1. 18th August'2010 Assessment and Evaluation in Child & Adolescent Psychiatry ::Moderator ::Dr. Kamala DekaAssociate Professor :: Speaker ::Dr. Santanu GhoshPostgraduate Student Department of Psychiatry, Assam Medical College 1
2. Layout of Presentation Introduction Clinical Interview of the child Special issues in the assessment of adolescence Special types of assessment Standardizes assessment instruments for children & adolescents Laboratory measures Diagnostic formulation and recommendations Conclusion Bibliography 2
6. Defining the Purpose of the Evaluation Before starting, one should consider the purpose of the evaluation and use this information to structure the evaluation to fit the reason. Possible referral sources include: Parents (recommended by school, friends, relatives, themselves) Legal guardian (or state custody) Schools they are paying for an evaluation of a student about whom they have concerns Court if the child has legal issues, custody issues 6
14. Special Considerations in Evaluating Children The psychiatric evaluation of a child or adolescent has a number of important differences from that of an adult: The referral is typically requested by someone other than the patient. The child (or adolescent) may feel ashamed, angry, or convinced that the evaluation is a punishment for being bad. Try to set the stage to be as nonjudgmental and collaborative as possible, giving the child as much control as is appropriate and safe. 8
15. Special Considerations in Evaluating Children contd… Different methods of collecting data and interviewing the child apply at different ages. The goal is to understand the child's inner world and perspective. Techniques may range from observing an infant, parent , or using play to understand the preschool and young elementary school child, to talking directly about symptoms with the adolescent. Remember to alter the approach to fit the developmental needs of the child. Drawing may be a helpful adjunctive tool at any age. 9
16. Special Considerations in Evaluating Children contd… Children are not just little adults. One should remember the developmental stages and what to expect of a child of each age. Use multiple informants. It is important to know if the child is having difficulties in all contexts, or only specific ones (e.g. doing well at home, but having behavioral difficulties at school). This may help clarify the nature of the difficulty and point to specific areas for remediation. 10
17. Special Considerations in Evaluating Children contd… Diagnosis is more complicated in children. Although children may technically be diagnosed with almost any DSM-IV diagnosis, the varying presentation of symptoms at different ages, the evolution of disorders, and the lack of diagnostic and etiological specificity for many symptoms (impulsivity and aggression, for example) make diagnoses more fluid and unclear. It should be clarified that the diagnosis may change over time. However, this should not delay intervention and treatment of disabling symptoms. 11
18. Specific Child Interview Techniques: Play Techniques. Imaginative play with puppets, small figures, The interviewer himself or herself can provide useful inferential material about the child's concerns, perceptions, and characteristic modes of regulating affects and impulses Usefulness: For diagnostic and rapport-building purpose The form of play also provides important information for the mental status examination 12
19. Specific Child Interview Techniques contd… Projective technique Invite the child to draw a picture Ask the child what animal he or she would most like or least like to be Whom he or she would take along to a desert island What he or she would wish for if given three magic wishes (Winkley, 1982) Describe a dream or a book, movie, or television show which he or she recalls Asking about a child's future ambitions provides information about the child's concerns, self-esteem, aspirations, and values 13
20. Specific Child Interview Techniquescontd… Direct questioning Inquiry about the presenting problem or other aspects of the child's life timing Attention to the child's cognitive and linguistic level of development Respect for the child's self-esteem. 14
22. Development: Psychomotor: Ability to stand, walk and react Cognitive : Children thought in concrete fashions Interactive: Both verbal & non verbal communication Moral development Harmful behavior: Towards him or others
23. Cognitive & academic development: It should be traced from early childhood, including verbal and attentional skills. Ask about the Child's ability to separate from parents and to attend school regularly Interpersonal relationships with peers and teachers Motivation to learn Ability to function independently Tolerance for frustration and delay of gratification Attitudes toward authority Ability to accept criticism 17
24. Cognitive & academic development contd… A grade-by-grade history of the schools attended Retentions- the reasons for them, and the child's reaction at the time and later in development . When the child's behavior or progress at school is among the reasons for the psychiatric evaluation, - obtain permission to communicate with the child's teachers, counselors, or other school personnel - review the school records, including results of standardized tests 18
25. Family Relationships: The parent interview should include assessment of how the child relates to each family member how the child fits into the overall family system. The child's reactions to major family changes should be noted (e.g., deaths; birth of siblings; marital separation, divorce, or remarriage; and changes in caretaking arrangements, custody, or visitation) 19
26. Family Relationships contd… 4. Parental responses to those reactions. 5. Ask about compliance with family rules and standards, as well as consequences when the child does not comply (i.e., usual mode of discipline or limit setting) 6. The child's response to such interventions. 20
