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Child Psychiatry: Assessment, Examination, and Psychological Testing

Psychiatric assessment of a child or adolescent includes identifying the reasons for referral; assessing the nature and extent of the child's psychological and behavioral difficulties; and determining family, school, social, and developmental factors that may be influencing the child's emotional well-being.

A comprehensive evaluation of a child is composed of interviews with the parents, the child, and other family members; gathering information regarding the child's current school functioning; and often, a standardized assessment of the child's intellectual level and academic achievement. In some cases, standardized measures of developmental level and neuropsychological assessments are useful. Psychiatric evaluations of children are rarely initiated by the child, so clinicians must obtain information from the family and the school to understand the reasons for the evaluation. In some cases, the court or a child protective service agency may initiate a psychiatric evaluation. Children can be excellent informants about symptoms related to mood and inner experiences, such as psychotic phenomena, sadness, fears, and anxiety, but they often have difficulty with the chronology of symptoms and are sometimes reticent about reporting behaviors that have gotten them into trouble. Very young children often cannot articulate their experiences verbally and do better showing their feelings and preoccupations in a play situation.

The first step in the comprehensive evaluation of a child or adolescent is to obtain a full description of the current concerns and a history of the child's previous psychiatric and medical problems. This is often done with the parents for school-aged children, whereas adolescents may be seen alone first, to get their perception of the situation. Direct interview and observation of the child is usually next, followed by psychological testing, when indicated.

Clinical interviews offer the most flexibility in understanding the evolution of problems and in establishing the role of environmental factors and life events, but they may not systematically cover all psychiatric diagnostic categories. To increase the breadth of information generated, the clinician may use semistructured interviews such as the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS); structured interviews such as the National Institute for Mental Health Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV); and rating scales, such as the Child Behavior Checklist and Connors Parent or Teacher Rating Scale for ADHD.

It is not uncommon for interviews from different sources, such as parents, teachers, and school counselors, to reflect different or even contradictory information about a given child. When faced with conflictual information, the clinician must determine whether apparent contradictions actually reflect an accurate picture of the child in different settings. Once a complete history is obtained from the parents, the child is examined, the child's current functioning at home and at school is assessed, and psychological testing is completed, the clinician can use all the available information to make a best-estimate diagnosis and can then make recommendations.

Once clinical information is obtained about a given child or adolescent, it is the clinician's task to determine whether criteria are met for one or more psychiatric disorder according to the text revision of the 4th edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR). This most current version is a categorical classification reflecting the consensus on constellations of symptoms believed to comprise discrete and valid psychiatric disorders. Psychiatric disorders are defined by the DSM-IV-TR as a clinically significant set of symptoms that is associated with impairment in one or more areas of functioning. Whereas clinical situations requiring intervention do not always fall within the context of a given psychiatric disorder, the importance of identifying psychiatric disorders when they arise is to facilitate meaningful investigation of childhood psychopathology.

Clinical Interviews

To conduct a useful interview with a child of any age, clinicians must be familiar with normal development to place the child's responses in the proper perspective. For example, a young child's discomfort on separation from a parent and a school-age child's lack of clarity about the purpose of the interview are both perfectly normal and should not be misconstrued as psychiatric symptoms. Furthermore, behavior that is normal in a child at one age, such as temper tantrums in a 2-year-old, takes on a different meaning, for example, in a 17-year-old.

The interviewer's first task is to engage the child and develop a rapport so that the child is comfortable. The interviewer should inquire about the child's concept of the purpose of the interview and should ask what the parents have told the child. If the child

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appears to be confused about the reason for the interview, the examiner may opt to summarize the parents' concerns in a developmentally appropriate and supportive manner. During the interview with the child, the clinician seeks to learn about the child's relationships with family members and peers, academic achievement and peer relationships in school, and the child's pleasurable activities. An estimate of the child's cognitive functioning is a part of the mental status examination.

The extent of confidentiality in child assessment is correlated with the age of the child. In most cases, almost all specific information can appropriately be shared with the parents of a very young child, whereas privacy and permission of an older child or adolescent are mandated before sharing information with parents. School-age and older children are informed that if the clinician becomes concerned that any child is dangerous to himself or herself or to others, this information must be shared with parents and, at times, additional adults. As part of a psychiatric assessment of a child of any age, the clinician must determine whether that child is safe in his or her environment and must develop an index of suspicion about whether the child is a victim of abuse or neglect. Whenever there is a suspicion of child maltreatment, the local child protective service agency must be notified.

Toward the end of the interview, the child may be asked in an open-ended manner whether he or she would like to bring up anything else. Each child should be complimented for his or her cooperation and thanked for participating in the interview, and the interview should end on a positive note.

Infants and Young Children

Assessments of infants usually begin with the parents present, because very young children may be frightened by the interview situation; the interview with the parents present also allows the clinician to assess the parent–infant interaction. Infants may be referred for a variety of reasons, including high levels of irritability, difficulty being consoled, eating disturbances, poor weight gain, sleep disturbances, withdrawn behavior, lack of engagement in play, and developmental delay. The clinician assesses areas of functioning that include motor development, activity level, verbal communication, ability to engage in play, problem-solving skills, adaptation to daily routines, relationships, and social responsiveness.

The child's developmental level of functioning is determined by combining observations made during the interview with standardized developmental measures. Observations of play reveal a child's developmental level and reflect the child's emotional state and preoccupations. The examiner can interact with an infant age 18 months or younger in a playful manner by using such games as peek-a-boo. Children between the ages of 18 months and 3 years can be observed in a playroom. Children ages 2 years or older may exhibit symbolic play with toys, revealing more in this mode than through conversation. The use of puppets and dolls with children under 6 years of age is often an effective way to elicit information, especially if questions are directed to the dolls, rather than to the child.

School-Age Children

Some school-age children are at ease when conversing with an adult; others are hampered by fear, anxiety, poor verbal skills, or oppositional behavior. School-age children can usually tolerate a 45-minute session. The room should be sufficiently spacious for the child to move around, but not so large as to reduce intimate contact between the examiner and the child. Part of the interview can be reserved for unstructured play, and various toys can be made available to capture the child's interest and to elicit themes and feelings. Children in lower grades may be more interested in the toys in the room, whereas by the sixth grade, children may be more comfortable with the interview process and less likely to show spontaneous play.

The initial part of the interview explores the child's understanding of the reasons for the meeting. The clinician should confirm that the interview was not set up because the child is “in trouble” or as a punishment for “bad” behavior. Techniques that can facilitate disclosure of feelings include asking the child to draw peers, family members, a house, or anything else that comes to mind. The child can then be questioned about the drawings. Children may be asked to reveal three wishes, to describe the best and worst events of their lives, and to name a favorite person to be stranded with on a desert island. Games such as Donald W. Winnicott's “squiggle,” in which the examiner draws a curved line and then the child and the examiner take turns continuing the drawing, may facilitate conversation.

Questions that are partially open-ended with some multiple choices may elicit the most complete answers from school-age children. Simple, closed (yes or no) questions may not elicit sufficient information, and completely open-ended questions can overwhelm a school-age child who cannot construct a chronological narrative. These techniques often result in a shoulder shrug from the child. The use of indirect commentary—such as, “I once knew a child who felt very sad when he moved away from all his friends”—is helpful, although the clinician must be careful not to lead the child into confirming what the child thinks the clinician wants to hear. School-age children respond well to clinicians who help them compare moods or feelings by asking them to rate feelings on a scale of 1 to 10.

Adolescents

Adolescents usually have distinct ideas about why the evaluation was initiated, and can usually give a chronological account of the recent events leading to the evaluation, although some may disagree with the need for the evaluation. The clinician should clearly communicate the value of hearing the story from an adolescent's point of view and must be careful to reserve judgment and not assign blame. Adolescents may be concerned about confidentiality, and clinicians can assure them that permission will be requested from them before any specific information is shared with parents, except situations involving danger to the adolescent or others, in which case confidentiality must be sacrificed. Adolescents can be approached in an open-ended manner; however, when silences occur during the interview, the clinician should attempt to reengage the patient. Clinicians can explore what the adolescent believes the outcome of the evaluation will be (change of school, hospitalization, removal from home, removal of privileges).

