Child Psychiatry: Assessment, Examination, and Psychological Testing

Psychiatric assessment of a child or adolescent includes identifying the reasons for

referral; assessing the nature and extent of the child's psychological and behavioral
difficulties; and determining family, school, social, and developmental factors that
may be influencing the child's emotional well-being.
A comprehensive evaluation of a child is composed of interviews with the parents,
the child, and other family members; gathering information regarding the child's
current school functioning; and often, a standardized assessment of the child's
intellectual level and academic achievement. n some cases, standardized measures
of developmental level and neuropsychological assessments are useful. Psychiatric
evaluations of children are rarely initiated by the child, so clinicians must obtain
information from the family and the school to understand the reasons for the
evaluation. n some cases, the court or a child protective service agency may initiate
a psychiatric evaluation. !hildren can be excellent informants about symptoms
related to mood and inner experiences, such as psychotic phenomena, sadness,
fears, and anxiety, but they often have difficulty with the chronology of symptoms and
are sometimes reticent about reporting behaviors that have gotten them into trouble.
"ery young children often cannot articulate their experiences verbally and do better
showing their feelings and preoccupations in a play situation.
#he first step in the comprehensive evaluation of a child or adolescent is to obtain a
full description of the current concerns and a history of the child's previous psychiatric
and medical problems. #his is often done with the parents for school-aged children,
whereas adolescents may be seen alone first, to get their perception of the situation.
$irect interview and observation of the child is usually next, followed by psychological
testing, when indicated.
!linical interviews offer the most flexibility in understanding the evolution of problems
and in establishing the role of environmental factors and life events, but they may not
systematically cover all psychiatric diagnostic categories. #o increase the breadth of
information generated, the clinician may use semistructured interviews such as
the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age
Children %&-'A$'(; structured interviews such as the National Institute for Mental
Health Diagnostic Interview Schedule for Children Version IV %)*+ $'!-"(; and
rating scales, such as the Child ehavior Chec!list and Connors "arent or #eacher
$ating Scale for ADHD.
t is not uncommon for interviews from different sources, such as parents, teachers,
and school counselors, to reflect different or even contradictory information about a
given child. ,hen faced with conflictual information, the clinician must determine
whether apparent contradictions actually reflect an accurate picture of the child in
different settings. -nce a complete history is obtained from the parents, the child is
examined, the child's current functioning at home and at school is assessed, and
psychological testing is completed, the clinician can use all the available information
to ma.e a best-estimate diagnosis and can then ma.e recommendations.
-nce clinical information is obtained about a given child or adolescent, it is the
clinician's tas. to determine whether criteria are met for one or more psychiatric
disorder according to the text revision of the /th edition of the Diagnostic and
Statistic Manual of Mental Disorders %$'*-"-#0(. #his most current version is a
categorical classification reflecting the consensus on constellations of symptoms
believed to comprise discrete and valid psychiatric disorders. Psychiatric disorders
are defined by the $'*-"-#0 as a clinically significant set of symptoms that is
associated with impairment in one or more areas of functioning. ,hereas clinical
situations re1uiring intervention do not always fall within the context of a given
psychiatric disorder, the importance of identifying psychiatric disorders when they
arise is to facilitate meaningful investigation of childhood psychopathology.
Clinical Interviews
#o conduct a useful interview with a child of any age, clinicians must be familiar with
normal development to place the child's responses in the proper perspective. 2or
example, a young child's discomfort on separation from a parent and a school-age
child's lac. of clarity about the purpose of the interview are both perfectly normal and
should not be misconstrued as psychiatric symptoms. 2urthermore, behavior that is
normal in a child at one age, such as temper tantrums in a 3-year-old, ta.es on a
different meaning, for example, in a 45-year-old.
#he interviewer's first tas. is to engage the child and develop a rapport so that the
child is comfortable. #he interviewer should in1uire about the child's concept of the
purpose of the interview and should as. what the parents have told the child. f the
child appears to be confused about the reason for the interview, the examiner may
opt to summarize the parents' concerns in a developmentally appropriate and
supportive manner. $uring the interview with the child, the clinician see.s to learn
about the child's relationships with family members and peers, academic
achievement and peer relationships in school, and the child's pleasurable activities.
An estimate of the child's cognitive functioning is a part of the mental status
examination.
#he extent of confidentiality in child assessment is correlated with the age of the
child. n most cases, almost all specific information can appropriately be shared with
the parents of a very young child, whereas privacy and permission of an older child
or adolescent are mandated before sharing information with parents. 'chool-age and
older children are informed that if the clinician becomes concerned that any child is
dangerous to himself or herself or to others, this information must be shared with
parents and, at times, additional adults. As part of a psychiatric assessment of a child
of any age, the clinician must determine whether that child is safe in his or her
environment and must develop an index of suspicion about whether the child is a
victim of abuse or neglect. ,henever there is a suspicion of child maltreatment, the
local child protective service agency must be notified.
#oward the end of the interview, the child may be as.ed in an open-ended manner
whether he or she would li.e to bring up anything else. 6ach child should be
complimented for his or her cooperation and than.ed for participating in the interview,
and the interview should end on a positive note.
Infants and Young Children
Assessments of infants usually begin with the parents present, because very young
children may be frightened by the interview situation; the interview with the parents
present also allows the clinician to assess the parent7infant interaction. nfants may
be referred for a variety of reasons, including high levels of irritability, difficulty being
consoled, eating disturbances, poor weight gain, sleep disturbances, withdrawn
behavior, lac. of engagement in play, and developmental delay. #he clinician
assesses areas of functioning that include motor development, activity level, verbal
communication, ability to engage in play, problem-solving s.ills, adaptation to daily
routines, relationships, and social responsiveness.
#he child's developmental level of functioning is determined by combining
observations made during the interview with standardized developmental measures.