27. 1. The number of friends2. Preferences regarding age and gender of friends3. Any major changes in peer group4. The child's satisfaction with these relationships5. Their relative stability6. Activities and interests shared with peers 7. Parents' feelings about the child's close peers 8. The parents' perspective on the child's social skills and deficits should be assessed, including their sense about any difficulties the child has in this domain. 21 Peer Relationships: The clinician should gather information about how the child relates to peers, regarding
28. Peer Relationships contd… For adolescents, 1. The capacity for intimate relationships, 2. Romantic interests, Sexual activity, and concerns over sexual orientation. 22
29. Development of conscience & values: The clinician should assess the development of conscience to gauge- 1. Whether it is too harsh, lax, or overly focused on particular issues. 2. The effectiveness of conscience in helping the child conform to family & societal expectations is important. 3. Religious or ethical concerns and their concordance with those of the family can be addressed in this phase of history taking. 4. The family's expectations with regard to the child's values and future life choices should be ascertained from the parents' perspective, 5. Areas of potential discord 23
30. Interests, Hobbies, Talents & Avocations: This inquiry is pursued with the child, as well as the parents’ perspectives on the Assessment of child's interests and activities Assessment of the parents' approval, involvement, and support for them. Existence of parent–child conflict. 24
31. Interests, Hobbies, Talents & Avocations contd… 3.The presenting difficulties may have affected the child's ability to focus on or to engage in previously enjoyable areas of interest or activity, such as sports or music. 4.The quantity and type of television programs, movies, and videos that a child is permitted to watch provide information on the child's interests and the quality of parental limit setting. 25
32. Unusual circumstances: The clinician should assess: The child's exposure to unusual or traumatic circumstances, such as sexual or physical abuse, family or community violence, natural disaster, or armed conflict. If a history of such exposure exists, the child's immediate and subsequent reactions and the nature of the response from parents or other adults 26
33. Prior Psychiatric Treatment History Prior psychiatric, psychological, or educational evaluations or interventions The outcome of any such interventions Child's and parents' attitude toward such earlier attempts to obtain help The reports of prior clinicians 27
34. Family Medical and Psychiatric History: Enquire about family members' past and current history of medical and psychiatric disorders- Psychotic and affective disorders Suicidal behaviors Anxiety disorders Tic and obsessive-compulsive spectrum disorders Alcohol and substance use Attention-deficit hyperactivity disorder Learning and developmental disabilities and delays Antisocial personality disorder Metabolic and neurological disorders. Enquiry should be made about their severity, treatment, outcome, and impact on the child 28
35. Temperament Categories: Activity level:The motor component present in a given child's functioning and the diurnal proportion of active and inactive periods Rhythmicity (regularity): The predictability or unpredictability in time of any function; it can be analyzed in relation to the sleep–wake cycle, hunger, feeding pattern, or elimination schedule Approach or withdrawal: The nature of the initial response to a new stimulus, be it a new food, a new toy, or a new person. 29
36. Temperament Categories contd… Adaptability: Responses to new or altered situations. Threshold of responsiveness: The intensity level of stimulation needed to evoke a discernible response, irrespective of the specific form of the response or the sensory modality affected. Intensity of reaction: The energy level of response, irrespective of its quality or direction. 30
37. Temperament Categories contd… Quality of mood: The amount of pleasant, joyful, and friendly behavior (as contrasted with unpleasant, crying, and unfriendly behavior) Distractibility: The effectiveness of extraneous environmental stimuli in interfering with or altering the direction of the ongoing behavior. Attention span and persistence: Attention span concerns the length of time a particular activity is pursued by the child. Persistence refers to the continuation of an activity in the face of obstacles to the maintenance of the activity direction. 31
51. Rating Scales/Assessment Instruments Rating scales range from systematized questionnaires that assess psychiatric symptoms in general to those that probe specific areas of difficulty in depth. Advantages of using rating scales include their assisting the clinician in the systematic evaluation of the child, including detecting problems that are clinically significant but not part of the presenting problem. Some adolescents may reveal concerns in writing that they do not verbalize. 39
52. Rating Scales/Assessment Instruments contd… Disadvantages of using rating scales include the time needed to complete them, the feeling of being check-listed, and clinicians' tendency to over-rely on rating scales for diagnosis. Rating scales are adjunctive tools used to complement a diagnostic evaluation, not replace it. With children and adolescents, the rating scales may be completed by the patient or by parents or teachers. 40
53. Rating scales in child assessment: Attention-deficit hyperactivity disorder (ADHD). Achenbach Child Behavior Checklist (CBCL) Conners questionnaires Screening tool that addresses some 20 Axis I entities The Children’s Interview for Psychiatric Syndromes (ChiPS) Diagnostic Interview for Children, or DISC Children's version of Schizophrenia and Affective Disorders Scale Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) The pictorial DOMINIC-R: A new pictorial assessment of anxiety symptoms in young children 41
