Which is the priority concern in developing a teaching plan for the parents of a 15 month old child?

Indian J Psychiatry. 2019 Jan; 61(Suppl 2): 158–175.

NEED FOR CLINICAL PRACTICE GUIDELINES

Assessing children and adolescents is challenging. Generally, the child/adolescent in question would not have initiated the consultation or may not be in agreement with the need for a consultation. The consultation may or may not even be sought for the most impairing problem at hand. While children may be able to report the nature of symptoms, they may not be very good at reporting the timing and duration of their problems. They may not report problems if they are embarrassing or show them in a bad light. Clinical assessments with children and adolescents are, therefore, elaborate and require the clinician to be astute and conscientious in obtaining information from multiple sources and settings, i.e., the child, parents, teachers, and other caregivers. There are bound to be discrepancies in the report; nevertheless, multi-source information is a requirement during diagnosis and management. Assessment and treatment are generally multidisciplinary. Information may also be gathered in a staged manner to not overwhelm the child and family. Gathered information has to be shared across professionals involved in the care of the child and family.

These guidelines cover general principles in the assessment of children and adolescents who present to a clinic (Box 1). These principles are not restricted to particular psychiatric presentations or contexts of evaluation. Assessments for forensic and legal purposes are beyond the scope of these guidelines. These guidelines must be used with an understanding and grasp of child development and childhood mental health disorders.

Aim of clinical practice guidelines on assessment of children and adolescents

Operational terms used in the guidelines

The term “child”/”children” will appear in most references to children and adolescents. At some places, distinguishing age groups becomes relevant. The term “child” will be used for all children between 0 and 12 years of age and the term “adolescent” for those between 13 and 18 years of age. To further delineate the early developmental period, where needed, the term “infant” will be used for children 0–12 months of age and “toddler” for children between 12 and 36 months of age. Given that children have to be evaluated and managed in the context of their caregiving environment, parents and the extended family are important informants and an integral part of the treatment plan. The term “parents” will be used for the biological or adoptive parents of the child, and the term “family” will be used for all other individuals who live in the same household (siblings, grandparents, other members in a joint family, etc.). For any other individual involved in primary caretaking responsibilities of the child, the term “caregiver(s)” will be used.

OBJECTIVES OF CLINICAL ASSESSMENT

The central goal of a clinical assessment is to come to a case formulation that would guide management decisions.[1] Delineating signs and symptoms through detailed clinical history and examination help ascertain key areas of concern and presence (or absence) of a mental health disorder. To adequately comprehend the origins, maintenance, and factors affecting remission from the disorder, it is essential to place the child within a psychosocial background, relate the presentation to his/her unique context, and to gather details about what has happened to the illness so far, including what has been the treatment and response history. On the face of it, these components appear factual. However, it is often challenging to get consistent, continuous, corroborative information from the child and family. A therapeutic alliance plays a vital role. If the child and the family perceive a mutually beneficial relationship, the elucidation of facts becomes more meaningful and useful leading to shared intervention goals. The case formulation is, therefore, a culmination of these individual components, helps adopt a holistic view of the child's problems, and helps in treatment planning, including assigning roles and responsibilities to the multidisciplinary team [Figure 1]. A clinical assessment also aids the child and family in developing a clearer understanding of their own difficulties and gives them an opportunity to reflect on the information they share.

Objectives of clinical assessment in child and adolescent psychiatry

Emphasis on a therapeutic alliance is limited in the context of forensic/legal evaluations. In this scenario, the person conducting the clinical assessment may not be part of the treating team. It is important, therefore, to check if the child/family is aware of and understands the reasons for referral, i.e., has the child been referred for a forensic evaluation or for treatment? The clinician should clarify to them the need for the evaluation, and the further course postevaluation, including confidentiality of the information, obtained.

Establishing therapeutic alliance with the child/family

Health professionals working with children know that interacting with children is no child's play! As adults we often find ourselves at a loss of ideas when interacting with children; as health professionals we also tend to get preoccupied with “saying the right thing,” and worrying about whether the child will “abide” by given advice. Getting caught up in these anxieties impedes assessment and therapeutic work with children. It is easier to empathize with adults because we have a more accessible frame of reference in ourselves. Adults are not children, but they have been children. We need to on several occasions recall our own childhood experiences, and from the lives of our siblings and peers, to draw parallels, to truly understand the predicament a given child may be in.

Clinicians sometimes neglect establishing a rapport in their work with children and practice purely paternalistic medicine. There is a need to respect the child's autonomy as well as look out for their best interests. Shared decision-making, with selective paternalism where needed, is the best form of practice, especially with children and families.[2] While establishing rapport, a common error is the assumption that communicating with parents is enough, and that interventions in children occur through parents. This is partially true, given that parent training and parent-child work form major components of intervention in childhood disorders. However, clinicians’ and the therapists’ relationship with the child independently affect intervention outcomes. Even though a child may not agree with the need for a consultation, we must know that children are aware of the processes and are trying to make sense of discussions around them that are about them! Therefore, direct communication with the child, acknowledging the child's understanding of the situation, and building a shared understanding, even if simplistic, is fruitful in the long-run.

The purpose of developing a rapport with a child must be clear in the clinician's mind. Immediate compliance with the clinician's advice is not the goal. Good rapport has a long-term agenda of providing the child with a safe, confidential, nonjudgmental place to “unburden” and discuss possible solutions to their difficulties. If a child is in trouble, he/she must be able to share it with the clinician honestly, rather than cover it up, which might, in turn, expose the child to additional trouble. Compliance, therefore, becomes a byproduct of the therapeutic alliance with the child. In addition, the child must also know what are the limits to confidentiality in a therapeutic relationship. Harm to self, harm to others, experiences of trauma and abuse, are issues that have to be taken out of clinician-child confidentiality agreement for systematic intervention. This must be communicated to the child and be reiterated over the course of consultations.

