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Assessment of psychiatric disorders in children
ASSESSMENT
It is then necessary to cover systematically the child’s recent health and behaviour (bearing in mind that parents do not have direct knowledge of the child’s mental state). Direct enquiry should be made about: • emotional symptoms (anxiety, fears, depression, suicidality) • behavioural problems (defiance, stealing, aggression, truancy, running away) • attention and concentration • motor skills (including activity level) • school performance and attendance • peer and sibling relationships • bladder and bowel control • physical health • recent adversity (e.g. bereavement). Information about the following areas should then be obtained. The family history – including mental illness and personality problems in the parents. The interviewer also needs to find out about the parents’ relationship. The child’s family life and relationships – key areas include disciplinary practices, family activities that involve the child and the child’s role in the family. The child’s personal history – the interviewer should ask where the child was born and whether there were any problems during the pregnancy. Were there any early separations or bonding difficulties? What about motor and language milestones? The child’s temperamental characteristics should be asked about.
Assessment of psychiatric disorders in children Richard Harrington
The assessment of psychiatric disorders in children is divided into the following stages: • family interview • parental interview • interview with the child • physical examination and investigations • obtaining other sources of information • making a diagnosis • understanding the causes of the child’s problems.
The family interview It is usually helpful to see all members of the family together at the start of the interview. Much can be learned from the way they relate to each other. For example, the interview can be used to determine how the parents respond to the child’s communications (e.g. sympathetically or critically), whether the parents have difficulties in their own relationship, or whether one family member tends to be scapegoated or ignored. The interviewer needs to avoid exclusive questioning of individuals, but should set up opportunities for interactions between family members. This is often achieved by setting the family a task, such as drawing up a family tree. This is a good time to ask what the family makes of the problem and what they believe the causes are. It can also be helpful to try to establish what kinds of treatment they feel are most appropriate. Some families have a very clear view about the kind of treatment that may be necessary, such as stimulant medication.
Interview with the child With older children and adolescents it may be possible to use procedures similar to those used to examine adults’ mental state. In young children formal examination of the mental state is impossible. Every opportunity should be taken to observe the young child’s behaviour and play. This should be reported systematically (Figure 1 shows the format for recording information). When requesting the child’s cooperation, ask for it directly, do not ask ‘may I …?’ as young children are not used to adults asking their permission.
Physical examination Although many children attending child mental health services are never examined medically, there are two important reasons for conducting a physical examination: to find a physical disorder that could have caused the child’s psychiatric disorder, and to detect signs of neglect or abuse. At the very least, the clinician should record height, weight, head circumference, and the appearance of the skin and face (see pages 13–18 for details of developmental assessments). The main indications for neurological examination are a history suggesting neurological problems (e.g. fits, developmental delay, loss of skills), dysmorphic features, deviation of height or weight from normal, or other features suggestive of a problem affecting the brain, such as skin signs of a neurocutaneous disorder, or abnormal gait. The basic neurodevelopmental examination should include: • measurement of head circumference, height and weight plotted on a growth chart • examination of the cranial nerves
The parental interview At some stage in the assessment the parent/s or guardian should be seen without the child. Like all psychiatric interviews, the parental interview should start with open questions and minimal cross-examination. The interviewer should try to clarify exactly what is meant by terms such as ‘depressed’ or ‘naughty’. What effects have the child’s problems had on, for example, schoolwork, peer relationships and the family?
Richard Harrington was Professor of Child and Adolescent Psychiatry and Chair of the Department of Child and Adolescent Psychiatry at the University of Manchester, Manchester, UK. Sadly, Professor Harrington died in 2004, but we are pleased to reprint his contribution to the first edition.
