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Clinical Child

Second Edition

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94
Clinical Child
Second Edition
William M. Klykylo and Jerald L. Kay
Wright State University School of Medicine, Dayton, Ohio, USA
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To our teachers, our students, our patients, and our families.

Dedication v Chapter 11 Disruptive Behaviour Disorders 191

Preface ix Niranjan S. Karnik and Hans Steiner
List of Contributors xi
Chapter 12 Child and Adolescent Affective
Disorders and their Treatment 203
Section I The Fundamentals of Child and
Rick T. Bowers
Adolescent Psychiatric Practice 1
Chapter 13 Anxiety Disorders in Childhood
Chapter 1 The Initial Psychiatric Evaluation 3
and Adolescence 235
William M. Klykylo
Craig L. Donnelly and
Chapter 2 Psychological Assessment of Debra V. McQuade
Children 21
Chapter 14 Substance Use in Adolescents 263
Antoinette S. Cordell
Jacqueline Countryman
Chapter 3 Neurobiological Assessment 49
Chapter 15 Childhood Trauma 275
George Realmuto
Sidney Edsall, Niranjan Karnik
Chapter 4 Educational Assessment and and Hans Steiner
School Consultation 65
Dorothyann Feldis
Section III Developmental Disorders 295
Chapter 5 Psychiatric Assessment of Medically
Chapter 16 Attachment and its Disorders 297
Ill Children, Including Children
Jerald L. Kay
with HIV 75
David M. Rube and G. Oana Costea Chapter 17 The Eating Disorders 311
Randy A. Sansone and
Chapter 6 How to Plan and Tailor Treatment:
Lori A. Sansone
An Overview of Diagnosis and
Treatment Planning 91 Chapter 18 Elimination Disorders: Enuresis
Brian J. McConville and and Encopresis 327
Sergio V. Delgado Daniel J. Feeney
Chapter 7 Assessment of Infants and Chapter 19 Sexual Development and the
Toddlers 109 Treatment of Sexual Disorders
Martin J. Drell in Children and Adolescents 343
James Lock and Jennifer Couturier
Chapter 8 Play Therapy 119
Susan Mumford Chapter 20 Learning and Communications
Disorders 361
Chapter 9 Cognitive Behavioral Therapy 129
Pamela A. Gulley
Christina C. Clark
Chapter 21 The Autistic Spectrum Disorders 371
Section II Common Child and Adolescent Tom Owley, Bennett L. Leventhal
Psychiatric Disorders 151 and Edwin H. Cook, Jr.
Chapter 10 Attention Deficit Hyperactivity Chapter 22 Mental Retardation 391
Disorder 153 Bryan H. King, Matthew W. State
David M. Rube and Dorothy P. Reddy and Arthur Maerlender

Chapter 23 Tic and Tourettes Disorder 415 Chapter 27 Sleep Disorders 487
Barbara J. Coffey and Martin B. Scharf and
Rachel Shechter Cyvia A. Scharf
Chapter 28 Loss: Divorce, Separation,
Section IV Special Problems in Child and
and Bereavement 507
Adolescent Psychiatry 431
Jamie Snyder
Chapter 24 Psychotic Disorders 433
Chapter 29 Foster Care and Adoption 521
Michael T. Sorter
Jill D. McCarley and
Chapter 25 Neuropsychological Assessment Christina G. Weston
and the Neurologically Impaired
Chapter 30 Child Psychiatry and the Law 531
Child 447
Douglas Mossman
Scott D. Grewe and
Keith Owen Yeates
Index 553
Chapter 26 The Somatoform Disorders 471
David Ray DeMaso and
Pamela J. Beasley
Preface To Clinical Child Psychiatry,
Second Edition

In the preface to the first edition of this work, we stated who in the United States now provide the preponder-
that the changes in child psychiatry occurring then ance of child psychiatric services, will find this volume
would have been barely imaginable 15 years earlier. useful. We also wish it to be informative to profes-
Pari passu, we could not have predicted then how much sionals outside of medicine as an overview of what
the whole world would change thereafter. Yet a world child psychiatry can and should do today. As
in crisis has only intensified the demands placed upon always, but in these times especially, we must work
child and adolescent psychiatry. We have ever-growing together as best we can.
demands for service to our patients, whose stressors Whatever its merits, Clinical Child Psychiatry,
and pathology become more severe and pervasive. We Second Edition, is the product of the many individu-
are fortunate that our understanding of disease and als efforts. We have been well served by our publisher
our armamentarium of treatments also continue to John Wiley and Sons, Ltd, and especially by our con-
increase. Regrettably, the resources allocated for those sultants Charlotte Brabants, Deborah Russell and
treatments have not always grown apace; and so we Andrea Baier. They bring to their work an enviable
must continue to do more with less and do so ever combination of knowledge, experience, patience, and
more quickly and efficiently. good humor that has encouraged and sustained us. We
The welcome growth of knowledge in our field has could not have assembled this book without the
effected changes in clinical practice and created a need support of our staff at Wright State University, most
for an update of this book. Like its predecessor, notably Edward Depp. David Rube, who served as
Clinical Child Psychiatry, Second Edition, is presented co-editor of the first edition, was able to assist us as an
neither as a comprehensive textbook covering the editorial consultant as well as the contributor of two
entire field, nor as a brief introduction. It still attempts chapters. Our contributors are the ultimate source of
to serve as a focused study of major problems, chal- this volumes content and value, and we are in their
lenges, and practices commonly encountered in clini- debt. Finally, our families continue to support us with
cal work. It remains directed toward experienced their affection and patience.
clinicians encountering new areas of practice, as well
as to students and residents entering the field. We espe- William M. Klykylo
cially hope that pediatricians and family physicians, Jerald L. Kay

Pamela J. Beasley, Harvard Medical School and Craig L. Donnelly, Section of Pediatric Psychophar-
Department of Psychiatry, Childrens Hospital of macology, Dartmouth-Hitchcock Medical Center,
Boston, Hunnewell 121, 300 Longwood Ave, USA One Medical Center Drive, Lebanon, NH 03756-
0001, USA
Rick T. Bowers, 1331 Talon Ridge Court, Kettering,
OH 45440, USA Martin J. Drell, LSU Medical School, 1542 Tulane
Ave, Room A 328, New Orleans, LA 70112-2822,
Christina C. Clark, University Psychological Services USA
Association, Inc., 1020 Woodman Drive, Suite 225,
Dayton, OH, USA Sidney Edsall, Department of Psychiatry, Stanford
University, 401 Quarry Road, Palo Alto, CA 94305
Barbara J. Coffey, Child Study Center, New York Uni-
versity School of Medicine, 577 First Avenue, New Daniel J. Feeney, Pediatric Psychiatry Services,
York, NY 10016, USA Willford Hall Medical Center (WHMC), 59th
Medical Wing, 2200 Bergquist Drive, Lackland
Edwin H. Cook, Jr, University of Chicago, Depart- AFB, TX 78236, USA
ment of Psychiatry, MC 3077, 5841 South Maryland
Avenue, Chicago, IL 60637, USA Dorothyann Feldis, College of Education, 341
Teachers College, University of Cincinnati,
Antoinette S. Cordell, 5045 N. Main Street, Dayton, Cincinnati, OH 45221-0002, USA
OH 45415, USA
Pamela A. Gulley, Greene Country Educational
G. Oana Costea, Queens Childrens Psychiatric Center, Service Center, 360 E. Enon Road, Yellow Springs,
74-03 Commonwealth Blvd, Bellrose, NY 11426, OH 45387-1499, USA
Scott D. Grewe, Tri-Cities Neuropsychology Clinic,
Jacqueline Countryman, 74th MDOS/SGOHC, 4881 303 Bradley Blvd., Suite 100, Richland, WA 99352-
Sugar Maple Drive, Wright Patterson AFB, OH 4497, USA
45435, USA
Jerald L. Kay, Department of Psychiatry, Wright State
Jennifer Couturier, University of Western Ontario, University School of Medicine, P.O. Box 927,
London Health Centre, 800 Commissioners Road Dayton, OH 45401-0927
East, Room E1-605, London, Ontario, Canada
Niranjan S. Karnik, Department of Psychiatry and
Sergio Delgado, Childrens Hospital Medical Center, Behavioral Sciences, Stanford University Medical
3333 Burnet Avenue, Cincinnati, OH 45229-3039, Center, 401 Quarry Road, Palo Alto, CA 94305, USA
Bryan H. King, Professor of Psychiatry and Behav-
David Ray DeMaso, Harvard Medical School and ioral Sciences, University of Washington and Chil-
Department of Psychiatry, Childrens Hospital of drens Hospital and Regional Medical Center,
Boston, Hunnewell 121, 300 Longwood Ave, USA Seattle, WA

William M. Klykylo, Department of Psychiatry, Dorothy Reddy, Queens Childrens Psychiatric

Wright State University School of Medicine, 627 S. Center, 74-03 Commonwealth Blvd, Bellrose, NY
Edwin C Moses Blvd, P.O. Box 927, Dayton, OH 11426, USA
45401-0927, USA
Lori A. Sansone, Premier Health Net, 6611 Clyo
Bennett L. Leventhal, University of Chicago, Depart- Road, Suite D, Centerville, OH 45459, USA
ment of Psychiatry, BH 440, 5841 South Maryland
Avenue, Chicago, IL 60637, USA Randy A. Sansone, Sycamore Primary Care Center,
2115 Leiter Road, Suite 300, Miamisburg, OH
James Lock, Department of Psychiatry and Behav- 45342-3659, USA
ioral Sciences, Stanford University School of Medi-
cine, 401 Quarry Road, Palo Alto, CA 94305-5719, Cyvia A. Scharf, Center for Research in Sleep Disor-
USA ders, 1275 East Kemper Road, Cincinnati, OH
45237, USA
Arthur Maerlender, Dartmouth-Hitchcock Medical
Center, One Medical Center Drive, Lebanon, NH Martin B. Scharf, Center for Research in Sleep Disor-
03757, USA ders, 1275 East Kemper Road, Cincinnati, OH
45237, USA
Jill D. McCarley, Department of Psychiatry, Wright
State University School of Medicine, 627 S. Edwin Rachel Shechter, Child Study Center, New York Uni-
C Moses Blvd, P.O. Box 927, Dayton, OH 45401- versity School of Medicine, 577 First Avenue, New
0927, USA York, NY 10016, USA

Brian J. McConville, Department of Psychiatry, Uni- Jamie Snyder, 3500 S. 91st Street, Lincoln, NE 69520-
versity of Cincinnati College of Medicine, MSB 1429, USA
7258, ML 0559, Cincinnati, OH 45267-0559, USA
Michael T. Sorter, Cincinnati Childrens Hospital
Deborah V. McQuade, Section of Child and Adoles- Medical Center, 3333 Burnet Avenue, Cincinnati,
cent Psychiatry, Dartmouth-Hitchcock Medical OH 45229, USA
Center, One Medical Center Drive, Lebanon, NH
03756, USA Matthew W. State, Department of Psychiatry, Wright
State University School of Medicine, 627 S. Edwin
Douglas Mossman, Division of Forensic Psychiatry, C Moses Blvd, P.O. Box 927, Dayton, OH 45401-
Wright State University School of Medicine, East 0927, USA
Medical Plaza, First Floor, 627 S. Edwin C. Moses
Blvd., Dayton, OH 45401-1461, USA Hans Steiner, Division of Child Psychiatry and Child
Development, Stanford University School of Medi-
Susan Mumford, Department of Psychiatry, Wright cine, 401 Quarry Road, Palo Alto, CA 94305-5719,
State University School of Medicine, 627 S. Edwin USA
C Moses Blvd, P.O. Box 927, Dayton, OH 45401-
0927, USA Christina G. Weston, Department of Psychiatry,
Wright State University, School of Medicine, PO
Tom Owley, University of Chicago, Department of Box 927, Dayton, OH 45401-0927, USA
Psychiatry, 5841 South Maryland Avenue, Chicago,
IL 60637, USA Keith Owen Yeates, Department of Psychology,
Childrens Hospital, 700 Childrens Drive, Colum-
George Realmuto, Department of Psychiatry, Univer- bus, OH 43205, USA
sity of Minnesota, F256/2B West, Riverside Avenue,
Minneapolis, MN 55454-1495, USA

David M. Rube, Queens Childrens Psychiatric

Center, 74-03 Commonwealth Blvd, Bellrose, NY
11426, USA
Section I
The Fundamentals of
Child and Adolescent
Psychiatric Practice
The Initial Psychiatric Evaluation
William M. Klykylo

This chapter serves as an introduction both to this text- social, and linguistic development; and identifies the
book and to the approach of patients and families in nature of the childs relationship with his or her family,
child and adolescent psychiatric practice. Child and school, and social milieu.
adolescent psychiatrists should be broadly trained cli- Second, child and adolescent psychiatrists, like all
nicians able to address a variety of somatic, psycho- physicians, treat illnesses, bringing to bear an arma-
logic, and social needs of the patient and family. Their mentarium of somatic treatments and the more
approach should combine the caution and competence traditional skills of individual, family, and group psy-
required of a physician treating an individual patient chotherapists. Because of the breadth of training they
with a broad concern for that patients development receive, child and adolescent psychiatrists should have
in the context of family, school, and society. This special skill in appreciating the interaction among
textbook provides an overview of child and adoles- these therapies and their effects on one another and on
cent psychiatric practice while focusing on the more the child and family.
common areas of clinical practice. As such, it should Finally, in many cases, child and adolescent psychi-
serve the established practitioner as a rapid and acces- atrists will serve as consultants. This role is more
sible introduction to unfamiliar areas by taking into developed in our specialty than in most other areas
account the ever-expanding breadth of clinical prac- of medicine because of the constant disproportion
tice. For general readers or students in professions between the number of patients and the number of
other than medicine, this book will serve as an intro- clinicians. Inevitably, we consult and collaborate
duction both to the assessment and management of with parents, educators, and other professionals who
some commonly encountered clinical entities and to may see the child and family more frequently and
the range and standards of practice expected of a con- intensively than we do; because of the breadth of our
temporary child and adolescent psychiatrist. There are training, we should offer a special competence in coor-
currently about 6000 child psychiatrists in some sort of dinating these efforts. Concurrent with this role, we
clinical practice in the United States, whereas there are often must serve as advocates for children and their
between 7 and 12 million children with psychiatric families in todays environment of great clinical needs
illnesses, as identified by DSM-IVTR criteria [1,2]. and comparatively limited resources.
Most of these children will not see a child and adoles-
cent psychiatrist and, in many instances, the parents,
Referral Sources
teachers, and other professionals attempting to
serve them may be unaware of the contribution that Because of the broad responsibility shared by child
child and adolescent psychiatry can make to the childs and adolescent psychiatrists, our evaluations must
care. address not only a narrow consideration of clinical
The traditional roles of child and adolescent psy- diagnosis but also a larger set of issues that are truly
chiatrists are those of diagnostician, therapist, and biopsychosocial and require a more than casual com-
consultant. First, child and adolescent psychiatrists petence in each of these areas. We must therefore
should offer a child and family a comprehensive diag- address the specific needs and questions posed by each
nostic assessment that addresses the medical condition referral source. Children are today served by a variety
of the child; delineates the childs emotional, cognitive, of individuals and agencies, each possessing their own

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

particular agendas and separately approaching physi- Collateral and Preliminary Information
cians and other consultants. These agendas must be
Today, most children who are seen by child and ado-
recognized and served, given todays consumer-
lescent psychiatrists have already received a great deal
oriented society. At the same time, we have a respon-
of attention from other professionals. To fail to gather
sibility to those individuals seeking our professional
information from these people prior to a formal eval-
services to educate them with the wider range of con-
uation is a serious mistake, leading to wasted time and
cerns that may be affecting a given childs or familys
frustrated relationships. If at all possible, it is usually
most efficient to speak directly with a referring profes-
In todays environment, we frequently receive refer-
sional. This is especially true in the case of primary
rals from, or may be employed in contractual relation-
care physicians, who may have a long-standing rela-
ships with, various social and legal agencies such as
tionship with the child and family. Other mental health
courts and departments of human services. Each
professionals referring a child usually have conducted
of these agencies has a particular agenda, generally
their own evaluation. Childrens school records can be
mandated by legislation or its charters, to determine
a rich source of information about their cognitive and
the eligibility of children for various services or
emotional development. Examination of all these data
proceedings. The agencies frequently approach their
can enrich an evaluation; similarly, failure to do so can
duties with an intense dedication to children but
lead to embarrassing lapses.
an incomplete familiarity with the knowledge and
Clinicians may at times be tempted to assess a child
assumptions that inform our practice. Referrals may
while deliberately ignoring collateral information, pre-
also come from teachers or schools. These referrals
sumably to evolve an unbiased assessment. There may
may be a result of the childs behavioral disruptions or
be certain unusual situations in which this tactic is indi-
eccentricities, his or her academic difficulties, or simply
cated. More often than not, however, this approach
the distinct if at times uncertain perception of a
ignores the reality of the lives of children, who live in
dedicated teacher that something is wrong. Referrals
asymmetrical relationships with adults and agencies,
may come to us from other physicians. In todays
both of whom have considerable knowledge and power
atmosphere of comprehensive primary practice, these
over them. In general, this approach is a departure
physicians may have already begun the diagnosis and
from best practices.
treatment of mental illness in a child, and established
an ongoing relationship with this child and his or
her family. Such referrals require a balanced response Encounters with Referring Professionals
of both expertise and respect. Finally, many referrals
come directly from parents, who are generally Often a child and adolescent psychiatrists first per-
very concerned about their childs impaired function- sonal encounter in assessing a patient is with another
ing and suffering. They may bring to the process a professional a clinician, educator, or case worker who
mixed heritage of concern, guilt, and shame, fre- has sought the evaluation. The enormous value of
quently fearing that they will be judged as they seek their information has already been addressed. The
help. Concurrent with this are often ambivalent feel- clinician must also recognize the sensitivities of these
ings of love and frustration toward a difficult child. people: they may be grateful for the opportunity to
The task of child and adolescent psychiatrists is to rec- meet with the psychiatrist and eager in their anticipa-
ognize all these needs and address them in a fashion tion of the evaluation, perhaps even to an unrealistic
that is not only authoritative but also tactful and degree. At the same time, the act of seeking a consul-
empathetic. tation may, at least unconsciously, signify to them a
failure on their part. They may be concerned that their
relationship with the child or family will in someway
Elements of the Evaluation be disrupted or supplanted, or that they will be criti-
This section provides an overview of the elements of a cized by the psychiatrist.
comprehensive child and adolescent psychiatric evalu-
ation in the context of contemporary knowledge and
patient needs. More detailed considerations of the
process of the clinical interview are also available [36]. Parents bringing their child to a child and adolescent
The assessment of particular disorders as well as lab- psychiatrist come with a rich and often contradictory
oratory, psychologic, and educational assessments is mix of feelings. Frequently they reach the psychiatrist
covered in other chapters of this book. at the end of a long, complicated process of evalua-

tions and treatment attempts. They are almost invari- child and adolescent psychiatrists, is the developmen-
ably concerned and anxious over their childs condition tal history. Child and adolescent psychiatrists must be
and prospects. In a way that may be difficult for those absolutely familiar with normal developmental pat-
who are not parents to understand fully, they may have terns, milestones, and expectations. Psychiatrists often
many fears about the consequences of a psychiatric approach these phenomena informed by traditional
referral, as do referring professionals. They may feel theories of psychosexual, social, and cognitive devel-
that they will be judged or, in extreme cases, that their opment. Although these theories frequently hold great
children will be removed from their care. In a more importance for their heuristic value, the clinician must
subtle way, they may also worry that their relationship remember that they are, at best, models or theories and
with their child will be supplanted or superseded. They not immutable facts. Thus, the clinician must also be
may be concerned about the moral and philosophic aware of contemporary empirical data about normal
basis of the psychiatrists approach, fearing that development and its variations. The developmental
parental ethical standards and religious beliefs will in history secured by a child and adolescent psychiatrist
some way be contradicted. Sometimes, simultaneously, should in many ways be similar in depth and breadth
they may have unrealistically optimistic or hopeful fan- to that obtained by a developmental pediatrician. At
tasies of absolution of unconscious guilt, or of quick the same time, as psychiatrists we should focus special
cures. More often than not, in my experience, parents emphasis on the social and affective consequences of
have no idea of the specifics of psychiatric assessment developmental phenomena. In other words, we should
or treatment. Their opinions have been formed by mass be concerned not only about what age a child reached
media and public prejudice. Before any specific infor- a given milestone but how the occurrence of that mile-
mation can be gathered or plans made, the above issues stone affected that child and his or her family. We must
must be addressed, in the interest of time and efficiency recognize that some developmental processes or stages
as well as of engagement. Simply put, the child and may inherently be more or less comfortable for some
adolescent psychiatrist needs to understand how the parents, and that there is a wide range of variation
parents feel about the referral and what they expect to in the degree of comfort and discomfort that devel-
gain from it. opment engenders. Finally, we must recognize the
A great deal of information should be collected from great variations in developmental patterns and expec-
parents, since they know the child best. The details of tations found among different cultures. Summaries
this data collection, including various outlines for its of typical developmental sequences are found in the
organization, are described elsewhere in this book. Appendix.
Most child and adolescent psychiatrists today use a A detailed consideration of family dynamics and
traditional medical format to organize their data, with therapeutics is beyond the scope of this textbook. We
headings such as Chief Complaint, History of Present know from the contributions of clinicians with
Illness, Past Medical History, Family History, and approaches as diverse as those of Satir [7], Whitaker
Review of Systems. More often than not, the specifi- [8], Minuchin [9], and Haley [10] that the family has an
cally medical aspects of these data are already avail- immense and profound influence on the development
able. Not infrequently, however, child and adolescent of each of its members and may be viewed as a
psychiatrists encounter families that have not received distinct entity. It is therefore invaluable, as part of
regular primary pediatric care. In these cases, it is a comprehensive psychiatric observation, to spend
incumbent on the psychiatrist as physician to take a some time in the company of the entire family.
comprehensive medical history in addition to acquir- Frequently, families referred to us have already
ing other information. In all these areas of question- been assessed in this fashion by competent family ther-
ing, psychiatrists collect data as do all other physicians, apists, and the child and adolescent psychiatrist may
usually attempting to delineate and organize the infor- not need or have the opportunity to pursue extensive
mation in a chronological fashion. What is unique family treatment. Nonetheless, the opportunity to
about a psychiatric evaluation is that physicians pursue observe firsthand how the members of a family act
not only the specific data but also their affective impli- with each other can be enriching for a clinician
cations. In other words, they seek to find out not only attempting to understand the consequences of each
what specifically happened but how it made the child family members behavior on the others. In addition, if
or family members feel and what consequences it had this observation is done early, it may serve as a more
on their lives. comfortable entrance to the evaluation process for a
Another area of inquiry of particular importance to shy or otherwise recalcitrant child or other uncooper-
physicians treating children, and perhaps especially to ative family member.

Meeting the Child as a talking doctor or problem doctor who deals

with the problems that many children have (general-
In practice, most clinicians develop a somewhat per- ization may make the child feel less singled out)
sonal style of interaction usually formed by psychody- through conversation as well as traditional somatic
namic and interactional approaches and also more treatments, and who does not give injections in the
structured, empirical techniques. Clinicians in any office setting. Older children and adolescents can often
setting soon realize that, outside of the specific require- be asked directly about how they were brought to eval-
ments of a structured interview instrument, they need uation, as well as their opinions about its necessity and
to be flexible in their approach. The schemes that we desirability. With school-age children, an initial request
use for reporting an interview are generally best con- about what sort of problems they may have encoun-
ceived as devices for retrospective organization rather tered in their life may be met with diffidence or avoid-
than templates for an interview. This is of particular ance. In this instance, simply playing together at some
importance with children. Any pediatrician knows that mutually acceptable activity may be an important first
in the course of a physical examination one does what step. Older children and adolescents may at this time
one can when one can. Similarly, in the psychiatric be able to tolerate tactful questions or the mention of
interview with the child, one must be flexible and other material or information. They will still benefit
mobile both verbally and physically. from the opportunity to talk or interact about areas
The most important element of an initial psychiatric that they like, perhaps later in the interview. A frequent
interview with the child is the establishment of a pro- icebreaker employed by child and adolescent psychia-
ductive relationship in other words, making friends. trists is drawing. Children who are seated in the waiting
The clinician must keep in mind how children feel in room while their parents are being interviewed can be
the context of an interview. Children may share or given the opportunity to draw a picture of their family
reflect the same complicated and ambivalent mixture or some other subject of interest to them. Such a
of fear, shame, hope, and misapprehension that their drawing can serve as both a projective device and a
parents bring to the process, and they often have not conversation starter later in the process. Of course,
been fully prepared by the parents or others for the children can also be encouraged to draw at other times
interview. Such preparation, if it can be done by during the interview.
parents prior to bringing the child in, can be helpful. In many instances, children do not respond to a
Many children, in my experience, have been told standard, direct, complaint centered line of question-
nothing at all, other than Come along, we are going ing, even after several attempts by the clinician. The
to see someone. Or they may have been told that they clinician is then best advised to relent and ask the child
are going to see a doctor, which can convey fears of to talk about more general aspects of his or her life.
injections and manipulations. Some children may have The patient can be encouraged to tell the physician
been led to assume that the evaluation is part of a puni- about his or her family, including each individual
tive process. Others may feel that by virtue of referral member and relationship, and school, including aca-
they have been singled out in some way as weird or demic and socialbehavioral aspects and social life in
crazy. Concurrently, the child may expect to see the general. In doing so, the clinician can often assemble
physician as some sort of remote, distant, punitive, or a broad picture of the childs life as well as specific
bizarre figure. All these issues must be promptly inves- medical information about phenomenology. Some
tigated and addressed in a developmentally appropri- areas may need to be more directly pursued, usually
ate fashion for a productive interview to ensue. later in the interview when a presumably more trusting
How one deals with the above issues is affected by relationship has been established. These include items
ones own personality and training, and by the cir- that are considered part of the mental status examina-
cumstances of the child and family. Preschool children tion, such as the presence of affective symptomatology
are seldom able to sustain any type of formal interview, (including suicidal ideation or plans) and psychotic
although they may answer some questions during play phenomena (including hallucinations, delusions, or
activities or while on the run. Their preoperational ideas of reference). Not every child needs to be asked
style of cognition makes the standard interview about these things, since for some children, merely
format, with its attention toward consequence and inquiring in an initial interview can be disruptive or
chronology, irrelevant. One assesses these children fearsome. Nonetheless, these issues must be pursued if
through observation and interaction. By contrast, the there is any indication of a disorder in the given area.
school-age child will have some comprehension of the Suicidal ideation in particular must be pursued in
psychiatrists role. It may help to introduce ones self the context of any affective disorder. Other important

behavioral areas such as sexual behavior, using drugs, Table 1.1 Mental status examination outline.
and health risk behavior may also need to be pursued.
The issue of confidentiality warrants special con- 1. Physical appearance
sideration. Child and adolescent psychiatrists must 2. Separation from parent
use their clinical skill to moderate two conflicting 3. Manner of relating
demands: the childs right to confidentiality as a 4. Orientation to time, place, and person
patient versus the right of parents and, in some 5. Central nervous system functioning
instances, agencies or institutions to be aware of the 6. Reading and writing
childs needs and requirements. In my experience, most 7. Speech and language
parents want to know what their child is experiencing; 8. Intelligence
concurrently, most children want their parents to 9. Memory
understand them, although they may prefer to conceal 10. Thought content
some specific details. Younger children may be told 11. Quality of thinking and perception
they have a right to hold secrets, but that their parents 12. Fantasies and inferred conflicts
also have a right to know what in general is going on 13. Affects
in their lives. Adolescents and their parents may be told 14. Object relations
that in general they have a right to confidentiality, but 15. Drive behavior
that some information involving a serious risk to 16. Defense organization
themselves or others could be shared. Conflicts over 17. Judgment and insight
confidentiality often overlie larger family issues that, 18. Self-esteem
if addressed, make the confidentiality issues moot or 19. Adaptive qualities
irrelevant. 20. Positive attributes
Child and adolescent psychiatrists have traditionally 21. Future orientation
been encouraged to pursue childrens fantasies in the
course of an assessment. The various approaches to Adapted from Lewis ME, King RA: Psychiatric assessment
this tend to be highly personalized by each clinician of infants, children and adolescents. In: Lewis ME, ed. Child
and may include asking a child for three wishes, posi- and Adolescent Psychiatry: A Comprehensive Textbook, Third
tive or negative animal identifications (what animal Edn. Baltimore, MD: Williams & Wilkins, 2002:531.
would you like or not like to be), story completion,
response to fables, or other techniques. Few if any of
patient in question possibly has a major thought or
these approaches, as used idiosyncratically in an
affective disorder, however, specific adherence to this
unstructured interview, have ever been validated. They
outline may be useful.
should not be treated as sources of empirical data in
and of themselves. They can, however, be important
probes to seek other information that can be validated Other Aspects of Psychiatric Evaluation
and, more importantly, that relate to specific emotional
Standardized Assessment Instruments
concerns of an individual child or adolescent.
Frequently nonmedical professionals refer to the Structured interviews, rating scales, and questionnaires
psychiatric evaluation as the mental status exam, but have become increasingly used in child and adolescent
in fact this examination is not always used in evaluat- psychiatry in recent years, although their primary
ing children and adolescents certainly a formal venue remains in research settings. In many cases,
mental status examination must be pursued when there a comprehensive evaluation can be conducted and
is evidence of a thought disorder. In these instances, reported without resort to these instruments; and some
the type of examination used with adults generally suf- instruments may require a degree of time and expense
fices for adolescents as well. In younger children, the unavailable outside a research setting. However, as
mental status examination is often a list of observa- diagnostic categorization under the DSM system has
tions that is retrospectively organized from the content become more standardized and reproducible, clinicians
of the interview thus far described. (The outline of this are more frequently using validated instruments to
examination is summarized in Lewiss article [6] and in clarify or affirm impressions that come from their
Table 1.1). In most child and adolescent psychiatric personal evaluations. Thienemann has produced a
assessments, these parameters are not all specifically thoughtful commentary on the process of combining
cited but are mentioned as part of the narrative or may these elements in a fashion that is both dynamically
be drawn from inference by the reader. When the sensitive and empirically valid:

Ideally, using intuition and experience, the psychiatrist blood- understanding of the patients emotional substrate,
hound will use clinical senses to sniff out clues to diagnosis especially early in the treatment of withdrawn or ver-
at first encounter. On picking up a diagnostic scent, he or she bally inhibited children.
will doggedly follow it into a specific diagnostic room to
gather details, thereby determining a diagnosis presence and
clarifying its severity. Integrating this reliable diagnostic Laboratory Assessment
information with clinical observations, the clinician will be
better positioned to engage patients and their families with Laboratory assessment has become a much more fre-
effective treatments. [11] quent part of psychiatric evaluation in recent years (see
also Chapter 3). Many patients of child and adolescent
Many clinicians use initial screening or parental report psychiatrists will have already undergone a compre-
instruments such as the Achenbach Child Behavior hensive laboratory assessment, even including neu-
Checklist (CBCL) [12] to aid in the early collection of roimaging, by their referring physicians; the burden of
data. Other instruments such as the Conners ques- further assessment of these patients is thus not borne
tionnaires used by parents or teachers [13,14] may be by the psychiatrist.
useful in the ongoing assessment for management of Conversely, some patients will have had little if any
specific disorders such as attention-deficit hyperactiv- laboratory workup, and such assessments may be indi-
ity disorder (ADHD). cated in an orderly, stepwise fashion. For example,
The Childrens Interview for Psychiatric Syndromes patients might receive standard hematologic and
(ChiPS) [15] is a screening tool that addresses some chemical screenings prior to more exotic endocrino-
20 Axis I entities. Respondent-based instruments rely logical and nutritional assessments. Similarly, it is
upon responders to identify the presence or absence of seldom appropriate to seek an expensive and compli-
symptoms. Besides the Conners scales, these include cated neuroimaging procedure in a patient who has not
the DISC [16], the computer-assisted (but not the yet received a neurologic examination.
live version) DICA [17], and the pictorial DOMINIC- Given both the immense progress in neuroimaging
R [18] which is used with children under the age of and the intense media coverage devoted to this
11 years. The specific utility of these instruments is progress in recent years, some patients and families will
discussed by Myers et al. [19] and in Chapters 2 and assume that procedures such as computed tomography
8. (CT) or magnetic resonance imaging (MRI) scanning
are an essential part of the psychiatric examination.
Psychologic and Educational Evaluation This, of course, is frequently not the case. Clinicians
may be best advised to deal with these demands by
Psychologic and educational evaluation are both dis- recognizing the underlying motivations of concern,
cussed in subsequent chapters. Along with psychiatric anxiety, or entitlement that evoke these requests. At the
evaluation, they stand as distinct and useful proce- same time, as physicians, child and adolescent psychi-
dures that cannot be substituted for each other. Today, atrists must be aware of the infrequent but poignant
many patients who come to a child and adolescent psy- circumstances in which gross central nervous system
chiatrist have already been given psychologic testing; pathology, such as vascular malformations and space-
the results, as noted, can be useful information. Far occupying lesions, may manifest themselves.
fewer of these children have received an educational
evaluation or prescription, which may be an extremely
useful part of the childs assessment and rehabilitation, Outcome of the Evaluation
especially as psychiatric treatment progresses. In both
Presentation of Findings and Recommendations to
cases, psychiatrists should present these assessments as
Parents and Referring Sources
opportunities to better understand a patients assets
and liabilities. Parents should not be led to believe that In the past, some psychiatrists, perhaps out of a spe-
either the psychologic or educational assessment will cialized conception of confidentiality, have been reluc-
produce some sort of miraculous answer to chronic tant or even reclusive in sharing their findings with
problems or that seeking them implies some failure others. In some instances, this practice has even been
or inadequacy on the part of them or the physician. directed to parents who may have been told merely to
Rather, these assessments are specialized procedures continue bringing their child for treatment. Such posi-
that hold unique value in understanding a childs cog- tions were, thankfully, relatively unusual, and current
nitive structure, learning style, and educational needs. demands for consumer orientation and accountability
Projective testing can be useful in obtaining a deeper have since made them utterly untenable. Parents or

guardians and referring professionals or agencies are inadequacy or incompetence. Fears may arise in con-
entitled to a concise and comprehensible statement of nection with specific treatment recommendations.
findings and recommendations. The manner in which The use and misuse of psychopharmacology has
this information is delivered depends on the needs of been pursued in excruciating detail and with variable
the child and the relationship of the child to these indi- accuracy by the media. In addition, certain religious
viduals or agencies. and political groups have publicly pursued an
As noted earlier, parents approach psychiatric eval- agenda opposing psychopharmacology, often in an
uation with a rich mixture of concerns, hopes, and ill-advised and misinformed fashion. All this informa-
fears, which often come to a head at the time of the tion can be on parents minds. Concurrently, however,
counseling or informing interview. I have met parents they or their children may see medication as a means
who could give me a verbatim account of their contact of control or as a source of some sort of magical
years earlier with a professional regarding their childs improvement.
status; the affective intensity of this moment sears it Although many parents may see psychotherapy as a
into memory. The fashion in which this powerful cir- more benign intervention than somatic treatment, they
cumstance is addressed can profoundly affect the may still have concerns or misconceptions about it.
subsequent conduct of the patients treatment. It is a The usual recommendation for family involvement or
truism that at such moments, parents may hear only family therapy may be interpreted by some parents as
the first thing told them. Indeed, it often may be an indictment of their own actions. Psychotherapy,
enough in one interview to convey a single major piece and the fashion in which it helps or cures, may also
of information and attempt thereafter to address its be a mystery to parents. A careful, thoughtful, and
affective consequences. If a diagnostic impression or concise explanation of the rationale for psycho-
therapeutic recommendations are at all complicated, therapy should always be given. The explanation
parents may need a frequent restatement of this should include the indications for psychotherapy, the
content, perhaps accompanied by written or audiovi- options of therapeutic methods and approaches
sual supplements and aids. Many parents may require applicable to a given situation, the manner in which
a series of contacts to fully understand and process this psychotherapy can be expected to help, the role of the
information. Given the restrictions in contact imposed family in this therapy, and an estimate of duration and
by some care-management agencies, it may be helpful cost.
to incorporate into this process case managers or other
professionals who have a relationship with the family.
Treatment Planning
In my experience, however, the ultimate responsibility
as well as the ultimate effectiveness in dealing with Treatment planning is considered in greater detail in
these issues for families resides with the diagnosing Chapter 6. It is informed by a variety of considera-
physician. It is therefore absolutely incumbent on child tions, including the specific disorders of the patient or
and adolescent psychiatrists to deal first and foremost family; the preferences, hopes, fears, and fantasies of
with the affective consequences of whatever informa- the patient or family; and systemic availability and
tion is being presented. To fail to do so is not only limitation of resources. A treatment plan must be
inhumane but is likely to seriously compromise the developed that is both appropriate for the disorder
subsequent physicianfamily relationship and the under treatment and realistic in the context of patient
familys compliance with treatment recommendations. and family wishes and resource limitations. In todays
It should go without saying that all these considera- environment of care management for fiscal ends and
tions must also be addressed, in a developmentally with limited resources, clinicians may frequently be
appropriate fashion, in explaining the findings and rec- tempted to offer treatment plans that are suboptimal
ommendations to the child or adolescent as well. or even inadequate for the patients needs. It is the pro-
Many psychiatric disorders of children have been fessional and ethical responsibility of any physician,
addressed with varying degrees of accuracy in the certainly including child and adolescent psychiatrists,
public media, for example, conveying both conscious to provide patients and families with a clear indication
and unconscious expectations to parents. The child of the most clinically effective treatment recommen-
and adolescent psychiatrist must thus explore the spe- dations even if they are not economically feasible.
cific meaning and implication of any diagnosis for a McConville (see Chapter 6) offers a model of treat-
given family. Specific treatment recommendations may ment planning that places interventions on separate
carry with them certain implications, any or all of continua of directivity and restrictiveness and allows
which may amplify or exaggerate a parents feelings of for a sequential arrangement of multiple interventions.

Sharing Information with Other Physicians, request can embroil the psychiatrist in conflicts that
Schools, and Agencies make further engagement with the family impossible,
while the child has been done no substantive good. The
Since many patients come to seek child and adolescent
psychiatrist should be ready to discuss the specific
psychiatrists as a result of a referral from physicians,
needs of a child, however, irrespective of the particu-
schools, or other agencies, information must frequently
lars of physical setting.
be shared regarding the patients condition, prognosis,
and treatment. It is axiomatic that information on any
patient cannot be released without the expressed (and Consultation, Collaboration, and Advocacy
usually written) permission of the patient or, in the Childrens needs are addressed in our culture by a wide
case of a minor, the patients parents or legal guardian. variety of people: parents, professionals, and educa-
Both the content of shared information and the tors, among others. Even in the case of the child with
manner in which it is communicated are matters of a major mental illness whose psychiatric needs may be
clinical judgment and practical wisdom and should paramount, it is usually impossible for a child and ado-
be discussed in advance with patients, families, or lescent psychiatrist to function alone. The psychiatrist
guardians. Information should be distributed only as will therefore be asked to consult with other profes-
requested, and psychiatrists should avoid automatic sionals and educators. (The manner of these consulta-
release of entire reports or clinical notes. These issues tions is discussed in Chapters 4, 5, 29, and 30.) Such
of confidentiality are especially complicated by third- consultation may be an intermittent advisory relation-
party reimbursement. Many patients and families ship, or it may involve ongoing collaboration wherein
routinely authorize unlimited release of clinical infor- child and adolescent psychiatrists and other profes-
mation for the purpose of reimbursement, and in fact sionals interact in discipline-specific roles.
may be forced to do so. Unfortunately, this informa- In todays environment of competition for social and
tion can then become accessible to an almost unlim- educational resources, and of active intervention in
ited number of individuals and organizations. the lives of children and families who are in danger, the
In general, referring sources should not be given child and adolescent psychiatrist has a special role of
detailed information about members of the family advocacy. This role may develop as a result of a request
other than the patient This is especially critical in by a patient and family or the psychiatrists perception
educational settings, since many school records are that some special intervention or communication is
virtually public documents. Much of the time, these required. Despite the changing and challenged role of
dilemmas can be claimed or resolved before any physicians in our society, the child and adolescent psy-
records or reports are released by conversing with the chiatrist can still be an important and potent agent in
professional or agency requesting information. The the workings of educational, social, and legal systems.
type of information shared with a referring physician
may be very different from that shared with the school,
however, in both content area and detail.
Referral sources sometimes pursue psychiatric The child and adolescent psychiatrist has a unique
evaluation of a child or adolescent in a conscious role within medicine, providing diagnostic assessment,
or unconscious attempt to gain information about the therapeutic services, consultation, and advocacy for
parents or other family members. Such requests, even children and their families. In a broad biopsychosocial
when made with good intentions, are usually ethically context, child and adolescent psychiatrists attempt to
indefensible. They are also logically suspect, since they best meet the needs of children and families by pro-
seek information that arises from hearsay and sur- viding these services in a fashion informed by scientific
mises. An extreme example of this situation is when the rigor, personal sensitivity, and social responsibility. An
child and adolescent psychiatrist is asked to comment encounter with the child and adolescent psychiatrist
on the fitness for child custody of a parent whom the should provide clinical clarification, personal reassur-
psychiatrist has never met. Complying with such a ance, and practical direction.


Biological Development
024 months
02 months
1820 months
Increasing organization of sleep patterns
Quantitative changes in brain developmet Density of dendritic spines
26 months Cerebral glucose metabolic rates
Rapid growth of synapses reach adult levels
Rapid increase in cerebral glucose metabolism Increasing lateral and anterior-
Social smiling emerges posterior cerebral specialization
Diurnal sleepwake cycles emerge of language centers

79 months
Growth in head circumference with rapid cerebral growth
Myelination of limbic system
Enhanced associative pathways
Improved inhibitory control of higher centers

0 2 4 6 8 10 12 14 16 18 20 22 24

Figure 1.1 Biological development during the first two years of life.

Cognitive Development
024 months
02 months
1820 months
Rapid development of olfactory and auditory recognition
Emergence of cross-modal fluency Development of
Recognition of maternal face symbolic representation
Emergence of personal pronouns
26 months Pretend play is progressively
Emergence of classical and operant conditioning other directed
Development of habituation
79 months
Means-ends behavior develops
Demonstration of object permanence
Stranger reaction and separation protest appear
Exploration of novel properties of objects
Emergence of mastery motivation and symbolic play
Emergence of the discovery of intersubjectivity

0 2 4 6 8 10 12 14 16 18 20 22 24

Figure 1.2 Cognitive development during the first two years of life.

Emotional Development
024 months
02 months
Maternal recognition of contentment 1820 months
Maternal recognition of interest The Rapprochment crisis occurs
Maternal recognition of distress Emergence of embarrassment,
empathy, and envy
23 months
Differentiation of joy from contentment
Differentiation of surprise from interest
Differentiation of sadness, disgust, and anger

79 months
Affect attunement
Emergence of instrumental use of emotion
Emergence of social referencing

924 months
Discriminates emotions by facial expressions
and vocalizations

0 2 4 6 8 10 12 14 16 18 20 22 24

Figure 1.3 Emotional development during the first two years of life.

Social Development
024 months
02 months 79 months
Interactive communication Increasing evidence of intersubjectivity
occurs Responds to caregiver empathy
Stimulates social responses Emergence of separation protest and
stranger reactions
23 months 1820 months
Vocalizations become social Words used for social functions
Emergence of turn taking in vocalizations Language development
Emergence of mutual limitation enhances relatedness
Emergence of sound localization Increased evidence of
Recognition of verbal affect social relationships
27 months
Eye to eye contact begins
Emergence of the social smile
Emergence of social interaction
Diminished crying

0 2 4 6 8 10 12 14 16 18 20 22 24

Figure 1.4 Social development during the first two years of life.
Biological Development
20 months5 years

Bowel control established

Daytime bladder control established

Activity level peaks

Nighttime bladder control established

Cerebral growth spurt

Brain weight 90% of

adult brain

20 2 3 4 5
months years years

Figure 1.5 Biological development during the preschool years (20 months5 years).

Cognitive Development
20 months5 years

Begins to report recalled information

Begins to form scripts of familiar events

Limited attention span

Easily distracted

Preoperational stage (magical thinking, symbolic play,

animism, artficialism)

Acquires a theory of mind


Begins to use two-word phrases

Initial emergence of strong past tenses

Begins to learn the social uses of language

Begins to form subjectverbobject sentences

Begins to tell narratives

Development of ed endings

20 2 3 4 5
months years years

Figure 1.6 Cognitive development during the preschool years (20 months5 years).

Emotional Development
20 months5 years

Begins to appraise meaning of stimuli within

the context of individual goals

Begins to adopt culturally defined rules of emotional expression

Begins to inhibit and delay behavioral plans

Development of object constancy

Development of internal working models of relationships

Begins to modulate behavioral

expression of emotion

Oedipus complex

20 2 3 4 5
months years years

Figure 1.7 Emotional development during the preschool years (20 months5 years).

Social Development
20 months5 years

Play modalities develop (solitary, pretend, parallel, associative, cooperative)

Can act out role-specific behaviors

Social role behavior in

complementary roles

20 2 3 4 5
months years years

Figure 1.8 Social development during the preschool years (20 months5 years).

Biological Development
612 years

First tooth lost

Increased ability to shift eyes

Increased bladder control (day and night wetting is rare)

Pyramidal cell shape and size undergo accelerated change

Handedness, eyedness, and footedness are established
Visuomotor and intersensory integrations emerge

Period of marked improvement Arm, shoulder,

in fine motor control and wrist
control is
fully mature

6 7 8 9 10 11 12

Figure 1.9 Biological development in the school-age child (612 years).

Cognitive Development
612 years
Piagets stages of development

Concrete operations

Role learning, categorization, or elaboration to enhance performance

Switch from egocentric to social speech

Understanding of temporal sequences and the differences between
day, time, and month emerges
Understanding of the conservation of material volume emerges
Make-believe play (role-playing)

Emergence of declarative memory

Ability to take anothers point of view emerges
Shift from irreversible to reversible operations occurs
Ability to understand logical principles develops (e.g., reciprocity,
classification, class inclusion, seriation, and number)

Increasing awareness of ones own abilities and

comprehension (or lack thereof)

Development of competence

6 7 8 9 10 11 12

Figure 1.10 Cognitive development during the school-age child (612 years).
Emotional Development
612 years
Emergence of emotional control
Vacillates from one emotional extreme to another

Increasing sensitivity to attitudes of others

Decrease in sensitivity
Increasing feeling of anticipation and impatience

Becomes more independent, dependable, and obedient

Development of a sense of empathy

Increased mood variation

and moodiness

6 7 8 9 10 11 12

Figure 1.11 Emotional development during the school-age child (612 years).

Social Development
612 years

Understands that people can have multiple roles

Likes some social routines

Interested in secrets, collecting, and organized games and hobbies

Off-color humor emerges
Primarily unisex friendships
Explains actions by referring to events of immediate situation

Redefines status relationships with friends

Same-sex groupings prominent
Punchlines emerge in humor
Focus on peoples physical appearances as opposed
to their personality dispositions

Adoption of groups values, speech patterns, and manners

Strong peer group affiliation

Rise in social consciousness with

respect to what is in
Increased self-regulation
Best friends rise in importance

Understands that emotions have

internal causes
Recognizes that people can have
conflicting feelings and can sometimes
mask true feelings

Relates actions to
personality traits and feelings
Sees friends as people who
understand each other and
share thoughts and feelings

6 7 8 9 10 11 12

Figure 1.12 Social development during the school-age child (612 years).
Cognitive Development
1318 years
Formal operations: Development of logical reasoning, including combinatorial system, ability to
understand combinations of objects and new propositional combinations, appreciation of
inversion, reciprocity, and symmetry.

Abstract thinking first emerges Resolution of adolescence:

Attain a personal value
Acquisition of processing capacity system respecting the needs
Development of mutual perspective taking of others and the needs of self

Refinement of processing capacity

Elaboration of skills for handling and processing information, including scanning skills,
flexible use of learning strategies, control or monitoring of information processing
Expansion of informational and factual catalog

Development of mutual perspective taking

Growing recursive thought

Formal operational thought

13 14 15 16 17 18

Figure 1.13 Cognitive development during the adolescent period (age 1318 years).

Emotional Development
1318 years

Understands others emotions

Appreciates mixed or
contradictory emotions
Increasing Observes and contemplates emotions
metacognitive as internal states
capacities: Separates behavior and emotion
Understands the influence of experiences
outside of immediate relationships as
affecting emotions

Emotions play more central function and guide behavior to a greater degree
Emergence of capacity for
more emotionally intimate

13 14 15 16 17 18

Figure 1.14 Emotional development during the adolescent period (age 1318 years).