A child-friendly space for assessment of children and adolescents

The clinical setting for the assessment of children and adolescents should engage the child for the requisite duration of time. The waiting period and meeting a doctor can intimidate children, making them irritable, and uncooperative during the assessment. Most child clinics pay special attention to the appearance of the place, and the availability of toys, books, and play spaces. Simple things such as walls painted in bright colors, with cartoon characters, and fables keep the children engaged and wanting to come back to the place, should repeat consultations be required. Having a few large blackboards with colored chalks are another engagement tool. Toys, play objects, papers, and color pens should be available in the consultation room also. Play and drawing activities can help break the ice with children and can be used as standalone assessment tools, especially with preschool children who may not have the verbal repertoire to narrate distressing experiences. All staff members in child clinics need to be attuned to the presence and activities of children. They should make active attempts at keeping children engaged.

Challenges in establishing rapport

The silent child

A major challenge in establishing rapport is when a child does not talk during the consultation. There can be several reasons behind this lack of verbal engagement [Figure 2]. The clinician must be open to examining the various possibilities and address them accordingly. This, of course, will take some extra consultation time and the clinician must be prepared for the same. The idea of understanding the underlying reasons is not essentially to get the child to talk, rather it is to communicate to the child that the clinician is really keen on knowing what the child wants to say and that the clinician appreciates the child's reasons/difficulties that are a barrier to talking now.

Understanding a child's silence during assessment

A common reason for a child's silence is anxiety. Children who are temperamentally slow to warm up may gradually open up during follow-up visits. The clinician could get an idea about this from the temperamental history of the child. The clinician should avoid intimidating the child by compelling him/her to talk. The child should be allowed to ease into the consultation process at his/her own pace. Talking about the child's favorite games, school, and other neutral topics would help put the child at ease before encroaching on the clinical context. Anxiety could also arise from more proximate factors - the presence of a mood/anxiety disorder, history of trauma/abuse, authoritarian parenting where the presence of parents/caregivers may cause the child to be more anxious. In this situation, and if the child assents, the clinician could speak to the child alone. Often, children are angry about being brought in for consultation. Asking the parents what the child understands about the consultation is one way of getting an idea about this.

Parents may have brought the child on some other pretext (e.g., consultation for parents, concerns about academics even though the real reason may be disruptive behavior), or may have just coerced the child into coming for the consultation. While one may question the rationale and judgment of parents in doing so, the clinician could understand it as helplessness arising out of aggressive behavior of the child or parenting skills deficits. Sometimes parents may reach out to the clinician before they bring the child. These situations usually arise with older children and adolescents. It is advisable to have a separate interaction with the child, involving a process of introducing oneself, giving the child time to respond, and gradually moving toward establishing the context of the interaction. Acknowledging the child's emotion and communicating an interest in understanding the child's perspective is crucial in reassuring the child that they will be heard and their concerns addressed without the use of any coercion or deception. It is crucial that the context of the consultation is established from the beginning. The child and the family could be addressed together, and some common concerns mentioned as a context for continuing consultations and work with the family. When children do not acknowledge the issues at all, using phrases such as “I can see that you and your parents have been unhappy.... I would like to understand this better and help....” may be useful rather than make the youngster the sole reason for the consultation.

Children with developmental delays or specific deficits in speech and social skills may find it difficult to express themselves. Unlike the previous two scenarios, the focus here shifts from handling the child's emotions to interacting with the child at his/her developmental level. Play methods are used in the assessment of toddlers and preschoolers. Young children may not have the intellectual, verbal, and social capacity to express themselves coherently. Their experiences and memories are often engraved in behavior that can be observed during play (e.g., a child who has witnessed/experienced a traumatic event may enact the same during play). In very young children, physiological needs - sleep, hunger, any form of physical discomfort may cause distress and make the child uncooperative during the assessment. Parents are usually able to identify these needs and the clinician should accommodate requests to address them. In fact, assessment of very young children such as infants and young toddlers must be scheduled at a time that they are awake, alert, and cooperative.

The presence of depressive/anxiety disorders could also underlie a child's silence. Selective mutism is a specific case in point. Children with this disorder have a history of not talking in unfamiliar social situations. The child can be engaged through nonverbal means, such as writing, drawing, and gestures. Comorbid social anxiety is common. With repeated interactions and reassurances the child may gradually open up. Systematic interventions for anxiety disorders must be pursued for lasting changes in interaction. Psychotic and obsessive-compulsive disorders can be another area where the “fearful” content of a child's experiences inhibit him/her from sharing information with the clinician. It is important to persist with efforts at interacting with the child. Mutism with posturing may be signs of catatonia. In such instances, standard assessment formats such as Kirby's method[3] for examination of uncooperative patients must be followed.

The “difficult” child

Older children and adolescents are often not keen on the consultation, especially where there are issues like disruptive behavior and substance abuse. The adolescent may be weary of being reprimanded and pulled up for his/her behavior or may be embarrassed to have his parents discuss his behavior with others. Sometimes, adolescents may not recognize the extent to which their behavior is problematic because their peers engage in similar behavior, for example, playing games on the mobile. Violent behavior, both toward caregivers or objects in the environment, could arise from emotional distress. The adolescent may justify aggression as “the only way” to deal with a particular situation.

It is paramount that every effort be made to gain the confidence of the child/adolescent. The efficacy of the intervention is influenced by the clinician's ability to establish a common ground with the child/adolescent. Older children and adolescents are in the phase of development where they are establishing self and group identities. They may be extremely sensitive to the disapproval of peers, interests or behaviors. In an effort to “protect” these, they refuse to talk about these issues. It is prudent to begin such interviews on a neutral ground. General enquiries about how the child/adolescent has been, how the school has been going, what their interests are, celebrities they admire/follow, etc., may help the clinician ease into establishing a rapport. It would be useful for the clinician to be familiar with the latest trends in TV, cinema, music, sports, games! This could facilitate efforts to engage the young person. It is important to not overly try to identify with the adolescent as that could appear artificial; rather a genuine interest, asking the child/adolescent to help the clinician understand their interests, may be more appealing.

It is important to acknowledge that the child/adolescent may not want to talk about the “problem.” The clinician must convey a keen interest in wanting to know the child/adolescent's perspective, and that he/she would be willing to do so whenever the child/adolescent is ready. While children/adolescents are not keen on sharing information, parents might come with a very different agenda. They may expect the clinician to figure out the problem by doing some “tests,” and “counsel” the child. Giving the parents a biopsychosocial perspective of the problem may go a long way in working with them. The cognitive, social, and emotional developmental changes in adolescence, and the longitudinal and multifactorial nature of the problem are key aspects to be discussed with the parents so that they appreciate that there are no “quick fixes” and that “advice from the clinician” may not be effective unless the underlying issues are addressed. The clinician must validate the parents’ concern and emphasize that a holistic approach is necessary to improve outcomes.