Some adolescents approach the interview with apprehension or hostility, but open up when it becomes evident that the clinician is neither punitive nor judgmental. Clinicians must be aware of their own responses to adolescents' behavior

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(countertransference) and stay focused on the therapeutic process even in the face of defiant, angry, or difficult teenagers. Clinicians should set appropriate limits and should postpone or discontinue an interview if they feel threatened or if patients become destructive to property or engage in self-injurious behavior. Every interview should include an exploration of suicidal thoughts, assaultive behavior, psychotic symptoms, substance use, and knowledge of safe sexual practices along with a sexual history. Once rapport has been established, many adolescents appreciate the opportunity to tell their side of the story and may reveal things that they have not disclosed to anyone else.

Family Interview

An interview with parents and the patient may take place first or may occur later in the evaluation. Sometimes, an interview with the entire family, including siblings, can be enlightening. The purpose is to observe the attitudes and behavior of the parents toward the patient and the responses of the children to their parents. The clinician's job is to maintain a nonthreatening atmosphere in which each member of the family can speak freely without feeling that the clinician is taking sides with any particular member. Although child psychiatrists generally function as advocates for the child, the clinician must validate each family member's feelings in this setting, because lack of communication often contributes to the patient's problems.

Parents

The interview with the patient's parents or caretakers is necessary to get a chronological picture of the child's growth and development. A thorough developmental history and details of any stressors or important events that have influenced the child's development must be elicited. The parents' view of the family dynamics, their marital history, and their own emotional adjustment are also elicited. The family's psychiatric history and the upbringing of the parents are pertinent. Parents are usually the best informants about the child's early development and previous psychiatric and medical illnesses. They may be better able to provide an accurate chronology of past evaluations and treatment. In some cases, especially with older children and adolescents, the parents may be unaware of significant current symptoms or social difficulties of the child. Clinicians elicit the parents' formulation of the causes and nature of their child's problems and ask about expectations about the current assessment.

Diagnostic Instruments

The two main types of diagnostic instruments used by clinicians and researchers are diagnostic interviews and questionnaires. Diagnostic interviews are administered to either children or their parents and are often designed to elicit sufficient information on numerous aspects of functioning to determine whether criteria are met from the DSM-IV-TR.

Semistructured interviews, or “interviewer-based” interviews, such as K-SADS and the Child and Adolescent Psychiatric Assessment (CAPA) serve as guides for the clinician. They help the clinician clarify answers to questions about symptoms. Structured interviews, or “respondent-based” interviews, such as NIMH DISC-IV, the Children's Interview for Psychiatric Syndromes (ChIPS), and the Diagnostic Interview for Children and Adolescents (DICA), basically provide a script for the interviewer without interpretation of the subject's responses. Two other diagnostic instruments use pictures, the Dominic-R and the Pictorial Instrument for Children and Adolescents (PICA-III-R). These instruments use pictures as cues, along with an accompanying question to elicit information about symptoms, especially for young children as well as for adolescents.

Diagnostic instruments aid the collection of information in a systematic way. Diagnostic instruments, even the most comprehensive, however, cannot replace clinical interviews, because clinical interviews are superior in understanding the chronology of symptoms, the interplay between environmental stressors and emotional responses, and developmental issues. Clinicians often find it helpful to combine the data from diagnostic instruments with clinical material gathered in a comprehensive evaluation.

Questionnaires can cover a broad range of symptom areas, such as the Achenbach Child Behavior Checklist, or they can be focused on a particular type of symptomatology and are often called rating scales, such as the Connors Parent Rating Scale for ADHD.

Semistructured Diagnostic Interviews

Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children

The K-SADS can be used for children from 6 years to 18 years of age. It presents multiple items with some space for further clarification of symptoms. It elicits information on current diagnosis and on symptoms present in the previous year. Another version can also ascertain lifetime diagnoses. It assesses diagnoses according to DSM-IV-TR. This instrument has been used extensively, especially in evaluation of mood disorders, and includes measures of impairment caused by symptoms. The schedule comes in a form for parents to give information about their child and in a version for use directly with the child. The schedule takes about 1 to 1.5 hours to administer. The interviewer should have some training in the field of child psychiatry, but need not be a psychiatrist.

Child and Adolescent Psychiatric Assessment

The CAPA is an “interviewer-based” instrument that can be used for children from 9 to 17 years of age. It comes in modular form so that certain diagnostic entities can be administered without having to give the entire interview. It covers disruptive behavior disorders, mood disorders, anxiety disorders, eating disorders, sleep disorders, elimination disorders, substance use disorders, tic disorders, schizophrenia, posttraumatic stress disorder, and somatization symptoms. It focuses on the 3 months before the interview, called the “primary period.” In general, it takes about 1 hour to administer. It has a glossary to aid in decision-making regarding symptoms and provides separate ratings of presence and severity of symptoms. It can be used to determine diagnoses according to the fourth edition of DSM (DSM-IV), the revised third edition of DSM (DSM-III-R), or the tenth revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10). Training is necessary to administer this interview, and the interviewer must be prepared to use some clinical judgment in interpreting elicited symptoms.

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Structured Diagnostic Interviews

National Institute of Mental Health Interview Schedule for Children Version IV

The NIMH DISC-IV is a highly structured interview designed to assess more than 30 DSM-IV diagnostic entities administered by trained “laypersons.” It is available in parallel child and parent forms. The parent form can be used for children from 6 to 17 years of age, and the direct child form of the instrument was designed for children from 9 to 17 years of age. It is applicable for a multitude of diagnoses keyed to DSM-IV-TR. A computer scoring algorithm is available. This instrument assesses the presence of diagnoses that have been present within the last 4 weeks, and also within the last year. Because it is a fully structured interview, the instructions serve as a complete guide for the questions, and the examiner need not have any knowledge of child psychiatry to administer the interview correctly.

Children's Interview for Psychiatric Syndromes

The ChIPS is a highly structured interview designed for use by trained interviewers with children from 6 to 18 years of age. It is composed of 15 sections, and it elicits information on psychiatric symptoms as well as psychosocial stressors targeting 20 psychiatric disorders, according to DSM-IV criteria. There are parent and child forms. It takes approximately 40 minutes to administer the ChIPS. Diagnoses covered include depression, mania, attention-deficit/hyperactivity disorder (ADHD), separation disorder, obsessive-compulsive disorder (OCD), conduct disorder, substance use disorder, anorexia, and bulimia. The ChIPS was designed for use as a screening instrument for clinicians and a diagnostic instrument for clinical and epidemiological research.

Diagnostic Interview for Children and Adolescents

The current version of the DICA was developed in 1997 to assess information resulting in diagnoses according to either DSM-IV or DSM-III-R. Although it was originally designed to be a highly structured interview, it can now be used in a semistructured format. This means that, although interviewers are allowed to use additional questions and probes to clarify elicited information, the method of probing is standardized so that all interviewers will follow a specific pattern. When using the interview with younger children, more flexibility is built in, allowing interviewers to deviate from written questions to ensure that the child understands the question. Parent and child interviews are expected to be used. It covers children 6 to 17 years of age and generally takes 1 to 2 hours to administer. It covers externalizing behavior disorders, anxiety disorders, depressive disorders, and substance abuse disorders, among others.

Pictorial Diagnostic Instruments

Dominic-R

The Dominic-R is a pictorial, fully structured interview designed to elicit psychiatric symptoms from children 6 to 11 years of age. The pictures illustrate abstract emotional and behavioral content of diagnostic entities according to DSM-III-R. The instrument uses a picture of a child called “Dominic” who is experiencing the symptom in question. Some symptoms have more than one picture, with a brief story that is read to the child. Along with each picture is a sentence asking about the situation being shown and asking the child if he or she has experiences similar to the one that Dominic is having. Diagnostic entities covered by the Dominic-R include separation anxiety, generalized anxiety, depression and dysthymia, ADHD, oppositional defiant disorder, conduct disorder, and specific phobia. Although symptoms of the above diagnoses can be fully elicited from the Dominic-R, no specific provision within the instrument inquires about frequency of the symptom, duration, or age of onset. The paper version of this interview takes about 20 minutes, and the computerized version of this instrument takes about 15 minutes. Trained lay-interviewers can administer this interview. Computerized versions of this interview are available with pictures of a child who is white, black, Latino, or Asian.

