Psychiatric assessment of children and adolescents is a
multifaceted process that includes interviewing parents,
children, and families, obtaining
... [Show More] current information and
histories from other sources, assessing the severity of symp-
toms and overall levels of functioning, and synthe sizing
this information into comprehensive psychiatric formula-
tions and treatment plans (for the American Academy of
Child and Adolescent Psychiatry’s practice parameters on
assessment, see King, 1997; Thomas et al., 1997). The goals
of this chapter are to describe the content and process of a
psychiatric assessment, as well as to provide an over view of
the diagnostic formulation and treatment plan ning process
with children and adolescents. The psy chiatric examination
and diagnostic process are closely interwoven. Even though
an accurate diagnosis depends on information collected in
the psychiatric interviews and the mental status examina-
tion, knowledge regarding diagnostic categories affects the
content and flow of clinical data collection. Nevertheless, for
purposes of exposition, the clinical and diag nostic processes
are described separately. This chapter considers assessment
from the perspective of the child and adolescent psychia-
trist, and it is intended for phy sicians who want to improve
their skills in the evalua tion of mental health functioning
in children and youth. It also includes a section on the role
of the primary care physician in psychiatric screening and
assessment.
Complexities of assessment in child and
adolescent psychiatry
There are several complex features of the psychiatric as-
sessment of children that differ from the assessment of
adults and that warrant special consideration. In children
Introduction
Complexities of assessment in child and adolescent psychiatry
The psychiatric examination
Interview with the child or adolescent
Diagnostic formulation and treatment planning
Psychiatric diagnosis in children and adolescents
Child psychiatry and the primary care physician
Summary
OUTLINE
Assessment and Evaluation4
ever, children are vastly different in their abilities to tell the
examiner about their peer and fam ily relationships, moods,
and how they conceptualize the reason for the evaluation.
Many children, especially younger ones, may provide only
an indirect glimpse into this material. They may be limited
in their abilities to verbalize their feelings and describe their
social interactions. As a result, the use of interactive play
and projective techniques is often required to obtain this
information. Play with dolls that represent family fig ures,
puppets, or drawing may take on greater impor tance in the
assessment for a younger child than for an older child. How-
ever, the verbal expression of feelings may also be difficult
for an older child or adolescent, and other, less directive pro-
cedures are often helpful.
It is important to remember that the psychiatric ex-
amination assesses a child’s or adolescent’s functioning at
a single point in time. Therefore, one cannot neces sarily as-
sume that the results of such an assessment are representa-
tive of the child’s general functioning. It is possible that the
physician may not see the symptoms described by the refer-
ring source in one or more evaluation sessions. Addition-
ally, symptoms may change dur ing the assessment process.
However, even seemingly minor behaviors that may be
observed during the evaluation can be highly indicative of
problems in day- to-day life. For instance, some children are
reluctant to participate in the individual session with the
psychia trist if it requires that their parents are left in the
wait ing room. Even though this degree of difficulty sepa-
rating might reflect a normal degree of anxiety in an initial
appointment with a young child, it could also indicate the
presence of separation anxiety disorder. On the other hand,
a child with oppositional defiant disorder (ODD) may be on
his best behavior with the inter viewer. Only by carefully lis-
tening to the child’s re sponses to direct questions about his
relationships with authority figures is it possible to develop
an under standing of the problem. Because of such special
con siderations, a full range of information from multiple in-
formants must be elicited and considered when formu lating
a diagnosis and treatment plan in children and adolescents.
The psychiatric evaluation of children further differs from
that of adults in that the child can provide only a limited
amount of historic information. A child cannot relate the
circumstances of his birth or his developmen tal history.
A younger child is also not cognitively ca pable of relating
symptoms in a temporal sequence. Therefore, the physician
must turn to other sources for a comprehensive picture of
the child. This includes the parents, other relatives, teachers,
pediatricians, guidance counselors, and camp counselors,
as well as sources of objective information, such as the re-
sults of psychologic testing and rating scales. A review of the
pediatrician’s records can often provide information about
the child’s early developmental history, and school report
cards can show the early cognitive and behavioral develop-
ment of the child.
A complete picture of the child’s strengths and the nature
of the problem arises from the various sources of informa-
tion. There are times when different informants provide
conflicting data, and it can be difficult to know who to be-
lieve. The physician must then use his judgment to assess
this information variance. It is important to remain mind-
ful of how well the various informants know the child and
to know which observers are best able to evaluate which
symptoms. For instance, it is not unusual for a child to ad-
mit to mood or anxiety symptoms of which the parent is
unaware. Therefore, such reports should be taken seriously
even if they are not confirmed by the parent. Conversely,
teachers’ reports of inattention and overactivity should be
given the highest priority when evaluating a child for atten-
tion-deficit/hyperactivity disorder (ADHD) because teach-
ers see the child in a structured setting and are therefore
considered the best informants regarding this behavior.
A general rule is that children are essential sources for re-
porting internalizing symptoms such as anxiety and mood
symptoms, whereas adults are often better informants
about the presence of externalizing behaviors such as con-
duct problems. When parents and teachers differ in their
accounts of a child, clinical judgment must be applied to
discern the reasons for this disparity. Differences may result
not only from the various perspectives of the informants
but also from the child actually exhibiting different behav-
ior in various settings.