Children are often brought for consultation as they enter important academic levels (class 10/SSLC in India), as parents feel that the child's behavior is affecting or might interfere with board exam results. It may also be that the school referred the child on noticing sub-average academic performance, while the parents had not identified any concern themselves. Clinical histories often reveal that long-standing problems have been accommodated so far rather than addressing them. Clinicians need to be cautious here. Giving hope about the problem's resolution must not come at the cost of negating the reality. One could empathize with parents about their concerns and reassure them of support. Yet, the developmental and longitudinal perspective must be conveyed. We know from clinical data that issues such as developmental disorders, temperamental difficulties, and severe disruptive behavior disorders are chronic problems with heterotypic continuities into adulthood.[4] We need to educate parents and keep this framework in mind.

Gathering information from both parents and child

It is imperative to get a narrative account of the clinical history from both parents and child. The parents account is about what they “see” the child do, i.e., observations of the child's behavior. However, behaviors do not exist in isolation. Additional layers of emotion thought, experience and context help to truly understand the origins and implications of a child's behavior [Figure 3]. Firestone[5] and Wieland[6] have spoken about the “inner voice,” a product of contexts and experiences, that determines emotional and behavioral responses. This model is used by the community service project[7] at NIMHANS while working with personnel from various childcare systems in the community. This model can also be used in a clinical scenario to understand not only observed behavior but also the child's underlying thoughts and emotions. Parents are more likely to report externalizing symptoms and children and adolescents are more likely to report internalizing symptoms.

Understanding a child's behavior

Interviewing the child and parent together or separately is a clinical judgment call. Situations where one absolutely must talk separately to the child include - older children or adolescents, history suggestive of parent-child discord, peer relationship issues, history of trauma/abuse, and children staying in child care institutions. A practical way of conducting these interviews would be to speak to the parents of young children separately before or after seeing the child together with the parents to observe the child and observe the interactions between the parents and the child. In the case of adolescents, they must be included in the initial interviews and thereafter must be spoken to separately first before conducting the parent interview. Parents and children come from their own personal histories. Their understanding and expression of the “problem” is colored by their own developmental, familial, and other salient experiences. It should, therefore, not surprise the clinician when stories do not match, or concerns vary widely between the parents and the child. Figure 4 illustrates salient influential factors for the parents and the child.

Factors influencing parent and child report

Background and context of presentation

Often, the first health-care contact for children and adolescents with behavioral concerns is not a mental health professional. Pediatricians or neurologists may be consulted first. Sometimes, difficulties that the child is experiencing behaviorally, emotionally or with respect to academics may be noticed by school teachers. The referral context and process shed light on the nature of problems, functional impact, and knowledge, attitude, and practices of the family. This has implications on future plan of management. Key questions that must be posed to each family coming in for a consultation to understand the referral context are presented in Box 2. When children and parents come in for a consultation that has not been initiated by them, the clinician must look into all available documentation and trace the referral pathway. This establishes a common context for consultation and helps prioritize nature and schedule of systematic assessment and intervention.

Questions to understand the “referral”

Clinical history and examination

The goals of clinical history and examination are to evaluate and ascertain the following:

1. Developmental trajectories and attainments

2. Presenting behavioral and emotional problems

3. Current functioning in various settings

4. Strengths/assets of the child/adolescent and the family

5. The highest level of functioning before the onset of the current concerns.

Know the child and the family - the sociodemographics

Clinicians are busy people. However, spending the first few minutes in getting to know the family is a great tool in developing rapport and adds to the understanding about the context of consultation. In India, for instance, there is a wide variation in parenting and social norms. Educational, occupational, residential and religious backgrounds can give the clinician a frame of reference for “where the family is coming from” and the context of the parent-child conflict. A clinician's consultation chamber can be an intimidating experience for the child and family. Basic information gathering gives them some time to gather their thoughts and adjust to the consultation situation before discussing the “problem.”

Ongoing concerns and Presenting complaints

Parents and children may be unclear about the extent or nature of the problem. For instance, in children with developmental delays, parents may only focus on the fact that the child does not speak, or school refusal may be the presenting concern in a child who has, in fact, had a long-standing mood or disruptive behavior disorder. Development so intricately intertwines with the child's experiences and the parent's repeated attempts at handling difficulties that the clinical picture becomes complex and layered. The clinician must give the parents sufficient time to describe all that they have to say and identify the behavioral concerns. The clinician should, as a rule, identify both ongoing concerns and presenting complaints. Ongoing concerns include all the developmental, psychological, emotional, and behavioral concerns over time while presenting complaints are what precipitated the current consultation. For example, a child with long-standing attention-deficit hyperactivity disorder (ADHD) may have always had complaints from school about incomplete work, restlessness in class, and impulsive anger outbursts; however, the current consultation was precipitated by the school wanting to know if the child is academically capable of writing board examinations. While the real solution lies in addressing the ADHD through pharmacological/behavioral interventions, the urgent issue is communication with the school about the nature of the child's problems and the manner of addressal. Some key questions that could help elucidate ongoing concerns and presenting complaints are depicted in Box 3.

Questions to elucidate ongoing concerns and presenting complaints

Clinical history of the child's problems

Identifying symptom dimensions

It is ideal if the parents can narrate the concerns they have had about the child from the “start” in a chronological manner, covering details about when they sought what consultation and how it impacted the child, both gains and any adverse reactions. This ideal scenario does not exist in child and adolescent psychiatry. Unlike in adults, the premorbid self is an evolving entity in children and adolescents, and environmental contexts impact a child's behavior significantly. Parents are, therefore, at a loss for how to describe the onset, and course of concerns. Initially, the parents must be allowed to talk about the concerns in whichever manner they want to, starting at whatever point in the child's life they want to. This brings to light the most prominent concerns and the most salient accounts of the complaints. During the parents’ narrative, however, the clinician must note the behavioral symptom profiles that the parent is talking about. Some examples of typical complaints arising from different symptom domains are depicted in Table 1. Complaints pointing towards specific symptom dimensions must thereafter lead into an enquiry about differential diagnoses under that domain. For instance, a child presenting with developmental concerns must be evaluated for intellectual disability, autism spectrum disorders, specific speech, and language developmental disorders and ADHD.

