This article focuses on strategies for the assessment of social functioning and psychiatric disorder in the school age child. While the interview with the parent is of great diagnostic value, techniques for the direct assessment of the child are also important.
THE CONCEPT OF PSYCHIATRIC DISORDER IN CHILDHOOD
Psychiatric disorder associated with functional impairment has been found to exist in 5% to 15% of school age children. ' Some feel that such disorders are merely temporary exaggerations of normal developmental processes.2,3 However, children with psychiatric disorders differ from those without such disorders in the following ways: 1) there is a strong tendency for such disorders to persist over time;4 2) the disotder is accompanied by other types of difficulties such as poor school performance or poor peer relationships; and 3) there is often considerable distress on the part of the child.
Psychiatric disturbance in childhood differs from many of the psychiatric disorders in adulthood insofar as adult-type disorders are defined in terms of signs and symptoms, whereas disorders in school age children are most often defined as a mismatch between environmental expectations and the behavior of the child.5 The most common syndromes seen in childhood, such as conduct disorder, attention-deficit disorder (ADD), and separation anxiety disorder can all be defined by the developmental inapptopriateness of a given set of behaviors. For example, conduct disorder can be seen as inadequate development of empathy and self-control, attention-deficit disordet as a lag in the development of age-appropriate attenti veness, and separation anxiety disorder as a failure to achieve ageappropriate autonomy. This says nothing about the etiology of such disorders, merely that the disorder is associated with a deficit in social functioning which frequently leads to its detection.5
THE IMPORTANCE OF MULTIPLE SOURCES OF INFORMATION
It is vitally important that the clinician have access to multiple data sources for the psychiatric assessment of children. Minimum sources are the parent, the teacher, and the child. Often these informants disagree, for good reasons. A given behavior may be situation specific, and hence may be observed at school but not at home. Different observers may have different expectations and criteria for normality and pathology.6 Parents and children tend to agree overall on the presence or absence of psychopathology, 7 but there are some impottant differences. Parents give more accurate descriptions of their children's socially inappropriate behavior when compared to the child's report. However, not surprisingly, parents give hss accurate descriptions of their children's thoughts and feelings.8
STRATEGIES IN INTERVIEWING CHILDREN
Some child psychiatrists stress the importance of the uniqueness of children as patients.9 While there are special problems associated with the psychiatric assessment of children, this attitude seems to create a mystique about child psychiatry.
Play interviews have a limited role in the diagnostic assessment of school age children. It has been demonstrated that a directed, verbally oriented interview yields the most information of diagnostic import.10,11 Play is most useful in the assessment of a child who is language impaired and cannot give an accurate self report. 12 Play may be useful in putting a child at ease initially, although it may be difficult to then redirect the child to a more structured format. Play may also be used as a reward for the completion of a more structured interview.
Rapport is key to the successful diagnostic interview, and is best facilitated by establishing a contract with the child concerning goals and methods. Much of children's resistance to any form of diagnostic interview may relate to inadequate preparation. It is important to ask the child what he/she thinks is the reason for psychiatric referral, and then to explain the clinician's reason for the basis for referral. It is necessary to discuss the degree of confidentiality with which the child can speak. If the child mentions something that the clinician feels should be communicated to the parents, then the child should be informed of the clinician's intent. Acknowledgment of feelings the child may have about being seen by a psychiatrist can be helpful before proceeding further with the interview.
ASSESSMENT OF LEVEL OF FUNCTION
It is useful to operationalize social functioning along three dimensions: school, peers, and family.13
It is generally less threatening to the child to initiate the interview by asking about his/her interests and activities. It is helpful to begin with a question like, "What do you do for fun ?" and attempt to get the child to specify whom he/she has fun with» and whether the amount of pleasure in his/her life has diminished of late. This gives information about the possibility of depression, whether the child has age-appropriate interests, and about the quality of peer relationships.
In school, the child should be learning the basic skills of language and arithmetic. School also serves as a place for the learning of social skills required to get along with peers and adults outside of one's family of origin. The child's behavior is an excellent source of information for the diagnosis of psychiatric disorder. School attendance may be disrupted by a separation anxiety disorder, chaotic family life, or truancy due to a conduct disorder. School performance may be impaired due to depression, ADD, learning disability, mental retardation, or may be secondary to conduct disorder or chaotic family life. Because poor school performance and psychiatric disorder in childhood are so frequently associated, ' it is helpful to obtain, as part of the assessment, psychoeducational testing. Conduct-disordered children almost universally have conflict at school in the form of fights, stealing, rebelliousness, or suspensions. The child's behavior at school may be the most important source of information regarding the diagnosis of an attention-deficit disorder with the hallmarks being difficulty completing tasks, concentrating, attending, and sitting still.
