The Psychiatric Evaluation

Essential Concepts

Providing a comprehensive initial psychiatric evaluation is the cornerstone for all effective treatment planning.
The psychiatric evaluation is typically initiated by adults, and engaging the child, as well, is essential.
A comprehensive evaluation includes gathering information from multiple sources (parents/guardians, school, primary care provider, child, and others).
Inventory strengths as well as deficits/areas of need.
The assessment of parent and family functioning is integral to the evaluation.

The work of psychological healing begins in a safe place…The psychological safe place permits the individual to make spontaneous, forceful gestures and, at the same time, represents a community that both allows the gestures and is valued for its own sake.”

–Lester Havens, M.D. A Safe Place

The psychiatric evaluation of a child or adolescent is not just a diagnostic interview and checklist of DSM-IV symptoms. It is much more—forming a rapport with the patient and family, learning about the child’s functioning in multiple domains and from multiple sources, and assessing the child’s family functioning (or environmental match if the child or adolescent is not living in the home). I like to think of myself as “Sherlock Holmes” during this time. I use the more obvious clues (usually the presenting complaint) to begin the investigation, as well as “digging deeper” to understand the nature of the symptoms and behavior, and the biological, psychological, and social factors which are precipitating and maintaining the impairing symptoms.

Basic Principles

Special Considerations in Evaluating Children

The psychiatric evaluation of a child or adolescent has a number of important differences from that of an adult:

The referral is typically requested by someone other than the patient. The child (or adolescent) may feel ashamed, angry, or convinced that the evaluation is a punishment for being “bad.” Try to set the stage to be as nonjudgmental and collaborative as possible, giving the child as much control as is appropriate and safe.
Children are not just little adults. Remember the developmental stages (Chapter 1) and what to expect of a child of each age.
Different methods of collecting data and interviewing the child apply at different ages. The goal is to understand the child’s inner world and perspective. Techniques may range from observing an infant–parent dyad, or using play to understand the preschool and young elementary school child, to talking directly about symptoms with the adolescent. Remember to alter the approach to fit the developmental needs of the child. Drawing may be a helpful adjunctive tool at any age.
The assessment of parental and family functioning is crucial. It is not possible to conduct an adequate assessment without an understanding of important environmental characteristics and family relationships, as well as the child’s response to them.
Use multiple informants. It is important to know if the child is having difficulties in all contexts, or only specific ones (for example, doing well at home, but having behavioral difficulties at school). This may help clarify the nature of the difficulty and point to specific areas for remediation.
Diagnoses are more complicated in children. Although children may technically be diagnosed with almost any DSM-IV diagnosis, the varying presentation of symptoms at different ages, the evolution of disorders, and the lack of diagnostic and etiological specificity for many symptoms (impulsivity and aggression, for example) make diagnoses more fluid and unclear. It should be clarified that the diagnosis may change over time. However, this should not delay intervention and treatment of disabling symptoms.

Defining the Purpose of the Evaluation

Although many components to a psychiatric evaluation are similar to that of adults, how it is conducted, what information you need to glean, and how the information is used may be very different. Before you start, consider the purpose of the evaluation and use this information to structure the evaluation to fit the reason. Possible referral sources include:

Parents (recommended by school, friends, relatives, themselves)
Legal guardian (or state custody)
Schools—they are paying for an evaluation of a student about whom they have concerns
Courts—the child has legal issues, custody issues

The dynamics of the evaluation and how and where you conduct it depend on why you are doing the evaluation.

Clinical Vignette

I was conducting an evaluation for a school system of a child with learning issues and acting-out behavior. The first meeting with the parents sought to clarify the dynamics of the evaluation.

Interviewer:	Hello [shaking hand of each parent and sitting down]. You know that I am a child and adolescent psychiatrist and that I have been asked by the school system to evaluate your son?
Father:	Right [looking disgruntled].
Interviewer:	I notice that you look unhappy to be here. Perhaps we can review what I have been asked to do to be sure that this is what you want.

In this case, the parents had requested a therapeutic school for their son (a school placement which would be expensive for the district and would place him with other special-needs children). The school district disagreed and maintained he would be better served in his home school. The parents felt the psychiatrist was a “hired gun” to prove the school’s view that the child could be programmed for within-the-home school. The parents felt coerced and helpless. Bringing that out early in the interview helped to identify a needed aspect of the consultation—addressing the school–parent tensions.

Key Point

Who is paying for the evaluation is not a minor detail. Being an expert witness for one or the other side of a court case can strongly influence the “spin” of the same information. Be clear with yourself and your referral source who your client is. If the school or other agency is asking for a hired gun, be clear with everyone what you do. I find that the “best interest of the child” model works best. I try to keep my assessments focused on what I believe will ultimately lead to a more healthy developmental outcome for the child.

