1. Bivin Jose
Department of Psychiatric Nursing
Mar Baselios college of Nursing

2. Class overview
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Introduction
Clinical interview of the child
Special issues in the assessment of
children
Techniques of assessment
Tools used in assessment
Laboratory measures

3. Introduction
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Most common psychiatric disturbances
in children are related to developmental
delay in one or more domains
Developmental status influence the
clinical presentation of various
syndromes
Distressing emotions/impairing
behaviors may occur as a part of normal
transition

4. Clinical assessment of the
child
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Possible referral sources include;
• Parents (recommended by school, friends,
relatives, themselves)
• Legal guardians (state custody)
• Schools (Teachers/Peers)
• Court (if the child has legal issues, custody
issues)

5. Evaluation/assessment
settings
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Clinical visits
Schools
Pediatric wards
Resident treatment centers
Detention centres
Hospital emergency depts
• Procedures necessarily vary with the
settings and reasons for carrying out the
assessment

6. Special considerations in child
assessment
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The referral is typically requested by
someone other that the patient
Assessments may misinterpret ass a for
of punishment for being bad
Assessment need to be non-judgmental
& collaborative
Give children as much as control as is
appropriate & safe

7. 
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Methods/tools of assessment are
specific to the age of the children
Primary goal is to understand child’s
inner world & perspective
Techniques range from observing an
infant, parent or using play to
understand the preschool & young
elementary school child to talking
directly about the symptoms to an
adolescent
Alter approaches according to the
developmental needs of the child

8. 
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Children are not to be considered as
little adults
Use multiple informants/problems
across all contexts (Help to clarify the
areas of remediation)
Specific diagnosis is more difficult in
children
• Varying presentation of symptoms at
different ages, the evolution of disorders, &
the lack of diagnostic and etiological
specificity for many symptoms
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Diagnosis vary with time

9. Specific assessment
methods
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Play techniques
• Imaginative play with puppets/small figures
• Play materials are given based on the
child’s concern, perceptions, &
characteristic modes of regulating affects &
impulses
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Uses
• For diagnostics/trust building
• Form of play as an important information to
MSE

10. 
Projective techniques (DAP)
• Invite the child to draw a picture
• Ask the child what animal he or she would
most like or least like?
• Whom she or he would take along to a
desert island?
• What he or she would wish for if given 3
magic wishes (Winkey, 1982)
• Describe a dream/ a book, movie, TV show
which he/she recalls
• Future ambitions?

11. 
Direct questioning
• Inquire about the presenting problems or
other aspects of the child’s life timing
• Attention to the child’s cognitive & linguistic
level of development
• Respect for the child’s self-esteem

12. Domains of Evaluation

13. Development
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Psychomotor:
• Ability to stand, walk, & react
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Cognitive:
• Concrete thinking fashions
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Interactive:
• Verbal & non-verbal communication
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Moral development
Harmful behaviors

14. Cognitive & academic
development
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Child’s ability to separate from parents
& to school regularly
Interpersonal relationship with
teachers/peers
Motivation to learn
Ability to function independently
Tolerance for frustration & delay of
gratification

15. 
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Attitude towards authority
Ability to accept criticism
A grade-by-grade H/o the schools
attended
Retentions & the reason
• Obtain permission to communicate with
the teachers, counselors, or other school
personal
• Review the school records, including
results of standardized tests

16. Family relationships
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How child relates to each family
member
How the child fits into the overall family
system
Child’s reactions to major family events
Compliance with the family rules &
standards & usual mode of
discipline/limit setting)
Child’s response to disciplinary actions

17. Peer relationships
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The number of friends
Preferences regarding age and gender
of friends
Any major changes in peer group
recently
Their relative stability
Activities of interests shared with peers
Parents feeling about the child’s close
friends/social skill or deficits

18. Development conscious &
values
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Harsh/lax focuses on
specific issues
Religious or ethical
concerns & their
concordance with
family expectations
Areas of potential
discord with the family
values/customs

19. Interests, hobbies & talents
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Child’s as well as parent perspective
Parents approval, involvement &
support to the interests & hobbies of the
child
Existence of parent-child conflicts
Impact of the present problems on the
child’s interests/hobbies
Quantity of TV programs, movies &
level of parents’ limit setting

20. Unusual circumstances
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Child’s exposure to unusual or traumatic
circumstances (Sexual/ physical abuse,
family/community violence, natural
disasters or armed conflicts)
Child’s immediate & subsequent
reactions & the nature of the responses
from the parents or other adults

21. Prior psychiatric treatments
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Prior psychiatric, psychological, or
educational evaluations/ interventions
The outcome of such interventions
Child’s parents attitude towards such
earlier attempts to obtain help
Previous health reports

22. Family medical & psychiatric
history
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Psychotic & affective
disorders
Suicidal behaviors
Anxiety disorders etc
Enquire about the
severity, treatments,
outcomes & impact on
the child

23. Temperament categories
1.
Activity level
The motor component present in a given
child’s functioning & the diurnal proportion of
active & inactive periods
2.
Rhythmicity (regularity)
The predictability/unpredictability in time of
any function.
Assessed in relation to sleep-wake-cycle,
hunger, feeding pattern or elimination
schedule

