IACAPAP Textbook of Child and Adolescent Mental Health

INTRODUCTION

ChapterA.5

THE CLINICAL EXAMINATION OF
CHILDREN,
ADOLESCENTS AND THEIRFAMILIES
Thomas Lempp, Daleen de Lange, Daniel Radeloff & Christian
Bachmann
Thomas Lempp MD
Department of Child andAdolescent Psychiatry,
Goethe-University of Frankfurt,
Germany
Conflict of interest: nonereported

Daleen de Lange MD
Okonguarri Psychotherapeutic
Centre, Namibia
Conflict of interest: nonereported

Daniel Radeloff MD
Department of Child andAdolescent Psychiatry,
Goethe-University of Frankfurt,
Germany
Conflict of interest: nonereported

Christian Bachmann MD
Sherlock Holmes statue at
Meiringen, Switzerland(Wikipedia commons)

Department of Child andAdolescent Psychiatry, Charité- Universitätsmedizin Berlin,
Germany

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 2012. 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. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Lempp T, de Lange D, Radeloff D, Bachmann C. The clinical examination of children, adolescents and theirfamilies. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child andAdolescent Psychiatry and Allied Professions 2012.

Clinical examination

A.5

1

IACAPAP Textbook of Child and Adolescent Mental Health

WAYS OF READING THIS CHAPTER•

You are a beginner in the field of pediatric mental health:
Welcome to this exciting subspecialty! We are inviting you to sit backand read the whole chapter.

•

You are already experienced and trying to improve your examination
skills:We suggest that you read the clinical pearls in the right column andtry them out in your practice. If you wish, you may collect more ofthem and share them with clinicians all over the world by sending
them to the authors for the next edition of this chapter.

•

You are experiencing difficulties with a specific patient’s diagnostic
assessment:
We suggest that you read the troubleshooting box at the end of
this chapter (pages 23-24). If this does not help, check our reading
recommendations in the references section (pages 24-25).

Conflict of interest: nonereported
Acknowledgements: ourgratitude to Friderike Fornoff(University of Frankfurt)
and Joseph Rey (University
of Sydney) for their help in
preparing this chapter.
Would you like to share your“clinical pearls”?
If you have comments
regarding this chapter,
especially more clinical pearls
from your own work you arecordially invited to send us yoursuggestions to lempp@em.unifrankfurt.de
The Sherlock Holmes
illustrations are from Sidney
Paget (1860-1908), who
illustrated Conan Doyle’s
stories in The Strand magazine.

Why should I read this chapter?
In many respects it seems worthwhile giving special attention to the clinicalexamination process in child psychiatry (except when otherwise specified, “child”
refers to “child” and “adolescent”):•

It is obvious that there has to be a thorough and comprehensive
diagnostic evaluation before treatment can be considered. If the diagnosis
is wrong, incomplete, not understood or accepted by all parties
involved, the chances of treatment failing are fairly high. The planningand initiation of a treatment regime in child and adolescent psychiatry
is usually time-consuming and costly. Therefore, the time spent in the
diagnostic process to create a valid and solid foundation for effective
treatment planning is wisely invested.

•

There are distinctive developmental aspects in the mental healthexamination of children and adolescents, which deserve special
attention. Children and adolescents are not little adults. They cannot
be assessed in isolation, speak a “different language” to the clinician andrarely seek help by themselves.

•

Especially for beginners in the field, it is easy to get confused by theamount of information and by inconsistent reports. To minimize this,
it is helpful to be clear about the aims of the evaluation process. The art
in daily practice is in finding the balance between standardization andindividualization when using different methods to reach these aims.

Distinctive aspects of the mental health examination in children andadolescents•Children rarely initiate psychiatric assessment and the referral istypically requested by someone other than the patient (e.g., parents,
teachers, pediatricians, courts). This can be of paramount importancein the interpretation of the case. Perhaps the adult’s expectations for thechild exceed the child’s abilities, or the parenting style may result in apoor fit between parents and this particular child, and parents seek to

Clinical examination

A.5“I like to think of myself as
Sherlock Holmes during
this time. I use the more
obvious clues (usually thepresenting complaint) to
begin the investigation,
as well as “digging
deeper” to understand thenature of the symptoms
and behavior, and thebiological, psychologicaland social factors, which
are precipitating andmaintaining the impairing
symptoms.” (Stubbe, 2007).

“Whatever the age ofthe child, and whatever
the clinical issue, it isimportant that the interview
combines an appropriate
degree of structureand standardization(which are essential forcomparability acrosschildren) and sensitivity to
the unexpected and to theindividual issue.” (Rutter &Taylor, 2008).
Be clear about the aims
and flexible in the methods.

2

IACAPAP Textbook of Child and Adolescent Mental Healthchange the child in order to remedy this poor fit. In other cases, parents
or teachers have mental health problems of their own, which alter theirperception of the presenting child in a negative way. In summary:− It is necessary to consider both the child’s and adults’contribution to the distressing behavior for which examination is
being sought− We need to pay explicit attention to the child’s perception of the
problems and what the child desires to change.
•••

Children need to be evaluated in the context of the family, the school,
the community and the culture, which means that no child can beassessed in isolation. Moreover, most children function differently in
different settings and it is helpful to know which surroundings improveor worsen the distressing behavior – also to identify the child’s areasof strength. Thus, the simultaneous examination of parental andfamily functioning is crucial, as is the need for multiple informants.
Building rapport with all the parties relevant to the case who may haveinformation or who could play a helpful role in furthering the child’s
progress is essential. Parental permission should also be obtained. For
example:− Parents living apart from the child (it is often helpful to involve
both parents to the greatest extent as early as possible)− Teachers (by phone or email, examination of school records
and obtaining teacher rating scales). A teacher will have seen
hundreds of children of a given age or grade level to serve as abasis of comparison, in contrast to the parent of an only child.
− General practitioners and pediatricians− Any past and current mental health provider− When appropriate: siblings, grandparents, child caretakers,
stepparents− For inpatient children: nursing staff, social workers, teachers,
physical- and occupational therapists.
The presenting problems must be considered in a developmental context.
Developmental factors often influence the presentation of psychiatric
symptoms (e.g., depression presents differently at different ages). Whilesome disorders look quite similar in children and adults (e.g., obsessive
compulsive disorder), other disorders are notably different in younger
children as compared to adolescents or adults (e.g., PTSD). Behavioral
problems in children can be due to a delay in skill development (e.g.,enuresis or bedwetting), the loss of previously attained skills (e.g.,consequence of a serious disorder, loss or trauma), or inability to selectappropriate skills from an existing repertoire (e.g., conduct disorder).
In summary, one needs to be aware of normal and abnormal childdevelopment, including the range of behaviors that can be observed
at different ages, contexts and the various forms of disturbance in eachdevelopmental stage (see Chapter A.2).
Children’s ability to reflect and discuss their feelings or experiences
is influenced by maturational factors. This means that child andclinician are at different developmental levels and speak “different
languages”. Moreover, stage-specific developmental features can
impede communication. For instance, younger children may not trust

Clinical examination

A.5

No child can be assessed
in isolation!

“There should be no
combination of events forwhich the wit of man cannot
conceive an explanation.”(Sherlock Holmes, “The
Valley of Fear”)

3IACAPAP Textbook of Child and Adolescent Mental Health

unfamiliar adults, adolescents often perceive clinicians as simply another
adult imposing expectations or judging them. Therefore, informationgathering from the child often requires modes of communication otherthan question and answer or verbal discourse. Children of different
ages need different methods of collecting data and interviewing (e.g.,observing a baby, playing with preschool children, talking directly
about symptoms to articulate children or adolescents, drawing with
anxious or uncommunicative children)•

The clinical assessment of children typically requires more time thanadults (about 2 to 5 hours), thus using time efficiently is an importantconsideration. Rating scales and questionnaires is a way of increasing
efficiency (see below), but can never replace a thorough face-to-faceevaluation.

