Pediatric Annals

The Neuropsychiatric Assessment of the Adolescent

Dorothy Otnow Lewis, MD

Abstract

There are at least two myths regarding the nature and temperament of adolescents that often work to their disadvantage. The first is the myth that adolescence is normally a time of great psychological turmoil characterized by extreme rebelliousness and hostility toward parents. In fact, there was a time when psychiatrists believed that a lack of overt rebellion during the teenage years was an ominous sign for future maturation.1,2 More recent studies suggest that although a moderate degree of dysphoria and rebelliousness may be characteristic of some adolescents, the majority of young people remain close to their parents emotionally and even subscribe to most of their parent's standards and beliefs.3 Thus, when an adolescent is brought to see a psychiatrist because of adaptational difficulties at school, home, or in the community, in the words of Arthur Miller, "Attention must be paid."

The second myth surrounding adolescents is that they have an extraordinary need for privacy such that a doctor's contact with parents is likely to jeopardize the development of a therapeutic relationship. Although we all need a certain amount of privacy, most adolescents expect their parents to be involved in their treatment to at least some extent. It is rare for an adolescent living at home, dependent upon his parents, to refuse to allow the parents to speak to the clinician, especially during the diagnostic phase of the relationship. Any thorough assessment requires that the clinician interview and obtain relevant information from parents. In fact, the clinician will learn most if it is made a practice to interview each parent separately, since many issues will not be discussed when parents are seen together.

Should the adolescent or his parents be interviewed first? Again, there are no absolute rules for this situation. If the youngster is motivated to talk with the clinician, he or she may choose to be the first to be seen. On the other hand, disturbed adolescents may be reluctant to see a doctor, in which case parents may need to discuss the issues first and may need help getting the youngster to the office, clinic, or hospital. There are even instances when the first visits are held jointly with the parents and the adolescent. If the adolescent is seen first, the clinician must ask whether the youngster wishes any of the issues they have discussed to remain confidential. The patient will often allow the clinician to share all information, or may want a seemingly inconsequential event to remain secret.

Many adolescents who come for evaluation have had a variety of problems in the past. Often there have been previous evaluations and psychological testing. Much time will be saved if the clinician makes it a point to review all available materials including school reports and hospital records. The youngster's medical history is one of the most important pieces of information with which the clinician works because he or she will be continually sorting out the interaction between intrinsic biological predispositions and environmental factors.

Not only must all medical records be reviewed, but also a detailed medical history from the adolescent and his parents should be obtained. Adolescents are often good reporters and can even furnish information regarding their own birth histories (eg, "They said I almost died"). The clinician, of course, will pay special attention to events affecting the central nervous system, including accidents, injuries, loss of consciousness, dizziness, headaches, etc. We have found, over the course of time, that certain questions must be asked several times in several different ways if an accurate history is to be obtained. For example, many adolescents will deny ever having had a…

There are at least two myths regarding the nature and temperament of adolescents that often work to their disadvantage. The first is the myth that adolescence is normally a time of great psychological turmoil characterized by extreme rebelliousness and hostility toward parents. In fact, there was a time when psychiatrists believed that a lack of overt rebellion during the teenage years was an ominous sign for future maturation.1,2 More recent studies suggest that although a moderate degree of dysphoria and rebelliousness may be characteristic of some adolescents, the majority of young people remain close to their parents emotionally and even subscribe to most of their parent's standards and beliefs.3 Thus, when an adolescent is brought to see a psychiatrist because of adaptational difficulties at school, home, or in the community, in the words of Arthur Miller, "Attention must be paid."

The second myth surrounding adolescents is that they have an extraordinary need for privacy such that a doctor's contact with parents is likely to jeopardize the development of a therapeutic relationship. Although we all need a certain amount of privacy, most adolescents expect their parents to be involved in their treatment to at least some extent. It is rare for an adolescent living at home, dependent upon his parents, to refuse to allow the parents to speak to the clinician, especially during the diagnostic phase of the relationship. Any thorough assessment requires that the clinician interview and obtain relevant information from parents. In fact, the clinician will learn most if it is made a practice to interview each parent separately, since many issues will not be discussed when parents are seen together.