Pictorial Instrument for Children and Adolescents

PICA-III-R is composed of 137 pictures organized in modules and designed to cover five diagnostic categories, including disorders of anxiety, mood, psychosis, disruptive disorders, and substance use disorder. It is designed to be administered by clinicians and can be used for children and adolescents ranging from 6 to 16 years of age. It provides a categorical (diagnosis present or absent) and a dimensional (range of severity) assessment. This instrument presents pictures of a child experiencing emotional, behavioral, and cognitive symptoms. The child is asked, “How much are you like him/her?” and a five-point rating scale with pictures of a person with open arms in increasing degrees is shown to the child to help him or her identify the severity of the symptoms. It takes about 40 minutes to 1 hour to administer the interview. This instrument is currently keyed to DSM-III-R. It can be used to aid in clinical interviews and in research diagnostic protocols.

Questionnaires and Rating Scales

Achenbach Child Behavior Checklist

The parent and teacher versions of the Achenbach Child Behavior Checklist were developed to cover a broad range of symptoms and several positive attributes related to academic and social competence. The checklist presents items related to mood, frustration tolerance, hyperactivity, oppositional behavior, anxiety, and various other behaviors. The parent version consists of 118 items to be rated 0 (not true), 1 (sometimes true), or 2 (very true). The teacher version is similar, but without the items that apply only to home life. Profiles were developed based on normal children of three different age groups (4 to 5, 6 to 11, and 12 to 16).

Such a checklist identifies specific problem areas that might otherwise be overlooked, and it may point out areas in which the child's behavior deviates from that of normal children of the same age group. The checklist is not used specifically to make diagnoses.

Revised Achenbach Behavior Problem Checklist

Consisting of 150 items that cover a variety of childhood behavioral and emotional symptoms, the Revised Achenbach Behavior Problem Checklist discriminates between clinic-referred and nonreferred children. Separate subscales have been found to correlate in the appropriate direction with other measures of intelligence, academic achievement, clinical observations, and

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peer popularity. As with the other broad rating scales, this instrument can help elicit a comprehensive view of a multitude of behavioral areas, but it is not designed to make psychiatric diagnoses.

Connors Abbreviated Parent-Teacher Rating Scale for ADHD

In its original form, the Connors Abbreviated Parent-Teacher Rating Scale for ADHD consisted of 93 items rated on a 0 to 3 scale and was subgrouped into 25 clusters, including problems with restlessness, temper, school, stealing, eating, and sleeping. Over the years, multiple versions of this scale were developed and used to aid in systematic identification of children with ADHD. A highly abbreviated form of this rating scale, the Connors Abbreviated Parent-Teacher Questionnaire, was developed for use with both parents and teachers by Keith Connors in 1973. It consists of ten items that assess both hyperactivity and inattention.

Brief Impairment Scale

A newly validated 23-item instrument suitable to obtain information on children ranging from 4 years to 17 years, the Brief Impairment Scale (BIS) evaluates three domains of functioning: interpersonal relations, school/work functioning, and care/self-fulfillment. This scale is administered to an adult informant about his or her child, does not take long to administer, and provides a global measure of impairment along the above three dimensions. This scale cannot be used to make clinical decisions on individual patients, but it can provide information on the degree of impairment that a given child is experiencing in a certain area.

Components of the Child Psychiatric Evaluation

Psychiatric evaluation of a child includes a description of the reason for the referral, the child's past and present functioning, and any test results. An outline of the evaluation is given in Table 37-1.

Identifying Data

To understand the clinical problems to be evaluated, the clinician must first identify the patient and keep in mind the family constellation surrounding the child. The clinician must also pay attention to the source of the referral—that is, whether it is the child's family, school, or another agency—because this influences the family's attitude toward the evaluation. Finally, many informants contribute to the child's evaluation, and each must be identified to gain insight into the child's functioning in different settings.

History

A comprehensive history contains information about the child's current and past functioning, from the child's report, from clinical and structured interviews with the parents, and from information from teachers and previous treating clinicians. The chief complaint and the history of the present illness are generally obtained from both the child and the parents. Naturally, the child will articulate the situation according to his or her developmental level. The developmental history is more accurately obtained from the parents. Psychiatric and medical histories, current physical examination findings, and immunization histories can be augmented with reports from psychiatrists and pediatricians who have treated the child in the past. The child's report is critical in understanding the current situation regarding peer relationships and adjustment to school. Adolescents are the best informants regarding knowledge of safe sexual practices, drug or alcohol use, and suicidal ideation. The family's psychiatric and social histories, and family function are best obtained from the parents.

Table 37-1 Child Psychiatric Evaluation

Identifying data Identified patient and family members Source of referral Informants History Chief complaint History of present illness Developmental history and milestones Psychiatric history Medical history, including immunizations Family social history and parents' marital status Educational history and current school functioning Peer relationship history Current family functioning Family psychiatric and medical histories Current physical examination Mental status examination Neuropsychiatric examination (when applicable) Developmental, psychological, and educational testing Formulation and summary DSM-IV-TR diagnosis Recommendations and treatment plan DSM-IV-TR, text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Mental Status Examination

A detailed description of the child's current mental functioning can be obtained through observation and specific questioning. An outline of the mental status examination is presented in Table 37-2. Table 37-3 lists components of a comprehensive neuropsychiatry mental status.

Table 37-2 Mental Status Examination for Children
Physical appearance Parent–child interaction Separation and reunion Orientation to time, place, and person Speech and language Mood Affect Thought process and content Social relatedness Motor behavior Cognition Memory Judgment and insight

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Table 37-3 Neuropsychiatric Mental Status Examination*

General Description General appearance and dress Level of consciousness and arousal Attention to environment Posture (standing and seated) Gait Movements of limbs, trunk, and face (spontaneous, resting, and after instruction) General demeanor (including evidence of responses to internal stimuli) Response to examiner (eye contact, cooperation, ability to focus on interview process) Native or primary language Language and Speech Comprehension (words, sentences, simple and complex commands, and concepts) Output (spontaneity, rate, fluency, melody or prosody, volume, coherence, vocabulary, paraphasic errors, complexity of usage) Repetition Other aspects Object naming Color naming Body part identification Ideomotor praxis to command Thought Form (coherence and connectedness) Content Ideational (preoccupations, overvalued ideas, delusions) Perceptual (hallucinations) Mood and Affect Internal mood state (spontaneous and elicited; sense of humor) Future outlook Suicidal ideas and plans Demonstrated emotional status (congruence with mood) Insight and Judgment Insight Self-appraisal and self-esteem Understanding of current circumstances Ability to describe personal psychological and physical status Judgment Appraisal of major social relationships Understanding of personal roles and responsibilities Cognition Memory Spontaneous (as evidenced during interview) Tested (incidental, immediate repetition, delayed recall, cued recall, recognition; verbal, nonverbal; explicit, implicit) Visuospatial skills Constructional ability Mathematics Reading Writing Fine sensory function (stereognosis, graphesthesia, two-point discrimination) Finger gnosis Right-left orientation “Executive functions” Abstraction *Questions should be adapted to the age of the child. Courtesy of Eric D. Caine, M.D., and Jeffrey M. Lyness, M.D.

Physical Appearances

The examiner should document the child's size, grooming, nutritional state, bruising, head circumference, physical signs of anxiety, facial expressions, and mannerisms.

Parent–Child Interaction

The examiner can observe the interactions between parents and child in the waiting area before the interview and in the family session. The manner in which parents and child converse and the emotional overtones are pertinent.

Separation and Reunion

The examiner should note both the manner in which the child responds to the separation from a parent for an individual interview and the reunion behavior. Either lack of affect at separation and reunion or severe distress on separation or reunion can indicate problems in the parent–child relationship or other psychiatric disturbances.

