Psychiatric Assessment of Children and Adolescents
Nancy C. Winters MD
Jenny Tsai MD
Introduction
The primary goal of psychiatric assessment of a child or an adolescent is to determine whether psychopathology is present and, if so, to establish a differential diagnosis, articulate a tentative diagnostic formulation, and develop a treatment plan in collaboration with the child or adolescent, and family. In order to reach this goal, much clinical and historic information needs to be gathered. We describe here a comprehensive psychiatric assessment. There are, however, situations in which specialized or focused assessments occur (e.g., forensic evaluation or risk assessment), and we will briefly review some such situations. Since time for assessment may be limited by external constraints such as funding or resources, a cogent method of assessment and treatment planning is pertinent. The aim of this chapter is to bring nonchild psychiatrists an understanding of the goals of psychiatric evaluation as well as a picture of what happens during psychiatric assessment. In this chapter, we refer to both children and adolescents as “children,” except when discussing specific developmental variations. The term “parents” is used for the child’s caregivers, who may include biologic, adoptive, or foster parents, or other family caregivers.
History Gathering
As summarized in Table 1-1, a comprehensive psychiatric assessment should include the following elements: (a) important identifying information, for example, child’s age, sex, and grade in school; (b) the referral source and reason for referral; (c) sources of information; (d) history of the current problem(s); (e) past psychiatric history; (f) medical and developmental history including intrauterine experiences, and past and current medications; (g) educational history; (h) family social and psychiatric history; (i) social history including substance and tobacco use, sexual behavior, peer relationships, and legal history; (j) history of trauma and/or stressors; (k) mental status evaluation; (1) clinical formulation and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) multiaxial diagnosis; (m) a problem list; and (n) treatment plan keyed to the problem list.
TABLE 1-1 Essentials of Psychiatric Assessment | |
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Special Considerations in Evaluating Children
There are important differences between the psychiatric assessment of children and that of adults. The most pertinent issue is that an evaluation of a child is generally initiated by the child’s parents or other adults involved in the child’s care (as in the case of a school referral). An exception may be the older adolescent who independently seeks treatment. Children may thus be anxious or even shamed in the initial contacts, and it is thus important to establish a positive and safe climate for them.
The rapid pace of children’s development, especially in early childhood, requires familiarity with the different competencies, vulnerabilities, and tasks of each stage of development. Different methods of collecting data and interviewing the child apply at different ages. For example, the infant or toddler is generally assessed with the parent, with special attention to the dyadic interactions, whereas adolescents are best able to furnish relevant clinical information when interviewed alone. There are also differences in the way children at different ages are able to report their symptoms. The younger child tends to have less ability to self-observe and may not have the vocabulary to describe feeling states. Also, symptoms developed early, such as obsessions or compulsions, may be experienced by the child as part of himself or herself and not be recognized as problems.
Because children are more dependent on their adult caretakers, an adequate assessment requires a comprehensive understanding of important environmental characteristics and family relationships, as well as the child’s response to them. Factors such as poverty, family violence, and parental substance abuse or mental health problems all increase the risk of a child developing a psychiatric disorder, and may also impair the family’s ability to adequately respond to the child’s problem.
Development of a differential diagnosis also differs when evaluating children. First, those disorders not specific to childhood, such as depression or obsessive-compulsive disorder, may show developmental variations. For example, depressed children may present as more irritable than sad, and compulsions in children may be experienced as acceptable, or egosyntonic. Additionally, a psychiatric disorder in evolution may have a different, possibly less “differentiated” earlier presentation. For example, young children with early oppositional behavior may later develop mood or anxiety disorders, and schizophrenia may be preceded by social abnormalities and
neuropsychological deficits. Thus, the clinician must inform the parents that there can be some uncertainty about the eventual diagnosis. In practice, child psychiatric assessment is generally an ongoing process that occurs over time. The reality, however, is that children with serious mental health problems who experience significant functional impairment cannot wait for intervention because of negative impact on their development as well as caretaker burnout and community safety. Also there is growing evidence that early treatment can improve the outcome of child psychiatric disorders. Therefore, even in conditions of uncertainty, a preliminary diagnosis and treatment plan are important, as well as a plan for further data collection based on an initial hypothesis. To arrive at a diagnosis, many pieces of information must be brought together. The child psychiatrist is in the unique position of integrating the medical, psychological, social, and developmental aspects of the child, while other clinicians may address specific components.
