Aims of Assessment

The aims of the psychosocial assessment in the pediatric setting are to determine whether there are signs and symptoms of cognitive, developmental, emotional, behavioral, or social difficulties and to characterize these signs and symptoms sufficiently to determine their appropriate management. The focus of the assessment varies with the nature of the presenting problem and the clinical setting. Under emergency circumstances, the focus may be limited to an assessment of dangerousness to self or others for the purpose of determining the appropriate level of care. In routine circumstances (well child visits), the focus may be broader, involving a screen for symptoms and functional impairment in all major psychosocial domains. The challenge for the pediatric practitioner will be to determine as accurately as possible whether the presenting signs and symptoms are likely to meet criteria for a psychiatric disorder and whether the severity and complexity of the disorder suggests referral to a mental health specialist or management in the pediatric setting.

Presenting Problems

Infants are brought to clinical attention because of concerns about failure to gain weight and length, poor social responsiveness, problems with eating and sleep regulation, relative lack of vocalization, apathy or disinterest, and response to strangers that is excessively fearful or overly familiar. Psychiatric disorders most commonly diagnosed during this period are feeding and reactive attachment disorders.

Toddlers are assessed for concerns about sleep problems, extreme misbehavior, extreme shyness, inflexible adherence to routine, language delay, motor hyperactivity, difficulty separating from parents, struggles over toilet training or new foods, and testing limits. Developmental delays and more subtle physiologic, sensory, and motor processing problems can be presented as concerns. Problems with goodness of fit between the child’s temperament and the parents’ expectations can create relationship difficulties that also require assessment. Psychiatric disorders most commonly diagnosed during this period are pervasive developmental and reactive attachment disorders.

Presenting problems in preschoolers include elimination difficulties, sibling jealousy, lack of friends, self-destructive impulsiveness, multiple fears, nightmares, refusal to follow directions, somatization, speech that is difficult to understand, and temper tantrums. Psychiatric disorders most commonly diagnosed in this period are pervasive developmental, communication, disruptive behavior, anxiety, and sleep disorders.

Older children are brought to clinical attention because of concerns about angry mood, depression, bedwetting, overactivity, impulsiveness, distractibility, learning problems, arguing, defiance, nightmares, school refusal, bullying or being bullied, worries and fears, somatization, communication problems, tics, and withdrawal or isolation. Psychiatric disorders most commonly diagnosed during this period are attention, disruptive behavior, anxiety (separation anxiety, selective mutism, generalized anxiety), elimination, somatoform, learning, and tic disorders.

Adolescents are assessed for concerns about the family situation, experimentation with sexuality and drugs, delinquency and gang involvement, friendship patterns, issues of independence, identity formation, self-esteem, and morality. Psychiatric disorders most commonly diagnosed during this period are anxiety (panic, social anxiety), depression, bipolar, psychotic, drug use, and eating disorders.

General Principles of the Psychosocial Interview

Psychosocial interviewing in the context of a routine pediatric visit requires adequate time and privacy. The purpose of this line of inquiry should be explained to the child and parents (“to make sure things are going OK at home, at school, and with friends”), along with the limits of confidentiality. Thereafter, the first goal of the interview is to build rapport with both the child and the parents.

With the parents, this rapport is grounded in respect for the parents’ knowledge of their child, their role as the central influence in their child’s life, and their desire to make a better life for their child. Parents often feel anxious or guilty because they believe that problems in a child imply that their parenting skills are inadequate. In addition, parents’ experiences of their own childhood influence the meaning a parent places on a child’s feelings and behavior. A good working alliance allows mutual discovery of the past as it is active in the present and permits potential distortions to be modified more readily. Developmentally appropriate overtures can facilitate rapport with the child. Examples include playing peek-a-boo with an infant, racing toy cars with a preschooler, commenting on sports with a child who is wearing a baseball cap, and discussing music with a teenager who is wearing a rock t-shirt.

