The document provides guidelines for conducting a psychiatric history and evaluation of a child patient. It outlines collecting demographic details and preliminary information about the child, referral source, chief complaints, history of present illness using chronological events and specific behavioral terms, past medical and psychiatric history, family history including a family tree, personal history of development, growth, and current general functioning at school, with peers, and in family relationships. A table is included listing normal age ranges for developmental milestones.

1. HISTORY TAKING :
CHILD

2. EVALUATION: psychiatric history
DEMOGRAPHIC DETAIL/ PRELIMINARY INFORMATION
• Identification of the case should include the patient’s:
– Name
– Date of birth
– Age
– Gender
– Name of the school
– Educational level
– Phone number
– Address
– Legal guardian

3. Referral source
Name of the referring physician and/ or any
other source of referral

4. SOURCE OF INFORMATION
• Identity of the informants
• Taking information from the patient
• Information from school
• Information from other physician if necessary

5. CHIEF COMPLAINTS/ CHIEF
PROBLEMS/ PRESENTING PROBLEMS
• The statement of the problem consists of a
brief description of the nature, duration and
severity of the principal difficulties.
• Use patient’s/ parents own words

6. HISTORY OF PRESENT ILLNESS
RECORD
EVENTS
CHRONOLOGICALLY
• Beginning with the first clear evidence
of emotional or physical or behavioral
problem.
• Note the exact sequence of the events
and record the exact dates of its
occurrence.
• Sequence of events - what happened
next? when was he last well? - what
was the first thing you noticed wrong?
e.g. pain - site, nature, frequency,
radiation, aggravating & relieving
factors
e.g. seizure – onset, characteristics,
duration, post episode

7. CONT..
USE SPECIFIC
BEHAVIORAL
TERMS
• Do not accept vague and general terms which
patients and their families frequently use to
describe symptoms. In short, get a good
behavioral description.
• E.g.: the patient describes his “nervous spells”
as episodes in which his heart suddenly begins
to beat very rapidly while he feels
apprehensive, tremulous and at times, sweats
to the point that he has to mop his brow. If he
is writing or eating, his hand may become so
tremulous that he is unable to continue or is
unable to light a cigarette without his trem.

8. PAST
HISTORY
Medical history
and psychiatric
history
• Discuss all relevant details of any
significant illness, injuries, accidents
or operations. Exact dates should
always be given.
• Special attention should be given to
whether or not the patient has ever
suffered:
– Any kind of head trauma
– Episodes of unconsciousness
– Episodes of amnesia
– Episodes of confusion
– Episodes of disorientation
– Convulsive seizures

9. FAMILY HISTORY
Describe the parents and the siblings in
separate paragraphs. List the siblings in the
order of age, including the patients, so that
his rank among the siblings is clearly
indicated. Including any still births or
abortions in their proper chronologic order.
Draw family tree.

10. PERSONAL HISTORY
• Pregnancy
• Mode of delivery
• Birth weight
• Neonatal problems: jaundice
• Feeding
• Respiratory problem
• Did the baby go home with you?

11. DEVELOPMENT & GROWTH
• Developmental History
- major milestones achieved i.e age smiled, sat,
crawled, walked, first words
- vision, hearing speech, motor skills, social skills
- comparison with sibs
- school performance
• Growth
- does mother think child is growing
- ask about puberty if appropriate to child’s age

12. DESCRIPTION OF CHILD’S CURRENT
GENERAL FUNCTIONING
• School
– Behavior and emotions
– Academic performance
– Peer and teachers relationships
• Peer relationships generally
• Family relationships
• Home behavior

13. S.NO ITEM NORMAL AGE RANGE MILESTONE DELAY IF
NOT ACHIEVED BY
1 Responds to name/voice 1-3 months 4th month
2 Smiles at others 1-4 months 6th month
3 Holds head steady 2-6 months 6th month
4 Sits without support 5-10 months 12th month
5 Stands without support 9-14 months 18th month
6 Walks well 10-20 months 20th month
7 Talks in 2-3 word sentences 16-30 months 3rd year
8 Eats/drinks by self 2-3 years 4th year
9 Tells his name 2-3 years 4th year
10 Has toilet control 3-4 years 4th year
11 Avoids simple hazards 3-4 years 4th year