-bservations of play reveal a child's developmental level and reflect the child's
emotional state and preoccupations. #he examiner can interact with an infant age 48
months or younger in a playful manner by using such games as pee.-a-boo. !hildren
between the ages of 48 months and 9 years can be observed in a playroom. !hildren
ages 3 years or older may exhibit symbolic play with toys, revealing more in this
mode than through conversation. #he use of puppets and dolls with children under :
years of age is often an effective way to elicit information, especially if 1uestions are
directed to the dolls, rather than to the child.
School-Age Children
'ome school-age children are at ease when conversing with an adult; others are
hampered by fear, anxiety, poor verbal s.ills, or oppositional behavior. 'chool-age
children can usually tolerate a /;-minute session. #he room should be sufficiently
spacious for the child to move around, but not so large as to reduce intimate contact
between the examiner and the child. Part of the interview can be reserved for
unstructured play, and various toys can be made available to capture the child's
interest and to elicit themes and feelings. !hildren in lower grades may be more
interested in the toys in the room, whereas by the sixth grade, children may be more
comfortable with the interview process and less li.ely to show spontaneous play.
#he initial part of the interview explores the child's understanding of the reasons for
the meeting. #he clinician should confirm that the interview was not set up because
the child is <in trouble= or as a punishment for <bad= behavior. #echni1ues that can
facilitate disclosure of feelings include as.ing the child to draw peers, family
members, a house, or anything else that comes to mind. #he child can then be
1uestioned about the drawings. !hildren may be as.ed to reveal three wishes, to
describe the best and worst events of their lives, and to name a favorite person to be
stranded with on a desert island. >ames such as $onald ,. ,innicott's <s1uiggle,= in
which the examiner draws a curved line and then the child and the examiner ta.e
turns continuing the drawing, may facilitate conversation.
?uestions that are partially open-ended with some multiple choices may elicit the
most complete answers from school-age children. 'imple, closed %yes or no(
1uestions may not elicit sufficient information, and completely open-ended 1uestions
can overwhelm a school-age child who cannot construct a chronological narrative.
#hese techni1ues often result in a shoulder shrug from the child. #he use of indirect
commentary@such as, < once .new a child who felt very sad when he moved away
from all his friends=@is helpful, although the clinician must be careful not to lead the
child into confirming what the child thin.s the clinician wants to hear. 'chool-age
children respond well to clinicians who help them compare moods or feelings by
as.ing them to rate feelings on a scale of 4 to 4A.
Adolescents
Adolescents usually have distinct ideas about why the evaluation was initiated, and
can usually give a chronological account of the recent events leading to the
evaluation, although some may disagree with the need for the evaluation. #he
clinician should clearly communicate the value of hearing the story from an
adolescent's point of view and must be careful to reserve Budgment and not assign
blame. Adolescents may be concerned about confidentiality, and clinicians can
assure them that permission will be re1uested from them before any specific
information is shared with parents, except situations involving danger to the
adolescent or others, in which case confidentiality must be sacrificed. Adolescents
can be approached in an open-ended manner; however, when silences occur during
the interview, the clinician should attempt to reengage the patient. !linicians can
explore what the adolescent believes the outcome of the evaluation will be %change
of school, hospitalization, removal from home, removal of privileges(.
'ome adolescents approach the interview with apprehension or hostility, but open up
when it becomes evident that the clinician is neither punitive nor Budgmental.
!linicians must be aware of their own responses to adolescents' behavior
%countertransference( and stay focused on the therapeutic process even in the face
of defiant, angry, or difficult teenagers. !linicians should set appropriate limits and
should postpone or discontinue an interview if they feel threatened or if patients
become destructive to property or engage in self-inBurious behavior. 6very interview
should include an exploration of suicidal thoughts, assaultive behavior, psychotic
symptoms, substance use, and .nowledge of safe sexual practices along with a
sexual history. -nce rapport has been established, many adolescents appreciate the
opportunity to tell their side of the story and may reveal things that they have not
disclosed to anyone else.
Family Interview
An interview with parents and the patient may ta.e place first or may occur later in
the evaluation. 'ometimes, an interview with the entire family, including siblings, can
be enlightening. #he purpose is to observe the attitudes and behavior of the parents
toward the patient and the responses of the children to their parents. #he clinician's
Bob is to maintain a nonthreatening atmosphere in which each member of the family
can spea. freely without feeling that the clinician is ta.ing sides with any particular
member. Although child psychiatrists generally function as advocates for the child,
the clinician must validate each family member's feelings in this setting, because lac.
of communication often contributes to the patient's problems.
Parents
#he interview with the patient's parents or careta.ers is necessary to get a
chronological picture of the child's growth and development. A thorough
developmental history and details of any stressors or important events that have
influenced the child's development must be elicited. #he parents' view of the family
dynamics, their marital history, and their own emotional adBustment are also elicited.
#he family's psychiatric history and the upbringing of the parents are pertinent.
Parents are usually the best informants about the child's early development and
previous psychiatric and medical illnesses. #hey may be better able to provide an
accurate chronology of past evaluations and treatment. n some cases, especially
with older children and adolescents, the parents may be unaware of significant
current symptoms or social difficulties of the child. !linicians elicit the parents'
formulation of the causes and nature of their child's problems and as. about
expectations about the current assessment.
Diagnostic Instruments
#he two main types of diagnostic instruments used by clinicians and researchers are
diagnostic interviews and 1uestionnaires. $iagnostic interviews are administered to
either children or their parents and are often designed to elicit sufficient information
on numerous aspects of functioning to determine whether criteria are met from the
$'*-"-#0.
'emistructured interviews, or <interviewer-based= interviews, such as &-'A$' and
the Child and Adolescent "s%chiatric Assess&ent %!APA( serve as guides for the
clinician. #hey help the clinician clarify answers to 1uestions about symptoms.
'tructured interviews, or <respondent-based= interviews, such as )*+ $'!-",
the Children's Interview for "s%chiatric S%ndro&es %!hP'(, and the Diagnostic
Interview for Children and Adolescents %$!A(, basically provide a script for the
interviewer without interpretation of the subBect's responses. #wo other diagnostic
instruments use pictures, the Do&inic-$ and the "ictorial Instru&ent for Children and
Adolescents %P!A--0(. #hese instruments use pictures as cues, along with an
accompanying 1uestion to elicit information about symptoms, especially for young
children as well as for adolescents.