Social Development
1318 years

Resolution of adolescence:
Separation from parents
Conflicts with parents increase Attain a stable sexual
Peers become more influential identity
Interest in sexual behavior emerges Develop ability to form
Crushes on older, unattainable people long-term sexual relationships
Uncertain about homosexuality Attain a steady job or
preparation for a career
Experimentation with drugs and alcohol

Reliance on confidence with parents continues

Heightened self-consciousness
Consolidation of identity
Peer relationships viewed as mutually beneficial

Romantic interests expand to a variety of people

Adult relationships outside of the family assume greater importance

Influence of peers regarded more objectively

Resolution of sexual orientation

Sexual experimentation

Exclusive romantic relationships develop

Anxieties about identity are prominent
Demands on sexual and vocational
identity increase

13 14 15 16 17 18

Figure 1.15 Social development during the adolescent period (age 1318 years).

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Psychological Assessment of Children
Antoinette S. Cordell

Effective diagnosis and treatment planning requires a ability. In the Parent Domain, the categories include
flexible approach to child assessment that includes data competence, isolation, attachment, health, role restric-
from multiple sources as well as parental involvement. tion, depression, and relationship with spouse. The
Mooney and Harrison reported that those psycholo- Total Stress score combines both domains and allows
gists who see many children for school-related con- for an analysis of the source of stress. This index, then,
cerns address cognitiveacademic or personality issues can be used to assess the degree to which the childs
but provide much less information on social influences behavior is stressful versus the difficulty the parents
and the context of the childrens lives [1]. The most fre- have in adjusting to their parenting roles. PSI results
quently used means of gathering information include are also helpful in communicating with parents; the
the Wechsler, Rorschach, and Bender Gestalt tests, clinician can report, for example, that the parents
the Thematic Apperception Test (TAT), achievement provided the information that they feel depressed or
tests, and drawings. There are limitations to the strictly that they are experiencing communication barriers
intrapersonal perspective, however, since children with their spouse. Parents are less likely to be defen-
should be understood within the context of their lives sive, and the clinician can be more reflective and under-
[1]. Assessment techniques should be broad and should standing rather than intrusive (Figure 2.1).
include measures that draw on the child in action. The same authors headed by Sheras (1998) devel-
Psychological techniques suggested for this type of oped the Stress Index for Parents of Adolecents
assessment include parent/teacher questionnaires, (SIPA), a questionnaire for parents which applies to
intelligence and achievement testing, drawings, projec- teens 1119 years of age [4]. Categories in the Adoles-
tive testing, child questionnaires, behavioral assess- cent Domain (AD) include: Moodiness/Emotional
ment, play observations, and family interaction Lability (MEL); Social Isolation/Withdrawal (ISO);
(Appendix 2.1). Delinquency/Antisocial (DEL); and Failure to
Achieve or Persevere (ACH). In the Parent Domain,
the following categories are assessed: Life Restrictions
Parent/Teacher Questionnaires
(LFR); Relationship with Spouse/Partner (REL);
The Eyberg Child Behavior Inventory is a straight- Social Alienation (SOC); and Incompetence/Guilt
forward 36-item questionnaire that can be completed (INC). The AdolescentParent Relationship Domain
by parents of children who are 27 years of age. The (PRD) assesses the parents view of the quality of the
Eyberg is relatively simple to fill out and yields infor- relationship that the parent has with the adolescent.
mation on a wide variety of behavioral problems [2] Additional scales include the Life Stressors scale (LS)
including dawdling, defiance, and opposition, seeking and an index of Total Parenting Stress (TPS). Like the
attention and difficulty concentrating. PSI, this tool is useful in assessing the parental per-
The Parenting Stress Index (PSI) by Abidin is filled spective in raising an adolescent. The parent is able to
out by parents of children ranging in age from 1 month provide information on their teens behavior, their own
to 12 years [3]. (A short form is available.) The PSI pro- assessment of their parenting, and the relationship
vides Child Domain scores for the following categories: between them.
distractibility/hyperactivity, adaptability, reinforce- The Child Behavior Checklist is completed by
ment of parents, demandingness, mood, and accept- parents or teachers of children aged 416 years [5,6].

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

Personality Component
& Pathology Child
Depression Social Support Adoptability
with Spouse

& Parental Parentling Child
Attachment Demandingness
Pathology Stress Characteristics

Sense of
Competence Role Hyperactivity/
Restrictions Health Distractibility

Reinforces Parent

Figure 2.1 Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204
North Florida Avenue, Lutz, Florida 33549, from the Parenting Stress Index Professional Manual by Richard R.
Abidin, Ed.D., Copyright 1983, 1990, and 1995 by PAR, Inc. Further reproduction is prohibited without permis-
sion of PAR, Inc.

The accompanying Youth Self-Report Scale is com- implications for treatment. These scales can also be
pleted by youngsters from 11 to 18 years of age. These used to assess improvements from the use of psy-
questionnaires have the advantage of providing a choactive medication.
behavior profile which gives information on the fol- The Attachment Disorder Questionnaire developed
lowing dimensions: Withdrawn; Somatic Complaints; by E. M. Randolph allows an assessment of the more
Anxious/Depressed; Social Problems; Attention Prob- problematic behaviors and traits of children who have
lems; Delinquent Problems; and Aggressive Behavior. reactive attachment disorder [10]. Items include state-
Separate forms are used for boys and girls aged ments such as My child uses his/her cuteness or
45, 611, and 1216 years. The Child Behavior Check- charm to get others to do what he/she wants; My
list-Direct Observation form can also be used for struc- child goes up to strangers and becomes overly affec-
turing behavioral observations. There is also the tionate with them or asks to go home with them; My
CaregiverTeacher Report Form for preschoolers 18 child is cruel to animals or other people. This ques-
months to 5 years of age to be filled out by the preschool tionnaire can be helpful in identifying the nature and
teacher or caregiver in a daycare setting. This tool pro- severity of the childs symptoms.
vides the clinician working with young children an addi-
tional perspective on the childs behavior and emotional
Cognitive Assessment
needs in a structured setting outside of the home [7].
The Conners Rating Scales-Revised provide Kaufman and Ishikuma presented a model for intelli-
teacher- and parent-rating scales and an adolescent gence and academic testing that allows the clinician to
self-report scales [8]. A new empirically based combine test administration with an in-depth under-
attention deficit hyperactivity disorder (ADHD) index standing of human development [11]. The goal is to
can be used to assess children at risk for ADHD. In assist individuals in addressing their problems and to
addition, the McCarney Attention Deficit Disorders improve their functioning, rather than to limit them via
Evaluation Scale condenses the three subscales of labeling or diagnosing.
inattentiveness, impulsivity, and hyperactivity to two Intelligence testing is both overrated and under-
scales: inattentiveness and impulsivity/hyperactivity rated. Many people place too much emphasis on intel-
[9]. It is useful to have a measure of both of these char- ligence quotient (IQ) scores per se. It is important to
acteristics in child evaluations since they have different realize that psychological tests provide a wide range of

information regarding strengths, weaknesses, learning Table 2.1 The WISC-III subtests grouped according
style, and needs. There are many personal qualities that to scale.
intelligence tests do not measure, however, such as cre-
ativity, determination, and persistence over a period of Verbal Performance
time. As a result, many individuals who score high on
IQ tests perform below this level of expectation, and 2. Information 1. Picture Completion
others who score at more modest levels nonetheless 4. Similarities 3. Coding
accomplish many fine and far-reaching goals. It has 6. Arithmetic 5. Picture Arrangement
never been possible to capture the inventiveness of the 8. Vocabulary 7. Block Design
human spirit on paper! 10. Comprehension 9. Object Assembly
There are many factors other than difficulties with 12. Digit Span 11. Symbol Search*
intellectual functioning that can lead to low IQ scores. 13. Mazes
Factors such as cultural or linguistic differences, dis-
tractibility or anxiety, refusal to cooperate, and dis- * Supplementary subtest that can substitute only for
abling conditions such as autism and deafness can all Coding.
limit a persons ability to perform the tasks on an IQ Supplementary subtest.
test. Research has shown that the norms for intelli- From Wechsler D: Wechsler Intelligence Scale for Chil-
gence tests become dated over time and that IQ scores dren Third Edition: Manual. New York: Harcourt
Brace Jovanovich; 1991:5.
gradually drift upward. When current norms are used,
a childs score may be slightly lower [12].
Intelligence tests give a wide range of information and Coding. There are seven Supplemental subtests:
about childrens abilities in several areas of function- (Symbol Search); (Comprehension); (Picture Comple-
ing. Wechsler considered intelligence a combination of tion); (Similarities); (Receptive Vocabulary); (Object
abilities reflecting an overall level of intellectual capa- Assembly); and (Picture Naming). For a six-year-old
bility. The newly revised Wechsler Intelligence Scale for child whose ability is below average, the best choice for
Children-Fourth Edition (WISC-IV) provides subtest intelligence testing may be the Wechsler Preschool and
and composite scores in specific areas as well as an Primary Scale of Intelligence-III (WPPSI-III).
overall cognitive score representing general intellectual One of the advantages of ability testing is that it pro-
ability (i.e., Full Scale IQ) [12]. This revised edition has vides us with information on the pattern of strengths
updated norms, new subtests, and greater emphasis on and weaknesses that can affect the students ability to
discrete domains of cognitive functioning. It is easier function in the classroom (Table 2.2). It gives informa-
to administer and score. The revisions were based on tion to the educator about the special needs and learn-
research findings on cognitive development and intel- ing style of the student. In clinical practice, several
lectual assessment. Ten subtests have been retained findings can be significant. When there is a low score
from the WISC-III, and there are five new subtests on the Coding subtest relative to the other scores, for
(Picture Concepts, Letter-Number Sequencing, Matrix example, the child often has difficulty with handwriting
Reasoning, Cancellation, and Word Reasoning). The and motor performance in the classroom. Some chil-
subtests of the WISC-IV cover a wide variety of abil- dren may exhibit only this single deficit. These children
ities that can contribute to successful performance in struggle greatly to perform written work in the class-
school (Table 2.1). room, particularly in the primary grades, and are often
For a 16-year-old whose ability is above average, the labeled as lazy, when in fact their neurologic process-
Wechsler Intelligence Scale-III test for adults may be ing proceeds at a different rate than that of other chil-
most appropriate. dren in the classroom. The Similarities subtest scores
The Wechsler Preschool and Primary Scale of can be quite important, since they relate specifically to
Intelligence-III (WPPSI-III), available since 2002, abstract reasoning and what we commonly consider
offers an assessment of the intelligence of children ages overall intelligence. All of the areas assessed on the
two years, six months through seven years, three WISC-IV, however, are relevant for understanding the
months [13]. Like the other Wechsler tests, it provides childs functioning in the classroom.
an overall cognitive score as well as scores for verbal Children who have marked discrepancies between
and performance abilities. A major advantage of the the Verbal Comprehension Index (VCI) and Percep-
WPPSI-III is that it follows the same structural format tual Reasoning Index (PRI) can experience difficulty
and philosophy as the WISC-IV. The seven Core sub- functioning in the classroom (Table 2.3, Table 2.4).
tests are: Block Design; Information; Matrix Reason- Any child who has a severe deficit may be affected
ing; Vocabulary; Picture Concepts; Word Reasoning; severely, even if many other subtest scores are average

Table 2.2 Scales derived from factor analyses of the WISC-III subtests.

Factor I Verbal Factor II Perceptual Factor III Freedom Factor IV

Comprehension Organization from Distractibility Processing Speed

Information Picture Completion Arithmetic Coding

Similarities Picture Arrangement Digit Span Symbol Search
Vocabulary Block Design
Comprehension Object Assembly

From Wechsler D: Wechsler Intelligence Scale for Children Fourth Edition: Manual. New York: Harcourt Brace Jovanovich;

Table 2.3 Abbreviations of composite scores. How does ADHD affect intelligence test results? No
conclusive battery of tests exists for this disorder.
Composite Score Abbreviation ADHD children often score low on one or more sub-
tests of the WISC-III, including Arithmetic, Coding,
Verbal Comprehension Index VCI Information, and Digit Span. The Freedom from Dis-
Perceptual Reasoning Index PRI tractibility factor is not a pathognomonic indicator of
Working Memory Index WMI ADHD, however. There is tremendous variability in
Processing Speed Index PSI the relative abilities of children with ADHD, and
Full Scale IQ FSIQ ADHD thus negatively affects performance on struc-
tured tests in varied ways. Further, ADHD symptoms
present in several childhood disorders. Suggestions for
or above average. Children with high verbal scores but diagnosis include using a variety of assessment instru-
low performance scores struggle with the production ments to improve convergent validity as well as taking
of work in the classroom. Children with high per- a thorough history from multiple sources if possible.
formance scores and low verbal scores are often impul- Believe your data. Carefully review intratest and
sive, action-oriented individuals who have difficulty intertest scatter, behavioral observations as the child
reflecting or using language to process their experience. approaches tasks, and unusual errors; work hard to
The psychologist should look for unique patterns of communicate to others the importance of your assess-
strengths and weaknesses and attempt to understand ment data for intervention and treatment planning.
them in relation to the overall functioning and per- The StanfordBinet Intelligence Scale fourth
sonality of the child. Edition yields scores for Verbal Reasoning, Abstract/
Some children, such as the learning disabled (LD)/ Visual Reasoning, Quantitative Reasoning, and Short-
gifted child, have complex combinations of cognitive Term Memory [15]. The current edition includes many
abilities. There appear to be multiple patterns of scores performance items and so has addressed earlier criti-
for LD/gifted students. One pattern involves high rea- cism of the Binet that it was too verbally oriented.
soning/verbal abilities with deficiencies in performance Using either the WISC-IV or the Binet to ascertain
abilities or slow fine-motor coordination (shown by a strengths can provide useful information for guiding
low Coding score); there may also be difficulties with an individual in school and in making later career
attention span and focusing. Another pattern is high choices. Our schools tend to be highly verbally and lan-
performance abilities combined with a low verbal guage oriented. Not all careers require such a strong
score; this pattern may be particularly difficult to emphasis in this area; some use performance abilities,
identify, because we usually rely on childrens verbal for example. It is often difficult for the classroom
functioning as an overall indication of high intelli- teacher to realize the ability areas of children who
gence. Another pattern is characterized by a relatively exhibit low verbal and language abilities but stronger
high overall IQ but a high degree of distractibility. In performance abilities.
the classroom, several areas of special needs should be The Leiter International Performance Scale-Revised
addressed, including distractibility, slowness in han- has the strong advantage of being a nonverbal test of
dling written work, difficulty with organization, emo- intelligence [16]. It can be used to evaluate children
tional lability, and negative self-concept [14]. with sensory or motor deficits or language problems,

Table 2.4 Comparison chart.


Completely nonverbal Yes No No No No

Domains measured
Visualization Yes Yes1 Yes1 Yes Yes1
Reasoning Yes Yes1 Yes1 Yes Yes1
Memory Yes Yes1 No Yes Yes
Attention Yes No No No Yes1,4
Growth scores Yes No No No Yes6
Age range 221 616 37 290 290
Appropriate for
Cognitive delay Yes Yes3 Yes3 Yes3 Yes
ESL Yes No No No No
Limited English Yes No No No No
Learning disabilities Yes Yes Yes Yes Yes
ADHD Yes Yes No Yes Yes
Deafness Yes No5 No5 No5 No5
TBI Yes No5 No Yes4,5 Yes4,5
Communication disorders Yes Yes5 No No5 No5
Diverse cultures Yes No5 No5 No5 No5
Motor impaired Yes Yes2,5 Yes2,5 Yes2,5 Yes2,5
Fast screening Yes No No No No

1. Some subtests measure related areas, but require hearing, language, reading or motor skills.
2. Verbal skills only.
3. Restricted lower bound of IQ ranges.
4. Some areas, but not the complete spectrum provided in Leiter-R.
5. Adjusted administration required.
6. Uses Rasch modeling to derive other special scores.
ADHD = Attention deficit hyperactivity disorder; ESL = English as a second language; Leiter-R = Leiter Revised; SB-4 =
StanfordBinet 4th Edition; TBI = traumatic brain injury; WISC-III = Wechsler Intelligence Scale for Children 3rd Edition;
WJ-R = WoodcockJohnson Revised; WPPSI-R = Wechsler Preschool and Primary Scale of Intelligence Revised.
From Leiter RG: Leiter International Performance Scale Revised. Wood Dale, IL: Stoelting; 1997.

or those who speak a different language from the the ages of 4 to 90 years. The test has the advantage of
examiner. It contains 54 tests from levels II to XIV and taking between 15 and 30 minutes to administer with
takes 30 45 minutes to complete. The tests involve only two subtests including Vocabulary and Matrices.
arranging a series of blocks initially from pairings of It appears to be useful for establishing a baseline of
colors, shapes, and objects to analogies, perceptual pat- intelligence but does not provide in-depth information
terns, and concepts at later levels. Instructions are on strengths and weaknesses. Specifically, the many
given in pantomime. The Leiter has recently been difficulties with cognitive functioning that a child or
revised and may thus address uneven item difficulty at adult may show may not be revealed. The use of
various levels. This test is certainly less culturally the K-BIT, therefore, is limited from a clinical
loaded than other IQ tests, but there is no evidence on perspective.
whether it is free of cultural bias (Table 2.4). Another relatively brief assessment of capability is
A quick assessment of intelligence is provided by the found in the Peabody Picture Vocabulary Test-Third
Kaufman Brief Intelligence Test (K-BIT) [17]. This Edition (PPVT-III) [18]. This test is designed to
can be used for children, adolescents, and adults from measure receptive vocabulary over a wide range using

a friendly approach. The subject is shown four pictures below his or her grade level [23]. This can be a diffi-
and given a single word. The child then indicates either cult, emotional process of decision making, so it helps
verbally or nonverbally which picture best represents to have a systematic method of weighing the facts. In
that word. The simplicity of the test is useful in some addition, the book Summer Children: Ready or Not for
situations when a more comprehensive assessment School can be reviewed [24].
might not be possible, and it may enhance the likeli-
hood of cooperation as well.
The WoodcockJohnson-III Tests of Achievement
(WJ-III) [19] and the Wechsler Individual Achievement DiLeo acknowledged that interpreting childrens
Test-Second Edition [20] provide information on basic drawings requires more than one approach to under-
academic skills. Learning disabilities are defined as standing [25]. In the correlational approach, data are
major discrepancies between IQ level and tested aca- collected and statistically analyzed to determine any
demic skills. Some children, however, experience sig- correlation between a characteristic in the drawing and
nificant learning problems in the classroom but do not the significance that the clinician attaches to it. In
show such severe discrepancies. The field of education the longitudinal approach, the clinician performs an
is moving toward a team-based method of assessing in-depth study of the patient and examines the rela-
learning problems and special educational needs, but tionship between characteristics shown in the patients
individual psychoeducational testing should remain an drawings and the patients behavior and overall
integral part of this assessment process. development.
IQ scores should never stand alone in patients being Clinicians use subjectivity as well as a backlog of
diagnosed for developmental disabilities or mental clinical experience in interpretating childrens draw-
retardation. Rather, clinicians should consider the ings. This process involves generating hypotheses to be
pattern of strengths and weaknesses on IQ tests, assess tested with the use of other data and behavioral obser-
adaptive and other behaviors, and use common sense. vations. Drawings should never be used by themselves
When assessing a child, it is important to seek mul- to establish clinical facts.
tiple sources of data, including information on the The age and developmental level of the child need
childs personal and social sufficiency at home, at to be considered in the interpretation of drawings, and
school, and in the community. The Vineland Adaptive the clinician should be familiar with what is normative
Behavior Scales can be used to measure communica- for specific developmental levels. Preschool children,
tion, daily living skills, socialization, and motor skills for example, often fail to integrate parts into a whole,
in children from birth to 18 years and 11 months of but this failure is abnormal in an older child. Devel-
age or in low-functioning adults [21]. The scales can be opmental milestones and stage-dependent theories
used for handicapped individuals as well. The Vineland have been presented by Freud, Erickson, Piaget, and
requires a respondent who is familiar with the individ- Gesell.
uals behavior. The survey form contains 297 items, Drawing characteristics that have interpretive signif-
although only those items necessary to establish basal icance include the use of space; the quality of line;
and ceiling levels are used. The test takes 2030 orientation; shading (as an indicator of anxiety); inte-
minutes to administer and yields useful information on gration of the human figure drawings, symmetry, and
strengths and weaknesses in adaptive behavior. balance; and style. Drawings are also reflective of cog-
Two additional tools may be helpful. First, the nitive development. The drawing of a person yields an
Achievement Identification Measure by S. Rimm can overview of intellectual maturity [25]. House drawings
be used to assess underachievement [22]. It identifies give information about the change from an egocentric
students who are performing in school below their to an objective view (Table 2.5 and Appendix 2.2).
ability level. Some may be sliding through on the basis DiLeo discussed several pitfalls in the analysis of
of brains, not effort, whereas others may be in the drawings, including inconsistency in drawing perform-
early stages of underachievement before it has been ance [25]. When features appear consistently in several
noted on their report card. The scale measures six drawings, there is a great likelihood that they have been
dimensions of adaptive attitudes toward academic integrated into the childs concept. Particularly when
competition, responsibility, control, achievement, working with young children, therefore, the clinician
communication, and respectas well as a total score should obtain several drawing specimens. Another
that reflects a childs overall potential for success in pitfall is to assign excessive weight to specific details. It
school. Second, Lights Retention Scale can assist in is important to use a holistic approach and examine
objectifying the issues involved in retaining a child the overall impression of the drawing and to appreci-

Table 2.5 Development of drawing related to Piagets stages of cognitive development A synoptic view.

Approximate age (yr) Drawing Cognition

01 Reflex response to visual stimuli. Sensorimotor stage

Crayon is brought to mouth; the infant Infant acts reflexively, thinks
does not draw. motorically.
12 At 13 months, the first scribble appears: Movement gradually becomes goal-
a zig-zag. Infant watches movement directed as cortical control is
leaving its marks on a surface. gradually established.
Kinesthetic drawing.
24 Circles appear and gradually predominate. The child begins to function
Circles then become discrete. In a symbolically. Language and
casually drawn circle, the child other forms of symbolic
envisages an object. A first graphic communication play a major
symbol has been made, usually role. The childs view is highly
between three and four years. egocentric. Make-believe play.
47 Intellectual realism Preoperational stage (intuitive phase)
Draws an internal model, not what is Egocentric. Views the world
actually seen. Draws what is known subjectively. Vivid imagination.
to be there. Shows people through Fantasy. Curiosity. Creativity.
walls and through hulls of ships. Focuses on only one trait at a
Transparencies. Expressionistic. time. Functions intuitively, not
Subjective. logically.
712 Visual realism Concrete operations stage
Subjectivity diminishes. Draws what Thinks logically about things. No
is actually visible. No more X-ray longer dominated by immediate
technique (transparencies). Human perceptions. Concept of
figures are more realistic, reversibility: things that were the
proportioned. Colors are more same remain the same though
conventional. Distinguishes right their appearance may have
from left side of the figure changed.
12+ With the development of the critical Formal operations stage
faculty, most lose interest in Views his/her products critically.
drawing. The gifted tend to Able to consider hypotheses. Can
persevere. think about ideas, not only about
concrete aspects of a situation.

From DiLeo JH: Interpreting Childrens Drawings. New York: Brunner/Mazel; 1983:38.

ate that environmental factors, such as the season of people, not cartoons or stick people. Remember to
the year or specific holidays, influence the content of make everyone doing something some kind of activ-
childrens drawings. DiLeo cautions against overinter- ity [26]. The child is given a plain white 81/2 11 piece
preting ambiguous sexual symbols in the drawings of of paper with a No.2 pencil placed in the center of the
young children or using a mechanistic, point-by-point paper and is seated individually in a chair at a table of
analysis [16]. It should be recognized that drawings can appropriate height. The examiner leaves the room and
be misleading. checks back periodically. Noncompliance is extremely
For the Kinetic Family Drawing (KFD), the child is rare. If children say I cant, they are encouraged peri-
asked to draw a picture of everyone in your family, odically and left in the room until they complete the
including you, doing something. Try to draw whole KFD.

Characteristics of individual figures that are ana- Projective Testing

lyzed in the KFD include arm extensions, elevated
figures, erasures, figures on the back of the page, Projective tests have received extensive criticism,
hanging, omission of body parts, omission of figures, because they are based on theories of unconscious
eyes, and rotated figures. The action depicted is also internal processes and are therefore difficult to estab-
analyzed in terms of intensity, symbolism, fixation, lish in terms of reliability and validity. According to
conflict, internalization, avoidance, and harmony. The Klein, the most commonly used projective tests are the
mean age for both boys and girls performing the KFD following [29]: Rorschach; Thematic Apperception
is about 10 years, and ages range from 5 to 20 years, Test (TAT) Childrens Apperception Test (CAT);
skewed toward the 10 and below age group. Data are Blackey Pictures Drawings; Bender Gestalt Test.
also available elsewhere on the actions of individual Klein discussed the origin of projective tests from
KFD figures and the frequency of actions for various psychoanalytic theory, which interprets all human
family members, including father, mother, and self [26]. experiences as colored by unconscious repressed
One should also consider the type of action between mental content [29]. More intrapsychic material can be
KFD figures, such as throwing balls, and the existence expected during ambiguous tasks. Projective tech-
of barriers, dangerous objects, or heat, light, and niques provide the individual with an ambiguous
warmth. Drawing styles can be categorized as com- stimulus, and the individuals response is thought to
partmentalization, encapsulation, lining at the bottom, reflect underlying conflicts, needs, and features of per-
underlying individual figures, edging, lining at the top, sonality. Klein argued that projective testing cannot
folding compartmentalization, and evasions. pinpoint types of personality organization, specific
In addition to the Draw-A-Person test (DAP) and personality characteristics, or the diagnosis of mental
the KFD, the HouseTree Person test (HTP) devel- disorders [29]. Further, the TAT has failed to show sat-
oped by J. Buck in 1948 can also be revealing [27]. In isfactory validity, and in Kleins view too little work
this approach, the house is viewed primarily as a reflec- has been done with the Rorschach to assess its valid-
tion of the home environment and family functioning, ity with children. Given our state of knowledge, it is
the tree is viewed as a reflection of psychosexual- certainly unjustified to rely on projective test results to
psychosocial history, and the person is viewed as a rule out the presence of disorders when symptoms are
reflection of interpersonal functioning and relation- evident, or to assume from the tests that personality
ships with others. The HTP can be used for children deviance is present when it is not shown in the childs
five or six years of age, although some children of this behavior. For diagnosis, Klein maintained that projec-
age may not be mature enough in terms of their draw- tive tests are not useful except in instances of mental
ings skills. One major advantage of this test is that it retardation and specific developmental disorders.
uses a projective technique that taps into unconscious She maintained that when test results can be used
behavior and cannot be faked, except possibly to fake accurately to diagnose, the deviance may already be
bad. (It is considered unlikely that individuals can obvious [29]. Similarly, it is unreliable to reconstruct
fake good.) the childs early developmental psychologic history
Drawings are useful for children to express their based on projective tests or to use projective tests to
feelings regarding their parents divorce. Cordell and predict what is likely to happen to a child.
Berman-Meador suggested that having children draw Despite the strength of the previous criticism, pro-
a picture of [their] family divorcing can help them jective tests are used extensively. So what is the useful-
express underlying attitudes regarding the divorce ness of these procedures? Projective tests can first and
as well as their attitudes or misconceptions about foremost provide a structured format for assessing a
the process [28]. The four rating scales are denial/ childs reactions and observing his or her behavior. It
acknowledgment, emotionality, aggression, and the takes the focus off the child and the need for verbal
use of people. Childrens divorce drawings can be rated response and instead allows the child to engage in
0 or I for the absence or presence of each of these action-oriented activity. Thus, the child can be more
four items (Figures 2.2 and 2.3). comfortable and spontaneous. Second, projective tests
Characteristics of childrens drawings can point to allow the psychologist to understand more about the
underlying fears and concerns that may be related to individual childs worldview. The Rorschach provides
coping styles such as repression or sensitization. This information on processing, and the TAT provides
technique can be used in initial assessments for treat- information on interpersonal relationships. Third, the
ment during the therapy process or for court-ordered structural approach, as exemplified by Exner, fulfills
evaluations regarding custody or visitation. criteria of the scientific method [30]. Projective

(a) (b)

(c) (d)

Figure 2.2 (a), seven-year-old boy, Scale I acknowledgment, 0 = no direct reference to divorce; (b), 13-year-old
girl, Scale I acknowledgment, 1 = divorce clearly acknowledged; (c), 12-year-old boy, Scale II emotionality, 0 =
no emotion directly depicted; (d), seven-year-old girl, Scale II emotionality, 1 = emotion shown.

(a) (b)

(c) (d)

Figure 2.3 (a), nine-year-old boy, Scale III aggression, 0 = no idication of aggression, conflict, or fighting; (b),
11-year-old boy, Scale III aggression, 1 = aggression, conflict, or fighting depicted; (c), 12-year-old girl, Scale IV
use of people, 0 = no people pictured; (d), teenage girl, Scale IV use of people, 1 = people pictured.

information can be useful in planning the treatment reactions and do not seem substantially different from
process and in identifying important goals and those of children with other diagnoses. Their responses
effective strategies. may not necessarily reveal the characteristics that
Projective tests appear to be particularly useful for could be considered indicators of conduct disorder. In
children who are anxious or depressed or who have a fact, projective techniques do not enjoy widespread
history of abuse and neglect. One area in which pro- use for conduct disorders (p. 301 [31]). This may be
jective tests can be quite misleading, however, is in the unfortunate, because the childs worldview can still sig-
assessment of children with conduct disorders. From a nificantly affect the treatment process.
clinical perspective, these children often have projective Exner and Weiner discussed the nature of the
test responses that reflect a wide range of feelings and Rorschach test and on what basis Rorschach inter-

pretations can be justified [32]. The Rorschach was tion uses the overlapping frameworks of private, or less
developed as a psychodynamic reflection of personal- conscious, motives and the public, more conscious
ity. It is now viewed as a perceptualcognitive task, approach to social interactions. Thus, the stories are
however, and we can be more certain in our interpre- derived from personal experiences as translated into
tation of the Rorschach results. When the Rorschach our social world [33].
is viewed as a perceptualcognitive task, the ink blots Individuals learn societal expectations through a
are considered an ambiguous source of stimulation in series of daily interactions in which skills and feelings
which the client imposes structure and organization; are required. As individuals learn to conform to these
interpretations are based on the structure of how indi- expectations, they develop and organize their own per-
viduals process stimuli. Rorschach scoring allows us to sonality. Their personality receives and processes the
derive data on how individuals perceive and respond demands of social interaction and is also projected
to their environment. We can then draw inferences outward onto behavior, including responding to the
about personality functioning, including traits, dispo- TAT cards, for example. Telling stories is similar to the
sitions, coping styles, and sources of concern that lend tasks involved in typical social interactions; in other
consistency to individual behavior. words, the individual responds to the pictures in terms
When interpreting the Rorschach, clinicians need of both personal significance and cultural training.
to be aware of situational and developmental factors People respond to the TAT pictures according to their
that influence the stability of the Rorschach indices. own techniques of adapting to emotions and social
Rorschach results generally give a picture of stable per- demands as well as the manifest content and latent
sonality characteristics. The results are also represen- content of the pictures. For some people, the form
tative of behavior; the task presented on the test is a and content of the picture draw emotional reactions
sample of behavior, and behavior is the best predictor that are termed the latent stimulus of the picture. Thus,
of future behavior. Interpretations on the Rorschach the TAT is able to produce material that reflects the
are reasonably certain and require very few levels of deeper emotional issues of the individual as stories are
inference [32]. told.
When the Rorschach is viewed as a stimulus to Henry discussed analyzing TAT stories in terms of
fantasy, different guidelines are applied in the analysis, form, content, and dynamic structure, including the
and interpretations may be based on Rorschach interpretation of symbolic content [33]. In the concep-
content. What individuals say as they respond with tual framework for individual case analysis, Henry
images is particularly revealing. Content interpreta- considered several areas: mental approach, imagina-
tions come from the language or words that the indi- tive processes, family dynamics, inner adjustment,
viduals use and can be used to address personality emotional reactivity, sexual adjustment, behavioral
dynamics; in this sense, Rorschach responses can also approach, and descriptive interpretive summary [33].
be viewed as symbolic of behavior. Interpretations Children generally enjoy the TAT, because they find
should be relatively speculative and phrased only it relatively undemanding and nonthreatening. Some
as hypotheses. Interpreters should remember that the five- and six-year-olds can handle the TAT cards, as
two forms of interpretation have differing levels of opposed to the CAT. Stories are often a transparent
certainty. reflection of a childs point of view. Occasionally,
Special consideration should be used to guide a child will exclaim, This is just like me! In these
the evaluation of Rorschach records obtained from instances, children typically proceed comfortably with
younger clients. Knowledge of the normative data is their storytelling. The TAT is a popular technique clin-
critical. The proper procedures must be used in ically. It may bias toward stimulating negatively toned
collecting the data, and the interpreters working stories, however, and the cards themselves are some-
with children should have a solid understanding of what dated.
developmental psychology and developmental psy- The Roberts Apperception Test for Children
chopathology. (Exner and Weiner argued, however, (RATC) is also a popular projective test to aid in
that Rorschach behavior means what it means regard- assessing the psychological development of children
less of the age of the subject [32]). [34]. The RATC was specifically designed for children
The TAT requires patients to examine picture cards age 6 through 15 years and depicts children in all 16 of
and then devise stories inspired by the cards. Henrys the cards. The current set of stimulus cards was drawn
book The Analysis of Fantasy described how stories up in 1968 and later compared by Roberts to the Chil-
reflect thought processes as well as emotional func- drens Apperception Test and the Thematic Appercep-
tioning [33]. The interpretation of thematic appercep- tion Test. The cards are realistic drawings of children

and adults engaged in everyday interpersonal events. ered for children 710 years of age or those who are
The RATC is easily scored with objective measures and particularly bright; it is available when the CAT has
a high degree of agreement between raters. Its goal is not yielded satisfactory results or vice versa. The Chil-
to assess childrens perceptions of interpersonal situa- drens Apperception Test, Supplemental (CAT-S) is
tions. The scoring system assesses both adaptive also available for exploring special circumstances such
and maladaptive traits. There is both qualitative and as physical disability, psychosomatic disorder, or the
quantitative interpretation, so structural analysis is mothers pregnancy [37].
possible. There is normative data for a sample of 200 The Projective Storytelling Cards are useful in
well-adjustment children ages 6 through 15 years. depicting a wide array of situations [38]. The 25 cards
The categories depicted on the cards include: Family represent a variety of themes dealing with problems
Confrontation; Maternal Support; School Attitude; that children and teens face, with a focus on traumatic
Support/Aggressions; Parental Affection; Peer/Racial events, conflict in the family or social arena, and pos-
Interaction; Dependency/Anxiety; Family Confer- sible physical and sexual abuse. These cards can be
ences; Physical Aggression Toward Peer; Sibling used at any time during treatment, but they are espe-
Rivalry; Fear; Parental Conflict/Depression; Aggres- cially useful for diagnosis and for establishing rapport.
sion Release; Maternal Limit-Setting; Nudity/Sexual- They have the goal of inspiring children to express
ity; and Paternal Support. their feelings, attitudes, and experiences in thematic
The CAT was designed for children aged 310 years form. The cards are particularly useful in helping
and was inspired by the TAT [35]. It was hypothesized children set goals to cope with physically or sexually
that children would identify easily with animal figures. abusive situations.
A set of 10 pictures of animals in a variety of situa- The Adoption Story Cards developed by R.
tions is used with an apperception method that studies Gardner can be used diagnostically as well as thera-
personality by examining individual differences in peutically to evoke issues relating to adoption [39].
response to standard stimuli and the dynamic signifi- This is a particularly difficult area to assess,
cance of these differences. The CAT provides data on since denial is often very strong. The cards were
how children relate to the key individuals in their life designed to provide the therapist with some access to
and to their own needs. The cards stimulate issues information that children may otherwise be resistant to
related to eating, sibling rivalry, relationships to reveal.
parents as individuals and as a couple, aggression,
acceptance of the adult world, loneliness at night, and
Child Questionnaires
Like the TAT, the CAT is concerned with content The Incomplete Sentences Blank forms are useful for
and what children see and think. The developers of the young people in high school or college [40]. The Sen-
CAT acknowledge that it may not facilitate formal tence Completion Test for Children has been used in
diagnosis like the Rorschach, but it is better able to this practice for the past 25 years (Appendix 2.3). It is
reveal the dynamics of interpersonal relationships, of a simple, two-page sentence completion form with 25
drive constellation, and the nature of defenses against items. It is useful for children ages 5 through 12 years.
them (p. 2 [35]). The animal pictures are equally appli- For some children, it may help for clinicians to read
cable for all groups of children, so the CAT is rela- the questions out loud and write down the childs
tively culture free [35]. The examiner tells the child, responses. Other children, particularly older children
We are going to engage in a game in which [you or those who seem very private, might respond more
have] to tell a story about pictures; [you] should tell openly by doing it themselves in their own hand-
what is going on, what the animals are doing now. At writing. In one evaluation, an 11-year-old girl gave as
suitable points, the child may be asked what went on little response as possible on all other assessment tools,
in the story before and what will happen later (p. 2 including an interview. The sentence completions,
[35]). however, were extremely revealing about the depth of
More recently, cards with human figures have been feeling and dissatisfaction toward her parents and
provided [36]. Some preliminary studies have indicated family. It was the only time in the entire evaluation
that human figures may have greater stimulus value process during which she shared these feelings.
than drawings of animals. Some children may do The Child Anxiety Scale (CAS) can be useful in
better with the animal cards and some with the human some instances for children 5 through 12 years of age
ones; the regular CAT is recommended for use first. [41]. It involves 20 straightforward questions in which
The CAT-Human Figures, however, might be consid- a child marks on either a red circle or a blue circle. It

can be administered through a tape or by the clinician. preassessment for both individual and group treatment
Children who are very anxious, however, may base [46]. The PiersHarris Self-Concept Inventory is
their responses on denial. CAS users need to note also available. With self-esteem measures, however,
extremely high or extremely low scores: high scores there is a strong tendency for children to report what
consistently reflect a high level of anxiety; and low they think the adult wants to hear or they themselves
scores could indicate a high anxiety level that is being want to believe [47]. Such inventories may be less
systematically denied. Further, studies have shown revealing of deeper feelings than many other assess-
that children may often resist reporting negative expe- ment tools.
riences and instead present a favorable view that may Seligman and colleagues emphasized success at per-
underestimate their actual anxiety levels. formance and accomplishment as a pivotal component
The Childrens Depression Inventory (CDI) is the of self-esteem [48]. They did not support the theory
most popular child questionnaire for assessing depres- that we can give our children self-esteem by seeking
sion in children [42]. It was developed by Kovacs based only to help them feel good and instead designed a
on the Beck Depression Inventory for adults [43]. The program for children to learn the skills of optimism.
long form has 27 items, and a short form (CDI-S) has Their Childrens Attributional Style Questionnaire
10 items. It is suitable for children 717 years of age measures aspects of self-esteem based on performance
and requires only a third-grade reading level, the capability rather than the feel good school of
lowest of any childhood depression measure. For each thought. Attitudes toward self and events contribute
item, children choose one of three statements reflect- to the experience of success.
ing minimal, moderate, or severe depression in the past Kurdek and Berg developed a helpful assessment
two weeks. The items pertain to depressive symptoms tool for children of divorce who are 518 years of age
such as a negative mood, a lack of pleasure, sleeping [49]. The Childrens Beliefs About Parental Divorce
or eating disturbances, their self-image, and behavior Scale has six scales that reflect peer avoidance, pater-
with peers or at school. There are high positive corre- nal blame, fear of abandonment, maternal blame,
lations of test scores with self-reported anxiety and hopes of reunification, self-blame, as well as a total
negative correlations of test scores with self-esteem. score for maladaptive attitudes. The questionnaire
Self-esteem, defined as the extent to which the indi- allows questions to be structured around divorce and
vidual believes himself to be capable, significant, suc- is therefore more revealing than generic questions that
cessful, and worthy (p. 5 [44]) is measured by items do not relate to divorce specifically, or questions that
such as Im doing the best work that I can, Im pretty make children feel put on the spot or require them to
sure of myself, I wish I were someone else, and I criticize their parents. This scale has been used in our
often get discouraged in school. Self-esteem involves a office since it was developed and has been found useful
personal assessment of worthiness and capability that even when the divorce occurred at some considerable
is apparent in the beliefs and attitudes that children time in the past.
maintain toward themselves. Although the CDI has
been shown to be a reliable measure of distress and
Behavioral Assessment
depressive symptoms, it should not be used alone to
diagnose depression. The behavioral assessment of children follows a
Following a social learning analysis, Harter dis- problem-solving strategy. It is an empirical approach
cussed how competence motivation leads children to clinical child assessment, utilizing what we know of
toward independent attempts at mastery [45]. They child development and developmental psychopathol-
may receive positive or negative feedback from ogy. Behavioral assessment allows for the evaluation of
several sources, including their own assessment of the treatment outcome and can improve the effectiveness
outcome as well as the reactions of others. Positive of services for children. Certain concepts are pivotal,
feedback leads to feelings of success, renewed efforts, such as the importance of situational influences, direct
an inner sense of capability, and worthiness or high observation of behavior, and treatment evaluation.
self-esteem. Overly negative feedback can lead to a This is a rapidly emerging field that is still refining
sense of failure and lower competence motivation. It techniques for clinical practice. Accurate observations
can contribute to a tendency to avoid challenges, to and objectivity in reporting are guiding principles.
depend on others to solve problems, and ultimately, to Behavioral assessment does not rely on inferences or
fail more often low self-esteem. underlying personality constructs but is instead
Among the self-esteem inventories, the Culture-Free concerned with the childs actual behavior in certain
Self-Esteem Inventory can be useful in assessment and situations.

For example, in the behavioral assessment of enure- anxious reaction, this approach is often used immedi-
sis, it is helpful to inquire whether children sleep in ately in treating an anxious child.
their own room or with siblings, where they sleep rel- There are refined behavioral techniques for assessing
ative to their parents bedrooms, and the time at which obsessivecompulsive disorder (OCD) in childhood
the children and their parents go to bed. Further, it is [50]. The Leyton Obsessional Inventory-Child Version
important to assess what children know about the and the 20-item Leyton Obsessional Inventory are
problem and the treatment. They may feel that the bed- extremely helpful in assessment and treatment plan-
wetting is their fault. Do they realize that it is a ning [50]. In addition, the YaleBrown Obsessive
common problem among other children? Projective Compulsive Scale has specific instructions for children
assessment can be used to determine how concerned [50]. There is also a National Institute of Mental
children are about bedwetting and how much they Health (NIMH) Teacher Rating of OCD [50].
want to be cured. Sometimes embarrassment or denial Behavioral assessment of conduct disorders in chil-
can lead parents to feel that their children are indiffer- dren has expanded rapidly in recent years (Table 2.6).
ent to the symptoms. Also, when children are dry sleep- Atkeson and Forehand discussed characteristics of
ing away from home, the parents might think that they conduct-disordered children, which include a high rate
are bedwetting on purpose at home. Usually, however, of negative commands, disapproval, humiliation,
children simply sleep less soundly in an effort to noncompliance, negativism, teasing, physically nega-
prevent the bedwetting away from home. tive acts, and yelling, as well as high-intensity deviant
When treating encopresis, the clinician should assess behavior such as destructiveness [51].
the frequency of the problem, when it occurs during These children also exhibit a low frequency of pos-
the day or night, how much occurs, and variations in itive behavior, such as approval expressed to others,
the pattern. The clinician should also ask who has the positive attention, independent activity, laughing, and
responsibility for the clean-up. Further, the clinician talking. Further, in the negative reinforcement model,
should inquire of the parents the exact words used in coercive behavior on the part of one family member is
talking to the child as well as what the child actually reinforced when it results in the removal of an aversive
does in response. The parents can keep a behavioral event being applied to another family member(p. 188
record for a week to answer some of these questions. [51]). Three strategies have been employed in the
Since this is an extremely frustrating symptom for assessment process; behavioral interviews, behavioral
parents, their tolerance level has usually been exceeded, questionnaires, and behavioral observations; see
and they may be extremely angry and frustrated. It is Hollands Interview Guide (p. 1951 [51]). Behavioral
important for the clinician to be able to get past the questionnaires have included the Becker Bipolar
emotional reactions into a more objective evaluation Adjective Checklist [51], Parent Attitude Test [51],
of what is actually occurring. In addition, it is impor- Walker Problem Behavior Identification Checklist [51],
tant to assess how emotions are handled generally and Behavior Problem Checklist [51]. Direct observa-
within the family. A merely mechanistic record of tions of parentchild interactions are considered the
behavior cannot by itself be definitive. most valid source of data.
Another symptom that can be usefully evaluated Researchers have developed elaborate coding
from a behavioral perspective is childrens fears. One systems for research in the home environment, such as
useful method with school-age children six years and the Family Interaction Coding System by Patterson
older as well as teenagers is to use systematic desensi- and colleagues [52]. Since few clinical settings have the
tization, beginning with constructing a rank ordering resources for this, structured clinical observations of
of fears. For older children, a 10-point scale can be parentchild interactions are instead recommended.
used, with 10 indicating the situation in which they One simple technique that can be used is the Behavior
would feel the most fear and 1 the situation in which Management Questionnaire, completed by parents,
they would feel the most relaxed and comfortable. As which covers the activities and interests of the child
children are selecting situations to put on their scale, and disciplinary practices of the parents. This was
their reactions and feelings in many situations can be developed for use with autistic children [53].
effectively diagnosed. This simple assessment can then Barkley presented an extensive training program for
be used in a systematic desensitization routine in which parents of children who have behavior problems,
the child is taught a method of relaxation and then including ADHD and conduct disorders [54,55].
imagines a situation on the scale and practices relax- Decreasing noncompliance, decreasing disruptiveness,
ing. This is an instance in which assessment and treat- and increasing independent play are major compo-
ment are closely combined. Given the aversiveness of nents of the program. Children are also taught a think

Table 2.6 Selected measures of antisocial behaviors for children and adolescents.

Measure Response format Age Special features


Childrens Hostility 38 truefalse statements 613 yr Derived from Buss-Durke

Inventory assessing different Hostility Guilt Inventory.
facets of aggression A priori subscales from
and hostility. that scale comprise factors
that relate to overt acts
(aggression) and aggressive
thoughts and feelings
Eyberg Child Behavior 36 items rated on 1 to 7 217 yr Designed to measure wide
Inventory points scale for range of conduct problems
frequency and whether in the home.
the behavior is a
Sutter-Eyberg Student 36 items identical in 217 yr Measures a range of conduct
Behavior Inventory format but not content problem behaviors at
to the Eyberg Child school.
Behavior Inventory.
Peer Nomination of Items that ask children to 3rd through Items reflect the childs
Aggression nominate others who 13th grade reputation among peers
show the regarding overall
characteristics (e.g., aggression. Different
Who starts a fight versions of peer
over nothing?). nominations have been
Adolescent Antisocial 57 items to measure Adolescence The items can be scored
Behavior Checklist antisocial behavior using different sets of
during hospitalization. subscales; one set
Behaviors are rated as focuses on the form of
having occurred or not the problems (e.g., physical
based on staff vs. verbal harm); another
observations. set focuses on the objects
of aggression (e.g., toward
self, others, property).
Different versions are
available and differ in
Family Interaction Direct observational 312 yr Individual behaviors are
Coding System (FICS) system to measure observed but usually
occurrence or summarized with a total
nonoccurrence of 29 aversive behavior score.
specific parentchild The general procedure
behaviors in the home. can be adopted using
Each behavior is some or all of the
scored within small behaviors of the FICS.

Table 2.6 Continued

Measure Response format Age Special features


intervals for an hour

each day for a period
of several days.
Parent Daily Report Parents identify 312 yr Measure does not reflect a
symptoms of antisocial standardized set of items
behavior. After but rather refers more to
symptoms are an assessment approach
identified, the parent is for collecting date on
called daily for several behaviors at home.
days. Each day the
parent is asked if each
behavior has or has
not occurred in
previous 24-hr period.
Childrens Action 30 items in forced-choice 615 yr Scores for response
Tendency Scale format, child selects dimensions:
what he or she would aggressiveness,
do in interpersonal assertiveness, and
situations. submissiveness.
Adolescent Antisocial 52 items, each of which Adolescence The measure samples a
Self-Report Behavior is rated by the child broad range of behaviors
Checklist on a 5-point scale from mild misbehavior to
(from never to very serious antisocial acts.
often). The items load four
factors: delinquency,
drug usage, parental
defiance, and
Self-Report Delinquency 47 items that measure 1121 yr Measure has been developed
Scale frequency with which as part of the National
individual has Youth Survey, an
performed offenses extensive longitudinal
included in the study of delinquent
Uniform Crime behavior, alcohol and drug
Reports. Responses use, and related problems
provide frequency with in American youths.
which behavior was
performed over the
last year.
Minnesota Multiphasic Truefalse items derived Adolescence Part of more general
Personality Inventory from Scales F (test- measure that assesses
Scales taking attitude), 4 multiple areas of
(psychopathic deviate) psychopathology.
and 9 (hypomania) are
summed to yield an
delinquency score.

