Introduction to child Psychiatry- Assessment issues


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Introduction to child Psychiatry- Assessment issues

  1. 1. Bivin Jose Department of Psychiatric Nursing Mar Baselios college of Nursing
  2. 2. Class overview       Introduction Clinical interview of the child Special issues in the assessment of children Techniques of assessment Tools used in assessment Laboratory measures
  3. 3. Introduction    Most common psychiatric disturbances in children are related to developmental delay in one or more domains Developmental status influence the clinical presentation of various syndromes Distressing emotions/impairing behaviors may occur as a part of normal transition
  4. 4. Clinical assessment of the child  Possible referral sources include; • Parents (recommended by school, friends, relatives, themselves) • Legal guardians (state custody) • Schools (Teachers/Peers) • Court (if the child has legal issues, custody issues)
  5. 5. Evaluation/assessment settings       Clinical visits Schools Pediatric wards Resident treatment centers Detention centres Hospital emergency depts • Procedures necessarily vary with the settings and reasons for carrying out the assessment
  6. 6. Special considerations in child assessment     The referral is typically requested by someone other that the patient Assessments may misinterpret ass a for of punishment for being bad Assessment need to be non-judgmental & collaborative Give children as much as control as is appropriate & safe
  7. 7.     Methods/tools of assessment are specific to the age of the children Primary goal is to understand child’s inner world & perspective Techniques range from observing an infant, parent or using play to understand the preschool & young elementary school child to talking directly about the symptoms to an adolescent Alter approaches according to the developmental needs of the child
  8. 8.    Children are not to be considered as little adults Use multiple informants/problems across all contexts (Help to clarify the areas of remediation) Specific diagnosis is more difficult in children • Varying presentation of symptoms at different ages, the evolution of disorders, & the lack of diagnostic and etiological specificity for many symptoms  Diagnosis vary with time
  9. 9. Specific assessment methods  Play techniques • Imaginative play with puppets/small figures • Play materials are given based on the child’s concern, perceptions, & characteristic modes of regulating affects & impulses  Uses • For diagnostics/trust building • Form of play as an important information to MSE
  10. 10.  Projective techniques (DAP) • Invite the child to draw a picture • Ask the child what animal he or she would most like or least like? • Whom she or he would take along to a desert island? • What he or she would wish for if given 3 magic wishes (Winkey, 1982) • Describe a dream/ a book, movie, TV show which he/she recalls • Future ambitions?
  11. 11.  Direct questioning • Inquire about the presenting problems or other aspects of the child’s life timing • Attention to the child’s cognitive & linguistic level of development • Respect for the child’s self-esteem
  12. 12. Domains of Evaluation
  13. 13. Development  Psychomotor: • Ability to stand, walk, & react  Cognitive: • Concrete thinking fashions  Interactive: • Verbal & non-verbal communication   Moral development Harmful behaviors
  14. 14. Cognitive & academic development      Child’s ability to separate from parents & to school regularly Interpersonal relationship with teachers/peers Motivation to learn Ability to function independently Tolerance for frustration & delay of gratification
  15. 15.     Attitude towards authority Ability to accept criticism A grade-by-grade H/o the schools attended Retentions & the reason • Obtain permission to communicate with the teachers, counselors, or other school personal • Review the school records, including results of standardized tests
  16. 16. Family relationships      How child relates to each family member How the child fits into the overall family system Child’s reactions to major family events Compliance with the family rules & standards & usual mode of discipline/limit setting) Child’s response to disciplinary actions
  17. 17. Peer relationships       The number of friends Preferences regarding age and gender of friends Any major changes in peer group recently Their relative stability Activities of interests shared with peers Parents feeling about the child’s close friends/social skill or deficits
  18. 18. Development conscious & values    Harsh/lax focuses on specific issues Religious or ethical concerns & their concordance with family expectations Areas of potential discord with the family values/customs
  19. 19. Interests, hobbies & talents      Child’s as well as parent perspective Parents approval, involvement & support to the interests & hobbies of the child Existence of parent-child conflicts Impact of the present problems on the child’s interests/hobbies Quantity of TV programs, movies & level of parents’ limit setting
  20. 20. Unusual circumstances   Child’s exposure to unusual or traumatic circumstances (Sexual/ physical abuse, family/community violence, natural disasters or armed conflicts) Child’s immediate & subsequent reactions & the nature of the responses from the parents or other adults
  21. 21. Prior psychiatric treatments     Prior psychiatric, psychological, or educational evaluations/ interventions The outcome of such interventions Child’s parents attitude towards such earlier attempts to obtain help Previous health reports