$iagnostic instruments aid the collection of information in a systematic way.
$iagnostic instruments, even the most comprehensive, however, cannot replace
clinical interviews, because clinical interviews are superior in understanding the
chronology of symptoms, the interplay between environmental stressors and
emotional responses, and developmental issues. !linicians often find it helpful to
combine the data from diagnostic instruments with clinical material gathered in a
comprehensive evaluation.
?uestionnaires can cover a broad range of symptom areas, such as the Achen(ach
Child ehavior Chec!list, or they can be focused on a particular type of
symptomatology and are often called rating scales, such as the Connors "arent
$ating Scale for ADHD.
Semistructured Diagnostic Interviews
Kiddie Schedule or Aective Disorders and Schi!o"hrenia or School#Age
Children
#he &-'A$' can be used for children from : years to 48 years of age. t presents
multiple items with some space for further clarification of symptoms. t elicits
information on current diagnosis and on symptoms present in the previous year.
Another version can also ascertain lifetime diagnoses. t assesses diagnoses
according to $'*-"-#0. #his instrument has been used extensively, especially in
evaluation of mood disorders, and includes measures of impairment caused by
symptoms. #he schedule comes in a form for parents to give information about their
child and in a version for use directly with the child. #he schedule ta.es about 4 to
4.; hours to administer. #he interviewer should have some training in the field of child
psychiatry, but need not be a psychiatrist.
Child and Adolescent Psychiatric Assessment
#he !APA is an <interviewer-based= instrument that can be used for children from C
to 45 years of age. t comes in modular form so that certain diagnostic entities can be
administered without having to give the entire interview. t covers disruptive behavior
disorders, mood disorders, anxiety disorders, eating disorders, sleep disorders,
elimination disorders, substance use disorders, tic disorders, schizophrenia,
posttraumatic stress disorder, and somatization symptoms. t focuses on the 9
months before the interview, called the <primary period.= n general, it ta.es about 4
hour to administer. t has a glossary to aid in decision-ma.ing regarding symptoms
and provides separate ratings of presence and severity of symptoms. t can be used
to determine diagnoses according to the fourth edition of $'* %$'*-"(, the revised
third edition of $'* %$'*--0(, or the tenth revision of International Statistical
Classification of Diseases and $elated Health "ro(le&s %!$-4A(. #raining is
necessary to administer this interview, and the interviewer must be prepared to use
some clinical Budgment in interpreting elicited symptoms.
Structured Diagnostic Interviews
$ational Institute o %ental &ealth Interview Schedule or Children 'ersion I'
#he )*+ $'!-" is a highly structured interview designed to assess more than 9A
$'*-" diagnostic entities administered by trained <laypersons.= t is available in
parallel child and parent forms. #he parent form can be used for children from : to 45
years of age, and the direct child form of the instrument was designed for children
from C to 45 years of age. t is applicable for a multitude of diagnoses .eyed to $'*-
"-#0. A computer scoring algorithm is available. #his instrument assesses the
presence of diagnoses that have been present within the last / wee.s, and also
within the last year. Decause it is a fully structured interview, the instructions serve as
a complete guide for the 1uestions, and the examiner need not have any .nowledge
of child psychiatry to administer the interview correctly.
Children(s Interview or Psychiatric Syndromes
#he !hP' is a highly structured interview designed for use by trained interviewers
with children from : to 48 years of age. t is composed of 4; sections, and it elicits
information on psychiatric symptoms as well as psychosocial stressors targeting 3A
psychiatric disorders, according to $'*-" criteria. #here are parent and child forms.
t ta.es approximately /A minutes to administer the !hP'. $iagnoses covered
include depression, mania, attention-deficitEhyperactivity disorder %A$+$(, separation
disorder, obsessive-compulsive disorder %-!$(, conduct disorder, substance use
disorder, anorexia, and bulimia. #he !hP' was designed for use as a screening
instrument for clinicians and a diagnostic instrument for clinical and epidemiological
research.
Diagnostic Interview or Children and Adolescents
#he current version of the $!A was developed in 4CC5 to assess information
resulting in diagnoses according to either $'*-" or $'*--0. Although it was
originally designed to be a highly structured interview, it can now be used in a
semistructured format. #his means that, although interviewers are allowed to use
additional 1uestions and probes to clarify elicited information, the method of probing
is standardized so that all interviewers will follow a specific pattern. ,hen using the
interview with younger children, more flexibility is built in, allowing interviewers to
deviate from written 1uestions to ensure that the child understands the 1uestion.
Parent and child interviews are expected to be used. t covers children : to 45 years
of age and generally ta.es 4 to 3 hours to administer. t covers externalizing behavior
disorders, anxiety disorders, depressive disorders, and substance abuse disorders,
among others.
Pictorial Diagnostic Instruments
Dominic#)
#he $ominic-0 is a pictorial, fully structured interview designed to elicit psychiatric
symptoms from children : to 44 years of age. #he pictures illustrate abstract
emotional and behavioral content of diagnostic entities according to $'*--0. #he
instrument uses a picture of a child called <$ominic= who is experiencing the
symptom in 1uestion. 'ome symptoms have more than one picture, with a brief story
that is read to the child. Along with each picture is a sentence as.ing about the
situation being shown and as.ing the child if he or she has experiences similar to the
one that $ominic is having. $iagnostic entities covered by the $ominic-0 include
separation anxiety, generalized anxiety, depression and dysthymia, A$+$,
oppositional defiant disorder, conduct disorder, and specific phobia. Although
symptoms of the above diagnoses can be fully elicited from the $ominic-0, no
specific provision within the instrument in1uires about fre1uency of the symptom,
duration, or age of onset. #he paper version of this interview ta.es about 3A minutes,
and the computerized version of this instrument ta.es about 4; minutes. #rained lay-
interviewers can administer this interview. !omputerized versions of this interview are
available with pictures of a child who is white, blac., Fatino, or Asian.