Table 2.6 Continued

Measure Response format Age Special features


Interview for Semistructured interview, 613 yr Yields scores for severity,

Aggression 30 items pertaining to duration, and total
aggression such as (serverity + duration)
getting into fights, aggression. Separate
starting arguments. factors assess overt and
Each item rated on a covert behaviors.
5-point scale for
severity and 3-point
scale for duration.

* The age ranges are tentative and derived from the ages of cases reported rather than inherent restrictions of the measure.
This measure has separate versions: (1) a self-report measure for children, and (2) a parent-report measure to evaluate childrens
From Kazdin AE: Conduct disorder. In: Ollendick TH, Herson M, eds. Handbook of Child and Adolescent Assessment. Boston:
Allyn & Bacon; 1993:295. Copyright 1993 by Allyn & Bacon. Reprinted by permission.

aloud-think ahead self-control technique. Parents may has implications for their success in the classroom [56].
be trained in the office, but in-home practice methods By studying preschool children, Parten identified five
are also an integral part of the program. ways that children play: (1) in solitary play, children are
Useful assessment tools of Barkleys program unaware of others and play alone; (2) in onlooker play,
include the ParentChild Interaction Interview children watch others play; (3) in parallel play, children
Form, Home Situations Questionnaire, Parents and play side by side with little interaction; (4) in associa-
Teachers Questionnaire, and School Situations Ques- tive play, children interact and share; and (5) in coop-
tionnaire [55]. In addition, there are behavioral sheets erative play, they relate to each other, helping and
for observing the parents and child together, which taking turns [57]. Piaget described three types of play
include Recording Observations of ParentChild practice games, symbolic games, and games with
Interactions and Coding Form for Recoding Parent rules through which children learn the rules of social
Child Interactions. Barkley also assists parents in exchange and enhance their sense of competence and
understanding their problems through the Profile of self-esteem [58].
Child and Parent Characteristics and the Family Prob- It has long been recognized that children use play as
lems Inventory [55]. their natural medium of self-expression and as an
Kazdin stresses that the assessment of conduct dis- avenue for cognitive development. It can therefore be
orders should be multimodal [31]. The process should useful to incorporate some opportunity to observe
include different methods (interviews and direct ob- unstructured play in child assessment procedures. Typ-
servations), perspectives (child, parent, and teacher) ically, a doll house, large blocks, and trucks can be
domains (affect, cognition, and behavior), and settings used. Childrens personalities are revealed in the way
(home, school, and community). Further, prosocial that they approach these materials. Straightforward
behavior and adaptive skills should be assessed as well observation of their behavior can indicate how they
as the theory that antisocial behavior is not merely the typically behave in similar situations. Some children
opposite of prosocial behavior (p. 392 [31]). are quiet and resilient, seeking permission before
beginning play, whereas others race rambunctiously
into the thick of it, with nary a thought to protocol or
Play Observations
manners. Some children play quietly without verbal-
The importance of play and the use of imagination in ization, whereas others talk constantly.
child development cannot be overstated. The use of Clinicians can use some of their own feelings and
fantasy enables children to delay gratification and to reactions to the child to diagnose potential problem
deal more effectively with frustration, which in turn areas, as demonstrated by the following case study.

There are articles on scales for developmental play,

CASE STUDY diagnostic play, parentchild interaction, peer interac-
tion, projective play assessment, and play therapy. As
A six-year-old girl was demanding and bossy
noted by Westby, the evaluation of childrens play
with her therapist; she would sweetly ask
skills permits assessment not only of the knowledge
the therapist to play with her and seemed
children have, but also of how they use this knowledge
dependent in this respect. Every time the ther-
in a real-world context (p. 133 [62]). The Westby Sym-
apist picked up a toy to begin to play or make
bolic Play Scale presents developmental levels for play
some independent gesture, however, the girl
shown by children from eight months to five years of
would give orders for it to be done differently.
age [62].)
The therapist, being very accommodating,
tried to comply, only to find herself feeling
irritated. Finally, the therapist identified that Family Interaction
this little girl was likely to be bossy and
Family interaction should be considered in any assess-
demanding in a sweet way in her interactions
ment of children. Family sessions can be used for diag-
with both peers and adults. This became a
nostic purposes and are also particularly useful when
major focus of the treatment plan.
working with children and their parents to teach child
management techniques for externalizing disorders
such as ADHD and oppositional defiant disorder
The themes of play can also be meaningful, (ODD). In all families, however, the childs role within
although the style of approaching the play materials the family strongly affects his or her feelings, attitudes,
should be observed as well. and behaviors, and clinicians should assess these char-
Many youngsters who come for assessment and acteristics when planning for treatment. Baumrind
treatment have difficulties engaging in pretend play. demonstrated that a childs characteristics are closely
Their play doesnt hang together; it may seem discon- related to the structure of that childs family [63], and
nected, a fragmented puzzle, hardly a way for them to Hetherington and Parke compared parenting styles
learn about themselves and the world around them (p. with childrens behavior and self-esteem [64]. Clini-
153 [59]). Different ways of using play in diagnosis and cians often assess the child individually, although
treatment have been presented that offer observation others advocate incorporating family assessment into
of the childs verbal and nonverbal reactions, thought comprehensive child assessment (p. 136 [65]). The
process and decision making, style in using materials, latter approach may make it more difficult to develop
nature and content of play, and interaction with the a rapport with the child or teenager, however.
clinician. Children reveal individualized aspects of per- Both approaches have their advantages and disadvan-
sonality in their responses as well as in their interests tages. In general, it is important for the individual
and preferences. conducting the assessment to be aware of certain
Behar and Rapoport discussed the usefulness of common family patterns that can influence a childs
summarizing play behavior of young children as a behavior.
general clinical screening tool: The diagnostic play It is important for clinicians to assess parental
interview seems particularly important for children warmth, a factor important to the child in terms of
before they have found more adult, or structured, seeking approval. Parents showing this warmth may be
outlets (p. 193 [60]). These authors recommended play more likely to provide information about alternative
assessment when: (1) parents and teachers offer con- social responses available to the child. Warm parents
flicting reports; (2) reports and clinical observation also frequently use reasoning and explanations that
differ; (3) verbal communication is inadequate or the permit children to internalize social rules and to iden-
child is too young; or (4) when there is shyness or with- tify and discriminate situations in which a given behav-
drawal in the childs behavior. Childrens play can ior is appropriate. Warmth is likely to be associated
reveal: (1) the style of interaction with a parent; (2) the with responsiveness to the childs needs. Warm parents
style of separation from parent; (3) the style of relat- do not have to resort to methods that are frustrating
ing to the examiner; (4) the use of toys in play; (5) to the child, and children are less likely to avoid contact
spontaneous behavior; and (6) play behaviors relevant with the parents; this facilitates the socialization
to the diagnosis [51]. Play may be particularly useful in process.
diagnosing young or nonverbal children. Clinicians should also evaluate parental control.
In an extensive manual, Schaefer and colleagues pre- Parental restrictiveness or permissiveness can lead to
sented a variety of uses for the assessment of play [61]. problems in child functioning. A permissive family

can cause problems of neglect and may also damage in the upbringing of children significantly. These
a childs adaptive ability. Authoritarian family trends appear to be increasingly prominent. As clini-
approaches may have the advantage of preparing cians, we see many children who are being raised by
children to deal with rules and limits but the disad- their grandparents. We also see many situations that
vantage of limiting overall competence. are essentially shared parenting between parents and
In families of neglect, the mother often exhibits grandparents or other family members.
depression and detachment. Depressed mothers have Grandparents may be raising children when they
difficulty finding the energy to take care of their chil- have little access to resources outside of their own
dren. Parental detachment may be encouraged by our family. In addition, in many states there is no legal
narcissistic culture that gives permission for seeking provision for grandparents to have parental rights
personal gratification before the needs of others. or legal rights to parenting time. In some situations,
Divorce also contributes to parental neediness. it even makes sense for a parent and grandparents
Beavers and Hampson presented a paradigm for to have shared parenting with each other. This
analyzing family interaction in terms of overall com- can be a useful arrangement, but Courts may be reluc-
petence and family style [66]. Family style relates to the tant to encourage these arrangements without legal
positioning of the family in the community: centripetal procedure that require cooperation between family
families bind their members to the family, making any members.
absence difficult; and centrifugal families expel the
child from the family before individuation is complete.
Family style and level of competence are used to clas- Special Issues
sify families into types that may be relevant to the
Social Skills and ADHD
problems shown by offspring. For example, it is
hypothesized that severely centrifugal families often It has recently been estimated that there are over two
have sociopathic offspring. million school-age children in the United States alone
Beavers and Hampson developed a comprehensive with ADHD [68].) These are children who show sig-
scale to rate the nature of family interaction, termed nificant behavioral problems that are very stressful for
the Beavers Interactional Scale: Family Competence family life. There is often conflict over chores, home-
and Family Style [66]. This scale is used by clinicians work, and getting along with siblings, with the ADHD
and allows ratings on the following dimensions: (1) child showing antagonistic behavior at school and in
structure of the family (specifically overt power, the neighborhood. Further, ADHD children typically
parental coalitions, and closeness); (2) mythology; (3) have difficulties modulating their own emotional reac-
goal-directed negotiation; (4) autonomy, including tions. Such intense reactions create difficulties in social
clarity of expression, responsibility, and permeability; relationships. Children with ADHD tend not to see the
and (5) family affect, assessed through range of feel- connection between their behavior and the outcome,
ings, mood and tone, unresolvable conflict, and whereas other children learn this automatically. Low
empathy. In addition, the Global Health-Pathology self-esteem results from the negative reactions of
Scale includes a Self-Report Family Inventory and others, and specific social skills are lacking in children
an Individual Family Style Scale for family members with ADHD.
to fill out, which can be useful in the assessment There is a wide variety of social skills, including
process [66]. The Self-Report Family Inventory (SFI) communication skills, sharing, social initiation, joining
includes a scoring system for health/competence, con- strategies, determining appropriate behavior for a
flict, cohesion, leadership, and expressiveness [66]. A given situation, listening and asking questions about
similar test that can be used in family sessions, called ambiguous messages, smiling, sharing, positive physi-
FACES II, was developed by Olson and colleagues cal contact, verbal complimenting, using instructions,
at the Department of Family Social Science at the modeling, praise, labeling emotions and facial expres-
University of Minnesota [67]. It yields information on sions, referential communication accuracy, taking per-
family cohesion and adaptability, indicating family spective, listening, making friends (including greeting),
type. asking for information, including extension, giving
A discussion of family interaction would not be information, giving help, and being observant of
complete without considering the profound effect of appropriate classroom behavior. Children with ADHD
extended family interaction, both for children who may be deficient in any number of these skills. Some-
have an intact nuclear family and for those who are times they have acquired certain steps but not the
being raised by other family members including grand- entire sequence of behaviors necessary for positive
parents. Further, extended family members may share social exchange.

Fortunately, there has been great interest in devel- makes a comment implying that they do not know how
oping procedures for enhancing childrens interper- to answer the items relating to sex, such as I enjoy
sonal relationships with peers, since having well- thinking about sex, or Sex is enjoyable. It is helpful
developed social skills corresponds to fewer mental to review the form carefully before sending it in for
health problems. Popular children behave in specific computer analysis, because some teenagers leave too
ways, initiate interactions, smile, and make positive many items blank. It is important for the teens to have
comments. The fact that children can be taught social a sense about why they are going through the assess-
skills has been applied to a wide variety of problems ment process. There will occasionally be difficulty with
and disorders, including ADHD. compliance, in which case it is best to move on to other
A variety of intervention strategies have been used assessment methods. We have found the narrative
to effectively teach social skills. These include contin- description of personality provided by the MACI to be
gent positive reinforcement, modeling, coaching and accurate and useful in treatment planning. It includes
behavioral rehearsal, and peer initiation. The first step a section on pointers for psychotherapy as well.
is to evaluate the strengths and weaknesses of each There is a new Millon assessment tool available
child individually, as there is a wide variety of specific January, 2005, for younger preteens ages 912 years
deficits. called the Millon Pre-Adolescent Clinical Inventory
Social skills can be evaluated using the Social Skills (M-PACI) [72].) It contains fewer than 100 questions
Rating System for parents, teachers, and children [(69]. and takes only 1520 minutes for youngsters to finish.
Behaviors that influence a childs social capability and It has been validated and there are up-to-date national
adaptive skills at home and school can be assessed sys- norms with a detailed interpretative report for the
tematically, which can help in further assessment and clinician. The M-PACI focuses on clinical problems
treatment planning as well as the outcome evaluation comprehensively, not just a single issue, and identifies
of individual or group intervention. Teacher and emerging personality styles that will aid the clinician
parent forms are available for preschool, kindergarten in planning intervention and pinpointing effective
through grade 6, and grades 7 through 12. Separate methods.
self-rating forms are available for students in grades 3 Teens can be engaged in assessment and treatment
through 6 and in grades 7 through 12. Prosocial behav- if the goals are defined on their terms. Many teens like
iors that are assessed include cooperation, assertion, the idea of learning more about themselves. Psychoe-
responsibility, empathy, and self-control. ducational assessment can also be interesting to them
Goldstein and colleagues skillstreaming material as a way of developing strategies for success in school
allows for the assessment of a wide variety of specific and planning for college (viewed as a chance to be away
social skills [70]. There are 50 social skills that can be from home!).
taught, and the curriculum even includes listening! The Of particular interest to teens are the personality
Structured Learning Skill Checklist is used in the styles of the Myers-Briggs Type Indicator [73].) This
assessment process. is a nonpathologizing measure of personality. Its
analysis of personality types provides a comprehensive
theory of personality functioning by describing four
types of mental processes: sensing (S), intuition (N),
Teens may be reluctant to sit and talk about their feel- thinking (T), and feeling (F). Sensing is the ability to
ings and experiences with a grown-up, particularly a understand through observation and the senses; intu-
professional. They generally respond well to structured ition is the conceptualization of possibilities; thinking
assessment procedures, however, including drawings, is the process of linking ideas together in a logical way;
projective tests, and sentence completions. Establishing and feeling is a more subjective process based on
rapport is possible by allowing teens space to express values. There are four basic personality types and the
themselves in their own way. possibility of 16 subtypes when two additional dimen-
The Millon Adolescent Clinical Inventory (MACI) sions are added (extrovertintrovert and judgment
for teens 1319 years is both useful and relatively short, perception). The four basic types of individuals are as
consisting of only 160 items [71]. The recent revision follows: ST, sensing and thinking; SF, sensing and
gives information on borderline tendencies and abuse feeling; NF, intuition and feeling; NT, intuition and
experiences. The four new personality scales for the thinking. STs focus on facts and the use of interper-
MACI measure self-demeaning, forceful, doleful, and sonal analysis. They tend to be practical and matter-
borderline tendencies. The majority of teens complete of-fact and to develop technical skills with facts and
the MACI easily. Occasionally, a younger teenager objects. SFs focus on facts and the use of personal

warmth. They tend to be sympathetic and friendly and ing. Such evaluations are extremely complex. Some of
emphasize practical help and services for people. NFs the following questionnaires may be useful as part of
focus attention on possibilities and the use of personal a comprehensive assessment.
warmth. They are enthusiastic and insightful and have Petty developed a Checklist for Child Abuse Evalu-
strengths in understanding and communicating with ation [76]. This is an expensive questionnaire that
people. NTs focus on possibilities by using impersonal covers all aspects of child abuse cases, including the
analysis. They are logical and ingenious and emphasize following: the accuracy of validations by the reporter;
theoretical and technical developments. Teens can be interview with the child physical or behavioral obser-
intrigued with learning more about themselves and, vations; interview with child disclosure; child psy-
without realizing it, may apply this information to help chologic status; history and observed or reported
them cope with their own lives. characteristics of the accused; and credibility of the
Although teens may be anxious and avoid responsi- child observed or reported. Conclusions cover the
bility for planning for the future, they also typically competence of the child as a witness, the level of stress
lack skills for systematically addressing these issues. on the child, and the protection of the child. Treatment
They often respond favorably to discussions on this recommendations are also included.
topic as well as to specific assessment procedures such The Sex Abuse Legitimacy (SAL) Scale developed
as the Harrington-OShea Career Decision-Making by Gardner attempts to differentiate between legiti-
System-Revised [74]. In their responses to the Survey mate and fabricated child sexual abuse allegations [77].
Booklet, teens express their likes and dislikes for many It is most effective when the child, accuser, and accused
activities, and Career Clusters that match their inter- all are interviewed. The scale is less valuable but may
ests are then suggested to the teens. Their interests only still be used, however, when the alleged perpetrator is
suggest jobs that they might like, however. Teens also unavailable. The SAL Scale was developed from
need to consider ability, values, training, and employ- studies conducted between 1982 and 1987 of children
ment outlook to make career decisions. who made allegations of sexual abuse. It helps to
Such nonpathologizing ways of working with teens organize data but does not produce a definitive con-
can be surprisingly effective. They learn problem- clusion and therefore should not be used as a ques-
solving skills that can help them overcome their tionnaire or a standardized psychological test. It can
difficulties. The process also emphasizes teens inde- only be used as a guideline and should not be used as
pendence from their family and their own responsibil- evidence in court proceedings.
ity for their futures. Peterson [78] proposed a child dissociation problem
It is easy for mental health clinicians to sidestep the checklist to be used in diagnosing the dissociation
issues of substance abuse as they are facing a young identity disorder now included in the Diagnostic and
and seemingly healthy individual who does not as yet Statistical Manual for Mental Disorders-Fourth Edition
typically show the long-term effects of substance use. Text Revision (DSM-IV-TR) [79]. The clinician may
To aid in assessing teens for substance abuse issues, not be diagnosing this disorder in early childhood,
the adolescent form of the Substance Abuse Subtle because it is extremely rare and in fact may not exist
Screening Inventory (SASSI) is available for ages 12 in childhood. It may be misdiagnosed, exist along with
through 18 year [75]. Many teenagers will give signifi- another disorder, or have an atypical presentation in
cant information regarding substance abuse habits on childhood (i.e., with fewer elaborate complex person-
a questionnaire when they may volunteer no informa- alities and their alters). In addition, clinicians may not
tion in an interview. Teenagers may not spontaneously ask the appropriate questions to make an accurate
provide information but may provide information on diagnosis. For example, they should ask about missing
their use if asked specific questions. However, the cli- blocks of time or other aspects of dissociation, and
nician may worry that it is easy to produce false posi- should also note if the child appears to be in a trance
tives by asking leading questions. Further, it is difficult at any point. These experiences may not be discussed
to distinguish between the acting-out adolescent who by children, owing to a fear of not being believed or
is chemically dependent and the acting-out adolescent being punished. There may be less differentiation
who is not. between personality aberration and the age appropri-
ate behaviors of a child.
The presentation of multiple personality disorder
Sexual Abuse
(MPD) in childhood may be different than in adult-
Evaluation for child sexual abuse should be compre- hood, since the common characteristics of MPD in
hensive and cover all aspects of personality function- adults are not present in children. These characteris-

tics in adults include persecutor personalities, inner ciently and in a standardized way. The data that are
self-helper personalities, and special-purpose frag- generated have specific applications and usefulness for
ments and systems of personalities. There may also be diagnosis and treatment planning. A broad approach
somatic complaints and severe headaches. Putnam and that includes multiple sources of data and allows us to
colleagues developed a child dissociation scale to be understand children in the context of their lives is rec-
completed by the parents [80]. ommended. Since children do not have the facility or
experience to fully express themselves verbally, we as
clinicians are interested in their worldview and how it
can be revealed to us.
Psychological testing allows the clinician to collect a
wide range of information about the child both effi-

Appendix 2.1 Assessment Protocol

Cognitive Tests
StanfordBinet 4th Edition
Wechsler Preschool and Primary Scale of Intelligence
Wechsler Intelligence Scale for Children 3rd Edition Leiter Revised
Peabody Picture Vocabulary Test
Bender Gestalt Test
Achievement Tests
WoodcockJohnson Revised
Wechsler Individual Achievement Test
Note: The average psychoeducational assessment can be completed in two sessions. Exceptions include
teenagers, very bright 1012-year-olds, and children experiencing unusual emotional reactions to testing. Be
sure to prepare the parents that a third session for psychoeducational testing may be necessary.


First Session
Background information from parents or guardian
Eyberg Child Behavior Inventory
Parenting Stress Index
Vineland Social Maturity Scale

Second Session
Developmental measures
Bayley Scales of Infant Development
Wechsler Preschool and Primary Scale of Intelligence

Third Session
Personality assessment
Rorschach (use modified method with no inquiry)
Childrens Apperception Test
Consider parentchild interaction
Fourth Session
Consultation with parents
Note: Assessment should be collapsed to three sessions when feasible.


First Session
Background information from parents or guardian
Eyberg Child Behavior Inventory
Parenting Stress Index
AttentionDeficit Disorders Evaluation Scale
Orientation with child
Testing with child
Kinetic Family Drawing
Sentence Completion Test for Children
Second Session
Personality testing
Thematic Apperception Test
Third Session
Exploring treatment goals and possible intervention strategies and enlisting childs cooperation
Fourth Session
Consultation with parents and treatment planning
Note: Additional sessions are required for psychoeducational testing, but in this instance, another option is
to collapse the second and third sessions into a one-hour session to reduce the number of sessions. Family
interaction session frequently follows the consultation session with parents.

First Session
Background information from parents
Achenbach (if needed)
Orientation with teen
Millon (some teens may not be ready)
Kinetic Family Drawing
Rotter Sentence Completions

Personality testing
Thematic Apperception Test
Third Session
Exploring treatment goals and possible intervention strategies (assess teens preferences)
Fourth session
Consultation with parents and treatment planning (teen can be invited to participate in part of session)
Note: Modifying the protocol may be needed in crisis situations or with teens who are seriously uncomfort-
able. A family interaction session frequently follows the consultation session with parents.
Appendix 2.2 Interpretation of Drawings: Suggested Procedure
Spontaneous selection of subject Head
Assigned topic Huge
Pleasant effect of the whole Disproportionately small
Unpleasant effect Eyes
Drawn from memory Large
Copied or imitating comic-strip character Small
Freely drawn and bold With pupils
Tiny and at bottom or well away from center
Elaborate Prominent
Limited Absent
Vivid fantasy Hair
Poor in content Abundant, coiffured
Own sex drawn first in Draw-A-Person test Scribbled
Other sex drawn first Scant, absent
Omission of self or other in family group Fingers
Inclusion of all members Five, supernumerary or absent stick- or clawlike
Excessive shading Mouth
Artistic shading for modeling of figure Absent or emphasized
Cosmetic or minimally represented
Static figures
Movement indicated
Large, muscular
Full-face Absent or sticklike
Profile Legs
Well-coordinated figure Two or more
Disjointed figure Wide apart or close together
Symmetry Crotch
Preoccupation with perfect symmetry Excessive attention, erasures
Excessive disregard Shading, covered by hands
Quality of line Trunk
Broken Absent or tiny, smaller than head
Continuous Emphasized, organs or navel visible
Pressure Nose
Barely visible figure Absent or tiny
Well defined Large, nostrils shown
Heavy, may punch holes through paper Breasts
Velocity Emphasized, firm or drooping
Speedy and careless Absent
Exasperatingly slow Genitalia
Mood Suggested
Peaceful Explicitly shown, exaggerated
Turbulent Apparently ignored
Large, pointed
Not visible
Composition Clothing
Simple Appropriate
Complex Incongruous
Profession or occupation shown
Scant or absent
Jewelry, ornaments
From DiLeo JH: Interpreting Childrens Drawings. New York: Brunner/Mazel, 1983:217220.

9. McCarney SB: ADDES. 2nd ed. Columbus, MO:

Appendix 2.3 Hawthorne Educational Services, 1995.
10. Randolph EM: Attachment Disorder Questionnaire.
SENTENCE COMPLETION TEST FOR 1993. Call 910/6748045 for information.
CHILDREN 11. Kaufman AS, Ishikuma T: Intellectual and achievement
testing. In: Ollendick H, Hersen M, eds. Handbook of
Name: Child and Adolescent Assessment. Boston, MA: Allyn
and Bacon, 1993:192207.
Date of Test:
12. Wechsler D: Wechsler Intelligence Scale for Children-
1. At times I feel . . . Fourth Edition: Manual. New York: Harcourt Brace
2. At home . . . Jovanovich, 2003.
3. Other kids . . . 13. Wechsler, D: Wechsler Preschool and Primary Scale of
4. My mother . . . Intelligence-Third Edition: Manual. San Antonio, TX:
5. My biggest worry . . . Harcourt Assessment, 2002.
6. I feel happy when . . . 14. Cordell AS, Cannon T: Gifted kids cant always spell.
7. My dad . . . Acad Ther 1985; 21(2):143152.
8. What I like best is . . . 15. Thorndike RL, Hagen EP, Sattler JM: Stanford-Binet
Intelligence Scale-Fourth Edition: Manual. Chicago, IL:
9. I cry . . .
Riverside Publishing, 1986.
10. I get mad when . . . 16. Leiter RG: Leiter International Performance Scale-
11. When I get mad, I . . . Revised. Wood Dale, IL: Stoelting, 1997.
12. If I could do anything, I would . . . 17. Kaufman AS, Kaufman NL: Kaufman Brief Intelligence
13. Boys . . . Test: Manual. Circles Pines, MN: American Guidance
14. Daddy gets mad when . . . Service, 1990.
15. People are . . . 18. Williams KT, Wang JJ: Peabody Picture Vocabulary Test-
16. I feel sad when . . . Third Edition: Manual. Circle Pines, MN: American
17. Girls . . . Guidance Service, 1997.
19. Woodcock RW, McGrew KS, Mather N: Woodcock-
18. What bothers me is . . .
Johnson-III (WJ-III) Tests of Achievement. Allen, TX:
19. Mommy gets mad when . . . DLM Teaching Resources, 1989.
20. When I get nervous, I . . . 20. The Psychological Corporation: Wechsler Individual
21. People think that I . . . Achievement Test-Second Edition: Examiners Manual.
22. I cannot . . . New York: Harcourt Assessment, 2002.
23. When I grow up . . . 21. Sparrow SS, Balla DA, Chicchetti DV: Vineland Adaptive
24. In school I . . . Behavior Scales. Circle Pines, MN: American Guidance
25. When I was little . . . Service, 1984.
22. Rimm S: Achievement Identification Measure,
Watertown, WI: Educational Assessment Service,
23. Light W: Lights Retention Scale, Novato, CA: Academic
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Neurobiological Assessment
George Realmuto

Introduction tion about brainbehavior relationships we might

decide that disorders of the frontal cortex should be
Neurobiological assessment for psychiatric disorders
a major DSMx category. Limbic system disorders
cant come along too quickly. Child mental health has
might encompass depression, anxiety and adjustment
several needs for such technology. The field needs to
disorders if assessment techniques could discriminate
rapidly and easily measure the various capacities of the
among them. New categories would group global brain
central nervous system (CNS) so that we can accu-
problems such as mental retardation and autism
rately evaluate cognitive, emotional and behavioral
together. Specific brain region disorders would be a
variation. We need to go further and measure the
collection of problems such as simple motor tic disor-
genetic variation of these domains to understand risk
der, habit disorders and blephrospasm. Rapid neuro-
and vulnerability prior to their developmental mani-
biological assessment using one of the many forms of
festations. The discovery, testing, validation and dis-
imaging such as positron emission tomography (PET),
semination of technological procedures to fill gaps in
single-photon emission computed tomography
our assessment protocols could reshape our practice of
(SPECT), and the various forms of magnetic reso-
patient care, standards of treatment, the scope of our
nance imaging (MRI) would improve identification
intervention goals and the direction that resources
and move treatment to early onset or even prodromal
are expended on mental health care. There are many
stages. We now have these technologies but they have
problems that we face with assessment that are now
not revolutionized the way we work with patients and
answered in ways that are not different from an
it may be time to hope the next generation of tech-
approach that is decades old. What tools do we need,
nologies will create these opportunities. An alternative
for example, that would allow us to know if a child
is to start to look elsewhere for technologies that are
with poor academic progress and identified dyslexia
waiting to be brought to clinical practice.
also had attentional problems that were consistent
with attention deficit hyperactivity disorder (ADHD)
inattentive type? Or if an adolescent presented as
withdrawn, isolated and self-destructive, what neuro-
biological assessment would allow us to easily tell Pharmacogenomics may be a new place to start. It is
whether this was an acute reaction to significant loss, a field that is as new as the effort to completely
a major depressive disorder or bipolar disorder? Could sequence the human genome. Only in 2001 was a first
we use neuroimaging to separate very early prodroms draft sequence of the entire human genome made
of schizophrenia from Asperger syndrome? Could we available to the public by Lander and Venter. The
curtail the time burden of developmental, family and human genome includes 22 pairs of autosomal chro-
medical history taking by simply applying a piece of mosomes and an additional pair of sex chromosomes.
modern day miracle technology? Do we have the The entire cellular DNA consists of approximately
neurobiological tools to refine diagnosis and treatment three billion base pairs that may encode 30 00070 000
planning? At this point we do not. If we could, our genes. One way of inquiring into this massive store-
entire nomenclature might need changing. For house of our potential is the field of pharmacoge-
example, if neuroimaging provided enough informa- nomics. What is pharmacogenomics not? It is not

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

pharmacogenetics. Pharmacogenetics is the study of when a genetic disorder with significant behavioral and
inheritance (a gene) and its interactions with medica- cognitive features is suspected. Fluorescence in situ
tions. Pharmacogenomics is the convergence of hybridization (FISH) is a method of creating a
advances in pharmacology and genomics. Pharma- sequence of DNA, attaching an identification tag on it
cogenomics is a scientific body of knowledge and pro- called a fluorophore and incubating it with the genetic
cedures that allows for genotypic screening to arrive at material in question. If the complementary sequence
an informed clinical choice for psychotropic medica- of genetic material to be tested is present, the probe
tion. Genomics is the study of whole sets of genes, will stick and the fluorophore will mark its presence
gene products and their interactions. Genomics is the through a light-emitting signal. FISH was developed
study of groups of related function genes as compared in 1986 by Pinkel et al. His group found a method to
to genetics that is limited to the study of single genes. visualize chromosomes using fluorescent-labeled
Pharmacogenomics then asks questions about med- probes. The procedure involves the annealing of the
ications as it relates to an array of genes that influence FISH probe DNA with complementary DNA
these medications. In some sense pharmacogenomics is sequences in the chromosomes. The presence or
a study of the heritability of the variance that exists in absence of the signal is observed with a fluorescence
drug effect. The implications of utilization of this microscope. FISH probes have been developed for
expertise are enormous as it applies to medicine. One many disorders of interest to psychiatry. These include
example is the choice of a chemotherapeutic agent for Fragile X, Velocardiofacial syndrome, SmithMagenis
the treatment of cancer. One treatment may be intol- syndrome, PraderWilli and Angelman syndrome and
erable for one cancer patient because drug metabolic Williams syndrome. New tests could be developed at
processes cause intolerable side effects and the full any time. A psychiatric researcher who had reason to
dosage cannot be applied. Another example is the believe that a specific sequence of DNA was responsi-
widespread use of an effective analgesic medication. ble for a product that affected CNS functioning could
While safe and effective in most patients in some cases, develope a systematic test for that DNA sequence.
popular accounts suggest that a very small group had FISH is less useful when variation in gene sequence is
very serious and life-threatening adverse effects. The the question, but it is very suitable for an application
pharmaceutical company established that this group in which the presence or absence of a known DNA
had a variant of a metabolic pathway that caused large base pair sequence is the question to be answered.
accumulations of the drug leading to near fatal conse-
quences. A simple test was devised to identify patients
Polymerase Chain Reaction
belonging to this group. Physicians were warned of this
potential hazard, educated about identification proce- An important procedure that underlies the incredible
dures and screening, and at-risk patients were excluded advances that have taken place in DNA sequencing is
from treatment with it. As compelling as these scenar- the polymerase chain reaction (PCR). It is the most
ios may seem in general medicine, in order for mental widely used molecular procedure and it underlies most
health to adopt pharmacogenomics a clear application genetic testing strategies. PCR permits copying pieces
needs to be found. Then why should pharmacoge- of DNA multiple times to produce exact replicas of the
nomic technology become part of a practical and effec- original. The procedure begins with the identification
tive neurobiological assessment? of the double stranded DNA template to be copied.
There is significant variation among individuals in the The double stranded DNA is heated to break the
way they metabolize medications. For example among hydrogen bonds between the base pairs and separate
individuals of European origin, one in ten metabolize the DNA into two complementary single strands.
certain antidepressants poorly. A much smaller group Other ingredients required include a synthetic or lab-
metabolizes the same drug rapidly. If the clinician knew oratory constructed version of DNA sequences called
the status of a particular patient would that clinician oligonucleotide primers. These primers are comple-
make a more informed choice and reduce the risk of mentary to a short segment of DNA sequence at either
adverse side effects, i.e., slow metabolism and adverse end of the template to be replicated. They serve as
effects, i.e., quick metabolism and poor response? starting points for the replication to take place. In
addition the building blocks nucleotide triphiophates
for DNA construction must be present. There are
Fluorescence In Situ Hybridization
four types of nucleic acid: adenine, guanine, thymine
Genetic testing is not new to psychiatry. We may not and cytosine that are subsequently attached to a
think too much about the procedure that we choose sugarphosphate backbone. Finally the enzyme that

catalyzes the reaction is the DNA polymerase. This removed by a process known as intron splicing. Probes
is an enzyme that synthesizes DNA by successively are looking for targets and the interaction between
adding nucleotides to the free 3 hydroxyl group of the probes and target is simply the processes of hybridiz-
growing strand. This enzyme is heat stable allowing for ing or alignment and attachment of base pairing.
cooling and heating cycles. Each cycle involves binding However some experimental tasks require the use of
of the primer to the DNA sequence that is immediately genomic DNA. If a single DNA base pair distin-
adjacent to the target sequence to be replicated, which guishes the subject from the norm, genomic DNA
sets into play the extension of the bound oligonucli- rather than expressed DNA or DNA made from RNA
otide primer which can then add free nucleotides. Each would be the target of choice. These are searches for
cycle results in doubling of the number of target DNA single nucleotide polymorphism or SNP. A particular
regions with a final target amplification of approxi- genes activity or efficiency, or developmental time
mately more than a million copies. sequence to come on line may be influenced by a SNP.
A SNP requires very fine scale detection procedures,
and preparation of the probes needs to be carefully
Microarray Analysis
thought through. As mentioned above PCR techniques
Microarray technology is a novel tool to evaluate many can produce large quantities of DNA products or
genes and gene products en masse with high efficiency. probes. Where should one choose to obtain these
Microarray analysis, as its name suggests, is possible probes? When looking for the variant it may be best to
with the availability of miniaturized, computer assisted have probes of the wild type or most common genetic
imaging systems. If an investigator thought that a variation. The absence then of a match between probe
disease state was caused by or associated with a and target says that a difference has been detected.
particular gene polymorphism or cluster of genes, Databases exist currently that detail extensive infor-
multiple patients with this disorder could have this mation about each probe at each cell location.
combination of genes evaluated and commonalties of
specific polymorphisms could be determined. For the
How are Matches and Nonmatches Detected?
clinician, once this grouping is identified treatments
could be devised to alter gene expression. The possible First, complementary DNA is deposited on the
applications of DNA microarray analysis include microarray cells by a computer assisted high-speed
identification of a specific gene of interest, screening robot. The number of cells on a chip depends on the
for mutations or polymorphisms, and comparative private company who supplies the chip. Some chips
genomic hybridization. carry as many as 65 000 cells. The probes are then
The physical features of a microarray chip might be processed with florochrome dye that is applied to the
consistent with a view of computers in general. The probes so that they can report the presence or absence
chip is made of chemically coated glass to which a of a target match. When a laser is focused onto a cell,
nylon membrane is attached. A coating of polylysine a light is emitted and each lit cell is detected and com-
or silane allows for the adhesion of the test probes. The puter coded. The laser beam excites the fluorescent dye
cells are small, less that 250 mm in diameter (Figure linked to the probe that has been hybridized with the
3.1(a)), and are topographically organized into target DNA (Figure 3.2(a)). A scanner can monitor
columns and rows capable of being assessed by fluorescence from each cell. The degree of fluorescence
computer-directed robotic readers with the input being correlates with the abundance of target molecules at a
systematically recorded. A place on the microarray specific cell (Figure 3.2(b)).
cell the intersection of a column and a row, desig- While the technology and processes are very sophis-
nates the location for the quantification of the expres- ticated, the advantage for clinical practice can be excit-
sion of a gene for a particular subject or patient. The ing and practical. One application already past the
microarray chip containing these cells is embedded pilot stage is the identification of differences in enzyme
with a small fragment of DNA (Figure 3.1(b)). The systems that influence psychoactive drug metabolism.
DNA molecule that is attached to each cell on the chip Of special interest to child and adolescent psychiatry
is referred to as a probe. Probes are used to detect is the P450 group of enzymes expressed in the liver.
targets. The target is usually complementary DNA, This family of enzymes is responsible for all of cur-
made by synthesis using an RNA sequence as the tem- rently available selective serotonin reuptake inhibitors,
plate. The advantages of complementary DNA is that tricyclic and some antipsychotic metabolism. There are
it is devoid of introns, sequences that are not repre- 10 enzyme systems in this family and each of the genes
sented in the product sequence of a gene. Introns are has an array of alleles that confer variability of meta-

Figure 3.1(a) GeneChipTM; Single feature cartoon depicting a single feature on an Affymetrix GeneChipTM; micro-
array. Image courtesy of Affymetrix.

bolic rate. Within different ethnic groups there may be tions, deletions or single nucleotide substitutions. The
less heterogeneity. One of these is the CYP2D6 allele. consequences for metabolic activity span slow to ultra-
Humans have two copies of this allele. Since this rapid. The slowest activity may be due to deletion or
enzyme is responsible for the metabolism of some inactivation of both copies of the gene. Another
antidepressants, the activity of a particular inherited version is the heterozygous variant with one inactive
variant may play a part in effectiveness of treatment. gene resulting in an intermediate level of metabolism.
The version of the gene inherited will be demonstrated The most common variant metabolizes some drugs in
by a specific expression of metabolic activity. The this class fairly extensively, and finally there is a very
kinds of gene differences that might lead to different rapid metabolic type that is due to multiple duplica-
outcomes could include a deletion of the allele, a tions of the gene. It is not uncommon for individuals
redundant version due to duplication of the gene or with the highest level of metabolism to be unrespon-
one-nucleotide differences or SNPs that have a spec- sive to treatment.
trum of effects. CYP2D4 has as many as 12 known To know how to proceed clinically, a sample of the
variants. The variations are produced by a different patients blood sample is required, and DNA
kinds of base pair alterations including shifts, addi- extracted. Multiple copies of cDNA that is represen-

Figure 3.1(b) GeneChipTM; Hybridization cartoon depicting hybridization of tagged probes to Affymetrix
GeneChipTM; microarray. Image courtesy of Affymetrix.

tative of this allelic site can be produced by PCR. A success of an antidepressant in a member of that
specific chip with probes for each variant can be pre- group. However, we now have the laboratory capacity
pared and depending on the hybridization that occurs to determine in an individual the specific polymor-
on the chip and the detection of target/probe match- phism of each of the P450 enzyme families. Therefore
ing through fluorescent emission, information about with a high degree of certainty, a laboratory test can
that individuals genetic variant can be determined. determine rate of metabolism and clearly indicate
This may be very useful for clinical decision-making. which antidepressant is likely to be effective or produce
Since different SSRI antidepressants have a different side effects, according to the rate of metabolism pre-
profile of P450 enzyme metabolism, a specific choice dicted from the presence of particular polymorphisms.
of SSRI might be made on grounds other than best There are several implications of these procedures.
guess. Paroxitine and fluoxitine are metabolized by the Genetic profiling may identify patterns of gene vari-
CYP2D6 enzyme system. This family is even more ants that at some point in time may be linked to risk
genetically diverse than the CYP2D4. It has been for disease. Informing a patient about their genotype
shown to have more than 50 allelic polymorphisms. As for clinical decisions about medication choice today
noted above, different ethnic groups have different pro- may expose them to knowledge about risk for disease
files of polymorphisms that in some cases can increase in the near future: a decision to know that was not
the accuracy of clinical guessing about the possible included in the informed consent that accompanied

Figure 3.2(a) Hybridized GeneChipTM; Microarray cartoon depicting scanning of tagged and un-tagged probes on
an Affymetrix GeneChipTM; microarray. Image courtesy of Affymetrix.

their decision to obtain information for medication provide a clinician with a profile of a patients cyto-
decision-making. Therefore additional consent about chrome P450 2D6 genotype with information about
the possible use of genetic testing would need to the activity of each of the identified variants. The lab-
include a discussion about how the information would oratory can be reached at 800 533 1710. Matching these
be documented and to whom the information would genetic determinates with a drugs preferred metabolic
be or would not be transferred now and in the future. pathway can be lifesaving: for example a patient is
Another implication is the role of pharmacogenomic admitted to an inpatient unit for continued suicidal
testing for practice standards. If there is a way to ideation and attempt, and it is determined that the
choose a medication that will have fewer side current SSRI is ineffective; making a wrong therapy
effects and better efficacy should we not adopt such choice could lead to a lengthy hospitalization whereas
a test? cytochrome P450 information could lead to an
These tests are really here now. A well-known informed choice. The costs of the tests would quickly
medical clinic in the Midwest is already making this be recouped through shorter length of stay. We have
test available for a small sum of about $300 (personal been disappointed by the promises that imaging and
communication Dr. David Mrazek). The test will other technology were expected to bring to child and

emitting radiolabeled substances produce a single

photon of energy that is detected by single-crystal scin-
tillation instruments external to the subject. The
radioactive distribution is analyzed by a computer and
displayed as an image based on the energy produced
and the position of the source of the energy (Figure
3.3). The procedure has gone through several refine-
ments, including an improved detection of photon
emissions of new radiopharmaceuticals.
There are several important differences between
SPECT and PET. SPECT radioscopes produce lower-
energy gamma rays than the photons produced by the
radionuclides used in PET. As a result, the former are
more easily absorbed by the body and therefore require
longer scanning sessions for adequate resolution. In
addition, lower-energy isotopes result in deeper struc-
tures of the brain absorbing or attenuating emitted
radiation, which requires some adjustment of the
signal to decrease artifact.
SPECT has been successfully used in the study of
Figure 3.2(b) GeneChipTM; Array output data from an patients with ADHD. In a series of studies in which
experiment showing the thousands of genes detected children and adolescents with ADHD inhaled radio-
by a single GeneChipTM; probe array. Image courtesy labled xenon, results were consistent with other evi-
of Affymetrix. dence for hypofrontality as well as hypoperfusion of
the caudate nuclei. Administration of methylphenidate
to a subgroup of these patients had a normalizing
effect on brain activity as shown after rescanning [6].
Another center studied a larger and better-described
adolescent psychiatry. Although new, we seem to have
group of children and adolescents with ADHD under
a need for a test for and a rationale for pharmacoge-
resting and stress conditions. Again, prefrontal prob-
nomic testing. Will we adopt it?
lems were noted [2].
There have been advances in the radiolabeling
Promising Technologies for Neurobiological of a variety of pharmaceutical antagonists whose
Assessments application is important to psychiatry, such as radio-
labeled probes for D1 and D2 dopamine receptors
Many tools currently used for research show promise
[14,15]. Poor morphologic resolution and the use of
of making their way into clinical practice. These tech-
radioactive substances that convey some small risk in
nologies are dependant upon sophisticated computer
developing children may limit the overall potential for
hardware and software. In some cases, scientists with
child psychiatry. However, improved detection
special expertise are needed beyond the highly trained
enhanced through computer software and other tech-
technicians who prepare the patient and operate the
nical improvements as well as targeted probes identi-
equipment. However, the costs of individual examina-
fying neurotransmitters and receptors may improve to
tions have been decreased, bringing such methods of
the point that SPECT closely rivals PET.
examination closer to clinical practice than ever before.
What follows is a brief description of the methods
and principles of experimental neurobiologic assess- Positron Emission Tomography
ment techniques (Table 3.1).
PET permits measurements of the rate of radioactive
substrate consumption. If the radioactive substrate
collects at points of increased neural activity, the decay
Single-Photon Emission Computed Tomography
of the substrate at that locale will identify such
The technique of single-photon emission computed processes. If the substrate binds to a particular recep-
tomography (SPECT) detects and images gamma rays tor, then the receptor will be localized during the
produced by radioactive isotopes. These gamma- degradation of the radioactive substrate.

Table 3.1. Potential neurobiologic techniques.