Table 1

Symptom dimensions in child psychiatry

Diagnostic overshadowing and masking

The clinician must bear in mind two important phenomena – diagnostic overshadowing and diagnostic masking. Sometimes, psychiatric disorders may be missed in children with developmental disorders, because all behavioral symptoms may be considered a part of the developmental disorder, thereby overshadowing primary treatable psychiatric conditions. The presence of developmental disorders can modify or mask the manifestations of a primary psychiatric disorder, by the presence of cognitive, language or speech deficits, especially when the developmental disability is severe, for example, mood disorders in children with developmental disorders may present with excessive laughing or just increase in stereotypic behaviors.

Multiple symptoms

Children may present with more than one symptom. It is important to decipher the order of development of symptoms, for example, a child who presents currently with “fainting spells,” may have had an onset of staying withdrawn, then irritability, then refusing to go to school, and then fainting spells started around examination time. This sequential order of the complaints gives better insight into underlying psychopathological states and helps in management. The clinician must also enquire about the “peak of illness/disability” in the ongoing concerns, and the circumstances around then.

Discrete behaviors

For any discrete behaviors, such as dissociative phenomenon or aggression, it is important to get details about – onset, course, frequency, when does the behaviors occur, how long does the behavior last, precipitating and ameliorating factors. These details add to the conceptualization/significance of the discrete behavior; they may also be insightful for parents and help in planning intervention.

Impact of environmental factors

In elucidating details about behavioral problems and how they have developed over time, the parents should be asked their understanding about the child's difficulties. One may ask, “What do you feel has led to the child's behavioral problems? OR Why do you think these behavioral changes have occurred in the child?” Changes in school, peer group, family environment, parent going away for work, sibling moving out of the house, may be significant factors that the parent can link the onset of the child's problems to. Processing and accepting change can be a complex task for children. Unpredictable interruptions in the formation of a coherent working model of the world can result in confusion, insecurity, and further unpredictability. This is also why bereavement and grief are the most challenging experiences for children. Evolving concepts of life and death interact with a personal loss; behavioral manifestations range from complete indifference to extreme agitation and distress. Children with developmental disorders are especially sensitive to any changes in their environment; they may present with general distress, sleep and food irregularities, irritability, aggression, and even developmental regression. The key is to understand the child's reactions to change and help them make sense of the situation keeping in mind the developmental perspective. In developmental disorders, understimulation can be quite prominent. The parents/caregivers may not understand the transactional nature of child development. The child's daily activities may largely be comprised of solitary play with general overseeing by the caregiver/parent, with little one-to-one engagement and stimulation. This is a sub-optimal environment for child development and would become the prime focus of intervention in children/adolescents with developmental disorders.

Functional consequences of symptoms

Concerns and symptoms picked up by parents must also be assessed for their impact on functional domains in the child's life - at home, at school, with peers, etc. A useful tool in understanding functioning is to ask the parents and child to describe a “typical day” – “What all activities, and at what times of the day, the child does from waking up to going to bed?”, “Who accompanies/supervises the child in which activities?”. Changes in the daily schedule after the onset of the current concerns should be enquired.

Additional information

When children have developmental disabilities/severe mental illnesses, the clinician could also check with the family if they have sought any disability benefits. In addition to being an important part of the management plan, this enquiry serves to enlighten parents on available support systems for disability in the country.

A note on “mobile use” and “gaming” - Epiphenomena as presenting complaints?

In the recent past, children brought for excessive use of mobile phones, and excessive time spent on internet/online games/video games is increasing. The common perception among parents is that the child has become “addicted” to the mobile phone or gaming. Since parents are more commonly able to report an approximate “onset,” course and duration of, say, the excessive mobile use, the underlying pathology may be missed. Children/adolescents presenting with these concerns must be evaluated for the whole range of child mental health issues. Learning issues, developmental deficits, and mood/anxiety states may all lead to this behavioral phenotype either as an escape from “difficulties” or as a manifestation of “novelty seeking.” A primary diagnosis of behavioral addiction rarely holds once other mental health conditions have been evaluated for.

Children in special circumstances

Children and adolescents are being increasingly referred for evaluation to psychiatrists and psychologists, from state-run institutions and agencies, and nongovernmental agencies. These children may be in difficult circumstances such as in conflict with the law or in need of care and protection, many having undergone traumatic experiences such as abuse and/or neglect. While comprehensive forensic evaluation procedures are beyond the scope of this chapter, we highlight some issues below.

• It is important to ascertain the reason for referral and ask for a written referral as far as possible. The case-worker's or probation officer's notes are important; both from a case formulation and management perspective. If this has not been made available, it must be asked for from the concerned agency

• Documentation is vital. Notes must be pristinely maintained by all parties involved in the care of the child

• The clinician must liaise with all the other people and agencies involved in the care of the child and must integrate obtained information to the extent possible

• Even if children are referred by the state, every effort must be made to contact the parents of the child, both to obtain history as well as to communicate the plan of management and offer therapeutic help, if required

• The purpose of the assessment must be expressly discussed with the child/adolescent, especially with respect to confidentiality and its limits

• As far as possible, multiple interviews and opportunities to observe and interact with the child are required before any report is made available

• Psychosocial adversities that they may have experienced or are currently experiencing such as abuse and/or neglect must be specifically enquired for in all children and adolescents. If the child comes from an institution, then the care provided at the institution must also be an area of enquiry including the risk of exploitation and abuse

• The plan of management including follow-up must be documented and conveyed to the child and the caregivers.

