IACAPAP Textbook of Child and Adolescent Mental Health

INTRODUCTION

Chapter

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CASE FORMULATION AND
INTEGRATION OF INFORMATION
IN CHILD AND ADOLESCENTMENTAL HEALTH
Schuyler W Henderson & Andrés Martin
Session at the Department of Child Development, Duhok, Iraq
Photo: Dr Abdulbaghi Ahmad

Schuyler W Henderson MD,
MPH
Associate Training Director,
New York University
Department of Child andAdolescent Psychiatry;
Assistant Unit Chief, 21S,
Bellevue Hospital, New YorkNY, USA
Conflict of interest: nonereportedAndrés Martin MD, MPH
Riva Ariella Ritvo Professor,
Yale Child Study Center, New
Haven, CT, USA
Conflict of interest: nonereported
Some of this material is adaptedfrom a chapter we wrote on this
topic: Henderson SW, Martin A.
Formulation and Integration. In:
Lewis’s Child and Adolescent
Psychiatry: A Comprehensive
Textbook, 4th Edition. A Martin,
FR Volkmar editors. Philadelphia,
PA: Lippincott, Williams andWilkins.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2014. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Henderson SW, Andrés Martin. Case formulation and integration of information in child and adolescent mental
health. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child andAdolescent Psychiatry and Allied Professions 2014.

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IACAPAP Textbook of Child and Adolescent Mental HealthBeing able to formulate a case is one of the key skills for clinicians working
in child and adolescent mental health, but it is not an easy skill to master. Case
formulation involves turning a patient’s narrative and all the information derived
from examinations, interviews with parents and teachers, and medical and school
reports into a coherent and not necessarily lengthy story that will help to develop atreatment plan (see Chapter A.11). The formulation is a distillation of a child’s andfamily’s complicated, nuanced experiences into a manageable, meaningful synopsis(Winters et al, 2007), but a good formulation is more than just a summary: it
provides information that may not be obvious in the isolated components leading
up to it.

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THE SHAPE OF A FORMULATION
A formulation has to convey relevant signs and symptoms as well as pertinent
negatives (i.e., key absent symptoms) ; provide meaningful, explanatory contexts
for these signs and symptoms, including familial, social, educational, and culturalcontexts; justify diagnoses (or no diagnosis, if warranted); and describe treatment
options based on the diagnostic considerations.
The core components informing a diagnostic formulation tend to follow
a standard trajectory with common signposts to guide the reader: referral source,
identifying information, history of present illness, significant past psychiatric andmedical histories, psychosocial contexts, mental status, diagnostic considerations,and treatment planning (Table A.10.1). The consistency in a formulation’s
architecture permits clinicians to follow a familiar route while attuned to importantdetails and nuances.
Whether in psychoanalytic case studies or in brief presentations on ward
rounds, and across systems and countries, the overall shape of the formulation
remains the same. Within this broad shape, there are two common models that
can help organize the conceptual backbone of the formulation. These are thebiopsychosocial formulation and the Four Ps.

THE BIOPSYCHOSOCIAL MODEL
As the biological sciences became increasingly sophisticated and dominant
in the twentieth century, concerns were raised about the value of non-biologicalfactors in the etiology, presentation, and treatment of diseases and disorders. In
the face of these changes, Meyer (1948) promoted the psychobiological approachand Engel subsequently developed, named, and advocated for the biopsychosocial
model, describing it as a “way of thinking that enables the physician to act
rationally in areas now excluded from a rational approach” (Engel, 1980). Overthe past three decades, the biopsychosocial model has become the most common
model for formulating a case in mental health circles and has been widely adopted
throughout medicine.
The fundamental goal of the model is to prevent reductionism, particularly
biological reductionism, by ensuring that psychological and social factors are notexcluded (see Table A.10.2). The biopsychosocial model may appear to be a neutral
mediator between the three domains but, quite specifically, it is not neutral: it isintended to oppose biomedical, psychological and social reductionism. RegardlessCase formulation

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Reductionism“A line of thought which holds
that a complex system isnothing but the sum of its
parts and that an account of
it can be reduced to accounts
of individual constituents”(http://en.wikipedia.org/wiki/
Reductionism).
In psychology, reductionism
usually refers to theories
or explanations that oversimplify behaviour or cognitive
processes often by excluding
different perspectives, and, in
doing so, neglect to explain thecomplexities of the mind. An
example of reductionism would
be to attribute behaviours
exclusively to biologicalprocesses while ignoring family
and social influences, or viceversa.

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Table A.10.1. Core components informing a diagnostic formulation
COMPONENTDETAILS CAN INCLUDE:

Sources of information

Patient, collateral information, medical records

Chief complaint

What brought the patient inHistory of present illness

Symptoms, course, severity, triggering events, pertinent negatives

Past psychiatric history

Previous evaluations, therapies, hospitalizations, medications andtreatments; history of aggression or harm towards self or others;
substance abuse history

Past medical history

Illnesses, hospitalizations, surgeries, and medications including
folk and alternative medicine remedies, etc.

Family psychiatric andmedical history

Pertinent positives and negatives in the family’s psychiatric andmedical history, especially substance abuse, suicide, and cardiac
history (e.g., sudden deaths)

Social history

Family constellation, peer relations, interactions with the law andsocial services, and key events such as immigration

Education history

Schools, grades, report cards, special or regular education,changes in schools, suspensions

Developmental history

Mother’s pregnancy and labor, delivery, milestones during infancy;
stages of motor, cognitive, social and behavioral development.

Psychological testing

IQ, tests of adaptive functioning, speech and language
evaluations.

Mental status exam
Assessment

Diagnoses, hypotheses of causality.