Technique Description Potential application References

Event-related Summed electrical activity form Neurodevelopmental disorder, [13]

potentials groups of neurons responding early identification, and
to a time-locked stimulus qualification of impairment
Magnetic resonance Detection of radio waves from Brain behavior correlations, [4,5]
imaging atomic particles and translation identification of structures
into computerized images abnormal for volume and
blood flow
Single-photon Radioactive substance produces Identification of subgroups [6,7]
emission computed an emission that can be within diagnostic groups that
tomography detected and visualized may have different
pathophysiologic processes
requiring different
Positron emission Radioactive substance emits Anatomic localization of [812]
tomography protons that produce photons important brain events of
that are detected and imaged, locales that underlie disorders
creating maps of activity or or responses to treatments
Functional magnetic T2*, the modified time constant Structure/function relationships [13]
resonance imaging for transverse relaxation, is of the central nervous system
measured in various tissues
whose differences emerge as a
result of the imposition of a
field magnet

The physics of PET scanning are founded on prin- surrounding tissue that produces cleaner images. Also,
ciples governing the emission of protons from radioac- PET does not use collimators or parallel filters to focus
tive nuclei as the radioactive substance decays. The photons that may compromise the resolution of
emitted proton inevitably collides with an electron, SPECT technologies.
resulting in two photons traveling in almost opposite There are limitations of PET, however. First, the
directions. The PET scanner can record these photons energy of the radioactive substance used to generate
with scintillation detectors using sodium iodide or protons is considered more hazardous to the host
bismuth germanate crystals. The scintillation detectors than that of the lower-energy chemicals in SPECT and
convert the photon energy into visible light that can be this is an important factor in limiting the recruitment
recorded on film. Only those photons traveling in of children for PET studies. Second, the collision of
linear but opposite directions are saved as data points proton and electron does not always produce photons
through the encircling array of scintillation detectors. traveling in exactly opposite directions, thus adding
The activity produced by the radioactive nuclei can be some blur to the image. Third, the scintillation detec-
pinpointed in two-dimensional space and reorganized tors themselves bear physical limits that affect clarity.
spatially to produce a graphic representation of the What begins as a single point of activity in the brain
photons. may ultimately emerge as a 10 cm image. Fourth, the
The advantages of PET over SPECT include higher- mathematical modeling methods used to extract
energy reactions and thus the emission of higher- absolute measurements are highly controversial.
energy protons with smaller attenuation from Because of differences between imaging centers

Figure 3.3 Transaxial single-photon emission computed tomography (SPECT) images at the level of the striatum
in a healthy subject (A) and two patients with Parkinson disease (B, early stage; C, late stage). The 123I-labeled radio-
pharmaceutical b-CIT binds to dopamine transporters on the presynaptic terminals of dopamine neurons. The
SPECT images demonstrate that patients with Parkinson disease have fewer striatal uptake sites than healthy sub-
jects, with greater loss in the putamen (posterior) region than in the head of the caudate. (Courtesy of John Seibyl,
MD, Ken Marek, MD, and Robert Innis, MD, New Haven, CT).

methods and equipment and mathematical algorithms, ulated by dextroamphetamine and methylphenidate
results might best be considered relative rather than [11,17]. Unfortunately, the findings about the action
absolute quantities. Finally, a unique requirement for sites of drugs did not give clear inferences about brain
PET scanning is the production of a radioactive tracer. response to medication in regions specific to ADHD.
High-energy radiolabeled pharmaceuticals with defin- A more promising study recently published by Matlay
able parameters of energy, proton emissions, and other and colleagues used PET to view the action of med-
physical characteristics must be created in a cyclotron. ication in adults [12]. In this study, cognitive tasks of
The substrates are bombarded with protons in the executive brain function were administered to subjects
cyclotron to produce the desired probe. Since the probe to stimulate metabolism in brain regions subserving
decays rapidly, this technique requires on-site facilities those functions. Differential oxygen uptake enhance-
to create tracer substances along with the personnel ment by stimulant drug was observed in the prefrontal
and capacity to deal with the spent low-level radioac- cortex and hippocampus.
tive waste [16]. In summary, although PET methodology was
PET scan studies of interest to child and adolescent applied in a research setting to differentiate ADHD
psychiatry were begun in 1990 by Zametkin and col- subjects from controls and to evaluate drug treatment
leagues, using a sample of adults with ADHD [8]. In effects, the results were disappointing. Few adolescents
1993, 10 adolescents with ADHD were studied, and six and no children participated in the studies because of
brain regions showed differences in activity when com- concerns about the protection of human subjects, thus
pared to controls. These included frontal, thalamic, significantly limiting application to the patients of
hippocampal, and temporal areas with findings dis- prime interest. Also, the results were neither anatomi-
tributed by both hemisphere and rate (increase or cally specific nor, for the most part, consistent with
decrease in brain metabolic activity) [9]. hypothesized defects derived from other sources. The
Further extension of these studies was pursued to long-term prospective of PET scanning for the child
evaluate the metabolic activation of brain areas stim- and adolescent population may not be bright, since

other technologies subserve similar goals. Functional symptom severity at different times, and as treatment
MRI (fMRI) has several advantages over PET and removed antistreptolysin O antigens, caudate size
obtains similar information (see next section). Com- diminished and symptoms decreased [4]. In the future,
petition among technologies is good for the field, an evaluation of structures such as caudate size may
improving the time, convenience, cost, and information be useful in differential diagnosis and the evaluation of
delivered. treatment response. Defining caudate volume may be
useful in differentiating habit disorders from adjust-
ment disorders, and neurobiologic phenomena such as
Magnetic Resonance Imagining
Tourette syndrome and OCD, and may also give spe-
The technologic procedure that appears to have the cific direction to treatment interventions and permit
easiest entry into child and adolescent mental health clearer measures of treatment response.
is MRI. The equipment required includes a high- Limitations to this procedure are minimal. Con-
powered magnet, which lines up protons according to traindications include mainly the presence of ferrous
the direction of the magnetic field, and coils conduct- metals in the body, although this is probably not a sig-
ing radio waves. Radio waves alter the alignment of the nificant problem in the child and adolescent popula-
protons, and the resulting signal produced from this tion. Multiple exposures were originally a concern, but
realignment can be detected and fashioned into images these are now being permitted when clinically indi-
using computer software. Stronger magnets, better cated, with few adverse experiences. Rapidly changing
software, and more experience with the location and the direction of the magnetic field potentially produces
pulse frequency of coils have improved the quality of electric shock and tissue damage, and alternations that
the images (Figure 3.4). are too rapid in magnetic polarity may induce electric
Interesting work with MRI has elucidated the size currents within the body and may thus produce an acti-
of important brain structures and allowed for clearer vation of peripheral nerves that the patient may feel.
correlations between structure and function. For In addition, tissues that have few ways to dissipate heat
example, a recent report contributed to a better under- can be exposed to the hazard of energy produced by a
standing of the basal ganglia in patients with rapidly changing magnetic field. The Food and Drug
obsessivecompulsive disorder (OCD). Basal ganglia Administration has set limits on these parameters,
volumes measured with MRI were compared with and most MRI scanners have these upper limits built

Figure 3.4 Sagittal view of the human brain at 4.1 Tesla demonstrating exquisite neuroanatomic resolution. (Cour-
tesy of Dr. Jullie W. Pan and Hoby Hetherington, PhD, Birmingham, AL).

into the system software to prevent untoward events. The specific type of MRI frequency that is measured
Another limitation of use has been cost, particularly in fMRI is the T2*. When a static magnetic field is
in setting up such equipment, but competition and the applied to a volume of tissue, atomic nuclei can
portability of the equipment have made MRI virtually respond by developing a magnetic field and thus mag-
universally available. netic susceptibility. However, the random directions of
Given the opportunities for better definition of CNS the magnetic fields of surrounding nuclei result in the
substrates of psychopathology, it behooves the profes- neutralization of any particular summed field strength.
sion to develop medical necessity guidelines and crite- These events are generated in the direction transverse
ria so that this and other technologic procedures will to the static magnetic field. This equilibration of the
be approved for use in children and adolescents as a magnetic field is called relaxation and it occurs over
standard of care. a specific time course. T2* therefore represents the
modified time constant for transverse relaxation
(Figure 3.5).
Functional Magnetic Resonance Imaging
Little work has been done with fMRI in any popu-
Mapping of physiologic activity is a capacity of MRI lation. Teicher and colleagues reported the effects of
technology shared with PET, SPECT, and evoked methylphenidate on ADHD symptoms and fMRI
potentials. However, high temporal and spatial resolu- in children and showed a strong correlation between
tion and the ability to repeatedly scan subjects give the number of child movements on placebo and T2*
fMRI an advantage over other imaging techniques. relaxation times of the right caudate [13]. The optimal
Although this technique may circumvent many of the dose of methylphenidate exerted significant effects
hazards that have precluded children from entering on frontal and caudate T2*, which affected the right
research protocols, fMRI has arrived only recently, and hemisphere more than the left. Another recent publi-
there is little in the literature to demonstrate its supe- cation investigating the neuroanatomy of OCD symp-
riority over other methods [18]. toms in adults showed the activation of specific brain
As described for MRI (see previous section), the regions, including limbic structures that had been iden-
physical basis of fMRI is the systematic manipulation tified previously for subjects but not controls [19].
of changes to the precession of atomic nuclei around
its axis. The activity of spinning atomic nuclei results
in minute magnetic fields, and anatomic structures
differ in their chemical composition and thus magnetic
characteristics. Differences in the magnetic susceptibil-
ity of these anatomic structures make it possible for
these magnetic dipoles to be manipulated to produce
radio frequencies that can be detected by specialized
receiver coils. Using sophisticated computer technol-
ogy, these differences are then spatially arranged into
images. The largest magnetic fields are produced at the
boundaries of volumes with the largest differences in
magnetic susceptibility.
Magnetic susceptibility is caused by the propensity
of a material to develop an internal magnetic field in
response to one applied from the outside. In the case
of the fMRI, the field that is applied is the large
magnetic field applied to the body [23]. Of particular
importance in fMRI are the physiologic changes that
occur in the blood as it perfuses neural tissue. Acti-
vated tissue deoxygenates blood, and thus maps can be
produced of localities in the brain where oxygen is Figure 3.5 The physical basis of fMRI signal changes.
being consumed at rates statistically different from From left to right, decreasing blood oxygenation
baseline. Oxygen changes the magnetic properties of increases field gradients surrounding vessels, which in
hemoglobin, and deoxygenated blood has very differ- turn decreases T2* and image intensity. Neuronal
ent magnetic properties from surrounding brain activity increases capillary level oxygenation, which is
parenchyma, which can be detected as differences in detected as an increase in T2*-weighted image inten-
magnetic field frequencies. sity. (From [16]).

Figure 3.6 Functional magnetic resonance (MR) map of the primary auditory cortex. Pixels with significant signal
changes associated with the presentation of sounds are shown in color (greater significance in lighter shades), super-
imposed on a conventional MR scan of the same slice through the brain (Courtesy of Rene Marois, Yale Univer-
sity, New Haven, CT).

Conceptually, fMRI is more complicated than other The basic principles of MRS and MRI are identi-
imaging systems. The master of fMRI requires skills cal. MRS, however, records differences in activity
in many technical and clinical areas. The first wave based on the detection of chemical shift. As described
of studies to be published will likely be a replication previously, atomic nuclei possessing magnetic proper-
of studies that have previously used other imaging ties rotate around an axis based on the strength of the
procedures. These replication studies may allow fMRI magnetic field applied. For MRS, however, detection
to quickly emerge as the imaging standard, and studies of the differences in chemicals is based on the magnetic
of all ages and conditions will likely follow (Figure properties of atomic nuclei as they are influenced by
3.6). the quantity of electrons possessed by a given chemi-
cal. This is the key point of the technique. Hydrogen
protons may precess at a certain frequency, but differ-
Magnetic Resonance Spectroscopy
ences exist if the hydrogen atom is part of water, with
Preceding the more widely used imaging techniques of an electric cloud produced by two oxygen atoms, or if
MRI was magnetic resonance spectroscopy (MRS), a it is a hydrogen atom that is part of a methane moiety
novel investigative tool developed to understand the of a large organic molecule. Since each hydrogen atom
functional basis of disease [20]. MRS is capable of experiences a slightly different local magnetic field
identifying important events in cell metabolism such as owing to shielding by different clouds of electrons,
energy production and dissipation through the identi- each chemical shift is the difference in resonance fre-
fication of chemicals that are produced or consumed quency caused by the characteristics inherent in a par-
by these processes. ticular nucleus. Detection of these differences is similar

to procedures described for MRI and includes tipping influenced be the relevance of the stimuli, the motiva-
the axis of the spinning atomic nuclei with a specific tion of the subjects, and other subject and stimuli vari-
radio frequency and recording changes in magnetic ables. This late-appearing wave may therefore have
field. Relaxation time as nuclei reequilibrate is trans- something to do with cognitive processing as com-
formed into frequency values and displayed as unique pared to earlier-appearing waves that may measure the
frequency spectra [21]. hard wiring of the CNS. The subject is asked to com-
MRS can detect cellular activity involving phospho- plete a cognitive task that is reflected in the P300. The
rylated compounds including adenosine triphosphate finding that nonretarded adolescent autistic subjects
and its phosphorylated intermediates. Chemical prod- demonstrate smaller P300 amplitudes as well as other
ucts available for measurement with this technique parameters suggests that autism is a disorder of
include choline and lactate. Further extension of this focused attention in which novel and common stimuli
technology includes quantitative measurement of neu- are perceived with equal relevance [2]. Evoked poten-
rotransmitter and neurochemical levels. Limitations tial procedures have been applied to infants and very
that are generic to magnetic resonance technologies are young children who have experienced prenatal or peri-
also present with spectroscopy, including slow acquisi- natal insults [22], and in a growing body of work, the
tion time, artifact created by patient movement, and examination of risk for chemical dependency has been
relatively poor spatial resolution. However, more pow- quite fruitful [1].
erful computer software, higher field strengths of the Current limitations of this procedure include costs
magnet, and creative ways of improving patient coop- for computer hardware and software and ongoing
eration may allow the detection of chemical events technical support as well as the time and energy con-
related to specific psychopathologic processes [21]. sumed by technical and computer glitches that appear
to be a by-product of cutting-edge technology.
Electrophysiologic Procedures:
Event-Related Potentials Electroencephalography
The event-related potential is a neural phenomenon Old technology namely the electroencephalogram
captured with a relatively noninvasive procedure, and (EEG) continues to have a place in the neurobiologi-
some applications are not particularly demanding of cal assessment of children and adolescents. The earli-
a childs attention or self-discipline. Brain electrical est work on EEG dates to the German psychiatrist
activity can be recorded through the placement of Hans Berger who published the EEG of his son in
electrodes on the skull in a system similar to that of 1929. He showed that changes occurred in his sons
electroencephalogram electrode placement. The brain alpha rhythm due to mental activity. EEG instrumen-
produces a sequence of positive and negative deflec- tation identifies changes in direction of the flow of
tions that are consistently observed as a consequence electrons from electrodes placed on the patients scalp.
of auditory, visual, or somatosensory stimuli. These As groups of neurons depolarize an electrical field is
waves are generated by groups of aligned cells that developed the direction of which can be noted by the
together reach a state of depolarization or hyperpo- electrode. Fluctuations in field strength for each elec-
larization that is detected by electrodesmuch the trode are recorded on paper and more recently cap-
same way the center of an earthquake is detected by tured by sophisticated computer software.
seismologic instruments distributed across the Earths Among the disorders relevant for EEG assessment
crust. Courchesne and colleagues have done consider- is autism. Differentiation of a disorder such as
able work using this technique to further our under- LandauKleffner syndrome, which has a specific treat-
standing of autistic disorder [2]. It is with such ment, from autism is very important. Also since autism
neuropsychiatric conditions that organ level measure- has an incidence of seizures of about 2030% with a
ments become most useful, because of the significant peak risk for onset in early adolescence, the clinician
communicative disability that makes direct inquiry dif- should consider ordering an EEG as part of a work-
ficult, if not impossible. One of the many findings con- up for any unusual change in the adolescents clinical
tributed by a series of studies with autistic subjects was condition. EEG differences from normal have been
the reduction of amplitude of the P300 waveform. The noted for ADHD, conduct disorder, and learning dis-
P300 waveform is a characteristic positive deflection orders but the findings are nonspecific and may not be
occurring approximately 300 milliseconds after the helpful for guiding treatment. Medication monitoring
onset of a stimulus. The P300 response is generally for drug treatments that lower seizure threshold may
invoked by target- or task-related events and may be continue to define a use for EEG testing.

Conclusion DNA polymerase

Any of various enzymes that function in the replica-
Neurobiologic assessment has a bright future in iden-
tion and repair of DNA by catalyzing the linking of
tifying clinically significant differences in activation
dATP, dCTP, dGTP, and dTTP in a specific order,
levels of specific brain regions, in measuring neurohu-
using single-stranded DNA as a template [24].
moral proclivities associated with fundamental bio-
logic activities, and in parceling out genetic and Fluorescence in situ hybridization (FISH)
environmental endowment associated with diagnostic A process which vividly paints chromosomes or por-
entities and behavioral, emotional, and ideational tions of chromosomes with fluorescent molecules [26].
symptoms. Further, the wedding of information
generated by these laboratory procedures to biologic Fluorophore
responses from the next generation of psychopharma- An atomic group with one excited molecule that emits
cologic agents may detail new insights into neuro- photons and is fluorescent; also written fluorophor [28].
chemical brainbehavior relationships. This may Fragile X
provide the child and adolescent psychiatrist a power- Fragile X syndrome is a hereditary condition that
ful technology to explore symptoms as well as com- causes a wide range of mental impairment, from mild
prehensive and integrative techniques that allow for learning disabilities to severe mental retardation. It is
predictive statements about disease progression and the most common cause of genetically-inherited
outcome. How this is to evolve is unclear. As with mental impairment and is associated with a number of
many challenges, the conquerors may already be physical and behavioral characteristics [30].
staging an assault. It was premature a decade ago to
assume that the dexamethasone suppression test would
All the DNA contained in an organism or a cell, which
provide diagnostically useful information. We now
includes both the chromosomes within the nucleus and
know much more about cortisol and its relationship to
the DNA in mitochondria [26].
acute and chronic stress and psychiatric disorders.
That experience should have taught us that we cannot [comparative] Genomic hybridization
clearly predict the utility of our enhanced neurobio- Comparative genomic hybridization (CGH) is a pow-
logic assessment tools. We must also be concerned that, erful molecular and cytogenetic technique that pro-
at this point in the evolution of managed care, invest- vides an overview of genetic imbalance within the
ment in these approaches may be minimal. As with all entire genome [29].
leaps forward, all the right ingredients need to come Genomics
together. Economic advantage, charismatic spoke- The study of all of the nucleotide sequences, including
spersons, and a critical event are at least three of the structural genes, regulatory sequences, and noncoding
requisite pieces to fuel this leap. DNA segments, in the chromosomes of an organism
Glossary Genotype
(i) The genetic makeup, as distinguished from the
Allelic polymorphisms physical appearance, of an organism or a group of
One of a pair or series of genes that occupy a specific organisms. (ii) The combination of alleles located on
position on a specific chromosome [24]. homologous chromosomes that determines a specific
Angelman syndrome characteristic or trait [24].
A genetic disorder with developmental and neurologial Microarray analysis
symptoms including severe mental retardation, A new way of studying how large numbers of genes
seizures, ataxic gait, jerky movements, lack of speech, interact with each other and how a cells regulatory
microencephaly, and frequent smiling and laughter networks control vast batteries of genes simultane-
[25]. ously [26].
Complementary DNA Oligonucleotide primers
cDNA is complementary to RNA. The RNA serves as Short sequence of single-stranded DNA or RNA.
a template for synthesis of the complimentary DNA Oligonucleotides are often used as probes for detecting
in the presence of the enzyme reverse transcriptase complementary DNA or RNA because they bind
[25]. readily to their complements [26].

Pharmacogenetics broad nasal bridge, marked mid-facial hypoplasia,

The study of genetic factors that influence an organ- short, full-tipped nose with reduced nasal height,
isms reaction to a drug [24]. micrognathia in infancy changing to relative prog-
nathia with age, and a distinct appearance of the
mouth, with fleshy everted upper lip with a tented
A biotechnological science that combines the tech-
appearance. Individuals with SMS function in the mild
niques of medicine, pharmacology, and genomics and
to moderate range of mental retardation. The behav-
is concerned with developing drug therapies to
ioral phenotype includes significant sleep disturbance,
compensate for genetic differences in patients which
stereotypies, and maladaptive and self-injurious behav-
cause varied responses to a single therapeutic regimen
iors. Childhood and adulthood are characterized by
inattention, hyperactivity, maladaptive behaviors
Polymerase chain reaction including frequent outbursts/temper tantrums, atten-
A fast, inexpensive technique for making an unlimited tion seeking, impulsivity, distractibility, disobedience,
number of copies of any piece of DNA [26]. aggression, toileting difficulties, and self-injurious
behaviors (SIB) including self-hitting, self-biting,
Polymorphisms and/or skin picking, inserting foreign objects into body
The regular occurrence of two or more alleles of a gene orifices (polyemoilokomania), and yanking finger nails
[25]. and/or toenails (onchyotillomania). Two stereotypic
behaviors, spasmodic upper-body squeeze or self hug
PraderWilli syndrome and hand licking and page flipping (lick and flip),
PraderWilli syndrome is characterized by severe seem to be specific to SMS.
hypotonia and feeding difficulties in early infancy, fol- Diagnosis/testing. The diagnosis of SMS is con-
lowed in later infancy or early childhood by excessive firmed either by detection of an interstitial deletion
eating and gradual development of morbid obesity, of the short arm of chromosome 17 band p11.2
unless externally controlled. All patients have some (del17p11.2) by G-banded cytogenetic analysis and/or
degree of cognitive impairment; a distinctive behav- by fluorescence in situ hydridization (FISH) [32].
ioral phenotype is common. Hypogonadism is present
in both males and females. Short stature is common. Velocardiofacial syndrome
Accurate consensus clinical diagnostic criteria exist, The most common features are cleft palate, heart
but the mainstay of diagnosis is DNA-based methyla- defects, characteristic facial appearance, minor learn-
tion testing to detect the absence of the paternally con- ing problems and speech and feeding problems. The
tributed PraderWilli syndrome/Angelman syndrome gene or genes that cause VCFS have not been identi-
(PWS/AS) region on chromosome 15q11.2q13. Such fied; most children who have been diagnosed with this
testing detects over 99% of patients. Methylation- syndrome are missing region 22q11 of the genome.
specific testing is important to confirm the diagnosis of VCFS is an autosomal dominant disorder; in most
PWS in all individuals, but especially those who are too cases neither parent has the syndrome or carries the
young to manifest sufficient features to make the diag- defective gene. The cause of the deletion is unknown
nosis on clinical grounds or in those individuals who [27].
have atypical findings [31].
Williams syndrome
Single nucleotide polymorphism A rare genetic disorder characterized especially by
Common, but minute, single base pair variations that hypercalcemia of infants, heart defects (as supravalvu-
occur in human DNA at a frequency of one every 1000 lar aortic stenosis), characteristic facial features (as an
bases. These variations can be used to track inheritance upturned nose, long philtrum, wide mouth, full lips,
in families [26]. and pointed chin), a sociable personality, and a high
verbal aptitude, but with mild to moderate mental
SmithMagenis syndrome
retardation [29].
SmithMagenis syndrome (SMS) is characterized by
distinctive facial features, developmental delay, cogni-
tive impairment, and behavioral abnormalities. The References
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intravenous dextroamphetamine on brain metabolism
Educational Assessment and
School Consultation
Dorothyann Feldis

Introduction to improving school performance have little value to

the classroom teacher. Lerner (2003) defines assess-
School is an environment in which children are asked ment as the process of collecting information about a
to learn certain basic academic and social skills and student that will be used to form judgments and make
in which their performance is judged and compared decisions concerning that student (p. 62 [2]). She also
with that of other children. If children perform well, states that the closer the connection between educa-
they learn that success provides opportunities and tion assessment and instruction the more effective the
social status. If, on the other hand, they perform assessmentteaching process will be (p. 62 [2]).
poorly for whatever reasons, they learn about failure The educational assessment of children is a special-
and restricted opportunities. It is demoralizing to try ized process that directly addresses overall achievement
to maintain a sense of self-worth and enthusiasm for in school. Generally, success in school is based on aca-
learning within the confines of educational expecta- demic performance. Students who achieve well aca-
tions that are impossible to achieve. Very early in their demically are usually considered successful and those
school careers, children essentially learn whether they who perform poorly are targets for academic assis-
are to be a success or a failure. The dilemma of failure tance and adjustments. However, variables considering
is exacerbated by the fact that children are powerless students dispositions motivations, feelings and
to change their environment; they need adult support desires must be included in that they directly influence
to identify learning problems and effective solutions to academic achievement (p. 199 [1]). This , of course,
these problems. Child and adolescent psychiatrists and implies that the assessment process must have a col-
other professionals involved with children who are laborative approach: one that includes not only teach-
experiencing difficulty in school must understand the ers, parents, diagnosticians but also the child. The child
devastating impact that school failure has on a childs must be more than the object of the process but a part
life and act swiftly to resolve the situation. of the process. Stiggins (2005) asks us to consider the
The first step in understanding a childs learning child as a consumer of assessment results (p. 19 [1]).
problems in school is devising some method of gath- Positive, constructive results of continuous assessment
ering information to help us understand the factors builds self-esteem along with feelings of hopefulness
influencing the students performance for the purpose and the expectation of more success in the future (p.
of generating a solution. Historically, assessment has 19 [1]). The outcome of any assessment process should
been used as a method of sorting students to be chan- provide information that allows teachers, parents and
neled into various segments of our social and eco- others to better create effective positive learning envi-
nomic system rather than a method of tracking and ronments: environments that allow students to assume
enhancing growth toward standards as well as a control of their own destiny in school. The perform-
method of motivating students to strive for academic ance of the child is not viewed in isolation but as part
excellence (p. 15 [1]). Classroom teachers are quick to of a large ecosystem containing numerous interde-
state that assessment is effective only if used as a pendent variables. This approach acknowledges that
problem-solving mechanism; data not directly related factors other than ability affect learning and therefore

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

requires that the environment adjust to support the family. Other new problems might be caused by illness
special learning needs of the child. or other family trauma that has affected school per-
formance for a child who historically has been consid-
ered a typical learner.
Who is Qualified to Conduct an Educational In some chronic situations children may have
Evaluation? received some form of assessment or intervention, and
in other cases they may not have received any consid-
Individuals who conduct educational evaluations
eration. An example of the former would be a sixth-
are usually called diagnostic educators; they must be
grade child with a history of reading problems who has
able to collect the data necessary to identify a learner
received some individual tutoring but whose report
problem and then use those data to devise educational
cards continue to indicate little or no improvement. An
intervention strategies. Their academic training should
example of the latter would be a ninth-grader with a
consist of at least a masters degree in education com-
history of learning problems who has managed to
bined with clinical testing and teaching experience, and
perform adequately through elementary and junior
knowledge of reading disorders. This diagnostic role is
high school, but who has significant difficulty adjust-
relatively new for educators, however, and it is there-
ing to the expectations of the secondary school
fore important to understand and distinguish the skills
of the diagnostic educator from those of other profes-
A crisis situation needs immediate action and has
sionals. The diagnostic educator must be able to iden-
the potential for seriously compromising the future
tify and analyze the childs learning patterns and assist
academic progress of the child. There are various cir-
the classroom teacher in implementing instructional
cumstances that might generate a crisis, but two situa-
methods that can accommodate learning differences.
tions should be addressed without hesitation: grade
To help accomplish this, he or she must understand
retention and school suspension or explusion. In the
the cause and nature of learning disabilities as well as
case of grade retention, one ground rule exists: no deci-
methods of accommodating learning differences in the
sion should be made until the child receives an inter-
classroom. The diagnostic educator must understand
disciplinary evaluation that includes an educational,
the purpose of a school-based problem-solving team
psychological, psychiatric, and speech and language
and be able to use this team to help facilitate change
assessment. The reason for failure must be specifically
in both attitudes and approaches to learning and
identified and a plan for intervention designed; the
assessment of outcomes. Because the role of the edu-
child deserves every resource available to resolve the
cational diagnostician involves interpreting perform-
problem. In the case of school suspension or explu-
ance in the classroom, teaching experience often
sion, the child also needs an interdisciplinary evalua-
validates these individuals credentials.
tion to determine the variables affecting behavioral
issues, and to rule out other contributing factors such
as learning disorders and psychiatric illness. If the
When Should A Referral be Made?
child has been assessed in the past, these reports need
The psychiatrist may have to request an educational to be reviewed and updated. If the child has been sus-
evaluation when there is a question about school per- pended, the present education program is not helping
formance or the need to adjust a childs educational him or her adjust to the expectations of the learning
program. The problem may be a new development or environment, and the childs situation needs to be
a chronic or crisis situation. A new problem is a recent reconsidered.
situation without an identified history, for example, The cause of problematic behavior must be identi-
a child in kindergarten or first grade for whom the fied and an intervention plan developed, if reentry is
teacher has expressed concerns about progress. Prob- to be successful. In these cases the psychiatrist needs
lems such as these might be considered developmen- the educator to assess academic performance and
tal, and teachers and other professionals might choose identify the necessary accommodations required for
to take the wait and see approach. Many of these successful progress to occur. Whatever the problem, it
issues, however, often materialize into significant learn- is important to remember that children cannot usually
ing problems in the second or third grade, when the develop coping mechanisms on their own or adjust
child actually begins to fail. Serious consideration their school environment to help them better meet
should therefore be given to early concerns about a expectations. If professionals hesitate in obtaining an
childs progress, before school expectations begin to assessment there can be misdirected, inefficient, and
appear insurmountable to the child and his or her often disappointing results for all.

Legislation and Rights This legislation emphasizes educating children in the

least restrictive learning environment possible, one that
Historically, classroom teachers have assessed children can provide inclusion in the general curriculum. Good
by trying to discover what they do or do not know and program decisions usually consider the childs educa-
why they have learned some things and not others. If tional needs, the support services needed to accom-
a teacher is skilled and the system supportive, this modate those needs, and methods of imbedding
method can be effective. The individual skill of the supports into the general curriculum.
teacher and the random sensitivity of the system, The Ohio Department of Education suggests that
however, do not ensure that all children experiencing a childs placement is presumed first to be the general
problems in school will be appropriately identified and education environment (p. 14 [3]). If the child is not
provided with the adaptations necessary for learning participating with nondisabled children, the IEP team
to occur. The enactment of Public Law (PL) 94142, must provide an explanation.
the Education of Handicapped Children Act (1975), The legislation also provides a specific set of
changed this process. Instead of depending on good procedures for identifying a childs disability and
teachers and interventions, the law mandated that all determining an appropriate educational program
children aged 521 years with an identified handicap (Table 4.1). These procedures ensure the right of all
will have a free and appropriate education. It also children to receive services for which they are eligible.
provided procedures to determine eligibility for special Any child suspected of a disability must have a multi-
education services and appropriate programming. factored evaluation (MFE), which assesses all areas
This legislation was revised in 1990 (PL 101 476) and related to the suspected disability, and an individual-
renamed Individual with Disabilities Education Act ized education program (IEP) conference to review
(IDEA) recognizing the concept of considering indi- the MFE data, determine eligibility for special services,
viduals first, then identifying their characteristics and and define the least restrictive learning environment
extended the mandate to serve children aged 321 to be used. Because of the schools obligation to
years. The most recent revision of the Individuals with determine an IEP for each identified child and to define
Disabilities of 1997 includes raising expectations for general educational goals and teaching strategies,
children with disabilities, ensuring that children with educators have begun to perfect the educational as-
disabilities have increased access to the general educa- sessment as a means of providing data pertinent to
tion curriculum and strengthening the role of parents. classroom learning and curricula.

Table 4.1 Identifying a childs disability: procedural safeguards.

Stage Components

Preferral Parents discuss program with teacher and request intervention, or school requests referral for
evaluation in writing.
Referral School explains referral process to parent. Parents receive copy of parents rights. Parents give
permission for testing.
Evaluation Parents participate in and contribute to team evaluation activities. School completes evaluation
and team determines eligibility for special education services.
IEP meeting Parents participate in IEP activities. Evaluation team jointly develops IEP. Parent gives consent
for placement to receive special education services which will enable child to participate in
general education curriculum.
Annual review School and parents review childs progress and current IEP.
Reevaluation School initiates reevaluation every three years. Parents initiate sooner needs of child change.
Independent Parent has a right to an independent evaluation if there is a disagreement over the evaluation.
educational School may initiate due process if evaluation team believes the evaluation is fair and
evaluation accurate.

IEP, Individual education program. Adapted from Ohio Department of Education Office for Exceptional Children: Whose Idea
Is This? A Resource Guide for Parents. Columbus, OH: Ohio Department of Education, 2004.

Schools must by law provide an MFE for any child Once a child is enrolled in special education, the
suspected of having a disability. The referral may be school district is obliged to conduct an annual review
made by the parents, school personnel, or community of the childs progress and notify parents of current
agency personnel. If parents are making the referral, IEP goals. A reevaluation by the school district is
they should do so in writing, indicating that they required every three years. Parents should be notified
suspect that their child has a disability and requires an of and informed about this process.
MFE. If the school district refers the child, the parents In summary, children with disabilities have a
must be contacted by the school and asked for their legal right to a free and appropriate education, and
consent to evaluate [3]. Prior to referral parents schools are legally obligated to meet these needs.
should expect the school to contact them to discuss Parents often require the support of mentors and pro-
the problem and obtain additional information. The fessionals to ensure that their childrens needs are in
school is also required to organize a team of profes- fact met.
sionals consisting of the parents, teachers, principal
and other school personnel such as the school psy-
The Evaluation
chologist or speech and language therapist, who might
help generate interventions strategies. If these strate- The purpose of the education evaluation is to collect
gies are not effective within a designated period, this the data necessary for determining eligibility for
team, often called an intervention-based assistance special education services and to identify specific learn-
team, then refers the child for an MFE. Schools some- ing needs and intervention strategies. Eligibility is ulti-
times ask professionals not part of the schools team, mately a procedural and legal decision that depends
including child psychiatrists or pediatricians, to assist on present levels of performance and standardized
in the problem-solving and evaluation process. If the data; the identification of specific learning needs re-
school requests this assistance, it is obliged to pay for quires additional data emphasizing an analysis of the
the service. If there is a disagreement over the evalua- students learning patterns, the school environment
tion, the parent has the right to an independent eval- and other social and cultural influences. Each com-
uation at the schools expense. Sometimes parents ponent of an educational evaluation should contain
decide to pursue an independent MFE rather than information necessary to help to determine eligibility
using services provided by the school. This is a legiti- but also to identify specific learning strategies. These
mate choice for parents, and the results must be con- components usually include background information,
sidered by the school, as long as the professionals have descriptive data, test data, and the educational plan
the appropriate certification or license in their specific (Figure 4.1).
discipline. In this situation, however, the parents are
obliged to cover the cost.
Background Information
The school is required to hold an IEP conference to
review the results of the MFE, determine eligibility for The background information in an evaluation includes
services, and plan an appropriate education program. school history, relevant medical history, the presenting
This meeting must include parents as joint decision problem, the duration of the problem, and the effect
makers. Parents may request other individuals to the problem has had on the childs development at
attend this meeting. These individuals may include home and in school. This information may be collected
professionals from outside the school who conducted from parents, teachers, and other professionals and
all or part of the MFE or who were involved in im- individuals involved in the care of the child. At this
plementing treatment programs namely tutors, child point in the process, the educational diagnostician
and adolescent psychiatrists, occupational or physical determines how parents, teachers, and the student each
therapists, and speech and language therapists. Parents perceive the problem. Do teachers perceive parents as
may also invite an advocate or mentor to help them helpful and supportive to the child and his or her learn-
deal with the educational system on behalf of their ing process? Do parents view the teachers and other
child. Advocates or mentors are available through school personnel as willing to adjust teaching strate-
parent or child advocacy programs in the community. gies to accommodate the child?
Many school districts are instituting parent mentor How does the child perceive his/her performance?
programs to help parents understand and effectively Can the student identify problems and possible solu-
access the IEP process. Special education regional tions? How have teachers and parents responded to the
resource centers exist in some areas and may also students school failure? Does the student view himself
provide advocates. to be in a hopeless situation? Differences in these per-

Background information Descriptive data Test data

Educational history Classroom observations Areas

Current problem Learning strategies Academic skills
Medical history Attitudes and dispositions Subject knowledge
Social factors Interview Learning strategies
Cultural factors Classroom teacher
School psychologist Instruments
Speech therapist Norm-referenced
Parents Criterion-referenced
Child Alternate and informal
Others methods

Educational plan
Differential instruction
Environmental adjustments
Behavioral intervention

Figure 4.1 Components of an educational evaluation.

ceptions may have a significant impact on the resolu- Depending on the presenting problem, information
tion of the problem. required for eligibility for special education services
emphasizes test performance in specific areas of aca-
demic, cognitive, language, and behavioral develop-
Test Data
ment. This information compares the child with others
An educational assessment usually includes both and is called norm-referenced. Information generated
norm- and criterion-referenced testing of academic from norm-referenced tests compares the childs per-
achievement, general knowledge, and specific skill formance to a group of children similar in age, grade
mastery. Most tests divide the academic areas of and sometimes other characteristics. Criterion-
reading, mathematics, and written language into dif- referenced tests, also standardized, identify a students
ferent components to allow a more thorough analysis mastery of specific skills based on an established
of the childs abilities. criterion usually aligned with classroom curriculum.
In addition to providing information about what the Criterion-referenced tests do not compare the child to
child knows the educational assessment also needs to a group of peers.
focus on how the child learns. This requires a careful Because criterion-referenced tests tend to be more
analysis of the results including the childs responses closely aligned with classroom curricula they allow
to content as well as different test requirements. For for a more detailed interpretation of the childs per-
example, some students do better on items that require formance than do norm-referenced tests. A norm-
a verbal response rather than timed, written responses. referenced test in reading and written language, for
If these types of responses are a theme throughout the example, may indicate that a childs performance in
assessment process, and also evident in the classroom, reading comprehension and written language is within
the educator can begin to identify effective learning two standard deviations below the mean. This infor-
strategies. Lerner (2003) states that when teachers help mation probably confirms the teachers concerns that
students acquire learning strategies, students learn how the child can read but is not comprehending or express-
to learn [2]. This, of course, is the ultimate goal of the ing thoughts well; it does not, however; identify learn-
educational evaluation. ing processes that might help the child or teacher to

better understand their performance. More specific What are peer interactions like in the school
analysis of reading comprehension and written lan- environment?
guage is necessary. In this instance, criterion- How do other students and the teacher respond to the
referenced tests can help the educator to better analyze childs performance?
the childs ability to manage specific aspects of the How is the child recognized in the classroom?
learning process required in the classroom. Is the child regarded as is a successful or unsuccessful
Although criterion-referenced tests do allow a more learner?
specific analysis of a childs performance, they may How frequently does the child receive positive feed-
also suggest solutions based on isolated skill deficits, back in the classroom?
thus neglecting the effect of other variables within the
learning environment. Additional data are required to Each source of information provides a different per-
adequately characterize a students learning and to ception of the problem, and information from all these
provide a more detailed analysis of the learning sources needs to be analyzed to identify the childs
process. learning problems, teaching approaches that might
enhance or obstruct learning and possible solutions.
The expectations and responses of all people involved
Descriptive Data must be understood if adjustments in the educational
program are to be successful.
Descriptive data help to identify the environmental
variables, teaching approaches, and other factors that
might be affecting a childs progress in school. The Educational Plan
data are usually collected via classroom observation
The final component of an educational evaluation is
and interviews with teachers, parents, and other spe-
the educational plan, which provides a framework for
cialists involved in the childs educational program.
generating solutions. In the case of a child with written
The child should also be included in this process and
language problems, for example, the educational diag-
provided the opportunity to contribute their percep-
nostician and the teacher must generate two solutions:
tion about the problem, its cause, and even possible
(1) a way to evaluate the childs knowledge of content
that does not employ a weak skill as the vehicle for
Classroom observation can provide information
testing, and (2) a plan to improve knowledge and,
about a childs behavior, attention, and general ability
where possible, deficient skills. In the past, solutions
to adapt to school expectations. The educational diag-
have focused on requiring the child to improve per-
nostician is interested in the childs ability to learn in
formance through remediation and, of course, try
the classroom. Understanding how material is pre-
harder without any significant environmental adjust-
sented to the child, how the child is requested to
ments. Creating a more accessible learning environ-
respond, how the child responds, and the attitudes
ment that emphasizes strengths and decreases negative
attached to the childs performance are all indicators
outcomes is crucial, however, if children with learning
of overall performance. For example, a child with a
problems are to succeed. Even with the appropriate
written language problem might be required to answer
intervention, some children will never totally correct
essay questions to pass tests in social studies. As a
these weaknesses and must instead learn how to com-
result of this testing procedure, the child will probably
pensate. Although children may have some ability to
fail. To generate effective intervention strategies, the
identify stumbling blocks in their learning environ-
educator must not only identify the childs ability in
ment, they are almost always powerless to change
social studies and written language but also under-
them. Adults must ensure that the necessary adjust-
stand the relationship between the two within the
ments occur.
structure of the classroom. All this may become appar-
When a child is referred for educational testing,
ent only after classroom observation and discussion
the problem has already been identified. Assessment
with the teacher, the child and the parents. Descriptive
should do more than confirm the referral question; it
data help to answer the following questions:
should identify skills or learning behaviors that are
Is the child motivated and interested in school? interfering with learning, as well as a set of effective
Is the child attentive in the classroom? learning strategies. The educational plan should iden-
Is homework and/or organization a problem? tify ways to adjust negative variables, introduce reme-
What is the childs attitude about school? diation, and emphasize possible variables to enhance
How does the child respond to discipline? learning. This purpose implies that intervention will

focus on implementing changes in the environment with diverse expertise to generate creative solutions
and in instruction. The most difficult aspect of this to mutually defined problems (p. 1 [7]). Such a model
approach is that persons other than the child may be allows teachers equal participation in a process that
expected to change and, consequently, that the childs will generate solutions for them to implement. Friend
progress may be dependent on changes in the and Cook (2000) further describe school consultation
environment. as a voluntary process where one professional assists
another to help a third (p. 73 [8]).
Historically, teachers have voluntarily sought in-
Consultation, Collaboration, and
formation from colleagues. The process of collabora-
Educational Planning
tion is complicated, however, when professionals from
Historically, the medical literature has described con- outside the school become involved in the process and
sultation as a process by which one physician requests in fact might initiate the process. Although these indi-
expert advice from another, usually pertaining to the viduals may have crucial information that needs to be
condition or situation of a patient [4]. In these situa- incorporated into the educational plan, effective results
tions the consultant providing the advice has assumed are dubious unless professionals understand teachers
no responsibility for the outcome but has merely expectations and roles within the configuration of the
shared knowledge. Although this is an accepted prac- school. In the hierarchy of professional competence,
tice in medicine, educators are attempting to approach physicians have historically been rated higher and
consultation as a process wherein teachers, parents, teachers lower than most other professionals. Teach-
and others involved with a child work jointly to solve ers, of course, have resented interference by physicians,
a problem. This usually involves adapting the learning who are viewed as more knowledgeable than them-
environment to better meet the specific needs of the selves yet are deficient in knowing how to teach chil-
child. It also emphasizes the need for professionals to dren. Many teachers return to their classrooms after
collaborate as a team to generate workable solutions planning meetings mumbling Id like to see them
that might involve joint responsibility for implementa- manage a class like this alone for just one day. The lack
tion and outcome a process called collaborative of support and professional respect has promoted
consultation. in teachers an attitude of suspicion of outsiders. The
psychiatrist must understand the process of collabora-
tion in schools as well as the various levels of compe-
School Dynamics and Collaborative Consultation
tence that exist. Some schools have established effective
The IDEA requires that a multifactored team assess collaborative intervention models, some are in the
the childs learning problems and develop intervention process of developing these models, and some have not
plans. Successful intervention, particularly in inclusive yet begun. Whatever the status of a school, the model
learning environments, requires that parents, adminis- of consultation used must be collaborative. IDEA, as
trators, support services, and teachers work together well as good educational practice, expects team
with the student to create a more effective learning collaboration.
environment All professionals involved in the care of To begin the process of collaboration, schools are
children, then, must understand the process of educa- required by law to hold an IEP meeting to review the
tional consultation and school dynamics. results of a multifactored assessment. Many schools
West and Idol defined consultation as a term used also establish teams to address the needs of a child who
across various disciplines to refer to some type of may not have been referred for a multifactored assess-
triadic relationship among consultants, consultees, and ment but who is experiencing learning or behavioral
clients or problems (p. 395 [5]). The expert consulta- problems. These teams provide a mechanism for teach-
tion model may be distinguished from the collabora- ers to discuss these problems with support personnel,
tive consultation model: the former refers to a type of parents and other teachers, and to collaboratively plan
consultation in which an expert, usually a school intervention strategies. It is fair to expect the childs
support professional such as a school psychologist, psychiatrist to also become a part of this problem-
analyzes the problem, evaluates options, and prescribes solving team. Although this meeting involves energy as
interventions for the teacher to implement [6]. His is well as time, the therapeutic process is augmented by
the model that many teachers have experienced, one in securing teacher cooperation and a formal method for
which they are given little input but all the responsi- problem solving in the school.
bility for change. Idol and colleagues defined collabo- Psychiatry, particularly child and adolescent psychi-
rative consultation as a process that enables people atry, is mysterious to the general public. Unless faced

with a child who requires the services of a child and ronment may require financial commitment and a
adolescent psychiatrist, most people are unfamiliar change in the schools perception of its responsibilities.
with the psychiatrists role in the care of children. As Parents make requests influenced by their perception
psychiatrists begin to interact with schools, they may of the childs problem in school, the schools legal
need to explain to school personnel their goals for the responsibilities to assist the child, the developmental
child and his or her family and intervention strategies issues affecting the childs performance, and their ulti-
such as therapy and medication. If medication is being mate goals for the child. Conflict arises when percep-
considered for treatment, psychiatrists should explain tions of the school and the family differ; resolution,
the medication and the expected outcome as they relate then, can occur only if both sides are able to jointly
to the overall treatment goals. They should emphasize address the childs learning needs and adjust environ-
the need for teachers to report behavioral changes in mental variables accordingly.
order to help determine the effectiveness of the medi- The planning process can sometimes be augmented
cation. It may help to provide teachers with a specific by inviting children to participate. Their interpretation
format or behavior checklist for collecting this infor- of the situation should be considered, even if they are
mation and to periodically contact them by phone. not present at the meeting, and their capacity to state
Establishing clear avenues of communication is their own educational needs should not automatically
crucial; whatever method is chosen, psychiatrists be dismissed. Children can often be helped in focusing
should be proactive in establishing communication on their school problems and beginning to identify
with teachers and other school personnel. Often, the intervention strategies that will help them succeed. If
most efficient way of achieving these goals and pro- the child does not wish to be present or is too young
viding the family with the appropriate support is to to understand the purpose of the meeting, the child
attend the IEP meeting. psychiatrist can be helpful in articulating the childs
The family as well as the child should play an equal perceptions of the problem and possible ideas about
part to that of the psychiatrist and the teacher in the the solution. Adolescents should definitely be given the
collaboration process. The IDEA actually requires that option to contribute to the planning process and, if
parents and the child become involved in the IEP comfortable, to be present at planning meetings. If the
assessment and planning process. This process is effec- adolescent is embarrassed to go to the office to be given
tive only if all members of the team appreciate the medication, or if the adolescent is teased about leaving
contribution of the family members and are skillful in class for tutoring, there is a good chance that he or she
including their participation. Many parents are proac- will not cooperate and the plan will fail. These proce-
tive and aggressively solicit intervention for their child; dures should be adjusted whenever possible to preserve
others, however, are timid and unfamiliar with their the childs dignity among his or her peers, because the
rights as parents and the capacity of their influence. success of any intervention program depends on the
Whatever the circumstances, the psychiatrist should cooperation of the child or adolescent.
facilitate the process of collaboration by helping
parents understand their childs needs, as well as the
Techniques of School Collaboration
roles of parents and the process of collaboration in the
problem-solving process. Successful communication with schools depends on
Whereas parents, teachers, and other professionals understanding the general administrative structure of
join together to plan educational programs for chil- schools as well as the function of individuals in the
dren, the child is often absent from the discussions. schools. Different problems require different adminis-
Young children, of course, are usually not able to con- trative authority, and knowledge about these lines of
tribute directly to this process and depend on the authority can be important (Table 4.2). Issues that
parents and others involved to represent their best focus on curriculum and adjustment in the classroom
interests. As Friend (2000) explains, the child, not a or school are generally managed by the teacher and the
direct participant in the interaction is the beneficiary principal. If a teacher is resistant to adjusting class-
of the process (p. 73 [8]). This is an interesting situa- room procedures or using a curriculum agreed on by
tion, since most professionals and parents believe that the planning team, this problem becomes the princi-
they are acting on behalf of the child but may in fact pals responsibility. Issues involving finances or the
have other agendas. Schools are affected by financial implementation of legislative mandates, including
boundaries and legislative mandates as well as their referral, evaluation, and eligibility for services, are
responsibility to accommodate the needs of an indi- responsibilities of the director of special education and
vidual child. Accommodations to the learning envi- the superintendent. Principals control building issues

Table 4.2 The function of school personnel in resolv- be knowledgeable about special education procedures
ing school issues. and services, including the referral process and legisla-
tive mandates, the director of special education may
School personnel Issue(s) need to be contacted directly. The superintendent is, of
course, responsible for all activities in the school dis-
Principal School entry trict and should be contacted if other administrators
Principal and teacher Classroom issues are unresponsive to the educational needs of a child.
Curriculum In practice, collaboration with a school is seldom
Instruction successful without the wholehearted support of the
Environmental principal.
variables For child psychiatrists, the most important part of
Support services School adjustment collaboration with schools is to participate as much as
School psychologists Referral and possible. Whatever the situation, open communication
Speech/language assessment with the school is important. Schools should be aware
therapist Behavior management of the psychiatrists involvement with the child, and the
Reading specialist Individualized psychiatrist should be aware of the childs performance
OT/PT intervention and adjustment to the school environment. The psy-
Administration personnel Procedural issues chiatrist must willingly share information with the
Principal Eligibility for special school but at the same time help the child and his or
Pupil personnel director services her family separate those issues that should be dis-
Superintendent Due process cussed with the school and those that should remain
procedures confidential. Children often have a clear perception of
School safety the things they would like teachers to know or not
Quality control know about them. The psychiatrist can become an
Curriculum guidelines important conduit between the child, family members,
and the school. This role, if supportive to all people
involved, can have a positive effect on the problem-
solving process.
The child psychiatrist should remember the follow-
and the functions of the school intervention or child ing rules when collaborating with schools.
study team; the director of special education, however,
becomes involved when a child is suspected of having
initiate contact with the school
a developmental disability that would qualify him or
share information
her for special education services.
explain your role
Contact with the school should generally begin with
represent the childs perspectives
the school principal. The principal should introduce
request school evaluation data
professionals from outside the school to the teacher,
expect team effort in problem solving
clarify the role of these professionals, and ensure that
expect parents to collaborate as team members
communication with the teacher has been authorized
be a team member
by the parents or guardian. It is important for out-
siders to understand that the principal establishes the
culture of the school building. This does not mean that
the principal obstructs contact between teachers and References
outside professionals, rather that he or she is aware of
individuals contacting teachers and monitors these 1. Stiggins R: Student-Involved Assessment For Learning.
contacts, particularly if he or she is concerned about Upper SaddleRiver, New Jersey: Pearson Merrill Prentice
Hall, 2005.
the ability of a teacher to interact appropriately. Thus 2. Lerner J: Learning Disabilities Theories, Diagnosis, and
failure to contact the principal before communicating Teaching Strategies. Boston, MA: Houghton Mifflin
with a teacher can be an irreparable mistake. The prin- Company, 2003.
cipal also arranges for the involvement of the director 3. Ohio Department of Education: Whose Idea Is This? A
Resource Guide for Parents. Columbus, OH: Ohio Depart-
of special education and other school support person- ment of Education, 2004.
nel (e.g., the school psychologist or a speech and lan- 4. Caplan G: The Theory and Practice of Mental Health Con-
guage pathologist). If a principal does not appear to sultation. New York: Basic Books, 1970.

