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).