APPROACH TO ASSESSMENT AND

OVERVIEW OF MANAGEMENT IN CHILD

AND ADOLESCENT PSYCHIATRY
Dr Suria Hussin
Child and Adolescent Psychiatrist
HRPZ II, Kota Bharu
03 May 2023
HOW DOES PSYCHIATRIC ASSESSMENT IN CHILDREN AND
ADOLESCENTS DIFFER?
■ Children seldom initiate the consultation
■ Consider child’s stage of development when deciding what is abnormal
■ Children are generally less able to express themselves in words
• Ability to reflect and discuss their feelings/experiences depends on
their
• maturity
• Observations/reports from parents/teachers/others
• Inconsistent reports are common – can be confusing, BE CLEAR
ABOUT THE AIMS OF ASSESSMENT

§ Medication is used less in treatment for children

 HOW DOES PSYCHIATRIC ASSESSMENT IN CHILDREN AND
ADOLESCENTS DIFFER?

•More flexible approach in interview

◦ Child and clinicians are at different developmental levels and speak
different language
◦ Often requires more time and use of other modes of communication

•No child can be assessed in isolation

◦ Assessment should be done in the context of family, school,
community and culture

•More emphasis in working with parents, family, schools

and related agencies
•Multidisciplinary work is important
GENERALLY….
No hard and fast rule

Important to see the family together at some

stage

Younger children – main informants are the

parents

Children over 6 – usually can be seen on their

own at some stage

Most adolescents can be seen alone

However it is reasonable to see the adolescent

and parents together at the beginning
Parents should be made to feel the interview is
supportive and does not undermine their
confidence
Suspected child abuse- interview with child is very
important
 THE AIMS OF ASSESSMENT
■ Create a good therapeutic relationship
• Exact reason for referral –why now, whose problem is it, who initiate the referral and why
• Main complaint
• Child’s and parent’s expectations and concerns about the assessment
• Current functioning
• Child’s development from birth to now, parents and family functioning, and family history of
medical and psychiatric disorders
• Identify individual, family and environmental factors –the 4 Ps (predisposing, precipitating,
perpetuating, protective factors)
• Mental state
• Formulate and communicate the clinical formulation and recommendations to parents and
child in an understandable and constructive way
• Establish target symptoms and clarify the focus of treatment
HOW TO CREATE GOOD THERAPEUTIC
RELATIONSHIP FORM THE BEGINNING
Try to find child friendly space- room with enough space, pleasant
lightings, toys/play materials, pencils and paper

Have enough time especially for the first interview

Greet parents/carer and child, introduce yourself – explain who are you,
what will you do, why and how long it will take

Clarify reason for referral and aim of interview

Explain confidentiality

Put family at ease with open generic questions first

Use simple language to engage the child

 CONFIDENTIALITY
The extent of confidentiality in child assessment is correlated with the age of
the child

In most cases, almost all information can be appropriately shared with the
parents of a very young child

Privacy and permission of an older child or adolescent are required before

sharing the information with parents

They are informed that if the clinician becomes concerned that any child is
dangerous to him/herself or to others, this information must be shared with
the parents/carer
 WHAT TO ASK ?
5 key areas: SIRSE

■ Symptoms – what sort of problems

■ Impact – how much distress/impairment does it cause
■ Risks – what factors initiated and maintained the problem
■ Strengths – what assets are there to work with
■ Explanatory model –what belief and expectations do family
bring

**It can be useful to start by exploring non-problem areas (esp

in externalizing disorders)
 SYMPTOMS
■ Initial focus should be on the symptoms that led to the referral and
those that cause the most distress to the patient and family
– Frequency
– Intensity
– Duration
– Context in which the behaviour emerged – pervasiveness,
triggers, consequences,
– Progression of the problem –present since early childhood,
intermittent or recurrent, deterioration of function
■ Previous treatment and intervention
■ Most of the psychiatric conditions that affect children and
adolescents involve combinations of symptoms (and signs)
from four main areas: emotions, behaviour, development
and relationships.
Four domains of symptoms are:

1. emotional symptoms
2. behavioral problems
3. developmental delays
4. relationship difficulties

**Exceptions eg. schizophrenia and anorexia nervosa.

• Is intermittent or recurrent (e.g., depressive or manic symptoms, tics), or
DOMAIN OF SYMPTOMS
• Represents a deterioration from a previously higher level of functioning (e.g., schizophrenia).

Most patients have symptoms from more than one domain

Syndromes may involve more than ONE domain
 IMPACT
■ How much distress or impairment does it cause
■ Generally a disorder is diagnosed, if symptoms have substantial
impact
■ Impact is judged from:
1. Social impairment
(a) family life (b) classroom learning (c) friendships (d) leisure
activities.
2. Distress for the child or adolescent eg. depression
3. Disruption for others eg. conduct disorder
 RISK FACTORS
Why the patient?