neuropsychological deficits. Thus, the clinician must inform the parents that there can be some uncertainty about the eventual diagnosis. In practice, child psychiatric assessment is generally an ongoing process that occurs over time. The reality, however, is that children with serious mental health problems who experience significant functional impairment cannot wait for intervention because of negative impact on their development as well as caretaker burnout and community safety. Also there is growing evidence that early treatment can improve the outcome of child psychiatric disorders. Therefore, even in conditions of uncertainty, a preliminary diagnosis and treatment plan are important, as well as a plan for further data collection based on an initial hypothesis. To arrive at a diagnosis, many pieces of information must be brought together. The child psychiatrist is in the unique position of integrating the medical, psychological, social, and developmental aspects of the child, while other clinicians may address specific components.
Sources of Information
The assessment of the child requires that information be obtained not only from the child but also from the family, school, primary physician, and past mental health providers. Obtaining information from multiple sources allows the clinician to better gauge whether the problem is global (occurring across all settings) or circumscribed to a certain environment. For children involved in the juvenile justice, child welfare, special education, or developmental disabilities systems, review of information from the agency records or caseworker is essential. Past and current medical records are helpful in discerning any medical issues that may contribute to behavioral or mood problems.
Clarifying the purpose and goal of the referral at the very outset is essential. Although the child’s behavioral and mood problems may be the obvious reason for referral, other more covert intentions may be present. For example, a pending juvenile court decision may be the motivating factor for an adolescent to seek “treatment,” rather than his or her condition itself propelling the desire for treatment. Parental custody conflicts and threats of school expulsion may be other motivating factors that promote the initial visit to a clinician’s office. These other intentions have implications regarding diagnosis and treatment recommendations, in addition to prognosis. For example, parental custody conflicts may influence a parent to overreport or underreport the child’s symptoms. At times, the referral may have been requested by adults other than the parents, for example, by the school or court, in which case parental permission usually is needed unless the child is a ward of the state, in which case consent of the caseworker is needed.
One informative question to ask at the beginning of an assessment is “why now?” Often, there is an acute stress incident that finally makes the parents realize their child needs professional help. Whether the parent recognizes the child’s need for help soon after problems develop or after the child has become very disturbed provides information about the closeness of the parent-child relationship and how well the family functions in promoting the health of family members. Often, fear of stigma delays seeking help for mental health conditions, and understanding the parents’ or child’s apprehensiveness facilitates forming a more collaborative relationship. This may be especially important when there are cultural, ethnic, religious, or even social class differences between the patient and the clinician, and these differences may contribute to delays in seeking treatment.
The Clinical Interview
The structure of assessment interviews depends on the individual case. It may be appropriate to have one or two initial interviews with the parents alone, especially when the patient is a younger child. This allows the parents to share a complete history of the problem without concern about what the child may hear. It also allows the parents to communicate about their response to the child and their own personal issues or concerns that may impact the child’s
mental health. That is not to say this is the only approach. One advantage of an initial conjoint interview with the child and parents is the opportunity to observe family interactions, such as the family’s manner of communicating with and about the child, whether the family exhibits aggression or affection, concern or derision toward one another, who sets the rules, and whether the parents argue in front of the child. How the parent communicates with the child also provides information as to his or her understanding of the child’s developmental capacity and the parent’s attunement to the child’s state of mind. During the conjoint interview, one can also appreciate the stress a child’s difficulties place on a parent, even with otherwise normal parenting skills.
mental health. That is not to say this is the only approach. One advantage of an initial conjoint interview with the child and parents is the opportunity to observe family interactions, such as the family’s manner of communicating with and about the child, whether the family exhibits aggression or affection, concern or derision toward one another, who sets the rules, and whether the parents argue in front of the child. How the parent communicates with the child also provides information as to his or her understanding of the child’s developmental capacity and the parent’s attunement to the child’s state of mind. During the conjoint interview, one can also appreciate the stress a child’s difficulties place on a parent, even with otherwise normal parenting skills.
With adolescents, however, it is usually preferable to include the adolescent in interviews with the parents, as not doing so may risk the teenager’s feeling that the clinician is colluding with the parents, with the result that a therapeutic alliance may be much more difficult to establish. An older adolescent may prefer to attend the first appointment alone. In either case, the child or adolescent should be prepared for the evaluation. At times, when parents think their child may refuse to come for a psychiatric evaluation, they may deceive the child by saying he or she will be taken to a medical doctor or a special school. The clinician then has the extra challenge to overcome the child’s sense of betrayal by the parent and to manage the child’s displaced anger and annoyance. It is also helpful to advise the parent to communicate the purpose of the evaluation in a manner that is supportive and nonblaming of the child, such as “we are going to see a kind doctor who will help you with your worries.”