Orientation to Time, Place, and Persons

Impairments in orientation can reflect organic damage, low intelligence, or a thought disorder. The age of the child must be kept in mind, however, because very young children are not expected to know the date, other chronological information, or the name of the interview site.

Speech and Language

The examiner should evaluate the child's speech and language acquisition. Is it appropriate for the child's age? A disparity between expressive language usage and receptive language is notable. The examiner should also note the child's rate of speech, rhythm, latency to answer, spontaneity of speech, intonation, articulation of words, and prosody. Echolalia, repetitive stereotypical phrases, and unusual syntax are important psychiatric findings. Children who do not use words by age 18 months or who do not use phrases by age 2.5 to 3 years, but who have a history of normal babbling and responding appropriately to nonverbal cues, are probably developing normally. The examiner should consider the possibility that a hearing loss is contributing to a speech and language deficit.

Mood

A child's sad expression, lack of appropriate smiling, tearfulness, anxiety, euphoria, and anger are valid indicators of mood, as are verbal admissions of feelings. Persistent themes in play and fantasy also reflect the child's mood.

Affect

The examiner should note the child's range of emotional expressivity, appropriateness of affect to thought content, ability to move smoothly from one affect to another, and sudden labile emotional shifts.

Thought Process and Content

In evaluating a thought disorder in a child, the clinician must always consider what is developmentally expected for the child's age and what is deviant for any age group. The evaluation of thought form considers loosening of associations, excessive magical thinking, perseveration, echolalia, the ability to distinguish fantasy from reality, sentence coherence, and the ability to reason logically. The evaluation of thought content considers delusions, obsessions, themes, fears, wishes, preoccupations, and interests.

Suicidal ideation is always a part of the mental status examination for children who are sufficiently verbal to understand the

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questions and old enough to understand the concept. Children of average intelligence more than 4 years of age usually have some understanding of what is real and what is make-believe and may be asked about suicidal ideation, although a firm concept of the permanence of death may not be present until several years later.

Aggressive thoughts and homicidal ideation are assessed here. Perceptual disturbances, such as hallucinations, are also assessed. Very young children are expected to have short attention spans and may change the topic and conversation abruptly without exhibiting a symptomatic flight of ideas. Transient visual and auditory hallucinations in very young children do not necessarily represent major psychotic illnesses, but they do deserve further investigation.

Social Relatedness

The examiner assesses the appropriateness of the child's response to the interviewer, general level of social skills, eye contact, and degree of familiarity or withdrawal in the interview process. Overly friendly or familiar behavior may be as troublesome as are extremely retiring and withdrawn responses. The examiner assesses the child's self-esteem, general and specific areas of confidence, and success with family and peer relationships.

Motor Behavior

The motor behavior part of the mental status examination includes observations of the child's coordination and activity level and ability to pay attention and carry out developmentally appropriate tasks. It also involves involuntary movements, tremors, motor hyperactivity, and any unusual focal asymmetries of muscle movement.

Cognition

The examiner assesses the child's intellectual functioning and problem-solving abilities. An approximate level of intelligence can be estimated by the child's general information, vocabulary, and comprehension. For a specific assessment of the child's cognitive abilities, the examiner can use a standardized test.

Memory

School-age children should be able to remember three objects after 5 minutes and to repeat five digits forward and three digits backward. Anxiety can interfere with the child's performance, but an obvious inability to repeat digits or to add simple numbers may reflect brain damage, mental retardation, or learning disabilities.

Judgment and Insight

The child's view of the problems, reactions to them, and suggested solutions may give the clinician a good idea of the child's judgment and insight. In addition, the child's understanding of what he or she can realistically do to help and what the clinician can do adds to the assessment of the child's judgment.

Neuropsychiatric Assessment

A neuropsychiatric assessment is appropriate for children who are suspected of having a neurological disorder, a psychiatric impairment that coexists with neurological signs, or psychiatric symptoms that may be caused by neuropathology. The neuropsychiatric evaluation combines information from neurological, physical, and mental status examinations. The neurological examination can identify asymmetrical abnormal signs (hard signs) that may indicate lesions in the brain. A physical examination can evaluate the presence of physical stigmata of particular syndromes in which neuropsychiatric symptoms or developmental aberrations play a role (e.g., fetal alcohol syndrome, Down syndrome).

An important part of the neuropsychiatric examination is the assessment of neurological soft signs and minor physical anomalies. The term neurological soft signs was first noted by Loretta Bender in the 1940s in reference to nondiagnostic abnormalities in the neurological examinations of children with schizophrenia. Soft signs do not indicate focal neurological disorders, but they are associated with a wide variety of developmental disabilities and occur frequently in children with low intelligence, learning disabilities, and behavioral disturbances. Soft signs may refer to both behavioral symptoms (which are sometimes associated with brain damage, such as severe impulsivity and hyperactivity), physical findings (including contralateral overflow movements), and a variety of nonfocal signs (e.g., mild choreiform movements, poor balance, mild incoordination, asymmetry of gait, nystagmus, and the persistence of infantile reflexes). Soft signs can be divided into those that are normal in a young child, but become abnormal when they persist in an older child, and those that are abnormal at any age. The Physical and Neurological Examination for Soft Signs (PANESS) is an instrument used with children up to the age of 15 years. It consists of 15 questions about general physical status and medical history and 43 physical tasks (e.g., touch your finger to your nose, hop on one foot to the end of the line, tap quickly with your finger). Neurological soft signs are important to note, but they are not useful in making a specific psychiatric diagnosis.

Minor physical anomalies or dysmorphic features occur with a higher than usual frequency in children with developmental disabilities, learning disabilities, speech and language disorders, and hyperactivity. As with soft signs, the documentation of minor physical anomalies is part of the neuropsychiatric assessment, but it is rarely helpful in the diagnostic process and does not imply a good or bad prognosis. Minor physical anomalies include a high-arched palate, epicanthal folds, hypertelorism, low-set ears, transverse palmar creases, multiple hair whorls, a large head, a furrowed tongue, and partial syndactyl of several toes.

When a seizure disorder is being considered in the differential diagnosis or a structural abnormality in the brain is suspected, an electroencephalogram (EEG), computed tomography (CT), or magnetic resonance imaging (MRI) may be indicated.

Developmental, Psychological, and Educational Testing

Psychological tests are not always required to assess psychiatric symptoms, but they are valuable in determining a child's developmental level, intellectual functioning, and academic difficulties. A measure of adaptive functioning (including the child's competence in communication, daily living skills, socialization, and motor skills) is a prerequisite when a diagnosis of mental retardation is being considered. Table 37-4 outlines the general categories of psychological tests.

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Table 37-4 Commonly Used Child and Adolescent Psychological Assessment Instruments