AIMS OF THE EXAMINATION“It is a capital mistake totheorize before one has thedata. Insensibly, one begins
to twist facts to suit theories,
instead of theories to suitfacts”(Sherlock Holmes, “A
Scandal in Bohemia”)

Before beginning the examination it is essential to be clear about its aims.
While the methods to reach this goal might differ in individual patients andfamilies, the aims are quite consistent, namely to:•Create a good therapeutic relationship. The need to develop a good
alliance between the multiple parties, especially between the clinician
and the child, the clinician and the parents and with other, possibly
helpful, family members as well as outside agencies. A rupture in these
relationships can dramatically interfere with treatment efforts•

Understand the exact reason for referral (“Whose problem is it?” “Whynow?”)•

Identify the child’s and parent’s implicit and explicit expectations andconcerns about the evaluation•

Identify the main complaint of the child and the family•

Evaluate the child in the context of his or her current functioning in
the family, the school, and with peers, with sensitivity to cultural orcommunity influences and the extent this has been impaired by thecurrent problem(s)•Obtain an accurate picture of the child’s developmental functioning frombirth to now and to obtain a picture of the parents and family functioning,
and family history concerning medical and psychiatric disorders•

Identify individual, family or environmental factors that may becausing, accelerating or ameliorating the presenting difficulties•

Condense all the information obtained into a clinical formulation.
That is, the clinician’s distillation of the data put together in a coherent
fashion to understand the multiple factors which are contributing to
the presentation. This understanding will inform diagnosis, prognosis,
and treatment recommendations•

Communicate this clinical formulation and recommendations to theparents and the child in an understandable and constructive way•

Establish target symptom priorities and clarify the focus of treatment

Clinical examination

A.5

In short, the aims of
the evaluation are theintegration of the complex(and sometimes disparate)
information gleaned fromthe examination process,putting it into a certain
context to understandthe child’s behavior andto clarify the treatment
focus and appropriate
interventions for thisindividual case.

The first diagnostic steps
are observation andcollection of facts.
It is a mistake to movequickly relying on single
symptoms.

4

IACAPAP Textbook of Child and Adolescent Mental Health•

Discuss with the patient and the family the relative benefits and risksof the proposed treatments and to identify and discuss all relevant
environmental factors which may influence adherence to treatment•

Achieve all this in a time-efficient manner.

BRINGING BUILDING BLOCKS TOGETHER
There are no specific biological or radiological markers for the diagnosisof psychiatric disorders (yet). In their absence, the multimodal diagnostic process
is the gold standard for the examination of mental health problems. This meansthat we cannot trust one specific method to make a valid diagnosis (e.g., to givea family a definitive diagnosis after one interview or after filling out a couple ofquestionnaires). Instead, it is necessary to collect different diagnostic building
blocks (e.g., separate interviews with parents and child, rating scales from teacher,psychometric assessment). If these blocks fit together (i.e., point in the same
direction) we can build a diagnostic wall out of them (i.e., the diagnosis). Standingon this more or less solid wall we can see a picture of the whole problem. Only
then are clinicians in a position to make appropriate recommendations. The final
diagnosis, treatment recommendations and prognosis must only be made in lightof all these circumstances.
Before you start to build the diagnostic wall (see below: Setting the stage),
we suggest collecting at least four basic building blocks:
1. Parents and child interview
2. The mental status examination“We balance probabilities
and choose the most likely.
It is the scientific use of theimagination.”(Sherlock Holmes, “The
Hound of the Baskervilles”)

3. The medical history and the physical examination
4. Rating scales and psychometric assessment.
Combining these blocks usually helps to find the suitable diagnosis according
to one of the two major classification systems: the Diagnostic and Statistical Manualof Mental Disorders (DSM-IV; American Psychiatric Association, 2000), and theInternational Classification of Diseases (ICD-10; World Health Organization,1996).
Comorbid problems
Parents and teachers usually describe the most prominent symptoms intheir children or those that cause them the most concern, with the result that someproblems can be easily overlooked. Internalizing symptoms, such as anxiety or
depression, can be difficult for children to describe and tend to be less troublesome
or apparent to adults than disruptive or externalizing symptoms (e.g., thoseseen in ADHD or conduct disorder). Comorbidity (the presence of more than
one concurrent disorder) is extremely common in child mental health; the cooccurrence of several disorders has implications for treatment and prognosis.
Differential diagnosis
Differential diagnosis is the method used to systematically identify thepresence of a disorder when several alternatives are possible. Psychologicalsymptoms are often equivocal diagnostically in that they often occur in various
disorders (e.g., irritability can be found in depression, bipolar disorder, ADHD,

Clinical examination

A.5

Be as transparent as
possible with the patient
and the family, especiallyat the beginning of theexamination.

5

IACAPAP Textbook of Child and Adolescent Mental Healthanxiety etc.) thus, disorders that share similar symptoms should be considered andsome excluded.
Setting the stage
The aim of this part of the examination is to build a good therapeutic
relationship with the child as well as the parents − right from the beginning − andto clarify all relevant administrative aspects, the reason for referral and expectationsof all relevant parties.
The right place
To reduce possible fears of the patients it is helpful to evaluate them in aroom with enough space, pleasant lighting, colored pictures on the walls and tohave at hand toys, pencils and paper.
A good therapeutic relationship from the beginning
Building of a good therapeutic alliance is a key consideration right fromthe start. Most families and children are intimidated by the prospect of seeing aclinician in a mental-health setting. Increasing the degree of transparency usually
helps lessen this difficulty. Often, it is effective to explain in advance every step of
the process, especially at the beginning – what you will do, why and how long it
will take.
Young children may need to be reassured about where they are going andwhich kind of doctor they will meet (e.g., “a feelings doctor”, “a talking doctor”,“a hospital for emotional problems”) and that there will not be needles or painfulphysical procedures. Children usually have no idea, or a false idea, of what occurs
in a mental health examination and may be afraid of being hospitalized, taken
away from the family or otherwise punished, especially if their difficulties havebeen a source of recrimination within the family. Parents and relatives are often
misinformed and may share some of these beliefs; it is also helpful to explain tothem what type of professional you are.
Administrative aspects
Make clear what the psychiatric examination entails, how long it will takeand what the family can expect at the end (e.g., a verbal recommendation, awritten report). The cost (if fees are involved) needs to be clarified at the onset.
It is important to ascertain also if there are financial or insurance limitations,which may influence the diagnostic process or treatment options. Scheduling,
confidentiality, and permission to contact other people to obtain information
should also be discussed right at the start. Parents should be asked to bring copies
of as many school reports as possible.

Example of how to explain
your profession:“I am a child andadolescent psychiatrist– a medical doctor
who is specialized inunderstanding and treating
emotional and behavioral
problems in children andteenagers. My first job isto try to understand the
problems you have…”

School reports should beroutinely checked for:•Sudden or gradualdecline in output or
performance•
Large differences
in marks in different
school subjects•
Comments aboutsocial and behavioral
problems.

Clarifying the reason for referral
Before you start, consider the purpose of the evaluation so that you structure
the examination to fit the reasons for referral. For example, assessment will differ
if the purpose is to prepare a court report in a custody dispute, if the evaluationis requested by social services, or the consultation is sought by parents concernedthat their child may be suicidal. This minimizes the chances of frustrating anddisappointing your patient, the family or other people.
Children often do not understand why they are going to see a mental
health practitioner because they do not feel ill − they may be attending because

Clinical examination

A.5

6

IACAPAP Textbook of Child and Adolescent Mental Healthof promises of ice cream or other treats after the appointment. School teachers
may want the child to show more self-control and push parents to manage thechild differently or consider medication. The mother may want the examination
to validate her parenting efforts; the father may want a diagnosis that would allow
access to additional school resources to improve the child’s school performance,
while the grandmother may wish for a totally different (“old-style”) parenting
approach.

“Whose idea was it thatyour child might need thisevaluation?”

Important questions in this part of the examination are:••••

Who initiated the referral and why? (e.g., parents, pediatrician, school,
court, the patient, emergency department)
Who else is concerned about the child and for what reason?
Why now?
What are the key concerns or questions for which people want a
response?

If there are conflicting reasons for the referral and you become confused,remind yourself that, when in doubt, you are the child’s clinician. Try to keep yourexamination focused on what you believe will ultimately lead to the best possible
outcome for the child.
Handling expectations
A common source of frustration is wrong or inflated expectations. It is
helpful to check the expectations of the family at the beginning of the interview.
This helps to build rapport and understanding. Preparing families for what toexpect diminishes parent and child anxieties. Managing expectations may requireclarifying what the examination process can or cannot fulfill.

Two crucial questions one
needs to ascertain at the
beginning of the examination:•
Whose problem is it?
•
Why now?

“What do you hope
this examination willaccomplish?”