After an overture with the child, it is helpful to begin with family-centered interviewing, in which the parent is invited to present any psychosocial concerns (development, thinking, feelings, behavior, peer relationships) about the child. With adolescent patients, it is important to conduct a separate interview to give the adolescent an opportunity to confirm or refute the parent’s presentation and to present the problem from his or her perspective. Following the family’s undirected presentation of the primary problem, it is important to shift to direct questioning to clarify the duration, frequency, and severity of symptoms, associated distress or functional impairment, and the developmental and environmental context in which the symptoms occur.

Because of the high degree of comorbidity of psychosocial problems in children, after eliciting the presenting problem the pediatric practitioner should then briefly screen for problems in all of the major developmentally appropriate categories of cognitive, developmental, emotional, behavioral, and social disturbance, including problems with mood, anxiety, attention, behavior, thinking and perception, substance use, social relatedness, eating, elimination, development, language, and learning. This can be preceded by a transition statement such as “Now I’d like to ask about some other issues that I ask all parents and kids about.”

A useful guide for this area of inquiry is provided by the “11 Action Signs” (Table 18-1), which was designed to give frontline clinicians the tools needed to recognize early symptoms of mental disorders. Functional impairment can be assessed by inquiring about symptoms and function in the major life domains, including home and family, school, peers, and community. These domains are included in the HEADSS (home, education, activities, drugs, sexuality, suicide/depression) interview guide, often used in the screening of adolescents (Table 18-2).

The nature and severity of the presenting problem(s) can be further characterized through the use of a standardized self-, parent-, or teacher-informant rating scale (Table 18-3 gives a sample of scales in the public domain). A rating scale is a type of measure that provides a relatively rapid assessment of a specific construct with an easily derived numerical score that is readily interpreted. The use of rating scales can ensure systematic coverage of relevant symptoms, quantify symptom severity, and document a baseline against which treatment effects can be measured.

Clinical experience and methodologic studies suggest that parents and teachers are more likely than the child to report externalizing problems (disruptive, impulsive, overactive, or antisocial behavior). Children may be more likely to report anxious or depressive feelings, including suicidal thoughts and acts, of which the parents may be unaware. Functional impairment also can be assessed with self -and other-rating scales. Although concerns have been raised about children’s competence as self-reporters (because of limitations in linguistic skills; self-reflection; emotional awareness; ability to monitor behavior, thoughts, and feelings; and tendency toward social desirability), children and adolescents can be reliable and valid self-reporters.

Clinicians are encouraged to become familiar with the psychometric characteristics and appropriate use of at least one broad-based measure of psychosocial problems, such as the Strengths and Difficulties Questionnaire (SDQ), the Pediatric Symptom Checklist (PSC) (Fig. 18-1), or the Swanson, Nolan, and Pelham–IV (SNAP-IV). If the interview or broad-based rating scale suggests difficulties in one or more specific symptom areas, the clinician can follow with a psychometrically sound, appropriate narrow-based instrument such as the Modified Checklist for Autism in Toddlers (M-CHAT), the Vanderbilt ADHD Diagnostic Rating Scale for attention and behavior problems, the Center for Epidemiological Studies Depression Scale for Children (CES-DC) for depression, or the Screen for Child Anxiety Related Emotional Disorders (SCARED) for anxiety.

Figure 18-1 Pediatric Symptom Checklist.

(From Green M, Palfrey JS, editors: Bright futures: guidelines of the health supervision of infants, children, and adolescents, ed 2, revised, Arlington, VA, 2002, National Center for Education in Maternal and Child Health.)

Children and adolescents scoring above standardized cutpoints in most cases should be referred to a qualified mental health professional for assessment and treatment, because scores in this range are highly correlated with clinically significant psychiatric disorders. Youths scoring just below or slightly above cutpoints (e.g., subsyndromal or mild mood, anxiety, or disruptive behavior disorders) may be appropriate for management in the pediatric setting, as may youths scoring well above cutpoints for certain biologically based disorders (e.g., attention-deficit/hyperactivity).