PSYCHIATRY 4:6
19
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
nancy, intracranial haemorrhage) • developmental regression • abnormal developmental history (e.g. floppy baby) • a history of seizure activity. Physical investigations may be required as part of the preparation for some kinds of therapy. Neurophysiology – the most widely used neurophysiological test is electroencephalography (EEG). This is most valuable as an aid to the diagnosis of epilepsy, though it should be remembered that the diagnosis of epilepsy is essentially a clinical one. EEG is also useful in the diagnosis of cerebral degenerative disorders. Non-specific EEG ‘signs’, such as diffuse slowing, are not a good guide to an organic basis for a psychiatric disorder. Standard chromosomal/genetic investigations – the need to perform such investigations depends on the history and the findings from the physical examination. All patients with mental retardation (IQ <70) should undergo a cytogenetic investigation and DNA tests for fragile-X syndrome. Chromosome tests are also indicated if there is a strong family history of psychiatric problems or mental retardation. Brain imaging is increasingly used in the evaluation of children with moderate or severe mental retardation, where it may be useful in diagnosing conditions such as tuberous sclerosis. No child psychiatric disorder, however, is consistently associated with specific structural brain abnormalities. Brain imaging should therefore be reserved for cases where the following conditions are suspected: • a focal brain lesion, such as a tumour • the sequelae of an earlier insult (e.g. neonatal hypoxia) • a focal EEG abnormality. A metabolic screen for neurometabolic disorders often has a low yield, even in patients with mental retardation. One of the most common indications for such screening is developmental regression, which is seen in conditions such as metachromatic leukodystrophy. However, the results of metabolic screens can be hard to interpret and such tests, which are often very expensive, should generally be organized only with expert agreement.
Interview with the child General behaviour • Dress and appearance • Parent–child interaction and separation • Emotional responsiveness • Mannerisms Anxiety and mood • Sadness, tension • Fears, worries • Restless, disinhibited, aggressive • Withdrawn or shy Talk (form) • Spontaneity and flow • Defects of prosody or articulation • Coherence Talk (content) • Persistence • Interests • Interruptions of attention Activity level Intellectual function • Rough assessment of reading level, spelling, arithmetic, knowledge 1
• examination of the motor system, including observations while running and heel–toe walking • handedness • tendon reflexes • coordination • neurocutaneous signs (e.g. café au lait spots) • observation of anomalies such as low-set ears or hypertelorism (excessive distance between the tear ducts). In children with mental retardation, there should also be a full physical examination that includes examination of the back, heart, eyes, ears and genitals. Figure 2 lists some congenital syndromes associated with behavioural or emotional problems. The strongest clues are mental retardation, dysmorphic features (such as unusual facial features) and extreme values for height, weight or head circumference.
Obtaining other sources of information Any agencies involved with the child or the family should be contacted, but practitioners should make sure that they have parental permission to contact the school. Although parents can often give an account of a child’s behaviour in school, it is usually best to obtain a report directly from a teacher. Teachers are particularly good informants on problems such as hyperactivity, and a number of standardized questionnaires are available. However, these scales were never intended to be diagnostic, and are not a substitute for a careful clinical history.
Making a diagnosis Physical investigations
Most children will have emotional or behavioural symptoms at one time or another, so the first issue is to consider whether the child’s behaviour is abnormal. Symptoms persisting for several months and occurring frequently are more likely to indicate disorder. The simultaneous presence of many symptoms is also an indicator of problems. However, some symptoms are much more likely than others to point to disorder. These include poor peer relationships, serious aggression and self-harm. As a general rule, symptoms that
Physical investigations are not generally needed unless there is a clinical indication, such as abnormalities found on physical examination, mental retardation or a history suggestive of organic brain disorder. Key findings in the history that suggest an organic cause include: • a specific familial disorder • a specific type of insult (e.g. maternal alcohol use during preg-
PSYCHIATRY 4:6
20
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
Examples of congenital syndromes associated with psychiatric disorders in children Syndrome
Physical features
Mental features
Fragile-X syndrome
Long face, prominent ears, large testes after puberty
Mental retardation, gaze avoidance, social anxiety
Fetal alcohol syndrome
Low height and weight and small head circumference; hypoplastic philtrum
Mild mental retardation; any psychiatric disorder, especially hyperactivity
Klinefelter’s syndrome (XXY) Height above normal with advancing age, hypoplastic testes
Most individuals show language and reading problems but few are mentally retarded; moderate increase in risk of all psychiatric disorders
XYY syndrome
Height above normal with increasing age
Many individuals have language problems; possibly some increase in antisocial behaviour
Tuberous sclerosis
Hypopigmented skin lesions, cutaneous nodules
Epilepsy and mental retardation; autistic features
2
Example 2: Peter’s problems (Figure 4) were different. He was a 10-year-old referred because of aggression to his peers; he was also aggressive at home. During the assessment, it became obvious that Peter believed his aggression was justified because everyone was against him. His natural parents had separated when he was an infant and he had been brought up by his mother. She had had a series of stormy relationships with boyfriends, and from an early age Peter had witnessed rows and physical fights in the home. His mother and her current partner often beat him when he hit his sister. The school reported that he had few friends apart from another aggressive boy.