PARENT AND CHILD INTERVIEW
Who should I talk to and in which sequence?
It is informative and reasonable to have the child together with the parents
at the beginning of the diagnostic process. Later on, it is helpful to interview
the patient and parents separately. While there are no hard and fast rules about
how to do this, it is mandatory to interview patients by themselves at some stage,
particularly to clarify issues that patients may not feel comfortable talking about
when parents are present such as suicidal thoughts, abuse or sexuality issues.

The child is usually thebest information source
for internalizing symptoms
whereas parents can give
reliable information about
externalizing ones.

In most cases, parents will have limited knowledge about their child’s innerfeelings, experiences outside of home and performance at school. Disagreements
between parents, child and teachers are common. Studies have shown thatagreement between parents and child are low to moderate (e.g., Achenbach etal, 1987; Salbach-Andrae et al, 2009). School-age children and adolescents arethemselves the best informants for anxious or depressive feelings, suicidal ideation,and behaviors the parents may not be aware of − such as sexual activity, sexual
identity issues, sexual abuse, drug use, obsessive thoughts, and hallucinations.
On the other hand, parents are a good source of information for behaviors suchas deceitfulness, overactivity, inattention, impulsivity, non-compliance, andaggression.

Clinical examination

A.5

7

IACAPAP Textbook of Child and Adolescent Mental Health

How should I formulate my questions?
It is adequate in almost all cases to start with one to three open-ended
questions. This helps to establish rapport and avoids premature narrowing of focus.
In addition, it is useful to allow parents to tell their version of the problem forat least several minutes. This helps to clarify what truly concerns them, allows
them to feel heard and understood by the clinician. It is helpful and improvescommunication to later on use parents’ actual words (e.g., “You talked about the
special hours of your little lion in the evening. When did they first happen?”)Using parents’ actual words
in the interview can help
ensure that parents feelheard.

As the interview progresses you can use more and more follow-up questions
to clarify details, and screening questions to check areas not yet mentioned. If these
do not reveal significant information, move on to another topic.
Who is truthful?
As already mentioned, disagreements between observers’ descriptions ofchildren’s behavior are common and have several potential sources:••••

Disagreement actually reflects differences in the behavior of the childin different settings or with different observers
Different standards when judging the child’s behavior
Ignorance about how other children of the same age behave
Observers’ biases.

To manage discrepant reports, it is useful to collect information from as
many sources as possible giving more weight to those that appear more reliablein the clinicians’ opinion. In most cases disagreements are more the result of
looking at the child from different perspectives or in a different contexts than oftruthfulness. The more perspectives from which you obtain information, the more
complete your understanding will be and the more accurate the assessment.
Important topics to ask about
There are five key areas of interest in the clinical examination; you may use
the acronym SIRSE to remember them:• Symptoms• Impact• Risk factors• Strengths• Explanations.
Symptoms
The initial focus should be on the symptoms that led to referral and thosethat cause most distress to the patient and the family (main complaint). Importantcharacteristics about the problematic behavior that need to be elucidated are:
• Frequency (changes over time?)• Intensity (changes over time?)• Duration• Context in which the behavior emerged• Progression of the problem.

Clinical examination

A.5

Many parents become
distressed when describing
their child’s deterioration.
Giving parents theopportunity to narrate
this history in their own
words, even if it is initiallyconfusing, may help.

8

IACAPAP Textbook of Child and Adolescent Mental Health

The next step is to obtain a detailed history of the problem(s). A goodunderstanding of their evolution is necessary to ascertain the right diagnosis. For
this, it is important to clarify whether a problem:• Has been present since early childhood (e.g., symptoms of autism)•

Is intermittent or recurrent (e.g., depressive or manic symptoms, tics),
or•Represents a deterioration from a previously higher level of functioning(e.g., schizophrenia).

Check the impact ofsymptoms on the patient,family, school and peers.

In this part of the examination one also gathers information about all
previous treatments including medication, counseling, hospitalization, or use of
traditional, complementary and alternative medicine (see Chapter J.2).
ImpactNext is to ask about the impact of these symptoms on the daily life of thechild and family members: effect on the patient’s quality of life, siblings, parents’relationship, extended family, school class, academic performance, contact withpeers, and development. This includes finding out in what context(s) the problems
occur and in which they do not or occur to a lesser extent (an example of marked
symptoms in the absence of impairment is frequently seen in specific phobias).
Remember that problem behavior may reflect:•

An underlying disorder in the child•

A mismatch between the child and the environment•

A problem within the child’s environment, or•Usually, a combination of all the above.

Risk factors
The next step entails screening for relevant risk factors, currently, in the past,and in the extended family (family history). Important risk factors are genetic,
developmental, familial, and social. Most of the presumed causes of mental healthdisorders in children are better understood in terms of risk factors. There are threedifferent kinds of risk factors and it is useful to divide them into “the 3 P’s”:•

Predisposing factors, which render the child vulnerable to a disorder(e.g., genes, birth weight, gender)•

Precipitating factors, which are associated with the emergence orworsening of symptoms (e.g., onset of puberty in anorexia nervosa)•

Perpetuating factors, which maintain the symptoms (e.g., inadequate
parenting style, lack of professional intervention, no access to healthservices).

A matching analogy is the wind, which blows through a hole in a window.
Before the hole existed, the glass might have been fragile in one spot (predisposing).
The glass was then hit by a stone (precipitating) and there were no craftsmen toseal the hole (perpetuating). So the wind is still blowing (symptoms of the disorder)(Goodman & Scott, 2005).

Risk factor
A risk factor is somethingthat increases the chancesof developing a disease.
This may come from what
one does (e.g., using
cannabis increases the riskof psychotic symptoms).
Other times, there isnothing one can do about
the risk. It just exists.
For example, adolescentfemales are more likely
to suffer from depression
than males. So, gender is
a risk factor for depression.

Before beginning to ask
questions about thedevelopmental history
it is helpful to explain to
the parents why this isnecessary. Otherwise theymight get confused about
these issues.

Developmental history. This is a detailed account of the child’s developmentfrom the beginning of the pregnancy to birth and early development. It is helpful
and time efficient to use a structured approach with screening questions about

Clinical examination

A.5

9

IACAPAP Textbook of Child and Adolescent Mental Healthimportant milestones (see Table A.5.3) and follow-up questions, if necessary.
Parents often vary in their recollection and timing of developmental milestones.
Check for problems in:•

Basic functions (sleeping, eating, toilet training)•

Psychomotor milestones: walking, sitting, fine and gross motor skills,
handwriting skills•

Cognitive development and school functioning: history of the child’s
language development, reading, writing and math skills. Progress at
school requires some innate cognitive abilities but also reflects thechild’s motivation, capacity to concentrate, attitude towards authority,
capacity for peer relations, tolerance for frustration and delayed
gratification, and a degree of parental support for learning•

Interpersonal development: reaction to separation early in life, ability toplay with other children, stability of relationships, number of friends,
types of activities shared•

Emotional development and temperament•

Trauma history: physical, sexual, emotional, neglect, acute or chronic,
intra- or extra-familiar, violence, natural disaster•Harmful behavior: head banging or self-injurious behavior, thoughts
or comments about death, self-mutilation, cutting, and harmful acts
toward other people or animals.

Family history. This includes (screening) questions about current and pastfamily functioning and about neuro-psychiatric disorders in other members of
the family (e.g., alcohol dependency, substance abuse, suicide, and unusual or odd
behavior in relatives). Knowing about mental health disorders in the family canhelp in finding the right diagnosis (e.g., a mother with alcohol dependency could
lead to the consideration of a fetal alcohol syndrome).
The possible parental genetic contribution to the disorder of the child should
be assessed (e.g., the existence of bipolar disorder in the father would cast his
son’s depressive symptoms in a different light), but almost no psychiatric disorderappears through genetic transmission alone, although increased vulnerability tovarious disorders is likely (Luthar & Prince, 2008). Though unspoken during thepsychiatric evaluation, many parents fear that their other children may be destined
to be affected when one sibling has a disorder, so clarification of the genetic
contribution to the expression of disorders can often be helpful in reducing fear,
guilt, and distress among parents and siblings.

Possible trauma screening
question to parents: “Hasyour child ever witnessed
anything really bad orfrightening?“
Possible trauma screening
question to the child: “Hasanyone ever tried to hurtyou?”