The safety of the child in the context of the home and community is of paramount importance. The interview should sensitively assess whether the child has been exposed to any frightening events, including parental arguing or domestic violence, abuse or neglect, or community violence, whether the child shows any indication of depression or suicidality, or whether the child (if age-appropriate) has been involved in any risky behavior, including running away, staying out without permission, truancy, gang involvement, experimentation with substances, and unprotected sexuality. The interview also should assess the capacity of the parents to adequately provide for the child’s physical, emotional, and social needs or whether parental capacity has been diminished by psychiatric disorder, family dysfunction, or the sequelae of disadvantaged socioeconomic status. Any indications of threats to the child’s safety should be immediately followed by thorough assessment and protective action.

Indications for Referral

There is variability in the level of confidence pediatric practitioners perceive in diagnosing psychosocial problems in children and adolescents. Pediatricians who have familiarity with psychiatric diagnostic criteria as presented in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care (DSM-IV-PC) may feel confident diagnosing certain disorders, particularly those with a strong biological base (e.g., attention-deficit/hyperactivity disorder, autistic disorder, enuresis, encopresis, anorexia). The disorders about which pediatric practitioners might have less diagnostic confidence include the disruptive behavior, mood, anxiety, psychotic, and substance-use disorders. Pediatricians should refer to a qualified mental health practitioner whenever they experience diagnostic uncertainty with a child who has distressing or functionally impairing psychosocial symptoms. Children who upon initial assessment are found to have indicators of dangerousness always should be referred to a qualified mental health professional.

Psychiatric Diagnostic Evaluation

The objectives of the psychiatric diagnostic evaluation of the child and adolescent are to determine whether psychopathology or developmental risk is present and if so, to establish an explanatory formulation and a differential diagnosis, and to determine whether treatment is indicated and if so, to develop a treatment plan and facilitate the parents’ and child’s involvement in the plan. The aims of the diagnostic evaluation are to clarify the reasons for the referral; to obtain an accurate accounting of the child’s developmental functioning and the nature and extent of the child’s psychosocial difficulties, functional impairment, and subjective distress; and to identify potential individual, family, or environmental factors that might account for, influence, or ameliorate these difficulties. The issues relevant to diagnosis and treatment planning can span genetic, constitutional, and temperamental factors; individual psychodynamics; cognitive, language, and social skills; family patterns of interaction and child-rearing practices; and community, school, and socioeconomic influences.

The focus of the evaluation is developmental; it seeks to describe the child’s functioning in various realms and to assess the child’s adaptation in these areas relative to that expected for the child’s age and phase of development. The developmental perspective extends beyond current difficulties to vulnerabilities that can affect future development and as such are important targets for preventive intervention. Vulnerabilities may include subthreshold or subsyndromal difficulties that, especially when manifold, often are accompanied by significant distress or impairment and as such are important as potential harbingers of future problems.

Throughout the assessment, the clinician focuses on identifying a realistic balance of vulnerabilities and strengths in the child, in the parents, and in the parent-child interactions. From this strength-based approach, over time a hopeful family narrative is co-constructed to frame the child’s current developmental progress and predict his or her ongoing progress within the scope of current risk and protective factors.

Although the scope of the evaluation will vary with the clinical circumstance, the full psychiatric diagnostic evaluation has 6 major components: the presenting problem; a review of psychiatric symptoms and risk status; a developmental history; a full mental status examination; a biopsychosocial formulation and multiaxial diagnosis; and a treatment plan. For infants and young children, the presenting problem and historical information is derived from parents and other informants. As children mature, they become increasingly important contributors to the information base, and they become the primary source of information in later adolescence. Information relevant to formulation and differential diagnosis is derived in multiple ways, including directive and nondirective questioning, interactive play, and observation of the child alone and together with the caregiver(s).

The explication of the presenting problem includes information about onset, duration, frequency, and severity of symptoms, associated distress and/or functional impairment, and predisposing, precipitating, or perpetuating contextual factors. The symptom review assesses potential comorbidity in the major domains of child and adolescent psychopathology, including problems with attention; anger; disruptive behavior; antisocial behavior; substance use; depressed, irritable, or manic mood; anxiety; eating; elimination; psychosis; development, language, or learning; and the details of prior psychiatric treatment. This review also includes a careful assessment of risk status, including suicidality, homicidality, and involvement in risky behavior or situations.