5. West FJ, Idol L: School consultation. Part 1: An inter- 7. Idol L, Paolucci-Whitcomb P, Nevin A: Collaborative
disciplinary perspective on theory, models, and research. Consultation. Rockville, MD: Aspen Publishers, 1986.
J Learn Disab 1987; 20(7):388408. 8. Friend M, Cook L: Interactions-Collaboration Skills
6. Reeve PT, Hallan DP: Practical questions about collabo- for School Professionals, 3rd ed. New York: Longman,
ration between general and special educators. Focus 2000.
Except Child 1994; 26(7):111.
Psychiatric Assessment in Medically Ill
Children, Including Children with HIV
David M. Rube, G. Oana Costea

Introduction refusing visitors. He was belligerent through-

out the day and consistently removed IVs. The
The majority of children with chronic medical prob-
consultation was held to evaluate Stephens
lems do not have a psychiatric illness. However, the risk
behavior. On examination, Stephen met crite-
for psychological and social adjustment problems in
ria for a depressive disorder with associated
those children is approximately twice the risk of
anxiety symptoms. Individual psychotherapy
healthy children. Additionally, comorbid psychiatric
and a trial of fluoxetine were initiated. Psy-
and pediatric medical problems contribute to increased
chotherapy entailed play, drawing, story-
health care costs, less satisfactory outcomes, and
telling and also distraction and relaxation
increased diagnostic uncertainty. The consultation-
techniques to help him cope with the proce-
liaison child psychiatrists role is to help educate the
dures. Areas of focus included: education
pediatric colleagues about the comorbidity of medical
about his illness, the effects of his cancer and
and psychiatric disorders, the importance of psychi-
its treatment on body image, issues of life,
atric consultation and to work as part of the multidis-
death and grief, at a developmentally appro-
ciplinary team in order to provide comprehensive care
priate level. Gradually, Stephen was noted to
for these children. This chapter examines the: (1) epi-
be more upbeat, cooperative, pleasant, more
demiology and characteristics of psychiatric disorders
open to procedures, and more emotionally
in medically ill children; (2) reasons for psychiatric
open to discuss his medical condition. He
consultation; (3) psychiatric assessment; (4) psychiatric
started to interact more appropriately with
sequelae of chronic medical problems; and (5) pedi-
physicians and staff and was more able to talk
atric HIV infection including epidemiology, neuro-
about death and dying to his parents and
developmental and psychological manifestations,
psychiatric assessment and treatment considerations.
Illustrative clinical cases are included.


A psychiatric consultation was received for During her second hospital admission for an
Stephen, a nine-year-old boy with stomach evaluation of abnormal wheezing, Sarah, a 12-
cancer. The hematology/oncology team and year-old girl, underwent a psychiatric consult.
the nursing staff found Stephen to be belliger- An extensive workup for wheezing, including
ent and aggressive during medical proce- X-rays, sweat tests, and a computed tomogra-
dures. During off hours he would be found phy (CT) scan, all proved negative. The only
in his room in the dark with the shades pulled, procedure that helped Sarah not wheeze was

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

lying recumbent. A psychiatric consultation setting. In this chapter, we discuss the epidemiology
was requested to elucidate any psychiatric and characteristics of psychiatric disorders and diag-
factors that might be contributing to Sarahs nostic dilemmas in the medically ill child. We follow
medical condition. After interviews with this with discussions of the consultation and assess-
Sarah and her parents, the physician found no ment process and the psychiatric sequelae of chronic
evidence of depression, hypochondriasis, or medical problems. We conclude with pediatric HIV
any reported anxiety symptoms. During the infection including epidemiology, neurodevelopmental
interview, Sarah described an adult supervisor and psychological manifestations along with the psy-
at recess who had been harassing her on the chiatric assessment and treatment considerations in
playground. This harassment consisted of this patient population.
teasing as well as telling other girls not to play
with Sarah. The parents had brought this issue Epidemiology
to the local school board but had received little
assistance. Sarah had made a presentation and Consultation-liaison child psychiatrists work with
written a letter to the school board herself their pediatric colleagues to convey to them the impor-
describing this harassment. It was about that tance of psychiatric consultation. When we assume the
time that Sarahs wheezing began. A school role of a consultant, we should help our pediatric col-
consultation was initiated by Sarahs psy- leagues by informing them of the data that exist
chiatric consultant. The harassment ended regarding the comorbidity of medical and psychiatric
and so did Sarahs wheezing. disorders. The majority of children with chronic
medical problems do not have a psychiatric illness.
Reports indicate, however, that the risk for psycholog-
ical and social adjustment problems in children with
These two cases illustrate the necessity and importance chronic medical problems is about twofold compared
of the appropriate use of psychiatric consultation in with the risk of healthy children [57]. Emotional and
the pediatric population. One- to two-thirds of in- behavioral problems have been found to affect 1820%
patient pediatric patients have to cope with psycho- of children in pediatric primary care practice [8] while
logical issues [1,2] and could potentially benefit from estimates of psychological morbidity associated with
psychiatric consultation. Chronic physical illness chronic illness in childhood range from 10 to 30% [1].
appears to be a significant risk factor for emotional Ten to 15% of the population under 18 years of age
and behavioral difficulties, while emotional, behavioral has chronic medical problems. A Swedish primary care
and family difficulties can negatively affect the course district, however, estimated the prevalence of chronic
of physical disease [3]. In addition, comorbid psychi- illness in childhood to be 6% [9]. In the Isle of Wight
atric and pediatric medical problems contribute to Survey, 6% of the population had chronic physical ill-
increased health care costs, less satisfactory outcomes, nesses [10]. In the latter study, Rutter and colleagues
and increased diagnostic uncertainty [4]. In this day of found that the prevalence of child psychiatric disorders
children who survive severe medical illnesses such as in the general population was 7% and that the preva-
leukemia, who undergo transplantation (e.g., cardiac, lence of psychiatric conditions in children with chronic
liver, lung, bone marrow), and who live with chronic physical illnesses was 12% (illnesses without brain
illnesses for much longer than previously (e.g., cystic lesions) and 34% (illnesses with brain lesions).
fibrosis, diabetes mellitus, infection with the human The National Survey of Health Development in
immunodeficiency virus HIV), psychiatric sequelae are England, Wales, and Scotland and the Rochester Child
common. It is incumbent on child and adolescent psy- Health Survey showed that the prevalence of chronic
chiatrists to work in collaboration with pediatricians medical problems ranges from 10 to 20% [11]. The
in an effort to provide comprehensive care for these former survey observed that 25% of physically ill chil-
children. dren younger than 15 years of age had two or more
Traditionally, consultation-liaison child psychiatry symptoms of behavior disorder, compared to 17% of
has taken place on pediatric wards and in hospital the healthy population [11]. Similarly, the Rochester
units. The influence of managed care, however, has survey showed that the rates of behavior problems in
shortened hospital stays, and more care is now being the chronically ill children were consistently higher
provided in the outpatient setting as well as in the than in healthy children and were reflected in behav-
home or day hospital. This implies that consultation- iors such as a poor attitude toward school and truancy
liaison must adapt to the outpatient and homecare [12,13]. Additionally, studies showed higher frequency

of oppositional disorder and conduct disorder in chil- [15]. Additionally, a meta-analysis of depression in chil-
dren with cystic fibrosis compared with children with dren with chronic medical conditions showed higher
sickle cell disease. The treatment regimen for cystic rates of depression in children with asthma and sickle
fibrosis being highly demanding and involving daily cell anemia as compare with children with cancer. The
numerous medications and chest physical therapy may unpredictable and long-term course of those illnesses
contribute to this difference [14]. may potentially explain the difference [16].
Different theories attempt to explain this comorbid- Adolescent females with chronic medical conditions
ity and to identify factors that account for the variabil- were found to have greater emotional problems,
ity in the psychological adjustment of children with depression, sadness, anhedonia, and suicidal thoughts
chronic illness. Reports have described risk factors at than were adolescent males with chronic medical con-
multiple levels that can impede the psychological ditions [17]. However, male gender may potentially
adjustment to chronic illness (Table 5.1). In this regard, pose a higher risk of emotional problems as suggested
studies suggest that severe asthma, inflammatory bowel by the immunoreactive theory [8]. It is hypothesized
disease (Crohn disease or ulcerative colitis) and dia- that males are selectively afflicted with neurodevelop-
betes may have specifically elevated rates of depression mental and psychiatric disorders of childhood and this
may relate to the relative antigenicity of the male fetus
which may induce a state of maternal immunoreactiv-
Table 5.1 Risk factors affecting psychological adjust- ity leading to fetal damage [57]. There are protective
ment in medically ill children. factors as well. Childrens personal strengths, whether
in academia, sports, music or interpersonal skills could
Illness related factors [1,8,14,19,20] help maintain self-esteem and build important rela-
1. Frequent or chronic pain (e.g., sickle cell tionships [1]. The coping style confrontation charac-
disease) terized by active and purposeful problem solving along
2. Brain dysfunction as a result of illness or with seeking social support were found to be related to
treatment positive psychosocial functioning [18]. Additionally,
3. Physical disability (e.g., decreased exercise family flexibility, positive meanings ascribe to the con-
endurance in advancing cystic fibrosis) dition, social integration, good communication, clear
4. Invisible condition boundaries, support network in the community appear
5. Uncertain prognosis to be also protective [19].
6. Multiple hospitalizations The epidemiologic evidence indicates a role for
7. Intrusive care routines (e.g., numerous liaison to medical subspecialties to educate other
medication and chest physical therapy in physicians about psychiatric disturbances that may
cystic fibrosis) become evident in their patients. Since not all children
8. Dietary restrictions (e.g., diabetes) develop psychiatric symptoms, baseline evaluations or
screening devices are needed to clarify which children
Patient related factors [8,18,19,20] and families are at risk. The Pediatric Symptom
1. Young age Checklist developed by Jellinek and Murphy has been
2. Male gender (immunoreactive theory) shown to be a helpful, user-friendly screening device
3. Genetic loading for pediatricians and pediatric residents [21]. Jones and
4. History of psychiatric illness colleagues recommend the Pediatric Symptom Check-
5. Insecure attachments list to routinely screen all pediatric patients and, for
6. Difficult temperament those patients who meet the cut-off criteria, then using
7. Low self-esteem the Child Behavior Checklist [22]. This approach there-
8. Coping style with depressive behavior in fore provides an efficient means of screening for and
reaction to daily problems then identifying child psychosocial problems in general
Family related factors [1,8,20] pediatric populations.
1. Single parent
2. Low family income
3. Parental anxiety, anger, sadness, guilt, blame The Consultative Process and Assessment
4. History of psychiatric illness Reasons for Consultation
5. Poor family support
6. Inadequate parenting Consultation-liaison child psychiatrists, like other
pediatric subspecialists, are called to consult on chal-

lenging or difficult cases. The most common reasons Table 5.2 Common reasons for child and adolescent
for psychiatric consultation encountered in major aca- psychiatric consultation [23,24].
demic centers and tertiary care hospitals are presented
in Table 5.2. 1. Emergencies (e.g., suicide attempts, mental status
2. Differential diagnosis of somatoform symptoms
Five Fundamental Questions
3. Collaborative care of children with stress-
Question l sensitive illnesses
4. Diagnosis and care of children with psychiatric
Is this patient safe to himself or herself or others in the
symptoms following a somatic illness
current treatment setting?
5. Chronic illness (e.g., major depression in a
The issues that may drive this question arise from
patient with cystic fibrosis)
individuals who attempt suicide and who may then
6. Reactions to major pediatric treatment
need to be hospitalized for medical treatment in the
techniques (e.g., post-traumatic stress disorder
intensive care unit (ICU) or on the general pediatric
following stem cell transplantation)
unit and may also require one-on-one intensive super-
7. Reactions to pediatric illnesses
vision. Other examples of this question may be the
8. The childs reaction to his or her illness and
child who develops delirium and has visual or auditory
9. Nonadherence to medical plan
10. Family assessments
11. Pretransplant (e.g., cardiac, liver, bone marrow)
psychiatric evaluation
Nancy is a 12-year-old girl with a previous
medical history of Burkitts lymphoma, which
was treated approximately three years prior to
the consultation and was currently in remis- assessment of the childs suicide attempt, as well as the
sion. She came to the childrens hospital emer- presence of a major psychiatric disorder.
gency department (ED) after having a seizure.
She was loaded with phenytoin in the ED and
Question 2
became highly agitated and needed restraints.
She professed to see airplanes going through Why is our patient not cooperating with treatment?
her room and stated that she had to follow This consultative question is seen in numerous areas,
them, even if it meant jumping out the e.g., the cancer patient who is extremely anxious and
window to get them. A psychiatric consulta- fearful around medical procedures, the diabetic child
tion was called to best evaluate where in the who is noncompliant, and the depressed mother who
hospital this patient should be placed and to has trouble following directions from the nursing staff.
help manage her delirium. The differential diagnosis of noncompliance with
treatment is broad and includes the following
behaviors or characteristics:
inability to understand directions
Another example in which this question is pertinent lack of education
is with a child who in the hospital manifests severe opposition and defiance
behavioral dyscontrol that interferes with his or her developmental issues (IQ, PDD, etc.)
treatment. This often takes the form of hyperactivity a passive wish to die
and aggressive behavior to the staff and other patients. anxiety
A corollary to this question is, What is the next treat- depression
ment setting for this patient? This latter question is denial of illness
particularly important for individuals who have passive vs. active coping style [1]
attempted suicide. Referral to an inpatient psychiatric embarrassment vs. pride with respect to self-care [1]
setting, an outpatient mental health agency, or private limited family or peer support [1]
psychiatric practice depends on the nature and the relationship with medical providers [1]

All of the above phenomena confront general pedia- headaches

tricians in their practice on a daily basis. Our liaison recurrent abdominal pain
work, therefore, must focus increasingly, in view of the limb pain
shorter hospital stays, on teaching our pediatric col- chest pain
leagues to ask the appropriate questions to achieve the fatigue [8]
right answers.
Additionally, patients could present with complex
syndromes involving both medical or neurological
and somatoform symptoms (e.g., a patient with both
seizures and pseudoseizures). Many parents with chil-
dren present with these medical complaints are fearful
Amber was a 16-year-old girl who was admit- of possible psychiatric consultation. As a result, there
ted to the diabetic service in a coma caused can be a relentless and aggressive medical workup. The
by diabetic ketoacidosis. Five days prior to primary fear of the child or family is that they are not
admission she had refused all laboratory tests being taken seriously or that nobody believes them.
during a clinic visit when she stated, Im fine The fear of calling a psychiatric consultation is that the
and I dont care. The patient had a long physician might think, It is all in your head or, I think
history of noncompliance with her diabetic youre crazy. The primary care physician fears losing
regimen. A psychiatric consultation was the alliance developed with the family.
requested to evaluate Ambers noncompli-
ance. During the assessment Amber admitted
to being embarrassed by her illness and avoid-
ing social contact. She stated that she slept CASE FIVE
most of the day, was truant from school,
couldnt concentrate, had little energy, and A seven-year-old hyperactive child had a joint
was anhedonic. Although she was not actively in his toe removed due to osteomyelitis and
suicidal, she was aware that noncompliance appeared despondent. The mother refused a
could lead to death. A diagnosis of major psychiatric consultation but agreed to let a
depression was made, with a recommendation third-year medical student pediatric clerk
for antidepressant medication and a trial of work with the boy. The clerk was supervised
brief psychotherapy. The patient was agree- on various techniques to engage the child and
able to this plan. Psychotherapy sessions establish rapport with the mother. On dis-
focused on psychoeducation regarding dia- charge, the mother arranged an appointment
betes and its treatment and the impact of with a child psychiatrist.
illness on her social, academic and family
functioning. Cognitive behavioral interven-
tions were employed to address her depresso-
The consultants goal is twofold: to consult with the
genic cognitions and promote behavioral
primary care physician on how to best approach the
activation. Her mood symptoms gradually
patient, and to be empathic with the patient and his or
improved and there was subsequent improve-
her family in their frustration with not getting answers.
ment in her diabetic symptoms.
A common approach is to present the psychiatric con-
sultants role as an adjunct to ongoing medical care, to
help the child cope with the chronic symptoms inter-
fering with his functioning, the stress of being in the
Question 3
hospital or the frustration of not finding the answer.
This patient has had an extensive and expensive Interaction with families should be supportive and
medical workup that has yielded no findings. Is there nonconfrontational, hopefully to begin the process of
a psychological or psychiatric reason for the patients forming a therapeutic alliance that will allow the con-
medical symptoms? sultant to make recommendations to the family and
Studies of somatization in children showed that primary care physician. It is essential in the assessment
medically unexplained physical symptoms are of such cases to view the physical symptoms as real
common in childhood and include in descending even if they seem to be occurring in the context of
order of frequency: stress or psychiatric illness. These children are gener-

ally not faking or malingering and the symptoms This question is generally posed by parents to their
are as real to them as the physical symptoms from a primary care physicians, especially in the face of
medical illness [25]. chronic illness. At times, parents will state that they are
concerned that their child is having difficulty adjusting
to a new diagnosis or may be suffering from depres-
sion as a result of treatment or the news of the diag-
CASE SIX nosis of a chronic illness. Or it may be a subtle request
Jane is a 15-year-old girl diagnosed as idio- for the parents or other family members themselves,
pathic pain syndrome fibromyalgia at age 11, who may be experiencing difficulty adjusting to their
re-admitted to the pediatric ward for further childs chronic illness. Often, parents request that the
assessment and recommendations. The pres- patients siblings or other family members be informed
entation at age 11 included abdominal and about their loved ones medical problems. As previ-
joint pain, migraines and fever followed there- ously noted, disturbances requiring psychiatric atten-
after by multiple episodes of joint pain of tion are manifest in a greater proportion of chronically
increasing severity and duration. The current medically ill patients and their families than in healthy
episode of one year includes right leg pain and children. This is extremely important in the context of
shakiness, only present upon weight bearing managed care, in which sicker and more unstable
and absent when lying down, leading to a sig- patients are at times the only patients on a hospital unit
nificant walking impairment and a subse- or ICU.
quent need to use a walker for assistance. For Parents sometimes request a psychiatric consulta-
the last year she has been home schooled. tion to discuss how to tell their child bad news, or to
There is a history of multiple failed treatment prepare the child for medical procedures. The child
interventions including medication trials (e.g., psychiatric consultant is uniquely qualified to give the
analgesics, antidepressants), inpatient and parents developmental guidelines with which to
outpatient rehabilitation, homeopathic treat- discuss these issues with their children.
ment with acupuncture. A psychiatric con-
sultation was requested to evaluate the
Question 5
underlying psychosocial factors for Janes
presentation and rule out the presence of a This patient has an end-stage organ disease and would
depressive condition. require a pre-transplant psychiatric evaluation as part
of the multidisciplinary transplantation assessment.
Solid organ transplantation has become recognized
as a legitimate treatment for many types of end-stage
The above question is also relevant to cases in which organ failures. Hence, this question is frequently
both psychiatric treatment and medical treatment are encountered by the psychiatric consultant in major
necessary, as in diseases such as anorexia nervosa or academic centers where he or she is a member of the
bulimia nervosa. With the number of eating disorder multidisciplinary transplantation team. The consul-
units decreasing, hospitals are administering more tants role is to conduct a thorough evaluation of the
medical and psychiatric care for anorexia and bulimia child and family with an emphasis on identifying psy-
nervosa on the general pediatric unit. Medical hospi- chopathology, potential risk factors for adjustment
talization is usually prompted by a rapid or profound reactions or nonadherence to treatment and the ade-
weight loss, cardiovascular abnormalities, electrolyte quacy of social supports [26].
imbalance, hypothermia and may represent a failure of
outpatient psychotherapy [1]. The psychiatric consul-
tants role is to jump start the psychiatric treatment Assessment
for these patients and make recommendations regard-
1 Consultative Question
ing the level of psychiatric intervention after medical
stabilization. A significant challenge for the consultant is determin-
ing and often narrowing the question raised by the
primary care team framing the consultative question.
Question 4
When training for this specific task, the students and
I think my child is having a hard time since her diag- residents can be given clinical vignettes and asked to
nosis. Can you please send someone to talk with her? arrive at the consultative question. Training our future

colleagues to ask appropriate consultative questions clinical practice, the primary care teams responsibility
will help teach them how to best work with their con- is to inform the patient and help the family obtain
sultants, and it will help us as psychiatric consultants authorization for a mental health consultation through
to best fulfill our responsibilities to the treatment team third-party carriers.
and to the patient and family. An important compo-
nent of an appropriate consultative request is to ascer-
3 Medical Record Review
tain who is asking the question. This helps focus the
intervention and recommendations of the consultant. It is imperative that the consultant be thoroughly
The following case illustrates this point. informed about the childs medical condition, the treat-
ment of this condition, and the related side effects of
treatment. The patients laboratory values, electrocar-
diograms, and medications, etc., need to be reviewed
CASE SEVEN thoroughly. A major component often lacking in psy-
chiatricpediatric collaboration has been communica-
Mark was a six-year-old boy who was admit-
tion. Stereotypes of psychiatrists depict them as
ted to the burn unit after spilling hot water on
impractical, unavailable, and not knowledgeable about
most of his body. Prior to this hospitalization,
medical illnesses and their treatment [27]. As psychia-
Mark was completely toilet trained and was
trists, we can debate whether this is appropriate or not;
progressing in his development. During his
however, these are the impressions that consultation-
hospitalization on the burn unit, he received
liaison psychiatrists face every day. Being aware of all
numerous procedures and operations, includ-
the medical issues ensures that the pediatrician and the
ing skin grafts. He became enuretic and enco-
consulting psychiatrist speak the same language and
pretic in his bed. A psychiatric consultation
thus provide the patient with the best service. In addi-
was ordered when the patient became enco-
tion, the best way to collaborate is to be familiar with
pretic in the middle of the hospital unit. It
each others work. An important finding is that child
became clear throughout the consultative
psychiatrists and pediatricians are better able to col-
process that the consult was requested by the
laborate when they have been trained in a setting in
charge nurse and the nursing staff, for they
which they worked together [28]. Working together is
had to clean up after the child. The consultant
illustrated by the next case.
worked with the staff to institute a behavioral
program to help the child regain control and
limit his regression.

In addition, it is helpful to clarify who the identi- A psychiatric resident was called to the ICU to
fied patient and who the real patient are. For evaluate a schizophrenic teenager who was
example, this question is critical when diagnoses such still psychotic, despite what appeared to be
as a failure to thrive or Munchausen syndrome by adequate antipsychotic treatment. The patient
proxy are being considered in the differential diagno- was being treated for multiple infections and
sis of the consultative request. was intermittently in septic shock. On review
of the patients chart, the consultant noticed
2 Consent of the Parent and Assent of the Child that the patients blood cultures revealed that
her current antibiotic therapy was inadequate.
It is imperative that the team requesting the consult A recommendation was made that the anti-
notify the family (in the form of a request) of the need biotics be changed and psychiatric follow-up
for psychiatric consultation and also inform the child conducted as needed.
that someone will be coming to talk with him or her.
This is an area in which residents and medical students
are fearful of patient reactions and need help in being
able to discuss the potential for psychiatric problems
4 Psychiatric interview
with the parents of their patients. An appointment is
scheduled with the parents so that the consultation can In Chapter 2, the details of the psychological
be completed, as quickly as possible. At this stage of assessment are discussed; however, the special con-

siderations needed to evaluate a child with a medical 5 Discussion of the Findings with the
condition are highlighted here. First, the psychiatrist Referring Team
should directly observe the patient and conduct an
Once the assessment is completed it is helpful for the
initial observation of the patients status, regardless of
consultant to discuss the findings directly with the
whether his or her family members are staying
team or physician calling the consultation. This allows
overnight or are available for the appointment or where
the consultant to fill in the gaps between the parental
the patient is located (such as the day hospital,
and the child interview. This will also allow the con-
inpatient unit, ICU step-down unit, and burn unit).
sultant to tailor psychiatric interventions that may be
This provides a rapid assessment of the patients
necessary and that are practical for this particular
medical needs at the time of consultation. Is the
patient, family, and treatment team and the medical
patient in bed, awake, alert, interacting with staff,
setting in which the patient is found.
watching television, playing games, or engaging in
childlike activities? Is the child demonstrating that he
or she is in pain? In general, for school-age children up
to age 11 years, the consultant should meet with Report and Recommendations
the parents first. The parents should be asked if
Our general medical and pediatric colleagues have
their physician or treatment team requested this con-
reported over time that, although they appreciate
sultation and whether they were aware of it, or whether
detailed psychological and psychiatric reports, they
they requested the consultation themselves. It is impor-
find practical and concrete suggestions and recom-
tant to ascertain the goals of the evaluation early
mendations for their patients to be the most helpful. It
in the process. A full history of the medical episode
is not helpful, then, to submit a long report with only
as well as a psychiatric review of systems, family
short, possibly unclear, recommendations. With those
history, social developmental history, current living sit-
considerations in mind, a consultation report could be
uation, and school performance is obtained from the
designed as follows:
Based on the information gathered from the treat- (1) Reason for consultation
ment team and the parents, the next step in the con- (2) Patients identifying data (age, gender, race, level
sultation is interviewing the child. The interview is of education, living arrangements, household and
generally briefer as the child could be too weak, irri- family structure)
table due to being ill and to tolerate a lengthy exami- (3) Sources of information (e.g., patient, family
nation [29]. In addition to conducting the general child members, friends, medical records).
psychiatric evaluation and mental status examination, (4) History of present illness:
the physician should direct special attention to the brief summary of the current medical condition
feelings and reactions toward the child by the family and treatment
(such as overprotective, distant, or fearful) and the psychiatric review of systems with pertinent
childs understanding of his or her own illness; the positives and negatives; onset, duration and
identification of any fantasy about the cause of course of the psychiatric symptoms relative to
illness is critical. It is important to know what the child the course of the medical condition
experiences and their perceptions of their medical con- recent psychosocial stressors
dition. The child may have fantasies of what caused (5) Past psychiatric history
their illness i.e., punishment, etc., which would be (6) Family history
important in assessing the patient. Assessing how well (7) Social/developmental history
family members are coping with the childs illness is (8) Medical/surgical history
also significant. Studies have measured the childs (9) Current medication, laboratory data, vital signs
ability to cope and assessed what type of coping (10) Mental status examination including the assess-
strategies children use to deal with their illnesses ment of cognitive function
[30,31]. This coping ability is especially important for (11) Assessment and diagnosis
children with chronic illness and their families. A (12) Plan and recommendations: will address the
thorough understanding of the patients and familys specifics of the consultation request and will
coping strategies and defense mechanisms yields include specific, concrete recommendations in
important information on how they cope with ongoing nonpsychiatric jargon and follow up, presented in
treatment and improvement or worsening of the list form and in decreasing order of importance;
medical condition. patients safety must be addressed first.

Table 5.3 Characteristics of an effective consultant The consultation-liaison psychiatrist may help the
and consultation. treatment team explain and educate about a newly
diagnosed illness. A psychiatric consultation may be
1. Available called to evaluate the educational level or develop-
2. Knowledgeable regarding medical issues mental level of a family, patient, or child and to assist
3. Communicative the treatment team in explaining the childs illness in a
4. Gives practical recommendations in non way that can be more easily understood.
psychiatric jargon (3) Developmental sequelae of chronic medical
5. Provides or arranges outpatient or ongoing follow illness. Children need to be children. The goal of treat-
up ing pediatric illnesses is to keep or return a particular
child and family to their normal developmental tra-
The psychiatric consultant must remain involved with jectory. Having an illness that results in multiple
the patients care throughout both hospitalization and hospitalizations, clinic visits, injections, breathing
follow-up to the outpatient setting, if indicated. The treatments, physical changes such as hair loss, and
psychiatric consultant should keep the patients other effects of medical problems or their treatments
primary care physician informed of the type of treat- can change the way a child views his or her body and
ment and its specific mode and goals. In our experi- his/her self-esteem. It can also alter academic potential
ence, pediatricians rarely receive these types of calls. because of absence from school or cognitive changes.
The parents of the children appreciate that their childs Sometimes these children have difficulty with peers
psychiatric care is being discussed with their primary who lack understanding about them and their medical
care physician. Table 5.3 summarizes the characteris- problem.
tics of an effective consultant and consultation.

Psychiatric Aspects of Chronic Medical Illness CASE TEN

The psychiatric aspects of chronic medical illnesses Billy was an eight-year-old boy diagnosed
are well documented [20,3234]. A few additional with rhabdomyosarcoma of his finger, which
points need to be made, especially for the child psy- required amputation. He did not want to leave
chiatry/psychology trainee that must be assessed. (1) the hospital on discharge, and a psychiatric
Does the illness or its treatment, such as brain tumor, consultant was called. During the evaluation,
diabetic ketoacidosis, or steroids, affect the brain? (2) it became clear that the patient was fearful of
What is the patients knowledge and information leaving the hospital because he did not know
regarding his or her illness? how to hold a baseball bat after his surgery. He
was afraid that other kids would make fun of
him. The consultant worked with the child
CASE NINE and his father, as did physical and occupa-
tional therapists, to show Billy how to hold a
Anna was an 18-year-old female who had had baseball bat.
diabetes mellitus since the age of eight years.
She had been repeatedly hospitalized for non-
compliance. During the evaluation, the psy-
chiatry resident discovered that the patient (4) Family dynamics. As is true with all child psy-
had little knowledge and understanding of chiatric assessments, careful attention must be directed
her illness. During the consultation and to the family, both immediate and extended, of a child
therapy sessions, the resident explained in with a chronic medical illness. Illness can change the
detail about diabetes, insulin, the pancreas, family milieu, due to parents staying with the child,
hormones, and other aspects of the illness. The possibly taking, time off from work, and losing
patient began to show more interest in caring income. Family sessions may be needed to help a
for herself after these sessions. She actively family adjust. Marital issues may arise owing to the
sought out the diabetic educator as well as extra strain of caring for a medically ill child. At times
other patients who had diabetes and began to it is up to the psychiatric consultant to remind these
take an active interest in diabetic control. parents to spend time together to keep the marriage
and family functioning. Siblings also need attention

from the treatment team and the psychiatric consult- Pediatric HIV Infection
ant to discuss issues about their ill brother or sister and
their feelings regarding family changes.
(5) Education of allied professionals. In these days Worldwide 38 million people were living with
of managed care and short hospital stays, it is imper- HIV/AIDS in 2003 and almost five million people
ative that treatment teams have in-services regarding acquired the virus, a rate that is higher than any year
the psychiatric review of systems. As previously men- before [35]. The new infections emerged particularly in
tioned, medically ill children report more psychiatric women and children. By the end of 1999, 1.2 million
symptoms than do well children [1012]. It is impor- children under the age of 15 years were living with
tant to have refresher courses in psychiatric signs and HIV/AIDS while 470 000 children died from AIDS
symptoms to enable the staff to identify children who [36].
may have developed new psychiatric symptoms. In the USA one million people were living with
Medical illnesses may present as psychiatric illnesses. HIV/AIDS in 2003. In the year 2002, there were
Children with brain disorders report psychiatric symp- 877 275 adult and adolescent AIDS cases and 9300
toms four to five times more than do well children [10]. AIDS cases in children under the age of 13 years [37].
At times, a change in mental status may be the first sign In the 1524-years old age group AIDS is the sixth
of a medication side effect, a recurrence of cancer, con- leading cause of death [38].
nective tissue diseases, or HIV. It is incumbent on con- Worldwide, over five million infants have been
sultation-liaison psychiatrists to work closely with infected with HIV since the beginning of the pan-
residents and the nursing staff to observe and identify demic, 90% of whom were or are in Africa [39]. Other
subtle mental status changes. areas of increased incidence rate include Central and
Psychiatric conditions may present as medical South-East Asia, Eastern Europe, and India [39].
illnesses. In one study, psychosomatic disorders Children at risk for HIV infection include infants of
accounted for 28% of all child psychiatric consulta- intravenous (IV) drug abusers, sexually abused chil-
tions [24]. The Ontario Child Health Study estimated dren, children who have received blood products
a prevalence rate of somatization syndromes of 4.5% between 1982 and 1985, adolescent IV drug abusers,
for boys and 10.7% for girls aged 1216 years [8]. These gay adolescents, and those who are sexually promiscu-
children had medical workups that were negative, and ous with multiple partners [40]. In the USA, pediatric
the presenting problems included failure to thrive, AIDS is over-represented among ethnic minorities
abdominal pain, headache pain, and eating disorders. (62% AfricanAmerican, 25% Hispanic) [36,38],
In our hospital, gastrointestinal complaints by far con- socioeconomically disadvantaged [36], in large metro-
stitute the majority of consultation requests in this politan areas (New York City, Miami, Newark) [36],
area. As mentioned previously, one of the difficulties and among the offspring of IV drug users [36].
the house staff tends to have with these patients is Child and adolescent psychiatrists are likely to
telling a parent that a psychiatric consultation is encounter HIV-positive children and adolescents in the
needed; they are fearful of parental reaction. We course of their clinical work, unless their practice
suggest the following approaches for house staff to excludes contact with minorities, chronically ill chil-
deal with these issues: dren, sexually active adolescents, gay youth, and
abused or molested children [41]. Advances in HIV
(1) Emphasize the need for multiple team members
treatment have led to survival past five years of age in
on the treatment team, including mental health
more than 65% of children with HIV and many of
those children will be encountered by mental health
(2) Do not imply that you are giving up on the patient
professionals [38]. Child psychiatry liaison service is
and his or, her problem.
used by multiple medical services to assist in the psy-
(3) Feel free to express frustration at not being able to
chosocial aspect of treating families with infected chil-
arrive at a medical diagnosis.
dren. The entire range of child psychiatric expertise,
(4) At times, request a consultation for the purpose of
such as family therapy, psychotherapy, crisis interven-
offering support to the patient and family in
tion, and knowledge of neuropsychology and psy-
dealing with medical complaints.
chopharmacology, is required to help these families
These suggestions may help patients accommodate to receive services [42]. Even if a vaccine or cure is found,
the possibility that a psychiatric component may psychiatrists will be called on to respond to the psy-
have initiated or maintained their ongoing medical chiatric sequelae of the AIDS epidemic for the next
problem. generation.

Sources of Infection in Children majority of new AIDS cases [38]. National data on
adolescents with AIDS indicate that 73% were infected
Vertical transmission
by intravenous drug use or sexual activity, and 22%
Perinatal transmission accounts for more than 90% of
through exposure to infected blood products [47].
pediatric HIV infection and could occur during preg-
Additionally, children who are runaways are at risk for
nancy, labor, delivery or breastfeeding [39]. The rates
having multiple sexual partners and engaging in pros-
of mother-to-child transmission range from 1525% in
titution, hence are at great risk for infection.
industrialized countries to 2535% in developing coun-
With these risk factors in mind during a thorough
tries [39]. Maternal transmission could be influenced
psychiatric assessment, psychiatrists should assess
by factors such as age of the child, severity of mater-
these issues in all of their patients. Risk factors for
nal HIV, amniocentesis, specific blood type or vitamin
HIV should be noted and a test performed when
deficiency (e.g., vitamin A) [38]. Vertical transmission
of HIV infection has been substantially reduced by the
pre- and perinatal use of zidovudine (AZT) [36,38]. It
is not usually possible to determine whether a child is
infected at the time of delivery due to the maternal Neurodevelopmental Aspects of Pediatric
HIV antibodies that cross the placenta. For the major- HIV Infection
ity of children, it is not known with certainty if the
Many children with HIV are considered to be asymp-
child is free from infection until maternal antibodies
tomatic, one study showing only 10% of children being
disappear and the HIV antibody test becomes negative,
symptomatic before the onset of an AIDS-defining
a process that occurs most commonly between 9 and
illness [48]. However, numerous studies document at
15 months of age. This unknown period will likely be
least some cognitive and language delays that could be
a particularly difficult time for parents and other care-
quite subtle [38,48]. Additionally, the severity of the
givers [43]. Additionally, infected infants not identified
neurological and the neuropsychological compromise
in the nursery may be diagnosed later by monitoring
positively correlate with the severity of HIV related-
their serostatus or by observing when they develop
illness [36].
failure to thrive and frequent infections.
Two relatively distinct neurodevelopmental patterns
have been described: static encephalopathy and pro-
Infection by Blood Products gressive encephalopathy [36]. Static encephalopathy is
The majority of cases of infection via blood products characterized by non-progressive neurologic and neu-
are in patients with hemophilia who received nonheat- rodevelopmental deficits and is likely etiologically
treated quality concentrates prior to 1983. Since 1985, related to non-HIV risk factors such as prematurity,
blood banks have been effectively monitored for heat- low birth weight, prenatal toxins or infectious agents
treated factor VIII concentrates. Prior to the use of this exposure, and or genetic factors [36,49].
precaution, the risk of infection depended on the Progressive encephalopathy, which corresponds with
severity of hemophilia: about 75% of patients in the the AIDS dementia complex in adults, can be the
severe group were infected, 45% in the moderate group, initial presenting problem of acquired immunodefi-
and 25% in the mild group [44]. ciency syndrome (AIDS) in up to 18% and eventually
up to 3060% of affected children in adolescence
Sexually Transmitted Disease [5052]. In a series that included both asymptomatic
Child sexual abuse is another cause of childhood HIV children and children with advanced disease, a 19.6%
infection [38,39], therefore HIV testing is clinically prevalence rate of progressive encephalopathy was
indicated in assessing children who have been abused reported [49]. The progressive encephalopathy is felt to
or molested. Additionally, a random sampling of result from both direct and indirect effects of HIV-1
youths in public health clinics showed that having a infection on the central nervous system and eventually
history of physical abuse, sexual abuse, or rape is results in an insidious and severe clinical neurological
related to practicing high-level HIV-risk behaviors [45]. deterioration [52,53]. Progressive encephalopathy is
Of note, female adolescents are at the highest risk for observed when immunosuppression is present,
completed rape and other forms of sexual assaults [46]. however there is no correlation between the immuno-
logic status (e.g., CD4 cell count) and the degree of
Adolescent Risk Factors neurocognitive impairment [38]. HIV-associated pro-
Adolescents constitute one of the fastest growing risk gressive encephalopathy in children is characterized by
groups [36] and sexual intercourse accounts for the a triad of symptoms:

(1) impaired brain growth, with either a decrease or Emotional and Behavioral Manifestations in
plateau of head growth velocity or a progressive HIV-Infected Children
loss of brain parenchymal volume, as seen on neu-
Pediatric HIV patients are at risk for psychological dis-
roimaging studies;
turbance due to both the direct effects of HIV infec-
(2) progressive motor dysfunction;
tion on brain structures and indirect effects related to
(3) loss or plateau of the acquisition of age-
coping with the range of medical, psychological and
appropriate neurodevelopmental milestones
social stressors associated with HIV disease [56]. Such
stressors include the repeated hospitalizations, fears of
death, disclosure of HIV infection, social ostracism,
Additionally, encephalopathic children manifest
and family conflict [38]. Additionally, HIV is associ-
apathy, decreased social interaction and symptoms of
ated with other high-risk factors such as poverty, pre-
depression and irritability as compare with non-
natal drug exposure, birth complications, and heritable
encephalopathic children [36]. Developmental prob-
parental psychopathology that may be more potent
lems are often multifactorial, and environmental,
mediators of mental health problems in HIV infected
psychosocial and nutritional factors may have an
children than HIV itself [36].
important influence on neurodevelopmental outcome
Developmental disabilities, learning disorders,
and testing [52]. Formal developmental testing of HIV-
behavior syndromes, anxiety, bereavement reactions
1-infected infants has yielded conflicting results, with
and depression have been reported in HIV-infected
abnormalities in age-appropriate testing of motor
children [36,38,52]. Additionally, attention deficit
skills or prelinguistic abilities predominating [49,52].
hyperactivity disorder-like symptoms were reported
The school-age child is at risk for impaired cog-
to be highly prevalent among school-age children
nitive functioning including declining IQ scores,
[36,38,52]. Learning disabilities are prevalent in HIV-
increasing difficulties with language, and attention and
infected children, and these children often require
special education services [52].
Neurodevelopmental testing should be an integral
part of the assessment of HIV-1-infected pediatric
patients, especially those with known neurologic Psychiatric Assessment and Interventions
abnormalities or receiving antiretroviral therapy. Addi- A multidisciplinary team including professionals in
tionally, one study found that the overall CT brain scan general pediatrics, infectious diseases, child neurology,
severity rating to be highly predictive of the level of child and adolescent psychiatry, nursing, social work,
cognitive functioning [38]. In a sample of HIV-infected and special education is needed to treat these children
children under the age of 10 years, CT scan abnor- and their families. Table 5.4 [54] provides an outline
malities were significantly correlated with poorer
receptive and expressive language functioning, the Table 5.4 Psychosocial assessment in HIV-infected
latter being more severely impaired among encephalo- patients and families.
pathic children [38]. A review of neuroimaging studies
found that 79% of the patients studied had at least one Family History of illness Child
abnormality on CT brain scan [55]. Most frequently,
cortical atrophy was found with ventricular dilatation Constellation Pre-illness
and/or sulcal enlargement, both of which were associ- Reaction to diagnosis School performance
ated with white matter abnormalities. These lesions Support system Relationships with peers
were equally common in vertically transmitted and Health status Development
other infected patients. Intracerebral calcifications Previous losses and Current reaction to
were only seen in vertically infected children. The coping skills diagnosis
lesions tended to be bilateral and symmetrical, occur- Behavioral changes
ring in basal ganglia and spreading to the periventric- Cognitive development
ular frontal white matter [55]. Current antiretroviral Coping skills
treatments have the potential to improve the cognitive
deficits in children with AIDS and the improvement is Adapted from Weiner L, Septimus A: Psychosocial support
independent of the immune status or the presence of for child and family. In: Pizzo PA, Wilfert CM, eds. Pediatric
encephalopathy at baseline [38]. However the effect is AIDS: The Challenge of HIV Infection in Infants, Children,
not sustained in many children beyond six months of and Adolescents, 2nd ed. Baltimore, MD: Williams & Wilkins;
treatment [38]. 1994: 809828.

geared toward evaluating children and families with psychiatric disorders, the importance of psychiatric
HIV. consultation and to work as part of the multidiscipli-
In addition to performing a thorough psychiatric nary team in order to provide comprehensive care for
assessment of the child and his or her family, it is crit- these children. Additionally, due to the advances in
ical that the child and adolescent psychiatrist works on HIV treatment with HIV infection becoming a suba-
behalf of the family with other practitioners and with cute, chronic disease, the child psychiatrist is being
schools. These children are at risk for learning disabil- called upon to help address the newly posed challenges
ities, cognitive impairment, and behavior problems. to the neurocognitive and psychosocial development of
Psychiatrists can ease the transition to school by children and families [38].
working with school officials to educate them about The liaison child psychiatrist has the additional
HIV and discuss their worries about dealing with an important task of educating the patients and their fam-
HIV infected child. ilies, in a developmentally appropriate way, about
Little data are available on the pharmacological medical procedures, medical illness and its potential
treatment of psychiatric disorders in HIV-infected chil- psychological consequences. Additionally, in working
dren, however treatment approaches similar with those with adolescent patients, the educative role with focus
used for noninfected patients are likely employed [38]. on the risks for HIV infection is essential, given their
Specific considerations include: especially increased risk.
Using the clinical skills and research in our field,
(1) Behavioral syndromes first require a thorough neu-
child and adolescent psychiatrists are well prepared to
rological assessment to rule out any organic causes.
deal with the complex psychological and social conse-
(2) A review of the antiretroviral, antimicrobial and
quences of chronic medical illness.
antifungal agents due to their potential neuropsy-
While there is a growing body of literature on the
chiatric side effects [36,38].
psychosocial adjustment in children with chronic
(3) The patients require lower start dose, slower titra-
medical illness and specifically in children with HIV
tion and close monitoring of the medications.
infection, more work would be needed especially in the
(4) The patients are more sensitive to drug side effects.
area of treatment interventions both nonpharmaco-
(5) Many antiretroviral (especially protease inhibitors)
logical and psychopharmacological. Additionally, the
and psychotropic medications are metabolized by
collaboration between the child psychiatrists, primary
the cytochrome P450 system and they are also
care physicians and pediatric specialists will require
inducers or inhibitors of the different P450 isoen-
ongoing attention and research in order to optimize
zymes. Therefore, it is important to review the
the multidisciplinary approach to the chronically ill
potential drugdrug interactions between anti-
pediatric patients.
retroviral and psychotropic medications before
initiating any psychoactive medications.
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How to Plan and Tailor Treatment:
An Overview of Diagnosis and
Treatment Planning
Brian J. McConville, Sergio V. Delgado

Introduction tion of goals both initially and during the period of

therapy. Such goals are usually imprecise, partly
The purpose of this chapter is to address the increas- because of the paucity of outcome data in psy-
ing imperative in child and adolescent psychiatry to chotherapy research [9].
form a coherent diagnostic and initial treatment plan Earlier models of a more reflective form of psy-
for a child, adolescent, or family, and to do so in such chotherapy, with indefinite goals and time periods, are
a way that this plan will be logical and agreed upon still necessary to obtain knowledge of certain aspects
by the consumers of mental healthcare including of the psychotherapeutic process, especially during the
the patients themselves, their families, employers and training of child psychiatrists. These patterns remain
insurers. It is also important to be flexible, so as to alter present especially in psychoanalytic psychotherapy
treatment approaches with evolving clinical realities. [10]. But there is also a need for formal training in more
Contemporary medicine, including psychiatry, is directive types of therapy, especially those directed
subject to specific treatment guidelines, such as the toward specific diagnoses (such as affective disorders
well-known Milliman and Robertson standards [1]. or OCD), or specific family and social situations and
The argument that this is unfeasible because of the modes of community intervention. Psychopharmaco-
imprecise nature of psychiatric diagnosis is invalid, logic and psychotherapeutic approaches are often used
since the precision of psychiatric assessment measures together, and need to be so, since pharmacotherapy
is comparable to that of physical diagnoses, and the essentially aims to reduce or suppress problematic
overall results of treatment in child and adolescent symptoms, and does not directly lead to new behavior.
psychiatry, especially for the Axis I diagnoses, are The usefulness of such combination approaches has
comparable to those in adult psychiatry [2]. As have been recently demonstrated in the MTA study of the
other specialty organizations, the American Academy combination of behavior therapy and psychostimu-
of Child and Adolescent Psychiatry has developed lants [11]. In the TADS study for cognitive behavior
practice parameters [3]. In pediatric pharmacotherapy, therapy (CBT) and antidepressants for child and ado-
the results for treatment of attention-deficit hyperac- lescent depression, the combination showed clear
tivity disorder (ADHD), obsessivecompulsive disor- improvement over the use of either medication or CBT
der (OCD), bipolar disorder, depressive disorder, and alone [12]. However, the lack of clear separation
other conditions have been empirically validated and between those treated with antidepressant medication
are extremely promising [48]. A perception of uncer- and those on placebo, as well as the inadequate capture
tainty still exists for the results of child and adolescent of initial and/or emerging suicidality during these
psychotherapy and other psychosocial interventions. studies, has lead in part to recent concerns about the
Currently, insurance companies award a limited use of antidepressants and suicidality in children and
number of sessions annually and require the designa- adolescents [13]. There is an emerging consensus about

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

the necessity of combining pharmacotherapy and psy- the DSM-IV-TR [15]. This consists of a number of
chotherapy, with a need for collaboration between the axes:
pharmacotherapist and the psychotherapist, who need
Axis I: Major clinical diagnoses
to work closely together. We believe that ideally these
Axis II: Developmental disorders and personality
roles should be fulfilled by the same person, since
otherwise it is problematic for either therapist to
Axis III: Physical disorders
know what the other is doing. However, this belief
Axis IV: Psychosocial stressors
awaits substantiation.
Axis V: Global assessment of functioning
In contrast, the dimensional or multivariate statistical
A General Framework for Diagnosis and system, such as that used in the Child Behavior
Treatment Planning Checklist of Achenbach and colleagues [18], uses the
convention that symptom groups indicate the universe
In the next two sections, general principles of diagno-
of behaviors in a given population. These symptom
sis and modes of therapy will be summarized, as to
groups are selected from a fixed group of behavioral
how to select and alter modes of therapy as needed.
symptoms derived from factor analysis and varying
Following this, brief descriptions of the different
with age and sex. Those cases that occur above a given
therapies will be given. Finally, combinations of ther-
cutoff point (usually the 98th percentile) are abnormal.
apies will be discussed, and clinical vignettes will be
Individual symptoms and particular narrow band
syndromes (those defined by scores in a narrow range)
may therefore occur or disappear at different ages and
also differ between sexes. Comorbidity frequently
Models of Diagnostic Classification
occurs, and rarer disorders such as autism do not
There are three general models for classifying disor- emerge in the usual analyses of normative or clinical
ders: categorical, dimensional, and ideographic [14]. populations. In addition, using the list of symptoms
This distinction is important because it is tempting to found at the predetermined cutoff point for abnor-
believe that the ordinary method of classification used, mality may affect the frequency of the disorder [19].
the clinicalcategorical approach, is the only feasible This system has been widely used in epidemiologic
one. studies, including international studies in which the
The categorical approach, which is similar to the general nature of the questions tends to minimize cul-
general medical model of classification, is dichoto- tural differences in syndrome expressivity [2022].
mous in that it views disorders as either present or The third system, ideographic diagnosis, uses an
absent. This approach implies that cases of a particu- approach that focuses on the totality of the individual
lar disorder show certain characteristic symptoms, childs life and circumstances and avoids simple
which in turn suggests an underlying pathophysiology, descriptive labels. Despite the seeming inherent valid-
or cause of disorder and treatment. But even in such ity of this approach, the lack of labels makes it diffi-
systems as the Diagnostic and Statistical Manual of cult for clinicians to communicate with each other
Mental Disorders, Fourth Edition, Text Revision regarding such studies of unique individuals. More-
(DSM-IV-TR) [15] or the still-evolving (in the US) over, proponents of this approach usually operate from
International Classification of Diseases (ICD-10) [16], some strict theoretical framework that slants their clin-
this approach is not always followed. Some disorders, ical approach, as in psychoanalytic, behavioral, family,
such as depressive disorders, require cardinal features sociologic, or psychopharmacologic viewpoints.
such as anhedonia, dysphoria, or irritability as cardi- Other diagnostic systems can be used, including psy-
nal symptoms, as well as a number of other symptoms chodynamic diagnosis, which has been proposed in the
for full diagnosis. In other disorders, such as ADHD, past for inclusion in the DSM system of classification,
six of nine symptoms of inattention or hyperactiv- and family diagnosis [23]. The psychodynamic diagno-
ity/impulsivity or a combination of both allow for the sis approach has been implicit in a number of systems,
diagnosis. Hence, disorders support the Chinese such as that espoused by Freud [24] and later by
menu style of diagnosis, rather than with a strictly Nagera [25].
convergent system where a given number of symptoms More recently, diagnostic systems have attempted
always indicates a particular diagnosis [17]. to avoid theoretical or etiologic considerations [26]
The most commonly used pattern of categorical and instead have widely used the phenomenological
diagnosis in child psychiatry in North America is approach that operated in the original definition of

Research Diagnostic Criteria [27]. Even under these This implies that different patterns of pathology may
conventions, however, disorders such as post-traumatic appear among the same children in different settings.
stress disorder or reactive attachment disorder of There are also times when the existence of problems
childhood clearly imply etiology. relates more to goodness of fit between parents and
It does not necessarily follow that the disease the infant rather than to a uniformly recognized dis-
concept is the most useful one to employ. An approach order in the child [31]. The childs and the parents tem-
favoring an extension of the DSM-IV TR Axis V, and peramental characteristics may interact negatively. In
stressing functional impairment may be more generally 1960, Kanner commented that behaviors thought of as
usefu1 [28], as in patients with mental retardation or disturbing by one set of parents were not necessarily
autism. A number of recent rating systems use this thought of similarly by other parents; he made a dis-
concept, as in the Childrens Yale-Brown Obses- tinction between the disturbing and the disturbed
siveCompulsive Scale (C-YBOCS) [7], which meas- child [32]. The work of Werner and Smith showed that
ures the number and nature of symptoms, but then the prognosis of children with behavior disorders was
uses the degree of functional impairment as the most dependent both on parenting techniques and social
important component. support [33]. LaRoche indicated that children of
parents who were depressed were particularly at risk of
perceiving their children as having behavioral prob-
Other Considerations in Child Psychiatric Diagnosis
lems, and that those parents who had violent and
A further aspect is to consider the question of what abusive parents were in turn likely to be abusive [34].
is being classified. Cantwell noted that diagnoses The work of David Reiss and his associates has
classified disorders, but not individual children [29]. demonstrated effects of differential parenting and the
Diagnosis refers to a process of assigning a label to a interplay of environmental and genetic factors upon
particular problem or a group of problems to allow for the outcome of adolescents [35,36].
greater precision about treatment, prognosis, and pos- Diagnosis in children, therefore, relates largely to the
sible etiology. But the diagnosis given to a child may issue of social context and also to factors of tolerance,
vary from time to time, or be relatively fixed, depend- parenting skills, temperament, and economic disad-
ing on whether the disorder is an adjustment to some vantage [37]. There are also reasons to believe that
external stressor or a more internalized disorder cultural factors may determine what is seen as prob-
following prolongation of a particular stressor, or the lematic in children.
emergence of other internal and probably neu-
ropathologic factors, as in schizophrenia.
In contrast to adult psychiatry, where the opinions Therapeutic Interventions: Models for Selection and
of various informants about a persons degree of Utilization of Different Forms of Child and
impairment are often overlooked, child and adolescent Adolescent Psychotherapy
diagnosis implies the gathering of information not
A General Model for Sequential Strategies in Child
only from the child but also from parents, teachers, and
and Adolescent Psychotherapy
others. One of the earliest studies in this area, Rutters
Isle of Wight Epidemiologic Study [30], focused on the To simplify the complex array of possible psychother-
number of behavior problems shown in children in a apies, a general model will first be presented, focusing
particular village, as determined by different inform- particularly on the strategies used or required to estab-
ants. When a group of village members was asked to lish particular goals. In turn, the type of therapy used
name those children who had the most problems, the will be selected for its utility for stipulated goals at par-
group of children selected showed a high degree of reli- ticular times during the course of the therapy. To this
ability among informants. Similarly, when the chil- extent, the idea of adhering only to a particular form
drens teachers were asked to name their problematic of psychotherapy especially one with dedicated dis-
children, they replied with a high degree of inter-rater ciples for all cases is nonsensical. It attempts to fit
reliability about their chosen group. All the children the patient into a Procrustean bed in conformity to the
came from the same pool of children in the village; therapists particular enthusiasms or limitations of
however, there was little overlap between the two training, rather than being responsive to the patients
groups selected by village members and teachers, needs. Good therapists can alter their approaches flex-
respectively. There was not only a difference in per- ibly as need be, ideally with the knowledge and assent
ceived behavior between informants, but also a differ- of the patient and/or parents, while still largely remain-
ence in particular situations (as in school and home). ing within their preferred or initial psychotherapeutic

Table 6.1 Patterns in sequential child psychotherapy.