Test Age/Grades Data Generated and Comments Intellectual ability Wechsler Intelligence Scale for Children—Third Edition (WISC-III-R) 6–16 Standard scores: verbal, performance and full-scale IQ; scaled subtest scores permitting specific skill assessment. Wechsler Adult Intelligence Scale—(WAIS-III) 16–adult Same as WISC-III-R. Wechsler Preschool and Primary Scale of Intelligence—Revised (WPPSI-R) 3–7 Same as WISC-III-R. Kaufman Assessment Battery for Children (K-ABC) 2.6–12.6 Well grounded in theories of cognitive psychology and neuropsychology. Allows immediate comparison of intellectual capacity with acquired knowledge. Scores: Mental Processing Composite (IQ equivalent); sequential and simultaneous processing and achievement standard scores: scaled mental processing and achievement subtest scores; age equivalents; percentiles. Kaufman Adolescent and Adult Intelligence Test (KAIT) 11–85+ Composed of separate Crystallized and Fluid scales. Scores: Composite Intelligence Scale; Crystallized and Fluid IQ; scaled subtest scores; percentiles. Stanford-Binet, 4th Edition (SB:FE) 2–23 Scores: IQ; verbal, abstract/visual, and quantitative reasoning; short-term memory; standard age. Peabody Picture Vocabulary Test—III (PPVT-III) 4–adult Measures receptive vocabulary acquisition; standard scores, percentiles, age equivalents. Achievement Woodcock-Johnson Psycho-Educational Battery—Revised (W-J) K–12 Scores: reading and mathematics (mechanics and comprehension), written language, other academic achievement; grade and age scores, standard scores, percentiles. Wide Range Achievement Test—3, Levels 1 and 2 (WRAT-3) Level 1: 1–5 Level 2: 12–75 Permits screening for deficits in reading, spelling, and arithmetic; grade levels, percentiles, stanines, standard scores. Kaufman Test of Educational Achievement, Brief and Comprehensive Forms (K-TEA) 1–12 Standard scores: reading, mathematics, and spelling; grade and age equivalents, percentiles, stanines. Brief Form is sufficient for most clinical applications; Comprehensive Form allows error analysis and more detailed curriculum planning. Wechsler Individual Achievement Test (WIAT) K–12 Standard scores: basic reading, mathematics reasoning, spelling, reading comprehension, numerical operations, listening comprehension, oral expression, written expression. Conormal with WISC-III-R. Adaptive behavior Vineland Adaptive Behavior Scales Normal: 0–19 Retarded: All ages Standard scores: adaptive behavior composite and communication, daily living skills, socialization and motor domains; percentiles, age equivalents, developmental age scores. Separate standardization groups for normal, visually handicapped, hearing impaired, emotionally disturbed, and retarded. Scales of Independent Behavior—Revised Newborn–adult Standard scores: four adaptive (motor, social interaction, communication, personal living, community living) and three maladaptive (internalized, asocial, and externalized) areas; General Maladaptive Index and Broad Independence cluster. Attentional capacity Trail Making Test 8–adult Standard scores, standard deviations, ranges; corrections for age and education. Wisconsin Card Sorting Test 6.6–adult Standard scores, standard deviations, T-scores, percentiles, developmental norms for number of categories achieved, perseverative errors, and failures to maintain set; computer measures. Behavior Assessment System for Children (BASC) 4–18 Teacher and parent rating scales and child self-report of personality permitting multireporter assessment across a variety of domains in home, school, and community. Provides validity, clinical, and adaptive scales. ADHD component avails. Home Situations Questionnaire—Revised (HSQ-R) 6–12 Permits parents to rate child's specific problems with attention or concentration. Scores for number of problem settings, mean severity, and factor scores for compliance and leisure situations. ADHD Rating Scale 6–12 Score for number of symptoms keyed to DSM cutoff for diagnosis of ADHD; standard scores permit derivation of clinical significance for total score and two factors (Inattentive-Hyperactive and Impulsive-Hyperactive). School Situations Questionnaire (SSQ-R) 6–12 Permits teachers to rate a child's specific problems with attention or concentration. Scores for number of problem settings and mean severity. Child Attention Profile (CAP) 6–12 Brief measure allowing teachers' weekly ratings of presence and degree of child's inattention and overactivity. Normative scores for inattention, overactivity, and total score. Projective tests Rorschach Inkblots 3–adult Special scoring systems. Most recently developed and increasingly universally accepted is John Exner's Comprehensive System (1974). Assesses perceptual accuracy, integration of affective and intellectual functioning, reality testing, and other psychological processes. Thematic Apperception Test (TAT) 6–adult Generates stories which are analyzed qualitatively. Assumed to provide especially rich data regarding interpersonal functioning. Machover Draw-A-Person Test (DAP) 3–adult Qualitative analysis and hypothesis generation, especially regarding subject's feelings about self and significant others. Kinetic Family Drawing (KFD) 3–adult Qualitative analysis and hypothesis generation regarding an individual's perception of family structure and sentient environment. Some objective scoring systems in existence. Rotter Incomplete Sentences Blank Child, adolescent, and adult forms Primarily qualitative analysis, although some objective scoring systems have been developed. Personality tests Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) 14–18 1992 version of widely used personality measure, developed specifically for use with adolescents. Standard scores: 3 validity scales, 14 clinical scales, additional content and supplementary scales. Million Adolescent Personality Inventory (MAPI) 13–18 Standard scores for 20 scales grouped into three categories: Personality styles; expressed concerns; behavioral correlates. Normed on adolescent population. Focuses on broad functional spectrum, not just problem areas. Measures 14 primary personality traits, including emotional stability, self-concept level, excitability, and self-assurance. Children's Personality Questionnaire 8–12 Generates combined broad trait patterns including extraversion and anxiety. Neuropsychological screening tests and test batteries Developmental Test of Visual-Motor Integration (VMI) 2–16 Screening instrument for visual motor deficits. Standard scores, age equivalents, percentiles. Benton Visual Retention Test 6–adult Assesses presence of deficits in visual-figure memory. Mean scores by age. Benton Visual Motor Gestalt Test 5–adult Assesses visual-motor deficits and visual-figural retention. Age equivalents. Reitan-Indiana Neuropsychological Test Battery for Children 5–8 Cognitive and perceptual-motor tests for children with suspected brain damage. Halstead-Reitan Neuropsychological Test Battery for Older Children 9–14 Same as Reitan-Indiana. Luria-Nebraska Neuropsychological Battery: Children's Revision LNNB:C 8–12 Sensory-motor, perceptual, cognitive tests measuring 11 clinical and 2 additional domains of neuropsychological functioning. Provides standard scores. Developmental status Bayley Scales of Infant Development-Second Edition 16 days–42 mos Mental, motor, and behavior scales measuring infant, development. Provides standard scores. Mullen Scales of Early Learning Newborn–5 yrs Language and visual scales for receptive and expressive ability. Yields age scores and T scores. (Adapted from Racusin G, Moss N. Psychological assessment of children and adolescents. In: Lewis M, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. Baltimore: Williams & Wilkins; 1991, with permission.)

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Development Tests for Infants and Preschoolers

The Gesell Infant Scale, the Cattell Infant Intelligence Scale, Bayley Scales of Infant Development, and the Denver Developmental Screening Test include developmental assessments of infants as young as 2 months of age. When used with very young infants, the tests focus on sensorimotor and social responses to a variety of objects and interactions. When these instruments are used with older infants and preschoolers, emphasis is placed on language acquisition. The Gesell Infant Scale measures development in four areas: motor, adaptive functioning, language, and social.

An infant's score on one of these developmental assessments is not a reliable way to predict a child's future intelligence quotient (IQ) in most cases. Infant assessments are valuable,

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however, in detecting developmental deviation and mental retardation and in raising suspicions of a developmental disorder. Whereas infant assessments rely heavily on sensorimotor functions, intelligence testing in older children and adolescents includes later-developing functions, including verbal, social, and abstract cognitive abilities.

Intelligence Tests for School-Age Children and Adolescents

The most widely used test of intelligence for school-age children and adolescents is the third edition of the Wechsler Intelligence Scale for Children (WISC-III-R). It can be given to children from 6 to 17 years of age and yields a verbal IQ, a performance IQ, and a combined full-scale IQ. The verbal subtests consist of vocabulary, information, arithmetic, similarities, comprehension, and digit span (supplemental) categories. The performance subtests include block design, picture completion, picture arrangement, object assembly, coding, mazes (supplemental), and symbol search (supplemental). The scores of the supplemental subtests are not included in the computation of IQ.

Each subcategory is scored from 1 to 19, with 10 being the average score. An average full-scale IQ is 100; 70 to 80 represents borderline intellectual function; 80 to 90 is in the low average range; 90 to 109 is average; 110 to 119 is high average; and above 120 is in the superior or very superior range. The multiple breakdowns of the performance and verbal subscales allow great flexibility in identifying specific areas of deficit and scatter in intellectual abilities. Because a large part of intelligence testing measures abilities used in academic settings, the breakdown of the WISC-III-R can also be helpful in pointing out skills in which a child is weak and may benefit from remedial education.

The Stanford-Binet Intelligence Scale covers an age range from 2 to 24 years. It relies on pictures, drawings, and objects for very young children and on verbal performance for older children and adolescents. This intelligence scale, the earliest version of an intelligence test of its kind, leads to a mental age score as well as an intelligence quotient.

The McCarthy Scales of Children's Abilities and the Kaufman Assessment Battery for Children are two other intelligence tests that are available for preschool and school-age children. They do not cover the adolescent age group.