are present in one situation only are less likely to presage serious problems than those that are pervasive. Of course, just because a symptom is statistically abnormal it does not necessarily follow that the child has a disorder. It is also necessary to know whether the symptom is doing any harm or whether it is leading to impairment. Four main criteria are used to judge impairment: suffering, social restriction, interference with development, and effects on others. Different components of the child’s problems are recorded separately using a multiaxial framework.
Understanding the causes of the child’s problems The assessment does not end with the diagnosis. It is important to put together a formulation about the psychological, biological and social mechanisms that might be operating. The practitioner must try to understand the meaning and function of the child’s behaviour. Apparently similar behaviours can have entirely different functions, as the following examples demonstrate (see also Figures 3 and 4). In both of these cases, the clinician used the results of the assessment to work out what the mechanisms underlying the behaviour might be.
Understanding aggression in a 10-year-old boy with autism
Autism
Example 1: Kevin was a 10-year-old boy of above-average intelligence who had autism (Figure 3). He failed to develop normal social relationships and although he had developed speech, it was stereotyped and odd. He had been maintained with a great deal of support from the education authority in a mainstream school until the age of 10, when he became aggressive, shouting and hitting out at other children in class. Observation in the classroom showed that these outbursts occurred only when children sat in different seats or when other children taunted him. Like many people with autism, Kevin needed a daily routine that was structured and well organized. His aggression settled when the teachers made the classroom environment more structured and took measures to stop the taunting. He was subsequently transferred to a special school for children with autism. This example shows how a biological disorder such as autism can lead to behavioural problems. However, in Kevin’s case both the mechanism and the solution were not biological, but involved his school environment.
PSYCHIATRY 4:6
Language problems
Social abnormalities
Peer problems and being bullied
Rigidity and unusual interests
Finds change difficult
Behaves aggressively
Change of routines
3
21
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
Understanding aggression in a 10-year-old boy with behavioural problems
Parental aggression
Rejection by non-aggressive peers
Associates with aggressive peers
Perceives ‘everyone’ as aggressive
Behaves aggressively
4
Peter’s aggression was caused by a number of factors. From an early age he had witnessed aggression at home and so he had learned that aggression was normal and a way of getting what he wanted. However, this made him unpopular with his non-aggressive peers, which meant that in order to have friends he started to associate with other aggressive children. These children were in turn aggressive towards Peter, with the result that by the age of 10, Peter believed everyone was aggressive, even when they were not. Treatment consisted of advice to his mother and her partner about how to encourage better behaviour and how to discipline Peter more effectively. He was also offered some sessions with a psychologist, with the aim of helping him to identify and change his beliefs about aggression.