The developmental history includes information about the circumstances of conception, pregnancy, or adoption; physical development and medical history; cognitive and linguistic abilities and school achievement; emotional development and temperament; conscience and values; interests, hobbies, talents, and avocations; family constellation, functioning, and relationships; family medical and psychiatry history; community and culture; peer relationships; stressful or traumatic exposures; and strengths. The mental status examination assesses appearance, relatedness, cognition, communication, mood, affective expression, behavior, memory, orientation, and perception.

The evaluation culminates in a biopsychosocial formulation and differential diagnosis. The formulation is derived from an assessment of vulnerabilities and strengths in the biologic, psychologic, and social domains and serves to identify targets for intervention and treatment. In the biologic domain, major vulnerabilities include a family history of psychiatric disorder and personality or behavior problems and a personal history of pre-, peri-, or postnatal insults; cognitive or linguistic impairments; physical illness; and a difficult temperament. In the psychologic domain, major vulnerabilities include failure to achieve developmental tasks, maladaptive coping skills, and immature defensive styles. In the social domain, major vulnerabilities include parental incapacity, unskilled parenting, family dysfunction, social isolation, poor social skills, unfavorable school setting, unsupportive community structures, and sociodemographic disadvantage. Major strengths include cognitive and linguistic capability; physical health and attractiveness; stable, moderate temperamental characteristics; and stable and supportive parenting, family, peer, and community structures.

The diagnosis must be made in accordance with the nomenclature in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). This nomenclature categorizes cross-sectional phenomenology into discrete clinical syndromes and seeks to improve diagnostic accuracy at the expense of theories of causation and dimensional presentations. Mental health clinicians use a multiaxial scheme to (along with the formulation) approximate a complete picture of the child. The diagnoses are coded on Axis I. Axis II and Axis III allow the developmental and medical disturbances to be brought into focus. Axis IV permits a similar consideration for social dimensions of stress. Axis V gives a numeric description of overall level of functioning on a scale from 1 (persistent risk of self-harm) to 100 (superior functioning in a wide range of activities with no symptoms).

The psychiatric diagnostic evaluation culminates in a treatment plan that brings the broad array of targeted psychosocial interventions to the service of the child. Diagnoses drive the choice of evidence-based psychotherapeutic and psychopharmacologic treatments. The formulation drives the selection of interventions targeted at biologic, psychologic, and social vulnerabilities and strengths. Many of these treatments and interventions are described in the succeeding chapters.

Special Considerations in the Diagnostic Evaluation of Infants and Young Children

Psychiatric evaluation of infants and young children includes the domains of physiology, temperament, motor behavior, affective behavior, social behavior, and communication. Although much of the information in these domains will be derived from parent report, much also can be gleaned from nonverbal behavior and observation of the parent-child interaction. Observations should include predominant affective tone of parent and child (positive, negative, apathetic); involvement in the situation (curiosity, disinterest); social responsiveness (mutuality of gaze, auditory responsiveness); and reactions to transitions (including separation).

A screen for maternal depression is critical at this stage, as is an assessment of the mother’s (or other caregiver’s) ability to rapidly respond on a contingent basis to the child’s expressed needs, regulate the child’s rapid shifts of emotion and behavior, and provide a stimulus shelter to prevent the child from being overwhelmed.

Standardized screening instruments (e.g., Bayley Scales of Infant Development) designed for this age group can be helpful in systematizing the evaluation. In addition, the Infant, Toddler and Preschool Mental Status Exam (ITP-MSE) is a reference tool that describes how traditional categories of the mental status exam can be adapted to observations of young children. Additional categories, including sensory and state regulation, have been added that reflect important areas of development in young children.

Diagnostic systems that are more age-appropriate than DSM-IV-TR have been developed for infants and young children. These systems include the Research Diagnostic Criteria—Preschool Age (RDC-PA) and the Zero to Three Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC: 0-3R). The DC: 0-3R includes relationship classification that assesses the range of interactional adaptation in each parent-child relationship and regulation disorders of sensory processing that identify a range of constitutionally and maturationally based sensory reactivity patterns, motor patterns, and behavior patterns that together can dysregulate a child internally and with his or her interactions with caregivers.