The school age child should be able to enjoy peer relationships both one-on-one and in the more structured format of games, clubs, and sports. The assessment of peer relationships is best accomplished by asking who the child's friends are, what sort of activities they do together, frequency of contact, and types of negative interactions with peers. Children with a variety of psychiatric disorders will show disturbed peer relationships,1 disrupted by aggression (conduct disorder, ADD), social withdrawal (depression, anxiety disorders), or scapegoating (any disorder).
The school age child should have an increasing amount of autonomy and responsibility as a family member. Children with psychiatric disorders often have disturbed family lives, although the direction of causality is at times unclear. H Separation anxiety disorder is defined as an inability to separate from parents, and often the problem is mutual. On the other hand, some conduct disordered children are both unsupervised and unsupervisable. It is important to inquire about parental discord and parent-child discord, and whether physical violence is used as a means of punishment. Children can be quite sensitive to their parents' disordered behavior, and can describe if their parents have been irritable, depressed, psychotic, or abusive of alcohol. The quality of the child's relationship with each person in the household should be assessed with regard to the presence of a confiding relationship, the degree of affection the child feels toward that person, and what sort of conflicts occur. It is useful to ask what the family does for pleasure, and how often that occurs.
The Role of the Interview
At this point in the interview, areas of impairment in the child's social functioning should be clear, and the mental status and symptom-oriented questions can be directed toward differential diagnosis. From the type of impairment of social functioning, it should be clear whether the problem is more of an externalizing (ie, oppositional disorder, conduct disorder, ADD), internalizing (depression, anxiety disorder), mixed disorder, developmental difficulty, or a response to a disordered social environment.5
In trying to clarify the existence of specific syndromes, certain principles are useful to follow:
1. If the child confirms the existence of certain symptoms, it is useful to ask how they have interfered with daily functioning.
2. It is often difficult for children to estimate the frequency and intensity of a symptom. The interviewer may approximate this by asking, "When was the last time this occurred?" and "What about the time before that?" and then estimate a frequency. One may estimate intensity of a symptom either by its interference with social functioning or by asking the child to compare his/her degree of symptomatology to other children in his/her class.
3. In order to aid the child in accurately estimating duration of symptomatology, the clinician may suggest comparison of onset of symptoms to temporal landmarks such as the child's birthday, holidays, or beginning and end of the school year.
4. Abstract descriptions of symptoms by school age children can be misleading. In order to ensure that the child and the interviewer are really discussing the same type of problem, it is helpful to ask, "Could you give me an example of that?"
The Role of Observation
Observation of the child is also useful in making the differential diagnosis, particularly if the child is unaware of the observer's presence.
Activity level in the waiting area is probably a more accurate reflection of the child's baseline than is his/ her behavior in the office. How does the child relate to other peers: cooperatively, aggressively, or not at all? How do the parent(s) and child interact? How does the child's mood and behavior change when separated from and reunited with his/her parents?
Observation in one's office is fraught with artifacts and the presence of a behavior probably carries more weight than its absence. The best example is the diagnosis of ADD. If the child is impulsive, distractible, and restless during the interview, he/she probably has the syndrome, but when faced with the absence of these symptoms in the office, the clinician will need to rely heavily on parent and teacher reports.
OTHER ASPECTS OF THE ASSESSMENT
A thorough medical history and physical examination should accompany every child psychiatric assessment. School reports and a psychoeducational assessment are also useful, particularly in any case where school problems play a role.
