Address for correspondence: Dr. Eesha Sharma, Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India. E-mail: moc.liamg@052.ahsee
Copyright : © 2019 Indian Journal of PsychiatryThis is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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
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.
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.
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.
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.
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
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”