Particular attention shouldbe paid to changes ordiscontinuities in thedevelopmental progress.

It should be routine to ask
about the neuro-psychiatricdisorders on both sides ofthe family.

The clinician should be
attentive throughout theinterview to parents’
psychopathology (e.g., adepressed mother will often
give more negative reports
about a child’s behavior
than a parent who is notdepressed.)Strengths
It is a capital mistake to focus only on the patient’s and family’s deficits andto neglect the almost always existing strengths, which can give important hints
for treatment. Such an approach supports the self-esteem of both the child andthe parents and provides information about factors that may help to ameliorate orcompensate areas of vulnerability.
Explanations
It is very informative to ask about the ideas parents have about the natureand causes of their child’s behavior in order to know what psychoeducation

Clinical examination

A.5“It is important thatthe tenor of diagnostic
inquiry should convey anappreciation that the childis not merely a patient or
bearer of symptoms” (King,
1997)

10

IACAPAP Textbook of Child and Adolescent Mental Healthinterventions may be necessary. To understand how parents and the childunderstand the evolution of their symptoms can also give important references tothe cultural background of this specific family (Sholevar, 2007).
Concluding the interview
Allowing the interview to end in a collaborative fashion increases thelikelihood that child and family will feel positive about it and any subsequentclinical encounters. Suitable questions at this stage are:• “What else have I not asked about that is important?”• “I have asked you a lot of questions. Do you have any questions for me?”

“When I meet the parentsof a child who suffers froma mental disorder, the firstthing I ask them is to tellme what is the most special
thing about their child,
which abilities, resources,
feelings, and talents theyrecognize in him/her.”(Giovanni Bollea, Italianchild psychiatrist)

INTERVIEW WITH PARENTS
Aims of the interview with parents
The parental interview seeks to clarify:• Which aspects of their child’s behavior is of greatest concern to them
• What they have tried in order to deal with the problem• The impact of the child’s disturbance on the rest of the family• If the problem behavior is situation-specific or pervasive (e.g.,
restlessness and inattention at school but not anywhere else could cast
doubt on the presumptive diagnosis of ADHD)• If there are neuropsychiatric disorders in the family.

Parents sometimes fearthat they are the only ones
who have a problem with
their child. It can be a relief
to hear from the clinician
that such problem is notuncommon and that he or
she has seen and helped
many families with this typeof problem.

Standardized interviews
Standardized interviews (diagnostic tools with specific questions in a given
sequence) are often used in research but can also be an effective help in daily
practice. On the one hand, especially for beginners, standardized interviews(especially for developmental and family history) can help cover the key domainsof psychopathology. They ensure that clinicians inquire systematically about abroad range of symptoms, particularly those that may be clinically significant but
are not the presenting complaint. Using these instruments makes it less likely thatcomorbid disorders will be missed. On the other hand, these tools can never takethe place of an individualized psychiatric interview; they cannot be relied uponas the sole basis for establishing diagnosis or planning treatment. Further, manyare only symptom inventories and do not ask for important symptom-related
information like situational context, ways of coping, feelings etc (Le Couteur &Gardner, 2008).

THE CHILD INTERVIEW
The aims of the child interview are to:• Gain the child’s trust. In general, the younger the child, the more timeis needed to achieve this• Obtain the child’s perception of the problem• Get a good understanding of the child’s current developmental stage• Obtain information about emotional symptoms, traumatic events,
delinquent acts, drug use, sexual problems• Collect data for the mental status examination (see below).

Clinical examination

A.5“It is of the highest
importance in the art ofdetection to be able torecognize, from a number offacts, which are incidental
and which vital. Otherwise,
your energy and attention
must be dissipated insteadof being concentrated.”(Sherlock Holmes, “TheReigate Puzzle”)

11IACAPAP Textbook of Child and Adolescent Mental HealthChildren can often indicate an acceptable point for the parents to leave
the room, usually within a matter of minutes, and transitional objects (blankets,
teddies) may ease this transition, although this may be impossible in cases ofseparation anxiety. The older the child the sooner you should be able to finish theconjoint session. Children often find it embarrassing to listen to their problems
being discussed in front of them.
How to start?
Once parents have left the room, it is wise to begin the interview withneutral topics that may interest the child such as talking about favorite hobbies,
animals, holidays, Christmas or birthday presents. The next step is to inquire about
what the child has been told or understands about the purpose of the interview; thisoften provides information about the relationship and openness of communication
between child and parents as well as on the cognitive development of the child.
Some children need encouragement to express their own concerns, instead of theworries of parents or teachers. Be aware of how you word your questions: younger
children are particularly open to influence of suggestion.
Developmentally appropriate interview techniques
Preschool children should not be expected to sit still during the interview
and the interviewer needs to decide what play material will be made available forthe child. Developmentally appropriate techniques include drawing, playing anddirect questioning. The appropriate method for each case will depend on the ageof the child (the developmental age more than the chronological age) and thepresenting problems (e.g., selective mutism). Inviting the child to draw a pictureis almost always a good start. Direct questions should be short, in simple, precise
vocabulary and deal with one concrete issue at a time (Jones, 2003). For example,
not “Do you get into trouble at school, get along with other students and likesports?” but “Are you getting into trouble at school?”
Getting involved in the child’s play can help to:• Empathize with them
• Assess their affective state• Ascertain their coordination and motor skills• Evaluate speech and language development• Test attention span
• Understand their capacity for complex thinking• Assess their capacity for interactive play and “as if ” games (especially
important when a pervasive developmental disorder is suspected)• Collect information for the mental status examination (see below).
Questions to explore children’s inner feelings include:• “What animal would you most/ least like to be?”• “Who would you take with you to a desert island?”• “What would you ask for if you were granted three magic wishes?”
Interviewing adolescence patients
The overall sequence is similar to when interviewing other children.
However, one would spend considerably more time with the adolescent alone. Itis crucial to avoid the perception that parents and clinician are allied against him.

Clinical examination

A.5“The clinician must beaware of the impact on
the interview process ofperceived differences orsimilarities between theclinician and the child (orparents) in terms of gender,
age, and ethnic or social
background.” (King, 1997)

Without trust and rapport,
valid information is lesslikely to be obtained.

The child’s description offeelings, mood, levels of
distress, and significant
events contribute to abetter understanding of thechild’s predicament.

Generic toys are preferable
since they are more likely
to evoke the child’s specificconcerns rather thanthe prefabricated scripts
associated with toys basedon TV shows or movies.
(Bostic & King, 2007)

The purpose, duration,
confidentiality issues, andthe role of the clinician
should be discussed
early in the child interview
in developmentally
appropriate terms. Sample
questions:•“What did yourparents tell you about
coming here today?”•“How do you feel
about being here?”

12IACAPAP Textbook of Child and Adolescent Mental Health

A suitable way to begin the interview with adolescents is to review and clarify
what the adolescent believes and has been told about the purpose of the interview.
Adolescents are very sensitive to beliefs that they are perceived as weak, weird ordifferent, about being included or excluded, and about fairness and justice. In thisline, useful questions for adolescents include:•“What do you see as fair or not fair in your life?”•“What would you most like to change in your school/ family/ theworld?”•“What are your plans for the next 10 years?”

Contrary to popular beliefs,
asking about suicide will
not induce or trigger it. A
caring clinician may be theonly adult able to talk about
these thoughts with theadolescent.

Confidentiality: “will you tell my parents?”
One of the key concerns among adolescents in relation to seeking medical
help is confidentiality. Adolescents should always be informed of the confidential
nature of the doctor-patient relationship and its limits at the outset: that
confidentiality would be broken without the patient’s consent only if the patient’s
safety or the safety of others is at risk. Many countries impose statutory obligations
on mental health practitioners to report instances of abuse. Laws in this regard varyand clinicians need to be up to date with the local requirements. The best way to
discuss confidentiality is at the beginning of the interview, when the parents andadolescent are present, thus educating parents that what their child discloses is
kept confidential.
Special areas of interest for the interview with adolescence patients•

Antisocial or delinquent behavior (e.g., “Have you done anything thatyou now look back on and think that was pretty dangerous?”)•

Sexual identity and activity (e.g., “Have you ever had romantic feelings
toward anyone?” Try to avoid asking questions to a male/female teenager
like “Is there a girl/boy whom you like?” that may be interpreted by themthat you assume heterosexuality when adolescents may be struggling
with homosexual feelings•

Alcohol and substance abuse (start with previous exposure, context
use – parents, friends, effects of substances – whether they believe that
substances alleviate their symptoms, e.g., self-medicate).