Pictorial Instrument or Children and Adolescents
P!A--0 is composed of 495 pictures organized in modules and designed to cover
five diagnostic categories, including disorders of anxiety, mood, psychosis, disruptive
disorders, and substance use disorder. t is designed to be administered by clinicians
and can be used for children and adolescents ranging from : to 4: years of age. t
provides a categorical %diagnosis present or absent( and a dimensional %range of
severity( assessment. #his instrument presents pictures of a child experiencing
emotional, behavioral, and cognitive symptoms. #he child is as.ed, <+ow much are
you li.e himEherG= and a five-point rating scale with pictures of a person with open
arms in increasing degrees is shown to the child to help him or her identify the
severity of the symptoms. t ta.es about /A minutes to 4 hour to administer the
interview. #his instrument is currently .eyed to $'*--0. t can be used to aid in
clinical interviews and in research diagnostic protocols.
*uestionnaires and )ating Scales
Achenbach Child Behavior Checlist
#he parent and teacher versions of the Achen(ach Child ehavior Chec!list were
developed to cover a broad range of symptoms and several positive attributes related
to academic and social competence. #he chec.list presents items related to mood,
frustration tolerance, hyperactivity, oppositional behavior, anxiety, and various other
behaviors. #he parent version consists of 448 items to be rated A %not true(, 4
%sometimes true(, or 3 %very true(. #he teacher version is similar, but without the
items that apply only to home life. Profiles were developed based on normal children
of three different age groups %/ to ;, : to 44, and 43 to 4:(.
'uch a chec.list identifies specific problem areas that might otherwise be
overloo.ed, and it may point out areas in which the child's behavior deviates from
that of normal children of the same age group. #he chec.list is not used specifically
to ma.e diagnoses.
!evised Achenbach Behavior Problem Checlist
!onsisting of 4;A items that cover a variety of childhood behavioral and emotional
symptoms, the $evised Achen(ach ehavior "ro(le& Chec!list discriminates
between clinic-referred and nonreferred children. 'eparate subscales have been
found to correlate in the appropriate direction with other measures of intelligence,
academic achievement, clinical observations, and peer popularity. As with the other
broad rating scales, this instrument can help elicit a comprehensive view of a
multitude of behavioral areas, but it is not designed to ma.e psychiatric diagnoses.
Connors Abbreviated Parent-"eacher !ating Scale for AD#D
n its original form, the Connors A((reviated "arent-#eacher $ating Scale for
ADHD consisted of C9 items rated on a A to 9 scale and was subgrouped into 3;
clusters, including problems with restlessness, temper, school, stealing, eating, and
sleeping. -ver the years, multiple versions of this scale were developed and used to
aid in systematic identification of children with A$+$. A highly abbreviated form of
this rating scale, the Connors A((reviated "arent-#eacher )uestionnaire, was
developed for use with both parents and teachers by &eith !onnors in 4C59. t
consists of ten items that assess both hyperactivity and inattention.
Brief Im$airment Scale
A newly validated 39-item instrument suitable to obtain information on children
ranging from / years to 45 years, the rief I&pair&ent Scale %D'( evaluates three
domains of functioningH interpersonal relations, schoolEwor. functioning, and
careEself-fulfillment. #his scale is administered to an adult informant about his or her
child, does not ta.e long to administer, and provides a global measure of impairment
along the above three dimensions. #his scale cannot be used to ma.e clinical
decisions on individual patients, but it can provide information on the degree of
impairment that a given child is experiencing in a certain area.
Com"onents o the Child Psychiatric Evaluation
Psychiatric evaluation of a child includes a description of the reason for the referral,
the child's past and present functioning, and any test results. An outline of the
evaluation is given in #able 95-4.
Identifying Data
#o understand the clinical problems to be evaluated, the clinician must first identify
the patient and .eep in mind the family constellation surrounding the child. #he
clinician must also pay attention to the source of the referral@that is, whether it is the
child's family, school, or another agency@because this influences the family's
attitude toward the evaluation. 2inally, many informants contribute to the child's
evaluation, and each must be identified to gain insight into the child's functioning in
different settings.
#istory
A comprehensive history contains information about the child's current and past
functioning, from the child's report, from clinical and structured interviews with the
parents, and from information from teachers and previous treating clinicians. #he
chief complaint and the history of the present illness are generally obtained from both
the child and the parents. )aturally, the child will articulate the situation according to
his or her developmental level. #he developmental history is more accurately
obtained from the parents. Psychiatric and medical histories, current physical
examination findings, and immunization histories can be augmented with reports
from psychiatrists and pediatricians who have treated the child in the past. #he child's
report is critical in understanding the current situation regarding peer relationships
and adBustment to school. Adolescents are the best informants regarding .nowledge
of safe sexual practices, drug or alcohol use, and suicidal ideation. #he family's
psychiatric and social histories, and family function are best obtained from the
parents.
Table 37-1 Child Psychiatric Evaluation
Identifying data
Identified patient and family members
Source of referral
Informants
History
Chief complaint
History of present illness
Developmental history and milestones
Psychiatric history
Medical history, including immunizations
Family social history and parents marital status
!ducational history and current school functioning
Peer relationship history
Current family functioning
Family psychiatric and medical histories
Current physical e"amination
Mental status e"amination
#europsychiatric e"amination $%hen applicable&
Developmental, psychological, and educational testing
Formulation and summary
DSM'I(')* diagnosis
*ecommendations and treatment plan
DSM'I(')*, te"t revision of the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders+
%ental Status &'amination
A detailed description of the child's current mental functioning can be obtained
through observation and specific 1uestioning. An outline of the mental status
examination is presented in #able 95-3. #able 95-9lists components of a
comprehensive neuropsychiatry mental status.