Setting the Stage

Setting the stage before you even meet the child or family is critical. Different clinics or private practitioners do this in different ways. Parents are often intimidated by the prospect of the evaluation, and few have a good notion of what it will entail. Most clinics use written statements of policies and procedures. As a trainee, you should know what information is given to families about policies and familiarize yourself with these. The following information should be included in communication (either on the phone or in the first session) with the parents or guardians before you begin:

Who you are—parents and guardians frequently need clarification about what different mental health professionals do. Explain your training and area of expertise.
What the psychiatric evaluation entails—with whom you will meet, in what order, what you do in the sessions, and what other information is needed.
How long it will take—how many sessions, how long per session.
What it will cost—for the evaluation as well as for ongoing treatment afterwards, if required.
What they can expect at the end—recommendations: a written report, ongoing treatment, etc.
What your policies are (define for patients and their families)—how and when to contact you, what to do in the event of an emergency, who you have permission to contact about the patient (HIPAA-friendly release of information forms required), and how you deal with missed appointments. Review for whom the evaluation is being done (parents or other agency) and the extent of confidentiality.
What to tell the child or adolescent to prepare him or her for the appointment.

If you are in a clinic, much of this work will be done by the intake person. Reiterating the information above is needed to clarify the goals and expectations for the evaluation.

The most uncomfortable part of an entire encounter for the clinician tends to be talking about billing. Although working in a clinic may spare you this difficult task, it is still important to mention it—to reiterate what the billing procedure is. I remember only too vividly my first encounter with a new patient’s family after graduation from training. The words “bill” and “payment” seemed to stick in my mouth. Once I finally made this part of my written and verbal policies, I got much better at it—and my patients were less anxious as well.

Tip

I recommend that for an evaluation of a child, you meet first with the parents or guardians. For an adolescent it may be advisable to meet with the parents and adolescent patient in the initial interview to allay concerns of collusion with the parents. It is important to meet with both parents (if they are married or not) whenever possible. This is helpful in terms of getting various perspectives, as well as understanding the nature of the parental interactions, and how they each relate to and understand their child. In the case of divorced parents, you may need to meet with each parent or step-parent group separately. Getting a sense of how the parents work (or don’t work) together in raising the child is important.

Tip

Explain to parents what type of professional you are. Many parents may confuse a psychiatric evaluation with psychological testing. The following introduction to the parents may be helpful:

I am a child and adolescent psychiatrist (or fellow)—a medical doctor who specializes in understanding and treating emotional and behavioral problems of children and teenagers. Perhaps we can spend just a few minutes reviewing what I do and what you expect, to make sure we’re on the same page.

[Ask at this point what the parents are hoping to achieve from the evaluation. Then give a brief description of the nature of the evaluation.]

I try to get the best understanding I can of your child and his/her strengths as well as areas in which he/she is having real difficulties. To understand and help your child, I need to talk to the people who know him/her best. That is you, as his/her family, of course. But I also find that information from the school, pediatrician, (any others) is helpful. I will also meet and get to know your child. I will talk to him/her about things that he/she likes and is good at, as well as to try to understand the reasons that he/she is having difficulties. For younger children, I also use play with toys or games as a way of getting to know and understand him/her.

It is helpful to mention that you use play as an evaluative (and later, perhaps, therapeutic) tool for younger children. Some parents will be confused and distressed when their child, who has been causing such chaos in the home, comes out of the office and reports, “It was fun! We just played.”

Follow up with how many times you will meet and get Release of Information forms signed (be sure to follow Health Insurance Portability and Accountability Act [HIPAA] guidelines).

I will meet with you for (an hour) today. Then I will meet with your child for (50 minutes, how many times and when). With your permission (explain HIPPA and get releases signed) I will also get information from your pediatrician, school, (any prior treaters, protective services, if there is involvement, any others. Ask if there are other sources with whom you should speak).

And now, for the difficult part—billing, cancellation policy, confidentiality, feedback, and procedure for contacting you. As a trainee, the financial aspects of billing and cancellation may seem irrelevant, but there are important clinical benefits to being clear about expectations (fewer cancellations and no-shows and more treatment compliance) and important training benefits to practicing this skill.

As you know, [review the clinic billing and cancellation procedure]. When my evaluation is complete, I will meet with you [review the recommendation feedback procedure. If there will be a report generated, or not, clarify that. Also clarify with whom you will share the information. If the entire evaluation is court-ordered or requested by another agency with which a report will be shared, be clear about that. Clarify the extent of confidentiality, or lack thereof, with the parents, as well as the child or adolescent. If the report is being done for the Court, there is no confidentiality. Even in a regular practice, confidentiality is limited if you feel the child or others are in danger—state that up front. Clarify the clinic procedure for contacting you—both regular communication and after hours or for emergencies.]

Before you end the session, review with the parents what they will tell their child about the evaluation. Help them practice explaining this to their child in a manner that is supportive and nonblaming. I have had parents tell their child that they were going out for ice cream, only to end up in my office. Although I learned a great deal about how the parents deal with their willful child (grist for the mill), needless to say, it did not set an inviting stage for the child to engage with me.