•

Suicidal ideation or behavior, including non-suicidal self-injury (e.g.,“Do you sometimes feel an urge to hurt yourself?”, “Have you ever thoutthat your life was not worth to live?”)

MENTAL STATUS EXAMINATION
The aim of the mental status examination (MSE) is to be an objective
description, not interpretation, of the child’s appearance, symptoms, behavior andfunctioning as manifested during the examination. A well-written MSE enables
another clinician or the same clinician weeks, months or years later to have a clear
picture of the patient’s mental state at the time of assessment. The MSE is an
essential part of any psychiatric examination (see Table A.5.1). Strictly speaking,the MSE is purely descriptive, includes no judgment of whether the appearance
and behavior is normal or abnormal, clinically significant or non-significant.

"Never trust general
impressions, my boy, butconcentrate yourself upon
details."(Sherlock Holmes, “A Caseof Identity”)“The day may comewhen there are drugs thatare specific to particulardiagnoses but that day is along way off at the moment.
Both psychological andpharmacological treatments
need to focus on particularpatterns of symptomatology
rather than the diagnosis
as such” (Rutter & Taylor,
2008)

Most disorders do not show abnormal feelings or behaviors that cannot
be found in normal children or adolescents in some circumstances. The severity

Clinical examination

A.5

13

IACAPAP Textbook of Child and Adolescent Mental Health

Table A.5.1

Mental status examination

MSE component

Take notice of:

ExamplePhysical appearance

•
•
•
•

Age (actual and apparent)
Age-appropriate clothes,Grooming and cleanliness
Dysmorphic features, bruises, scars“Stephanie is a pleasant looking, wellgroomed and appropriately dressed 9-yearold girl who looks older than her age (like a
12 year old)”••

Eye contact
Ability to cooperate and engage withexamination
Behavior towards parents andsiblings“She avoids eye contact but cooperates
with the examination process.”•

Type, range and appropriatenessof affect (e.g., depressed, elated,
irritable)“Stephanie looks depressed (e.g., cries
often, does not enjoy activities andpastimes, feels hopeless), her affect shows
limited variation (i.e., within a narrow range)and she describes a depressed mood”

Anxiety

•
•
•
•
•

Fears
PhobiasObsessions
Compulsions or rituals
Separation difficulties“She shows no evidence of unwarranted
fears or anxiety symptoms”

Psychomotor behavior(including activity level andunusual motor patterns)•••

Tics, mannerisms
Activity level
Coordination“Activity level seems reduced”

Form and content of thinking•••

Hallucinations
DelusionsThought disorder“Thinking is slowed down but coherent.
There is no suggestion of hallucinations ordelusions.”

Speech and language

•
•
•
•

FluencyVolumeRate
Language skills,“Her speech is age-appropriate. There is nopressure of speech.”•••

Developmentally appropriate
vocabulary
Fund of knowledge
Appropriate drawings“Her cognitive ability seems impaired andher vocabulary is below average for herage.”

Attention and concentration••

Attention
Concentration“Becomes easily tired and appears to havedifficulty following conversations over along period.”

Memory••Short-termLong-term“Shows no deficits in recalling events.”

Orientation•

Orientation in time, place, person“Is oriented in time and place.”

•
•
•
•

Acknowledgement of problems
Capacity to judge hypotheticalsituations
Attitude towards receiving help
Compliance with treatment“ patient is aware of the fact that she has aproblem, wants to be helped and cooperatewith treatment”

•
•
•
•

Suicidal thoughts or behavior
Self-harming behavior
Thoughts or plans of harming others
Risk-taking behavior“There is no evidence suggesting suicidalityor threats to others.”

Manner of relating to examinerand parents, including ease of
separation

Mood and affectOverall cognitive functioning

Judgment and insightExamination of risk•

Source: King (2007) modified.

Clinical examination

A.5

14

IACAPAP Textbook of Child and Adolescent Mental Health(amount), pervasiveness and nature (quality) of the symptoms determines theirclinical significance.
Although presented as a separate component that is distinct from thehistory-taking, in reality much of the MSE takes place implicitly as the clinician
interacts and observes the child during the individual and family interviews. Whilesome components of the examination may require specific inquiry or examination(e.g., orientation, memory, specific symptoms such as hallucinations or obsessions)most will be noted as the interview progresses.

Describe before
interpreting
Since any given symptom
may have different
meanings, functions
and clinical implications
in different children it isimportant not to jump fromsymptom to diagnosis.

Clinicians should use every opportunity to observe the patient and his
interaction with others, particularly with the family. For example behavior:• In the waiting room (e.g., how did they choose to sit? Are they talking
to each other? Arguments?)• During the initial greeting and introduction• In the office• Upon separation (e.g., when parents leave the room)
Table A.5.2
diagnoses

Psychiatric symptoms and examples for corresponding somatic differential

Symptom

Differential diagnosis

Depression

•
•
•
•
•
•
•
•
•

Neurological disorders (e.g., tumor, epilepsy, trauma, cerebral atrophy)
Endocrine disorders (e.g., hypo-/ hyperthyreosis, Addison’s disease, Cushing’s disease)
Kidney diseases (e.g., chronic nephritis)
Metabolic diseases (e.g., hypoglycemia)
Infectious diseases (e.g., AIDS, Lyme borreliosis)
Intoxication (e.g., alcoholism)
Malignant disorders (e.g., chronic leukemia)
Pharmacologic: antihypertensives (e.g., beta blockers), antiepileptic drugs, psychotropic
drugs (e.g., neuroleptics, barbiturates), steroids (e.g., glucocorticoids), analgesics
Other: tuberculostatics, antibiotics, cytostatics, antimycotics

Psychosis••••

Neurologic disorders (e.g., brain tumor, epilepsy, encephalitis, infections, multiple sclerosis)
Illegal substances (e.g., marijuana, cocaine, LSD)
Intoxication (e.g., alcohol)
Pharmacologic: psychotropic drugs , anticonvulsants, anticholinergics, steroids, antibiotics

Anxiety•

Substance-use disorders: drugs, amphetamine, cocaine, hallucinogens, alcohol, nicotine,
caffeine, ecstasy, opioids
Neurologic disorders: organic seizures, migraine, multiple sclerosis, increased intracranialpressure, reduced cerebral perfusion
Other medical disorders: hypoglycemia, hypoxia, hyperthyroidism, carcinoid, dysrhythmia,
pheochromocytoma••
Anorexia nervosa

•
•
•
•

Cancer
Endocrine disorders (e.g., hyperthyroidism, diabetes mellitus)
Gastro-intestinal disorders(e.g. Crohn’s disease, ulcerative colitis, gastritis, gastric ulcer)
Malabsorption (e.g. coeliac disease)

Enuresis••••

Urological and genital abnormalities (e.g., urethral valve, labial fusion)
Urinary tract infection
Neurologic disorders (e.g., myelomeningocele, spina bifida, tethered cord)
Other medical disorders (e.g., diabetes mellitus)

Source: Herpertz-Dahlmann & Bachmann (2007), modified.

Clinical examination

A.5

15

IACAPAP Textbook of Child and Adolescent Mental Health•During psychological testing•

During physical examination

MEDICAL HISTORY AND PHYSICAL EXAMINATION
The aim of the medical history and physical examination is to identify
causative, associated or exacerbating medical problems; it has the potential touncover a treatable somatic condition. Medical conditions can:•Increase the child’s risk for psychopathology•

Be relevant for treatment•

May explain the current psychopathology.

While physical illness mimicking psychiatric disorder is relatively rare in
daily practice, knowledge of these possible “diagnostic traps” is important (Table
A.5.2.). If there are hints in the medical history that medical conditions ortreatments play a role in this patient, further investigations should be done.
We suggest a stepwise approach to this part of the examination (time andcost-effective):•

Step 1: brief medical history•

Step 2: basic physical examination.

Don’t forget the somatic partof your diagnostic process,but mental health cliniciansalso need to know when to
accept that a child has beenadequately examined andinvestigated.

If steps 1 and step 2 are unremarkable, it seems reasonable to avoid further
examination and investigations. If further examination is necessary:•

Step 3 (if indicated by steps 1 or 2): investigations and specialist referral.