Table 37-2 Mental Status Examination for Children
,+ Physical appearance
-+ Parent.child interaction
/+ Separation and reunion
0+ 1rientation to time, place, and person
2+ Speech and language
3+ Mood
4+ 5ffect
6+ )hought process and content
7+ Social relatedness
,8+ Motor behavior
,,+ Cognition
,-+ Memory
,/+ 9udgment and insight
P.4493
Table 37-3 euro!sychiatric Mental Status Examination:
5+ ;eneral Description
,+ ;eneral appearance and dress
-+ <evel of consciousness and arousal
/+ 5ttention to environment
0+ Posture $standing and seated&
2+ ;ait
3+ Movements of limbs, trun=, and face $spontaneous, resting, and after
instruction&
4+ ;eneral demeanor $including evidence of responses to internal
stimuli&
6+ *esponse to e"aminer $eye contact, cooperation, ability to focus on
intervie% process&
7+ #ative or primary language
>+ <anguage and Speech
,+ Comprehension $%ords, sentences, simple and comple" commands,
and concepts&
-+ 1utput $spontaneity, rate, fluency, melody or prosody, volume,
coherence, vocabulary, paraphasic errors, comple"ity of usage&
/+ *epetition
0+ 1ther aspects
a+ 1b?ect naming
b+ Color naming
c+ >ody part identification
d+ Ideomotor pra"is to command
C+ )hought
,+ Form $coherence and connectedness&
-+ Content
a+ Ideational $preoccupations, overvalued ideas, delusions&
b+ Perceptual $hallucinations&
D+ Mood and 5ffect
,+ Internal mood state $spontaneous and elicited@ sense of humor&
-+ Future outloo=
/+ Suicidal ideas and plans
0+ Demonstrated emotional status $congruence %ith mood&
!+ Insight and 9udgment
,+ Insight
a+ Self'appraisal and self'esteem
b+ Anderstanding of current circumstances
c+ 5bility to describe personal psychological and physical status
-+ 9udgment
a+ 5ppraisal of ma?or social relationships
b+ Anderstanding of personal roles and responsibilities
F+ Cognition
,+ Memory
a+ Spontaneous $as evidenced during intervie%&
b+ )ested $incidental, immediate repetition, delayed recall, cued
recall, recognition@ verbal, nonverbal@ e"plicit, implicit&
-+ (isuospatial s=ills
/+ Constructional ability
0+ Mathematics
2+ *eading
3+ Briting
4+ Fine sensory function $stereognosis, graphesthesia, t%o'point
discrimination&
6+ Finger gnosis
7+ *ight'left orientation
,8+ C!"ecutive functionsD
,,+ 5bstraction
:Euestions should be adapted to the age of the child+
Courtesy of !ric D+ Caine, M+D+, and 9effrey M+ <yness, M+D+
Physical A""earances
#he examiner should document the child's size, grooming, nutritional state, bruising,
head circumference, physical signs of anxiety, facial expressions, and mannerisms.
Parent+Child Interaction
#he examiner can observe the interactions between parents and child in the waiting
area before the interview and in the family session. #he manner in which parents and
child converse and the emotional overtones are pertinent.
Se"aration and )eunion
#he examiner should note both the manner in which the child responds to the
separation from a parent for an individual interview and the reunion behavior. 6ither
lac. of affect at separation and reunion or severe distress on separation or reunion
can indicate problems in the parent7child relationship or other psychiatric
disturbances.
,rientation to Time, Place, and Persons
mpairments in orientation can reflect organic damage, low intelligence, or a thought
disorder. #he age of the child must be .ept in mind, however, because very young
children are not expected to .now the date, other chronological information, or the
name of the interview site.
S"eech and -anguage
#he examiner should evaluate the child's speech and language ac1uisition. s it
appropriate for the child's ageG A disparity between expressive language usage and
receptive language is notable. #he examiner should also note the child's rate of
speech, rhythm, latency to answer, spontaneity of speech, intonation, articulation of
words, and prosody. 6cholalia, repetitive stereotypical phrases, and unusual syntax
are important psychiatric findings. !hildren who do not use words by age 48 months
or who do not use phrases by age 3.; to 9 years, but who have a history of normal
babbling and responding appropriately to nonverbal cues, are probably developing
normally. #he examiner should consider the possibility that a hearing loss is
contributing to a speech and language deficit.
%ood
A child's sad expression, lac. of appropriate smiling, tearfulness, anxiety, euphoria,
and anger are valid indicators of mood, as are verbal admissions of feelings.
Persistent themes in play and fantasy also reflect the child's mood.
Aect
#he examiner should note the child's range of emotional expressivity,
appropriateness of affect to thought content, ability to move smoothly from one affect
to another, and sudden labile emotional shifts.
Thought Process and Content
n evaluating a thought disorder in a child, the clinician must always consider what is
developmentally expected for the child's age and what is deviant for any age group.
#he evaluation of thought form considers loosening of associations, excessive
magical thin.ing, perseveration, echolalia, the ability to distinguish fantasy from
reality, sentence coherence, and the ability to reason logically. #he evaluation of
thought content considers delusions, obsessions, themes, fears, wishes,
preoccupations, and interests.
'uicidal ideation is always a part of the mental status examination for children who
are sufficiently verbal to understand the 1uestions and old enough to understand the
concept. !hildren of average intelligence more than / years of age usually have
some understanding of what is real and what is ma.e-believe and may be as.ed
about suicidal ideation, although a firm concept of the permanence of death may not
be present until several years later.
Aggressive thoughts and homicidal ideation are assessed here. Perceptual
disturbances, such as hallucinations, are also assessed. "ery young children are
expected to have short attention spans and may change the topic and conversation
abruptly without exhibiting a symptomatic flight of ideas. #ransient visual and auditory
hallucinations in very young children do not necessarily represent maBor psychotic
illnesses, but they do deserve further investigation.
Social )elatedness
#he examiner assesses the appropriateness of the child's response to the
interviewer, general level of social s.ills, eye contact, and degree of familiarity or
withdrawal in the interview process. -verly friendly or familiar behavior may be as
troublesome as are extremely retiring and withdrawn responses. #he examiner
assesses the child's self-esteem, general and specific areas of confidence, and
success with family and peer relationships.
