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The clinician conducting a psychiatric evaluation of a child or adolescent faces two important questions: 1) Does this child have a disorder?, and 2) If so, what is the correct diagnosis? Without a diagnosis, treatment recommendations are not possible. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association (1994), specifies criteria, backed by years of research, to be used in making a psychiatric diagnosis. The disorders usually first diagnosed in infancy, childhood or adolescence are: Mental Retardation, Learning Disorder, Motor Skills Disorder, Communication Disorders, Pervasive Developmental Disorders, Attention-Deficit/Hyperactivity Disorders, Tic Disorders, Elimination Disorders, Separation Anxiety Disorder, Reactive Attachment Disorder of Infancy or Early Chilhood,Sterotypic Movement Disorder. Often mood and anxiety disorders are first seen in childhood and adolescence.
The evaluation of psychiatric illness requires time. Insufficient time spent on developing a diagnosis may contribute to three common errors: over-diagnosis, using the response to treatment as validation of the diagnosis, and missing co-existing conditions.
The prototypical child referred for a psychiatric evaluation is not asking to be evaluated. Rather, it is the family, or very often the child's school, that is requesting the evaluation. Some of the common symptoms that drive the request for an evaluation are that the child is disruptive in school, oppositional at home, withdrawn, aggressive, defiant, fearful, intellectually impaired, or acting-out.
The Assessment Process
The procedures for a complete evaluation and diagnosis outlined below are followed at the NYU Child Study Center. The first step, even before the child and family are seen, is the gathering of information.
- A packet of questionnaires and rating scales is sent to the family. These yield demographic information, including where and with whom the child lives, where he/she attends school, description of the problem for which the family is seeking consultation, and the nature of any previous assessment and treatment. Data is collected concerning the child's early development and medical and neurological history. Detailed information about the child's current school and any previous schools attended, a psychosocial and family history, and current and past stressors in the family is also gathered. If the youngster being evaluated is a teenager, a separate questionnaire should be sent for the teen to complete.
- In addition, parents should be asked to send copies of any previous psychological and/or educational tests and to bring copies of previous report cards. Just as important as the forms completed by the parents, are rating scales to be completed by the child's teachers. These questionnaires can be requested before the child is seen and then repeated periodically during the course of treatment. The school guidance counselor or nurse can often be a very useful resource and point person when these questionnaires need to be completed, collected and returned by multiple teachers.
Behavior rating scales or checklists, in addition to providing information from multiple informants, enable the clinician to understand the similarities and differences in a child's behavior across settings. These scales ask qustions about a variety of symptoms and are rated on a scale from "never occurs" to "always." The symptoms are tied to the criteria for the various disorders listed in the DSM-IV. Some of the scales ask a number of questions about the youngster's academic achievement and pro-social behaviors. These scales enable the clinician to compare behavior in different settings, set treatment goals, and follow a child's progress and change in symptoms over time. Rating scales have been developed by a number of different groups and include the Child Behavior Checklist (CBCL), the Revised Conner's scales, and the SNAP-IV. Because they are standardized and extremely useful, there is a danger in using them to make the diagnosis. Rating scales alone should ever by used to make or disprove a diagnosis but should be considered like any laboratory test as an addition to the clinical database.
- Finally, some guidelines on preparing the child for the evaluation should be provided. Before the appointment, parents should tell their child, in an age-appropriate way, the purpose and goals of the evaluation.
Some clinicians divide the evaluation into several sessions. At the NYU Child Study Center, we prefer to begin with a two-hour evaluation. Parents are asked to come with the child. The time can be divided into three components - meeting with the entire family, meeting with the child or adolescent alone, and meeting with the parents alone. Occasionally, with an adolescent, we will meet with the teenager alone before meeting with the parents alone.
The initial portion of the time spent with the child and parents is used to identify any early questions they may have, to review the process and set goals, and to make sure that the parents have clarified to the child the reasons for seeking the evaluation. Generally, after this family meeting, the clinician meets with the parents alone.
The goal of meeting with the parents is to gather comprehensive information, using a standardized diagnostic interview, of every aspect of the child's strengths and difficulties. In general, information is best obtained using a combination of open-ended and focused, semi-structured questions. As previously stated, information about the child's functioning in different settings and contexts is essential. In order to completely understand the problem, the clinician must be aware of the onset of the difficulties, and where and under what circumstances the symptoms occur. The intensity of symptoms in each setting must also be ascertained. It is important to ask about academic achievement, family life, peer relationships, leisure activities, independent functioning and self-care. It is often useful to ask for a detailed behavioral description of the child's typical school day and weekend day from the moment of waking until bedtime. Very specific examples of a child's problematic behavior, including when it occurs, how often, under what circumstances, and how the parents handle the behavior, are critical information.
A review of the family and psychosocial history will provide information about how the family has handled the child's difficulties and will clarify the strengths and impediments the family may have in dealing with possible treatments. Assessment of such factors as the quality of the relationships among family members, the role of the child and his/her responsibilities in the home, etc. are among the family issues to be considered. A detailed medical history is important to rule out any possible physical causes that may account for symptoms. A physical exam should have been completed within the previous year. Routine laboratory screening, lead levels, and thyroid function tests may be requested if the history suggests that they are warranted.
Mental status: examination A meeting with the child takes place after the meeting with the parents. The evaluation of the child must be developmentally appropriate, and begins with an observation of the child's behavior in the office and waiting room. Included in the interview is an assessment of the child's awareness of the social, behavioral or academic difficulties reported by parents and teachers. Throughout the interview, the child's comfort level, social interaction and the presence or absence of odd behaviors are appraised. It is important to be aware that symptoms may not be present in the structured setting of an office, and occasionally it is useful to observe the child in the classroom and on the playground.
One of the responsibilities of the clinician conducting the evaluation is to probe for symptoms other than those reported by parents and teachers, since certain disorders may mimic or coexist with the reported symptoms. As part of the assessment, it is important to evaluate for the presence of oddities of thought, suicidal thinking, hallucinations and symptoms of anxiety, depression, conduct disorder, and in teenagers, substance abuse. Other symptoms and issues may include: enuresis/encopresis, tics, possible psychotic symptoms, impaired relatedness, developmental disabilities, communication disorders, trauma reactions. If there is a possibility of a learning disorder, a neuropsychological evaluation is warranted.
Specialized testing: A neuropsychological evaluation is useful in evaluating a youngster for a learning disorder. A battery of objective tests that measure intelligence, academic achievement, and areas of academic difficulties is administered; it can clarify learning styles and learning weaknesses and recommend specific strategies, the optimum educational setting and/or modifications that can enhance learning. During the comprehensive test sessions the child can sometimes display a variety of behaviors, including distractibility, hyperactivity, inattention, avoidance, and fatigue. However, the absence of these behaviors in the structured setting does not rule out a possible diagnosis.
Once the evaluation is complete, the findings are reviewed with a clinical team before the follow-up meeting with the family. During the conference, the results of the evaluation are presented, and following discussion, a consensus on the best course of treatment is obtained.
The final step in the evaluation process is providing feedback, first to the parents and then to the child. This meeting includes several components: 1) explaining the diagnosis in a way that helps parents understand how the clinician reached his/her conclusions, 2) education about the diagnosis, including the expected course and prognosis, and 3) treatment recommendations. Following discussion with the parents, the child needs to be informed, in language that is age-appropriate and with useful metaphors, about the nature of the problem, and how parents, clinician, teachers and the child will work together to help reduce the trouble that the child has experienced.
A version of this article appeared previously in School Nurse News.