Psychiatric Assessment of Children and Adolescents

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chapter 14 Psychiatric Assessment of Children and Adolescents

Harriet L. Macmillan, Jan E. Fleming, Ellen Jamieson

There is no health without mental health.

WORLD HEALTH ORGANIZATION, 2007

Community studies indicate that approximately one in five children and adolescents suffer from some type of psychiatric disorder, and at least 12% of young people have clinically important mental disorders. This chapter focuses on pediatric clinical skills useful in identifying psychiatric disturbances in childhood and adolescence. One of the major challenges in evaluating children and adolescents for the presence of psychiatric disturbance is that emotional and behavioral symptoms occur commonly in this age group; a disorder is present when there are clinically significant symptoms associated with impairment. For example, in disruptive behavioral problems, most children have a few antisocial symptoms, but very few have a large number of symptoms associated with impairment. We hope that the assessment strategies outlined here will assist clinicians working with children and adolescents to distinguish those who require further evaluation and/or treatment from those who need no further intervention.

We provide guidelines for the approach to the clinical interview and the content, including:

• Specific aspects of interviewing children, adolescents, and parents about emotional and behavioral problems
• How to elicit information about the most common psychiatric conditions: disruptive behavioral problems, substance abuse, eating disorders, emotional disorders, and somatoform problems
• Approaches to asking about child maltreatment
• Interviewing patients with mental retardation
• Cultural considerations
• Importance of the physical examination
• Use of standardized instruments and questionnaires

For the sake of brevity, the word child will be used to refer to all ages, including adolescents up to age 18 years, throughout the chapter unless otherwise specified.

Clinical Interview

The clinical interview with children and parents is the best way to assess behavioral and emotional disturbances. Whenever possible, history about an emotional or behavioral problem should be obtained from multiple informants, preferably including the child, parent (both, if more than one is available), and teachers or daycare personnel.

It is well documented that there is only moderate agreement among different informants in describing the same child, including the parent-child agreement. Reasons for these differences include:

1. Different people have different access to information; for example, children may not tell parents about feelings such as anxiety or sadness.
2. Different people have varying perceptions of behavior. What is highly concerning to one parent may not be considered abnormal to another.
3. Psychiatric problems may be specific to particular situations; for example, a child may be highly anxious at school but not at home, or vice versa.

If the child is in a two-parent family, both parents should be invited to the first interview. If only one parent attends, you should emphasize the importance of meeting with the other parent. Families vary in structure and membership; it should not be assumed that a child is living with a mother and a father.

Format

It is not unusual for the child and/or family members to be uncomfortable about discussing mental health concerns and to be reluctant about attending the interview. Children may have received no advance information about the visit and have little understanding about the need for the assessment. Establishing a friendly atmosphere and clearly outlining the plan for assessment (e.g., explaining who will be interviewed and in what order) helps reduce anxiety and facilitates the gathering of information. You should encourage family members to express their concerns, and ask them why they have come to see you. Be prepared for responses such as, “Because my family doctor told me to.” Such comments should be followed up by asking the family members what they hope to accomplish by this meeting, apart from what others may have suggested. The following guidelines are useful in planning the interview:

1. The child and parents should be seen together for at least part of the initial session. With a young child, the interview can begin with the child and parents together, followed by time with the child alone. When seeing an adolescent, it is often helpful to start with interviewing the youth alone and then asking the parents to join the interview.
2. At some point in the first session, the child should be interviewed separately. Children may be reluctant to reveal certain information in the presence of their parents. Young children may not feel free to talk about how things are at home, and adolescents may be uncomfortable discussing sexuality or drug use with parents present.
3. Preschoolers, particularly those older than age 2 years, should also be seen alone. Although it can be difficult to maintain a conversation with very young children, it is important to observe, even briefly, how the child behaves without the parent(s) present. During this time, the child should be evaluated for the ability to play, relate to the clinician, and explore new surroundings. Although a child may be reluctant to separate from a caretaker, with reassurance (e.g., about the parent’s close proximity), most children can be seen individually.
4. Although adolescents may attend an appointment on their own, at some point it is necessary to have contact with the parent(s) to carry out a comprehensive assessment. This should be clearly explained to the adolescent before any contact with the parent(s).
5. Parents should also be interviewed separately for part of the session. Children are very sensitive to history reported by a parent(s) in their presence. Parents and clinicians sometimes assume that comments they make in the presence of a preschool child are not understood. Particularly when discussing sensitive issues (e.g., concern about a possible separation from a partner), ensure that the child is not present. It is the clinician’s responsibility to safeguard the child from hearing potentially harmful and inappropriate information. If a clinician’s office does not have the facilities for a young child to be supervised while parents are interviewed alone, a second appointment can be made for the parents to return without the child.

