Appendix 3–1. Detailed outline for the psychiatric
assessment of the school-age child
Informants and persons present
Some combination of the following individuals may be
used as informants:
and/or caregiver(s) without child
and other adult, such as a grandparent, designated by the guardian
to accompany child to the evaluation visit
and other adult, such as social services case worker or guardian
alone (may occur more commonly in certain settings, such as an inpatient psychiatric
Additional information, including the mental status examination,
will be obtained when the child is interviewed.
If there are other adults present, ask who the person is,
ascertain their relationship to the child and caregiver(s), and
obtain a formal release of information from the legal guardian to
allow that adult's participation in the evaluation.
"Hi, Julie, I'm Dr. ____________;
you and your parent(s) are going to meet with me today to talk."
"We are going into my office to talk together—I'll
show you the way there."
Remember, younger children in this age group usually experience
well-child visits with their primary care doctors, at which times
they may receive scheduled immunizations. Telling the child that
you don't usually give "shots" in your
office may help to ease their anxiety about what will happen during
their initial visit with you.
Introduce parent(s) and child to your office if this
is where you will evaluate the child.
Have special areas for the child, such as smaller seats and
table, toys, and an artwork area with supplies.
In settings other than your office, such as in an emergency
room or inpatient unit, attempt to make everyone comfortable.
Evaluations of children in this age range may occur
in different settings, each with a modified purpose:
mental health setting
room or crisis setting
setting, either inpatient or outpatient
If this has not already been addressed, ascertain who
the child's legal guardian is.
If the adult present at the initial appointment is not legally
able to consent to an evaluation, the evaluation usually should
not proceed until this issue is addressed and resolved.
Reason for referral
Understand from the parent(s)/caregiver(s)
the "why now?" related to seeking psychiatric
evaluation (e.g., what prompted arranging this initial evaluation?).
brings you in today?"
can we do today to be helpful to you and your child?"
someone recommend that you bring your child for an evaluation?"
If the child is present: "What does your child understand
is the reason you are here today?"
This information includes the following:
The clinician can also ascertain if the child has a nickname
or abbreviated name that he or she prefers.
Depending on the setting of this initial interview,
vital signs will not always be taken during the initial clinical
contacts with the child and caregiver(s).
If vital signs are taken, the following can be included:
Height and weight percentiles can be recorded on standardized
growth charts for boys and girls in this age range.
Body mass index can also be calculated for the patient using
height and weight values.
Chief complaint and history of present illness
Allow the parent(s)/caregiver(s) to freely
discuss the concern(s) for which they are seeking an evaluation.
Gather the following information about the chief complaint
Guide the interview if necessary to ascertain the above details,
including asking direct questions if necessary.
Includes all previous mental health contacts, whether
through the child's school, primary care provider, or mental
your child ever seen someone else for these concerns?"
so, what was the outcome of those contacts?"
Obtaining the actual psychiatric evaluation and treatment
history is important, as is understanding the parents' and
the child's reactions to past psychiatric contacts and
Detailed psychiatric history includes
outpatient psychiatric evaluation and treatment
emergency-level evaluations and their outcome (e.g., hospitalization)
and current psychotropic medication treatment and responses
history of suicidal/homicidal statements, intent, and/or
"Is your child healthy?"
Pay special attention to past history related to potential
neurological insult, such as seizure disorders, history of serious
head injury, brain insults, and/or infections.
Ascertain who is the child's primary care provider
and the following related information:
This information is also important since collaboration
with the primary care physician, with the parent(s)' consent,
may be needed during psychiatric evaluation and/or treatment.
Detailed medical history includes
to medications/environmental sources
neurological insults, including seizure disorders or symptoms, serious
head injury, toxic brain insults
of systems, including cardiac, gastrointestinal, and pulmonary systems
of cardiac system should include history possible for congenital disease/structural
or hepatic disease
complaints, including headaches and stomachaches
surgery, previous medical hospitalizations, procedures
previous serious injuries
Get to know the child's home environment,
the child's role in the family, and the family's
interactions with the child.
Questions for the parent(s)/caregiver(s):
Questions for the child:
All of the following information, if gathered, can help to
understand the child's family situation:
(parents') age and occupation
(parents') level of education
(parents') own childhood and social circumstances and how
these have influenced their parenting practices
children in the home, their ages, and functioning
arrangements, if applicable
relationship, if applicable
parent's parenting style and compatibility with that of
the other parent
Inquire about individual and family stressors, past and present—for
How have these stressors impacted the child? the family?
"Have you ever had any concerns about your
Developmental history can be divided into these areas:
history includes pregnancy complications, medication/substance exposure,
history includes complications, birth weight, method
of delivery, Apgar scores
history includes requirement of neonatal intensive
care unit, approximate days in hospital, jaundice, early feeding
milestones can include age when spoke first words,
crawled, walked, spoke in phrases and sentences; toilet training
development includes the child's temperament
and how this temperament matches or does not match those of his
or her parents (Schor 1999)
developmental functioning includes peer interactions
and friendships, school functioning, family interactions, level
development includes assessing pubertal development
since its onset is usually during the latter school-age years
assessments—Has the child received previous
developmental assessment, such as through early intervention services,
a developmental pediatrician, or specialist?
interventions—Has the child received a
past speech and language evaluation or treatment, or occupational
therapy evaluation and treatment?
Strengths, interests, and assets
This section can be one that especially helps the clinician
to form an alliance with the child and the family.
It helps the child and family to understand that the evaluation
is not just problem-focused and that these areas are important too.
Questions for the parent(s)/caregiver(s):
Questions for the child:
"What do you like to play at home?"
