The formulation in child and adolescent psychiatry distills clinical encounters with a child and his or her family into a manageable and meaningful synopsis. It arranges the child’s symptoms and circumstances into a specific format and establishes a set of hypotheses about the child, which can then be adapted depending on further clinical encounters and collateral information. The formulation need not be the condensation of a child’s life into a single, perfect narrative. Rather, it can be seen as an evolving appraisal and an iterative process, accommodating further information as it is elicited from the child and family. In parallel with an appreciation for the complexities of the process of development itself, the clinician need not view the formulation as static, but as a format that can be adjusted and expanded over time, taking into account the processes of maturation and growth through which the child and family are going. The flexibility of this format reflects the clinician’s emerging understanding of a child.

Because treatment options comprise the full spectrum of interventions, including decisions not to treat, the formulation must be able to communicate the important information about the child leading to these decisions; explain the rationale for treatment in a clear and concise way; and incorporate new information, new hypotheses, and ongoing assessments of the severity of the child’s condition.

The rich history of psychiatric formulations runs the gamut from fragmentary allusions in clinical anecdotes to the most elaborate case studies of Freud and Jaspers. A contemporary clinical formulation would likely avoid some of the more ornamental terms of a classic case study, but the composition would follow a similar trajectory. Throughout the history of the psychiatric formulation, the path has remained fairly steady, signposted by referral source, identifying information, history of present illness, and significant past psychiatric and medical histories (Table 4.2.6.1; see also Chapter 4.2.2). This consistency not only allows for communication between the generations, but permits clinicians to follow a familiar route while attuned to important details and nuances.

Although there is a historical precedent for the overall shape of the formulation, we ought not to be naive about the theoretical work a formulation performs. Tauber notes that in science “observations assume their meanings within a particular context, for facts are not just products of sensation or measurement, as the positivists averred, but rather they reside within a conceptual framework that places the fact into an intelligible picture of the world” (2). The formulation is not a value-neutral format containing dispassionately arranged facts. The choice as to which facts to include and which to reject and the subsequent ordering and presentation of the facts collude to produce a value-laden product.

An obvious example of this is how formulations vary according to clinical circumstances. Certain situations and clinical locations require specific formulations. Encompassing everything from the haiku-like précis and the SOAP note to lengthy descriptive discussions of a patient’s life, the formulation mirrors a set of clinical priorities. It can range from the no-nonsense focus of a crisis service where the severity and acuity of a patient’s needs must be brought into focus and where biomedical perspectives are prominent, to the developing working model of the inpatient unit, and through to the gradual blossoming of relationships, defenses, and cathexes cultivated and analyzed in a psychodynamic formulation. What each clinical milieu values is reflected in how the child’s assessment and treatment will be formulated.

What can a formulation accomplish? It organizes the clinician’s interaction with patients into a communicable form that should justify and explain further investigation and intervention. We will examine several formats that can be used to do this, from the biopsychosocial model and the 4 Ps to pluralistic and integrationist critiques of these models. There are, however, two distinct goals of the formulation: understanding the patient and explaining the patient’s symptoms, conditions and concerns (3). We must guard against confusing the one for the other (see Pruett, Chapter 1). In some cases, the depth of our understanding of a patient’s experience may not help explain the etiology of a symptom in a way conducive to treatment, and likewise a model of behavior may not adequately impart the patient’s experience of that behavior. The various models approach these two goals with different degrees of clarity and transparency.

In this chapter, we cover four ways of conceptualizing the formulation— the biopsychosocial model, the 4 Ps, the pluralist approach, and the integrationist approach. The models are not all mutually exclusive, and the strengths, weaknesses, and compatibility of each will be noted. None of the models was specifically created for child and adolescent psychiatry. Issues such as a youth’s rapid, tumultuous, and uneven development (which spans all domains of a child’s life) and the centrality of family, school, and peer milieu deserve fuller recognition and integration than originally afforded in these models.