Practice points • Always try to interview parents and children separately at some point in the assessment • Remember to get parental permission before contacting the school • Understanding the causes of children’s problems starts with the diagnosis, rather than ending with it • Bring all the information from the assessment into a formulation that attempts to explain the mechanisms underlying the child’s behaviour
PSYCHIATRY 4:6
22
© 2005 The Medicine Publishing Company Ltd
It is then necessary to cover systematically the child’s recent health and behaviour (bearing in mind that parents do not have direct knowledge of the child’s mental state). Direct enquiry should be made about: • emotional symptoms (anxiety, fears, depression, suicidality) • behavioural problems (defiance, stealing, aggression, truancy, running away) • attention and concentration • motor skills (including activity level) • school performance and attendance • peer and sibling relationships • bladder and bowel control • physical health • recent adversity (e.g. bereavement). Information about the following areas should then be obtained. The family history – including mental illness and personality problems in the parents. The interviewer also needs to find out about the parents’ relationship. The child’s family life and relationships – key areas include disciplinary practices, family activities that involve the child and the child’s role in the family. The child’s personal history – the interviewer should ask where the child was born and whether there were any problems during the pregnancy. Were there any early separations or bonding difficulties? What about motor and language milestones? The child’s temperamental characteristics should be asked about.
Assessment of psychiatric disorders in children Richard Harrington
The assessment of psychiatric disorders in children is divided into the following stages: • family interview • parental interview • interview with the child • physical examination and investigations • obtaining other sources of information • making a diagnosis • understanding the causes of the child’s problems.
The family interview It is usually helpful to see all members of the family together at the start of the interview. Much can be learned from the way they relate to each other. For example, the interview can be used to determine how the parents respond to the child’s communications (e.g. sympathetically or critically), whether the parents have difficulties in their own relationship, or whether one family member tends to be scapegoated or ignored. The interviewer needs to avoid exclusive questioning of individuals, but should set up opportunities for interactions between family members. This is often achieved by setting the family a task, such as drawing up a family tree. This is a good time to ask what the family makes of the problem and what they believe the causes are. It can also be helpful to try to establish what kinds of treatment they feel are most appropriate. Some families have a very clear view about the kind of treatment that may be necessary, such as stimulant medication.
Interview with the child With older children and adolescents it may be possible to use procedures similar to those used to examine adults’ mental state. In young children formal examination of the mental state is impossible. Every opportunity should be taken to observe the young child’s behaviour and play. This should be reported systematically (Figure 1 shows the format for recording information). When requesting the child’s cooperation, ask for it directly, do not ask ‘may I …?’ as young children are not used to adults asking their permission.
Physical examination Although many children attending child mental health services are never examined medically, there are two important reasons for conducting a physical examination: to find a physical disorder that could have caused the child’s psychiatric disorder, and to detect signs of neglect or abuse. At the very least, the clinician should record height, weight, head circumference, and the appearance of the skin and face (see pages 13–18 for details of developmental assessments). The main indications for neurological examination are a history suggesting neurological problems (e.g. fits, developmental delay, loss of skills), dysmorphic features, deviation of height or weight from normal, or other features suggestive of a problem affecting the brain, such as skin signs of a neurocutaneous disorder, or abnormal gait. The basic neurodevelopmental examination should include: • measurement of head circumference, height and weight plotted on a growth chart • examination of the cranial nerves
The parental interview At some stage in the assessment the parent/s or guardian should be seen without the child. Like all psychiatric interviews, the parental interview should start with open questions and minimal cross-examination. The interviewer should try to clarify exactly what is meant by terms such as ‘depressed’ or ‘naughty’. What effects have the child’s problems had on, for example, schoolwork, peer relationships and the family?
Richard Harrington was Professor of Child and Adolescent Psychiatry and Chair of the Department of Child and Adolescent Psychiatry at the University of Manchester, Manchester, UK. Sadly, Professor Harrington died in 2004, but we are pleased to reprint his contribution to the first edition.
