The Adult Evaluation
The process of an adult psychiatric evaluation consists of detailed interview and review of past treatments. It is best if you can bring copies of previous medical records to facilitate the review. Alternatively, you can write up a timeline of your treatment, including dates or ages, medications with doses (if known), the positive and negative effects of each medication, and any other treatments you have received. It also is important to provide a complete list of all medications that you are currently taking. Medication interactions (drug-drug interactions) are extremely important, but can easily be missed without careful review.
Depending on the nature of the problem we are exploring, additional testing may be required. This can include computer-based testing and/or laboratory testing. Biological problems, such as mild traumatic brain injury, vitamin deficiencies, or chronic low level infections, can manifest as psychiatric symptoms. Past medical history, family history, lifestyle choices, and history of any head trauma also are explored. Psychiatric evaluations concludes with a discussion of the diagnosis, alternative diagnoses, and treatment plan. If medications are being considered, then the main effects, side effects, risks and benefits are carefully explained. Only after the patient states an understanding of the treatment plan and agreement with the treatment option, is a prescription written. A follow-up plan, additional testing, and other lifestyle recommendations are then made.
The Complexities of Child Psychiatric Evaluations
The process of a child psychiatric evaluation is considerably different from that of an adult psychiatric evaluation. First, the patient is unable to provide detailed introspection and considerable amounts of the history must be gathered from others. Second, the differential diagnosis, that is the possible diagnoses that can look similar upon initial presentation, is quite extensive in children. Third, most common psychiatric condition presents somewhat differently in children than they do in adults. Moreover, different aged children have different presentations. For example, major depression disorder in a toddler or preschooler can look quite different from the same condition in a school-age child or adolescent. Time must be spent to gain an appreciation or understanding for the dynamics in the family, because often these are critical in rendering an appropriate diagnosis. Lastly, children come to child psychiatric evaluations with a variable degree of trepidation. Unlike adults, who come prepared to talk about their feelings, children are often frightened by the prospect of discussing their feelings. Part of the process of a child psychiatric evaluation is initially gaining a child’s comfort and trust so that they can begin to talk about things that are truly disturbing for them.
In university settings, psychiatric evaluations of children can take as much as six hours, spread over several appointments. It has been my policy and practice, both in my private practice and in the various mental health centers with which I work (a total of 10 sites), to perform a 2 hour evaluation. This is considered the bare minimum. As I work with a child, I will gain a more complete understanding of the dynamics of the family relationships and how they impact the child’s mental health.
The differential diagnosis of children is complex. For instance, let’s take the classic case of a child who presents with hyperactivity. Typically, the automatic thought on the part of mental health professionals and lay people alike is that the child has ADHD. So, one might think that in 30 minutes a doctor could diagnosis ADHD and prescribe Ritalin and be done with it. However, children can present with hyperactive behavior for a host of reasons. Some of these are medical reasons, such as lead toxicity, heavy metal toxicity, hyperthyroidism, hypoparathyroidism, uremia, Vitamin B12 deficiency, adrenal tumors, and brain tumors. Some of these are psychiatric reasons, such as Postraumatic Stress Disorder, disturbed parenting, anxiety disorders, depressive disorders, psychotic disorders, Tourette’s syndrome, pervasive developmental disorders or autism, and (the much-cited, but actually quite rare) Bipolar disorder. Even a child who has previously diagnosed and treated for a psychiatric diagnosis requires careful scrutiny and evaluation. Previous medications must be carefully reviewed and evaluated for efficacy, side effects, untoward effects, and medication interactions.
The evaluation process can be divided into four parts. The first part lasting 10-15 minutes consists of interaction solely with the child to connect with the child to foster comfort and trust. This joining period can take a variety of forms. It can be simply talking about why they are here and allaying their fears about such things as shots. Or it can be engaging the child in one of their interests. For example, one school-age child had been involved in two previous psychiatric evaluations. In both cases, the patient did not speak a word to the examiners. (This is another example of why previous psychiatric evaluations must be viewed carefully.) However, by engaging the patient around her Barbie coloring book, she began to open up and became quite talkative. This first part can then extend into why they are getting a psychiatric evaluation. Often children have very good ideas about why they are being evaluated. Other times, they can have quite distorted ideas, which need to be addressed and their fears allayed.
The second part of the evaluation is to explore with parents or caretakers the issues that have prompted them to seek an evaluation. This includes identifying behaviors, suspected feelings, the implications, ways they have dealt with the behaviors, parenting styles, past psychiatric history, past medical history, developmental history, school history, psychosocial history and stressors, and family psychiatric history.
The third part of the evaluation is a direct interview of the child using a variety of techniques. With older children, a direct question and answer period is sufficient, but with younger children other techniques are often needed. For example, I often use a “feeling pie” as a technique to help children focus their attention on their feelings. Then by exploring their feelings, we often can uncover significant areas of distress, anxiety, fear, and anger for the young patient. During this process, I explore with the patient any hallucinatory experiences, delusions, obsessive or compulsive features, and suicidal or homicidal ideation. If there is the luxury of time, it is often important to explore the dynamics of the child’s relationships with siblings, peers, parents, and other adult caregivers. With adolescents, drug and alcohol use, and sexual behavior need to be explored.
The fourth part of the psychiatric evaluation is discussing the diagnosis, alternative diagnoses, and treatment plan. It is often important for parents to have an explanation of the diagnosis. Second, the treatment options must be presented to the parents. Frequently, it is important to talk about parenting techniques and strategies. It is important when discussing medication for children, that the main effects, side effects, risks and benefits are carefully explained to the parents so that they can make an informed decision. The importance of fully explaining the treatment options to the parents can not be underestimated. Only after the parents and the child (if of an appropriate age) state understanding of the treatment plan and agreement with the treatment option, is a prescription written. The structuring of the relationship between the patient, the patient’s parents, and the psychiatrist as a team is a crucial strategy for successful treatment in children.
If one reads the Expert Consensus Guidelines or the APA Practice Guidelines for the treatment of adult psychiatric illnesses, it is striking how much of the content is devoted to non-pharmacological interventions. This is the nature of psychiatric treatment, as we all know. Medications are only part of the answer. The successful treatment of psychiatric illness often requires medications, lifestyle changes, dynamic changes in the patient’s family, and psychotherapeutic interventions. In the case of a child, lifestyle and dynamic changes in the family are not possible without the full cooperation of the parents. This only serves to underscore the importance of fostering a sense of teamwork with the patient and his/her parents.