%otor .ehavior
#he motor behavior part of the mental status examination includes observations of
the child's coordination and activity level and ability to pay attention and carry out
developmentally appropriate tas.s. t also involves involuntary movements, tremors,
motor hyperactivity, and any unusual focal asymmetries of muscle movement.
Cognition
#he examiner assesses the child's intellectual functioning and problem-solving
abilities. An approximate level of intelligence can be estimated by the child's general
information, vocabulary, and comprehension. 2or a specific assessment of the child's
cognitive abilities, the examiner can use a standardized test.
%emory
'chool-age children should be able to remember three obBects after ; minutes and to
repeat five digits forward and three digits bac.ward. Anxiety can interfere with the
child's performance, but an obvious inability to repeat digits or to add simple numbers
may reflect brain damage, mental retardation, or learning disabilities.
/udgment and Insight
#he child's view of the problems, reactions to them, and suggested solutions may
give the clinician a good idea of the child's Budgment and insight. n addition, the
child's understanding of what he or she can realistically do to help and what the
clinician can do adds to the assessment of the child's Budgment.
(euro$sychiatric Assessment
A neuropsychiatric assessment is appropriate for children who are suspected of
having a neurological disorder, a psychiatric impairment that coexists with
neurological signs, or psychiatric symptoms that may be caused by neuropathology.
#he neuropsychiatric evaluation combines information from neurological, physical,
and mental status examinations. #he neurological examination can identify
asymmetrical abnormal signs %hard signs( that may indicate lesions in the brain. A
physical examination can evaluate the presence of physical stigmata of particular
syndromes in which neuropsychiatric symptoms or developmental aberrations play a
role %e.g., fetal alcohol syndrome, $own syndrome(.
An important part of the neuropsychiatric examination is the assessment of
neurological soft signs and minor physical anomalies. #he term neurological soft
signs was first noted by Foretta Dender in the 4C/As in reference to nondiagnostic
abnormalities in the neurological examinations of children with schizophrenia. 'oft
signs do not indicate focal neurological disorders, but they are associated with a wide
variety of developmental disabilities and occur fre1uently in children with low
intelligence, learning disabilities, and behavioral disturbances. 'oft signs may refer to
both behavioral symptoms %which are sometimes associated with brain damage,
such as severe impulsivity and hyperactivity(, physical findings %including
contralateral overflow movements(, and a variety of nonfocal signs %e.g., mild
choreiform movements, poor balance, mild incoordination, asymmetry of gait,
nystagmus, and the persistence of infantile reflexes(. 'oft signs can be divided into
those that are normal in a young child, but become abnormal when they persist in an
older child, and those that are abnormal at any age. #he "h%sical and Neurological
*+a&ination for Soft Signs %PA)6''( is an instrument used with children up to the
age of 4; years. t consists of 4; 1uestions about general physical status and
medical history and /9 physical tas.s %e.g., touch your finger to your nose, hop on
one foot to the end of the line, tap 1uic.ly with your finger(. )eurological soft signs
are important to note, but they are not useful in ma.ing a specific psychiatric
diagnosis.
*inor physical anomalies or dysmorphic features occur with a higher than usual
fre1uency in children with developmental disabilities, learning disabilities, speech and
language disorders, and hyperactivity. As with soft signs, the documentation of minor
physical anomalies is part of the neuropsychiatric assessment, but it is rarely helpful
in the diagnostic process and does not imply a good or bad prognosis. *inor physical
anomalies include a high-arched palate, epicanthal folds, hypertelorism, low-set ears,
transverse palmar creases, multiple hair whorls, a large head, a furrowed tongue,
and partial syndactyl of several toes.
,hen a seizure disorder is being considered in the differential diagnosis or a
structural abnormality in the brain is suspected, an electroencephalogram %66>(,
computed tomography %!#(, or magnetic resonance imaging %*0( may be indicated.
Develo$mental) Psychological) and &ducational "esting
Psychological tests are not always re1uired to assess psychiatric symptoms, but they
are valuable in determining a child's developmental level, intellectual functioning, and
academic difficulties. A measure of adaptive functioning %including the child's
competence in communication, daily living s.ills, socialization, and motor s.ills( is a
prere1uisite when a diagnosis of mental retardation is being considered. #able 95-
/outlines the general categories of psychological tests.
Table 37-" Commonly #sed Child and $dolescent Psycholo%ical $ssessment &nstruments
Test $%e'(rades )ata (enerated and Comments
Intellectual ability
Bechsler Intelligence
Scale for ChildrenF
)hird !dition $BISC'
III'*&
3.,3 Standard scoresG verbal, performance and
full'scale IE@ scaled subtest scores
permitting specific s=ill assessment+
Bechsler 5dult
Intelligence ScaleF
$B5IS'III&
,3.adult Same as BISC'III'*+
Bechsler Preschool and
Primary Scale of
IntelligenceF*evised
$BPPSI'*&
/.4 Same as BISC'III'*+
Haufman 5ssessment
>attery for Children $H'
5>C&
-+3.,-+3 Bell grounded in theories of cognitive
psychology and neuropsychology+ 5llo%s
immediate comparison of intellectual
capacity %ith acIuired =no%ledge+ ScoresG
Mental Processing Composite $IE
eIuivalent&@ seIuential and simultaneous
processing and achievement standard
scoresG scaled mental processing and
achievement subtest scores@ age
eIuivalents@ percentiles+
Haufman 5dolescent
and 5dult Intelligence
)est $H5I)&
,,.62J Composed of separate Crystallized and
Fluid scales+ ScoresG Composite
Intelligence Scale@ Crystallized and Fluid
IE@ scaled subtest scores@ percentiles+
Stanford'>inet, 0th
!dition $S>GF!&
-.-/ ScoresG IE@ verbal, abstractKvisual, and
Iuantitative reasoning@ short'term memory@
standard age+
Peabody Picture
(ocabulary )estFIII
$PP()'III&
0.adult Measures receptive vocabulary acIuisition@
standard scores, percentiles, age
eIuivalents+
Achievement
Develo"ment Tests or Inants and Preschoolers
#he *esell Infant Scale, the Cattell Infant Intelligence Scale, Bayley Scales of
Infant Develo$ment, and the Denver Develo$mental Screening "est include
developmental assessments of infants as young as 3 months of age. ,hen used with
very young infants, the tests focus on sensorimotor and social responses to a variety
of obBects and interactions. ,hen these instruments are used with older infants and
preschoolers, emphasis is placed on language ac1uisition. #he ,esell Infant
Scale measures development in four areasH motor, adaptive functioning, language,
and social.