Key Point

In assessing psychiatric problems, it is important to interview the child alone. Even very young children may be reluctant to talk about certain issues in the presence of parents.

Setting

The issue of privacy has been mentioned in Chapter 1. Although privacy in interviews with adults is often emphasized, children’s needs for privacy are frequently overlooked. Ensure that the child’s interview is free of intrusions and cannot be overheard.

Ideally the room should contain small chairs and a table suitable for preschoolers, or at least a place where you can join the child at his or her level. It can often be very helpful for the adult professional to get down on the floor at the same level as the child. This approach helps engage the child and is less intimidating.

When interviewing children, toys and drawing materials should be available. Toys help build rapport, decrease anxiety, and can be used in exploring the child’s wishes, fears, impulses, and relationships. However, too many toys and activities can be distracting. Useful play materials include nontoxic washable markers and/or crayons, paper, building blocks, male and female dolls, a dollhouse with accompanying figures and furniture, and a toy telephone. Board games may help engage a child initially, but, as outlined by Morrison and Anders, their use rarely leads to clinically meaningful information. They are typically highly structured and provide little opportunity for imaginative play.

Confidentiality

Parents and children should be informed early in the interview about issues of confidentiality. Children should not be assured of absolute confidentiality because issues about self-harm or abuse may arise. If children are assured that nothing will be shared with any other person and, subsequently, an issue such as abuse surfaces during the interview that must be disclosed to others, it can lead to feelings of betrayal. Such situations can result in a serious disruption of the therapeutic alliance. We find it useful to inform the child in developmentally appropriate terms that what is discussed is confidential unless it involves someone’s safety (e.g., people hurting themselves or being hurt by others). With young children, it is helpful to explore their understanding of the concept of safety.

An example of how to discuss confidentiality follows: “I will not tell anyone what you and I talk about without you saying it’s all right, unless it has to do with someone’s safety.” “Do you know what safety means?” (Often the child, depending on the age, can provide an explanation. It is still helpful to clarify what you mean by safety). “If you, or someone you know, is hurting themselves or being hurt by someone else, then that’s a problem with safety.”

The clinician and the child can decide together what information can be discussed with parents. Often a focus on themes, rather than specific comments, can be shared with the child’s permission. “I will be meeting with your parent(s), but we can decide together what is okay to share with them.” Parents are sometimes reluctant to have their child interviewed alone. They may be worried about what the child will say about them or their home situation. Parents should be reassured that it is a routine part of the assessment to get the child’s perspective.

Length

Interviews about behavioral and emotional problems often require more time than the assessment of physical problems. The clinician, parents, and child must have the opportunity to establish rapport, and exploration of psychiatric issues can be stressful. We recommend that 45 minutes to 1 hour be set aside for the first encounter regarding a mental health problem. The child’s age, developmental stage, and ability to be seen alone will influence the proportion of time spent with the child alone, parents alone, and the child and parents together. It is most important to establish a positive rapport with the patient and family, rather than adhering to a rigid schedule for the assessment. For example, some young children can tolerate being seen alone for very brief periods only. The clinician should structure the length of time with each person accordingly.

Key Point

Set aside 45 minutes to 1 hour for the first encounter when interviewing children and families about emotional and behavioral problems. Subsequent interviews should generally be scheduled for similar lengths, until the assessment is completed.