Plan

Treatment goals and options, other persons or agencies tocontact.

of anatomical lesions, clear psychological or obvious social etiologies, this model
insists that all three domains be accounted for. By doing so, it has been a powerfuland successful model for physicians in all fields of medicine.
The biological domain circumscribes neuropsychiatric, genetic andphysiological issues, focusing on, but not limited to, the functional operationsof the brain and what might be directly affecting it. The psychological dimension
includes an evaluation of the child’s psychological make-up, including strengths
and vulnerabilities, and offers the opportunity to include psychodynamic principles
like defense structures, consciously and unconsciously driven patterns of behavior,
responses to trauma and conflict, transferences and counter-transferences. The
social dimension situates the child in their communities, exploring relationships

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Table A.10.2: The Components of the biopsychosocial model
BIOLOGICALPSYCHOLOGICALSOCIAL•

Family history•

Emotional development•

Family constellation•

Genetics•

Personality structure•

Peer relationships•

Physical development•

Self-esteem•

School•Constitution•

Insight•

Neighborhood•

Intelligence•

Defenses•Ethnic influences•

Temperament•

Patterns of behavior•

Socioeconomic issues•

Medical comorbidities•

Patterns of cognition•

Culture(s)•Responses to stressors•

Religion(s)•Coping strategies

Defense mechanisms
Coping styles or defense mechanisms are “mechanisms that mediate the individual’s reaction to emotional conflicts and external stressors”(American Psychiatric Association, 2000 p821). Dysfunctional defense mechanisms tend to allow people to avoid reality or result in worsening
problems, while functional coping skills help us deal with reality.
Defense mechanisms are part of everyday life. One is usually not aware of utilizing them. Defenses are:••••

A major means of managing conflict and affect.
Relatively unconscious
Discrete from one another
Reversible•

Adaptive as well as pathological (Vailliant, 2012).

DSM-IV TR in Appendix B (American Psychiatric Association, 2000, pp. 811-813) describes a long list of defence mechanisms. The morecommon, from immature to mature, include:•

Denial, when individuals refuse to accept the truth or face reality (on hearing of the death of a pet, a child says “no, my dog is still
alive.”).

•

Repression involves ‘forgetting’ something bad or unpleasant (e.g., forgetting a meeting with someone one does not like).

•

In the case of regression we revert to child-like behaviour usually as a response to stress (e.g., an adult cuddling up with an old toy
when feeling sick with the ‘flu)•

In displacement one transfers one’s original feelings (usually anger) away from the object of one’s anger to a harmless victim (e.g.,arguing with one’s partner after having a conflict at work; ‘kicking the cat’).

•Projection leads us to project one’s feelings or insecurities unto others (e.g., ‘what are you looking at; don’t you like what I am
wearing?’ when one is concerned about what one is wearing).

•

Reaction formation is when individuals express the opposite of their inner feelings in their behavior (e.g., bringing your boss a
coffee instead of saying you’re really angry at him/her)•

In rationalization individuals deal with conflicting or unpleasant stressors by explaining them away (e.g., car accident due to
speeding explained away as a statistical fact).

•

Sublimation occurs when emotional conflict or stressors are dealt with by channeling maladaptive impulses into productive activities(e.g., a person who was neglected during their childhood channelling these feelings in helping other people).

To learn more about defence mechanisms in children you may read the article by Carol Kurtz Walsh.

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IACAPAP Textbook of Child and Adolescent Mental Healthwith family and friends, as well as larger collective cultural organizations likeschools, religion, socioeconomic class and ethnicity.
Advocates for the biopsychosocial model argue convincingly that it isneeded because a “broad approach [is] essential to avoid premature closure of ourefforts to understand the patient’s needs, tunnel vision or an overly narrow approach
to treatment” (Jellinek & McDermott, 2004). Furthermore, it is particularly
useful for psychiatrists, who are in a unique position within medicine to address
the biological, psychological and social dimensions of the patient (Gabbard & Kay,
2001), and therefore are responsible for being attuned to each.
Nevertheless, critics of the model, also convincingly, note that thebiopsychosocial model is “silent as to how to understand those aspects under different
conditions and in different circumstances” (Ghaemi, 2003, 2009). While insistingthat medical materialism or psychological and social dogmatism cannot suffice,this model does not guide the clinician how to weigh the relative contributionsof each in any given patient. If a child is being bullied and has an aunt who isdepressed, and has always been noted to be a worrier, the biopsychosocial model
would provide slots for where each of these facts would fit, but no guidance on
what needs to be addressed first, what is most important, what treatment should
ensue, etc.

Medical materialism,
psychological andsocial dogmatism
Medical materialism is thebelief that a physiological,
biomedical explanation suffices
to explain abnormal or atypicalbehaviors, and therefore is aform of reductionism. The term
was used by William James
who argued against explaining
diverse or atypical psychic
experiences as mental illness.
Psychological or social
dogmatism is the belief thatpsychology or the social
environment is, respectively,
uniquely causal in abnormal or
atypical behaviors, as when, forexample, disruptive behavior
in children is ascribed only to achaotic social environment.

An additional flaw in this regard is that because the model is agnostic about
the roles of biology, psychology and society, those who prefer one particular realm
can devote their attention to it while paying lip service to the others in a few
short sentences (Jellinek & McDermott, 2004). In particular, the tailing ‘social’domain is often the least explored (Grunebaum, 2003). Virchow, the German
physician, said that “medicine is a social science” and although psychiatry has ahistory of collaborating with sociology (Bloom, 2005), the academic and clinicalintersections between mental health and other social sciences remain underexplored. This is especially true in regards to children, many of whom present tochild and adolescent mental health workers due to fundamentally social concerns,
such as impulsivity and hyperactivity in the classroom, conflict with parents,
truancy and school refusal, or other externalizing disorders (Centers for Disease
Control and Prevention, 2005), and where the ‘social’ component is neverthelessgiven short shrift.
The most worrying critique of the biopsychosocial model is that it does
not blend or integrate the three dimensions as much as loosely knit them together
through proximity in the formulation. Thus, how the social, biologic andpsychological are integrated is left unanswered (McLaren, 1998).
The biopsychosocial model has been a step towards re-thinking
reductionism and an opportunity for generating hypotheses about multiplydetermined etiologies, which may lead to improved capacity for further synthesis
and understanding (Freedman, 1995). It is, nevertheless, not sufficient and barely
good-enough.