"What do you do well at school?"
"What do you like best about yourself?"
Includes the following detailed elements:
Current grade level
Name of school
Type of school (public, private, religiously based)
Past history of grade retention?
Any change in school functioning over the past
Ascertain the child's functioning in the following
Specialized educational services:
Is the child receiving these?
Has the child received any type of educational
assessment through the school?
What were the results of this assessment?
Does the child have an individualized education
What specialized services is the child receiving
If the child is receiving services at school, how
is the child responding to these interventions (i.e., is there improvement
noted and reported?)?
In general, understand the parent's and the child's
impressions about how well the school is working with them to address
the child's problems if they are school related.
Questions for the parent:
"Has your child been affected by any traumatic
events in his or her life?"
"Do you have any concerns that your child
may have been physically or sexually abused?"
"Has your child ever witnessed violence?"
Questions for the child:
Be aware of your state's legal mandatory reporting
requirements for any professional having concerns for possible child
abuse and/or neglect.
Be prepared to react appropriately to any such concerns for
possible physical/sexual abuse and/or neglect.
If the patient has a reported history of physical or sexual
abuse, ascertain whether the child and family are interacting with
the legal system to address the abuse.
Has the family experienced any involvement with the department
of social services?
Assess the level of media exposure the child has to violent
and/or sexual content through television, computerized
games, and the Internet.
Family psychiatric history
The following detailed information should be obtained
as part of the family psychiatric history:
Presence of mental health diagnoses and treatment
in parents, grandparents, and siblings, as well as other more distant
Presence of substance use disorders and treatment
in family members
History of psychiatric hospitalization and reasons
for that hospitalization if known
History of legal involvement by family members,
including family history of violent acts/threats and domestic
History of self-harmful threats and/or
acts by family members
If there is a positive mental health history found in close
relatives, has this impacted the child and the family?
Family medical history
The following detailed information regarding family
medical history should be obtained:
Family history of serious illnesses, including
chronic illnesses, such as diabetes mellitus, and cancer
History of cardiac disease, including hypertension,
infarctions, strokes, congenital heart disease
Inquire specifically about family history of sudden
cardiac death and obtain details of this history if known, since
this may be pertinent in the future if medications with potential
adverse cardiac effects are considered
Neurological, developmental, and genetic disorders,
such as seizures, fragile X syndrome, developmental delays, autism,
Psychiatric review of symptoms
The major DSM-IV-TR (American Psychiatric Association 2000) diagnostic categories should be covered as appropriate.
Some categories may be more appropriate to cover in greater
detail than others.
Many children may present with problems that do not "fall
into" DSM-IV-TR categories. Examples of these problems
may be the following, covered in more detail in this chapter:
Poor social skills
Keep in mind that children may also present with symptoms
that qualify under strict DSM-IV-TR criteria as a diagnosis, but
the use of the diagnosis alone does not adequately define treatment
needs or the level of resulting impairment (McClellan and Hamilton 2006).
Mental status examination
Refer to Appendix 3–2.
The evaluating clinician is gathering data regarding the child's
mental status throughout the clinical contact (American Academy of Child and Adolescent Psychiatry 1995).
Many sections of the formal mental status examination are
assessed through observation, such
as the child's appearance, ability to separate from caregiver, affect,
impulse control, and motor activity.
Some sections are best assessed with direct
discourse with the child, such as the child's
mood report and thought content, as well as items covered in the
next section of this appendix ("Risk assessment").
The importance of assessing risk for a patient is highlighted
by separating this topic into a separate section from the mental
This assessment should address any possible issues of self-harm
or harm to others, including presence of suicidal or homicidal thoughts
or intent, violence exposure, and access to weapons including guns.
Directly ask the child questions regarding possible suicidality:
Understand the child's concept of death to aid in
understanding his or her answers to such questions.
Directly ask the parent(s)/caregiver(s) similar questions
regarding the child's possible suicidality and homicidality
The formulation can be assimilated in the biopsychosocial
model, addressing each area of this approach (American Academy of Child and Adolescent Psychiatry 1995):
What are the patient's and family's assets
and strengths that will aid in the treatment and recovery process?
Often initial history and presentation do not allow
the clinician to adequately confirm one or more DSM-IV-TR-based
diagnoses. Further clinical contacts may need to occur, as well
as collateral information gathered, before the clinician can adequately
diagnose the condition(s).
Diagnoses, if present, should be given on Axis I through
The completed assessment should have identified target
treatment areas through the biopsychosocial formulation.
These treatment targets may be
The child's psychiatric symptoms
The child's and/or the family's
dysfunction and distress related to those psychiatric symptoms
Family systems issues
Community and cultural issues.
Treatment targets may have to be prioritized based on acuity
or on other more practical issues, such as the ability of the family
to pursue psychiatric treatment or the paucity of psychiatric treatment
resources in their local area.
This issue may be an especially important and sensitive
area to the parents/caregivers seeking the initial psychiatric
Parents will often refer to this issue during the interview
and may state: "We didn't seek help before now
because we thought he or she would grow out of it."
Questions helpful in understanding parents' hopes
and fears for their child's future as impacted by a possible
mental illness include
Referrals may need to be made for the following additional
evaluation(s) to aid in the evaluation process:
Psychological assessment, including psychological
testing and neuropsychological testing; psychological testing is
further described in detail in the section "Use of Rating
Scales and Semistructured Interviews" in this chapter (see
also Chapter 7, "Diagnostic Interviews," and
Chapter 8, "Rating Scales")
Speech and language evaluation and services
Developmental assessment, including developmental