Obtaining the Presenting History

The following guidelines outline the approach to obtaining presenting history from the parents and children:

1. Encourage each person to describe the problem in his or her own way. An open inquiry followed by more focused questions later in the interview provides the most information. Examples of open versus more directive questions are provided in Chapter 1. At times a child will respond repeatedly with “I don’t know.” It is important to determine whether the patient genuinely does not understand or whether this response is to avoid answering the question. Rephrasing the question or giving examples can assist with the former situation. When avoidance is suspected, it can be helpful to ask the patient directly, but in a nonthreatening way, whether the repeated “I don’t know” means he or she is having trouble comprehending or whether there are barriers to answering the question. It can be useful to explain how such responses can be confusing, and that an alternative such as “I don’t want to talk about that” is preferable if indeed that is the case.
2. Seek detailed descriptions of the behavioral or emotional symptoms; ask for specific examples of the behavior.
3. Avoid leading questions that suggest the answer. An example of a leading question is “I bet that really made you angry, right?” A better question would be, “How did you feel when that happened?” Young children, particularly, may be prone to conform to an interviewer’s expectations.
4. Ask about the impact of the problem. How much does the behavior affect the child’s and family’s functioning? For example, if the problem is oppositional behavior: How often is the behavior happening? What happens in response to the behavior? Who in the family is most affected by the child’s behavior? What is that like for the child? When [child’s name] behaves like that, what is it like for other family members?
5. Ask about the presence of the chief complaint across a range of activities and situations. For example, is the child fearful at night only?
6. Ask about historical data, such as developmental milestones using direct questions; an open approach works best for relationships and feelings.

The following case example illustrates how information from multiple sources is important in addressing emotional and behavioral symptoms and in moving toward a diagnosis and treatment plan.

Case History 1

History. Emma (age 7) and her parents were referred by their family physician because of Emma’s teacher’s concerns about her withdrawn behavior at school and her lack of friends. According to her parents, Emma played well at home with her 4-year-old sister and often helped with chores around the house. She appeared happy and enjoyed doing errands with her mother. Neither parent had observed any problems with Emma. They thought she was likely just shy at school and would become more sociable with time. Her second grade teacher noted early on that Emma did not interact with her classmates and often wanted to stay in the classroom during recess. Emma appeared to understand her schoolwork and completed it without difficulty. However, she resisted saying anything in class and refused to work in groups with other children. She often stayed behind in the classroom until everyone else had left. When Emma was interviewed individually, she initially denied any problems and said that her parents and her sister were her friends; she did not need anyone else. As the clinician probed further, Emma admitted to being very lonely but feeling too self-conscious to interact with peers. She acknowledged feeling so worried about meeting other children that she hated school. Together the clinician and Emma talked about sharing this information with her parents. At first Emma was hesitant but then agreed that it was important for her parents to know how she had been feeling. Both parents were supportive of Emma as she told them, assisted by the clinician, about how she had been feeling at school. They agreed to meet with the teacher to discuss ways of helping Emma with her anxiety about interacting with classmates and were referred to a child psychiatrist for further assessment to determine whether Emma needed additional treatment for her anxiety symptoms.

Specific features of the interview with parent(s)

1. Studies show it is essential to interview both parents (if there is more than one available) when assessing an emotional or behavioral problem. Reports by one parent of the perspective of the other are often inaccurate. Often details of the personal, family, and social background can be obtained from the parents only, particularly when assessing younger children.
2. Ask the parents about their own childhood. Useful questions include:

• Who was in your family?
• Tell me about your family when you were growing up.
• What is your best memory of growing up?
• What is the worst (or most painful) memory of your childhood?
• What happened in your family when someone got in trouble?
• Whom did you go to for help?

3. Inquire about relationships between the parents and grandparents. For example, say to parents:

• Tell me about the relationship between your parents (both then and now).
• How did you and your mom get along?
• How did you and your dad get along?

4. Ask about communication patterns, family alliances, and parent-child interactions, including discipline and control:

• How do people in the family get along?
• What do you and [child’s name] do together? (ask of each parent individually)
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