Therapy Directive
spectrum Nondirective

Therapy type Custodial- Part-relationship Complex Analytic

supportive relationship relationship

Do therapy to Do therapy to or Do therapy with Be with the

the patient with the patient the patient patient while he
or she re-
experiences or
works through
past issues
Associated Supportive Concrete reward Negotiated Verbal or play
strategies systems behavioral therapy; re-
rehearsals experiencing
Suppressive Induced partial Induced full Corrective
modeling modeling experience with
new skills;
tension relief

mtier. Implicit in this approach is that the therapist mous. The model to be presented will describe how a
must be broadly and flexibly trained. This is why variety of therapies may be selected depending on the
general strategies rather than labeled therapies are diagnosis of the child, family or group, and also point
stressed in this section. out how the style of therapy may evolve over time,
Psychotherapies with their attendant strategies can related in part to what occurs in therapy and to other
be conceptualized as existing in a spectrum between events or clinical considerations. The model also indi-
more goal-directed, behaviorally oriented modes and cates how both the therapeutic relationship and the
more nondirective analytic therapies [38]. Intermediate therapy style are also dependent on diagnosis. Therapy
are those directed relationship therapies that use the often evolves from simpler to more complex phases
therapist as a partial model for limited patterns of or sometimes vice versa using a sequential approach
social interaction, as in assertiveness training tech- that allows for interphase negotiations with the child
niques [39], or as a total model of an adult or parent and family about how to proceed throughout therapy.
figure (Table 6.1). Such an approach is particularly suited to episodic and
In addition, the concept of patient unit is intro- planned therapies with associated specified outcome
duced here to stipulate whether the therapy is with the goals; both apply to the realities of practice in the
individual child, the parent(s), the parents plus child, current clinical environment.
the family, the group, the immediate society in general, The strategies associated with this sequence of
or other units, for example, residential groups. Again, directive to nondirective child therapies frequently
the unit may vary from time to time, but always within evolve from behavioral methods to more dynamic
the context of clinical evolving realities. Put another approaches, especially with action-oriented and mis-
way, the therapist should be able to define at any time trustful children, as suggested by the leftright
why he or she is following a certain pattern of thera- sequence in Table 6.1. Such an evolving sequence of
peutic intervention in a case. strategies, however, has also been found useful in more
The various psychotherapeutic strategies, viewed as internalizing children with subjective inner distress.
a continuum or spectrum, can be classified from direc- After a full initial clinical diagnosis, there follows in
tive to nondirective, and also as suppressive to expres- sequential psychotherapy a first stage of initial con-
sive. There is a general parallel between these two tract negotiation with different styles as required by the
dimensions, although they are not necessarily synony- type of case (as described below), followed by a second

stage of rehearsal of more simple interactional and the child should be cared for in a structured and pro-
affectual behaviors, and a possible third stage of explo- tective setting. This fulfilled the childs need for nurtu-
ration of more complex intrapsychic, intercommuni- rance and protection. This general point of good
cational, and intrafamilial issues. To illustrate these enough care is similar to Winnicotts concepts [40]. In
points, examples follow of the three-stage, sequential another child with asthma and associated depression,
psychotherapy approaches to children with different the initial contract for good enough care involved
diagnoses. However, this sequence is not invariant, and assurance of adequate pediatric help while avoiding
may vary with different children. the overprotection and subsequent shamerage reac-
tions that had plagued the child in relationships with
Stage I: Initial Contract Negotiation and his own family.
Formation, with Different Styles of The therapist in this situation is cast into a nurtur-
TherapistPatient Relationship ing role with a child who can accept the usefulness of
Several clinical variants of stage 1 occur, requiring dif- helping adults and has therefore achieved a degree of
ferent styles of approach by the therapist. Examples of trust, or at least a suspension of mistrust. If this is not
three common styles follow. These are defined by the initially possible for the child, a brief period of more
context of the relationship. neutral contractual maneuvering in the whats in it for
you? style may be required. In reality, very few thera-
Style A: Therapist as Manipulated Helper: Whats In peutic interactions are exclusively or perpetually Style
It For You to be in Therapy? A or Style B.
In children with disruptive behavior disorders, interac-
tions with authority figures are usually both unsatis- Style C: Therapist as Empathic Participant: Whats It
factory and punitive. Such children are often Like Being You?
mistrustful, action-oriented, and desirous of escaping The two former patterns in contract formation have
from the therapeutic situation. Therapists must for- stressed doing things with or for the child. In contrast,
mulate the initial contract in terms of whats in it for questions asked about Whats it like being you? relate
you? They stress the therapists role as a helpful adult, to the therapists wish to understand the child and also
pointing out how the child might, for example, be able achieve some notion of the childs own perceptions.
to remain in school or avoid further punishment by the In all three styles the therapists total understanding
law if he or she conforms to certain rules. Therapists of the child must of necessity be limited; the child is
are not the law but merely members of that particular still guarded, and the time available for obtaining
society. As manipulated helpers rather than prime information is short. But the therapist does signal his
authority figures, they act in response to the commu- or her basic interest in the child as a person, and the
nication of the patient. Out of respect for the patients contractual position of usefulness, helpfulness, and
needs they are able to avoid moralizing but they do empathy reflects an honest transaction between one
indicate the logical consequences involved in the childs person and another.
antisocial actions. During this initial contract formation, there may
Therapists should refrain from imposing their own have been an unfolding elaboration of roles, from the
values. Novice clinicians may be at special risk to man- therapist as a nonpersonalizing informer of conse-
ifest their own values of permissiveness or punishment. quences or routes of legal or social redress, to that of
For most children, a decision to avoid misbehavior to parenting caretaker in the second style, to that of an
avert the response that will follow from school or other interested and empathic person in the third style.
authorities is sufficient motivation for therapy to Many children and adolescents may progress through
proceed. Once this understanding has been reached, all three styles in contract formulation, but such a
the child and therapist can move on to specific behav- sequence is not invariable or even necessary for
ioral rehearsals in the second stage of sequential successful therapy. Such contractual groundwork
psychotherapy. provides a basis for the second stage in sequential
Style B: Therapist as Nonmanipulated Helper: How
Can I Help or Take Good Enough Care of You? Stage 2: From Instrumental to Interactional
In a more trusting child the therapeutic relationship Patterns: Doing Therapy To or With the Patient
can become more personalized. In a suicidal child, for This stage initially employs an elaboration of simple to
example, formation of the initial contract stressed that more complex behavior modification methods. Thera-

pists may initially use concrete reward systems and ior and demonstrate in a concrete way that such inter-
behavioral rehearsals, but then develop more complex actions are possible.
interactional patterns by using themselves as models of
interactions, while augmenting the childs capacity to
observe himself or herself interacting more success-
The Children with Internalizing and/or
fully. Similarly, children progress in their perception of
Psychophysiologic Disorders
the therapist. Whereas initially they may regard the
therapist as somebody to be manipulated for gain, they The sequential psychotherapy model is also relevant
are secondarily involved with the therapist as a model for children and adolescents with internalizing or psy-
towards whom they have ambivalent liking. Finally, chophysiologic disorders. In the suicidal child men-
they understand being with the therapist and share tioned previously in the vignette in Style B, one of the
their excitement about increasing capacities. Following key conflicts addressed in therapy related to his inef-
the formation of the initial contract, a number of pos- fective aggressive assertion. This in turn followed from
sible therapies may therefore occur. his unmastered and murderous rages toward his
The next case examples illustrate this approach with mother, arising from a recently threatened separation
children with different diagnoses and attitudes towards from his father. Such murderous rages were immedi-
the therapist. ately internalized because of the familys structure of
strict and punitive values, leading to internalizing
aggression and a resultant suicidal attempt. The key
The Children with Externalizing Disruptive
strategy area (after basic nurturance was achieved)
Behavior Disorders
was to encourage effective aggression. Accordingly,
These children are best approached by directive thera- aggressiveassertive role playing was used, with role
pies for agreed-on target behaviors such as high inten- reversal to decrease the childs anxiety when necessary.
sity aggression or other maladaptive social behaviors. With coaxing and support, he managed to express his
Often such target behaviors are best approached by anger first at the therapist in a role, and then in a real
using rewards and time-outs for positive and negative fashion-playing the person who would not allow him
behavior. This therapeutic interchange in the whats in to return home for the weekend. He initially became
it for you relationship spells out to children the con- more comfortable in therapy sessions, but as he
sequences of their actions, but also avoids the intense expressed conscious anger during later sessions, he
and often exhortative personalizing that has often suddenly became aware of murderous rage impulses,
taken place with other adult figures. followed immediately by a wish to kill himself and an
In group interactions dominancesubmission absolute conviction of his own wickedness.
maneuvers with other children usually predominate, These emotions were dalt with directly by telling him
since such children have frequently not managed to about the nature of such early and primitive feelings,
achieve sharing or a capacity to delay gratification. As and by demonstrating that the therapist did not drop
a result, social skills training with peers and adults can dead or attack him for his anger even when the child
sometimes be employed. Often group approaches are said he really meant it. The child then relaxed,
used: group peer interactions may be broken down into although further working through was required as part
such simple behavioral objectives as spending more of a continuing process of interpretation and identifi-
time with the group by avoiding fights and tantrums, cation of affects.
with later sequential elaboration into more complex In another example, an asthmatic child also had his
patterns of doing something that somebody would aggression toward his mother identified, but initial
like, and then into doing something so that someone attempts to have this well-socialized, charming child
will try to please a third person [41]. express and channel his anger were unsuccessful. In
In later individual or group therapy, techniques to one session, however, a childcare worker to whom the
limit or redirect excessive and ineffective verbal expres- patient related warmly as a mothering person role
sion may be used once a child has experience with more played his attacking and rejecting mother. The patient
concrete reward systems. The primary therapist can immediately became suffused with rage and attempted
also use direct modeling to channel the child into more to attack her physically. Afterward, when this event
effective modes of affectual assertion. Role-playing was examined, the therapist was able to help the
techniques of possible aggressive techniques may be patient recognize the presence of his emotions and
employed, along with role reversals; here, the child can explore their source. Subsequently, they were able to
try out different patterns of verbal and physical behav- rehearse this sequence with good results.

In summary, the second stage of behavioral therapy at this point. In other cases, the child or family
rehearsals focuses on a series of simple to more will wish to explore more complex issues.
complex behavioral, interactional, and affective
rehearsal systems. Such intervention increases chil- Stage 3: Lets Go On: Exploration of More
drens learned ability to perform social maneuvers, as Complex Intrapsychic, Intercommunicational, and
well as their internalization and comfort in their own Intrafamilial Issues
abilities, which is often associated with more positive In more verbal and subjectively oriented children, the
self-esteem. behaviorally oriented techniques used in the second
phase facilitate exploration during the third stage into
Renegotiation at the End of the Second Stage: Do You more complex individual and familial psychodynamic
Want To Go On, or Stop at this Stage? material.
In sequential psychotherapy it is frequently possible to In the depressed suicidal child described earlier, the
stop at the end of the second stage. In the case of the rehearsal of more effective aggressiveassertive pat-
disruptive behavior-disordered child, the acquisition of terns was initially paralleled by an increase in rage
more appropriate social behaviors usually leads to toward his mother. Further exploration in therapy
better acceptance by the family and society, although revealed that he had always been angry at his mother
there may be technical difficulties. For example, for her threats of deserting the family. He also felt that
counter-reactions by the family may follow the use of his death by strangulation might cause his mother to
reward systems; parents may feel that a child should feel guilty in this life, and also to be punished in the
not be rewarded for fulfilling only normal expectations. next life for her lack of attention to him. This led to
Alternatively, guilty, self-punitive behaviors may an associated fantasy of their being linked together in
emerge from the behavior-disordered child once more life and death, since he would also be punished in Hell
effective social maneuvers have been learned; this may because of his suicide.
arise from an internalizing of the anger that had pre- The ambivalent association between the child and
viously been contained by the aggressive acting out. his mother was also sustained by the family structure.
Again, the emphasis on behavioral reinforcers The mother had formed a close alliance with the child,
throughout the second stage might result in the parents using him as a shield against the aggressive and sexual
and child still dealing with each other at the end of this advances of her husband. Moreover, her basic ambiva-
stage of therapy as good or bad, rather than as lence toward the boy was heightened because she
loving or loved persons. Hence the very use of social became pregnant with him soon after she had adopted
learning techniques might lead to the childs using her first daughter, at a time when she felt or had
adults in a more facile nature, but still with problems convinced her husband that it was not possible for
in affectual expression. her to have a child. The childs perception of himself
Many behavior-disordered children who have been as unloved and unwanted was at the heart of his
brought up in a fashion that values objects and con- depression.
crete transactions over affective interactions may expe- An interesting question asked by behavior therapy
rience considerable difficulty with affect verbalization colleagues is whether knowledge of such dynamic
[42]. But both they and their parents are often capable material alters subsequent therapeutic strategies. In
of a general but strong warmth, which is released practice, such knowledge does seem to be useful. In the
once more effective modes of expression and interac- above case, knowledge of the use of the patient and his
tion are demonstrated. Once satisfactory behavioral sister as defenses against sexuality was addressed
interchanges have been elaborated, increased comfort directly in family therapy, as was the unsuccessful
between child and parent is often sufficient to allow attempt at dominance of the father. Behavioral and
the termination of therapy. Malone made this point in insight approaches often coexist; the prime symptom
his analysis of the role of family therapy in different of aggression in this patient was treated concomitantly
social classes, noting that families from different by rehearsal of increasingly modulated aggressive
backgrounds may manifest very different patterns of behaviors. The child later observed that he was more
communication that are nonetheless still imbued with comfortable in expressing anger toward his peers and
positive affective content [43]. his parents; as he did this, his suicidal wishes decreased
Many children and parents will accept the symptom and he was able to cry. His extremes of murderous rage
change in social and affectual behavior accomplished had been modulated into more useful affects, which
during this second stage, and in the renegotiation resulted in his being more spontaneously cheerful
phase will tell the therapist of their wish to stop and less depressed. Therapeutic strategies therefore

continued to come directly from previous stages of schools of thought in each general form of therapy.
behavioral rehearsal, even though new treatment Usually, these concepts and strategies overlap with
dealing with family relationships, sexual impulses, and those described above under the general model,
other aspects of his life then entered into therapy. although the jargon associated may be different.
In the case of the child with asthma described above,
the demonstration of increased ability to cope added
Child and Adolescent Psychopharmacotherapy
to his general self-esteem and capacity to envision
himself as exploring the world. Although he had pre- Recently, there has been a rapid evolution in the psy-
viously avoided school, the child now planned suc- chopharmacotherapy of children and adolescents [5].
cessful reentry. He began learning again and also Given the recent changing patterns of psychiatric prac-
started to play with other children; this replaced his tice, there is now great emphasis on this mode of
previous behavior of sitting sadly with adults, endlessly therapy.
reciting tales of the sports heroes he had observed in The ordinary purpose of pharmacotherapy is to
hours of passively looking at television. reduce the severity of selected target symptoms. Mat-
The model of sequential psychotherapy presented urational and developmental issues may influence
therefore indicates a reasonable and rational approach physiologic, cognitive, psychological, and experiential
for planning the initial moves and subsequent strate- factors. The provision of pharmacotherapy is part of
gies to be used in therapy with many different types of an overall treatment plan that includes comprehensive
children. The different stages are as follows: (1) an diagnostic formulations as well as the involvement of
initial diagnostic evaluation; (2) a period of contrac- the family. Compliance with medication is an issue
tual negotiation; (3) a stage of behavioral, interac- of particular importance. It is a reflection of the
tional, and affectual rehearsal; and (4) a possible doctorpatient relationship and of family experience
stage of further exploration into more involved intra- and expectation, and a powerful determinant of
psychic, environmental, and intrafamilial issues. outcome.
Although the complexities of the case often suggest Each medication and its effects need to be explained
many complicated possibilities, initial therapeutic fully to the child and adolescent. Medico-legal and
strategies are often couched in rather simple behavioral ethical concerns require that the parent or guardian
terms. Similarly, even though strategies become more also understand the medication and its effects. In addi-
complex as therapy progresses, they still maintain tion, several issues concerning informed consent will
their inner consistency. As children achieve greater require discussion. There may be unknown risks when
skills, they internalize increasing self-esteem and are taking medication, especially when novel psychophar-
therefore able to attack the more internalized and macologic treatments are used or when the risks versus
often frightening material that emerges in therapy. benefits are uncertain. Since many medications are
Even when such material emerges, behaviorally based not specifically designated by the Food and Drug
approaches often provide the best inroads to these Administration (FDA) as being safe or effective for
complex interactional and intrapsychic problems. children, many are used in an off-label (non-FDA-
One final caveat regarding either simple or complex approved) fashion. In all cases, however, the use of
accounts of the mechanisms of therapy remains. such medication should be consistent with ordinary
Whatever elegant hypotheses might be made by the clinical practice, and there should be some notation
therapist, the focus or impetus for change might follow in the chart that the available literature has been
from basic and simple perceptions of the patient. The studied.
noted Canadian psychoanalyst analyst Stanley Greben Medication should continue to be monitored using
wrote a book about a particular analysis, which con- the appropriate physical examination and laboratory
tained complex descriptions of the analytic process. In tests and procedures such as complete blood count
contrast, the patients remark at the end of the analy- with differential, urinalysis, liver, renal and thyroid
sis was: He was always there! [44]. profiles, and electrocardiograms (ECGs) and elec-
troencephalograms (EEGs) as required. Baseline
clinical observations may include standard rating
Commonly Described Forms of Psychotherapy
scales such as the Conners Parent/Teacher Scale and
The following sections refer to the most commonly the Abnormal Involuntary Movement Scale. And
described forms of psychotherapy and pharmacother- because of recent concerns about antipsychotic weight
apy. Basic underlying concepts in each form of therapy gain, leading to predictable increases in insulin resist-
will be outlined; and it will be noted that there are ance, and risk for hyperglycemia, hypertension, dys-
frequently a number of different strategies and even lipidemias and cardiovascular disease, monitoring

guidelines have recently been issued. These include terns and may allow for longer-term remissions [47]
personal/family history, weight, waist circumference, than pharmacotherapy, in which stopping medication
blood pressure, and fasting glucose and lipid profiles usually results in the return of symptoms. This section
during antipsychotic therapy [45]. outlines the more common child and adolescent
In this age of cost-consciousness, the clinician will psychotherapies.
often be required to distinguish between generic and
brand-name preparations. In general, it is probably Psychodynamic Psychotherapy
wise to start off with the brand name and then see Historically, child and adolescent psychotherapy has
whether the patient can be switched to a generic prepa- tended to focus on intensive individual psychodynamic
ration without loss of effect or the development of psychotherapy [48]. The approach is to form a trusting
unknown side effects due to the congeners found in relationship between the therapist and the patient and
some generic preparations. to allow the verbal expression of feelings with increas-
Since some children may require more than one ing self-knowledge and self-mastery [49]. While these
drug, they may experience significant drug inter- elements exist in all psychotherapies, in psychody-
actions, particularly interactions involving the namic models they are considered to be primary to
cytochrome P450 isoenzyme systems. The drug dosage the therapeutic process. Formation of the therapeutic
varies with age, with younger children often requiring alliance is fundamental, especially in the initial phase
larger doses proportional to age. Pharmacokinetics when children are told that they will have a series of
and pharmacodynamics (the interactions of one drug times set aside to begin to understand the their prob-
with another) are seldom fully studied in children, and lems. Children may indicate particular problems
much additional research is needed in this area. Some through play and with defensive structures. Following
drugs and/or their metabolites require monitoring of the initial phase, the therapist moves into the middle
blood levels, particularly those drugs used for bipolar phase of psychotherapy, whose goals are to work
disorders, such as lithium, valproic acid, and carba- through problems and also interpret the transference
mazepine. For most other medications, including by which conflicts and associated symptoms experi-
methylphenidate, levels are not usually obtained nor enced by the child are passed on to the therapist. As
are they clearly related to clinical response. Lewis pointed out, the normal dependent development
Other than for finite problems, it is customary to of the child throughout therapy may modify the trans-
continue psychotropic medication for a considerable ference [48].
time, often for many years. Periodic withdrawal and For example, a very young child would be expected
tapering of medications may be undertaken, if the to establish a transference with infantile aspects, which
patients clinical state allows, to determine if it is pos- might become less regressive and more assertive as the
sible to discontinue such medications. In the case of child grows older.
methylphenidate or other psychostimulants, medica- Linking the childs behaviors with fantasies may be
tions may be withheld during the weekends or summer helpful, especially in the context of a personal myth
because of possible adverse effects on growth and held by the child. This myth may be used to link
height, or because the patient can function adequately current and earlier behavior and to help explicate
without them. In disorders such as bipolar disorder defenses. During the interpretative process, the thera-
and schizophrenia, however, it may be difficult to pist may place observations in the context of what has
reduce the dosage of medication, especially in those previously taken place or what is happening during the
medications that require an adequate blood level. relationship between the child and the therapist. This
When drugs are withdrawn or tapered, relapse or with- process models that of the observing ego initially in the
drawal effects may occur. adult therapist, and then in the child. In the case of
In summary, pharmacotherapeutic agents are essen- child therapy, this needs to be spelled out in a concrete
tially suppressive, in that they reduce unwarranted way, given the childs relative inability to abstract [50].
symptoms or behaviors. They may also in some cases The process of working through requires a sustained
be neuroprotective, as current studies of antidepres- therapeutic effect, since repetitive defensive conflicts
sants suggest [46]. However, by themselves they rarely will remain relatively unchanged unless the affects con-
allow for the development of new behavior. tained by such conflicts are able to be expressed. Often
a process of mourning occurs, as children let go of
worked-through material, and also during the subse-
The Verbal/Behavioral Psychotherapies
quent formation of alternate modes of coping. For
Psychotherapy, in contrast to pharmacotherapy, example, in a session a child may set aside a favorite
usually aims to change behavioral maladaptive pat- toy or game, but do so with reluctance or sadness. The

process of gaining insight gradually leads to change of young boy named Albert heard a loud noise when he
thought and behavior. began to play with a rat and subsequently became
As in most models, during the termination phase, fearful of the rat and other furry animals, illustrating
the goals of therapy are to reduce anxiety, increase stimulus generalization [61]. A more flexible pattern of
frustration tolerance, and improve relationships and conditioning identified by Skinner as operant condi-
the capacity for pleasure. The termination phase often tioning involved behaviors that could be modified or
brings up issues of separation and loss, relating both maintained by their consequences [62]. Behavior fol-
to previous experiences and the loss of the therapist. lowed by pleasant consequences was likely to increase
These issues may relate to more global concerns in frequency, whereas that followed by unpleasant
regarding the acceptance of limitations in life. consequences was likely to decrease.
Play is a frequent feature of psychodynamic psy- A third development was cognitive behavior therapy,
chotherapy [51]. Anna Freud and Melanie Klein which has been widely used in both adult and child
[52,53] initially provided principles for the use of play psychiatry [63,64]. The basic assumption is that cogni-
in child therapy as well as the understanding that play tive processes, including expectations, beliefs, or attri-
had unconscious meaning. Winnicott [54] expanded butions, influence behavior and affect. Irrational and
these concepts, using play as an intermediate or tran- faulty cognitive processes foster maladaptive behav-
sitional object between fantasy and reality. Currently iors, which can be reversed by modification of this
the techniques in psychodynamic psychotherapy are cognition. The cognitive behavioral approach is there-
modified to meet the developmental needs of the child fore less concerned with the influence of affect. This
and there is active involvement of the parents in the approach recognizes the field-dependence of children,
process. Other aspects of play therapy include the and emphasizes that other individuals in the childs
mastery of conflictual situations, with the therapist environment should be enlisted in the treatment of the
suggesting alterations in repetitive or nonproductive child. The cognitive behavioral model requires that
play sequences, even in children with ADHD [55]. the success of therapy should be determined from
Alternatively, the therapist may remain an observer, observed behaviors rather than reported subjective
while the child seeks his or her own solutions. Coppo- experiences, and that all treatment techniques should
lillo indicated the powerful effects of play therapy, be based on empirically derived clinical techniques.
including the childs immersion into play and how pos- In contrast to cognitive behavioral models, social
sible affects are offset by the reality of the therapists learning theory, developed by Bandura, includes obser-
presence and his or her capacity to tolerate the childs vational learning, in which behaviors change as a result
impulses [51]. of observing a model [65]. A child who views another
The effectiveness of psychodynamic therapy is child being rewarded for a particular behavior is more
unclear, since most therapies are used by individual likely to perform similar behavior. Hence, the child is
clinicians. Weisz and Weiss [56] and Weisz et al. [57] able to effect change by himself or herself.
reported that psychodynamic therapies had less meas-
ured therapeutic effect than behavioral treatments. On Behavior Therapy Techniques Particularly Used for
the other hand Fonagy and Target found that children Disruptive Behavior Disorders
with disruptive behavior who remained in psychody- Several terms are frequently used in the behavioral
namic psychotherapy for more than a year 69% were literature, many of which refer to the treatment of
no longer diagnosable on termination [58]. In any case disruptive behavior disorders. General techniques of
psychodynamic therapies have been less rigorously behavior therapy include reinforcement, in which
tested than behavioral treatments. behavior is strengthened by its consequences, as in
operant conditioning. In positive reinforcement the
Behavior Therapy reward is presented after the occurrence of a desired
As described by Vitulano and Tebes [59] behavior behavior, and in negative reinforcement the reward
therapy originated from the well-known experiments involves the removal of an aversive stimulus after the
of Pavlov, who found that when an unconditioned desired behavior happens. Continuous reinforcements
stimulus appeared repeatedly with a previously neutral are administered each time a response occurs. In con-
stimulus, this neutral stimulus would eventually elicit trast to intermittent reinforcement, in a fixed, interval
a conditioned response that resembled the uncondi- schedule a child is reinforced after a specific time
tioned reflex [60]. For example, Pavlovs dogs, who ini- period regardless of the response, and in a variable
tially salivated at the presentation of food, eventually interval schedule, the rate of reinforcement varies ran-
salivated at the sound of a bell. Similarly in humans, a domly. A fixed ratio technique administers reinforce-

ment after a specific number of the childs responses, elicit a rapid decrease in problem behaviors and may
whereas a variable ratio technique reinforces randomly be useful for some self-injurious or aggressive behav-
around a specific average of desired responses by the iors. The behaviors usually change only temporarily,
child. Intermittent reinforcement responses may be however, and may be associated with fear or escape
difficult to change; compulsive gambling, for example, responses, or even by reinforcement due to the nega-
demonstrates how intermittent reinforcement can lead tive attention the child receives during punishment (as
to high rates of response. Parents who are inconsistent distinct from the lack of attention otherwise received
and variable in their responses to a child may reinforce from the parent). The behavior may simply be dis-
the behaviors they wish to extinguish. placed. Parental commands such as Dont let me see
Other techniques include reinforcing a particular you hit your sister may lead to the child hitting his or
response in the presence of one stimulus but not in her sister somewhere else; the parent who punishes
the presence of another. Common examples include may in turn model aggressive, physical, or verbal
shaping, in which closer and closer approximations of behavior as well as a lack of respect for the rights of
behavior produce a final desired behavior. In this others. Children who are physically aggressive have
approach, rewarding and reinforcing initially occur for often seen such behavior modeled by others; similarly,
small changes of behavior, and as the behavior those who have been severely beaten will frequently
becomes closer to the goal, the rewards continue but continue this behavior as they grow older.
the tasks and standards of behavior become more Punishment procedures that appear to be effective
stringent. In contrast, fading involves changing a include time-out, in which the child is removed from
stimulus so that a new stimulus eventually produces the setting where the behavior occurred and is placed
the same response. Chaining involves reinforcing in a restrictive environment such as his or her room for
more and more links to produce a complex chain of a brief period, and response cost, in which a reinforcer
behavior, as in teaching an autistic child the sequence is removed because of misbehavior. In the latter case,
of dressing. Contracting is primarily used to increase a child may have privileges such as the use of a televi-
specific behaviors or eliminate unwanted behavior. Con- sion or telephone temporarily removed, with the
tracts for particular patterns of performance commonly opportunity to earn back these privileges. In overcor-
involve sequences about what the child and the parents rection, the child may be required to negate the effects
should do. They are used especially with adolescents of his or her actions, for example in cleaning crayon
and have the advantage of distancing: the contract off the walls or contributing toward the cost of repair-
involves a relatively neutral, agreed-on interchange that ing damage in the house. Alternatively, the child may
is distinct from high-level arguing. Finally, modeling is be required to practice positive behavior incompatible
frequently used in modifying parentchild or other with misbehavior; for example, a child who leaves his
adultchild interactions at home or at school. or her books around in a messy fashion may be
Several suppressive techniques in behavior therapy required to line up the books in a particularly neat
are used to reduce or eliminate behavior; some of these fashion.
techniques have achieved a degree of notoriety [66]. The treatment of conduct disorder and antisocial
For example, the use of massive negative stimuli such behavior may consist of problem-solving skills train-
as cattle prods to change the behavior of autistic chil- ing (PSST) or behavioral parent training [67,68].
dren gave rise to justifiable concern. More generally, Kazdin and colleagues [69] and Barkley et al. [70]
extinction occurs when reinforcement is withheld after showed that a combined approach of PSST and parent
an offered response in order to reduce the frequency of training is effective in treating antisocial behavior in
this response. For example, parents may be taught to children. As in all therapies, those children who
respond to a childs crying at night by not going into respond best, may have more internal motivation and
the room immediately and to progressively increase the more motivated parents.
length of time before they go in. A similar response is Behavior therapy for ADHD has been shown to
that of differential reinforcement, in which reinforce- enhance learning and improve academic performance,
ment is given for nonoccurrence or low rates of occur- although the usefulness of such techniques in the
rence of a problem behavior, such as hitting teachers absence of psychostimulant medication is still a matter
or other children. of discussion [71]. This issue has been clarified by
Punishment such as scolding, spanking, or remov- results of the National Institute of Mental Health mul-
ing privileges is used to reduce undesirable behavior timodality treatment study of children with ADHD
through the introduction of an aversive stimulus or the [11,72]. In this large study, subjects were randomly
removal of a positive stimulus. Punishment is able to assigned to one of three manually based protocols

medication only, psychosocial therapy only, or tion (being blamed for particular events), and dichoto-
combined medication and psychosocial therapy mous thinking (which does not allow for intermediate
versus a community standard treatment (assessment positions).
and referral). Therapists may use such cognitive techniques to
Other areas for behavioral techniques include per- explore the bases of faulty assumptions and to teach
vasive developmental disorders, autism, and mental alternate coping skills such as assigning measures of
retardation, all of which focus on suppressing probability and reassigning attribution. In contrast,
unwanted behaviors and teaching new skills [73,74]. more formal cognitive behavioral techniques help
Behavioral approaches have also been used for enure- patients test their dysfunctional cognitions and change
sis and encopresis. The bell and pad treatment for their behavior by using homework assignments or time
enuresis has been in use since its description in 1938 by structuring, increasing specific activities, or carrying
Mowrer and Mowrer [75]. This technique is effective out exercises related to specific situations. Some studies
in 7580% of cases but also has a relapse rate of about have described the successful use of cognitive therapy
40%. The dry-bed training technique of Azrin and in adolescents with issues such as depression and dis-
colleagues incorporates several behavioral techniques, torted perceptions regarding appearance, sexuality,
including positive practice, reinforcement, punish- and competency [79]. Leahy has suggested using a rep-
ment, and the urine alarm and thus may be more effec- resentation of dichotomy, with figures such as the bad
tive than the urine alarm only [76]. Behavior therapy thoughts monster and the smart thoughts man [80],
for functional encopresis uses positive conditioned but challenging assumptions may be difficult with
reinforcement and/or regular checks toward full clean- children [81,82].
liness. Laxatives or suppositories are often used as A variant of the cognitive approach, which has been
adjuncts. particularly used for depression among adolescents, is
interpersonal therapy, as described by Moreau and col-
Behavior Therapy Techniques Particularly Used for leagues [83]. In contrast to formal cognitive behavioral
Internalizing Disorders therapy with its emphasis on internal cognitions and
Desensitization has been widely used to reduce chil- relatively less emphasis on affect, interpersonal psy-
drens fears, as in the gradual exposure of a child to a chotherapy emphasizes particular emotional and cog-
conditioned stimulus such as separation, test taking, nitive situations that exist between the patient and
or frightening animals [77]. An extension of this stressful circumstances or persons. By going through
technique is participant modeling, in which a parent these areas, it is possible for the patient not only to
models a lack of fear of a particular animal, for recognize how certain situations may provoke depres-
example, and the child is then able to follow this behav- sion or other affects but also to work on alternate
ior. In systematic desensitization, the child works with strategies.
the therapist to establish a hierarchy of fears about Behavior therapy has been used for child and ado-
anxiety-provoking stimuli; these stimuli are then pro- lescent depression dealing with poor self-esteem, social
vided during therapy from the least to the most anxiety isolation, and hopelessness, and self-control training
producing. This may be done either in imagination or has demonstrated efficacy in treating depression in
in vivo, as in taking a child to school who has school children and adolescents. As noted, it has also been
phobia. Flooding or implosion therapy involves having shown to be effective in a recent study of depression
the child come into contact with the most feared item the combination of fluoxetine and CBT by March and
in the hierarchy. It has been found useful for children colleagues, where again the combination was more
not responding favorably to gradual desensitization, effective than either individually, but the CBT had a
but its general use is discouraged because it is often more robust effect [12]. Previously, Brent and col-
anxiety producing and may be used as a punishment leagues found that individual cognitive behavior
technique. therapy was superior to systemic behavior family
Other behavioral therapies for anxiety or depression therapy and individual nondirective supportive
that stress a more cognitive approach include cognitive therapy in the treatment of adolescents with major
behavioral therapy (CBT) and interpersonal therapy. depressive disorders [84]. OCD has been shown by
As Petti has noted [77], in the former therapy, cogni- March and colleagues [85] to be responsive to exposure
tive distortions or errors in reasoning (such as those and response prevention techniques, where patients are
noted by Beck and colleagues [78], and Kovacs and asked to expose themselves to real or imagined dis-
Beck [79]) include arbitrary inferences, selective tressing thoughts or experiences until the distress
abstraction (details taken out of context), personaliza- caused by these agents has abated. This technique,

combined with medication to offset the more severe These points are described in the manual on sys-
forms of OCD, has been shown to be particularly tematic training for effective parenting [91]. In contrast
effective and often utilizes manuals that lead to a more to behavior therapy, which emphasizes doing things to
rational cognitive behavioral therapy approach. or with the child, Adlerian therapy aims to give the
In contrast to the above cognitive approaches, child as much power as possible, including allowing the
rational emotive therapy emphasizes an active dispute child to make choices. These choices are often demar-
with the patient concerning fundamental dysfunc- cated by the parent, as in You have a choice to stop
tional thoughts and teaches the evaluation of actions hitting your brother or to go to your room, but are
[86]. Waters used rational emotive therapy for dis- nonetheless choices. If the child cannot make a deci-
turbed youth and focused on cognitions and the iden- sion, then the parent has the option of taking over and
tification of sources causing specific problems [87]. making the decision for the child. The child is told,
Goals for young children are to identify emotions, dis- however, that the parent is willing to hand back the
tinguish thoughts from feelings, be alert to self-talk decision to the child as soon as the child is capable of
(private speech about oneself), connect self-talk and doing this. The general phraseology is, I see that you
feelings, and develop rational coping statements. There are unable to choose how to sort out your problem. I
is a possibility of confrontation in this technique, will take care of your problem, but then I will solve it
which may cause concern to some patients and fami- my way. You may have your problem back at any time
lies, and which must be handled in a tactful fashion. when you are able to solve it.
Interpersonal cognitive problem solving, which It is important for the parents to give directions as
Shure and Spivack found effective with pupils in poor neutrally as possible, and for the therapist to reinforce
urban preschools, is conducted by teachers and stresses this. Usually a prior group program of parent training
alternative solution thinking as well as means-end is useful. A somewhat counter-intuitive approach is
thinking, which in turn leads to better interpersonal that when a child is being aggressive or oppositional,
adjustment and less psychopathology [88]. Self- parents should be free to remove themselves from the
management skills in cognitive therapy include self- scene, on the basis that quarreling cannot occur in the
regulation for some phobias and self-instructional absence of one of the two parties.
training. The latter may be particularly useful for chil-
dren with concrete thinking or learning problems and Family and Group Therapies
either low to average intelligence or retardation [89,90]. There are many models of family therapy with differ-
In summary, the various behavior therapies pre- ent theoretical bases. They have in common a focus
sented have been found to be particularly useful for on treating the family as the defined unit for therapy:
treating internalizing disorders. problems evolve from the family structure and history,
and although the child or adolescent may be the iden-
Adlerian Psychotherapy tified patient, the basic problems rest within the family.
Although not generally described in many compendia These approaches therefore address interactional com-
of therapy, the Adlerian or NeoAdlerian approach ponents, although Ravenscroft has noted that earlier
described by Dinkmeyer and McKay is often extremely patterns of family therapy stressed psychoanalytic
useful, especially with intelligent verbal children with principles [92]. Satir and colleagues at the Mental
oppositional defiant disorder whose parents are also Health Institute in 1958 focused on a communications
intelligent and verbal [91]. The goals of misbehavior family therapy model, which later led into Haleys con-
as defined in this form of therapy include: (1) requir- cepts of strategic family therapy [92]. Minuchin devel-
ing attention in which children only feel they belong oped structural family therapy based on working with
when they are being noticed or served; (2) power, in multiproblem families from low socioeconomic groups
which children feel that they belong only when in [93]. Earlier systemic approaches to family therapy
control; and (3) revenge, in which children feel that were based on general systems theory, including the
hurting others is necessary because they cannot be concept of cybernetics, which held that families tend
loved. Displays of inadequacy also convince others not to maintain equilibrium: a tension always exists
to expect anything from the child. In contrast, the between homeostasis and change, balancing stability
goals of positive behavior include involvement and and self-preservation with change and adaptation.
contribution, feelings of power and autonomy, feelings Strategic and structural family therapy arose from this
of justice and fairness, and feeling the opportunity to theory and focused on observable as well as reported
withdraw from conflict. (It is not necessary to fight all family behavior. Structural family therapy requires
battles!) that dysfunctional family structures are observed when

the family is in action and allows for active suggestions stresses phases of engagement and motivation, behav-
for change. Strategic family therapy primarily empha- ioral change, and generalizations which are linked to
sizes deciphering the family communication rules that specific goals for each family. Further forms of family
underlie problems, leading to planned strategies for therapy include extended family therapy and object
change and greater emphasis on cognition (Table 6.2). relations family therapy; the former obviously relates
Other schools of family therapy include behavioral to extended family and social networks, and the latter
approaches such as the parent behavioral training returns to the psychoanalytic roots of family therapy,
model for family therapy described by Griest and Wells in which internal psychologic development occurs in
[94]. Another behavioral approach is functional family relation to significant caretakers.
therapy, in which maladaptive behavior evolving from There are a number of schools of family therapy,
the family context becomes more interpersonally adap- whose basic components are often associated with par-
tive [95]. This active approach has been widely used in ticular therapists who in turn tend to have their own
intervention and prevention programs for children disciples. The style of family therapy used is frequently
with substance abuse and antisocial problems, and overly dependent on the practitioners schooling.
Alternatively, family therapists may eschew labels for
Table 6.2 Varieties of Family Therapy. an eclectic approach; frequently, however, the thera-
pist functions flexibly with patients but then has diffi-
Strategic (Haley, Madanes) culty defining what he or she is doing.
The pattern of symptomatic behavior is the best Family diagnosis as such is not a major feature of
solution to conflicts that the family has developed family therapy, although a number of clinicians,
The therapist disrupts negative patterns of including Epstein and colleagues [23] and more
interaction by prescribing tasks that the family as a recently the Family Therapy Committee of the Group
whole needs to contribute for the Advancement of Psychiatry, have advanced
concepts for family therapy diagnosis. Other diagnos-
Structural (Minuchin) tic models and typologies include the Beavers systems
The therapist recognizes dysfunctional patterns model of family competence and adaptability versus
within the family that leads to children to exhibit family interaction styles versus the Olson circumplex
behavioral problems. Frequent dysfunctional patterns model, which measures dimensions of family behavior
are enmeshment (ineffective closeness), such as cohesion, adaptability, and communication
disengagement (excessive distance) and scapegoating [96]. Combrinck-Graham described families in a
Systemic (Bowen) more developmental fashion, with the introduction
The therapist promotes differentiation and may use of the family life cycle [97]. The multiplicity of models
triangulation (therapist may pair with family member allows family therapies to evolve from more behavi-
to understand other member) to elicit help within the oral to intercommunicational and intrapsychic func-
family to reflect and work through intergenerational tioning, in line with the general sequential model of
conflicts. Genograms are used to help explore the psychotherapy.
way the family system has created rules, and
hierarchy Group Therapy for Children and Adolescents
As described by Cramer-Azima [98] group therapy
Behavioral (Patterson) started with group analytic models, as with that of
The therapist identifies problematic behavior in Anthony [99] and then evolved to activity group
children and helps parents reinforces positive therapy, focusing on observation of the childs behav-
behavior. This form of therapy focuses on the here ioral and motoric communications in a particular
and now conflicts group action. Most group therapists now use a mixture
Psychodynamic/object relations (Ackerman, Framo) of developmental and group assignment frameworks,
The therapist helps members of the family recognize either with parents in parallel treatment with younger
that their needs in the family are based on their own children or with groups of children who have common
early parentchild experiences. The insight gained or at least interconnected problems. One of the tech-
helps members appreciate their limitations and nical difficulties is to focus on what represents a group.
understand the distortions they have of others The group allows for a commonality in approach, but
intentions it may lead to a number of children or adolescents held
to be similar for therapy purposes, but actually very

different individually and clinically. The observation Summary

that other children have similar problems is nonethe-
In this chapter, the processes of diagnosis and psy-
less useful in reducing a childs anxiety and may lead
chopharmacologic and other psychotherapeutic treat-
to the evolution of shared coping skills.
ments in children and adolescents has been outlined.
A number of groups for special populations there-
A sequential model was described that allows for a
fore exist, including those for social skills, under-
rational selection of therapies for the complex prob-
achievement in school, divorce, abused children, and
lems met by child and adolescent psychiatrists. Such an
drug-using children, as well as parent/family groups
approach, which leads to the sequential descriptions of
stressing family evolution and parent training [100].
defined goals and objectives, is increasingly important
Groups for older children and adolescents using inter-
in an era marked by increasing impetus for accounta-
personal and cognitive behavioral models have been
bility. Finally, the complex and rapidly adumbrating
established [100102].
areas of specific forms of psychotherapy have been
Groups can be used in an evolutionary fashion,
briefly discussed. Child psychiatrists and others train-
changing over time from behavioral to more commu-
ing in this area need to have a broad training, proba-
nicational emphases. Group therapies are often attrac-
bly with an emphasis in a particular area. But they
tive to a number of insurance companies, because they
should also be able to tailor their approaches to the
give the impression that more can be achieved for a
varying clinical needs of the child, parent or society.
greater number of children with less cost; the hard
It is hoped that this brief summary will help child
evidence for this is unclear, however. In one analysis,
psychiatrists choose competently and selectively
group therapy treatment was found to be more effec-
from among the often-bewildering mosaic of available
tive than individual treatment in 31% of the cases.
Some studies have discussed the effects of group
therapy for particular diagnoses. Fine and colleagues,
for example, found that depressed adolescents in a References
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Assessment of Infants and Toddlers
Martin J. Drell

Introduction the unending march of development, the problems

noted often change with time or even disappear. It is
In this chapter, I explain the basics of conducting
only when caregivers perceive that there is a significant
an infant assessment. I do so by answering three
problem and the problem endures despite their best
efforts to solve or deny it that they seek an assessment.
(1) What are the fundamental aspects of an infant The overall goal of an infant assessment is to col-
assessment? laborate with the caregivers to identify the problem,
(2) What models does one use to conceptualize infant mutually agree on the factors that contribute to the
assessments? problem, and design an appropriate treatment strategy.
(3) How does one actually conduct an infant If any members of this team of caregivers and pro-
assessment? fessionals disagree, this constitutes a separate thera-
peutic problem. Often, important clinical information
As I address each of these questions, I suggest general
can be ascertained while working from disagreement
modifications and accommodations to make when
toward mutual agreement. Like any diagnostic assess-
assessing very young children. Other articles address
ment, such a process provides an absolutely unique
the specific content of infant assessments in more
entree into how the caregivers see the world, get along
detail [1 4].
with people in this world, and solve problems.
Fundamental Aspects of an Infant Assessment
The purpose of the assessment is to define the problem
and elucidate its cause. An assessment is triggered by
the perception that there is a problem. In the case of A couple brought in their 24-month-old son
very young children, the perception is usually voiced by for an evaluation. The mother was upset that
a parent or caregiver. The problems generally center on her child was hyperactive and unmanageable.
aspects of normal daily activities such as eating, sleep- The father felt that there was no problem,
ing, bathroom functions, motor activities, and interac- stating that boys are just that way. He went
tions. Based on their own experiences including those on to denigrate his wifes parenting skills. The
with other very young children, what they read, and evaluation showed a child who was caught in
what they are told by others, the parents have a general the middle of his parents marital problems.
idea of what their child should be doing. When their The childs behavior was a response to these
child does not meet these expectations, they become difficulties. The behaviors ceased immediately
concerned and try to figure out whether there is a after the parents were counseled on the impact
problem and, if so, what to do about it. In the vast of their difficulties on the child and sought
number of instances, this perception of something marital therapy. They were astounded that a
being wrong is not enough to lead to a formal assess- two-year-old could pay attention to these
ment. Parents assume that the problem is transient, that issues. This is an example of how disagree-
it is within the range of normal behavior, or they deny ments about what the problem is can be used
that there is a problem. And indeed, due to the dynamic in the treatment effort.
nature of very young children, their relationships, and

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

Most experts agree that it is helpful to gather data Language. Does the child laugh? Does the child turn
from many sources. As in the first case study, differ- in response to anothers voice? Does the child imitate
ences in perception often occur between the various speech sounds? Does the child speak? How complex
persons involved. It is also vital to observe the infant is his or her speech?
and to judge the infants interactions with the key Gross motor. Can the child roll over? Can the child
persons in the infants life, as well as with the assessor. sit? Can the child stand? Can the child walk? Can the
The importance of these interactions is a key focus in child walk backward? Can the child walk upstairs?
infant work. Finally, most experts admit that no one Can the child kick and throw a ball? Can the child
specialty or person has a mastery of all the knowledge balance on one foot?
needed to assess infants and their caregivers. As a
result, infant assessments often involve the expertise of All these skills have been tested on thousands of chil-
numerous disciplines, including, but not limited to, dren to determine what are the normal ranges of
child and adolescent psychiatry, pediatrics, clinical behaviors in each of these categories. A failure to
psychology, developmental psychology, speech and develop appropriately in any of these areas may indi-
hearing, physical therapy, genetics, and social work. cate a deviation. Certain types of developmental
Each of these disciplines has its own approaches, failure are indicative of specific types of problems and
knowledge base, and formal assessment tools. When disorders. For example, children with early autistic dis-
integrated, the information provided by these disci- order show a cluster of abnormalities in their ability to
plines can be invaluable in defining problems and interact with people, in their ability to play, and
formulating what needs to be done to help moderate perhaps in some of their motor skills. A fundamental
the problem. component of assessing young children is appreciating
what is normal and abnormal development for a par-
ticular age group. This is learned over time by seeing
Models of Infant Assessment many young children.
A biopsychosocial approach implies that problems
I use a systems oriented developmental, biopsycho-
(and their solutions) evolve from the interaction of
social model. The term systems refers to the belief
biologic, psychologic, and social phenomena. These
that people are best understood when they are viewed
phenomena should not be considered all negative and
as important interacting parts of a larger family system
include protective factors and individual resiliences.
that is in turn part of still larger social systems such as
During assessments, one must attend to these strengths
peer groups, religious groups, organizations, and cul-
and weaknesses and the possibility of problems in
tures. This emphasizes the importance of the continu-
all these overarching categories. Unfortunately, when
ous interaction of all these systems and it assumes the
dealing with infants or toddlers and their caregivers,
continual evolution of problems and people. A systems
there has been a tendency to accept the first reasonable
approach also implies interest in the antecedents of the
theory. For example, in the 1950s it was thought that
problem as well as its consequences.
autistic disorder was caused by faulty parenting. The
A developmental perspective implies that children
experts who believed this at the time were correct that
develop over time. It stresses the need to examine the
the parents of autistic children acted differently than
child against established norms for other children his
the parents of other children. They were incorrect,
or her age. This perspective recognizes that develop-
however, in attributing the cause of the disorder to
ment occurs in numerous areas of the childs life. The
the parenting. Subsequent research has shown that the
Denver Developmental Screening Test, a long stand-
abnormalities in parenting noted are within the norm
ing and popular screening instrument for very young
of expectable responses of parents faced with a young
children, categorizes the areas of development in the
child who is different and who therefore poses unique
following way [5].
parenting challenges. The cause of early infant autism
Personalsocial. Does the child smile? Does the child is now believed to be neurodevelopmental (i.e., a
respond to his or her caregivers in ways that indicate disruption in early brain development). Numerous
that they are special? Does the child respond differ- prenatal, perinatal, and postnatal biologic events are
entially to strangers? Does the child indicate his or also known to cause the types of behaviors that lead
her needs? Does the child imitate other people? to the diagnosis of autistic disorder. A short list of
Fine motor-adaptive. Does the child grasp a rattle? these includes maternal rubella, untreated phenyl-
Does the child sit? Does the child have the ability to ketonuria, tuberous sclerosis, anoxia during birth,
transfer an object from one hand to the other? encephalitis, infantile spasms, and fragile X syndrome.