Long-Term Stability of Intelligence

Although a child's intelligence is relatively stable throughout the school-age years and adolescence, some factors can influence intelligence and a child's score on an intelligence test. The intellectual functions of children with severe mental illnesses and of those from low socioeconomic levels may decrease over time, whereas the IQs of children whose environments have been enriched may increase over time. Factors that influence a child's score on a given test of intellectual functioning and, thus, affect the accuracy of the test are motivation, emotional state, anxiety, and cultural milieu.

Perceptual and Perceptual Motor Tests

The Bender Visual Motor Gestalt Test can be given to children between the ages of 4 and 12 years. The test consists of a set of spatially related figures that the child is asked to copy. The scores are based on the number of errors. Although not a diagnostic test, it is useful in identifying developmentally age-inappropriate perceptual performances.

Personality Tests

Personality tests are not of much use in making diagnoses, and they are less satisfactory than intelligence tests in regard to norms, reliability, and validity, but they can be helpful in eliciting themes and fantasies.

The Rorschach test is a projective technique in which ambiguous stimuli—a set of bilaterally symmetrical inkblots—are shown to a child, who is then asked to describe what he or she sees in each. The hypothesis is that the child's interpretation of the vague stimuli reflects basic characteristics of personality. The examiner notes the themes and patterns. Two sets of norms have been established for the Rorschach test, one for children between 2 and 10 years and one for adolescents between 10 and 17 years.

A more structured projective test is the Children's Apperception Test (CAT), which is an adaptation of the Thematic Apperception Test (TAT). The CAT consists of cards with pictures of animals in scenes that are somewhat ambiguous, but are related to parent–child and sibling issues, caretaking, and other relationships. The child is asked to describe what is happening and to tell a story about the scene. Animals are used because it was hypothesized that children might respond more readily to animal images than to human figures.

Drawings, toys, and play are also applications of projective techniques that can be used during the evaluation of children. Dollhouses, dolls, and puppets have been especially helpful in allowing a child a nonconversational mode in which to express a variety of attitudes and feelings. Play materials that reflect household situations are likely to elicit a child's fears, hopes, and conflicts about the family.

Projective techniques have not fared well as standardized instruments. Rather than being considered tests, projective techniques are best considered as additional clinical modalities.

Educational Tests

Achievement tests measure the attainment of knowledge and skills in a particular academic curriculum. The Wide-Range Achievement Test-Revised (WRAT-R) consists of tests of knowledge and skills and timed performances of reading, spelling, and mathematics. It is used with children from 5 years of age to adulthood. The test yields a score that is compared with the average expected score for the child's chronological age and grade level.

The Peabody Individual Achievement Test (PIAT) includes word identification, spelling, mathematics, and reading comprehension.

The Kaufman Test of Educational Achievement, the Gray Oral Reading Test-Revised (GORT-R), and the Sequential Tests of Educational Progress (STEP) are achievement tests that determine whether a child has achieved the educational level expected for his or her grade level. Children with an average IQ, whose achievement is significantly lower than expected for their grade level in one or more subjects, are considered to be learning disabled. Thus, achievement testing, combined with a measure of intellectual function, can identify specific learning disabilities for which remediation is recommended. Children who do not reach their grade level according to their chronological age, but who function intellectually in the borderline range or lower, are not necessarily learning disabled unless a disparity exists between their IQs and their levels of achievement.

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Biopsychosocial Formulation

The clinician's task is to integrate all of the information obtained into a formulation that takes into account the biological predisposition, psychodynamic factors, environmental stressors, and life events that have led to the child's current level of functioning. Psychiatric disorders and any specific physical, neuromotor, or developmental abnormalities must be considered in the formulation of etiologic factors for current impairment. The clinician's conclusions are an integration of clinical information along with data from standardized psychological and developmental assessments. The psychiatric formulation includes an assessment of family function as well as the appropriateness of the child's educational setting. A determination of the child's overall safety in his or her current situation is made. Any suspected maltreatment must be reported to the local child protective service agency. The child's overall well-being regarding growth, development, and academic and play activities is considered.

Diagnosis

Current evidence suggests that the use of structured and semistructured (evidence-based) assessment tools enhance a clinician's ability to make the most accurate diagnoses. These instruments, described earlier, include the K-SADS, the CAPA, and the NIMH DISC-IV interviews. The advantages of including an evidence-based instrument in the diagnostic process include decreasing potential clinician bias to make a diagnosis without all of the necessary symptoms information, and serving as guides for the clinician to consider each symptom that could contribute to a given diagnosis. These data can enable the clinician to optimize his expertise to make challenging judgments regarding child and adolescent disorders which may possess overlapping symptoms. The clinician's ultimate task includes making all appropriate diagnoses according to DSM-IV-TR. Some clinical situations do not fulfill criteria for DSM-IV-TR diagnoses, but cause impairment and require psychiatric attention and intervention. Clinicians who evaluate children are frequently in the position of determining the impact of behavior of family members on the child's well-being. In many cases, a child's level of impairment is related to factors extending beyond a psychiatric diagnosis, such as the child's adjustment to his or her family life, peer relationships, and educational placement.

Recommendations and Treatment Plan

The recommendations for treatment are derived by a clinician who integrates the data gathered during the evaluation into a coherent formulation of the factors that are contributing to the child's current problems, the consequences of the problems, and strategies that may ameliorate the difficulties. The recommendations can be broken down into their biological, psychological, and social components. That is, identification of a biological predisposition to a particular psychiatric disorder may be clinically relevant to inform a psychopharmacologic recommendation. As part of the formulation, an understanding of the psychodynamic interactions between family members may lead a clinician to recommend treatment that includes a family component. Educational and academic problems are addressed in the formulation and may lead to a recommendation to seek a more effective academic placement. The overall social situation of the child or adolescent is taken into account when recommendations for treatment are developed. Of course, the physical and emotional safety of a child or adolescent is of the utmost importance and always at the top of the list of recommendations.

The child or adolescent's family, school life, peer interactions, and social activities often have a direct impact on the child's success in overcoming his or her difficulties. The psychological education and cooperation of a child or adolescent's family are essential ingredients in successful application of treatment recommendations. Communications from clinicians to parents and family members that balance the observed positive qualities of the child and family with the weak areas are often perceived as more helpful than a focus only on the problem areas. Finally, the most successful treatment plans are those developed cooperatively between the clinician, child, and family members during which each member of the team perceives that he or she has been given credit for positive contributions.

References

Achenbach TM, Dumenci L, Rescorla LA. Ratings of relations between DSM-IV diagnostic categories and items of the CBCL/6-18, TRF, and YSR. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families; 2001.

Bird HR, Canino GJ, Davies M, Ramirez R, Chavez L, Duarte C, Shen S. The Brief Impairment Scale (BIS): A multidimensional scale of functional impairment for children and adolescents. J Am Acad Child Adolesc Psychiatry. 2005;44: 699.

Doss AJ. Evidence-based diagnosis: Incorporating diagnostic instruments into clinical practice. J Am Acad Child Adolesc Psychiatry. 2005;44;947.

Hamilton J. Clinician's guide to evidence-based practice. J Am Acad Child Adolesc Psychiatry. 2005;44:494.

Hamilton J. The answerable question and a hierarchy of evidence. J Am Acad Child Adolesc Psychiatry. 2005;44:596.

Kestenbaum CJ. The clinical interview of the child. In: Wiener JM, Dulcan MK, eds. The American Psychiatric Publishing Textbook of Child and Adolescent Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004:103–111.

King RA, Schwab-Stone ME, Peterson BS, Thies AP. Psychiatric examination of the infant, child, and adolescent. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2005:3044.

Lyneham HJ, Rapee RM. Evaluation and treatment of anxiety disorders in the general pediatric population: A clinician's guide. Child Adolesc Psychiatr Clin N Am. 2005;14(4):845.

Pataki CS. Child psychiatry: Introduction and overview. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2005:3015.

Puig-Antich J, Orraschel H, Tabrizi MA, Chambers W. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version. New York: New York State Psychiatric Institute and Yale School of Medicine; 1980.