THE FOUR Ps
The Four Ps model is more sophisticated than the biopsychosocial modelin that it provides a framework imposing a chronology and an etiology on theCase formulation

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Table A.10.3. Examples of where the biopsychosocial model meets the Four Ps modelTHE ‘P’
CHARACTERISTICAND TRIGGERQUESTION

BIOLOGICALPSYCHOLOGICALSOCIAL

Predisposing
Why me?

Genetic loading

Immature defensive
structure

Poverty andadversity

Precipitating
Why now?

Iatrogenic reaction

Recent loss

School stressors

Perpetuating
Why does it
continue?

Poor response to
medication

No support at school

Unable to attend
therapy sessions
because of parents’work schedule

Protective
What can I rely on?

Family history oftreatment response

Insightful

Community andfaith as sources of
supportformulation and that suggests how and where interventions may take place.
This model organizes the patient’s presentation into Predisposing, Precipitating,
Perpetuating and Protective factors (Table A.10.3):
•

•
•

•

Predisposing factors are the constellation of features that render thechild vulnerable to the presenting symptoms such as family history,
genetics, medical and psychiatric history, and chronic social stressors
Precipitating factors identify current symptoms, diagnostic reasoning
about the role of inciting events, and concurrent illness
Perpetuating factors are those that make the condition endure, suchas the severity of the condition, compliance issues, and unresolved
predisposing and precipitating factors.
The fourth, protective, describes a patient’s strengths, resilience andsupports. Although other models can include strengths, this model
explicitly foregrounds it.

The Four Ps can be easily used in conjunction with other models. For
example, it can be blended with the biopsychosocial model (see Table A.10.3).
As a framework, it can also be used to organize a psychodynamic formulation,
beginning with predisposing vulnerabilities, personality structure, and history;
precipitating trauma or life events; perpetuating maladaptive behaviors andresistances; and protective facets of the identity.
The Four Ps can be used with the Collaborative Problem Solving (CPS)model (Greene & Ablon, 2005). The CPS model comprehensively assesses
cognitive deficits around frustration tolerance, flexibility and problem-solving, andit exemplifies a collaborative approach to the formulation, with caregivers coming
together to understand the child and then working with the child to prevent

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IACAPAP Textbook of Child and Adolescent Mental Healthdangerous or aggressive behaviors. As the child is also involved in formulating theplan, the Four Ps provides a concrete way of organizing the different factors thatlead to problematic behaviors in a manner comprehensible to staff and patientsalike.
The CPS approach expands on the precipitating and perpetuating factors,
especially the ones pertaining to the child’s learning (including his or her social
learning). It then allows the staff to formulate appropriate, testable and patientspecific interventions based on observed behaviors and analysis of triggers(precipitating events), continued stresses (perpetuating factors), and strengths
that can be tapped into (protective factors). This combination of the Four Ps
formulation and the CPS model may be particularly apt on inpatient units (Greene
et al, 2006).
Similarly, Havinghurst and Downey (2009) propose a Mindful Formulation.
After collecting information, the Mindful Formulation uses a “patterns” worksheet
where the child’s affective responses, behaviors, and cognitions are collected in fourdomains:••••

Child functioning
Parents’/carers’/siblings’/significant other’s functioning
Relationships with the child and among significant others; andRelationships with and among the community.

The goal is trying to discern patterns of strength as well as patterns of
weakness and vulnerability and then to use these patterns to flesh out the Four Ps.
Biological, psychological and social elements can fall under each category.
The limitations of the Four Ps model include the nonstandard format (one does not
begin a formulation with “predisposing factors”) and an uneasy overlap between
categories. There is little consolidation of the many factors except as to how theyaffect the patient’s symptomology, although a strength of the model is that it isnevertheless explicit about arranging potentially etiological factors.

IACAPAP Study Group, Abuja,
Nigeria, 19-21 October, 2009

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THE VARIETY OF FORMULATIONSTauber writes that in science “observations assume their meanings within aparticular context, for facts are not just products of sensation or measurement, as the
positivists averred, but rather they reside within a conceptual framework that places
the fact into an intelligible picture of the world” (Tauber, 2005). The formulation
is not a value-neutral format containing dispassionately-arranged facts. The choice
as to which facts to include and which to reject and the subsequent ordering andpresentation of the facts collude to produce a value-laden product. A formulationis thus a condensation of values, informed by the nature of the encounter between
the clinician and the patient; practical goals; training and experience; and implicit
and explicit ethics.

‘The formulation is not avalue-neutral format containing
dispassionately-arranged facts.’