Neurodevelopmental problems also affect a young (1) What the mother (and other key persons involved
childs social skills, which in turn have consequences in the infants caregiving system, including pedia-
for the caretakers. A systemics oriented developmen- tricians) thinks is happening. This constitutes the
tal, biopsychosocial approach assumes that the behav- RM (mothers representation) part of the model.
iors of the parents reciprocally affect the social skills (2) How the mother and the other involved caregivers
of the child, which may in turn affect the biology and behave and interact with the infant (and each
brain development of the child. other) as well as how the infant behaves and inter-
Development is a dynamic process that affects and acts with the mother and other caregivers. This
is changed by interacting biologic, psychologic, and constitutes the BM (behaviors of the mother)/BI
social events. Thankfully, for the assessor, these inter- (behaviors of the infant) part of the model, which
actions usually have a predictable quality that facili- defines the interaction.
tates diagnosis. As with the psychiatric disorders of (3) What the infant thinks is happening. This coin-
older children and adults, there are key behaviors cides with the RI (infants representation) part of
and interactions that differentiate the infant disorders the model. Knowledge concerning the representa-
from one another. tions of infants is sparse and remains speculative,
In 1989, Stern-Bruschweiler and Stern proposed a since it is difficult for researchers to ascertain with
systems model for conceptualizing the role of the certainty what goes on in an infants mind [7].
mother or primary caregiver in motherinfant thera-
An infant assessment, then, involves asking questions
pies [6]. I find this model helpful in my approach to
about what may have occurred to get things to their
infant and toddler assessments. The model consists of
present state and then developing a coherent story con-
four interdependent elements in constant dynamic
cerning the relationship of these four elements.
equilibrium (Figure 7.1). These elements are the
(1) the infants overt interactive behavior; Conducting an Infant Assessment
(2) the mothers overt interactive behavior (items 1 There are varying ways to accumulate the essential
and 2 together constitute the interaction); data for a comprehensive assessment. All the tech-
(3) the infants representation of the interaction (i.e., niques are directed at clarifying the nature of the
how the infant understands what is happening in problem and constructing a formulation that will serve
the situation, including whats happening to him or as the basis for a treatment plan. This section is organ-
her and others in the interactions); ized around the three major categories of information
(4) the mothers representation of the interaction. set forth in the Stern-Bruschweiler and Stern model.
All four elements together constitute the relationship.
In the assessment, this translates into the need to eval-
Assessing the Perceptions of the Mother and
uate three major categories of information:
Other Caretakers
The first step of any evaluation is to identify the people
The relationship who are involved with the infant. One then asks each
of these individuals to define the problem. Consider
speaking to the person who made the initial contact
with you, since this person has probably been chosen
as the spokesperson for the family. It is often best to
start with the familys perception and move from there.
Often this means dealing with the fears, mispercep-
tions, misunderstandings, and defenses of the family,
all of which can interfere with an accurate accounting
The interaction of what is happening. The same processes are critical
to each step of the treatment.
Figure 7.1 The Stern-Bruschweiler and Stern model. People to be interviewed are those who can provide
Reproduced from Plotkin J: The at-risk infant. In: information on problem definition, who might have
Parmelee DX, ed. Child and Adolescent Psychiatry. been involved in the creation of the problem, and who
New York: Mosby, 1994:194. With kind permission of might be involved in solving the problem. This almost
Dean Parmelee, M. D. always includes the parents, and it can also include

grandparents, siblings, and other caregivers such as specific, detailed information is gathered about the
foster parents, community agencies involved in the care parents families [9]. In some cases this is done in sep-
of young children, pediatricians, professionals from arate sessions (one with each parent) that discuss how
other medical disciplines, and daycare providers. each parents family functioned as they grew up.
Having identified these key people, the clinician Parents are told that such information is valuable in
must investigate their unique stories concerning the learning about the forces that molded them into the
infant under assessment. One should cover the five Ws: people and the parents they are. Ghosts from the past
when, where, why, what, and who. Make sure everyone can lead to inconsistent or nonexistent disciplinary
is asked about their impression of the problem. It is habits and confusing interactions for infants and their
important to collect data on antecedents, behaviors, parents. Frequently family of origin issues arise natu-
and consequences (the ABCs in behavior terminol- rally during the assessment as parents associate to
ogy). Thus, the assessment will investigate events events, often stressful, in their past lives.
before the problem started, while the problem occurs,
and what happens as a result of the problem. Are there
times and situations when the problem doesnt occur
or things that make the problem better or worse? It is
important to determine with whom the problem CASE TWO
occurs, since the infants behavior can be person spe-
A mother brought her two-year-old in for an
cific. The clinician should understand that at this stage
evaluation to see if he was hyperactive. The
in the assessment, the perceptions of key people vary.
child was indeed more hyperactive than most
Problems are, of course, in the eye of the beholder.
children his age. In the interview, I was
Often one parent may feel that there is no problem
puzzled that the mother put extraordinary
(e.g., Hes just a spirited boy, or My parents told me
emphasis on the fact that she had read that
I was just like that when I was that age, and I turned
hyperactive children had something wrong
out OK). When faced with differing perceptions, the
with their brains. After a successful behavioral
assessor should ask questions about these differences.
intervention and parenting work, the childs
This line of questioning elicits peoples differing per-
behavior moderated. Rather than being
ceptions of what is normal or not normal. It also
pleased, the mother continued to worry about
allows the assessor to identify misconceptions or
her son and the possibility of brain damage.
knowledge deficits about infants that can be remedied
She especially wanted to know if he would
through education. Such differences of perception are
get better. More careful family of origin work
often the first sign the assessor receives of problems
on my part unearthed a brother with profound
between the parents that may be contributing to the
mental retardation that had been sent to live
infants or toddlers behavior.
in an institution at an early age. A discussion
It is wise to ask questions about how and why the
of the impact of this brother on the mothers
parent has arrived at his or her perception. How did
family when she was growing up provided
you come to that idea?; What does the infant do that
clues about the mothers concern over
leads you to believe that?; Who told you that? If these
damaged brains that do not get better.
initial questions are not productive, the answer needs
to be pursued in the past history of the parent. This
approach is reflective of the early infant work of Selma
Fraiberg on what she called ghosts in the nursery [8],
In this pioneering work, Fraiberg hypothesized that The assessor should gather information concerning
many infant and toddler problems stem from unre- the infants development and maturation, including
solved parental conflicts that distort their interactions gestation, birth, perinatal events, and developmental
and behaviors with their children in the here and now. milestones. The assessor should also ask about medical
To emphasize this point, I often tell parents: You raise problems, medical procedures, current medications,
your kids exactly as you were raised or exactly the allergies, and hospitalizations. Information should be
opposite, and both are wrong because you arent your received from the pediatrician when indicated, espe-
parents and your child isnt you! This starts parents cially if there is suspicion of a biologic disorder. In
thinking about their pasts. cases in which the infant has not had routine pediatric
A more formal technique for getting at the ghosts care, this should be suggested as a means of providing
in the nursery uses family of origin work, wherein preventive care.

psychologist is suggested. These psychologists have

CASE THREE access to and knowledge of specific developmental
tests and instruments that usually yield a clear
A mother was very concerned about her 12-
profile of the infants strengths and weaknesses
month-old daughter who was not responding
(Table 7.1).
to her. She worried that her daughter might
As the assessor gathers the history, usually a story
have autistic disorder. The assessment showed
or major themes emerge that create a clearer sense of
that the child was hearing impaired. Referral
the problem. In a few cases, the caregivers information
to speech and hearing specialists led to a
is sufficient to determine the problem and suggest a
dramatic improvement in the responses of
solution. In most cases, however, the clinician assesses
her child.
the behaviors and interactions of the infant and the
caregivers through interactional sessions.

The assessment should seek to elicit key events in the

past history of the infant and his or her family that Assessing the Interaction
might perturb or influence the families interactions. The interactional approach may include sessions with
These events include deaths in the family, the subse- the evaluator and the infant as well as with the infant
quent reactions to these deaths by family members, and family members. Sessions with the infant help the
separations, medical or emotional problems in other assessor better understand the infant outside the
family members that might change the parentinfant context of his or her caretaking environment. Sleep
interaction (e.g., postpartum depression or medical disorders, attention deficit hyperactivity disorder,
illness of a parent), accidents, fires, or persons being developmental disabilities, and anxiety disorders can
laid off from work. prove important in the genesis of interactional prob-
lems. In short, if the evaluator is overwhelmed by the
child, uncomfortable with the child, or cannot get
CASE FOUR the child to interact normally, then this is important
information. Likewise, it is equally important if the
The 22-month-old daughter of a single father evaluator has no difficulty interacting with a child
whose wife had recently died in an auto acci- who appears normally behaved. It may indicate that
dent was having temper tantrums daily and the problem stems from something the parents are
was kicking, refusing to go to sleep at the doing or not doing to which the infant is reacting
proper time, and incredibly oppositional. The with relationship or situation-specific problematic
father was overwhelmed both with his grief behaviors.
and with his new duties as a single parent. The
father was helped to appreciate that his
daughter had equally strong feelings concern-
ing the death of her mother. He was instructed
to talk to his daughter about the death and to CASE FIVE
open this area for discussion. He was coun- A two-year-old with severe temper tantrums
seled on what to expect from his daughter and played beautifully with the evaluator. The
how to deal with her emotions. He was further same two-year-old was then observed while
supported in the process by the therapist, who she played with her mother. This play session
helped the father with his own grief. As part was punctuated by numerous temper
of the process, the father and daughter put tantrums. The evaluator noted that these
together a scrapbook of mementos and pic- occurred when the mother intervened to finish
tures of the mother. The oppositional symp- play sequences that the two-year-old wanted
toms lessened over several weeks. to do herself. The mother would repeatedly
tell her child that she was doing it wrong
and, in frustration, would take over the play.
In cases in which the assessor has specific questions At this point, the child would complain. If the
concerning the childs development or lacks the knowl- mother did not turn the play back over to the
edge base or expertise to properly assess his or her child, then she would begin to tantrum.
development, referral to a developmentally trained

Table 7.1 Infant development screening tests.

Screening test Age range Time to administer (min)

Batelle Developmental Inventory 08 yr 30

Bayley Scales of Infant Development 130 mo 4590
Clinical Adaptive Test/Clinical Linguistic Auditory 136 mo 1520
Denver Developmental Screening Test II 06 yr 30
Developmental Screening Inventory Revised 118 mo 2030
Early Language Milestone Scale 036 mo 5
Gesell Preschool Test 2.56 yr 40
Infant Monitoring Questionnaire 436 mo 1520
Miller Assessment for Preschoolers 8 mo5 yr 2030
Minnesota Child Development Inventory 16 yr 1015
Peabody Picture Vocabulary Test 2.54 yr 1020
Vineland Adaptive Behavior Scales 019 yr 2060

From Plotkin J: The at-risk infant. In: Parmelee DX, ed. Child and Adolescent Psychiatry. New York: Mosby; 1994:194.

Interactive sessions can provide information that

cannot be gathered by parental interviews alone, as CASE SEVEN
some problems are outside the awareness of the
A father complained that his 21-month-old
parents. Calling such patterns to the attention of the
was not obedient. In a videotaped play
parents during the assessment can allow the parents to
sequence, it was noted that the father would
see their childs problems in a new light. Parents can
ask his young son to do something but would
be quite resistant to such insights, however. Because of
not give his son adequate time to respond. The
this, the material elicited by the assessor must be
fact that the son did not respond immediately
handled with great therapeutic sensitivity. The evalua-
frustrated the father, who would then re-ask
tor must be empathic to the fear and guilt in many
his son in a louder voice. The son who wanted
parents that they are responsible for their childs prob-
to respond but didnt have time also became
lems. In cases in which the interactions are too subtle,
frustrated and began to say No. At this point,
too complex, or too confusing to keep track of in real
the father became angry and began to yell at
time, videotaping the sessions can be useful. Be sure to
his child, who he felt was being disrespectful.
obtain appropriate consent for these procedures.
The evaluator showed the videotape sequence
to the father, who was able to see how his son
was really trying to please him. The father was
CASE SIX given some developmental guidance on what
a 21-month-old is capable of and was told
A mother was concerned that her three-
to wait at least three seconds for a response.
month-old son was not breast feeding prop-
This allowed the son to respond to his
erly. The history proved noncontributory, so
fathers requests. The fatherson relationship
the breast feeding was videotaped. This
improved measurably after this session.
showed that the son would interrupt his
feeding at regular intervals to make eye
contact with his mother. Whenever the mother
did not reciprocate the eye contact, the baby It is not uncommon for infant experts to videotape
would become upset and interrupt the feeding interactions (usually between the expert and the infant
until eye contact was made. Once this pattern or between the infant and his or her caregiver) and to
was identified, the mother was able to adjust repeatedly replay the tape to catch all of these nuances.
her responsiveness, which caused the feedings Often combinations of unstructured time (free play in
to improve. which you ask the parent to be with the child as they
normally would be at home) and structured time (in

which you ask the parent to perform a specific inter- Table 7.2 Typical set of toys.
active task such as feeding or playing a simple game
with the infant) are more helpful and time conserving 1. Doll house and family figures
than videotaping a regular session. To facilitate inter- 2. Tea set
actions, the assessor is advised to equip his or her office 3. Trucks
with toys, games, furniture, and equipment develop- 4. Nesting cups
mentally suitable for very young children. Any combi- 5. Pop-it beads
nation of age-appropriate toys will do (Table 7.2). If 6. Playpath, with small balls in large ball
the evaluator does not have toys, he or she can ask the 7. Wooden blocks
parents to bring favored examples of the childs play 8. Pounding bench and hammer
equipment from home. This, however, does not allow 9. Dolls
the evaluator to see what play is like with new toys (a 10. Book
crude test of curiosity) or toys that might be too diffi- 11. Play telephones (2)
cult for the childs developmental level (a crude test of 12. Stuffed bear
frustration tolerance). 13. Fisher-Price hourglass
14. Playskool school bus and seven passengers
15. Playskool teddy bear shape sorter
16. Fisher-Price stacking rings
CASE EIGHT 17. Fisher-Price ring stand
A mother complained that her six-month-old 18. Plastic bowl and lid
infant cried incessantly and seemed to not like 19. Pie plate
her. The history proved unhelpful. During a 20. Wooden spoon
subsequent observation session, the evaluator 21. Gabriel busy driver
noted that the mother was grossly overstimu- 22. Fisher-Price musical roller (push toy)
lating the child with her constant and intru-
sive rocking and bouncing of the infant. It was From Harmon R: How to do an infant psychiatry assessment:
Fundamental knowledge for clinical work with infants
further noted that the mother would become
and toddlers. Paper presented to the premeeting institute,
increasingly frustrated and increase her intru- American Academy of Child and Adolescent Psychiatry,
sive behaviors the more the child cried, thus Los Angeles; 1986.
further exacerbating the situation. The evalu-
ator then videotaped the interaction and
showed it to the mother, who was able to mod-
erate her responses. Her infants crying subse- type of problem noted, such as eating disorders,
quently decreased. The mother was quite temper tantrums, and sleep disorders. The latter
pleased by the change in her infant and admit- approach is especially useful for research and for gath-
ted that she had been told that rocking and ering a personal database on the range of interactions
forceful bouncing were what one should do noted in infant work.
when babies begin to cry. While interacting with the infant, the assessor
should conduct a mental status evaluation to provide
a baseline snapshot of how the child looks, acts, and
responds. Such baselines are extremely valuable to
In several cases, I have suggested that the parents set
monitor subsequent behavioral changes. Assessors new
up a video camera at home to record problematic
to this population could profitably use the five devel-
behavior. This is especially helpful in those instances in
opmental areas in the Denver Developmental Screen-
which the infant, for whatever reason, does not display
ing Test to organize their remarks [5]. Researchers of
the problem behaviors during the assessment. Home
infants and toddlers are currently trying to formally
videos can provide wonderful additional material and
define an appropriate mental status examination for
often can be a vindication for parents who can be quite
this population [10]. Their initial attempts include the
embarrassed and angry when their infant fails to
following categories:
show the problem to the evaluator.
Some clinicians have a routine for their evaluative physical appearance, including dysmorphic features;
sessions. Some have very structured assessments that motor functioning, tone, coordination, gross and
include specific questions, tests, and tasks based on the fine tics, abnormal movements, seizure activity;

reaction to new settings and people, adaptation an increased use of words and play. Toddler assess-
during evaluation; ments also take into consideration the fact that
self-regulation: state regulation, sensory regulation, toddlers increasingly spend time with people other
activity level, attention span, frustration tolerance, than their parents. Thus, toddler assessments more
unusual behaviors; often include information about daycare and peer
speech and language, expressive and receptive lan- interactions.
guage, speech production; Having conducted a thorough assessment in which
thought: hallucinations, dissociative states, night- you have assessed the perceptions of the key players
mares, fears; involved in the presenting problem, viewed their inter-
affect and mood: behavioral, nonverbal cues to actions, assessed the infants and parents interactions
affect, intensity, range, modes of expression; with you, taken a past history and a developmental
play: structure, content, symbolic functioning, history, performed a mental status examination, and
expressions of and control of aggression; tried to assess what is going on in the childs mind, a
intellectual functioning; reasonable formulation of the problem should be
relatedness: to parent figures, other caregivers, made. The assessor should be able to view the problem
examiner. from a systems perspective and determine its develop-
mentally influenced biopsychosocial causes. At this
point, the assessor should share this formulation with
Assessing the Perceptions of the Infant
the parents and gather their feedback concerning their
The third category of information in the Stern- reactions. Any discrepancies between the assessors
Bruschweiler and Stern model is assessing the subjec- perception of the problem and those of the parents
tive experience of the infant. This often proves difficult should be clearly addressed. These discrepancies can
because of the lack of knowledge about the mental be due to simple straightforward misinterpretations
processes of infants. The younger the child is, the and misunderstandings of the facts, but they may also
greater the challenge. We cannot easily ask infants to be due to resistances. When resistances arise, the asses-
tell us their opinions of their problems. We can, sor should interrupt the process and try to empathi-
however, make assumptions based on how infants inter- cally understand their causes. Such processing of
act with their parents and the evaluator. These assump- resistances ensures that the therapeutic relationship is
tions are based on response patterns such as smiles, maintained and that treatment can continue.
reaching for objects, putting objects in their mouth, No effective treatment can occur unless the parents
periods of rapt attention, noting what is attended to, buy into the formulation. This is not the same,
crying, pouting, insistent grunts, falling asleep, crawl- however, as saying that the formulation cannot change
ing away, and avoiding certain people or objects. over time as new information is gained. My particular
As infants grow older, they develop an increased style is to share my formulations with the parents as
ability to share their experiences. The most significant the assessment unfolds. I talk out loud and share my
of these advances is the addition of babbling at 45 best guess of what is occurring at the moment and
months, words at 12 months, and the ability to think challenge the parents to tell me what is right or wrong
symbolically at 1618 months. The latter two abilities with my guesses. This technique involves the parents
allow skilled assessors to engage the infant in play and gives them a feel for the way I think, prioritize, and
therapy-type assessments. The developmental achieve- solve problems. It also allows for modeling and numer-
ments that occur at around 18 months, which include ous mid-course corrections as the evaluation proceeds.
the ability to truly pretend play, to pretend with other If the assessor has gathered the appropriate data and
people, to use one object to represent another, to is unable to arrive at a formulation, some key element
use personal pronouns, and to realize the difference or point has probably been missed. Such a situation
between self and others, distinguish infancy from tod- should prompt the evaluator to reanalyze the questions
dlerhood. Just as an assessor uses different strategies asked and the data gathered. If this reanalysis fails to
for children in middle childhood versus adolescence clarify the situation, then a consultation is probably
because of their different developmental levels, an needed. A consultant can bring additional expertise
infant assessor needs different strategies for toddlers and more objective fresh eyes to the situation. In
versus infants. Strategies for working with toddlers some cases, however, the family and assessor need to
include spending more individual time with the toddler take a wait and see approach, in which time either
than with an infant, with a corresponding emphasis on clarifies the missing element or solves the problem, or
relationship building. Within this relationship, there is the problem evolves into another form.

Table 7.3 Diagnostic Classification: Zero to Three. Should the assessor wish to make a diagnosis, he or
she can do so using the Diagnostic and Statistical
The diagnostic framework is multiaxial. It consists of Manual of Mental Disorders, Fourth Edition (DSM-IV-
five axes: TR), which includes the standard diagnostic nomen-
clature for the field [11]. Unfortunately, the DSM-IV
was not developed with very young children as its main
Traumatic stress disorder
priority. It contains only a few infant and toddler diag-
Disorders of affect
noses (e.g., separation anxiety disorder, reactive attach-
Anxiety disorders of infancy and early childhood
ment disorder, early infant autism, and pica) and does
Mood disorder: Prolonged bereavement or grief
not capture the interactive realities of most infant and
toddler problems [12]. A group of infant experts have
Mood disorder: Depression of infancy and early
attempted to address the weaknesses of the DSM-IV-
TR by designing a diagnostic classification especially
Mixed disorder of emotional expressiveness
for children younger than four years of age. It is enti-
Childhood gender identity disorder
tled Diagnostic Classification: Zero to Three (Table
Reactive attachment deprivation or maltreatment
7.3) [13]. Like the DSM-IV, the classification system
disorder of infancy
consists of five axes, each of which focuses on varying
Adjustment disorder
factors thought to be important to an infants or a
Regulatory disorders
toddlers problems. Owing to the differing develop-
Type I Hypersensitive
mental realities of this population, the axes are not all
Type II Underreactive
similar to those of the DSM-IV-TR. The Diagnostic
Type III Motorically disorganized, impulsive
Classification: Zero to Three has allowed a new gener-
Type IV Other
ation of infant/toddlers diagnosis and research to
Sleep behavior disorder
occur [1419].
Eating behavior disorder
Disorders of relating and communicating Conclusion
Multisystemic developmental disorder
Although performing a psychiatric assessment on a
AXIS II: RELATIONSHIP CLASSIFICATION very young child can be intimidating, it can be suc-
Overinvolved relationship cessfully achieved by keeping track of the fundamen-
Underinvolved relationship tal aspects of any assessment and modifying them to
Anxious or tense relationship the needs of infants and toddlers. The assessor must
Angry or hostile relationship have a solid understanding of development in this age
Mixed relationship range, as in all other ages of children and adults.
Abusive relationship
Verbally abusive References
Physically abusive
Sexually abusive 1. Greenspan S, Wieder S: The assessment and diagnosis of
infant disorders: Developmental level, individual differ-
AXIS III: MEDICAL AND DEVELOPMENTAL ences, and relationship-based interactions. In: Osofsky J,
Fitzgerald H, eds. Early Intervention, Evaluation, and
Assessment I, Vol II. New York: John Wiley & Sons,
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DEVELOPMENTAL LEVEL In: Zeanah C, ed. Handbook of Infant Mental Health,
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13. Diagnostic Classification: Zero to Three. Diagnostic Clas-
sification of Mental Health and Developmental Disorders
Play Therapy
Susan Mumford

Introduction help the child patient gain control over otherwise

unmanageable feelings or situations. Play allows for
Childhood aint what it used to be, so say profes-
the process of catharsis and reflects both the childs
sionals and parents alike. The whirlwind of activities
wishes and wish fulfillment. Fantasy, and the break
in which children have become involved often leave
it offers from reality, facilitates the growth of the ego
families overscheduled, with woefully little time for
in children. In the fluid atmosphere of fantasy, the
spontaneous interactions. Concern about the acceler-
ego can reckon with both id and superego demands,
ated pace of childrens lives emerged in the mid-1980s.
enabling the child to experiment with novel solutions
The hurried child was now reported to be missing
to conflict. Freud followed up these early discussions
crucial elements of childhood as he rushed from one
of play with the publication of Little Hans, one of the
activity to another. However, despite this call for sim-
first pieces about psychotherapy with a child. Melanie
plification, there has been little change in the com-
Klein and Anna Freud subsequently emerged as the
plexity of life for many children [1]. The dramatic surge
major theorists of child development and one of its
in the identification of childhood mental health disor-
natural subsets play. Both offered significant but dif-
ders in part reflects the mounting pressures on todays
ferent ways of treating the conflicts of children. Kleins
children yet there has not been a comparable increase
theory of object relations, which placed great impor-
in treatment methods or opportunities. The onset of
tance on the preoepidal period of human development,
managed care has reduced care options for patients
distinguished her from classical psychoanalysts. Her
and treatment restrictions have discouraged some
revolutionary work posited that children have a rich
mental health experts from participating in modalities
and complicated internal life that can be shown to
such as individual therapy or groups. For the child
the therapist through the use of toys. Klein used her
patient in particular, receiving appropriate treatment
knowledge of adult psychoanalysis as her technical
has become especially challenging as the treatment
template, especially the principles of free association,
balance tilts toward pharmacology rather than
transference and interpretation. She believed that the
psychotherapy or a mixture of the two. Despite this
child patient free associated not only with words but
trend, play therapy, the traditional therapeutic
also with his play activities and these associations
approach with children, remains a viable treatment
could be interpreted. Moreover, Klein saw that the
option. The purpose of this chapter is to familiarize
transference provided clues about the childs past and
the reader with the basic principles of play therapy
his unconscious world. She was attuned to the impor-
including its history, definition and technique.
tance of selecting toys which were not function-specific
but instead could be used by the child in a variety of
ways. This concept has of course, stood the test of time
and remains a technical underpinning of play therapy
As early as 1905, Sigmund Freuds writings contained today [3].
references to play [2]. Freud maintained that play facil- While Anna Freud never published a monograph
itates instinctual discharge as well as mastery of trau- exclusively on the subject of play, many of her writings
matic or unpleasant events. It provides a safe medium focused on the development of ego capacities and
through which the repetition compulsion functions to defenses which make play possible [4]. She postulated

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

that the seeds of the ability to play are planted in the

early interactions between a baby and his mother.
Through play with his body and hers, the baby learns
the rudiments of self/other differentiation and by
extension, reality and fantasy. Anna Freud believed
that play both facilitates and reflects the childs growth
process which ideally results in personal autonomy, a
developed sense of self and the ability to work. Play
provides a way to explore and master internal and
external conflicts and gives clues about the childs
unconscious strivings. Anna Freuds particular interest
in the development of the ego and its impact on id and
superego functioning is well known. Moreover, her
Figure 8.1 Development of play: the cradle of creativ-
concept of developmental lines illustrates the cumula-
ity. A, Mother; B, potential space; C, infant.
tive nature of child development, how successes or
problems in one phase affect growth in the next.
This idea remains useful today as child therapists are
responsible for identifying where a patients develop- this simple-sounding treatment. It is therefore incum-
ment went off track and what is needed to return him bent upon the professional to be well informed about
to a normal developmental point. the properties of play, how they are therapeutic and to
In addition to both Freud and Klein, there were a be able to share this information with parents in a clear
number of early pioneers who have made significant and cogent manner. Despite this obligation, some pro-
contributions to the theory of play. Robert Waelder [5] fessionals find themselves more comfortable doing play
echoed Freuds idea about the usefulness of the repe- therapy rather than explaining what it actually is.
tition compulsion in his writings about trauma, how it
can be worked through in play by turning passive into
The Function of Play Therapy
active. Waelder also conceptualized that play permits
children to break down the whole untoward nature of Play is marked by a variety of characteristics which,
a traumatic event into manageable pieces. Erik Erikson when used in therapy, contribute to an improvement in
[6], known for his epigenetic view of development, the childs functioning. Fueling a childs maturation is
pointed out that play allows children to prepare for his innate developmental thrust forward, his built-in
adult life by trying on different roles and identities. ability to progress. Child therapists are able to use
In addition to his work with mothers and babies, this energy as an ally in psychotherapy. Moreover, the
Winnicott [7] also provided much to the understand- natural power of play has been harnessed for treatment
ing of the origins and purpose of play and its persist- by clinicians representing a number of theory bases
ence through the life span. In brief, Winnicott including psychodynamic, cognitive behavioral, child-
conceptualized that the newborn initially makes no dif- centered, Alderian, and short-term play therapy [9].
ferentiation between himself and mother. Next, the Despite differences in orientation, there are some
infant makes minute movements away from mother, shared features including recognition of the value for
out of this unified position with her. A space is then a strong therapeutic alliance, the need to work with
created that is not mother, not baby but something in the child patient differently than with the adult patient,
between (Figure 8.1) Winnicott termed this important the importance of viewing children developmentally,
space potential space and identified it as the cradle of and an appreciation for play as the language of the
creativity, the place which allows for the selection of a child [10]. An example of two different concepts of
transitional object as well as the emergence of the play therapy are as follows. Cognitive behavioral play
capacity to play. Understanding of this concept is therapy uses play to subtly communicate cognitive
crucial for child therapists whose assessment of a change. It introduces the child to different, more adap-
patient must first confirm the patients ability to play tive responses to his difficulties which are then modeled
and second, assess its quality and range [8]. using developmentally appropriate materials. The
therapist conveys through play possible solutions to
problems which resemble those of the patient [11].
Play and Play Therapy
The psychodynamic play therapist relies on four main
Although many parents are familiar with the clinical interventions. Confrontation and then clarification are
term play therapy, few understand the complexity of used to facilitate the growth of the observing ego. The

therapist helps the child to understand what is occur- clearly showed that the therapist had departed from
ring internally and points out defenses before drives. the childs line of thinking. It would have been more
Interpretation is used to help the patient see the history effective for the therapist to have instead remained
of a problem, the purpose of defenses and to facilitate silent, accepted the doll from the patient, and awaited
the working through process. Finally, the psychother- what came next. In this way, the therapist would have
apeutic process itself loosens the childs defensive followed the childs lead and allowed the play to unfold
structure, enabling more adaptive defenses to emerge, in a more natural fashion.
as well as providing increased drive satisfaction in a Second, play is absorbing. It can be so encompass-
healthier fashion [12,13]. ing for a child that he can appear to be oblivious to
other activities around him and have difficulty stop-
The Properties of Play ping his play before he is ready. The play activity can
be complete in and of itself and it is not necessarily
The process of play therapy, made possible because of
something a child does in order to accomplish some-
the relationship between the therapist and the patient,
thing else. This qualifier does not mean that play
builds on the properties of play. Four properties of
cannot be goal-directed, (e.g., build a fort, set up a doll
play are as follows.
house) but rather, that these goals are part of the larger
First, play is fun; it provides not only pleasure for
play activity in general. The process of abreaction is
the child but also a sense of internal satisfaction. It is
also accomplished through play; the child relives
the external manifestation of a childs imagination and
painful situations and experiences the affect belonging
in this way, straddles the boundary between fantasy
to them.
and reality. Creativity is both nurtured and expressed
by play. It is a medium for self-definition and expres-
sion and valuable for the unfettered freedom it pro-
vides. Play is a process through which a child acquires CLINICAL EXAMPLE: ABSORPTION
self-confidence and a sense of efficacy as he finds IN PLAY
solutions to problems in his own time and on his own
terms. It provides an outlet for the childs creativity. A child, age eight, with significant concerns
These features are implicit in the therapeutic process. about his place in his family has been working
While play certainly has elements of frivolity and on a huge, multifaceted Lego scene with his
excitement, it is also intense and serious. It is mean- therapist for a number of sessions. The par-
ingful for the child and loaded with affect. It is often ticular structure is a castle which houses the
helpful for the therapist to follow the lead of a child in orphaned but determined child hero of the
play, to include asking the child what he would have game. Great attention is given to the assembly
the therapist do or say. of this structure and is accompanied by a rich
narration of the heros struggles. Aware of the
childs absorption in his play, the therapist
CLINICAL EXAMPLE: CHILD-LED PLAY provides him a five minute reminder of the
sessions end. He responds with dismay but I
Child, age nine, is being treated for adjust- just got here!
ment difficulties stemming from a move to a
new city. She has set up an elaborate scenario
using the dolls and doll house, a game she
informs that therapist, she often plays with The above example describes a clinical situation
her eight-year-old sister. The patient gives the where the patient is intensely invested in his play.
therapist a doll. The therapist then asks if the Attention to the aspects of real life such as the
patient wishes she had more friends to play passage of time are therefore temporarily suspended.
with in her new neighborhood. However, in Being so immersed in the play scene, the patient is
response the child suddenly shrieks What are caught off guard by the sessions approaching end.
you saying? You dont know how to play! The therapist has anticipated this response and thus
announces the time but the child is still surprised.
Third, displacement is operative in childs play. Due
In this example, the therapist appears to have to the childs ability to combine reality and fantasy
associated the patients description of the game and without conflict, he can transfer his own affect and per-
subsequent attempt to include her as a possible indi- sonal situation into the play arena. A child changes
cation of loneliness. The patients sharp response passive into active; he can be the initiator of events

rather than the reactor he may feel himself to be in real reflect his own particular needs and wishes. Piagets
life. Displacement permits distance from the original study of the cognitive development of older children
problem as well as from uncomfortable emotions that (ages 411 years) included the use of language, com-
go along with it. It prevents the child from becom- munication, the meaning of rules and moral judgments
ing overwhelmed by his feelings or needing to overly [14]. Again, cognitive maturation will be reflected in
inhibit them to keep them in check. Displacement also the increasingly complex play of older child patients.
allows the child patient to talk or act in ways that are
not possible without the protection the defense pro-
vides. Another important function of displacement is
that it permits the childs ego to balance id and super-
ego influences and to be employed in resolution of the
difficulty. A patient, aged four years, was recently
adopted, having lived with his maternal
grandmother for most of his life. His mother,
CLINICAL EXAMPLE: DISPLACEMENT a drug addict with occasional periods of absti-
IN PLAY nence, came and left the home unpredictably.
During his first treatment session the child
A six-year-old boy is being seen by a child exhibited little interest in the toys, with the
therapist following removal from his home exception of several puppets which he named
due to child endangerment. While he has been the monster catchers. He kept one puppet
quite laconic with the therapist about the and gave the other to the therapist and
events in his life, his play is very expressive. pointed to the space under the couch. The
Using the doll house, the patient acts out patient declared that it was the hiding spot for
scenes of parental violence. A mother doll is the monster, a monster who came and went
shown threatening a child doll whom the and repeatedly evaded our attempts, as
patient has hidden behind a piece of doll fur- monster catchers, to get him.
niture. Suddenly, the patient moves the child
doll out into the open and forcefully tells the
mother to stop or he will put her in jail.
The Child Therapist
In psychotherapy with both adults and children, the
therapists warmth, sensitivity, and nonjudgmental
In this example, displacement allows the child to attitude are the basis for the therapeutic alliance
behave in a way that is not possible in his day-to-day and critical to therapeutic success. However, due to
life. Feelings or fears that cannot be otherwise released the immaturity of the childs cognitive and psychic
can be expressed in play, giving the child access to them development, the therapist must possess a unique set
in a safe, manageable dose. of behavioral and emotional traits to effectively work
Fourth, a childs capacity for imaginative play dove- with a child. Most importantly, the therapist must gen-
tails with his cognitive growth. Piaget [14] postulated uinely enjoy children, have the capacity to be authen-
that there are four periods of intellectual development: tic and to be at ease in the childs presence [3]. It is
sensorimotor (birth to the age of two years), preoper- beneficial for the therapist to have had a personal
ational (27 years), concrete operational (711 years) psychotherapy so that his own life experiences do
and formal operational (11 years and after). Accord- not unduly influence his interactions with the child.
ing to Piaget, between the ages of two and four years, Accordingly, the therapist should have easy access to
a child acquires the ability to form symbols. Through his own imagination and to be comfortable playing
symbolism, mental representations are created of expe- while simultaneously watching and reflecting upon the
riences, people and objects and remain in the childs childs particular situation. To be able to enter the
mind. Such representation frees the child from having childs world through play yet also remain outside of
to see an object to know it exists; a mental image or a it requires a great deal of mental elasticity, but without
word is sufficient. Through symbolic play, a child can it, the therapist is likely to be more of an observer of
bridge the gap between the concrete and abstract. Sym- rather than a participant in the therapy. Empathy, the
bolism gives a childs play its distinctly individualized capacity to feel what the patient feels, is of course vital
flavor because the child can manipulate the play to to any sound therapeutic relationship. With a child

patient, it may be easier to feel sympathy for his situ- communities thoughts, fantasies and wishes. In short,
ation rather than empathy with his feelings unless the the toys used in therapy should facilitate the childs self
therapist is able to tolerate and give veracity to his own expression. These criteria contraindicate, for example,
childhood experiences and residual childlike emotions. theme toys or toys of well-known television or movie
Further, empathy enables the therapist to respect the characters which might have a fixed identify rather than
reality of the patients struggles as well as his attempts, one created by the child. The toys should be in good
however imperfect, to deal with them [15]. repair and clean; a worn-out toy could leave the patient
Consistency in technique, acceptance of the patient feeling devalued. While a therapist may see a number
and flexibility are essential as the child patient can be of children in the same office, it can be helpful for the
very attuned to clinical variations or insincerities. The individual patient to have his own container in which
therapist should be patient, tolerant and honest with to place special items or projects. This move contributes
the child which will enhance the patients ability to be to the childs sense of place and belonging in the office
that way with himself; the therapist in this way serves as well as to a positive therapeutic atmosphere of safety,
as an ego ideal. Children most often have not requested containment and continuity.
psychotherapy and can therefore be suspicious, with- Toys that are useful in therapy can be divided into
drawn or concerned that the therapy is a punishment three categories: toys that draw out real life experi-
or a consequence of their behavior. Also, the child ences; those that elicit or reflect anger or aggressive
may not necessarily feel troubled or believe he needs emotions; and those material that facilitate creative
help despite the concerns of others. The therapist thus expression [17]. Real life toys include a doll house
needs to be able to convey the helpful intent of the and a doll family, cars, airplanes, stuffed animals,
therapy to the patient and to develop a shared under- zoo animals; as well as a toy telephone, puppets, a
standing of the problem to be addressed. The therapist doctors/first aid kit and a few soft baby dolls with
needs to assure the child patient that their interactions bottles. These items naturally appeal, both consciously
will take place in a safe, confidential atmosphere. This and unconsciously, to the childs experiences and rela-
particular issue can be challenging as the therapist tionships in daily life and provide a means for explo-
must know how to inform the parents about the treat- ration and expression. This basic inventory of real
ment but also protect the childs confidences. Most life toys is quite sufficient for most play therapies.
research about the role and characteristics of the ther- However, if the patient has a particular situation which
apist has been done by those who work with children; calls for the addition of specific toys, the therapist
there has been minimal study about how children could provide them.
themselves view the therapist. Ethical considerations
and difficulty obtaining a sufficient sample size obvi-
ously have hampered this type of research. However, CLINICAL EXAMPLE: PLAY MATERIALS
the available data suggest that children most valued FOR A SPECIFIC SITUATION
kindness, helpfulness, and the therapists ability to
understand and reflect back feelings [16]. A seven-year-old girl was seen due to anxiety
after witnessing her mother being injured in
an accident. The patient and her mother were
Play Materials and the Play Space riding bicycles when the mother accidentally
Beginning therapists are often unsure about both the rode off the sidewalk and suffered serious
materials needed to equip the playroom as well as the injuries. She was taken by ambulance to the
rationale behind the selection. Toys or play, in and of hospital in the presence of the patient and
themselves, are not therapeutic. Rather it is the way in remained in a coma for several days. Aware of
which they are used in treatment that make them effec- this situation, the therapist added a doll-sized
tive. It is suggested that from the onset that the ther- bicycle to her toy supply before meeting with
apist refer to the toys in the office as play equipment the child. The patient used the doll bicycle
or play materials. In this way, through both words and during the first session in her play.
actions, the child starts to see that toys and play have
different meanings and purposes than they do outside
of the office. The toys chosen by the therapist should All children have aggressive feelings, including those
be interesting and intriguing; they should capture the who are referred for very different reasons. However,
childs attention and imagination. They need to be because they have a limited ability to fully express
capable of being used symbolically as this how the child emotions with words, children can be helped by having

aggressive toys with which to play out these feelings. tional, possible interpretations demonstrate the need
Moreover, the child patient may feel safer engaging for therapists to remain attuned to more than the play
these feelings in a displaced way with the therapist scenes surface meaning.
than in other settings; this is true especially for The final category of toys refers to tactile and
inhibited children. Aggressive-type toys include army creative materials such as crayons, markers, colored
men and related equipment (e.g., tanks, fighter jets,) pencils, tape and paper, modeling clay or Play-Doh.
wild animals especially with mouths open, teeth Some therapists use sand and water tables with child
exposed angry-appearing puppets, and police cars. patients but this type of equipment clearly requires a
Some therapists provide punching bags or foam balls large office space and therapist tolerance for potential
and bats for a physical release of aggression or energy. spills. Additionally, blocks and Legos of a wide
With these types of toys, a childs aggression can be variety of shape and sizes can be useful in several ways.
easily visible to the therapies. However, the expression First, they offer the patient a chance to build, dis-
of a particular affect is not dependent on having a assemble and recreate new structures. Although con-
corresponding toy in reality; anger can be expressed crete, the use of blocks can metaphorically mirror
through other means than through, per se, army men treatment, a process which builds, takes apart and
or dinosaurs. Children will use materials in noncon- recreates new ways of thinking and being in the world.
ventional ways to reveal themselves and therapists Second, they can easily be used in conjunction with
need to be alert to the wide variety of meanings a par- many other toys; they are not function-specific. Third,
ticular action or toy may have. they are appealing to a wide age group, from pre-
schooler through elementary school-aged patients.

A four-year-old girl with an unstable, chaotic CLINICAL EXAMPLE
family history (i.e., exposure to continual
A seven-year-old boy, who was reported to be
parental arguments, mother often absent from
an excellent student and well-behaved child at
home) presented for an evaluation due to
school, was referred due to his explosive
noncompliance and aggressive behavior at
rages and out-of-control behavior at home.
preschool and home. During the second diag-
The patient was an avid race car fan and
nostic session, the child used the doll family
during an early session in the treatment, con-
and house to play out a very angry scene
structed an elaborate race track out of blocks.
between family members. Later in the hour,
Special attention was given to reinforcing the
she took the marble game and very carefully
walls with extra blocks in case of a car crash.
arranged them in an intricate pattern. Sud-
The therapist noted how race car drivers who
denly, the patient took another marble
were concerned about spinning out of control
and obliterated the design while muttering
and crashing might find these well con-
crash and bonk. The patient then com-
structed walls both necessary and valuable.
mented sadly, all the crashing and bonking
has wrecked what I worked so hard on.

