and drug use more accurately than their parents do. Parents typically report history, observable behavior problems, and family background more accurately than the child does. The details of the interview vary with developmental stage. The content of the mental status examination is outlined in Table 2–4.

Family Evaluation

Each person living with the patient, as well as noncustodial parents, grandparents, and siblings who are no longer living at home, may be crucial to understanding family dynamics, including both unexpected sources of emotional support and areas of conflict. Meeting simultaneously with all significant family members to collect information and to observe interactions is often useful. Families with young children may benefit from the use of role playing, family drawings, or puppet play. The clinician may ask the family to complete a task during the session in order to assess family interactions. A family tree or genogram helps the clinician to organize data on family members and their relationships.

Regardless of a family’s structure or members, the well-being of the child requires that certain tasks be accomplished (Table 2–5). Well-functioning families respond resiliently to stress, communicate effectively, assign roles that suit the needs and abilities of each family member, respond appropriately to emotions, solve problems both within and outside the boundaries of the family, and find effective and humane ways to control the behavior of family members.

Standardized Evaluation Instruments

Selected parent, teacher, and self-report behavior checklists, questionnaires, and rating scales supplement the clinical evaluation by providing a systematic review of behaviors and psychiatric symptoms. Scores may be compared with norms obtained from large community-based samples or groups of clinically referred children. Ratings may also be done at intervals to measure progress. The most commonly used broad-spectrum package consists of the Child Behavior Checklist (CBCL) parent rating form, the Teacher Report Form (TRF), and the Youth Self-Report (YSR) Form (Achenbach System of Empirically Based Assessment; http://www.aseba.org). More specific instruments are available for one or more diagnoses. Structured and semistructured diagnostic interview protocols (see Table 2–6) are more commonly used in research but often have clinical usefulness.

Medical Evaluation

A standard evaluation includes a medical history and physical examination (within the past year or more recently if the onset of problems is acute) to identify any medical causes of symptoms or coexisting medical disorders. Neurological consultation or testing (e.g., electroencephalogram, brain scan) is indicated only if focal neurological signs or symptoms are present or if the history suggests seizures, loss of cognitive or physical skills, or sequelae of brain injury. Laboratory tests may be obtained, especially if pharmacological treatment is anticipated. Urine testing for drugs and, in female adolescents, a pregnancy test are often indicated. Scientific evidence does not support the use of brain imaging in clinical diagnosis or treatment of psychiatric disorders in youth.

School Assessment

School reports are almost always useful. Attention, learning, quality and quantity of homework and classwork, behavior in class and on the playground, and social relationships are sensitive indicators of the presence of psychiatric symptoms and of developmental status. After obtaining parental consent, the clinician may talk with the teacher or school counselor, obtain school records (educational testing, behavior, grades, and attendance), arrange for teachers to complete standardized checklists, and perhaps even visit the school to observe the youngster.

Psychological Testing

Standardized tests administered by a clinical psychologist are used to assess intellectual potential, cognitive skills, fund of knowledge, and adaptive functioning (Table 2–7). Individually administered tests provide a more accurate evaluation than those given to children in the classroom. Tests have been criticized because of cultural influences on performance, unresponsiveness to “creative” responses, the dangers of using a rigid construct of intelligence that masks individual strengths, the use of test results to exclude children from mainstream education, and potential insults to developing self-esteem. Despite these concerns, IQ tests provide a global assessment that has clinical predictive value, particularly when combined with an evaluation of adaptive behavior. Projective tests such as the Children’s Apperception Test (CAT) or the Rorschach Inkblot Technique are not useful in making diagnostic or treatment decisions. The most commonly used test for assessing infants (ages birth to 3 years) is the Bayley Scales of Infant Development, Third Edition. It is used to evaluate motor (fine and gross), language (receptive and expressive), and cognitive development.