Should the adolescent or his parents be interviewed first? Again, there are no absolute rules for this situation. If the youngster is motivated to talk with the clinician, he or she may choose to be the first to be seen. On the other hand, disturbed adolescents may be reluctant to see a doctor, in which case parents may need to discuss the issues first and may need help getting the youngster to the office, clinic, or hospital. There are even instances when the first visits are held jointly with the parents and the adolescent. If the adolescent is seen first, the clinician must ask whether the youngster wishes any of the issues they have discussed to remain confidential. The patient will often allow the clinician to share all information, or may want a seemingly inconsequential event to remain secret.

Many adolescents who come for evaluation have had a variety of problems in the past. Often there have been previous evaluations and psychological testing. Much time will be saved if the clinician makes it a point to review all available materials including school reports and hospital records. The youngster's medical history is one of the most important pieces of information with which the clinician works because he or she will be continually sorting out the interaction between intrinsic biological predispositions and environmental factors.

Not only must all medical records be reviewed, but also a detailed medical history from the adolescent and his parents should be obtained. Adolescents are often good reporters and can even furnish information regarding their own birth histories (eg, "They said I almost died"). The clinician, of course, will pay special attention to events affecting the central nervous system, including accidents, injuries, loss of consciousness, dizziness, headaches, etc. We have found, over the course of time, that certain questions must be asked several times in several different ways if an accurate history is to be obtained. For example, many adolescents will deny ever having had a serious accident and then, when asked specifically about car or bicycle accidents, recall previously forgotten events. Similarly, the adolescent may deny any history of loss of consciousness, then report "spells" or "blackouts" or "falling out" episodes when asked in more specific terms.

The clinician will almost surely begin the interview by focusing on current concerns and reasons for referral. The interviewer can usually progress easily to questions regarding the family and then to a comprehensive family history. The history should not be limited to first degree relatives but should also include grandparents, aunts, uncles, and cousins. The discovery that close relatives suffer from specific partially heritable disorders such as bipolar illness or epilepsy may shed light on the nature of an adolescent's puzzling behavior.

In this country many adolescents are physically abused although few are eager to admit this fact. One technique for eliciting such information from the adolescent is to put parental behaviors in the context of the youngsters behaviors (eg, "When you do something your dad doesn't approve of, what happens? Does he ever lose his cool? What's the worst that has happened to you?"). Similarly, the parent can be approached with: "1 know your son can really be hard to manage. Does he ever make you lose your cool? Have you ever gone further than you intended? What happened?"

Aggressive behavior is probably the most common reason for which an adolescent is brought for evaluation. Therefore, the nature of this aggression must be explored in detail. How quickly does anger begin? Is it predictable? Can the anger always be stopped? What happens after a fight? Is everything done or said remembered? It is too easy, otherwise, to dismiss the adolescent's behavior as an understandable response to a poor social environment or to extreme family conflict. Although both of these factors affect behavior, they often do not explain it entirely. The clinician who fails to determine the nature and periodicity of aggressive outbursts may overlook underlying mood disorder, organic dysfunction, or psychotic mispetceptions and paranoia.

The interpretation of aggressive behavior raises important issues of diagnostic prejudice. In an effort to appear psychologically sophisticated, the clinician may dismiss the adolescent's assaultive behavior as developmentally or socioculturally normal. This misconception is most likely to occur in the case of socioeconomically deprived, minority youngsters. Most adolescents, White, Black, or Hispanic, are not recurrently aggressive. In no culture is it acceptable to curse at teachers. The minority youngster deserves as careful an assessment of socially maladaptive behaviors as does a White counterpart.

Sometimes aggressive behaviors occur in the context of a mood disorder. For example, certain adolescents drive fast, insult teachers, and pick fights during manic episodes. Chronic irritability and suspiciousness often accompany depression. Since both suicide and homicide are among the major causes of death in the adolescent population, the potential for both must always be assessed. Furthermore, the difference between a gesture and an act may be two extra pills or a quarter of an inch of flesh

School is probably the most likely environment in which maladaptive behaviors come to light. A review of school records or a discussion with school counselors may save hours of interviewing. Has the adolescent always done poorly, or are the difficulties of more recent onset? Are there specific subjects that have always posed problems, in contrast to others in which the youngster does well?