Use of structured assessment tools in child and adolescent psychiatry

Clinical judgment plays a pivotal role in the diagnosis and management of children and adolescents. Careful clinical interviews of multiple informants are usually the best method to aid clinical decision making. Structured assessment instruments and observation methods can sometimes contribute to the process of this clinical decision-making. Two key uses of structured instruments are for (a) diagnostic interviewing, and (b) gathering descriptive information about various aspects of emotional, behavioral and social problems. The latter's utility essentially means the use of rating scales for quantifying symptom severity. Structured tools are also standard practice in the area of research where inter-rater reliability is important. Structured instruments can be categorized based on the domain of symptoms/assessment, and on the administration characteristics of the tool. This has been illustrated in Table 2. The reader will note that the majority of tools are structured, in that the behaviors or items to be assessed are specified and are to be rated in a specific manner. The interviewer must be sufficiently familiar with the tool to correlate the behavior described/observed via history or clinical observation to the items described in the tool. The use of screening tools, structured diagnostic interviews or scales for particular disorders must be used based on the purpose of the assessment. For instance, if a child is diagnosed to have obsessive-compulsive disorder (OCD), the Children's Yale-Brown Obsessive Compulsive Scale may be used to assess the severity of the condition or response to treatment, etc. In the same child, an anxiety or depression screening tool may be used to ascertain anxiety and depression, apart from the clinical interview, to rule out the above-mentioned conditions as they are highly comorbid with OCD and not easily discernible in this population, unless enquired into specifically. Thus, the use of these measures must be done with careful thought regarding the need that the particular measure is going to serve. No measure is a replacement for a good history, examination, and sound clinical judgment. While choosing these instruments, it is also important to consider the psychometric properties as well as other practical considerations including the impact of culture. Another challenge in using these measures is that it may interfere with the rapport that the clinician is trying to develop with the child. The timing, need, and explanation regarding these measures, provided to the child and family, is vital in getting appropriate and useful information from them. However, and this cannot be reiterated enough, that no measure can be a replacement for a comprehensive clinical evaluation and clinical expertise.

Table 2

Structured assessment tools in child and adolescent psychiatry

Medical history and physical examination

Child and adolescent psychiatry straddles psychiatry, pediatric medicine, and neurology. A clinician needs to take a detailed medical history and conduct appropriate physical examination, and laboratory investigations where needed, to support or refute the provisional diagnosis from a biopsychosocial perspective.[8] For example, a child may be inattentive in school and may hail from a family with limited resources; the physical examination must look for signs of anemia and malnutrition, as contributory factors toward inattention. In a country like India, for many children/adolescents contact with a psychiatrist, in the context of behavioral concerns, maybe their first ever medical contact. Therefore, getting a good medical history/examination is vital for the global health of the child. If a child presents with psychological issues as part of a chronic medical condition such as juvenile onset diabetes or HIV, then the psychiatrist must be part of the multidisciplinary team involved in the care of the child and must be privy to the medical history, treatment provided, and investigations of the child. A history of recurrent falls or fractures/injuries, secondary enuresis or encopresis, must alert the clinician to the possibility of abuse.

Physical examination

The physical examination must be guided by presenting complaints, hypotheses and differential diagnosis that the clinician is considering based on history obtained from the child and family (Box ​4 and ​5). Generally, the physical examination begins with recording vital signs, and height and weight on a growth chart. Head circumference must also be recorded on a growth chart. This helps track vital parameters over time as they are important measures of well-being and optimal development in children and adolescents. It is crucial to measure the height, and weight in children who are on stimulants or selective serotonin reuptake inhibitors (SSRIs) at every follow-up. Calculating the child's Body Mass Index (BMI) and measuring waist circumference has also become important given the extensive use of atypical antipsychotic drugs.

General principles of physical examination in a child/adolescent

Physical examination in psychiatric assessment of children and adolescents

Examination of skin, hair, nails

In child and adolescent psychiatry, apart from the presence of systemic illnesses and neurocutaneous disorders, the clinician must also look for signs of intentional self-injury, abuse (scars, bruising, and petechiae), abrasions, skin picking that may be suggestive of compulsive behaviors; patterns of hair loss either on the scalp or other parts of the body may be suggestive of trichotillomania. The presence of acne must also be noted – it may be due to adolescence itself or due to the use of Lithium or may be a sign of polycystic ovarian disease. As acne causes considerable distress in young people measures must be taken to help the adolescent with this particular skin ailment. Signs of neglect and poor self-care must also be noted, such as unkempt general appearance, lice or other parasitic infections.

Examination of the head, eyes, nose, and throat

This examination must begin with the recording of the head circumference. Signs of dysmorphic facial features characteristic of specific genetic disorders such as Fragile X, Prader-Willi, Angelman, Williams or Turner's Syndrome must be noted. Examination of teeth, gums, and mouth is important to ascertain dental hygiene and signs of self-induced vomiting. If there are any concerns regarding vision or hearing, then a referral for a detailed assessment with an ophthalmologist and/or an audiologist must be done.

Neurological examination

This is of utmost importance in psychiatry and must include an examination of the cranial nerves, sensory and motor systems, balance, coordination, and reflexes. Mental status examinations must pay particular attention to changes in the emotional state and cognitive functions. Asking the child to copy a geometrical figure or to draw something of their choice not only gives an insight into their fine motor functions but also their cognition, attention, and emotional state.

Genital examination

A psychiatrist under most circumstances is not required to perform a genital examination. In certain genetic disorders such as Prader Willi Syndrome, Klinefelter's Syndrome, or other such conditions where an inspection of the genitalia is required for making a diagnosis, it can be done, with prior permission from the parent/guardian, in the presence of another health-care provider and taking adequate care to keep the young person comfortable. Otherwise, referral to a pediatrician for evaluation may be considered.

Laboratory investigations

Laboratory investigations must be guided by history and physical examination (Box 6). There is no standard battery of investigations for psychiatric disorders. Under ideal circumstances, a child will have a pediatrician involved in their regular care. All investigations must be done in the context of the child's global health care. The psychiatrist may do specific investigations pertaining to the child's mental health condition. For example, if a child is on lithium then serum lithium level, renal function tests, and thyroid function tests must be done. Similarly, an electrocardiogram (ECG) is sought at baseline prior to starting atypical antipsychotic agents such as quetiapine or ziprasidone that could prolong the “QT interval.” Subsequent measurements during dose increments may also be needed. While a routine ECG is not required while starting stimulant medication it may be required if the child has symptoms suggestive of a cardiac illness or a family history of cardiac illness. An electroencephalogram is not routinely required in psychiatric disorders but may be ordered if one suspects seizures or in high-risk groups such as children with intellectual disability and autism spectrum disorders. Routine genetic evaluations must not be done. The presence of dysmorphic features and intellectual disability in a child may prompt a genetic evaluation, with the parents’ express consent. Conditions such as early-onset psychosis and autism spectrum disorders may have some differential diagnoses and the laboratory investigations must be guided by these possibilities. Laboratory investigations relevant to a particular disorder will be dealt with in guidelines pertaining to those clinical conditions.