Location
The shape of a formulation may depend less on the patient’s narrative andmore on the location of the clinical encounter. As an example, on a crisis service,an excellent trainee with a longstanding interest in psychoanalysis was presenting
thoughtful and rich formulations about children with a focus on developmental
conflicts with family and peers; although these issues were far from irrelevant, they
did not help the team decide what treatment options were required that day orwhat immediate services we wanted to offer the family. The trainee’s formulations
were, however, well suited to his long-term therapy cases. With education on how
to revise the formulation for the clinical milieu, the trainee was able to provide
thoughtful, psychodynamically-informed formulations in concert with otherobservations and information that resulted in our ability to make plans for thefamilies right then and there.
A formulation needs to reflect the imperatives of the system in which theencounter takes place and therefore mirrors clinical priorities. A formulation may
focus on the severity and acuity of a patient’s symptoms and needs in a crisis service;
it may develop a working-model of treatment trials and planning in an inpatient
unit; it may narrate the gradual blossoming of relationships, defenses and cathexes(emotional investments) cultivated and analyzed in a psychodynamic treatment.
What each clinical milieu values is reflected in how the child’s assessment andtreatment will be formulated.

‘A formulation needs to reflect
the imperatives of the system
in which the encounter takes
place and therefore mirrors
clinical priorities.’

Treatment values
One of the goals of a formulation is to drive a treatment plan (including
no treatment, if warranted), and therefore the shape of a formulation will be
influenced by treatment options (see Chapter A.11). Depending upon the type oftreatment, the clinician will select questions and areas of assessment to explore. A
clinician’s training, biases, and experiences will naturally influence how questions
are asked and what is explored; one of the advantages of learning different types offormulation techniques and perspectives is that it allows the clinician to becomeaware of his or her own biases, but also allows them to be explicit about theirperspective and why it leads to certain treatment options.

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Click on the image tolisten to “One Case,
Two Formulations:
Psychodynamic and CBTPerspectives” (35:17)

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IACAPAP Textbook of Child and Adolescent Mental Health

Etiological values
What causes mental health disorders, maladies, diseases, problems, issues?
What factors conspire to make a child drop out of school? The biopsychosocialand Four Ps models create a great deal of space in which these questions can be
answered, and yet they do not compel an answer. They do no prognostic work
themselves. Some have suggested that we need to use models that are less flimsy
and wishy-washy, and that we use models that confidently assert etiological claims(not with arrogant hubris, but based on what we know as clinicians and respect forwhat we have learned from our science and our history, and so on).
The Four Perspectives model
Attempting to provide an alternative to the biopsychosocial model isanother model, the Four Perspectives (not to be confused with the Four Ps) (seeTable A.10.4). The Four Perspectives model provides a means of distinguishingmental health conditions based not on the conglomerative biopsychosocial model,
but on etiology and treatment options (McHugh & Slavney, 1998). The conceptof pluralism, defined by Havens (2005) as a process of “refining methods, notmixing them” has deeply informed the Four Perspectives model.
The Four Perspectives each come with a treatment paradigm:
•

•

•

•

Disease, the keystone of the biomedical perspective, is a clinical entity,a pathological condition with a specific etiology and with a likely
prognosis. The treatment for disease involves prevention and cure,by interventions that directly or indirectly affect the pathologicalprocess and/or produce symptom relief (which may, of course, include
psychological interventions)
Dimensions are based on vulnerabilities due to a person’s position
within ranges of psychological domains (such as intellectual disabilityor temperament). They are addressed with guidance
Behaviors, maladaptive or undesirable goal-directed activities, need tobe ameliorated, stopped or interrupted, through social, psychologicaland/or medical means
The fourth perspective is the life story, based in the reconstruction of
narratives through talk therapy. Treatment is usually sought due toemotional states of distress and proceeds through interpretation.

Some of the participants in IACAPAP’s Helmut Remschmidt Research Seminar
Beijing, February 21-26, 2010

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McHugh (2005) points to the potential adverse effects of each intervention.
As they note, all medications can be toxic; guidance can be paternalistic; stopping
can be stigmatizing; and interpretations can be hostile. By making the assessment
and acknowledgement of potential adverse effects a cornerstone of the formulation,
mental health professionals can collaborate more fully with the patient and family
in a transparent and compassionate way.
In a previous publication (Henderson & Martin, 2007), we added anothercategory, requirement, to be included in the Four Perspectives formulation. The
requirement is what is needed for the intervention. For a biomedical cure to beeffective there must be an assessment of compliance or adherence to treatment.
With guidance, there must be identification of developmental potential, which
the guidance can develop. For example, in working with a patient with intellectual
disability, intellectual, vocational and occupational strengths must be assessed.
Changing behavior requires a will to change, whether this is intuitive, as in thecase of a boy who wishes to stop smoking marijuana and has moved from precontemplation into contemplation, or cultivated through a system of positive
and negative reinforcement. And for interpretations to be effective, the patient’s
insight needs to be appraised.
A formulation based on the Four Perspectives would take as its conceptual
point of origin a conviction about the patient’s presentation, which would remain
adaptable within the overall formulation, and which would then guide theformulation towards specific interventions. One advantage of the Four Perspectives
is that they make “explicit aspects of reasoning about patients that are often left
implicit or vague”(McHugh & Slavney, 1998).
The pluralistic formulation would proceed as the mental health professional
ascertains which categories, perspectives or dimensions best describe the child’s

Table A.10.4 The Four Perspectives*
PERSPECTIVE
DiseaseWhat a patient has
Dimension
What a patient isBehavior
What a patient does
Life Story
What a patient wants

TREATMENTPROBLEM/CRITIQUE

REQUIREMENT

Cure

Medicines can be toxic

Compliance

Guide

Guidance can bepaternalistic

Location of strengthInterrupt

Stopping can bestigmatizing

Will to change

Re-script

Interpretations can be
hostileInsight*adapted from McHugh and Slavney (1998)

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IACAPAP Textbook of Child and Adolescent Mental Healthcondition; the formulation would then explain how the mental health professional
engages in appropriate, directed treatment, having assessed the requirements andacknowledged the concerns.
The biological approach (the disease model) has a better fit with conditions
like bipolar disorder, schizophrenia and Rett Syndrome than it does with grief.
The behavioral approach, which targets known harmful behaviors, may be bestfor substance abuse (although, of course, medical interventions directed towards
addiction as a disease can be countenanced as supplemental). The life story model
is geared towards understanding and narrativizing stresses and so would be more
helpful for bereavement after loss or stagnation in life’s journey.