■ The presence of a disorder can be explained in terms of:

– predisposing factors – make the child vulnerable to a disorder eg.
genetics, family history
– precipitating factors – associated with the emergence of
symptoms eg. the onset of puberty in anorexia nervosa
– perpetuating factors – maintain the symptoms eg. inadequate
parenting style, lack of medical intervention, no access to health
service
– and the absence of protective factors.
■ Developmental history – details of the child’s development form the
beginning of pregnancy to birth and early development
-Screening questions about important milestones
-Developmental domains eg. gross motor, fine motor, speech and
language, personal social
-Emotional development and temperament
-Attachment
■ Trauma History
■ Family History
 STRENGTHS
■ Important to establish what is right about this individual and family.
■ Relevant protective factors include a sense of worth from being good
at something, a close supportive relationship with an adult, and an
easy temperament.
■ Treatment plan needs to build on the strengths of the individual and
the family – and also on the strengths of the school and wider social
network
■ Use the strengths in the child or adolescent, such as the ability to
make friends or respond to praise, and the strengths in the parents,
such as an openness to trying new approaches in the family.
■ This approach support the self-esteem of both child and parents
 EXPLAINATIONS
■ Ask for their explanation of the problem; what they think it is due to;
and how they think it might be investigated or treated
■ It is also worth asking the parents whether other important people,
including grandparents, friends, neighbours, teachers, have expressed
strong opinions about causation, investigation or treatment.
■ Knowing about people’s explanatory models gives us a chance at the
end of the assessment to present our views in the way that will be
most relevant to them
 SOME HOW TO TIPS

■ Best to see child with parents/carer first

■ Gain child’s confidence
■ Ask child’s permission to be assessed alone
■ Children can often indicate an acceptable point for the
parents to leave the room
■ Children often find it embarrassing to listen to their
problems being discussed in front of them
 THE CHILD ALONE

■ Child above 5
■ Both sit down
■ Often help to ask child while drawing
■ Chat & use directed questions
■ Wise to begin the interview with neutral topics that may
interest the child eg hobbies, holidays, birthday presents
■ Then inquire about what the child has been told or
understands about the purpose of the interview
■ Child below 5

– Should not be expected to sit still

– Decide what play material to be available
– Observe play
– Play together
– Use fewer directed questions
 AIMS :- OBSERVE & INQUIRE

Quality of social interaction

Activity &attention –ability to – eye contact, engagement, Developmental level –
complete task, distractibility, anxiety, friendly, over language, drawing, play,
fidgetiness/restlessness familiar, cheeky, feelings ideas
evoked in us

Emotional symptoms –rarely

Ask about friends, school, Sometimes needs to ask
volunteer their feelings, ask
directly bully, teasing about undisclosed abuse

Explore feelings about

disorder
 INTERVIEWING THE ADOLESCENTS

Overall sequence is similar

Spend more time with the adolescent alone

Crucial to avoid the perception that parents and clinician are

allied against him

Begin by reviewing and clarifying what the adolescent

believes and has been told about the purpose of interview
 WILL YOU TELL MY PARENTS?

Key concern for adolescents

Best is to inform at the beginning about confidentiality when

the parents and adolescents are present, thus educating the
parents that what their child disclose is confidential
 SPECIAL AREAS OF INTEREST FOR THE
INTERVIEW WITH ADOLESCENTS
■ Antisocial/delinquent behaviour – eg have you done
anything that you now look back on and think that was
pretty dangerous?
■ Sexual identity and activity – eg have you ever had romantic
feelings towards anyone
■ Alcohol and substance abuse
■ Suicidal ideation and behaviour- eg do you sometimes feel
an urge to hurt yourself, have you ever thought that your life
was not worth to live
OBSERVING THE FAMILY INTERACTIONS
■ Observing family interaction in consultation room gives clues to nature of interaction
and the family dynamic
■ Notice the seating arrangement, any tension in the air

Notice the:
■ Child’s behaviour towards parents – ignore, challenging, interrupting, watching from
a distance
■ Parents’ reaction towards child – supervision, limit setting, warmth, criticizing,
sensitive and attuned, supportive, alienating eg ‘anak ayah’, ‘cucu nenek’
■ Siblings’ relationship -rivalry, harmonious, competing, comparing, cooperative
■ Relationship between parents –supportive, conflicting values, marital friction, ‘finger
pointing’
 CONCLUDING THE INTERVIEW

■ End the interview in a collaborative way

■ What else have I not asked about that is important?
■ I have asked you a lot of questions. Do you have any
questions for me?
 OVERVIEW OF MANAGEMENT

q Assessment
• History taking
• Mental Status Examination (MSE)
q Physical Examination
q Investigation –biopsychosocial
q Treatment -biopsychosocial
MENTAL STATE EXAMINATION

■ Objective description of the child’s appearance, symptoms, behavior

and functioning as manifested during the examination.
■ Presented/documented as a separate component from the history-
taking
■ In reality much of the MSE takes place implicitly as the clinician
interacts and observes the child during the individual and family
interviews.
■ Some components of the examination may require specific inquiry or
examination (e.g., orientation, memory, specific symptoms such as
hallucinations or obsessions)
Continue….