An infant's score on one of these developmental assessments is not a reliable way to
predict a child's future intelligence 1uotient %?( in most cases. nfant assessments
are valuable, however, in detecting developmental deviation and mental retardation
and in raising suspicions of a developmental disorder. ,hereas infant assessments
rely heavily on sensorimotor functions, intelligence testing in older children and
adolescents includes later-developing functions, including verbal, social, and abstract
cognitive abilities.
Intelligence Tests or School#Age Children and Adolescents
#he most widely used test of intelligence for school-age children and adolescents is
the third edition of the -echsler Intelligence Scale for Children %,'!--0(. t can be
given to children from : to 45 years of age and yields a verbal ?, a performance ?,
and a combined full-scale ?. #he verbal subtests consist of vocabulary, information,
arithmetic, similarities, comprehension, and digit span %supplemental( categories. #he
performance subtests include bloc. design, picture completion, picture arrangement,
obBect assembly, coding, mazes %supplemental(, and symbol search %supplemental(.
#he scores of the supplemental subtests are not included in the computation of ?.
6ach subcategory is scored from 4 to 4C, with 4A being the average score. An
average full-scale ? is 4AA; 5A to 8A represents borderline intellectual function; 8A to
CA is in the low average range; CA to 4AC is average; 44A to 44C is high average; and
above 43A is in the superior or very superior range. #he multiple brea.downs of the
performance and verbal subscales allow great flexibility in identifying specific areas
of deficit and scatter in intellectual abilities. Decause a large part of intelligence
testing measures abilities used in academic settings, the brea.down of the ,'!--
0 can also be helpful in pointing out s.ills in which a child is wea. and may benefit
from remedial education.
#he Stanford-inet Intelligence Scale covers an age range from 3 to 3/ years. t
relies on pictures, drawings, and obBects for very young children and on verbal
performance for older children and adolescents. #his intelligence scale, the earliest
version of an intelligence test of its .ind, leads to a mental age score as well as an
intelligence 1uotient.
#he McCarth% Scales of Children's A(ilities and the Kauf&an Assess&ent atter% for
Children are two other intelligence tests that are available for preschool and school-
age children. #hey do not cover the adolescent age group.
+ong-"erm Stability of Intelligence
Although a child's intelligence is relatively stable throughout the school-age years
and adolescence, some factors can influence intelligence and a child's score on an
intelligence test.
#he intellectual functions of children with severe mental illnesses and of those from
low socioeconomic levels may decrease over time, whereas the ?s of children
whose environments have been enriched may increase over time.
2actors that influence a child's score on a given test of intellectual functioning and,
thus, affect the accuracy of the test are motivation, emotional state, anxiety, and
cultural milieu0
Perce"tual and Perce"tual %otor Tests
#he ender Visual Motor ,estalt #est can be given to children between the ages of /
and 43 years. #he test consists of a set of spatially related figures that the child is
as.ed to copy. #he scores are based on the number of errors. Although not a
diagnostic test, it is useful in identifying developmentally age-inappropriate
perceptual performances.
Personality Tests
Personality tests are not of much use in ma.ing diagnoses, and they are less
satisfactory than intelligence tests in regard to norms, reliability, and validity, but they
can be helpful in eliciting themes and fantasies.
#he 0orschach test is a proBective techni1ue in which ambiguous stimuli@a set of
bilaterally symmetrical in.blots@are shown to a child, who is then as.ed to describe
what he or she sees in each. #he hypothesis is that the child's interpretation of the
vague stimuli reflects basic characteristics of personality. #he examiner notes the
themes and patterns. #wo sets of norms have been established for the 0orschach
test, one for children between 3 and 4A years and one for adolescents between 4A
and 45 years.
A more structured proBective test is the Children's Apperception #est %!A#(, which is
an adaptation of the #he&atic Apperception #est %#A#(. #he !A# consists of cards
with pictures of animals in scenes that are somewhat ambiguous, but are related to
parent7child and sibling issues, careta.ing, and other relationships. #he child is
as.ed to describe what is happening and to tell a story about the scene. Animals are
used because it was hypothesized that children might respond more readily to animal
images than to human figures.
$rawings, toys, and play are also applications of proBective techni1ues that can be
used during the evaluation of children. $ollhouses, dolls, and puppets have been
especially helpful in allowing a child a nonconversational mode in which to express a
variety of attitudes and feelings. Play materials that reflect household situations are
li.ely to elicit a child's fears, hopes, and conflicts about the family.
ProBective techni1ues have not fared well as standardized instruments. 0ather than
being considered tests, proBective techni1ues are best considered as additional
clinical modalities.
Educational Tests
Achievement tests measure the attainment of .nowledge and s.ills in a particular
academic curriculum. #he -ide-$ange Achieve&ent #est-$evised %,0A#-0(
consists of tests of .nowledge and s.ills and timed performances of reading, spelling,
and mathematics. t is used with children from ; years of age to adulthood. #he test
yields a score that is compared with the average expected score for the child's
chronological age and grade level.
#he "ea(od% Individual Achieve&ent #est %PA#( includes word identification,
spelling, mathematics, and reading comprehension.
#he Kauf&an #est of *ducational Achieve&ent, the ,ra% .ral $eading #est-
$evised %>-0#-0(, and the Se/uential #ests of *ducational "rogress %'#6P( are
achievement tests that determine whether a child has achieved the educational level
expected for his or her grade level. !hildren with an average ?, whose achievement
is significantly lower than expected for their grade level in one or more subBects, are
considered to be learning disabled. #hus, achievement testing, combined with a
measure of intellectual function, can identify specific learning disabilities for which
remediation is recommended. !hildren who do not reach their grade level according
to their chronological age, but who function intellectually in the borderline range or
lower, are not necessarily learning disabled unless a disparity exists between their
?s and their levels of achievement.