Once the family comes in, the primary task is to build a therapeutic alliance with the family and child. This means setting up an ambience of respect, warmth, and trustworthiness. Some means of doing this include having good eye contact, allowing ample time for all participants to describe their concerns, and speaking in a respectful, concerned way. Some adults and children may be intimidated by visiting a clinician. Asking the child simple questions such as his or her name or birthday, and the names of his or her siblings may help put the child at ease. Asking the child to spell his or her name or write down his or her birthday and other family members’ birthdays on a piece of paper may lend valuable information regarding the child’s cognitive abilities. With regard to teens, discussing hobbies, interests, and job responsibilities can create a sense of ease and convey that the clinician is interested in what they have to say.
Once a sense of mutual regard is established, the next stage of the interview involves exploring the reason for bringing the child in for evaluation, that is, the chief complaint. The goal is to ascertain the child’s current difficulties and the impact of his or her symptoms on parents and the family. If there are several complaints, it is important to understand how disturbing each one is from the child’s and the parents’ points of view, and which ones they would like to address first in treatment. As the assessment progresses, it is not uncommon for the prioritization of concerns to change. Elaborating on the chief complaint entails careful data gathering of the frequency and severity of the problem, as well as the where, when, and how of the situation. A functional analysis of behavioral disturbance is helpful. Any elucidated triggering or alleviating factors should be explored. Does the behavior occur only at school, at home, or at both places? Is it in relation to only specific people, or does the child’s behavior occur globally? What impact has this had on the child and family? How long has this behavior or symptom been occurring?
In addition to exploring current issues, it is crucial to learn about past psychiatric history, medical history, medications, family psychiatric history, social history, school functioning, legal involvement, and a review of systems. Each of these realms may provide a clue and/or have an influence on the present complaint. For example, if it is found in the substance abuse history that a teenager has abused illicit drugs in the past, it is possible that the parent’s complaints that he or she is displaying agitated behaviors might be related to drug use. Similarly, in a child presenting with depressive symptoms, a review of the past medical history and medications may yield clues regarding the etiology. If a parent has a particular psychiatric disorder,
he or she may be requesting an evaluation to see whether the child might be similarly affected. Such a situation requires balancing sensitivity to the parent’s concerns with conducting an objective assessment of the child as a separate individual. Social history should also include a review of the child’s extracurricular activities and peer relationships, especially whether the child is being bullied at school. Also, clarifying the nature and extent of the child’s use of electronic media, including the Internet, video/computer games, text messaging, and movies, may be related to the presenting complaint, as in the case of a teenager who met with a stranger she met on the Internet, or the child at risk for aggression whose behavior is exacerbated by violent content in movies or video games, or the socially isolated teenager who spends excessive time playing Internet games. The importance of investigating the child’s use of electronic media is highlighted by several recent investigations that have found a role in psychiatric disturbances, sexual victimization, and suicide. As reviewed by Huesmann, exposure to violence in electronic media is associated with increased aggression, especially in youth already at risk for psychiatric disorder. Other work has shown cyberspace-related victimization and promotion of suicide among young people. Even simple television viewing as toddlers appears related to the development of attention-deficit hyperactivity disorder (ADHD). Family members’ use of electronic media is also important to explore, as parental preoccupation with online relationships may be disturbing to children. Similar to parental tobacco, drug, and alcohol use, excessive use of electronic media in adults may influence these behaviors in children.
he or she may be requesting an evaluation to see whether the child might be similarly affected. Such a situation requires balancing sensitivity to the parent’s concerns with conducting an objective assessment of the child as a separate individual. Social history should also include a review of the child’s extracurricular activities and peer relationships, especially whether the child is being bullied at school. Also, clarifying the nature and extent of the child’s use of electronic media, including the Internet, video/computer games, text messaging, and movies, may be related to the presenting complaint, as in the case of a teenager who met with a stranger she met on the Internet, or the child at risk for aggression whose behavior is exacerbated by violent content in movies or video games, or the socially isolated teenager who spends excessive time playing Internet games. The importance of investigating the child’s use of electronic media is highlighted by several recent investigations that have found a role in psychiatric disturbances, sexual victimization, and suicide. As reviewed by Huesmann, exposure to violence in electronic media is associated with increased aggression, especially in youth already at risk for psychiatric disorder. Other work has shown cyberspace-related victimization and promotion of suicide among young people. Even simple television viewing as toddlers appears related to the development of attention-deficit hyperactivity disorder (ADHD). Family members’ use of electronic media is also important to explore, as parental preoccupation with online relationships may be disturbing to children. Similar to parental tobacco, drug, and alcohol use, excessive use of electronic media in adults may influence these behaviors in children.