24. 3.
Approach/withdrawal
The nature of the initial response to a new
stimulus (New food, toy or a new person)
4.
5.
Adaptability
Threshold of responsiveness
The intensity of stimulation needed to evoke
a discernible response
6.
Intensity of reaction
The energy level of response, irrespective of
its quality or direction

25. 7.
8.
9.
Quality of mood
The amount of pleasant, joyful & friendly
behavior
Distractibility
The effectiveness of extraneous environmental
stimuli in interfering with or altering the
direction of the ongoing behavior
Attention span & persistence
Length of time a particular activity is pursued
by the child
Persistence refers to the continuation of an
activity in the face of obstacles to the
maintenance of the activity direction

26. Inferring the temperament
Easy
Difficult
Slow-to-warm-up

27. Overview of the assessment
Content component
Primary informant
Reason for
referral
Usually parent,
guardian,
sometimes school
or court
History of
problems
Past problems
Additional resources
Letter from
school, or other
agency seeking
evaluation
Referral sources
Child & parent
Child & parent
Structured
interviews/screeni
ng scales

28. Content
component
Primary
informant
Comorbid
symptoms
Child & parent
Child’s
development
School staffs
& parent
Additional
resources
Structured
interviews &
screening
scales
Previous
Clinicians,
Mental health
assessments/t Child & parent
records
reatments
School
records, incl.
spl education
evaluation

29. Content
component
Primary
informant
Additional
resources
Family history
Parent
Genogram
Medical
history
Parent, health
care providers
MSE
Child
Review of
system
checklist,
laboratory
tests
MMSE

30. Mental Status Examination

31. 
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MSE components may be gathered
through direct questioning, play
activities, or observations during the
session
Appearance & behavior
• Grooming, size & type of dress,
dysmorphic features, bruises, scars or
injuries, eye contact
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Ability to co-operate & engage
Speech & language
• Fluency, volume, rate & language skills
(Apt for developmental level, articulation

32. 
Motor function
• Activity level, co-ordination, attention,
frustration tolerance, impulsivity, tics or
mannerisms
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Mood & affect
• Neuro-vegetative symptoms, manic
symptoms, range & appropriateness of
affect
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Thought process & content
• Psychotic symptoms (delusion)
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Insight
Perception

33. 
Anxiety
• Fears, obsessions or compulsions, post
traumatic anxiety, separation difficulties
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Conduct symptoms
• Oppositionality, aggression
(verbal/physical)
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Cognitive function
• Developmentally appropriate vocabulary,
fund of knowledge
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Risk assessment
• Suicidal thoughts/behaviors, thoughts/plan
on harm others/self, legal issues,

34. Instruments in Assessment

35. 
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Ranging from systematized
questionnaires to specific areas
difficulty
Rating scales are adjunctive to clinical
diagnosis
Ratings scales are completed along
with parents or teachers

36. 
Rating scales
• Achenbach Child Behavior Checklist
• Conners’ questionnaire
• SADS-C (Schizophrenia & affective
disorders scale-children V)
• Kiddie Schedule for affective disorders and
schizophrenia (K-SADS)
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Diagnostic interview for children
Pictorial DOMINIC-R (For anxiety
symptoms in young children)

37. The 4 Ps in diagnostic
formulation
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Predisposing: those factors that render
the child vulnerable to a disorder
Precipitating: stressors or
developmental factors
Perpetuating: factors that maintain the
disabling symptoms
Protective: strengths & assets

38. Lab Investigations

39. 
Mental retardation & PDDs
• Woods lamp examination (Tuberous
sclerosis)
• EEG (Seizures)
• Chromosome analysis to exclude fragile X
syndrome, down syndrome
• S.lead estimation (pica)
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Mood disorders
• Routine thyroid function
• Infectious disease
• Toxicology tasting

40. 
ADHD
• Thyroid profile
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Tic & OCD
• Throat culture & serological studies for group A βhemolytic streptococcus infection
• Antideoxyribonuclease B
• Antistreptolysin O antibody titres
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Substance use disorders
• Toxicology screening for all adolescents who are;
• psychiatric symptoms or who have exhibited acute behavioral
changes
• High-risk (delinquents and runaways)
• recurrent accidents or unexplained somatic symptoms

41. Recommendations for
Treatment

42. 
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Child is at imminent risk & required
acute hospitalization
Care is provided in a safe, nonthreatening, home-like environment
Child requires treatment services like;
• Individual therapy: CBT, IPT, DBT etc
• Psychotropic medications: Psychiatric
symptoms & stabilization of persons
• Group therapy
• Family therapy: Parent management
programs, psychoeducation, couples
therapy, divorce & conflict resolution etc.

43. 
Adjunctive childcare services include
• School services for emotional, attention
&/or learning related problems
• School-based counseling
• Remedial education services
• Speech therapy etc
• State protective services
• Mentoring programs for the siblings as well
as the parents
• Legal guardian

44. References

Vyas JN & Ahuja N (1999).
Textbook of postgraduate
psychiatry, 2nd ed., vol 2,
Jayppe Medical publishers.
Ch 36