Laboratory investigations in psychiatric assessment of children and adolescents - some examples guided by history and examination findings

Pasthistory

A history of similar or other behavioral concerns and history of medical issues must be asked for. It may not be easy to disentangle “past episodes” in a child's clinical history as developmental, emotional, behavioral issues most often run a continuous course. In developmental disorders, therefore, there is no history. The history must flow in a continuous manner from early developmental period. However, in acting out behavior and in severe mental illnesses such as bipolar disorder and psychosis, episodic exacerbations can be made out. Functioning of the child in the intervening period must be explored in different contexts - interaction with parents and significant others, self-care, academic performance, relationship with peers, and pursuance of hobbies and interests outside of academics. One must also look for factors contributing to relapse - drug discontinuation, familial/social stressors, any changes in the child's living or educational setting.

Medical illnesses can have multi-pronged effects on clinical presentations [Figure 3]. These can broadly be understood as direct effects emerging as behavioral manifestations of medical/neurological illnesses, and indirect effects resulting from the socio-emotional, occupational, and functional consequences of the illness [Figure 5].

The impact of medical illnesses in childhood

Pregnancy, perinatal, early developmental history

Several associations are seen between pregnancy, maternal health, early exposure related variables and developmental and behavioral outcomes during childhood and adulthood. At the clinical assessment level, it may not be possible to always conclude causal influences, however, the knowledge of these variables can guide further evaluations, shed light on psychosocial circumstances of the family, help the parents, and clinician gain some perspective on the “global risk” in a child. Systematic questionnaires such as the Pregnancy History Instrument-Revised[9] could be used for a comprehensive coverage of various pregnancy related and early developmental stressors. During clinical evaluation, the areas covered in Table 3 could be assessed.

Table 3

Pregnancy, perinatal and early developmental history

Developmental history

The developmental history of a child, across different domains gives the “background” on which to understand the current behavioral concerns and to plan pharmacological and psychotherapeutic management. For instance, a child with a developmental history of social and language delay, presenting with peer relationship issues and bullying in school, most probably has social skill deficits arising from autism spectrum disorder. Another child with declining academic performance with increasing school level, on exploration may have developmental delay in multiple domains, and the intellectual disability may be responsible for the academic difficulties. A developmental profile of the child requires information on (a) age at acquisition of various milestones and (b) the current developmental level. Under-stimulation and malnutrition could present with a picture of early developmental delay, followed by rapid catch-up growth and development, with the correction of environmental and nutritional factors. Therefore, while assessing development in a child, environmental stimulation, and physical growth must be assessed alongside developmental milestones. Children with developmental problems are also most sensitive to environmental and general health factors, i.e., a child with a developmental delay is more likely to show developmental regression in the context of a medical illness or parental absence due to illness, than a child who was developing normally. A detailed coverage of developmental milestones and elicitation techniques is outside the scope of these guidelines. The clinician is referred to key resources,[10] and webpages (https://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/milestonemomentseng508.pdf, http://ctsmed.blogspot.com/2012/09/how-to-learn-understand-and-memorize.html) for further information. The developmental assessment must also proceed with attention to parental and child sensitivities. Parents are usually aware of even mild delays in their child's development, and there is a tendency to self-blame. In fact, some parents have a eureka moment when, say, the clinician points out how excessive screen time and insufficient contact with same age peers is playing a role in the child's speech and social delay. Some questions to elicit information on different aspects of child development[11] are given in Table 4.

Table 4

Questions to elicit information on developmental domains

Temperamental history

In addition to developmental milestones, the temperamental characteristics of a child have to be elicited. Temperament refers to patterns of emotional and behavioral reactivity to environmental situations and capacity for self-regulation.[12] It is essentially a reflection of social and emotional development in a child. Temperamental traits described by Thomas and Chess[11] are useful to generate a comprehensive picture of a child's temperament. Table 5 gives the temperamental traits with questions on how to elicit them. The parents may have to be reminded during interview to give information on the child's behavioral tendencies prior to the occurrence of current behavioral concerns. Parents’ information on different temperamental traits in a child should be corroborated with examples of the child's behavior in different circumstances. This is important as sometimes parents judge a child's behavior based on their own personality characteristics. Parents who are passive and calm may over-report normative increases in a child's activity levels, for example, a child restless in the first few days of starting school, or a child quickly moving from one toy to the next at a friend's place before settling on one. This “goodness of fit”[13] or the absence of it can have major influences on the parents perception and reporting of behavioral concerns in a child.

Table 5

Questions to elicit temperamental traits in a child

Schooling history

School is the primary occupational arena for children and adolescents. It is where elaboration of developmental abilities, especially cognitive and socio-emotional abilities, occurs. Information about school should be collected from the child, parents, and teachers at school. There is a large amount of information that could be collected about the schooling experience of a child. Some important areas include – age at starting school, initial adjustment challenges, academic learning, peer group interactions, participation in extra-curricular activities, absenteeism, change of school (if ever, including reasons for the change) and troubles or challenges the child is currently experiencing in school, if any. Details about the school per se are also important in order to completely understand the adjustment between a child and the school. These include – the academic board the school is affiliated to, if the school follows any particular education philosophy (e.g., Waldorf education system), teacher-student ratio, facilities for co-curricular and extra-curricular activities, distance of the school from child's home, methods of disciplining followed by the school, response of the school to bullying, etc. A lot of children and adolescents attend tuitions postschool hours. The duration, and nature of these tuitions including whether these tuitions are one-on-one or group should also be explored, in addition to the reasons for these extra tuitions, and the child's inclination for them.

Child's interests, skills and talents

The child and the parents must be asked about the skills, and interests of the child (Box 7). It is important to frame specific questions to get an accurate understanding about the child. Enquiring about the child's interests, skills and talents, can be an ice-breaker or a communication starter with the child. It makes the child aware that the interviewer sees the child as a “person” and not just a problem. The clinician must make a conscious effort to separate the illness from the personhood of the child.