It is important to supplement the information derived
from the history and the mental status examination with
additional data from rating scales, psychologic and neu-
ropsychologic tests, and any requisite medical evaluation or
laboratory tests (see Chapter 3). Clinically useful and easy-
to-administer rating scales (see Chapter 2) are Achenbach’s
Child Behavior Checklist (CBCL) for parents and Teacher
Report Form (TRF) for teachers (Achenbach and Rescorla,
2001) and the Connors rating scales for teachers and parents
(Connors et al., 1998). These rating scales have been stand-
ardized and normed for age and gender, and therefore they
provide comprehensive tests for the presence or absence of
symptoms. They do not provide diagnosis, but rather levels
of psychopathology in general. Psychologic (cognitive/ed-
ucational) testing is necessary to diagnose mental retarda-
tion and learning disorders. The battery may include tests
of verbal and nonverbal cognitive abilities, achievement
tests (to assess academic functioning), and projective tests
(to assess reality testing and interpersonal functioning). A
significant discrepancy between a child’s measured intel-
ligence quotient (IQ) and his performance on a standard-
ized academic achievement test is indicative of a learning
disability. An IQ below 70 may lead to a diagnosis of men-
tal retardation, although this requires evidence of adaptive
functioning delays as well. Specific neuropsychologic tests
may suggest organic pathologic conditions or localizing le-
sions.
Psychiatric Examination and Diagnosis in Children and Adolescents 5
The psychiatric examination
Overview
The psychiatric assessment is the comprehensive clinical
evaluation used to determine whether a psy chopathologic
condition is present, whether treatment is indicated, and
what treatment should entail. The emotional and behavioral
functioning of the child are evaluated and placed in the con-
text of the child’s cur rent developmental level and expected
developmental gains.
Before the evaluation begins, the parents should be in-
formed about the assessment process and give help to pre-
pare the child for the evaluation. This process is normally
fraught with anxiety, and if the child is not properly pre-
pared, he may not be optimally cooperative dur ing the in-
terview. Therefore, it is also important to find out what the
parent has told the child about the upcoming evaluation.
Parents often ask for the physician’s opinion regarding how
to prepare a child for an evaluation. The response to this
question should be at least partially related to the nature of
the impairment. For example, a parent might tell the child
that he is going to see a talking (or playing) doctor who will
fi nd out how to help him im prove his school performance
or his behavior. Typically, children are worried about nee-
dles or blood, and they are reassured if they are told that
there will be no skin pricks, poking, or injections. Parents
should also be given specific information about the length
of the evaluation, the cost, and what they can expect when
the evaluation is complete (such as a for mal report or an
informing session).
During the assessment, the physician gathers information
about a child’s problem, psychiatric history, present and
past medical history, family history, current developmen-
tal status, early developmental history, school history, and
mental status (see Box 1.1). When performing the assess-
ment, the physician should consider not only the child’s
pathologic condition and which symptoms are present or
absent, but also the areas of strength in both the child and
the family. In fact, focusing on strengths may be the best
way to engage the child and the family in the assessment
process. When developing this profile, it is important to
consider the child’s age as well as his physical, cognitive,
and social capabilities. The physician uses his knowledge
of normal development and psychopathologic conditions
to formulate a working diagnosis based on the information
gathered and on the observations made. Ultimately, a treat-
ment plan is developed (Chapter 4), and it is shared with
the child and the family.
There are many approaches to the parent interview. To
avoid making younger children wait excessively, it is help-
ful to gather a child’s history from the parents in a separate
appointment before the child is seen. However, regardless of
the method, it is useful to have time with the parents apart
from the child and, sometimes, to interview each parent
separately. In the event of divorced or separated parents, it
is particularly im portant to have both parents participate in
the assessment of the child, and it is advisable to interview
each parent separately. It is often helpful to meet with the
entire family together at least once during the assessment
to understand what each member of the family sees as the
problem and what each person sees as a realistic solution.
The parent interview provides the physician with in-
formation regarding the existing problem; the child’s psy-
chiatric, medical, and developmental histories; the family
and social history; and the school history (see Box 1.1). It
should include a review of past physical and emotional
stresses, adjustments to school and social situations (past
and current), and the patient’s relationships with siblings
and with each parent or caregiver. Requests for release of in-
formation from pediatricians, school personnel, and previ-
ous treatment providers should also be obtained at the time
of the initial parent interview.
The reason for referral and the history of present
and past problems
When beginning the psychiatric assessment, the physician
needs to consider the referral source and the reason for the
referral. Often, it is the parents, primary caregivers, or school
officials who initiate the evaluation process, but referrals
may also come from the legal or social service systems. If the
referral has not come from the parents, the physician must
find out whether they see a problem and if so, how they can
be engaged in the treatment process.