It is worth noting that each individual family member may have a different perspective about the child’s problem. This is relevant in the case of the child’s parents, who, whether living together or divorced, are likely to perceive the child differently. Each point of view is likely to contain some kernel of truth. The parents may disagree in a way that compromises their ability to function together as parents and thereby contributes to the presenting problem. Such differences may relate to the parents’ family-of-origin issues, differences in parenting styles, current psychiatric conditions, or stressors. How a parent describes the child’s difficulties is also informative about the parent-child relationship. For example, a parent who describes the child’s behavior in pejorative terms may be angry at home and may need additional help to support the child.
An analysis of the child’s environment is an integral part of the assessment. The child’s functioning is highly influenced by his or her ecologic context, which includes the “microsystem” of his or her family, school, and immediate neighborhood and the “macrosystem” of his or her larger community and culture. Exploring contributing factors within the home, school, community, and larger culture can yield clues for effective interventions. Culture is an integral aspect of family life, and this area should be included in the child’s psychiatric assessment. Important aspects of the cultural interview include the family’s ethnic identification, their relationship with a cultural community, the family’s migration history, the structure of the extended family including languages spoken and roles of each family member, religious affiliations, child-rearing practices that may be related to culture, and the family’s attitudes about illness and health care, including use of traditional healing. Of particular relevance to the presenting problem may be the child’s attempts to live within both his or her family’s traditional values and his or her new American culture. As described by Abad and Sheldon, differences in the degree of acculturation between immigrant parents and their children may cause family turmoil. Such issues should be explicitly raised with the child and family so that they realize these are appropriate issues to discuss and that the clinician is interested in their circumstances. The essentials of obtaining a psychiatric history are summarized in Table 1-2.
Developmental Issues
One main goal during the history gathering and mental status examination is to gauge the child’s developmental stage in order to recommend appropriate interventions. This entails the evaluator’s understanding variations of normal and abnormal child development, including
the expected range of behaviors at different ages and the typical manifestations of sundry forms of disturbances in each developmental phase. The evaluator ideally would be skilled in verbal and nonverbal techniques for assessing the child. In general, children are not silver-tongued historians who narrate their travails in a straightforward verbal fashion, although there are exceptions. Hence, in order to elicit information that may be helpful in evaluating the child’s current mental status and developmental level, the evaluator should be familiar with a variety of techniques that may facilitate information sharing on the child’s part. Relevant aspects of the developmental assessment are summarized in Table 1-3.
the expected range of behaviors at different ages and the typical manifestations of sundry forms of disturbances in each developmental phase. The evaluator ideally would be skilled in verbal and nonverbal techniques for assessing the child. In general, children are not silver-tongued historians who narrate their travails in a straightforward verbal fashion, although there are exceptions. Hence, in order to elicit information that may be helpful in evaluating the child’s current mental status and developmental level, the evaluator should be familiar with a variety of techniques that may facilitate information sharing on the child’s part. Relevant aspects of the developmental assessment are summarized in Table 1-3.
TABLE 1-2 Essentials of History Taking | |
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Younger children, particularly preschool and early-school-aged children, are more able to communicate their thoughts, fears, and perceptions of themselves and others through play. Techniques for engaging the child in evaluative play include following the child’s lead, using humor, exploring the child’s interests, encouraging imaginative play, and matching the affect the child expresses during the interview. For younger children, it is usually advisable to start out making observations about the child’s play. Small children can easily become frustrated with too many questions, and refuse to interact further. Other ways of engaging young children include reflecting the child’s ideas and vocabulary, and using projective questions, for example, “If you had three wishes, what would they be?” “What animal would you choose to be if you could be one?” “Who would you take with you if you went on a trip to Mars?”
Related posts:
Trauma and Associated Disorders
Suicidality and Youth: Identification, Treatment, and Prevention
Community-Based Systems of Care
Oppositional Defiant Disorder and Conduct Disorder
Early Childhood Mental Health in Clinical Practice
Caring for Children and Adolescents with Mental Health Problems in the General Health Setting
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