PSYCHIATRY 4:6
19
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
nancy, intracranial haemorrhage) • developmental regression • abnormal developmental history (e.g. floppy baby) • a history of seizure activity. Physical investigations may be required as part of the preparation for some kinds of therapy. Neurophysiology – the most widely used neurophysiological test is electroencephalography (EEG). This is most valuable as an aid to the diagnosis of epilepsy, though it should be remembered that the diagnosis of epilepsy is essentially a clinical one. EEG is also useful in the diagnosis of cerebral degenerative disorders. Non-specific EEG ‘signs’, such as diffuse slowing, are not a good guide to an organic basis for a psychiatric disorder. Standard chromosomal/genetic investigations – the need to perform such investigations depends on the history and the findings from the physical examination. All patients with mental retardation (IQ <70) should undergo a cytogenetic investigation and DNA tests for fragile-X syndrome. Chromosome tests are also indicated if there is a strong family history of psychiatric problems or mental retardation. Brain imaging is increasingly used in the evaluation of children with moderate or severe mental retardation, where it may be useful in diagnosing conditions such as tuberous sclerosis. No child psychiatric disorder, however, is consistently associated with specific structural brain abnormalities. Brain imaging should therefore be reserved for cases where the following conditions are suspected: • a focal brain lesion, such as a tumour • the sequelae of an earlier insult (e.g. neonatal hypoxia) • a focal EEG abnormality. A metabolic screen for neurometabolic disorders often has a low yield, even in patients with mental retardation. One of the most common indications for such screening is developmental regression, which is seen in conditions such as metachromatic leukodystrophy. However, the results of metabolic screens can be hard to interpret and such tests, which are often very expensive, should generally be organized only with expert agreement.
Interview with the child General behaviour • Dress and appearance • Parent–child interaction and separation • Emotional responsiveness • Mannerisms Anxiety and mood • Sadness, tension • Fears, worries • Restless, disinhibited, aggressive • Withdrawn or shy Talk (form) • Spontaneity and flow • Defects of prosody or articulation • Coherence Talk (content) • Persistence • Interests • Interruptions of attention Activity level Intellectual function • Rough assessment of reading level, spelling, arithmetic, knowledge 1
• examination of the motor system, including observations while running and heel–toe walking • handedness • tendon reflexes • coordination • neurocutaneous signs (e.g. café au lait spots) • observation of anomalies such as low-set ears or hypertelorism (excessive distance between the tear ducts). In children with mental retardation, there should also be a full physical examination that includes examination of the back, heart, eyes, ears and genitals. Figure 2 lists some congenital syndromes associated with behavioural or emotional problems. The strongest clues are mental retardation, dysmorphic features (such as unusual facial features) and extreme values for height, weight or head circumference.
Obtaining other sources of information Any agencies involved with the child or the family should be contacted, but practitioners should make sure that they have parental permission to contact the school. Although parents can often give an account of a child’s behaviour in school, it is usually best to obtain a report directly from a teacher. Teachers are particularly good informants on problems such as hyperactivity, and a number of standardized questionnaires are available. However, these scales were never intended to be diagnostic, and are not a substitute for a careful clinical history.
Making a diagnosis Physical investigations
Most children will have emotional or behavioural symptoms at one time or another, so the first issue is to consider whether the child’s behaviour is abnormal. Symptoms persisting for several months and occurring frequently are more likely to indicate disorder. The simultaneous presence of many symptoms is also an indicator of problems. However, some symptoms are much more likely than others to point to disorder. These include poor peer relationships, serious aggression and self-harm. As a general rule, symptoms that
Physical investigations are not generally needed unless there is a clinical indication, such as abnormalities found on physical examination, mental retardation or a history suggestive of organic brain disorder. Key findings in the history that suggest an organic cause include: • a specific familial disorder • a specific type of insult (e.g. maternal alcohol use during preg-
PSYCHIATRY 4:6
20
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
Examples of congenital syndromes associated with psychiatric disorders in children Syndrome
Physical features
Mental features
Fragile-X syndrome
Long face, prominent ears, large testes after puberty
Mental retardation, gaze avoidance, social anxiety
Fetal alcohol syndrome
Low height and weight and small head circumference; hypoplastic philtrum
Mild mental retardation; any psychiatric disorder, especially hyperactivity
Klinefelter’s syndrome (XXY) Height above normal with advancing age, hypoplastic testes
Most individuals show language and reading problems but few are mentally retarded; moderate increase in risk of all psychiatric disorders
XYY syndrome
Height above normal with increasing age
Many individuals have language problems; possibly some increase in antisocial behaviour
Tuberous sclerosis
Hypopigmented skin lesions, cutaneous nodules
Epilepsy and mental retardation; autistic features
2
Example 2: Peter’s problems (Figure 4) were different. He was a 10-year-old referred because of aggression to his peers; he was also aggressive at home. During the assessment, it became obvious that Peter believed his aggression was justified because everyone was against him. His natural parents had separated when he was an infant and he had been brought up by his mother. She had had a series of stormy relationships with boyfriends, and from an early age Peter had witnessed rows and physical fights in the home. His mother and her current partner often beat him when he hit his sister. The school reported that he had few friends apart from another aggressive boy.