Developed over the past three decades, the biopsychosocial model is probably the most common formulation used in psychiatry. With its roots deep in the history of medical practice, based on the understanding that the clinician is treating a person and not just a pathology, the model has
been successfully adopted throughout medicine. The model is often attributed to Engel, who deserves credit for developing it, naming it, and advocating effectively for it as a “way of thinking that enables the physician to act rationally in areas now excluded from a rational approach” (4). Meyer also merits citation for his “psychobiological” approach (5). Both Engel and Meyer were responding to biomedical advances in medicine and psychiatry— Meyer to the influence of Kraepelin, and Engel to the blossoming of neuropsychiatry in the 1970s— and both sought a balance between what was commonly seen as two warring factions in psychiatry: the psychoanalytic and the biological.

The biopsychosocial model concentrates on three realms of a patient’s experience, presenting symptoms and circumstances: the biological, psychological, and social (Table 4.2.6.2). Questions are geared toward eliciting information about each of these domains, and the subsequent formulation is constructed from each one. The biological domain circumscribes neuropsychiatric, genetic, and physiological concerns, focusing on, but not limited to, the functional operations of the brain and what might be directly affecting it. The psychological dimension includes an evaluation of the child’s psychological makeup, including strengths and vulnerabilities. It offers the opportunity to note psychodynamic principles like defense structures; consciously and unconsciously driven patterns of behavior; characterization of wishes and desires; responses to trauma and conflict; and strategies the patient has used to resolve these; transference and countertransference (6). The social dimension situates the child in his or her communities, exploring relationships with family and friends, as well as larger collective cultural organizations like schools, religion, socioeconomic class, and ethnicity.

The formulation brings the three domains together into a narrative, arranged according the core components described above. Although the biopsychosocial model may appear to be a neutral mediator between the three domains, it quite specifically is not: It is a considered response to biomedical, psychological, and social reductionism. Regardless of anatomical lesions, or clear psychological or social etiologies, this model insists that all three be accounted for, and in doing so has been a powerful and successful model for physicians in all fields of medicine.

Advocates for the biopsychosocial model argue convincingly that the “broad approach [is] essential to avoid premature closure of our efforts to understand the patient’s needs, tunnel vision or an overly narrow approach to treatment” (7). Furthermore, psychiatrists are in a unique position within medicine to minister to the biological, psychological, and social needs of the patient (8), and so are responsible for being attuned to each.

Nevertheless, critics of the model, also convincingly, note that the biopsychosocial model is, as Ghaemi puts it, “silent as to how to understand those aspects under different conditions and in different circumstances” (9). While insisting that medical materialism or psychological and social dogmatism cannot suffice, this model does not guide the clinician on how to weigh or measure the relative contributions of each in any given patient. This results in the so-called “eclectic error,” in which the neutrality of the model implies that what works in one area of psychiatry can be applied to all areas.

In addition, the biopsychosocial model does not blend the various dimensions as much as loosely knit them together: The model offers very little direction as to how to bring together three conceptually different areas of a patient’s life other than through proximity in the formulation. Thus, how the social, biologic and psychological are integrated is left unanswered (10). Some have noted that those who prefer one particular realm can pursue that course while paying lip service to the others in a few short sentences (11). Nevertheless,
treating the biopsychosocial formulation as a way of rethinking reductionism and as an opportunity for generating hypotheses about multiply determined etiologies may lead to improved capacity for further synthesis and understanding (12).

A final comment about this model is that even when it is used, the tailing “social” domain is often the least explored (13), either by necessity or by choice. Virchow said that “medicine is a social science,” and although psychiatry has a history of collaborating with sociology (14), the intersection of psychiatry and sociology is still underexplored. This is especially true in regard to children, many of whom present to child and adolescent psychiatrists due to some fundamentally social concern, such as impulsivity and hyperactivity in the classroom, conflict with parents, truancy, and school refusal, or other concerns in the realm of externalizing disorders (15). Including the social factors that may be influencing a child’s life and symptoms in the formulation is an important contribution of the biopsychosocial model, and it is not necessarily a flaw of the model itself that this dimension is often not given the prominence it deserves.