55. Biopsychosocial formulation It interweaves Biological vulnerabilities (prenatal, birth, early temperament, development, genetic predispositions/family history, medical & neurological disorders) Psychological factors (personality, psychological issues and attributions, defense mechanisms, developmental stage tasks), and social/environmental contributors (family/interpersonal, socio-environmental, trauma, and cultural factors) It gives An understanding of what brings the child or adolescent to this point in life. With this understanding, the most focused and effective treatment recommendations can be formulated. 43
56. The 4 Ps Another useful method of formulation is the 4 Ps as proposed by Barker. Predisposing: those factors that render the child vulnerable to a disorder Precipitating : stressors or developmental factors that are associated with the emergence or worsening of symptoms Perpetuating: factors that maintain the disabling symptoms Protective: strengths and assets that may be accessed to promote more healthy adjustment and diminish the severity of symptoms 44
59. Testing in Specific Childhood Disorders The pediatric history and physical examination guide the appropriate use of laboratory tests. Mental Retardation & Pervasive Developmental Disorders: Wood's lamp examination - for tuberous sclerosis EEG - to exclude seizures Chromosome analysis to exclude fragile X synd. , Down’s synd. Serum Lead estimation: In pica 2. Mood Disorder Routine thyroid function Infectious disease Toxicology testing 47
60. Testing in Specific Childhood Disorders contd… 3. Psychotic Disorders: CSF analysis: Cognitive decline, an altered level of consciousness, headache, an abnormal neurological examination, altered vital signs, leukocytosis, or new-onset seizure disorder 4. Attention-Deficit/Hyperactivity Disorder: Thyroid Profile: not routinely indicated in ADHD who do not have other signs or symptoms of thyroid dysfunction. 5. Tic & OCD: Throat culture and serological studies for group A β-hemolytic streptococcus (GABHS) infection - AntideoxyribonucleaseB - AntistreptolysinO antibody titers, 48
61. Testing in Specific Childhood Disorders contd… 6. Substance Use Disorders: The high prevalence of substance abuse in adolescent populations has prompted recommendations that toxicology screens be obtained for All adolescents who have psychiatric symptoms or who exhibit acute behavioral changes High-risk adolescents, such as delinquents and runaways Adolescents who have recurrent accidents or unexplained somatic symptoms 7. Sexually Transmitted Diseases: Children and adolescents with a history of sexual activity or sexual abuse who are being evaluated for depression or a change in cognitive function should be evaluated for STD, including HIV infection and syphilis. 49
63. A comprehensive treatment plan should include consideration of the intensity of treatment required for the child in a systems-based manner: Child is at imminent risk and requires acute hospitalization Child needs higher level of care than can be provided safely in the home, but is not at imminent risk residential treatment, group home, temporary residential stabilization, therapeutic foster home, safe home, etc. Child can be maintained safely in the home only with intensive wraparound services in-home behavioral services, partial hospitalization or after-school therapeutic program, intensive case management, etc. 51
64. Recommendations for Treatment contd… Child requires regular outpatient therapeutic services Individual therapy (cognitive behavioral therapy (CBT), insight-oriented, supportive, interpersonal therapy (ITP), dialectic behavioral therapy (DBT), anger management, etc.) Psychotropic medication for treatment of psychiatric symptoms that are amenable to medication Group therapy (therapy group, social and coping skills groups, DBT group) Family therapy (regular family therapy, parent management training, parent psycho-education, multisystem treatment , couples therapy, divorce mediation and conflict resolution, or parents accessing needed treatment for themselves) 52
65. Recommendations for Treatment contd… 5.Other adjunctive services School services for emotional, attentional, and/or learning issues, including in-school counseling, therapeutic interventions and services within mainstream classroom, special education classroom, or out-of-district placement at a school specializing in working with children with emotional, social, and/or behavioral difficulties Speech therapy for language problems (including social conversation) as appropriate to the child's difficulties 53
66. Recommendations for Treatment contd… c. State Protective Service involvement as needed for suspected abuse or neglect or for voluntary services for the family d. Legal involvement accessed by the family to help monitor a child with severe out-of-control behavior e. Other supports, such as Big Brother or Sister, mentoring programs, respite home, recreational therapy, and pet therapy. 54
67. Conclusion The child and adolescent psychiatrist has a unique role in providing diagnostic assessment, therapeutic services, consultation, and advocacy for children and their families. In a broad biopsychosocial context, child and adolescent psychiatrists attempt to best meet the needs of children and families by providing these services in a fashion informed by scientific rigor, personal sensitivity, and social responsibility. An encounter with the child and adolescent psychiatrist should provide clinical clarification, personal reassurance, and practical direction. 55
68. 56 Bibliography: CTP – Kaplan & Shaddock, 8thed, P Child & adolescent Psychiatry- A Practical Guide, 1sted, P 15-32 Willey’s clinical child Psychiatry, 2nded, P 3-21 Lewis’s child & adolescent Psychiatry,4thed,P 310-83 Web: - www.googleimage.com - www.wikipedia.com