are present in one situation only are less likely to presage serious problems than those that are pervasive. Of course, just because a symptom is statistically abnormal it does not necessarily follow that the child has a disorder. It is also necessary to know whether the symptom is doing any harm or whether it is leading to impairment. Four main criteria are used to judge impairment: suffering, social restriction, interference with development, and effects on others. Different components of the child’s problems are recorded separately using a multiaxial framework.
Understanding the causes of the child’s problems The assessment does not end with the diagnosis. It is important to put together a formulation about the psychological, biological and social mechanisms that might be operating. The practitioner must try to understand the meaning and function of the child’s behaviour. Apparently similar behaviours can have entirely different functions, as the following examples demonstrate (see also Figures 3 and 4). In both of these cases, the clinician used the results of the assessment to work out what the mechanisms underlying the behaviour might be.
Understanding aggression in a 10-year-old boy with autism
Autism
Example 1: Kevin was a 10-year-old boy of above-average intelligence who had autism (Figure 3). He failed to develop normal social relationships and although he had developed speech, it was stereotyped and odd. He had been maintained with a great deal of support from the education authority in a mainstream school until the age of 10, when he became aggressive, shouting and hitting out at other children in class. Observation in the classroom showed that these outbursts occurred only when children sat in different seats or when other children taunted him. Like many people with autism, Kevin needed a daily routine that was structured and well organized. His aggression settled when the teachers made the classroom environment more structured and took measures to stop the taunting. He was subsequently transferred to a special school for children with autism. This example shows how a biological disorder such as autism can lead to behavioural problems. However, in Kevin’s case both the mechanism and the solution were not biological, but involved his school environment.
PSYCHIATRY 4:6
Language problems
Social abnormalities
Peer problems and being bullied
Rigidity and unusual interests
Finds change difficult
Behaves aggressively
Change of routines
3
21
© 2005 The Medicine Publishing Company Ltd
ASSESSMENT
Understanding aggression in a 10-year-old boy with behavioural problems
Parental aggression
Rejection by non-aggressive peers
Associates with aggressive peers
Perceives ‘everyone’ as aggressive
Behaves aggressively
4
Peter’s aggression was caused by a number of factors. From an early age he had witnessed aggression at home and so he had learned that aggression was normal and a way of getting what he wanted. However, this made him unpopular with his non-aggressive peers, which meant that in order to have friends he started to associate with other aggressive children. These children were in turn aggressive towards Peter, with the result that by the age of 10, Peter believed everyone was aggressive, even when they were not. Treatment consisted of advice to his mother and her partner about how to encourage better behaviour and how to discipline Peter more effectively. He was also offered some sessions with a psychologist, with the aim of helping him to identify and change his beliefs about aggression.
Practice points • Always try to interview parents and children separately at some point in the assessment • Remember to get parental permission before contacting the school • Understanding the causes of children’s problems starts with the diagnosis, rather than ending with it • Bring all the information from the assessment into a formulation that attempts to explain the mechanisms underlying the child’s behaviour
PSYCHIATRY 4:6
22
© 2005 The Medicine Publishing Company Ltd