Questions to explore child's interests, skills and talents

Family history

Family history is a vital component in the detailed assessment of a child/adolescent. The occurrence, manifestation, and exacerbations of all kinds of mental health issues are affected by the medical/psychiatric history in the family and relational dynamics. Enquiry into various aspects of family history has to be sensitively carried forward as parents may not readily appreciate the need for details on this front. They may even be defensive, or nondisclosive. Adequate understanding about family factors may happen over a period of time. Parents need to be comfortable talking about themselves, and sharing family details. Some questions for exploration about various aspects of the family are presented in Table 6. Responses to these questions can be supplemented by further clarifications.

Table 6

Questions to elucidate family factors in child mental health

The presence of psychiatric and/or medical illnesses in the family can impact the child in several ways.[14] Factors that may directly impact the child include - genetic endowment, early life exposures including intrauterine environment, postnatal exposure to parental mental illness and the physical/emotional unavailability of the parent. Factors that may indirectly play a role include socioeconomic disadvantages and parental conflict associated with mental illness. Enquiry about mental illnesses in the family may have to be done separately with each parent, and in the absence of the child, as they may not have discussed this with each other at all. At times parents may not even reveal the fact that they themselves are suffering from mental illness. Parental mental illness affects attachment dynamics, and cognitive, emotional, social, and behavioral development of children. It also puts the offspring at risk of developing a mental illness in childhood, adolescence and later in adult life.

Developmental disorders may be part of genetic syndromes that may be associated with a unique family history profile. The clinician may find consanguineous parentage, other first/second degree relatives with developmental delays or dysmorphic features or neurological or psychiatric conditions. Family history could also impact treatment decisions. A family history of young onset cardiac illness or sudden death in young family members is especially relevant for those children with ADHD in whom stimulant drugs are being considered.[15] In such children, a detailed history related to cardiac symptoms such as dyspnoea, palpitations, fainting spells brought on by exercise needs to be obtained apart from a referral to a pediatrician for a more detailed cardiac assessment. A family history of diabetes mellitus, hypothyroidism or neurological disorders are relevant from a risk perspective, especially when psychotropics are being considered for management.

More than just ascertaining the presence of a mentally/medically ill parent, or significant family member, it is important to understand what this has meant for the child(ren) in the family. Children as young as infants and preschoolers are able to “catch” the emotional environment of the house and may respond with a variety of behavioral, emotional changes - irritability, feeding, and sleeping irregularities. The parent-child relationship and the child's relationship with significant others in the family give further insights into how various behavioral patterns may have established over a period of time. These relationships are determined by the parent's/family member's own personality traits and relational dynamics within the family. These become particularly relevant in the context of internalizing and externalizing disorders. Vulnerabilities to anxiety disorders are perpetuated where there is a combination of temperamental anxiety, behavioral inhibition, and an anxious, over-cautious parent. Disruptive behavior problems worsen with both over-authoritative, and over-permissive parenting, where limits and boundaries are unclear. The “goodness of fit” model[12] is pertinent here - “...it is the nature of the interaction between the temperament and the individual's other characteristics with specific features of the environment which provides the basic dynamic influence for the process of development…”.[16]

Adoption – an experiential reality of its own

When a child is adopted into the family, it affects interpersonal dynamics at every level. Once the time-consuming legalities and practicalities of adoption are done with, parent-child adjustments take priority, and may take a long time to settle down, especially in the case of older children. We are consciously refraining from going into the details of enquiry in the context of adoption. This merits independent practice guidelines. However, we would like to mention a few issues here that the clinician must enquire – the events preceding parents’ decision to adopt, parents’ and child's age at adoption, whether the child knows about the adoption, how has the parent-child relationship been before and after disclosure, child's relationship with other extended family members. In addition, since currently the parents are bringing in the child for a mental health concern, has this raised any thoughts/concerns in their minds about adoption.

Past evaluation and interventions

Details about past assessments, evaluations, treatments, response to the treatment, and side effects must be collected. This informs future direction of evaluation and management.

Examination

Interview of children and adolescents

History and examination (Table 7) are not watertight compartments. Observation of the child/adolescent has to start soon as he/she first meets the clinician Box 8. Mental states in children and adolescents may have a higher intensity and frequency variation than adults. For instance, depressive disorders in young people have preserved reactivity such that a depressed child may appear reasonably excited when given a toy to play with during examination. Serial examinations are more useful in getting a true picture about the mental state characteristics. Children and adolescents may also not be ready to immediately share their experiences, feelings, and thoughts. This may happen because of unfamiliarity and intimidation by the clinical setting, or a developmental unreadiness. The clinician must not make presumptions about the capacity of children to give information/participate in an interview. Children as young as 2–3 years old can answer simple questions about what they like, who they like, what makes them angry, etc. The clinician must make it a point address the child and ask questions in an age appropriate language.

Table 7

Components of the mental status examination

General principles for mental status examinations of children and adolescents

Use of developmentally appropriate techniques

Young children

Expressive channels evolve from play in very young children, to art and other creative methods, and finally to verbal dialogue in adolescents. The manner of exploration and engagement with children must follow this understanding. Therefore, waiting for preschool children to cooperate across an interview table may not be successful, whereas letting the child sift through toys, or be in a play area may reveal his activity levels, attention span, ability to tolerate frustration, and cognitive abilities. Use of colors, pens, paper, puzzles, peg boards, can all be used in the office to facilitate interaction with young children. Direct questions to a child should be short, precise, in simple words, dealing with one concrete issue at a time. For example, if a child is being bullied at school, asking him/her “Does anyone trouble you at school?” would be better than asking, “Can you tell me about any problems you are facing at school?” Children are able to relate to, and identify with cartoon characters and animals better than they are able to talk about their own feelings and behaviors. Talking to them using these familiar themes may facilitate disclosure about their emotions, and experiences. Children may be intimidated by the clinical setting, and uncomfortable with direct questions. Use of paper and line diagrams, with both the clinician and the child looking at the paper and talking may be better than direct eye to eye contact.

Adolescents

The development of formal operational thinking in adolescents puts them in a position to be able to not only report their experiences, but also draw interpretations and hypotheses. It is important to interview the adolescent alone, since a developing self-awareness and self-consciousness may make them feel inhibited in front of family. Adolescents are also very concerned about not being believed, or being considered weak or different. They often put a lot of time and energy into “normalizing” their experiences, or denying them. The clinician must therefore make all attempts to make the adolescent feel comfortable and acknowledge their subjectivities. Confidentiality can be a big issue, especially in the context of substance use or sexuality. The clinician must avoid false promises of confidentiality just to get the adolescent to open up. Adolescents appreciate logical arguments and find comfort in predictability. It is, therefore, advisable for the clinician to be honest about the limits of confidentiality.

