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.
Children may present with more than one symptom. This sequential order of the complaints gives better insight into underlying psychopathological states and helps in management. 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.
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. OR Why do you think these behavioral changes have occurred in the child? 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. 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.
Changes in the daily schedule after the onset of the current concerns should be enquired. 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. Children and adolescents are being increasingly referred for evaluation to psychiatrists and psychologists, from state-run institutions and agencies, and nongovernmental agencies. 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. As far as possible, multiple interviews and opportunities to observe and interact with the child are required before any report is made available.
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.
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. 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 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. 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. 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.
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.
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. 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. 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. A psychiatrist under most circumstances is not required to perform a genital examination. Otherwise, referral to a pediatrician for evaluation may be considered. 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.
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. 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. A history of similar or other behavioral concerns and history of medical issues must be asked for. 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. Medical illnesses can have multi-pronged effects on clinical presentations [ Figure 3 ]. Several associations are seen between pregnancy, maternal health, early exposure related variables and developmental and behavioral outcomes during childhood and adulthood.
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. 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. A detailed coverage of developmental milestones and elicitation techniques is outside the scope of these guidelines.
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. 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. 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. 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. 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. 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.
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.
The clinician must make a conscious effort to separate the illness from the personhood of the child. 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. 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. 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.
A family history of diabetes mellitus, hypothyroidism or neurological disorders are relevant from a risk perspective, especially when psychotropics are being considered for management. 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 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. 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.
Details about past assessments, evaluations, treatments, response to the treatment, and side effects must be collected. This informs future direction of evaluation and management. History and examination Table 7 are not watertight compartments. 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.
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.
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. First of all, the child usually does not have the language skills to explain coherently what they are experiencing - rather they will communicate their problems through behavioral red flags, which, by their very nature, are non-specific.
Similarly, parents may also struggle to understand and explain the difficulties they are experiencing with their children and with parenting skills.
Additionally, medical, social work, or educational professionals looking to screen for emergent social-emotional challenges in early childhood may not be certain how to ask the questions. Moreover, although clinicians are generally trained extensively in assessing symptoms in an individual, fewer are familiar with the systematic evaluation of relationships between parents and children - but this is an integral part of the early childhood assessment.
Despite these challenges, accurate and efficacious screening and assessment maximizes the potential to direct young children and families to the help they need before problems have become entrenched. Standardized tools validated for the young child can assist with screening and assessing young children and the relationships with their caregivers in a reliable way.
Following is a list of tools that are available and are commonly used - although not comprehensive, hopefully this can be a good starting point to help you find what you need in your work with young children! It is useful also to assess progress across domains of development since young children are not developing social-emotional skills independent of language, cognitive, and motor development. Some useful broad range developmental questionnaires are in the final table below. Crowell JA Assessment of attachment security in a clinical setting: Observations of parents and children.
Developmental andBehaviouralPediatrics, Infant Mental Health Journal, Obtaining formal developmental and neuropsychological testing can be very helpful in working with very young children.
Reasons for obtaining testing include: 1. To help clarify diagnostically complex and ambiguous cases, 2. To further evaluate a specific cognitive domain, 3. For educational placements and to tailor educational plans, 4.
Pre-post comparisons after intervention e. Psychologists, CBT therapists, and other mental health professionals often ask their clients to complete self-report measures regularly to assess changes in symptom severity. Tolin, D. Psychiatry Research, , Jump to. Only qualified mental health professionals should use these materials. Why Psychology Tools?
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