COMMON PROBLEMS IN DIFFERENTIAL DIAGNOSIS
One area of difficulty has to do with the distinction between depression and separation anxiety disorder. Children with pure separation anxiety disorder often appear dysphoric to the examiner, but this dysphoria should remit when the child is returned to his/her parents. 15 In children with a major or minor affective disorder, mood is not a function of proximity to parents. The examiner should be cautioned that separation anxiety disorder and depression can co-exist, but that when they do, the separation anxiety disorder is secondary to the affective disorder.16
The differential diagnosis between conduct disorder and ADD is problematic, and, in fact, some authors do not recognize the distinction between the two. l7 Others have argued that the two disorders are distinct but frequently co-exist.18,19 The hallmark of ADD is an inability to attend, as reported by classroom teachers, and observed in diagnostic settings and parents. Attentional problems show great situational variability. Children with ADD generally have more difficulty with attention in unstructured or group settings, and tend to do better with one-to-one instruction and structured situations. In children with pure conduct disorder, inattention may be volitional. If the two disorders co-exist, the history often suggests that the attentional problem antedated the onset of the disorder of conduct.19,20
Children with overanxious disorder may show some superficial resemblance to children with ADD. However, overanxious children are restricted rather than impulsive, and if their environment can be manipulated so as to reduce their anxiety, then inattention no longer will be a prominent part of their presentation. An important caveat: some children with ADD are also overanxious.
This article is meant to serve as an introduction to the psychiatric assessment of the school age child. For a more detailed discussion of this topic, the reader is referred to some basic21,22 and more advanced texts on child psychiatry.23,24
1. Rutter M, Tirard J, Whitmore K (eds): Education. Heakh and Behavior. London, Longman, 1970.
2. Lapouse R, Monk M: An epidemiologic study of behavior characteristics in children. AmJ Public Heakh 1958; 48:1 134-1144.
3. Shepherd M, Oppenheim B, Mitchell S: Childhood Behavior and Mental Health. London, University of London Press, 1966.
4. Rutter M: Prospective studies to investigate behavior change, in Strauss J. Babigian H, Martin J (eds): Methods of Longitudinal Research in Psychopathology. New York, Plenum, 1976.
5. Achenbach T, Edelbrock C: Behavioral problems and competencies reported by parents of normal and disturbed children aged 4 through 16. MonogrSoc Res Child Dev 1981.
6. Cowen E, ftderson A, Babigian H, et al: Long-term follow-up of early detected vulnerable children. J Consult CIm Psychol 1973; 41:438-446.
7. Sonis W, Costello A: Evaluation of differential data sources. Application of the diagnostic process in child psychiatry. J Am Acad Child Psychiatry 1981; 20:597-610.
8. Herjanic B, Herjanic M, Brown F, et at: Are children reliable reporters? J Abnorm Child Psychol 1975; 3(l):41-48.
9. Adams P; A Primer of Child Psychotherapy. Boston, Little-Brown. 1982.
10. Graham P, Rutter M: The reliability and validity of the psychiatric assessment of the child. H. Interview with the parent. Brit J Psychiatry 1968; 114:581-592.
11. Rutter M, Graham P: The reliability and validity of the psychiatric assessment of the child. I. Interview with the child. Brit J Psychiatry 1968; 114:563-579.
12. Rutter M, Martin ) (eds): The Child with Delayed Speech. London. SIMP/ Heinemann, 1972.
13. American Psychiatric Association, Diagnostic and Statistkal Manual of Mental Disorders, ed 3. Washington, DC, 1980.
14. Rutter M, Quinton D, Yule B: family Pathology and Disorder in Children. London. Wiley, 1977.
15. Gittelman-Klein R, Klein DF: Controlled Imipramine treatment of school phobia. Arch Gen Psychiatry 1971; 25:204-207.
16. Puig-Antich J, Blaus Marx N, et al: Prepubertal major depressive episode: Pilot study. J Am Acad ChM Psychiatry 1978; 17:695-707.
17. Shaffer D, Greenhill L: A critical note on the predictive validity of "The Hypergenetic Syndrome". J Child Psychol Psychiatry 1979; 20:61-72.
18. Stewart M, Cumming C, Singer S, et al: The overlap between hyperactive and unsocialized aggressive children. J Child Psychol Psychiatry 1981; 22:35-45.
19. Canrwell D: Hyperactivity and antisocial behavior. J Am Acad Child Psychiatry 1978; 17:252-262.
20. Satterfteld J, Cantwell D; Psychopharmacology in the prevention of antisocial delinquent behavior. International Journal J Mental Heakh. 1975; 4:227-237.
21. Simmons J: Psychiatric Examination of Children, ed 3. Philadelphia, Lea and Febiger, 1981.
22. Barker P: Bask Child Psychiatry, ed 4- Baltimore. MD, University Park Press, 1983.
23. Rutter M, Hersov L: ChUd Psychiatry: Modem Approaches. London, Blackwell, 1977.
24. Quay H , Werry J (eds): Psychopathologkal Disorders of Children. New York, Wiley, 1979.