.io"sychosocial 1ormulation
#he clinician's tas. is to integrate all of the information obtained into a formulation
that ta.es into account the biological predisposition, psychodynamic factors,
environmental stressors, and life events that have led to the child's current level of
functioning. Psychiatric disorders and any specific physical, neuromotor, or
developmental abnormalities must be considered in the formulation of etiologic
factors for current impairment. #he clinician's conclusions are an integration of
clinical information along with data from standardized psychological and
developmental assessments. #he psychiatric formulation includes an assessment of
family function as well as the appropriateness of the child's educational setting. A
determination of the child's overall safety in his or her current situation is made. Any
suspected maltreatment must be reported to the local child protective service agency.
#he child's overall well-being regarding growth, development, and academic and play
activities is considered.
Diagnosis
!urrent evidence suggests that the use of structured and semistructured %evidence-
based( assessment tools enhance a clinician's ability to ma.e the most accurate
diagnoses. #hese instruments, described earlier, include the K#SADS, the CAPA,
and the $I%& DISC#I' interviews. #he advantages of including an evidence-based
instrument in the diagnostic process include decreasing potential clinician bias to
ma.e a diagnosis without all of the necessary symptoms information, and serving as
guides for the clinician to consider each symptom that could contribute to a given
diagnosis. #hese data can enable the clinician to optimize his expertise to ma.e
challenging Budgments regarding child and adolescent disorders which may possess
overlapping symptoms. #he clinician's ultimate tas. includes ma.ing all appropriate
diagnoses according to DS%#I'#T). 'ome clinical situations do not fulfill criteria for
$'*-"-#0 diagnoses, but cause impairment and re1uire psychiatric attention and
intervention. !linicians who evaluate children are fre1uently in the position of
determining the impact of behavior of family members on the child's well-being. n
many cases, a child's level of impairment is related to factors extending beyond a
psychiatric diagnosis, such as the child's adBustment to his or her family life, peer
relationships, and educational placement.
)ecommendations and Treatment Plan
#he recommendations for treatment are derived by a clinician who integrates the
data gathered during the evaluation into a coherent formulation of the factors that are
contributing to the child's current problems, the conse1uences of the problems, and
strategies that may ameliorate the difficulties. #he recommendations can be bro.en
down into their biological, psychological, and social components. #hat is,
identification of a biological predisposition to a particular psychiatric disorder may be
clinically relevant to inform a psychopharmacologic recommendation. As part of the
formulation, an understanding of the psychodynamic interactions between family
members may lead a clinician to recommend treatment that includes a family
component. 6ducational and academic problems are addressed in the formulation
and may lead to a recommendation to see. a more effective academic placement.
#he overall social situation of the child or adolescent is ta.en into account when
recommendations for treatment are developed. -f course, the physical and
emotional safety of a child or adolescent is of the utmost importance and always at
the top of the list of recommendations.
#he child or adolescent's family, school life, peer interactions, and social activities
often have a direct impact on the child's success in overcoming his or her difficulties.
#he psychological education and cooperation of a child or adolescent's family are
essential ingredients in successful application of treatment recommendations.
!ommunications from clinicians to parents and family members that balance the
observed positive 1ualities of the child and family with the wea. areas are often
perceived as more helpful than a focus only on the problem areas. 2inally, the most
successful treatment plans are those developed cooperatively between the clinician,
child, and
family members during which each member of the team perceives that he or she has
been given credit for positive contributions.
)eerences
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diagnostic categories and items of the !D!FE:-48, #02, and I'0. Durlington, "#H
Jniversity of "ermont, 0esearch !enter for !hildren, Iouth, K 2amilies; 3AA4.
Dird +0, !anino >L, $avies *, 0amirez 0, !havez F, $uarte !, 'hen '. #he Drief
mpairment 'cale %D'(H A multidimensional scale of functional impairment for
children and adolescents. 0 A& Acad Child Adolesc "s%chiatr%. 3AA;;//H :CC.
$oss AL. 6vidence-based diagnosisH ncorporating diagnostic instruments into clinical
practice. 0 A& Acad Child Adolesc "s%chiatr%. 3AA;;//;C/5.
+amilton L. !linician's guide to evidence-based practice. 0 A& Acad Child Adolesc
"s%chiatr%. 3AA;;//H/C/.
+amilton L. #he answerable 1uestion and a hierarchy of evidence. 0 A& Acad Child
Adolesc "s%chiatr%. 3AA;;//H;C:.
&estenbaum !L. #he clinical interview of the child. nH ,iener L*, $ulcan *&,
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"s%chiatr%. 9rd ed. ,ashington, $!H American Psychiatric Publishing, nc.;
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infant, child, and adolescent. nH 'adoc. DL, 'adoc. "A, eds. Kaplan 1 Sadoc!'s
Co&prehensive #e+t(oo! of "s%chiatr%28th ed. "ol. 3. DaltimoreH Fippincott ,illiams
K ,il.ins; 3AA;H9A//.
Fyneham +L, 0apee 0*. 6valuation and treatment of anxiety disorders in the
general pediatric populationH A clinician's guide. Child Adolesc "s%chiatr Clin N A&.
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Pata.i !'. !hild psychiatryH ntroduction and overview. nH 'adoc. DL, 'adoc. "A,
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Puig-Antich L, -rraschel +, #abrizi *A, !hambers ,. 'chedule for Affective
$isorders and 'chizophrenia for 'chool-Age !hildren-6pidemiologic "ersion. )ew
Ior.H )ew Ior. 'tate Psychiatric nstitute and Iale 'chool of *edicine; 4C8A.
'taller LA. $iagnostic profiles in outpatient child psychiatry. A&erican 0ournal of
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