Past medical history
A systematic history-taking approach should be used as a guide to thepossibility that somatic problems might be relevant with respect to the presenting
symptoms. This includes a clinical history of medical disorders in the patient andin the family. Studies have shown that medical history-taking often influences
management while physical examination only rarely does (Dooley et al, 2003).
Red flags that would suggest the need for a more detailed physical examination(step 3) include:•

Atypical presentation of symptoms or atypical age of onset (e.g.,
hallucinations in a 7-year-old girl)•

History of seizures•

History of head trauma or central nervous system infection•

Regression in development•

Over the 97th or under the 3rd percentile in any of the growth curves•

Suggestions of child abuse or factitious illness (e.g., Münchausen by
proxy)•

Sudden onset of new and odd behavior (e.g., hand flapping in Rett
syndrome)•

Altered level of consciousness, severe fatigue, cognitive changes, andphysical symptoms such as sore throat, fever, headache, nausea, andweight changes

Clinical examination

A.5

Parents will occasionallyreport a loss of previously
acquired skills; thisalways needs to be taken
seriously and should
lead to suspicion ofneurodegenerative disorderand specialist referral.

16

IACAPAP Textbook of Child and Adolescent Mental Health•

Acute onset of obsessions and compulsions and or motor or vocal tics,
particularly following pharyngitis (PANDAS, see Chapters F.4 and
H.5).

The following checklist lists all relevant parts of a medical history in childmental health:Pre- and perinatal development•

Consanguinity of the parents?

•

Use of assisted reproductive technologies?

•

Pregnancy (full range of teratogens: alcohol, tobacco, illicit substances,medications; history of rashes and fever during pregnancy – may
indicate exposure to congenital viral infection)•

Previous neonatal deaths or acute life-threatening episodes in siblings(could be a pointer towards inborn error of metabolism)•

Previous spontaneous abortions (two or more) – one in 20 of theseparents will carry a chromosome translocation or inversion (Gardner& Sutherland 1996)•

Birth and neonatal history: gestational age at birth; weight; APGAR
score, if available (difficult birth is a risk factor for developmental
problems).

Table A.5.3

Overview of developmental milestones

Age

Motor skills

3 months

Holds head steady

6 months

Can roll over

9 months

Sits without support

12 months

Stands alone

15 months

Walks alone
Plays with ballUses 20 single words

18 months

Carries items while walking

Can make two-word sentences

2 years

Can runCan kick a ball forward

Child uses own nameAsks “Why?”Can name at least six body parts

3 years

Jumps, balances on one footUses four to five words in a sentence
Uses singular and plural

4 years

Bounces

Language
Imitates sounds
Combines syllables into word-likesoundsAccidents or illnesses
with a potential for central
nervous system impact
deserve specific inquiry.
•
Lead exposure•
Seizures•
Head trauma•
Loss ofconsciousness.

Uses past tense, recounts experiences

5 years
6 years“The little things are infinitely
the most important.”(Sherlock Holmes, “A Caseof Identity”)

Bounces cross-step

Language development completed*Use only as rough reference.

Clinical examination

A.5

17

IACAPAP Textbook of Child and Adolescent Mental Health

Postnatal development
Early developmental history (up to 5 years). Encourage bringing parentheld records of vaccinations etc to the first examination if available. A general viewof the milestones of development is given in Table A.5.3.
History of past illnesses
Common disorders in childhood (e.g., asthma) should lead to an enquiry
into medications that the child takes, both prescribed and over-the-counter. All
extended hospital stays after birth; surgical procedures; vaccination; states of lossof consciousness and seizures; hearing or vision difficulties; allergies (particularly
to medications); and response or side effects to previous medications should becollected.
The clinician should be especially alert to the mentioning of diseases that
can affect the central nervous system including HIV/AIDS, tuberculosis, lupus
erythematosus, epilepsy, migraine, traumatic brain injury thyroid disorders,
diabetes.
Basic physical examination
Who should do medical examination?
Physicians who keep up their skills to perform a physical examination (forwhich they usually worked hard in medical school) this can provide an additional
opportunity to learn more about the child’s concerns (especially about body-related

Table A.5.4

Skin inspection in child psychiatry

Dermatologic symptoms•

Needle tracks, abscesses or
hyperpigmentation on the arms•

Possible hints for:•

Substance use disorder

Bruises, hematomas of different age••

Child neglect
Physical abuse•

Signs for non-suicidal self-injury (e.g., scars)•

Borderline personality
disordera•••“Café-au-lait” marks after age of 1 year
>1.5cmFreckling in armpits after 3 years

Neurofibromatosis type 1b(rare)•••

Ash-leaf depigmented macules
Adenoma sebaceum
Periungual fibromas•

Tuberous sclerosisc,d (rare)•

Port wine stain usually in the trigeminal region•

Sturge Weber syndromeb (rare)

Click on the picture toaccess an 8-minute crashcourse on neurocutaneous
disorders.

The most common location for non-suicidal self-injuries is the inner part of the left under arm.
Neurofibromatosis Type 1, tuberous sclerosis, and Sturge Weber syndrome areneurocutaneous syndromes (phakomatoses). These disorders affect the central nervous
system, the skin and the eye. All these tissues have a common ectodermal origin.
c
0.4%-3% of children with autism are found to also have tuberous sclerosis (Smalley et al,1991).
d
The best diagnostic test is a cerebral MRI.
ab

Clinical examination

A.5

18

IACAPAP Textbook of Child and Adolescent Mental Healthissues) and about the mental status. For psychologists and other mental healthprofessional with a non-medical education it is practical to find out if there had
been a physical examination of the child in the recent past or to refer the patient
to a physician (optimally, a pediatrician).
A screening neuro-developmental examination is sufficient and does not
require the child to fully undress.
The following parameters should be assessed:•

Height and weight (centile charts)•

Head circumference (centile charts; the most common cause of large
and small heads is simply familial, and thus comparison of mid-parental
head centiles should precede interpretation of a single measurement)•

Blood pressure (use an appropriate cuff for the size of the child –e.g., one that covers two-thirds distance from the elbow to shoulder;interpret with age-appropriate values)

The following procedures should be undertaken:•

Skin check (see Table A.5.4)•

Basic neurological examination:−

Stance and gait−

Tests for cerebellar function (e.g., check for dysdiadochokinesia)−

Tone, power, reflexes−

Abnormal movements (fasciculations, tics, myoclonus, dystonia,
athetosis, hemiballismus, tremor).

Of all the aspects of the neurological examination, observing the child’s
gait is the most valuable. A normal gait depends on intact and delicately balanced
motor, sensory, and coordination systems. A normally walking child is unlikely tohave a severe neurological impairment (Wolf et al, 2008).
Investigations, tests and specialist referral
The range of investigations, tests and specialist referrals available may vary
substantially from country to country. What is described here is the optimalsituation but many of these investigations will not produce positive findings in theimmense majority of cases:•

Blood tests•

Urine tests (toxicology screen, pregnancy testing)•Brain imaging (first choice: MRI; second choice: CT)•

Genetic investigation (key pointers in physical examination: noticeable
dysmorphy of the face, hands and feet; over the 97th or under the 3rd
percentile in any of the growth curves).

•

Metabolic investigation (key pointers in history: consanguinity, failure
to thrive, episodic decompensations, often during minor illnesses;
hepatosplenomegaly, coarse facial features). A general metabolic
screening is more useful than a genetic investigation, EEG or cerebral
imaging, and may therefore be more worthwhile.

•

Electroencephalography (EEG)

Clinical examination

A.5

If you suspect a raremetabolic or genetic disease
and you do not have theoption of referral to a
specialist, click on the picture
to access “orpha.net” andcheck the “search by signs”
function. This portal (forrare diseases and orphan
drugs) is available in English,
Spanish, German, Italian,
French and Portuguese.

Use any chance you haveto see children with rare
disorders. Knowledge ofwhat phenotypes exist isa precondition for theirrecognition. Phenomizer isa site with useful informationthat allows clinicians to entera patient’s clinical featuresand obtain probabilistic
differential diagnoses. For
a tutorial on how to use
Phenomizer click here.

Rating scales are tools tocomplement an evaluation,
not to replace it.

19

IACAPAP Textbook of Child and Adolescent Mental Health•Electrocardiogram (EKG)••

Hearing examination
Eye examination.