Culture•••Different people are in different
states of readiness for change.
Identifying where an individuallies in the process of change
allows for a better matching oftreatment interventions.
The widely used five stages ofchange are:••

The formulation can integrate the individual with his or her cultural context,
without which it may not be possible to understand fully the patient. The cultural
formulation itself has several core components:•

Stages of change
model

The cultural identity of the individual (including self-identified cultural
affiliations, languages spoken, and levels of involvement with culturesof origin and host/dominant cultures)
Cultural explanations of illness (such as local meanings, cultural
explanations for symptoms, and idioms to describe illness)
Cultural adaptations to the environment and stresses (such as specificstresses in the community as well as areas of support in the community,
including possible sources of collaboration); andCultural areas of convergence and divergence between the clinician andthe individual (American Psychiatric Association, 1994; Pumariega etal, 2013).

Attending to this allows for culturally valid assessments on the part ofthe clinician, but can also be essential in formulating subsequent plans that are
acceptable to the patient (Lewis-Fernández & Díaz, 2002). Culture is everywhere,
and children are usually exploring it with vigor. Of all the cultures children
participate in, few are more important than the culture of childhood itself. A good
formulation will include the child’s relationship to this rich culture, including thechild’s interactions with peers and participation in childhood rituals, and his or her
engagement with television, video games, sports, movies and books.

•

•

•

Precontemplation,
when the young person
does not see the need tochangeContemplation: theperson acknowledges
the need to change but isambivalent about taking
the steps to deal with it or
too concerned about thenegatives of changing
Preparation: when
individuals are aware of
the benefits of changing
and take small steps
towards it
Action: the young
person is actually taking
steps towards significant
changeMaintenance: theyoung person has
achieved change and isable to successfully avoid
a relapse

This model was initiallydeveloped for substance abuse
treatment but is now widelyused to describe situations inwhich behavioural change issought.

THE USES OF A FORMULATION
A case formulation is hypothesis-generating and iterative, and can changeover time depending upon further clinical encounters, new information and theclinician’s evolving understanding of the child. So what purpose does a formulation
serve?
Before focusing on the pragmatics, let us remember that a formulation is away in which the clinician can understand and explain the patient. As proposed by
Jaspers, understanding and explaining may be distinct ways of knowing the patient(Jaspers, [1913]1997). The depth of our understanding of a patient’s experience
may not explain the etiology of a symptom in a way conducive to treatment, andlikewise a model of behavior may not adequately impart the patient’s experience ofCase formulation

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A formulation is a mode ofcommunication and a way
in which the clinician canunderstand and explain thepatient.

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IACAPAP Textbook of Child and Adolescent Mental Healththat behavior. Nevertheless, formulating a case allows the clinician to balance hisor her understanding of the patient and his or her explanations.
Understanding a patient requires an intersubjective appreciation of thepatient’s experiences, hopes and concerns, and is acquired through listening,talking and interacting with the patient (as well as his or her family and others
occupying important roles in his or her world). Explanation of a patient’s
symptoms and conditions itself has two dimensions: the interpretative task, where
psychological, sociological and neurobiological theories are used, ideally in an
explicit and evidence-based manner, in order to locate the contributing factors; andthe explanatory task, which connects these factors with the patient’s experience.
Understanding and explanation work in concert.
A formulation, first and foremost, is a mode of communication. The
question of its utility then depends upon the audience: consultation letters,discharge summaries; pre-authorization of treatment for an insurance company;
for legal purposes etc.

WRITING A CONSULTATION LETTER
Consultation letters are another area where the case formulation is essential.
It is widely believed that poor communication between healthcare professionals is
responsible for many problems. In one worrying study, the authors reviewed 150
assessment letters from psychiatrists at a clinic in Rottherham, UK, and discoveredthat 94% of them did not include a case formulation (Abbas et al, 2013).
What should a consultation letter look like? Keely et al (2002) provide a
useful guide.

Information
•
•

•
•
•

Explain the purpose of the consultation at the outset
Explain the role the consultation letter will take (for example, what
the letter will include, such as historical information, diagnosis, andrecommendations for further treatment)
Include an appropriate case formulation
Include diagnostic rationale and clear plans for follow-up
The letter is also a tool for education so may include references andexplanations to educate the various potential audiences of the letter.

Pragmatics
•

•
•
•

Know your audience: write the letter with an awareness of who will
be reading it (potentially including multiple different professions andparents, lawyers, insurance companies, agencies)
Remember that your audience may include your patient and his/herfamilyEnsure that it will be comprehensible to all your audiences while
including the information they need
Make it clear and organized

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IACAPAP Textbook of Child and Adolescent Mental HealthParticipants in the Donald J Cohen Fellowship program
during IACAPAP’s Beijing World Congress 2010.

•

Readability (and, in the era of computers, scannability): clear
paragraphs, bullet points•

Ensure that trainees get experience and feedback on letters.