Examination of infants and toddlers

Assessment of infants is especially challenging as the clinician has no direct linguistic access to the problems concerned. The assessment must rely on a three pronged approach – parent interview, infant/toddler observation and parent-child interaction.[17]

Parent interview

Given the proximity to and the evidence for influence of birth and neonatal events on infant growth and development, the parents’/caregivers’ must be asked to give an account of events starting from pregnancy, delivery and subsequent developmental details, comprehensively. In addition, the psychological and emotional relationship of the infant with parents and other family members needs to be understood – “Was the pregnancy planned? What were the parents’ expectations? How the infant fits into the family? What does the infant mean to each family member? What do caregivers like about the infant? What is a typical day like in the life of the infant?” Parents/caregivers may be overwhelmed with fears and guilt about being responsible for the infant's problems. They may be scared of finding out that the infant is “damaged” or “defective.” Given these emotional overtones, the historical account may not be clear and coherent in the very first interaction. Parents may need reassurance about the multi-factorial influences on child development so that they feel confident enough to share more information.

Infant and toddler observation

Observing infants and toddlers can uncover a range of behavioral and developmental facets. Using play techniques, especially with toddlers, can clarify cognitive, linguistic, social, and motor developmental achievements. The child has to be in a calm, alert state for the best estimation of cognitive and socio-emotional development. Therefore, if the child is irritable, from hunger or some physical discomfort, the parents may be asked to attend to the immediate needs of the child and then resume assessment process.

Physical health status of the child could give important clues to possibility of underlying medical conditions as also under-stimulation and parent-child attachment. Height/length, weight, state of skin and hair, and the activity levels – curiosity, interest in the environment – can be easily observed during the first few minutes of the assessment.

Sensory abilities – vision, hearing – mature rapidly during the 1st year of life. Up to 2–3 months of age, infants are long-sighted and can see clearly at about 12 inches away, thereafter visual accommodation matures and the infant is able to track near and far objects, and respond to parents’ faces. In a quiet, alert state even neonates can turn their head to sound. The clinician should note if the child appears sensitive to sounds and visual stimulation. Some children with premature birth, and developmental disorders could have very low or very high sensory thresholds. Sensory stimulation may need to be accordingly adjusted to effectively engage the child.

Domains of growth and development to be observed during consultation are given in Table 8. The child can be made to do these activities with encouragement from the parents. Variations could arise from developmental deviations. Temperamental differences may affect how easy/difficult it is to engage the child. Thus, a single assessment may not give an indication of the child's “highest” developmental achievements. A combination of historical information from the parents and a series of observations are more informative.

Table 8

Observation of infants/toddlers

While attempting simple activities to observe above mentioned developmental abilities, the clinician could also gain an idea about the child's temperament (Box 9).

Temperamental characteristics of the infant/toddler

Parent-child interaction

In toddlerhood, with their increasing motor and cognitive capacities, children are quite exploratory. It is during this time that attachment and parent-child responsivities can play a significant role in facilitating/hampering growth. Some simple observations during consultation are listed in Box 10. Children with developmental problems may not show these behaviors, and may stay engrossed in solitary activities.

Multidisciplinary referrals

Child and adolescent psychiatry necessitates evaluations and interventions from a multidisciplinary team most often consisting of a clinical psychologist, pediatrician, psychiatric social worker, speech and language pathologist, occupational therapist, and other health-care professionals. The psychiatrist needs to make appropriate referrals to these professionals to gain a holistic understanding of the child and family and plan interventions accordingly.

Record keeping

Children, parents, and families who come in for a psychiatric consultation are often loaded with historical details, and are distressed by the referral and evaluation process. It is understandably tedious for them to have to repeat information over consultations. Reviewing clinical notes from previous consultations puts the clinician in a clearer frame of mind in terms of future course of enquiry and future planning. It is good practice to have a recording format for recording history, examination, and clinical discussion details. The information gathered can be fed back to the family so that they have an understanding about the future course of action - one child may need to be scheduled for an IQ test, another child may need to come in for a more elaborate consultation with additional members of the family, and so on. Evaluation in child and adolescent psychiatry is layered and complex. Clinical impressions may change from the first contact to the next. It is useful to go over in detail the clinical history at least a few times. The “detailed work-up pro forma” systematically records information on all aspects of a child's life. As parents answer questions pertaining to different domains they too get clarity on the multi-factorial contributors to the child's difficulties.

CONCLUSION

Child and adolescent mental health shares close links with other medical specialties such as neurology and pediatrics while being rooted in the child's psychosocial environment and experience. Assessment of children and adolescents must evolve from a biopsychosocial perspective, taking into account these inextricably interlinked aspects. Clinical history taking and interviewing are one of the most powerful tools available to the child and adolescent mental health professional to make a diagnosis and plan management. These guideline can be used as an aid in that endeavor. Other measures such as rating scales, diagnostic interviews, and laboratory investigations must be used in conjunction with the information obtained during history taking and interviewing. The clinician must be sensitive to the child's lived experience and culture as well as their developmental and cognitive capabilities. Clinical judgment and expertise is required to assimilate the information obtained from the child and other key informants. In child and adolescent mental health, multidisciplinary inputs are required for almost every child and family and efforts must be made to link the different arms of evaluation and treatment such that there is convergence. Confidentiality and the limits thereof must be discussed with the child and family. Documentation is a very important aspect of assessment and must be strictly maintained. A comprehensive clinical assessment goes a long way in ensuring interventions in the best interest of the child and family.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors would like to acknowledge Dr. Gautam Saha (Consultant Psychiatrist, Clinic Brain, Barasat, Kolkata), Dr. I. D. Gupta (Professor of Psychiatry, SMS Medical College, Jaipur) and Dr. Chimay Barhale (Consultant Psychiatrist, Shanti Nursing Home, Aurangabad) for their valuable inputs during the workshop on the development of Clinical Practice Guidelines in Jaipur, August, 2018.

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