■ Use every opportunity to observe the patient and his interaction with others,
particularly with the family.
■ For example, behavior:
◦ In the waiting area (e.g., how did they choose to sit? Are they talking to each
other? Arguments?)
◦ During the initial greeting and introduction
◦ In the consultation room
◦ Upon separation (e.g., when parents leave the room)
 PHYSICAL EXAMINATION

■ Look for:
■ Evidence of a physical disorder that probably affects the brain
eg abnormal neurological signs, dysmorphic features, and cutaneous stigmata of a
neurocutaneous syndrome.
■ Signs of neglect or abuse
■ Weight and height-plot on growth chart (evidence of injury /growth failure)
■ Rule out any visual/hearing problems
■ Good to do systemic examination
 WHO NEEDS NEUROLOGICAL
EXAMINATION
■ history of seizures or regression
■ developmental delay or intellectual
disability
■ abnormal gait
■ not using both hands well, for
example, when playing
■ dysmorphic features
■ skin signs of a neurocutaneous
disorder
■ other suspicious features
Basic neurological examination:
◦ Stance and gait
◦ Tests for cerebellar function (e.g.,
check for dysdiadochokinesia)
◦ Tone, power, reflexes
◦ Abnormal movements
(fasciculations, tics, myoclonus,
dystonia, athetosis, hemiballismus,
tremor).
Observing the child’s gait is the most
valuable
◦ A normally walking child is unlikely to
have a severe neurological impairment
 INVESTIGATIONS -BIOPSYCHOSOCIAL
APPROACH
■ Blood investigations are not diagnostic for psychiatric disorders
■ Depends on the indication – no routine blood investigation
■ Metabolic and genetic investigations (refer to paeds if suspicious)
■ When necessary
◦ ECG
◦ Urine test (toxicology, UPT)
◦ Brain imaging
◦ EEG
 RATING SCALES AND PSYCHOMETRIC
ASSESSMENT
■ Rating scales are used for:
– additional diagnostic information to monitor and measure the effectiveness of
treatment
– screening
– research tools
– eg Vanderbilt Assessment Scale, Children Depression Inventory (CDI)
■ Psychometric assessments are useful to:
– Find the diagnosis or comorbidity
– Identify the individual’s profile of cognitive strengths and weaknesses
– Plan treatment
eg IQ test, personality test
 SOCIAL INVESTIGATION

■ School report
■ School visit
■ Home visit
■ Relevant agencies
 COMMON MENTAL HEALTH DISORDER AMONG
CHILDREN AND ADOLESCENTS
Onset from childhood Onset during early/middle Onset during late
(1-9 yrs old) adolescence adolescence
(10-14 yrs old) (15-19 yrs old)

Autistic Spectrum Disorder (ASD) Bipolar Mood Disorder Schizophrenia

Attention Deficit hyperactivity Depression Substance Abuse
Disorder (ADHD)

Learning Disabilities Oppositional Defiance Disorder Obsessive Compulsive

Disorder

Anxiety Disorder Conversion

Substance Disorder Eating d/o

Conduct Disorder Conduct d/o

 TREATMENT

BIOPSYCHO- Engagement
SOCIAL Multidisciplinary and Multiagency
SPIRITUAL team collaboration when necessary
APPROACH with family
 PHARMACOTHERAPY IN CHILDREN AND
ADOLESCENTS

■ Prescribing varies widely –across countries

■ Remains the object of debate and controversy
■ Most psychotropic medications were first developed to treat
psychiatric conditions in adults, and only later extended to
children
 WHEN TO USE PHARMACOTHERAPY IN
CHILDREN AND ADOLESCENTS
■ Requires a comprehensive diagnostic evaluation and formulation
■ Patients with psychotic disorders often require pharmacological
treatment as a first step to control symptoms and restore
functioning
■ Patients with non-psychotic disorders may often be successfully
treated with non-pharmacological interventions first
■ However, not all children improve with just psychosocial
intervention
■ In many conditions, combination of psychosocial intervention
and pharmacotherapy has been found to be more beneficial
 KEY CONSIDERATION IN CHOOSING
THERAPEUTIC OPTIONS
■ Strength of evidence supporting the efficacy and safety of the
treatment for the specific condition and the age of the child
■ Approval for pediatric indications by drug regulatory agencies (i.e., the
FDA in the US or the EMA in the European Union)
■ However, there are medications that have a high level of evidence but
do not have FDA approval - on-label vs. off-label
– sertraline has Type I level of evidence for efficacy in anxiety
disorders in childhood, but no FDA indication
PSYCHOTROPIC MEDICATIONS AND
LEVEL OF EVIDENCE
PRINCIPLES OF PRESCRIBING PRACTICE
Target symptoms, not diagnosis

Begin with less, go slow

Monotherapy is ideal but polytherapy may required

Off label use often necessary

Where possible change one drug at a time

Allow time for an adequate trial of treatment

Monitor outcome in more than one setting

Patient and family medication education is essential.

QUESTIONS
Credit to Dr Noorul Amilin Harun
Child & Adolescent Psychiatrist, HTAA