What should you not include in a consultation letter?
Being able to write discreetly about sex, drugs, conflicts with family, andother topics is an important skill to develop, and this raises the broader issue that aformulation requires communication skills that are sensitive to ethical and clinicalrelationships. A formulation includes these values as well as the values of accuracy
and veracity; it should convey clinical material in a way that is sensitive to patients,
their confidentiality and their privacy; it should not include information that isirrelevant to the current problems.
In this era of Twitter and text messaging, letters should be brief and to thepoint. Professionals are unlikely to read a letter longer than one or two pages. For
example, general practitioners/family physicians would expect in the letter: thepsychiatrist’s formulation including a provisional diagnosis; an explanation of thepatient’s condition including what the patient/family have been told; assessmentof suicide risk, where appropriate; treatment recommended or provided; follow-up
arrangements, if any; and prognosis, if possible. (Wright, 1997)

CHILDREN AND FORMULATIONS
The models for case formulation have typically been derived from adultpsychiatry. Although child and adolescent psychiatry has offered much to adultpsychiatry, and vice versa, the mantra that children are not simply ‘little adults’ is
nowhere more true than in the mental health and experience of youngsters.

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IACAPAP Textbook of Child and Adolescent Mental Health

How do we specifically adapt formulations for children?
JargonThe language of the formulations needs to be precise and relevant to the child’slife. This means resisting reliance on jargon, with a cautious use of terminologies
that might be derived and more epidemiologically justified in adult populations.
Children are frequently referred for mental health evaluation, including from othermental health professionals, for “auditory hallucinations”, not necessarily because
they are having auditory hallucinations but because they may have answered “yes”
to questions that are, for them, vague and strange, that possibly approximate theirexperience, or that are answered concretely (“do you hear voices?”). Although thereferral may warrant expert evaluation, the subsequent formulation should resist
using auditory hallucination unless that precise term is clinically warranted, andnot, for example, when the child is lying in bed, trying to go to sleep, and spookedby vivid memories of a horror film watched the night before.
The chief complaintThis is usually a single line or a symptom, but with children who are brought
in by adults, it would be worth considering assessing two chief complaints: thechief complaint of the adults and the chief complaint of the child (which, it is true,
will often be “I don’t know”)
Explicitly including family and school as separate categories
Although this might also be good for adult patients (with a focus
on employment rather than school), these realms should be explicitly andcomprehensively evaluated in children, and thus may merit sections of theirown, rather than subsections of ‘social’ in a formulation. Stressors in thefamily and school can reflect a child’s symptoms, exacerbate them, or, indeed,be fundamentally etiological. In fact, there are no situations in which a child’spresentation for services does not reflect difficulties in one or both of these realms,
whether the child is reacting to stressors, posing challenges to these domains withhis or her behavior, or where his or her symptoms are exacerbated by what he or
she is experiencing at home or at school.

See the Appendix for an
example of formulation
focussing on different aspects
and acording to different
models.

Development
Children deserve an assessment of development that is not cursory. Much ofa child mental health professional’s diagnosis and treatment planning is predicatedon what is typical or atypical at that child’s age and how the presenting symptoms
will affect subsequent development.
Development is often put into its own section of the formulation, but
this may run the risk of allowing a brief synopsis of broad developmental stages
without integrating development specifically and thoughtfully into all aspects ofthe formulation. This can be challenging because, for example, often there is a
gestalt sense of whether hyperactivity or moodiness are deemed excessive, andbecause sometimes fairly ‘typical’ behaviors coalesce to produce a constellation ofsymptoms that would be detrimental.

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IACAPAP Textbook of Child and Adolescent Mental HealthModels of development
A formulation that is not book-length cannot run stage by stage through,for example, Freud, Erikson, and Piaget; the formulation requires making
choices. In this regard, as well as others, children suffer from the frictions
and misunderstandings of different mental health professions and theoreticalorientations. Using or thinking through various paradigms does not necessarily
imply allegiance and dogmatism. This is not to say that all models of development
are equally right, but the capacity to invoke or countenance different models should
not be based on professional competition. Although everybody changes over time,children are in a whirlwind of growth and maturation, accumulating language
and skills, experimenting with their expanding world, gaining mastery over tasks
while being introduced to more complicated ones on a daily basis. This process is
not straightforward and may be better viewed as a punctuated evolution than as asmooth and even progression; the course charted by the developing child depends
on biological factors, family constellation and social circumstances. Nevertheless,a basic appreciation of expected norms can situate the child and alert the clinician
to delays and disorders. In light of this, a useful tool for the formulation can be anassessment of the child’s tasks in terms of motor, cognitive and social development,
based on models including Piaget’s stages of cognitive development and Erikson’stasks. Expressing the child’s development in these terms in the formulation will
have additional longitudinal value, just as growth charts map a child’s physicaltrajectory.
The individual focus of case formulations
Children can be the canaries in the coal mine. Profound family stressors
may become manifest in the child’s behavior, and knowing that these need to beaddressed—and how to figure this into the treatment plan—will not only preventthe child from getting unnecessary treatment when better treatments could
address the situation, it avoids collusion in a failure to address predisposing andprecipitating symptoms.

CONCLUSION
The formulation is an exciting confluence of ideas, where the values ofchild and adolescent mental health professionals come together with the patient’s
experience to create a narrative about that patient leading to treatment. An
iterative and adaptive format, the formulation can accommodate different theories
and perspectives to explain what is happening to our patients while we strive
better to understand them. Despite all these variables, the formulation neednot be either intimidating or cumbersome. The science of the formulation is its
hypothesis-generating format, modifiable with new information, in service of
causal explanations. The art of the formulation is not instantaneously pinning
down the right diagnosis, but rather providing a thoughtful, sympathetic portraitof a child in the world.

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•
•

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APPENDIX A.10.1
FOR SELF-DIRECTEDLEARNING
EXERCISES AND
SELF-ASSESSMENTQUESTIONS

15

IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Abbas MJ, Premkumar L, Goodarzi A, Walton R (2013).
Lost in documentation: a study of case-formulation
documentation in letters after outpatient assessment.
Academic Psychiatry 37:336-338.