RATING SCALES AND PSYCHOMETRIC ASSESSMENT
The aim of this section is to give readers a brief overview of tools that may
assist in finding the right diagnosis and in individualizing treatment.
Rating scales
Rating scales are instruments (paper and pencil or computer-based)
used to collect data about the presence (qualitative measurement) and severity(quantitative) of symptoms. Rating scales can be used as a source of additional
diagnostic information, to monitor and measure the effectiveness of treatment(outcome), and as research tools. They can also be used for screening, to ascertain
whether a child should be evaluated more thoroughly for mental health disorders(Verhulst & Van der Ende, 2008).
Pros and cons of rating scales
Pros:
•
•
•
•

•

Helping to detect problems that are clinically significant but not partof the presenting problem
Helping to conduct a comprehensive examination
Some parents and adolescents may reveal concerns in writing that they
do not verbalize
Rating scales can be completed by parents, teachers, and patientsoutside the interview and so help to make the interview more effective
and efficient
Scales that rate severity can be useful to quantify a baseline to later
assess response to treatment (e.g., ADHD-symptom checklist before
and after treatment with methylphenidate).

"There is nothing more
deceptive than an obvious
fact.”(Sherlock Holmes, “TheBoscombe Valley Mystery”)

Cons:
•
•

Require time and literacy
May be disliked by parents or children

Table A.5.6

The Strengths and Difficulties Questionnaire (SDQ)

PurposeLanguages

Comments

Screening for mental healthdisorder in children andadolescents(Goodman et al, 2000)

Available in 73
languages

•
•
•
•
•
•

Free for noncommercial purposesHigh SDQ-scores –upper 10% in a community sample –were associated with increased psychiatric risk
Used worldwide
Very brief: 25 items all in one page
High specifity but low sensitivity (use only as a screening
instrument)
Can be completed by the patient on-line and get
immediate feedback.

Source: Carandang and Martin (2009).

Clinical examination

A.5

20

IACAPAP Textbook of Child and Adolescent Mental Health•Require time to rate and analyze•

Clinicians may over-rely on them.

There are rating scales for completion by the patient, the clinician, theparents, teachers and other informants (e.g., youth workers). A combinationof these tools is used in everyday practice. An example of a rating scale usedworldwide − available free in numerous languages for noncommercial purposes− is the Strengths and Difficulties Questionnaire (SDQ), presented in Table A.5.6.
Completed by parents, teachers, the child, or all of them, the 25 SDQ items were
designed to include both strengths and difficulties. The SDQ is a generic scale torate a wide range of problems. In many cases, however, particularly if a specificdisorder is suspected (e.g., depression, ADHD) using a more detailed, targeted
rating scale in addition to a generic one is useful (see the diagnosis section of therespective chapter in this e-book).
Psychometric assessment
The art of an effective psychometric assessment is the accurate use and validinterpretation of psychometric tests. Test results may help clinicians to:•

Find the diagnosis or comorbidity•

Identify the individual’s profile of cognitive strengths and weaknesses•

Plan treatment (e.g., the level of communication in future
psychotherapy).

There are a huge number of psychological tests for children and adolescentsand the choice depends on the individual patient, the suspected diagnosis andthe knowledge and experience of the tester. Assessment of the patient’s cognitive
functioning is often helpful for diagnosis and treatment planning (see Chapters
C.1 and C.3).
Intelligence: “the sum of all higher mental processes”
There is disagreement among experts on what exactly intelligence is but there
is strong empirical evidence that intelligence tests measure something meaningful
about development, cognitive abilities and adaptive behavior (Charman et al,2008). The intelligence quotient (IQ) shows moderate to high stability over timeand correlates highly with real-life outcomes, such as academic achievement,
employment and income.
Suitable IQ-Tests have age-graded norms and are well standardized (seeChapter C.1). When a test was normed is relevant because there has been a modest
increase in scores over time in some countries, possibly due to improvements indiet and education. Standardized intelligence tests produce scores with a mean of
100 and standard deviation of 15. Standard scores are then used to define average,
below average or superior ability depending on how many standard deviations
above or below the general population mean a child’s performance lies. An IQ
below 70 is a strong indicator for the existence of an intellectual disability (seeChapters C.1).
Observation of the child in the test situation is an important part ofassessment. The following characteristics should be documented and consideredwhen interpreting the test results:•

Degree of cooperation with the examiner

Clinical examination

A.5

21

IACAPAP Textbook of Child and Adolescent Mental Health

Testing the theory of mind: the Sally/Anne test
The Sally/Anne test is a psychological test with dolls, used in developmental mental
health to measure a person's social-cognitive ability to attribute false beliefs to others (i.e.,
the theory of mind, for more details see Chapter C.2). The clinician uses two dolls, "Sally"and "Anne". Sally has a basket; Anne has a box. Cliniciansshow the children a simple sketch, in which Sally puts amarble in her basket and then leaves the scene. While Sally
is away and cannot watch, Anne takes the marble out of
Sally's basket and puts it into her box. Sally then returns andthe children are asked where they think she will look for her
marble. Children are said to "pass" the test if they understandthat Sally will most likely look inside her basket before
realizing that her marble isn't there. Children under the age of four, along with most autistic
children (of older ages), will answer "Anne's box," seemingly unaware that Sally does notknow her marble has been moved.
Click on the picture to access a video clip explaining the Sally/Anne test.

•••“There is nothing morestimulating than a casewhere everything goesagainst you.”(Sherlock Holmes, “The
Hound of the Baskervilles”)

Activity and concentration level
Social and communication skills
Specific areas of difficulties

Test results may be influenced by:
•
•
•
•
•

Language problems
Motor coordination problems
Medications
The current psychopathology (e.g., depression)
Vision and hearing problems.

If there are major discrepancies between the test results and the child’s
performance described by parents or teachers or with the clinical observations, thiswill always require further study.

COMMUNICATING FINDINGS AND
RECOMMENDATIONSThe examination is notcomplete until findings arecommunicated to parents,
the child and referring
agency.

The aim of this last but essential part of the examination process is tosummarize the findings into a clinical formulation, a clinical diagnosis and tocommunicate them in a clear and helpful way to all relevant parties. This may
require one or more sessions where treatment recommendations and options are
discussed and decided upon.
In most cases it is useful to spend some time processing all the informationcollected, scoring rating scales and considering the differential diagnoses andrecommendations. Parents may be anxious to hear what is wrong with their child(and family). So, much sensitivity is required. Disappointment, sadness or grief,
denial and other emotions are common, especially when the diagnosis destroys
expectations about the child’s future.
You need to be aware that very little of the information you give will be
retained, especially if the session is highly emotive. So, in some cases you may

Clinical examination

A.5

Guiding principles for
feedback:•
Plain, non-technicallanguage•
Nonjudgmental•
Strength-orientated•Sensitive•
Practical.

22

IACAPAP Textbook of Child and Adolescent Mental Healthprovide a report or a succinct written summary for the parents. If appropriate andfeasible, offer further sessions to discuss issues once the family has had the chanceof working through the information.
An explicit emphasis on the child’s and the family’s strengths and abilities
facilitates the feedback process and gives a more realistic picture of the patient as anindividual rather than a mere illness-oriented diagnosis. Avoid technical terms andpsychiatric jargon (instead of: “The theory of mind of your daughter is insufficient” itseems better to say: “Sally has some problems understanding that others have beliefs,
desires and intentions that are different from her own.”). Just naming the diagnosis isnever enough. Explain the rationale for the diagnosis and influencing factors. The
formulation is more helpful than a simple clinical diagnosis in understanding andhelping the child and the family. Explain if areas of uncertainty remain, including
whether diagnosis can change over time and what the likely outcome, treated anduntreated, might be. If the diagnosis is provisional, be clear that you are not sure.
With or without the child?
••

Never let a family gowith just the diagnostic
information. Always present
them with treatment options
and hope.

“To cure sometimes, torelieve often, to comfort
always.” (Edward
Livingston Trudeau, 18481915)

Depending on the nature of the problem and the developmental stageof the child it may be appropriate for the child to be present. If yes,take a few minutes and explain your findings to the child directly. A
good strategy is to start describing the strengths of the patient, thentalk about the difficulties and the options to reduce them, and end
again talking about the strengths and instilling hope that the current
situation will get better
Provide a clear focus for therapeutic intervention.