How intelligent is the adolescent? When evaluating the intelligence of minority youngsters one again runs the risk of dismissing academic difficulty or low scores on intelligence tests as merely signs of cultural deprivation that have no implications for social functioning. Unfortunately this attitude leaves many learning disabled and mildly retarded adolescents to function as best they can without the benefit of the special educational programs they may need. In other words, the clinician must beware of the tendency to exercise a double standard for the diagnosis and treatment of adolescents from different racial or ethnic backgrounds.

One of the most awkward yet essential parts of an evaluation is the mental status examination. It is an art to weave aspects of this assessment into the fabric of the rest of an interview. Nevertheless, we have found that responses to certain tasks such as subtracting serial 7's and remembering 5 digits backward may be the first solid evidence of central nervous system dysfunction or extreme anxiety. The failure to calculate in one's head or recall digits backward are in a way psychiatric soft signs. They are not diagnostic of a specific disorder but rather indicative of a variety of possibilities.

The most difficult aspect of any mental status assessment is the determination of the presence or absence of hallucinations. Adolescents are extremely fearful of being thought crazy and if simply asked about hearing voices or seeing things that are not there, they are likely to deny both experiences. On the other hand, if these areas are covered in the context of a medical history, the adolescent is far more likely to respond openly. For example, after discussing the problem symptoms and situations that brought the youngster to treatment one can, as it were, change gears, saying, "Now I'd like to ask you some other questions about your health. Do you ever get headaches? etc. . " In this context it is appropriate to inquire, "Have you ever had earaches? How were they treated? Have your ears ever played tricks on you? Have you ever had the experience of thinking that someone said something bad about you or your mother and you turn around and find you were mistaken?" In the context of wearing glasses, the interviewer will be comfortable asking whether the patient's eyes ever played tricks on him. Similarly, inquiries about nosebleeds and colds can introduce the question of olfactory hallucinations.

The style of interview described, with its matter-offact ways of posing questions, often elicits surprising information. It is, therefore, essential that the interviewer appreciate the sensitivity of material that may never before have been discussed by the adolescent. When asked whether these kinds of symptoms have ever been talked about before, the answer will often be, "No - I thought people would think I was crazy. " At this time the youngster needs reassurance that no matter what his symptoms, he is not "crazy" and that many people have complained of similar experiences. The interviewer can usually add with honesty that the symptoms can be treated so that the youngster will not be as troubled by them.

Even the most meticulous psychiatric assessment may not bring to light evidence of subtle organic, psychological, and intellectual dysfunction which can be tapped through neuropsychological testing. Often a neurological assessment and electroencephalogram will prove useful, although in our experience neuropsychological testing is often more sensitive than routine neurological examination. There is a certain danger, however, inherent in requesting additional special evaluations. The danger lies in the unfounded assumption that since a neurologist, psychologist, or pediatrician will be examining the adolescent, particular areas of inquiry can be left to them. The pediatrician may be not only the primary responsible physician but also the clinician with whom the adolescent and his family have the greatest contact. It is therefore up to him or her to make certain that all useful areas of investigation are pursued. The dangers of misdiagnosis are probably greatest for adolescents because so many different kinds of disorders, ranging from attention deficit disorder to psychosis, manifest themselves in similar ways, namely school difficulties, friction within the family, and antisocial behavior in the community. The conscientious clinician will therefore resist the temptation to dismiss the adolescent prematurely as suffering from a "conduct disorder." More often than not he or she will discover that the adolescent patient has a multiplicity of different kinds of vulnerabilities which do not fit neatly into a DSMAIl category but each of which is amenable to therapeutic intervention.

REFERENCES

1. Geleerd ER; Some aspects of psychoanalytic technique in adolescence. Psychoetud Study Child 1961; 12:263-283.

2. Freud A: Adolescence. Psychoand Study Child 1958; 13:255-278,

3. Rutter M, Graham P, Chadwick O, et al: Adolescent turmoil: Fact or fiction?; Child Psychol Psychiatry 1976; 17:35-56.

10.3928/0090-4481-19850501-07

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