Henderson SW, Martin A (2007). Formulation and integration.
In A Martin & FR Volkmar (eds) Lewis’s Child andAdolescent Psychiatry: A Comprehensive Textbook, 4th ed.
Philadelphia, PA: Lippincott, Williams & Wilkins.

American Psychiatric Association (1994). Diagnostic andStatistical Manual of Mental Disorders, Fourth
Edition (DSM-IV). Washington, DC: American
Psychiatric Association.

Jaspers K (1997 [1913]) General Psychopathology, Volume 1.
Translated J Hoenig and Marian W Hamilton.
Baltimore: The Johns Hopkins University Press.

American Psychiatric Association (2000). Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition,
Text Revision. Washington, DC: American Psychiatric
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Bloom SW (2005). The relevance of medical sociology to
psychiatry: A historical view. The Journal of Nervousand Mental Diseases 193:77-84.
Centers for Disease Control and Prevention. Mental Healthin the United States: Health Care and Well Beingof Children with Chronic Emotional, Behavioral,
or Developmental Problems—United States, 2001.
Morbidity and Mortality Weekly Report, 2005 Oct 7;54(39):985-9.
Engel GL (1980) The clinical application of the biopsychosocial
model. American Journal of Psychiatry 137:535-544.
Freedman AM (1995). The biopsychosocial paradigm and thefuture of psychiatry. Comprehensive Psychiatry 36:397406.
Gabbard GO, Kay J (2001). The fate of integrated treatment:
Whatever happened to the biopsychosocial
psychiatrist? American Journal of Psychiatry. 158:19561963.
Ghaemi SN (2003). The Concepts of Psychiatry: A Pluralistic
Approach to the Mind and Mental Illness. Baltimore:
The Johns Hopkins University Press.
Ghaemi SM (2009). The Rise and Fall of the Biopsychosocial
Model. Baltimore: The Johns Hopkins University
Press.
Greene RW, Ablon JS (2005). Treating Explosive Kids: The
Collaborative Problem Solving Approach. New York:
Guilford Press.
Greene RW, Ablon JS, Hassuk B et al (2006). Use ofcollaborative problem solving to reduce seclusion
and restraint in child and adolescent inpatient units.
Psychiatric Services 57:610-612.
Grunebaum H (2003). Biopsychosocial psychiatry. American
Journal of Psychiatry. 160:186.
Havens L (2005). Psychiatric Movements: From Sects to Science.
New Brunswick : Transaction Publishers.

Jellinek MS, McDermott JF (2004). Formulation: Putting thediagnosis into a therapeutic context and treatment
plan. Journal of the American Academy of Child andAdolescent Psychiatry 43:913-916.
Keely E, Dojeiji S, Myers K (2002). Writing effective
consultation letters: 12 tips for teachers. Medical
Teacher 24:585-589.
Lewis-Fernández R, Díaz N (2002). The cultural formulation:
A method for assessing cultural factors affecting theclinical encounter. Psychiatric Quarterly, 73:271-295.
McHugh PR (2005). Striving for coherence: psychiatry’s efforts
over classification. Journal of the American Medical
Association 293:2526-2528.
McHugh PR (2005). The Mind Has Mountains. Baltimore: The
Johns Hopkins University Press.
McHugh PR, Slavney PR (1998). The Perspectives of Psychiatry(2nd ed). Baltimore:The Johns Hopkins University
Press.
McLaren N (1998). A critical review of the biopsychosocial
model. Australian and New Zealand Journal of
Psychiatry 32:86-92.
Meyer A (1948). The Commonsense Psychiatry of Dr. Adolf Meyer.
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Pumariega AJ, Rothe E, Mian A et al (2013). Practice parameterfor cultural competence in child and adolescent
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Tauber AA (2005). Medicine and the call for a moral
epistemology. Perspectives in Biology and Medicine 48:
42-53.
Vaillant GE (2012). Lifting the field’s “repression” of defences.
American Journal of Psychiatry 169:885-887.
Winters NC, Hanson G, Stoyanova V (2007). The caseformulation in child and adolescent psychiatry. Childand adolescent psychiatric clinics of North America,
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Wright AF (1997). What a general practitioner can expectfrom a consultant psychiatrist. Advances in PsychiatricTreatment 3:25-32.

Havighurst SS, Downey L (2009). Clinical reasoning for childand adolescent mental health practitioners: The
Mindful formulation. Clinical Child Psychology andPsychiatry 14:251-271.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.10.1
EXERCISES
Read this case vignette and write:
1. A formulation following the biopsychosocial model focusing on risk for a clinically significant depressive disorder
2. A formulation following the Four Ps model focusing on suicidality
3. A letter to the referring professional outlining the result of your evaluation and your recommendations.
See model responses in the next pages.

A CASE, FORMULATED
A composite case is presented, followed by a biopsychosocial formulation focusing on risk
factors for depression, and a Four Ps formulation focusing on suicidality.
A fourteen year old girl, Sara, comes to the clinic after trying to swallow a handful oflithium tablets during an argument with her father. She was stopped by her father and thenthrew the pills on the floor.
Her chief complaint when she meets you is that that she is depressed and angry.
She says she was angry that her father wanted her to go back to her hometown to live withher mother. Her father had become increasingly frustrated that Sara was smoking so much
marijuana and failing at school. Sara says that her depressed mood preceded coming to livewith her father. She says she has had months of trouble falling asleep because she’s ruminatingon her day’s failures, and then can’t wake up because she’s exhausted after a long night oftossing and turning. She says she can’t concentrate in her new school, which is why she says
she leaves school every day to smoke marijuana. She says it helps her focus and relax andis the one time she enjoys being her new friends. She misses being with her old friends. Shesays that she has no desire to die right now, but that when she gets really upset she thinks
about wanting to be gone forever, particularly because her parents would be sorry and would
miss her.
Her father adds that she has been irritable for about two months since joining him in
the city and that she wasn’t like this as a little girl. He says that it has been worsening recently
as her school performance has worsened. He says that during arguments she has said withincreasing vigor that she wishes she weren’t alive. He took her to a doctor who prescribed
lithium for mood lability, irritability and depressed symptoms. Neither Sara nor her father reportthat she has ever had any psychotic episodes or manic symptoms, although she has been
anxious at times, just like her mother was. Her father says that he has no psychiatric history but
her mother was “moody” and tried to kill herself when he first said he was leaving for the city.