As with the traditional medical history, the physician first
determines the chief complaint and the history of the present
illness, in the words of the child or a parent. There must be
BOX 1.1 Components of a psychiatric examination
• Reason for referral
• History of present illness
• Past psychiatric history
• Medical history
• Developmental history
• Milestones for pregnancy, birth, and the neonatal
period; infancy; toddlerhood; preschool age; school
age; and adolescence
• School history
• Family history
• Mental status; appearance, behavior, relatedness,
speech and language, mood and affect, thought
process and content, and cognitive and developmen-
tal assessment
• Formulation
• Diagnosis
• Treatment plan
Assessment and Evaluation6
descriptions of the develop ment of the symptoms and of
the historical context of the problem. The patient or a parent
should also explain what has happened recently to prompt
the appointment. The presenting problem may be a behav-
ioral problem, an emotional or mood problem, a specific or
a pervasive developmental disability, a psychotic disorder,
a reaction to an adverse life event, or some combi nation of
these. Many dimensions used to elucidate symptoms in the
medical model are also useful for gath ering information
about the history of the present illness in the field of child
and adolescent psychiatry. The physician should gather in-
formation about the chronol ogy (onset, duration, periodicity,
and course), quality, quantity (intensity, degree of functional
impairment, frequency), setting, aggravating or alleviating
factors, and associated manifestations of the problem. The
course of the symptoms should be recorded, but not neces-
sarily gathered, in chronologic order from the onset of the
symptoms to the time of the evaluation. A child’s level of
adjustment, developmental status, and social, academic,
and family functioning relative to the pre senting problem
are also recorded in this section. It should be noted whether
a child is taking any psy chotropic medications or any other
medication that may affect his mental status.
The history includes information about previ ous psychi-
atric evaluations and treatment, either for the same problem
or for any other psychiatric condition. Past use of psycho-
tropic medication is highlighted, and dosages, responses,
adverse effects, and duration of use are noted. If permission
from the parent (and for older chil dren and adolescents,
from the patient as well) can be obtained, it is often helpful
to contact physicians and therapists who have treated the
patient.
When gathering the history of the presenting prob lem, it
is important to include a “psychiatric review of systems.”
This allows the physician to obtain additional data that may
not have been revealed spontaneously but may be relevant
to the history and clinical presen tation of a particular child.
This information can be ex tremely useful in differential di-
agnosis and in determin ing whether comorbidity is present.
The psychiatric re view of systems includes questions re-
garding all major areas of function, such as the child’s gen-
eral level of function, developmental delays or deviations,
anxiety symptoms, mood symptoms, attention or behavior
problems, learning problems, somatic complaints, psy-
chotic symptoms, elimination disorders, eating disorders,
weight problems, and drug or alcohol use. Specific ques-
tions should be asked to assess the presence of suicidal or
homicidal thoughts, as well as disturbances in social, aca-
demic, or family functioning.
Medical history of the child
The medical history of the child is obtained from the prima-
ry caregivers or the pediatrician. Pediatric records are also
commonly available to complement the history obtained
from the family. The psychiatrist should note any current or
past medical conditions and previous hospitalizations (in-
cluding any surgery). If there have been any major illnesses,
the child’s emotional and behavioral reactions should be
recorded. Children who have had multiple hospitalizations
for a chronic illness may show a range of developmental
problems as a result of altered environmental stimulation,
direct effects of the illness, or an interplay be tween variables
involving the parent and the child. For example, bed wet-
ting in a 5-year-old child hospitalized for asthma who had
previously obtained sustained bladder con tinence might be
viewed as an expected developmen tal regression in a child
who was otherwise develop ing normally.
The use of medications to treat general medical conditions
and any allergies to medications should also be noted in this
section, since the behavioral symptoms presented by the fam-
ily and the child in the history of the present illness may be
related to prescribed medications. For example, steroids are
an integral part of medical management after an organ trans-
plantation and can have important emotional and behavioral
manifestations, such as severe agitation and psychosis.
It is important to remember that the psychiatric problem
may be a direct effect of a congenital or an acquired medical
illness, or an indirect manifestation of the stress caused by a
medical illness. Fetal alcohol syndrome is an example of a
disorder that may be accompanied by psychiatric symptoms.
Children with fetal alcohol syndrome have mental retarda-
tion and facial dysmorphism, and they may also have learning
disorders and ADHD. Additionally, general medical condi-
tions not directly associated with psychiatric disturbances
may cause psychiatric symptoms. For example, a child with
acute lymphocytic leukemia may show the symptoms of
decreased energy, anhedonia, and a poor appetite dispro-
portionate to what is normally expected from the medical
illness or the chemotherapeutic agents used in its treatment.
This child may possibly be suffering from a superimposed
major depressive episode or an adjustment disorder with a
depressed mood. As with the psychiatric history, a general
medical review of systems should be included, so that the
possibility that a medical condition that may be contributing
to the psychiatric symptoms will not be overlooked. For ex-
ample, vision or hearing deficits may be related to psychiatric
or cognitive problems. Thus, if a preschool child is brought
to the physician with problems in language acquisition and
a history of recurrent otitis media, it is important to ask about
the child’s hearing and to consider obtaining additional as-
sessments to determine whether a hearing disorder may be
contributing to the language delay.
Developmental history
The child’s developmental history should be gath ered dur-
ing the parent interview, and supplemental information [Show Less]