Staller JA. Diagnostic profiles in outpatient child psychiatry. American Journal of Orthopsychiatry. 2006;76(1):98.

Winters NC, Collett BR, Myers KM. Ten-year review of rating scales, VII: Scales assessing functional impairment. J Am Acad Child Adolesc Psychiatry. 2005;44:309.

Youngstrom EA, Duax J. Evidence-based assessment of pediatric bipolar disorder. Part 1: Base rate and family history. J Am Acad Child Adolesc Psychiatry. 2005;44:712.

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Adjustment Disorders

The adjustment disorders are a diagnostic category characterized by an emotional response to a stressful event. Typically, the stressor involves financial issues, a medical illness, or a relationship problem. The symptom complex that develops may involve anxious or depressive affect or may present with a disturbance of conduct. By definition, the symptoms must begin within 3 months of the stressor and must remit within 6 months of removal of the stressor. A variety of subtypes of adjustment disorder are identified in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), varying on the particular predominant affective presentation. These include adjustment disorder with depressed mood, anxious mood, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified type.

Epidemiology

According to DSM-IV-TR, the prevalence of the disorder is estimated to be from 2 to 8 percent of the general population. Women are diagnosed with the disorder twice as often as men, and single women are generally overly represented as most at risk. In children and adolescents, boys and girls are equally diagnosed with adjustment disorders. The disorders can occur at any age, but are most frequently diagnosed in adolescents. Among adolescents of either sex, common precipitating stresses are school problems, parental rejection and divorce, and substance abuse. Among adults, common precipitating stresses are marital problems, divorce, moving to a new environment, and financial problems.

Adjustment disorders are one of the most common psychiatric diagnoses for disorders of patients hospitalized for medical and surgical problems. In one study, 5 percent of persons admitted to a hospital over a 3-year period were classified as having an adjustment disorder. Up to 50 percent of persons with specific medical problems or stressors have been diagnosed with adjustment disorders. Furthermore, 10 to 30 percent of mental health outpatients and up to 12 percent of general hospital inpatients referred for mental health consultations have been diagnosed with adjustment disorders.

Etiology

By definition, an adjustment disorder is precipitated by one or more stressors. The severity of the stressor or stressors does not always predict the severity of the disorder; the stressor severity is a complex function of degree, quantity, duration, reversibility, environment, and personal context. For example, the loss of a parent is different for a child 10 years of age than for a person 40 years of age. Personality organization and cultural or group norms and values also contribute to the disproportionate responses to stressors.

Stressors may be single, such as a divorce or the loss of a job, or multiple, such as the death of a person important to a patient, which coincides with the patient's own physical illness and loss of a job. Stressors may be recurrent, such as seasonal business difficulties, or continuous, such as chronic illness or poverty. A discordant intrafamilial relationship can produce an adjustment disorder that affects the entire family system, or the disorder may be limited to a patient who was perhaps the victim of a crime or who has a physical illness. Sometimes, adjustment disorders occur in a group or community setting, and the stressors affect several persons, as in a natural disaster or in racial, social, or religious persecution. Specific developmental stages, such as beginning school, leaving home, getting married, becoming a parent, failing to achieve occupational goals, having the last child leave home, and retiring, are often associated with adjustment disorders.

Psychodynamic Factors

Pivotal to understanding adjustment disorders is an understanding of three factors: the nature of the stressor, the conscious and unconscious meanings of the stressor, and the patient's preexisting vulnerability. A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment disorders. Vulnerability is also associated with the loss of a parent during infancy or being reared in a dysfunctional family. Actual or perceived support from key relationships can affect behavioral and emotional responses to stressors.

Several psychoanalytic researchers have pointed out that the same stress can produce a range of responses in various persons. Throughout his life, Sigmund Freud remained interested in why the stresses of ordinary life produce illness in some and not in others, why an illness takes a particular form, and why some experiences and not others predispose a person to psychopathology. He gave considerable weight to constitutional factors and viewed them as interacting with a person's life experiences to produce fixation.

Psychoanalytic research has emphasized the role of the mother and the rearing environment in a person's later capacity to respond to stress. Particularly important was Donald Winnicott's concept of the good-enough mother, a person who adapts

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to the infant's needs and provides sufficient support to enable the growing child to tolerate the frustrations in life.

Clinicians must undertake a detailed exploration of a patient's experience of the stressor. Certain patients commonly place all the blame on a particular event when a less obvious event may have had more significant psychological meaning for the patient. Current events may reawaken past traumas or disappointments from childhood, so patients should be encouraged to think about how the current situation relates to similar past events.

Throughout early development, each child develops a unique set of defense mechanisms to deal with stressful events. Because of greater amounts of trauma or greater constitutional vulnerability, some children have less mature defensive constellations than other children. This disadvantage may cause them as adults to react with substantially impaired functioning when they are faced with a loss, a divorce, or a financial setback; those who have developed mature defense mechanisms are less vulnerable and bounce back more quickly from the stressor. Resilience is also crucially determined by the nature of children's early relationships with their parents. Studies of trauma repeatedly indicate that supportive, nurturant relationships prevent traumatic incidents from causing permanent psychological damage.

Psychodynamic clinicians must consider the relation between a stressor and the human developmental life cycle. When adolescents leave home for college, for example, they are at high developmental risk for reacting with a temporary symptomatic picture. Similarly, if the young person who leaves home is the last child in the family, the parents may be particularly vulnerable to a reaction of adjustment disorder. Moreover, middle-aged persons who are confronting their own mortality may be especially sensitive to the effects of loss or death.

Family and Genetic Factors

Some studies suggest that certain persons appear to be at increased risk both for the occurrence of these adverse life events and for the development of pathology once they occur. Findings from a study of more than 2,000 twin pairs indicate that life events and stressors are modestly correlated in twin pairs, with monozygotic twins showing greater concordance than dizygotic twins. Family environmental and genetic factors each accounted for approximately 20 percent of the variance in that study. Another twin study that examined genetic contributions to the development of posttraumatic stress disorder (PTSD) symptoms (not necessarily at the level of full disorder and, therefore, relevant to adjustment disorders) also concluded that the likelihood of developing symptoms in response to traumatic life events is partially under genetic control.

Table 26-1 DSM-IV-TR Diagnostic Criteria for Adjustment Disorders

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant as evidenced by either of the following: marked distress that is in excess of what would be expected from exposure to the stressor significant impairment in social or occupational (academic) functioning The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. The symptoms do not represent bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify if: Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months or longer Adjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV. With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Unspecified (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000.)

Diagnosis and Clinical Features

Although by definition adjustment disorders follow a stressor, the symptoms do not necessarily begin immediately. Up to 3 months may elapse between a stressor and the development of symptoms. Symptoms do not always subside as soon as the stressor ceases; if the stressor continues, the disorder may be chronic. The disorder can occur at any age, and its symptoms vary considerably, with depressive, anxious, and mixed features most common in adults. Physical symptoms, which are most common in children and the elderly, can occur in any age group. Manifestations may also include assaultive behavior and reckless driving, excessive drinking, defaulting on legal responsibilities, withdrawal, vegetative signs, insomnia, and suicidal behavior.

The clinical presentations of adjustment disorder can vary widely. DSM-IV-TR lists six adjustment disorders, including an unspecified category (Table 26-1).

Adjustment Disorder with Depressed Mood

In adjustment disorder with depressed mood, the predominant manifestations are depressed mood, tearfulness, and hopelessness. This type must be distinguished from major depressive

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disorder and uncomplicated bereavement. Adolescents with this type of adjustment disorder are at increased risk for major depressive disorder in young adulthood.

Adjustment Disorder with Anxiety

Symptoms of anxiety, such as palpitations, jitteriness, and agitation, are present in adjustment disorder with anxiety, which must be differentiated from anxiety disorders.

Adjustment Disorder with Mixed Anxiety and Depressed Mood

In adjustment disorder with mixed anxiety and depressed mood, patients exhibit features of both anxiety and depression that do not meet the criteria for an already established anxiety disorder or depressive disorder.