  22. 22. Family medical & psychiatric history     Psychotic & affective disorders Suicidal behaviors Anxiety disorders etc Enquire about the severity, treatments, outcomes & impact on the child
  23. 23. Temperament categories 1. Activity level The motor component present in a given child’s functioning & the diurnal proportion of active & inactive periods 2. Rhythmicity (regularity) The predictability/unpredictability in time of any function. Assessed in relation to sleep-wake-cycle, hunger, feeding pattern or elimination schedule
  24. 24. 3. Approach/withdrawal The nature of the initial response to a new stimulus (New food, toy or a new person) 4. 5. Adaptability Threshold of responsiveness The intensity of stimulation needed to evoke a discernible response 6. Intensity of reaction The energy level of response, irrespective of its quality or direction
  25. 25. 7. 8. 9. Quality of mood The amount of pleasant, joyful & friendly behavior Distractibility The effectiveness of extraneous environmental stimuli in interfering with or altering the direction of the ongoing behavior Attention span & persistence Length of time a particular activity is pursued by the child Persistence refers to the continuation of an activity in the face of obstacles to the maintenance of the activity direction
  26. 26. Inferring the temperament Easy Difficult Slow-to-warm-up
  27. 27. Overview of the assessment Content component Primary informant Reason for referral Usually parent, guardian, sometimes school or court History of problems Past problems Additional resources Letter from school, or other agency seeking evaluation Referral sources Child & parent Child & parent Structured interviews/screeni ng scales
  28. 28. Content component Primary informant Comorbid symptoms Child & parent Child’s development School staffs & parent Additional resources Structured interviews & screening scales Previous Clinicians, Mental health assessments/t Child & parent records reatments School records, incl. spl education evaluation
  29. 29. Content component Primary informant Additional resources Family history Parent Genogram Medical history Parent, health care providers MSE Child Review of system checklist, laboratory tests MMSE
  30. 30. Mental Status Examination
  31. 31.   MSE components may be gathered through direct questioning, play activities, or observations during the session Appearance & behavior • Grooming, size & type of dress, dysmorphic features, bruises, scars or injuries, eye contact   Ability to co-operate & engage Speech & language • Fluency, volume, rate & language skills (Apt for developmental level, articulation
  32. 32.  Motor function • Activity level, co-ordination, attention, frustration tolerance, impulsivity, tics or mannerisms  Mood & affect • Neuro-vegetative symptoms, manic symptoms, range & appropriateness of affect  Thought process & content • Psychotic symptoms (delusion)   Insight Perception
  33. 33.  Anxiety • Fears, obsessions or compulsions, post traumatic anxiety, separation difficulties  Conduct symptoms • Oppositionality, aggression (verbal/physical)  Cognitive function • Developmentally appropriate vocabulary, fund of knowledge  Risk assessment • Suicidal thoughts/behaviors, thoughts/plan on harm others/self, legal issues,
  34. 34. Instruments in Assessment
  35. 35.    Ranging from systematized questionnaires to specific areas difficulty Rating scales are adjunctive to clinical diagnosis Ratings scales are completed along with parents or teachers
  36. 36.  Rating scales • Achenbach Child Behavior Checklist • Conners’ questionnaire • SADS-C (Schizophrenia & affective disorders scale-children V) • Kiddie Schedule for affective disorders and schizophrenia (K-SADS)   Diagnostic interview for children Pictorial DOMINIC-R (For anxiety symptoms in young children)
  37. 37. The 4 Ps in diagnostic formulation     Predisposing: those factors that render the child vulnerable to a disorder Precipitating: stressors or developmental factors Perpetuating: factors that maintain the disabling symptoms Protective: strengths & assets
  38. 38. Lab Investigations
  39. 39.  Mental retardation & PDDs • Woods lamp examination (Tuberous sclerosis) • EEG (Seizures) • Chromosome analysis to exclude fragile X syndrome, down syndrome • S.lead estimation (pica)  Mood disorders • Routine thyroid function • Infectious disease • Toxicology tasting
  40. 40.  ADHD • Thyroid profile  Tic & OCD • Throat culture & serological studies for group A βhemolytic streptococcus infection • Antideoxyribonuclease B • Antistreptolysin O antibody titres  Substance use disorders • Toxicology screening for all adolescents who are; • psychiatric symptoms or who have exhibited acute behavioral changes • High-risk (delinquents and runaways) • recurrent accidents or unexplained somatic symptoms
  41. 41. Recommendations for Treatment
  42. 42.    Child is at imminent risk & required acute hospitalization Care is provided in a safe, nonthreatening, home-like environment Child requires treatment services like; • Individual therapy: CBT, IPT, DBT etc • Psychotropic medications: Psychiatric symptoms & stabilization of persons • Group therapy • Family therapy: Parent management programs, psychoeducation, couples therapy, divorce & conflict resolution etc.
  43. 43.  Adjunctive childcare services include • School services for emotional, attention &/or learning related problems • School-based counseling • Remedial education services • Speech therapy etc • State protective services • Mentoring programs for the siblings as well as the parents • Legal guardian
  44. 44. References  Vyas JN & Ahuja N (1999). Textbook of postgraduate psychiatry, 2nd ed., vol 2, Jayppe Medical publishers. Ch 36