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IACAPAP Textbook of Child and Adolescent Mental Health

Biopsychosocial formulation focusedon risk for a clinically significant
depressive disorder

A Four Ps formulation for suicidality

Sara is a fourteen year
old girl with symptoms ofdepression, including depressedmood and irritability, trouble
sleeping, poor concentration,negative ruminations and a
recent interrupted suicide
attempt. Biological risks for a
depressive disorder include afamily history of mood lability;
substance abuse, which may be
exacerbating her depression or
her performance in school; andlithium toxicity. Psychologicalfactors include ongoing distressover her parents’ separation,
feeling trapped between them,and school failure. Social
factors include decreased
supervision now that she has
moved to live with her father,
distance from her old friends
and family, and conflict with new
friends at school.

Sara is a fourteen year
old girl with symptoms ofdepression and a recent suicide
attempt. Predisposing factors
for suicidality include hermother’s history of suicide
attempts; Sara’s suicidal
ideation, expressed as threats
during arguments with herfather; having less supervisionand being in a new, isolating
environment. Precipitating
factors include the stressesof moving to a new city, being
in a new school, and a fightwith her father. Perpetuating
factors include insufficient
treatment and worsening
depressive symptoms. Protective
factors include strong social
relationships prior to themove, which can be developed,
and a willingness to start newtreatments.

IACAPAP’s Pacifica Study Group
Melbourne, 2013

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IACAPAP Textbook of Child and Adolescent Mental Health

Letter from the child psychiatrist to the referring family
physicianJanuary 20, 2014
Dear Dr NN,
Thank you for referring Sara, a 14 year old
girl living with her father, for evaluation of her
suicidality. I saw her on her own and together
with her father on two occasions. I also spokewith one of her teachers.
Sara describes having been unhappy and cranky
for some months, smoking marijuana daily andnot doing well at school. Father confirmed thesebehaviours and said they were having increasingarguments because of his concern about her using
marihuana and wanting her to stop. Following oneof these arguments she tried to poison herself
with lithium tablets (prescribed by anotherphysician) in the presence of her father. She
denied having a current plan to harms herself.
This resulted in the referral. Sara was describedby her teacher as finding it hard to settle in
the new school, having few friends and drifting
towards troublemakers.
Sara is an only child. Parents divorced
several years ago following considerable maritaldisharmony and after father deciding to come tolive in the city. Sara used to spend the holidays
with her father and requested to live with him
two months ago. Relationship between Sara andher mother had been strained for some time. Her
father says that he has no psychiatric history but
her mother was ‘moody’ and tried to kill herself
when he first said he was leaving for the city.
Sara was born following a normal pregnancy anddelivery. Milestones were average and she wasdescribed as a bright, happy and cooperative
child. She was average at school and had a few
friends. Menarche was at age 12. Her behaviours
seemed to change at that point: she became moody,
had frequent arguments with her mother and began
to challenge limits.
Sara presented as well groomed, appropriately
dressed young woman who looked older than herage. She was articulate and able to give a goodhistory. However, there was obvious tension
between her and her father. When seen on herown, Sara was articulate and able to give a goodhistory. She described having been unhappy every

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Purpose of theconsultation

Summary of
the history

Summary of
the family
situation

Briefdevelopmental
history

Summary of MSE

19

IACAPAP Textbook of Child and Adolescent Mental Healthday for some time; she had lost interest in
everyday activities and pastimes, had recurring
thoughts that she may be better off dead, mainly
after arguments with her father. Her school
performance, concentration and motivation had
deteriorated also. She was sleeping and eating(she attributed this to the marijuana use) morethan usual. She denied and there was no evidenceof hallucinations, delusions, obsessions orcompulsions. She seemed of average intelligencebut was not formally tested. Sara appeared to havesome insight into her behaviour and prepared toattend treatment but was not motivated to stopusing marijuana at this point (“it is the only
thing I actually enjoy”). She scored in the mildlydepressed range in a depression rating scale.
I summary, Sara is a fourteen year old girl withsymptoms of depression and a recent suicide
attempt. I consider her current suicide risk
as mild to moderate. Predisposing factors for
suicidality include her mother’s history ofsuicide attempts; Sara’s suicidal ideation,
expressed as threats during arguments with herfather; having less supervision and being in a
new, isolating environment. Precipitating factors
include the stresses of moving to a new city,
being in a new school, and a fight with her father.
Perpetuating factors include insufficient treatment
and worsening depressive symptoms. Protective
factors include strong social relationships
prior to the move, which can be developed, and awillingness to start new treatments.
Sara’s symptoms are also consistent with a major
depression of mild to moderate severity comorbidwith marijuana use disorder. She has not benefitted
from treatment with lithium carbonate.
Management wise I would suggest that Sara istreated with interpersonal or cognitive behaviour
therapy, initially addressing her depressive
symptoms and her substance use. Her father may
also need to be involved. Medication is notrecommended at this stage.

Symptoms present
Key symptoms
absentInsight
Investigations

Formulation

Diagnosis

Summary ofmanagement

Yours sincerely

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