A 48-year-old married woman, in good health, with no previous psychiatric difficulties, presented to the emergency room reporting that she had overdosed on a handful of antihistamines shortly before she arrived. She described her problems as having started 2 months earlier, soon after her husband unexpectedly requested a divorce. She felt betrayed after having devoted much of her 20-year marriage to being a wife, mother, and homemaker. She was sad and tearful at times, and she occasionally had difficulty sleeping. Otherwise, she had no vegetative symptoms and enjoyed time with family and friends. She felt desperate and suicidal after she realized that “he no longer loved me.” After crisis intervention in the emergency setting, she responded well to individual psychotherapy over a 3-month period. She occasionally required benzodiazepines for anxiety during the period of treatment. By the time of discharge, she had returned to her baseline function. She came to terms with the possibility of life after divorce and was exploring her best options under the circumstances. (Courtesy of Jeffrey William Katz, M.D., and Oladapo Tomori, M.D.)

Adjustment Disorder with Disturbance of Conduct

In adjustment disorder with disturbance of conduct, the predominant manifestation involves conduct in which the rights of others are violated or age-appropriate societal norms and rules are disregarded. Examples of behavior in this category are truancy, vandalism, reckless driving, and fighting. The category must be differentiated from conduct disorder and antisocial personality disorder.

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

A combination of disturbances of emotions and of conduct sometimes occurs. Clinicians are encouraged to try to make one or the other diagnosis in the interest of clarity.

Adjustment Disorder Unspecified

Adjustment disorder unspecified is a residual category for atypical maladaptive reactions to stress. Examples include inappropriate responses to the diagnosis of physical illness, such as massive denial, severe noncompliance with treatment, and social withdrawal, without significant depressed or anxious mood.

Differential Diagnosis

Although uncomplicated bereavement often produces temporarily impaired social and occupational functioning, the person's dysfunction remains within the expectable bounds of a reaction to the loss of a loved one and, thus, is not considered adjustment disorder. Other disorders from which adjustment disorder must be differentiated include major depressive disorder, brief psychotic disorder, generalized anxiety disorder, somatization disorder, substance-related disorder, conduct disorder, academic problem, occupational problem, identity problem, and PTSD. These diagnoses should be given precedence in all cases that meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant. Patients with an adjustment disorder are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another condition, clinical judgment is necessary. Some patients may meet the criteria for both an adjustment disorder and a personality disorder. If the adjustment disorder follows a physical illness, the clinician must make sure that the symptoms are not a continuation or another manifestation of the illness or its treatment.

Acute and Posttraumatic Stress Disorders

The presence of a stressor is a requirement in the diagnosis of adjustment disorder, PTSD, and acute stress disorder. PTSD and acute stress disorder have the nature of the stressor better characterized and are accompanied by a defined constellation of affective and autonomic symptoms. In contrast, the stressor in adjustment disorder can be of any severity, with a wide range of possible symptoms. When the response to an extreme stressor does not meet the acute stress or posttraumatic disorder threshold, the adjustment disorder diagnosis would be appropriate. PTSD is discussed fully in Chapter 16.5.

Course and Prognosis

With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later have mood disorders or substance-related disorders. Adolescents usually require a longer time to recover than adults.

Treatment

Psychotherapy

Psychotherapy remains the treatment of choice for adjustment disorders. Group therapy can be particularly useful for patients who have had similar stresses—for example, a group of retired persons or patients having renal dialysis. Individual psychotherapy offers the opportunity to explore the meaning of the stressor

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to the patient so that earlier traumas can be worked through. After successful therapy, patients sometimes emerge from an adjustment disorder stronger than in the premorbid period, although no pathology was evident during that period. Because a stressor can be clearly delineated in adjustment disorders, it is often believed that psychotherapy is not indicated and that the disorder will remit spontaneously. This viewpoint, however, ignores the fact that many persons exposed to the same stressor experience different symptoms, and in adjustment disorders, the response is pathological. Psychotherapy can help persons adapt to stressors that are not reversible or time limited and can serve as a preventive intervention if the stressor does remit. Psychiatrists treating adjustment disorders must be particularly aware of problems of secondary gain. The illness role may be rewarding to some normally healthy persons who have had little experience with illness's capacity to free them from responsibility. Thus, patients can find therapists' attention, empathy, and understanding, which are necessary for success, rewarding in their own right, and therapists may thereby reinforce patients' symptoms. Such considerations must be weighed before intensive psychotherapy is begun; when a secondary gain has already been established, therapy is difficult. Patients with an adjustment disorder that includes a conduct disturbance may have difficulties with the law, authorities, or school. Psychiatrists should not attempt to rescue such patients from the consequences of their actions. Too often, such kindness only reinforces socially unacceptable means of tension reduction and hinders the acquisition of insight and subsequent emotional growth. In these cases, family therapy can help.

Table 26-2 ICD-10 Diagnostic Criteria for Adjustment Disorders

Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type. The individual manifests symptoms or behavior disturbance of the types found in any of the affective disorders (except for delusions and hallucinations), any disorder in neurotic, stress-related, and somatoform disorders, and conduct disorders, but the criteria for an individual disorder are not fulfilled. Symptoms may be variable in both form and severity. The predominant feature of the symptoms may be further specified. Brief depressive reaction A transient mild depressive state of a duration not exceeding 1 month. [3pt] Prolonged depressive reaction A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years. Mixed anxiety and depressive reaction Both anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders. With predominant disturbance of other emotions The symptoms are usually of several types of emotions, such as anxiety, depression, worry, tensions, and anger. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder or for other mixed anxiety disorders, but they are not so predominant that other more specific depressive or anxiety disorders can be diagnosed. This category should also be used for reactions in children in whom regressive behavior such as bed-wetting or thumb-sucking is also present. With predominant disturbance of conduct The main disturbance is one involving conduct, e.g., an adolescent grief reaction resulting in aggressive or dissocial behavior. With mixed disturbance of emotions and conduct Both emotional symptoms and disturbances of conduct are prominent features. With other specified predominant symptoms Except in prolonged depressive reaction, the symptoms do not persist for more than 6 months after the cessation of the stress or its consequences. However, this should not prevent a provisional diagnosis being made if this criterion is not yet fulfilled. (Reprinted with permission from World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Copyright, World Health Organization, Geneva, 1993.)

Crisis Intervention

Crisis intervention and case management are short-term treatments aimed at helping persons with adjustment disorders resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. The frequency and length of visits for crisis support vary according to patients' needs; daily sessions may be necessary, sometimes two or three times each day. Flexibility is essential in this approach.

Pharmacotherapy

No studies have assessed the efficacy of pharmacological interventions in individuals with adjustment disorder, but it may be reasonable to use medication to treat specific symptoms for a brief time. The judicious use of medications can help patients with adjustment disorders, but they should be prescribed for brief periods. Depending on the type of adjustment disorder, a patient may respond to an antianxiety agent or to an antidepressant. Patients with severe anxiety bordering on panic can benefit from anxiolytics such as diazepam (Valium), and those in withdrawn or inhibited states may be helped by a short course of psychostimulant medication. Antipsychotic drugs may be used if there are signs of decompensation or impending psychosis. Selective serotonin reuptake inhibitors have been found useful in treating symptoms of traumatic grief. Recently, there has been an increase in antidepressant use to augment psychotherapy in patients with adjustment disorders. Pharmacological intervention in this population is most often used, however, to augment psychosocial strategies rather than serving as the primary modality.

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ICD-10

The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) also contains a category of adjustment disorders. The diagnosis is similar to the DSM-IV-TR entity in outlining the development of psychological symptoms following a stressor. In ICD-10, however, the symptoms must appear within 1 month of the stressor, instead of the 3-month temporal course of DSM-IV-TR (Table 26-2). The ICD-10 criteria share with DSM-IV-TR the requirement that symptoms must not persist for longer than 6 months after the removal of the stressor. The ICD-10 and DSM-IV-TR differ in their consideration of chronicity. Whereas the DSM-IV-TR requires the specification of acute or chronic for all subtypes of adjustment disorder, the ICD-10 only refers to chronicity if the primary experience involved is a depressed state. In this case, the diagnosis of prolonged depressive reaction is used to describe symptoms lasting for as long as 2 years.

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