Clinicians have to ensure that findings and recommendations are:
• Heard• Understood and• Experienced as helpful.
To enhance compliance with future treatment, rather than experts,
clinicians should become partners with the patient and family in the decisionmaking process. In most cases it is possible to outline several treatments, with theirrisks and side effects, and help parents decide which one they wish to follow. If
parents are eager to pursue treatments that are unhealthy, unproven or dangerous,
the clinician should highlight the risks of such a decision.
When discussing prognosis, it is necessary to combine instilling hope witha realistic view of the long-term outcome of the disorder. In many cases the longterm therapeutic goal will be finding ways to live with the illness (including therisk of recurrences), than a cure.

TROUBLESHOOTINGThe following advice is in case you feel lost in the evaluation process andhave no idea about the right diagnosis in a particular child. The sequence should
be applied flexibly:•

Ignore the DSM and ICD constructs for a moment and go back to
the description of the problems. Just try to describe as well as you canwhat is unusual in this patient. After that, think again about which
diagnosis(es) match this pattern of symptoms

Clinical examination

A.5“Nothing clears up a case somuch as stating it to anotherperson.”(Sherlock Holmes, “Silver
Blaze”)
There is an imperfectmatch between the neatdiagnostic descriptions
given in textbooks and theclinical presentations seen
in clinical practice. Cliniciansmust always be on the alert
for unusual patterns that do
not fit existing diagnostic
conventions.
(Rutter & Taylor, 2008).

23

IACAPAP Textbook of Child and Adolescent Mental Health

•
•
•

•
•
•
•

•
•

•

•

Talk with a colleague about this case, especially experienced ones
If possible, videotape an examination (with the permission of patientand parents), show it to colleagues and ask for their opinion
Maybe there is nothing wrong with the child. For whatever reason thechild is presented seeking help when a family member is the one withmental health problems
It is often not possible to conduct the whole diagnostic process in one
appointment
If you get stuck in the differential diagnosis, remember that common
disorders are frequent and rare disorders are rare
Symptoms can present atypically in cases with multiple comorbidities(e.g., depression in an autistic child)
If you have a prime suspect diagnosis but you are still unsure, thencheck the differential diagnosis part of the respective chapter in this or
another good-quality textbook (see References)
Do not ignore possible somatic diagnosis, side effects of medications oreffects of illicit drugs
Think about the possibility of factitious or shared disorders (e.g., amother with schizophrenia makes her young child believe that both arebeing pursued by the secret service)
There will always be cases in which symptoms do not fit in with a
specific diagnosis because classification systems are not perfect andpresumably will never be. As Leo Kanner, a pioneer child psychiatrist,
put it in the title of his paper on differential diagnosis: “The children
haven’t read those books” (Kanner, 1969).
There will be cases in which there is no suitable diagnosis, because theillness is not yet described or, more likely, because the patient has no
psychiatric or medical illness but a problem of living and is more inneed of advice than of complex therapy.

“When you hear hoof beats
behind you, don’t expect tosee a zebra” (Theodore E
Woodward MD)

REFERENCES
Achenbach TM, McConaughy SH, Howell CT (1987).
Child/adolescent behavioral and emotional
problems: implications of cross-informant
correlation for situational specificity. Psychological
Bulletin,101:213-232.

Carandang CG, Martin A (2009). Clinical assessment ofchildren and adolescents with depression. In Rey
JM, Birmaher B (eds) Treating Child and Adolescent
Depression. Philadelphia, PA: Lippincott Williams &Wilkins, pp23-37.

American Psychiatric Association (2000). Diagnostic andStatistical Manual of Mental Disorders, 4th edition,
Text revision (DSM-IV-TR). Washington, DC:
American Psychiatric Association.

Charman T, Hood J, Howlin R (2008). Psychologicalexamination in the clinical context. In Rutter M,
Bishop D, Pine D et al (eds), Rutter’s Child andAdolescent Psychiatry, 5th Edition. Osford: Blackwell,pp299-316.

* Baird G, Gringras P (2008). Physical Examination and Medical
Investigation. In Rutter M, Bishop D, Pine D et al(eds). Rutter’s Child and Adolescent Psychiatry. 5th
Edition. Oxford: Blackwell, pp317-335.
Bostic JQ, King RA (2007). Clinical assessment of children
and adolescents: content and structure. In Martin
A, Volkmar FR (eds) Lewis’s Child and Adolescent
Psychiatry, 4th edition. Philadelphia, PA: Lippincott
Williams & Wilkins, pp323-344.

Clinical examination

A.5

Dooley JM, Gordon KE, Wood EP et al (2003). The utility ofthe physical examination and investigations in thepediatric neurology consultation. Pediatric Neurology,
28:96-99.
Gardner RJM, Sutherland GR (1996). Pregnancy loss andinfertility. In Chromosome Abnormalities and Genetic
Counseling. Oxford Monographs on Medical
Genetics, No. 29. New York: Oxford University
Press,pp311-321.

24

IACAPAP Textbook of Child and Adolescent Mental HealthGoodman R, Ford T, Simmons H et al (2000). Using theStrengths and Difficulties Questionnaire (SDQ) to
screen for child psychiatric disorders in a community
sample. The British Journal of Psychiatry, 177:534-539.

Sholevar GP (2007). Cultural child & adolescent psychiatry.
In Martin A, Volkmar FR (eds), Lewis's Child andAdolescent Psychiatry, 4th Edition. Philadelphia, PA:
Lippincott Williams & Wilkins, pp57-65.

* Goodman R, Scott S (2005). Child Psychiatry, 2nd edition.
Oxford: Blackwell.

Smalley S, Smith M, Tanguay P (1991). Autism and psychiatricdisorders in tuberous sclerosis. Annals of the New York
Academy of Sciences, 615:382-3.

Herpertz-Dahlmann B, Bachmann C (2007). [Körperliche
Untersuchung]. In Remschmidt H, Mattejat F,
Warnke A (eds), Therapie psychischer Störungen bei
Kindern und Jugendlichen. Stuttgart Thieme, pp17–20.
Jones DPH (2003). Communicating with Vulnerable Children: A
Guide for Practitioners. London: Gaskell.
Kanner L (1969). The children haven't read those books,
reflections on differential diagnosis. Acta
Paedopsychiatrica, 36:2-11.
Le Couteur A, Gardner F (2008). Use of structured interviews
and observational methods in clinical settings. In
Rutter M, Bishop D, Pine D et al (eds). Rutter’sChild and Adolescent Psychiatry, 5th Edition. Oxford:
Blackwell, pp271-288.
Luthar SS, Prince RP (2007). Developmental psychopathology.
In Martin A, Volkmar FR (eds), Lewis's Child andAdolescent Psychiatry, 4th Edition. Philadelphia, PA:
Lippincott Williams & Wilkins, pp291-301.
* Rutter M, Taylor E (2008). Clinical assessment and diagnostic
formulation. In Rutter M, Bishop D, Pine D et al(eds). Rutter’s Child and Adolescent Psychiatry, 5th
Edition. Oxford: Blackwell, pp42-57.
Salbach-Andrae H, Klinkowski N, Lenz K et al (2009).
Agreement between youth- reported and parentreported psychopathology in a referred sample.
European Child and Adolescent Psychiatry, 18:136-143.

Clinical examination

A.5* Stubbe D (2007). Practical Guides in Psychiatry: Child andAdolescent Psychiatry. Philadelphia, PA: Lippincott
Williams & Wilkins.
Verhulst FC, Van der Ende J (2008). Using rating scales in aclinical context. In Rutter M, Bishop D, Pine D etal (eds), Rutter’s Child and Adolescent Psychiatry, 5th
Edition. Oxford: Blackwell, pp289-298.
Wolf SM, McGoldrick PE, Cohen L (2008). Pediatricneurological examination for the psychiatrist. In
Walker AM, Kaufman DM, Pfeffer CR et al (eds),
Child and Adolescent Neurology for Psychiatrists, 2ndedition. Philadelphia: Lippincott Williams & Wilkins.
* King RA (1997). Practice Parameters for the psychiatricexamination of children and adolescents. Journalof American Academy of Child Adolescent Psychiatry,
36:4S-20S.
World Health Organisation (1996). The ICD-10 Classificationof Mental and Behavioral Disorders in Children andAdolescents. Cambridge, UK: Cambridge University
Press.
*Recommended reading.

25