While not undoing the displacement, the therapist

The above vignette raises several points. First, responded to one of the likely meanings the patient
aggressive affect can be expressed through many had communicated with blocks.
mediums, not just with aggressive looking objects. The above listing of toy possibilities is not exhaus-
Here, it is expressed with the dolls and marbles. tive; other materials such as books, bendable figures,
Second, more meaning can be attributed to the board games, flashlights, and cards can useful. Board
patients sadness than just the destruction of her games can be particularly useful when working with
marble design. It is possible that the ruin of her older children, latency-age and adolescents who are
arrangement is also a reference to the damage she too old for pretend play. The elements of board
experienced as a result of the constant fighting (crash- games turn taking, following rules, winning or
ing and bonking) at home or a reaction formation losing simulate aspects of real life. To conclude,
to minimize unconscious guilt she may have felt about individual therapists may find through their own
her contribution to the parents problems. These addi- experience and experimentation, additional toys which

enrich their therapy with children. It is how the toys arrangement will certainly weaken the alliance with the
are used and how the play is developed and understood more distant parent and potentially have a negative
by the child that is therapeutically valuable. The child impact on the child as well. In some cases, regardless
patient uses the toys to express his inner world and to of marital status, one parent may refuse to participate
make sense of his experiences in the presence of the or to support the treatment. The therapist should con-
therapist; this combination is what is mutative. tinue to invite that parent to meetings and most impor-
tantly, try to discuss the reasons for opposition to the
treatment. This action is derived from Freuds original
Conducting Child Psychotherapy advice to address the negative transference in treat-
ment while leaving intact the unobjectionable positive
Getting Started: The Evaluation Period
transference [2].
The Therapists Relationship with Parents During the first session, the therapist should
While evaluation is an ongoing part of therapy, a thor- also obtain certain information about the child
ough diagnostic assessment is vital for effective treat- including:
ment planning. The first step in the assessment of a
(1) both parents perception of the (childs) present-
child is to meet with the parents. As previously noted,
ing problem;
it is not often the child who has sought treatment, but
(2) precipitant of/background to presenting problem;
rather the parents due to either their own concerns or
(3) BASIC developmental and medical history;
those that have been brought to their attention by
(4) significant family history;
others, such as the school or neighbors. Moreover,
(5) family history of mental illness, drug and/or
the child is obviously having some developmental dif-
alcohol addiction;
ficulty which is troubling to the parents even if it is not
(6) history of school progress including peer
ostensibly bothersome to the child. It is therefore
important for the therapist to remember the vulnera-
(7) description of personality, fears, interests;
ble position parents are in when they seek help and
(8) reason for seeking treatment at this time;
to respond to them in a nonjudgmental fashion. It
(9) prior treatment/attempts to solve problem;
is essential that from the initial contact forward, the
(10) parents perception of childs strengths and
parents view the therapist as accepting, helpful and
trustworthy; there can be no treatment of the child
(11) parents long-term hopes for and fears about the
without ongoing support from the parents.
During the 1960s and 1970s, young patients were
most frequently seen in hospital settings or child guid- Additionally, the basic administrative aspects of
ance clinics which were equipped to simultaneously psychotherapy such as fees, cancellation policy, and
work with the parents. While this model is not often confidentiality are reviewed in this initial meeting. The
practiced today, treatment of children is still indis- therapist also discusses ways to prepare the child for
putably more effective when the problems of the his first visit, something which parents are often uncer-
parents are addressed as well [18]. The treatment plan tain how to do. Briefly, parents need to simply inform
of a child patient should include provision for parental the child that they have made an appointment with a
contact. Additionally, the therapist should be prepared special type of doctor, one who helps to figure out
to recommend additional services for the parents if problems but who does not administer familiar types
needed to support the childs progress. of medical care, such as giving shots. The parents indi-
The therapist first meets with both parents to cate that it is their belief that the therapist can assist
explain the diagnostic assessment procedure. Depend- the child and them with the current difficulties. They
ing on the setting (e.g., clinic, private office), this can also state that this type of doctor uses toys and
process will take between one and four sessions. The games as the treatment equipment and that the child
first is generally with parents alone, the following will have a chance to investigate these during the
one(s) with the child and the final one with the parents appointment. While parents should answer if the child
to explain treatment recommendations. If the parents has additional questions, it is not necessary to inundate
are divorced or separated, it is still highly preferable to him with a detailed description of the play therapy
have both parents present during the first session. process. Such an explanation could both confuse the
Inclusion of both parents reduces the risk that the child and generate anxiety. More information about
therapist becomes aligned primarily with one parent therapy can be furnished in a natural way as the ses-
or hears only one side of the story. Such a lopsided sions go along.

Meeting the child patient tings and new rules; her outbursts seemed to
Regardless of the childs age, upon meeting the child, have become worse with each change. She
the therapist should greet the child by name before announced to the therapist that she was a
the parents. This action makes it evident to both child tornado, that tornadoes were dangerous and
and parent who the patient is and where the therapists happened outside and wondered if the thera-
focus will be. Some children may be apprehensive pist planned to put her and her tornado-self
about separating from the parent. It is not recom- outside where she belonged. The therapist
mended that the child be forced to separate but rather, responded that it sounded as if Mary knew a
that the therapist acknowledge the childs concern, and lot about tornadoes but also that it might be
if need be, suggest that the parent accompany the ther- scary to be outside alone with such a power-
apist and child to the office. In this way, the child is ful tornado swirling so close to her. Perhaps it
certain that the parent knows where he is and vice would be the best idea to have Mary stay in
versa. If the child continues to be uncomfortable, the the office where they could learn more about
parent should be permitted to stay. Preschoolers may tornadoes and tornado-feelings together.
initially need for the parent to remain for the entire
session but the therapist needs to ensure that the atten-
tion is fixed on the child. Having a parent in the room
may pose an extra challenge for some therapists In this example, Mary clearly is concerned about the
(particularly new ones) as feelings of inhibition, destructiveness of her anger and the potential impact
self-consciousness and professional uncertainty may it might have on the therapist. Respect for Mary and
surface. It is helpful for the therapist to keep in mind acceptance of her anger is communicated by the ther-
that despite his discomfort, the parent is undoubtedly apist in the following ways:
feeling more nervous and that the parental focus is
(1) The therapist does not un-do the displacement.
probably on the child.
She stays with Marys language and talks about
tornado-feelings, not Marys actual anger. She
The First Session
accepts the patients need for the defense.
How to proceed during the first session will depend to
(2) The therapists statement to remain in the office
some degree on the therapists theoretical orientation.
and work together obviously conveys acceptance
Nondirective play therapy recommends following the
of Mary and her feelings. It also suggests to Mary,
childs thoughts and actions and refraining from doing
perhaps unconsciously, that the therapist will be
more than reflecting back to the child. Brief psycho-
able to weather her storms.
dynamic therapy starts with the identification of
(3) The therapists statement confirming Marys
general treatment goals [19]. However, the common
knowledge of tornadoes shows awareness and
denominator among all theory bases is the requirement
respect for Marys experiences.
for a therapeutic alliance and the therapists actions
and comments should be made with this end point in Many children will look for some direction from the
mind. Acceptance and respect for the patient, essential therapist in the first several sessions as they might from
components of the alliance, need to be conveyed to the the adults at home or school. It can therefore be
patient early in the therapy. Like other aspects of psy- helpful to familiarize him/her with the office and any
chotherapy, these features will be communicated to the relevant limitations, such as the therapists desk or file
child patient somewhat differently than to the adult. cabinet. When showing the toys, it is important to
The question of acceptance, which may be raised in include a statement about the unique role they play in
subtle ways by adults, is often more apparent with chil- therapy. For instance, the therapist might say Here is
dren and may call for a more direct response. where I keep the play materials.We will use them as we
play and work together to help us better understand
your feelings. This type of introduction makes the
point to the child, right from the start, that toys are
used differently in therapy than in other settings. It also
identifies the therapist as a person who will work with
Mary, aged six years, reluctantly entered the him/her, rather than instruct him/her. During the
therapists office having been referred for dif- initial sessions, the therapists task is to provide an
ficulties with anger. She had lived in multiple atmosphere of safety and acceptance, as well as to note
foster homes and had grown used to new set- the emergence of play themes. The concerns and con-

flicts of most children can be expressed through play diagnostic in which the purpose leans more toward
even when they are not or cannot be discussed verbally observation and formulation than interpretation.
[17]. The therapists remarks should be tailored to the Second, such a remark would have undone the dis-
childs developmental level. Without probing or press- placement, potentially leaving the child inadequately
ing, the therapists statements should correspond to the defended. Third, the child might have been made
childs moves and comments. anxious by the comment and inhibit his play as a

Continuing Therapy
CLINICAL EXAMPLE One of the basic precepts of psychotherapy is to begin
where the patient is. The child patient will respond to
A three-year, six-month old boy was referred the therapist with emotions and behaviors that reflect
for an evaluation due to aggressive behavior. not only where his/her development has been derailed
The therapist and the boys mother agreed but also the defenses with which he/she has protected
that the mother could remain in the office for himself/herself. In the beginning period of treatment,
the first several sessions although she was the child patient learns that the therapist is a person
advised to be as unobtrusive as possible. The whom he/she can trust and who can accept his/her
patient quickly left mothers side and easily needs, wishes and fears. A connection then forms
explored the office, looking under chairs and between patient and therapist which in turn, enables
eyeing toys which were quite visible on the the child to invest in the therapy. During the middle
shelf. The therapist commented there are so phase of treatment, the therapist and child work
many new things to look at in this place. You together to achieve a sense of a more organized self.
do not need mother right now; you can be an The patient has an idea of his/her conflicts and can
explorer on your own. The boy found a foam safely explore them with the therapist. The final stage
ball and threw it to the therapist who returned of treatment brings resolution to or a reduction of the
the pitch stating: we can play something childs difficulties and acceptance of the change that
together, now that youve found the ball!. The has occurred. It is not uncommon at this time to see
patient then went to the doll house and threw the reappearance of original issues as the child deals
the baby doll out the window, and said that with separating from the therapist, a person who has
the family did not need that baby anyway. become very meaningful to him.
The therapist, knowing about the recent birth
of a sibling added the family seemed fine the Limit Setting
way it was before baby sister was born. Psychotherapy with both adults and children involves
the setting of limits. Indeed, from the outset, limits are
demarcated by the therapist as he/she establishes the
frame with the patient and details the conditions of
In this example, the therapist pulled out what therapy [20]. These requirements include at a mini-
appeared to be the main threads in the interaction mum, the therapists payment and cancellation policy,
between herself and the patient without over- informed consent and the limits of confidentiality.
interpreting or patronizing. First, the therapist noticed While most therapists are comfortable establishing
that the child is able to leave mothers side to investi- limits, there is far more uncertainty when it comes to
gate the new place. Such curiosity is both desirable and the testing or the enforcing of them. With child
developmentally appropriate; the therapists comment patients, whose behavior might result in damage to the
speaks to this achievement. Second, the therapist noted office or therapist, limits are clearly necessary. There is
the patients effort to initiate contact with her. Her sub- agreement among most therapists that the office space,
sequent action and comment demonstrated her will- the therapist and the patient cannot be hurt and these
ingness to reciprocate. Third, the therapist slightly rules must be clearly established and enforced. Other-
extended and thereby perhaps, clarified the childs wise, it is not necessary or even possible for the thera-
comment. Fourth, the therapist did not make a link pist to spell out every limit that might be required. It
between the patients action and his real-life sibling. To is more practical to instead to limit the problematic
have made a direct connection between the patients behavior as it arises. Nonetheless, some therapists are
action and his home situation would have been pre- uncomfortable with such ambiguity and it is beneficial
mature for several reasons. This particular session was to know at what point the childs behavior exceeds

ones own limit of acceptable behavior. The following 3. Axline V: Play Therapy. New York: Ballantine Books,
guidelines can be used to set limits [21]. 1947.
4. Marans S, Mayes L, Colonna A: Psychoanalytic views of
First, the therapist provides a verbal reflection to the childrens play. In: The Many Meanings of Play. Solnit
child of his/her attitudes or wishes. AJ, Cohen DJ, Neubauer PB, eds. New Haven, CN: Yale
University Press, 1993.5.
Example: I see that you want to take the puppets home 5. Waelder R: The psychoanalytic theory of play. Psy-
with you and that is why you are trying to put them choanal Quarterly 1933; 2.
in your bag. 6. Erikson EH: Childhood and Society. New York: Norton,
Second, the therapist verbally states the limit. 1950.
7. Winnicott DW: Playing and Reality. London: Routledge,
Example: I can tell that you want to the puppets home
very much, so much that you are trying to take them 8. Landreth G, Baggerly J, Tyndall-Lind A: Beyond adapt-
out of the office. But the play materials must stay ing adult counseling skills for use with children: The
here and you can use them when you are here. paradigm shift to child-centered play therapy. J Individ
Third, the therapist intervenes physically to control the Psychol 1999; 55:272287.
9. Kottman T: Integrating the Crucial Cs into Alderian
childs behavior. Play Therapy. J Individ Psychol 1999; 55(3):288297.
Example: While I know how much you want to take 10. Solnit A, et al.: The Many Meanings of Play. New Haven:
the puppets with you, they must stay here until next Yale University Press, 1993.
time. (Therapist removes them from the child) 11. Knell S: (1999) Cognitive-Behavioral Play Therapy. J
Clin Child Psych 1999; 27:(1)2833.
It can be very frightening to a child to feel that the 12. Kottman T, Schaefer C: Play Therapy in Action: A Case-
adult is unable or unwilling to maintain adequate book for Practitioners. New Jersey: Jason Aronson, Inc.
13. Prat R: Imaginary hide and seek, A technique for
control. By defining and enforcing the limits of safe opening psychic space in child psychotherapy. J Child
and acceptable behavior, the therapist assures the child Psychotherapy 2001; 27:2.
that his/her impulses can be tolerated and contained. 14. Ginsburg H, Opper S: Piagets theory of intellectual
development: An Introduction. Englewood Cliffs, New
Jersey: Prentice-Hall, Inc., 1969.
15. McWilliams N: Psychoanalytic Psychotherapy. New
Conclusion York: The Guilford Press, 2004.
Although methods of play therapy have both evolved 16. Caroll J: Play therapy: the childrens views. Child and
Family Social Work 2002; 7:177187.
and expanded over time, its value as a clinical inter- 17. Schaefer C: The Therapeutic Powers of Play. New Jersey:
vention remains [22]. Play therapy provides a way Jason Aronson, Inc., 1993.
for the child patient to define and understand personal 18. Wilson K, Ryan V: Helping parents by working with
struggles within a developmentally appropriate their children in individual child therapy. Child and Fam
Social Work 2001; 6:209218.
context. 19. Racusin R: Brief psychodynamic psychotherapy with
young children, J Am Acad Child Adolesc Psychiatry
2000; 39:6.
References 20. Luborsky L: The Principles of Psychoanalytic Psy-
chotherapy. Basic Books, Inc., 1984.
1. Elkind D: The Hurried Child. 3rd ed. Cambridge, MA: 21. Schaefer C: The Therapeutic Use of Childs Play. New
Perseus Books, 2001. Jersey: Jason Aronson Inc., 1979.
2. Freud S: The Dynamics of Transference. Standard 22. LeBlanc M, Ritchie M: A meta-analysis of play therapy
Edition (12), 1912. outcomes. Counseling Psychology Quarterly 2001; 14:2.
Cognitive Behavioral Therapy
Christina C. Clark

Overview phobia [10], obsessivecompulsive disorder [11,12],

depression [1317] and externalizing disorders [18],
Mental health providers serving the needs of children,
including a parent training component to address
adolescents, and their families find themselves in the
childhood attention deficit/hyperactivity disorder
midst of challenging and exciting times: challenging
(ADHD) [19], aggression [20], conduct disorder [21],
because current prevalence rates of significant psychi-
and anger [22,23]. Reviewing treatment effectiveness
atric problems (behavioral, emotional or developmen-
from an EBM perspective, Compton et al. [5] stated
tal) within this historically underserved population are
that CBT is the treatment of choice for children and
between 17% and 22% [1,2], exciting because there has
adolescents with internalizing (anxiety and depression)
been increased focus on expanding the knowledge
base and developing effective treatments for this
This chapter is intended to be used as a resource for
clinicians interested in delivering CBT to children and
Indeed, it is remarkable to reflect on the fact that the
adolescents. Before discussing CBT specific informa-
initial publication of the Diagnostic and Statistical
tion, a brief overview of important issues that should
Manual (DSM-I) in 1952 contained only one child-
be considered regardless of theoretical approach is
hood disorder while the current version (DSM-IV-TR)
mentioned. This is followed by specific CBT-oriented
has expanded to more than 20 childhood diagnostic
information, including a brief description of the CBT
categories that include research findings as well as
model and its principles. Following that, treatment will
beginning to include developmental and contextual
be discussed. Finally, a set of guidelines that can help
aspects. Furthermore, there has been an explosion of
clinicians integrate theory and research into daily use
information within the past 10 years regarding child
with children and adolescents will be presented.
development and psychopathology [3].
At the same time, a number of forces including
Special Issues
managed care, have created a climate of accountabil-
ity to ensure that mental health providers are provid- Children and adolescents constitute a special popula-
ing empirically supported treatment (EST) [4], tion, and as such, require the clinician to pay particu-
evidence-based medicine (EBM) [5] or evidence-based lar attention to certain aspects of treatment. These
treatment (EBT) [2]. considerations are not unique to CBT; however, as they
Clinicians and researchers utilizing cognitive- are integral to clinical work with this population they
behavioral therapy (CBT) have responded to these will be briefly highlighted here. Included are ethical
forces by expanding the model downward (i.e., treat- considerations, developmental factors, family involve-
ments originally designed for use with adults were ment, and cultural factors. These issues are not discrete
adapted for use with youth) and subjecting treatment entities, in other words, these considerations often
outcome to evaluation of effectiveness. Although interact or overlap.
much more investigation regarding the effectiveness of Mental health professionals serving children, ado-
CBT with children and adolescents remains to be done, lescents, and their families need to remain mindful of
thus far CBT has been shown to be effective for inter- the complex nature of serving various family members
nalizing disorders, including anxiety [69], social and of the fact that children are still developing, i.e.,

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

they are vulnerable [24,25]. Ethical considerations developing; therefore, they are dependent on parents
include, but are not limited to, issues related to refer- for guidance and support. Furthermore, the younger
ral, informed consent, and provision of effective treat- the child, the more likely it is that problems are occur-
ment. Children and adolescents are typically brought ring within the family setting. Therefore, taking into
to treatment by adults, usually parents [26,27]. account the interactions between the family and the
Although the child may be identified as the patient it child/adolescent will be an important part of under-
is the adults who are typically stating what they would standing the child and delivering treatment. In most
like treatment to address. Mental health providers con- cases, the therapist should work to ensure that adults(s)
sider the perspectives of all parties and attempt to involved have a good understanding of appropriate
determine what is likely to be in the best interest of the developmental expectations, as recommended by
child [25] which at times may be in direct opposition Holmbeck et al. [32]. In addition, the clinician facili-
to what the parents are requesting, resulting in poten- tates parents exploration of their own beliefs [36,37]
tial conflicts of interest [26]. However, the mental regarding developmental expectations and helps them
health provider who has followed ethical and legal to recognize when their own beliefs (thinking), feel-
guidelines regarding informed consent (for example, ings, and/or behavior may contribute to the childs
encouraging participation and providing information problems.
in developmentally appropriate language [25] has made The mention of parents elicits a parenthetical
it a habit to discuss expectations, responsibilities, risks/ remark: Although many texts use the word parent to
benefits and outcome at the outset of treatment and as denote adults involved in the childs life, throughout
needed. Best practices for obtaining informed consent this chapter the terms parent and caregiver will be
with children are briefly outlined by Fisher, Hatashita- used interchangeably to describe any adult who would
Wong, and Greene [24]. Regarding provision of live with and/or have major day-to-day responsibility
effective treatment, Lyddon [4] states that practition- for the child including biological and/or step-parents,
ers are obligated us use empirically supported treat- grandparents, other biological relatives, foster-parents,
ments to guide their work as a matter of ethical adoptive parents, or other adults.
accountability. Other contextual areas that should be attended to
Special attention to developmental factors, on the by the clinician include school, peer group, religion,
part of the clinician, is required throughout the sexual orientation, social class, and ethnicity/culture
therapy process. Doing so increases the likelihood that [38]. To aid clinicians pay particular attention to these
developmentally appropriate communication and important areas, Friedberg and McClure [30] compiled
assessment procedures occur, leading to developmen- a table of culturally sensitive questions (Table 9.2) and
tally titrated goals and selection of interventions. As a Fisher, Hatashita-Wong and Greene [24] briefly outline
result, clinicians report that the child is often more a set of best practices for culturally valid assessment
engaged [2831]. Furthermore, it would appear that and treatment.
the likelihood of progress is increased because, accord-
ing to Holmbeck et al. [32] developmental sensitivity is
Principles of Cognitive-Behavioral Therapy
thought to increase quality of treatment, though more
developmentally oriented research is needed to deter- Cognitive therapists remain mindful of the basic
mine whether this is true. In the meantime, Holmbeck principles regarding the process of cognitive therapy
and colleagues [32], in a chapter discussing the rele- as they work with clients. These principles as outlined
vance of developmental issues for therapists and by Beck [39] include the idea that the process is
researchers, have included a table of developmental collaborative, structured, active, time-limited, and
milestones (Table 9.1) for child/adolescent therapists to goal-oriented. The conceptualization of the client
integrate into treatment. Finally, it is useful to distin- evolves continually as new information comes to light.
guish between deficiency and distortion [3335] Based on that conceptualization, numerous cognitive
when working with children, and to recognize that and/or behavioral techniques are suggested to aid the
either or both can occur. That is to say, the therapist client in exploring and changing cognitions and/or
needs to determine whether a child is engaging in inac- behaviors. Typically, at the beginning the therapist
curate thinking or simply lacks skills/experience and takes on more of the responsibility for the content
aim interventions accordingly. and direction of therapy; however, another principle
Generally speaking, the younger the child, the more holds that the ultimate goal is for the therapist
likely it is that parents may become involved in treat- to educate the client to become their own cognitive
ment. This is because the child is still in the process of therapist.

Table 9.1 Developmental milestones and stages across childhood, adolescence, and emerging adulthood.

Infancy Infants explore world via direct sensorymotor contact

(02 years) Emergence of emotions
Object permanence and separation anxiety develop
Critical attachment period: secure parentinfant bond promotes trust and healthy
growth of infant; insecure bonds create distrust and distress for infant
Initial use of sounds and words to communicate
Piagets Sensorimotor stage
Toddler/preschool years Use of multiple words and symbols to communicate
(26 years) Learns self-care skills
Mainly characterized by egocentricity, but preschoolers appreciate differences in
perspectives of others
Use of imagination, engagement in pretend play
Increasing sense of autonomy and control of environment
Develop school readiness skills
Piagets Preoperational stage
Middle childhood Social, physical, and academic skills develop
(610 years) Logical thinking and reasoning develops
Increased interaction with peers
Increasing self-control and emotion regulation
Piagets Concrete Operational stage
Adolescence Pubertal development; sexual development
(1018 years) Development of metacognition (i.e., use of higher-order strategizing in learning;
thinking about ones own thinking)
Higher cognitive skills develop, including abstraction, consequential thinking,
hypothetical reasoning, and perspective taking
Transformations in parentchild relationships; increase in family conflicts
Peer relationships increasingly important and intimate
Making transition from childhood to adulthood
Developing sense of identity and autonomous functioning
Piagets Formal Operations stage
Emerging adulthood Establishment of meaningful and enduring interpersonal relationships
(1825 years) Identity explorations in areas of love, work, and worldviews
Peak of certain risk behaviors
Obtaining education and training for long-term adult occupation

Collaboration includes the notion of a positive Sessions are structured (with mood-check, review of
therapeutic alliance with the client and is most likely homework, agenda setting, addressing issues, feed-
achieved when the therapist demonstrates the well- back, and setting new homework) [30,39]. While it may
known common factors including skills of accurate seem obvious, again, it is important to keep in mind
empathy. This can be a particularly demanding and what is developmentally appropriate with regard to
challenging task when working with children and ado- structure. Therefore, as long as each of the session ele-
lescents, because it is not uncommon for caregivers to ments gets addressed during the therapy hour, younger
be involved in the treatment, in which case the thera- children may require a greater amount of flexibility.
pist needs to consider how to work collaboratively with Content of the session (as well as homework) needs
various members of the system without alienating or to engage the child or adolescent. How is this done?
favoring anyone. We return to the theme of developmental fit. In

Table 9.2 Sample questions addressing cultural child/adolescent should be solicited at the level at
context issues. which is judged to be developmentally appropriate.
In addition to helping the client with his/her current
What is the level of acculturation in the family? concerns, cognitive therapy takes an educative
How does the level of acculturation shape approach, that is, to prepare them to learn skills and
symptom expression? general concepts that can be extended to their life after
What characterizes the childs ethnocultural therapy. CBT attempts to help the client become their
identity? own cognitive therapist [39] by teaching the client
How does this identity influence symptom skills to apply to current problems while simultane-
expression? ously teaching them about the CBT model and
What are the child and family thinking and feeling learning to formulate a coherent picture (conceptual-
as a member of this culture? ization) of themselves. Therefore, the therapist is not
How do ethnocultural beliefs, values, and practices doing something to the client, but is teaching the client
shape problem expression? how to understand themselves and what to do to help
How representative or typical is this family of the themselves, both now and, hopefully, in the future.
culture? The therapist attempts to establish alliances with all
What feelings and thoughts are proscribed as participants and explains the conceptualization to
taboo? individuals within the system at the level that is devel-
What feelings and thoughts are facilitated and opmentally appropriate for each member.
promoted as a function of ethnocultural context?
What ethnocultural specific socialization processes
The Model
selectively reinforce some thoughts, feelings, and
behaviors but not others? Cognitive behavioral therapy (CBT) is based on a
What types of prejudice and marginalization has combination [5,41] of behavioral principles such as
the child/family encountered? classical and operant conditioning combined with
How have these experiences shaped symptom concepts from social learning theory [30]. Cognitive
expression? therapy emphasizes the role of thinking (i.e., cognitive
What beliefs about oneself, the world, and the mediation) which mutually interacts with three other
future have developed as a result of these aspects of a person, namely, behavior, emotions, and
experiences? physical reactions [4244]. In turn, a person affects and
is affected by, his/her environment [44]. Environment
or context, which is particularly relevant for children
and adolescents, includes peers, family, and teachers.
general, the younger the child, the more active and Given the emphasis on cognition as playing a major
play-oriented treatment will be. Preschoolers may need role in influencing emotions, behavior, and physical
toys, games, books, and/or a sandbox as, generally reactions, several points are relevant here. First,
speaking, play is their language. Relaxation skills can thinking is not a unitary concept: cognition is an
be delivered in a playful way, for example, using games information-processing system [28,45]. This system is
like Simon Says or using soap bubbles to teach them comprised of different levels of thinking, structures,
to moderate their breathing. School-age children enjoy and processes including automatic thoughts, interme-
activities such as drawing, crafts, games, books, and diate beliefs (rules, attitudes, assumptions), schemas,
age-appropriate workbooks, such as Therapeutic and compensatory strategies [28,39,43]. Automatic
Exercises for Children [40]. Adolescents are frequently thoughts are the most accessible level of thinking,
able to engage in talk therapy similar to that of adults which can be thought of as the running commentary
but homework might involve journaling, poetry, or that goes through your head during your daily activi-
artwork. The therapist uses guided discovery to help ties. Intermediate beliefs are conditional and reveal
the child, adolescent and/or caregivers to increase assumptions or rules used by the patient to organize
understanding and to learn/practice new ways of his/her experience. For example, a child who receives
thinking and behaving. praise only when achieving may come to believe If I
Setting goals is an opportunity for collaboration as work hard enough, I will be loved. Schemas or core
well as for the therapist to gain additional under- beliefs are typically absolute, such as I am unlovable
standing of beliefs and expectations of the child/ado- and are usually brought to light over time by the ther-
lescent, as well as the caregivers. Input from the apist. Compensatory strategies refer to the behaviors

Patients name: Date:

Diagnosis: Axis I Axis II

Relevant Childhood Data

Which experiences contributed to the development and
maintenance of the core belief?

Core Belief(s)
What is the most central belief about himself/herself?

Conditional Assumptions/Beliefs/Rules
Which positive assumption helped him/her cope with the core belief?
What is the negative counterpart to this assumption?

Compensatory Strategy(ies)
Which behaviors help him/her cope with the belief?

Situation 1 Situation 2 Situation 3

What was the
problematic situation?

Automatic Thought Automatic Thought Automatic Thought

What went through
his/her mind?

Meaning of the A.T. Meaning of the A.T. Meaning of the A.T.

What did the automatic
thought mean to him/her?

Emotion Emotion Emotion

What emotion was
associated with the
automatic thought?
Behavior Behavior Behavior
What did the patient do

Figure 9.1 Cognitive Conceptualization Diagram.

that help the patient deal with their beliefs [39]. Con- Second, according to the content-specificity hypoth-
tinuing with the example above, a compensatory strat- esis proposed by Beck [45], cognitive content will reflect
egy for a child with these beliefs would be for him/her themes that correlate with specific disorders [43]. For
to work to achieve what is expected by those whose example, anxiety disorders are characterized by cogni-
love he/she wants. These levels of thinking are captured tions related to themes of threat whereas depression is
on the Cognitive Conceptualization Diagram [39] characterized by themes of loss. A recent study includ-
shown in Figure 9.1. Beck [39] provides detailed expla- ing children and adolescents aged 716 years demon-
nation of these structures and gives strategies for strated support for the content-specificity hypothesis,
eliciting client cognitions as well as modifying them, for both internalizing and externalizing disorders [47].
although not geared specifically to children and Finally, the distinction of deficiency versus distortion
adolescents. Stallard [46] demonstrates the applica- [27] is particularly relevant for the therapist working
tion of some of these concepts with children and with children and adolescents because the distinction
adolescents. will influence intervention selection.

Adaptations Once the initial conceptualization is developed, the

therapist uses the model to generate and test hypothe-
Overall, the cognitive behavioral model has appeared
ses regarding treatment approaches and specific
to produce efficacious treatment results when adapted
interventions. As treatment progresses the therapist
for children and adolescents. However, much more
continues to collect information about the client while
work is needed to fine-tune the model and treatment
also deciding whether hypotheses are supported or dis-
for this population. The process is underway. There are
confirmed. Therapists are not tied to their original
attempts to continue to adapt the CBT model to even
ideas, because as scientistpractitioners, they revise the
younger children. One study [48] using randomized
conceptualization in an iterative fashion [30,39]. With
controlled treatment (RCT) involved children aged
each successive approximation, however, the model
412 years diagnosed with disruptive behavior disor-
should become clearer and more accurate, forming the
ders. Those treated with a manualized CBT-interven-
basis for both within-session and extra-session [54]
tion called collaborative problem solving (CPS),
decisions about the client.
involving parentchild problem solving, experienced
A second use for the conceptualization is to promote
significant improvement.
client self-awareness, leading to generalization of skills.
Other extensions to young children include cognitive
This is accomplished by sharing the working model of
developmental therapy [31] (CDT) and cognitive
the client with him/her. That being said, it is para-
behavioral play therapy [49,50] (CBPT). Although
mount that the therapist considers the capacity of the
CDT and CBPT have not been subjected to RCT
client to receive and process information. Expectations
studies, case studies are available to illustrate their
for the level of sophistication regarding the conceptu-
principles. Both CDT and CBPT utilize play tech-
alization would be based on the clients developmental
niques. Although play has long been used as technique
level. For example, a young child may have the capac-
in child-oriented therapy, there are few RCT studies to
ity to recognize and label feelings along with a recent
evaluate its effectiveness. Russ [51], apparently in an
situation whereas a school age child may be able to
attempt to encourage the integration of play (in ways
begin to identify themes like I always get mad when
that are empirically supported) has compiled informa-
my Mom tells me no but not when my teacher tells me
tion that could be valuable to practitioners working
no. Adolescents, if motivated, may want to link their
with young children.
formative experiences with current patterns, I was
always worried that I would disappoint my Dad so I
never tried new things to keep from failing at them.
Developing the Conceptualization
Clinicians could make use of the Cognitive Conceptu-
Conceptualization is an essential cornerstone for effec- alization Diagram [39] for adolescents and, with some
tive delivery of CBT and refers to the process by which adaptation/assistance from the therapist, may be able
the therapist gathers and integrates information to have the teen complete it also. From the foundation
from several sources [30,39,52,53] including: (1) knowl- of the well-developed conceptualization, the therapist
edge of child/adolescent normal biopsychosocial begins to make use of it for treatment.
development [32]; (2) knowledge of child/adolescent
psychopathology; (3) knowledge of the cognitive-
behavioral model, including generic models of pathol-
ogy and the content-specificity hypothesis; and (4) A typical outline for an episode of CBT treatment is
specific presenting symptoms, including the back- shown in Table 9.3 [55]. Generally speaking, while
ground of the child/adolescent and his/her family. making initial treatment recommendations, I explain
Once integrated, this information creates a picture of that frequently each family member may need to do
the client allowing the therapist to understand and their own changing to help the child or adolescent who
make predictions (i.e., generate hypotheses) about the has been brought in for treatment. In addition, I
client and his/her family. provide the rationale for my decisions to the client
The rationale for developing a conceptualization is (titrated to their developmental level) and his/her
that, simply put, it leads to effective treatment [52]. parents as well as expectations for therapy. Whenever
Why? Because a cogent conceptualization that possible, I prefer to hold this meeting with everyone
accounts for the clients problems and proposes to involved; however, in cases where it appears it may be
understand the underlying mechanisms will aid the counter-therapeutic (for example, the parents actions
therapist in delivering appropriate treatment, including cause the child to shut down), I meet individually
selecting, timing, and tailoring interventions [5254]. with separate parties. Expectations include responsi-

Table 9.3 Outline of standard course of cognitive however, the details of how E/RP will be carried out
behavioral therapy. are not yet known for that particular child.
Treatment focuses simultaneously on two levels of
1. Therapist elicits information regarding the intervention: addressing the specific here-and-now
development of specific symptoms, as well as problems of the client and secondly, teaching the client
situational determinants and temporal course. skills and concepts that would prevent relapse as well
Objective and subjective data are collected as deal with future problems [39].
(preferably from multiple informants) regarding Research on how best to involve parents in CBT
the nature of the presenting problem. treatment has been limited, what is meant by a parental
2. A goal list is developed with the child and the or family component to treatment has not been well-
parents or other caregiver. Cognitive behavioral defined in the research studies and adding parents to
formulation and treatment recommendations are the treatment can present challenges. However, based
shared with the child and his or her parents. on the number of EBTs that include parents and
3. Underlying beliefs, attitudes, assumptions, appear to be effective, clinicians need to routinely con-
expectations, attributions, goals, and self- sider including parents. There are several reasons for
statements or automatic thoughts are identified. this. Involving parents in treatment can help support
Patients learn to monitor negative or maladaptive the child, by acting as a coach, to remind them of
thoughts and emotions. Attempts at self- what theyve learned and help them to use it between
monitoring are rewarded. sessions or after termination. A second advantage of
4. Specific behavioral and interpersonal skills deficits involving parents in treatment is the opportunity for
are identified. the clinician to assess and address, if necessary, the
5. Medical, social, and environmental factors parentchild relationship and its impact on the childs
maintaining the symptoms are identified. The symptoms, parental beliefs and expectations.
latter may include stressful life events (both major Typically treatment will consist of interventions that
and minor, short-term and chronic) or the combine both behavioral and cognitive techniques [56]
modeling and reinforcement of the symptoms by that have been selected by the therapist to fit that spe-
others in the childs life. cific individual [39], as well as taking into account the
6. Cognitive and behavioral interventions are clients developmental capacity [31]. Independent of
selected and introduced based upon the specific technique, however, it is paramount that the therapist
needs of the child. ensure that the child or adolescent understand the
7. Homework is assigned. The patient practices the CBT model, i.e., the link between thinking and feel-
cognitive or behavioral skills during the session. ings. Friedberg and McClure [30] suggest that clini-
Attempts are made to ensure that the cians select techniques based on the stage of therapy,
interventions are clearly understood, that the child i.e., make sure that the client can identify/distinguish
is motivated to attempt the assignment, and that thoughts and feelings before the therapist implements
they expect the intervention to be helpful. Factors more complex techniques.
that may interfere with the successful completion Determining whether the treatment strategy is effec-
of the homework assignment are identified and tive should be evaluated on an ongoing basis by having
addressed. the client explain their understanding as well as deter-
8. Effectiveness of the intervention is evaluated mining what mood or behavioral changes are occur-
through objective ratings, behavioral observations, ring. If the therapist sees that a particular intervention
and subjective reports. is not working, the therapist will attempt to determine
9. Relapse prevention interventions are introduced. the source of difficulty so as to modify some aspect of
Follow-up or booster sessions are scheduled. the current approach or to select a new intervention.
All these decisions are made based upon the revised

bilities of both parties and an overview of the antici-

Examples of Treatment
pated treatment process. For example, families who
have a child with symptoms of obsessivecompulsive Let us turn to some examples to illustrate, in particu-
disorder (OCD) should understand that exposure with lar, adapting CBT interventions to children at differ-
response prevention (E/RP) will likely be a significant ent stages of development. Consider a male who has
aspect of treatment. At the beginning of treatment, been brought to treatment by his mother, who reports

he has been having behavioral problems at school Therapist: And how did you feel when she didnt
(arguing and fighting with peers). During the first listen?
interview, the mother provides information that sup- Child: Mad.
ports a diagnosis of oppositional defiant disorder Therapist: Yeah, I can see how mad you must feel
(ODD). Furthermore, you have decided that the child because I heard your voice getting louder and
may be depressed based on your observation of him louder.
and his responses to some questions. During a later Child: Yep.
session, while the therapist and his mother are dis- Therapist: I wonder what you said to yourself inside
cussing an incident that occurred at school (he is your head when she didnt listen.
present in the room), he wants to speak with his Child: She never listens to me. All she ever does is yell.
mother. He tries getting her attention twice, then yells, (Starts to cry and mother starts to comfort him).
picks up an object, preparing to throw it at her. Therapist: I wonder if there was anything else in your
head about you mom. . . .
Child: Maybe she loves my sister more.
Preschool Age (age four years six months)
Mother: (angrily) That is not nice! You could hurt Adolescence (14 years)
someone doing that!
Mother: (angrily) That is not nice! You could hurt
Child: But mommy . . .
someone doing that!
Therapist: What made you get ready to throw that?
Child: But . . . I didnt throw it.
Child: She wouldnt listen to me.
Therapist: What made you get ready to throw that?
Therapist: And how did you feel when she didnt
Child: She wouldnt listen to me.
Therapist: And how did you feel when she didnt
Child: Huh?
Therapist: (changing strategies to labeling) I wonder if
Child: Frustrated.
you felt mad.
Therapist: And what was going through your mind?
Child: No.
Child: Parents never listen to their kids because they
Therapist: Well I heard your voice get loud, like a tiger
think they know everything!
growling, and your face got red. I think that goes
Therapist: How often do you get as mad as today?
with being mad. You got mad when she kept on
Child: Almost every time we talk about school,
because all they ever do is get on my back!
Child: (nods)
Therapist: I wonder what else you could have done?
Child: I dunno.
Therapist: Here, let me show you. Well, you could just CASE ONE: PRESCHOOL AGE
zip your lip (making zipping gesture and funny
Danny, age five years six months, was brought
face, child smiles) until mommy stopped talking, or
to treatment by his mother who was concerned
you could have tried staying still and raising your
about his growing oppositional and defiant
hand, or if it was real real important (like having to
behaviors, which occurred primarily in the
go the restroom), you could even flap your hand
home setting but had also started to manifest in
around like a flag like this! And that would let us
kindergarten. Initially, the therapist recom-
know you cant wait for us to stop talking. But thats
mended that mom use a behavioral chart with
only something you do once in a while. Understand?
three daily tasks, two that were already occur-
Child: Nods yes.
ring (so she could practice praise and positive
Therapist: OK, lets practice with mommy right now.
reinforcement) and one challenging task that
tended to elicit opposition. After two weeks of
using the chart, an exasperated mom said that
School Age (age nine years)
the clients behavior had actually become more
Mother: (angrily) That is not nice! You could hurt oppositional, not less. In the meantime, the
someone doing that! therapist asked mother to note any patterns
Child: But . . . related to opposition. The only pattern she
Therapist: What made you get ready to throw that? could see was that when Danny cried, he
Child: She wouldnt listen to me. became more oppositional. Further discussion

of recent events revealed that when Danny was Danny: No, I dont hear him crying but he still
asked to do the difficult task, he would fre- would like to play.
quently cry to which mom responded by Therapist: I know.
saying it wasnt so hard or that it wouldnt take
Comment: Although all of the oppositional
very long. When asked if she talked with him
behavior did not disappear, through the com-
about his crying or attempted to comfort him,
bination of mother reading and learning how
she expressed concerns that this would make
to interact in a more positive fashion with
him into a cry-baby and he would try to get out
Danny, about eight weeks into treatment, she
of doing things. Two interventions took place
stated, You know, after reading that book, I
over time to address the interaction between
realize that I was a big part of the problem.
Danny and his mother. First, the therapist
Over time, Danny continued to reveal more of
explained that expressing understanding of
his feelings and thoughts to his mother, who
childrens feelings does not mean that the
learned to tolerate negative affect and coach
parent has to cave to whatever the child
him. This example illustrates how a parents
wants. To gain a more in-depth understanding
beliefs about developmental expectations can
of how to deal with Dannys negative feelings,
interact with and influence a childs behavior.
mother was asked to read a parenting book that
It also demonstrates that the child was most
explains the role of parent as coach [57]. At the
likely operating from deficits that were
same time, the therapist gathered information
addressed when his mother learned how to
from play with Danny, then modeled for
respond to him. Finally, the coaching stance
mother how to coach Danny through difficult
of the parent is a good example of a parent
feelings. Due to his age, a small sandbox with
modeling emotional regulation and problem-
plastic animals (he chose horses) was used to
solving for the child.
facilitate the play. The following example
shows how information was collected:

Therapist: So, this horse here (pointing to

smaller horse). Is it a boy or girl horse?
Danny: A boy.
Therapist: I wonder how old he is . . . Alonzo, a nine year four month old Latino
Danny: Five and a half! male, was brought for treatment by his single
Therapist: And I see that the Mommy horse mother, who explained that he was being
just asked him to take his nap. treated for ADHD by a psychiatrist, who
Danny: Yep, and he doesnt want to. advised the mother to seek psychological serv-
Therapist: How do you know? ices to help her manage her sons temper out-
Danny: Because he wants to play. bursts. His mother has been working with his
Therapist: So he wants to play oh, and I teacher to track his daily in-school behaviors,
think I hear him crying. including turning in assignments, paying
Danny: Yup (frown). attention, transitioning, and not interrupting.
Therapist: Hmmm. I wonder what the The daily goal was to obtain an OK in each
Mommy horse could do to help him. area, thereby earning points that he could
Danny: Tell him he can play. cash in at school for rewards. Furthermore,
Therapist: Well, but Mommy horse wants him his mother based home privileges on his
to have his nap. I know, she can tell him he school behaviors, as reported by his teacher.
can take his favorite book to read while he As long as Alonzos behavior was in the
goes to sleep and then he can play when he acceptable range, all was fine. When it didnt,
wakes up. Or . . . Mommy horse can say It however, he would receive a warning from
isnt that hard to take a nap. the teacher with the purpose of giving him
Danny: No, its better if she says its OK for feedback to help him get back on track. In
him to take a book into his room. most cases, after he received a warning, he
Therapist: OK, so he goes and finds his became angry, upset and uncooperative,
favorite book do you think he is still leading to more difficulties for the rest of the
crying? day. At a session with Alonzo and his mother,

I asked Alonzo to explain what he thought chances and we implemented the graduated
was making it so difficult for him to meet his reward system, to discourage the all-or-
goal, leading to the following dialogue: nothing thinking of both the adults and
Alonzo. As soon as these two interventions
Alonzo: Well, when I hear the warning I
were put into place, the conflict level between
think that my teacher is just trying to make
Alonzo and his mother was greatly reduced
me fail and once I miss my goal for the day,
though not absent by any means.
I cant have any fun at home.
Comment: In this case, it is clear that the
Therapist: Wow, that sounds like a lot of pres-
parents beliefs and expectations were influ-
sure and like you feel the grown ups are out
encing the childs feelings and beliefs. The
to get you.
intervention modified beliefs of the parent and
Alonzo: Right! Like last week mom told me
child as well as teaching them the skill of col-
that if I could get a perfect week, then I
laborative problem-solving.
could buy a new computer game.
Therapist: So you were probably trying your
hardest because I know how much you like
computer games.
Alonzo: Yeah, and then I get a warning on Guidelines for CBT-Oriented Treatment
Thursday! And it wasnt even my fault but
Mental health providers may wish to consider the fol-
the teacher wouldnt listen.
lowing guidelines to for a CBT-oriented approach in
Therapist: So, when you get a warning
their work with children, adolescents, and their
what does that mean?
Alonzo: It means I am probably not going to
make my goal for the day OR the week.
Therapist: Sounds like you worry a lot about Using CBT Principles
not meeting your goal.
Familiarize oneself with, and utilize in each session,
Alonzo: Yeah and I get mad thinking about
the principles of the CBT model. Cognitive therapists
how they dont want me to earn my points.
are active and directive, while creating an atmosphere
Therapist: I wonder what would happen if
that conveys a sense of teamwork comprised of the
you think of your warnings as strikes, like
therapist, the client, and if applicable, family members.
in baseball you know, three strikes and
That team utilizes structure (agenda and homework,
youre out. Only your teacher gives you two
for example) to work together cooperatively to explore
existing beliefs and behaviors (collaborative empiri-
Alonzo: You mean like chances?
cism), as well as to create new ones (skill-building
Therapist: Yep. It seems like youve been
and/or correcting distorted beliefs).
thinking that a warning is an out.
Alonzo: I do and then I just feel like giving up
because its too hard. Assessment
At this point, the therapist spoke with Conduct assessment that includes instruments that will
Alonzos mother privately to set up a way that lead to a conceptualization that is specifically CBT-
he could earn some privileges even if his day oriented and/or that are conducive to evidence-based
wasnt perfect. She expressed concern that if practice, for example, semistructured interviews that
you give him an inch, he will take a mile but have been used by researchers [58]. Semistructured
we worked out a graduated system that interviews, in comparison to unstructured interviews,
would allow her to give him basic privileges generally produce more reliable and valid diagnoses, as
for 70% achievement, better privileges for 80% well as sometimes collecting broad-based information
achievement and deluxe privileges for 90% for the case conceptualization, leading to decisions
and above. Any day with achievement below about treatment [58] including the choice and timing
60% would result in a loss of all privileges at of specific techniques or interventions. Specifically, as
home for that day. We included Alonzo in the information is collected related to presenting problems
discussion by asking him to rate his favorite and symptoms, the mental health provider frames the
privilege as a 1 and so on. Mom agreed to information according to the CBT model of the person
remind Alonzo to think of warnings as (thinkingfeelingbehaviorbody). Similar to other

models, assessment will also include the mutual inter- myself because I wonder if Im permanently dam-
action between the person (child or adolescent) and the aging him by sending him to daycare.
childs context, including family, school, culture, etc.
Here, what distinguishes the CBT approach from other
Scenario Three
models is that the cognitive therapist listens for beliefs
and observes behaviors (while connecting them to Julie: Im not really sure. Maybe it is just a phase.
affect and physiological symptoms), so that the data Therapist: And what do you do to help him when he
can be organized into a CBT conceptualization. wakes up?
Thinking or cognition is further organized, to the Julie: I dont really do anything, I mean, I try to
degree that it is developmentally appropriate, into a console him by telling him we all have bad
system that reflects the way in which the client con- dreams sometimes but he just cries. I dont know if
structs his/her world. Common terms comprising this anything can really help. Wont he just grow out of
system include automatic thoughts, conditional it?
beliefs/values/rules, and core beliefs/schemas.
A brief example may serve to clarify. Using three dif- Admittedly, before knowing additional details about
ferent scenarios that could occur, lets look at how dif- this child and family, one would not make major
ferent responses on the part of the caregiver may treatment decisions. However, after just two questions
contribute to a difference in how interventions would posed by the therapist, we see three very diverse
be planned. Suppose a mother, Julie, brings her seven- responses that exemplify the worldviews of the care-
year-old son, Danny, to see you because he has started givers and give important clues (evidence) which will
to have nightmares within the past three months, be used by the therapist to add to the case formulation,
around the same time she returned to full-time employ- eventually leading to hypotheses. As information from
ment outside the home. The therapist, using collabo- caregivers is collected, the therapist fits it with what is
ration, asks Julie if she has any ideas about what has known about the child (organizing it according to
triggered this episode and (to assess problem-solving thinkingfeelingbehaviorbody domains) and imag-
ability) what she typically does to help him. Note that ines (hypothesizes) the dynamic interplay both intrap-
although this appears casual and conversational, the ersonally and interpersonally.
therapist is gathering information about the world Quite possibly, the same cognitive techniques would
view (cognitions, beliefs, values, rules) of the caregiver eventually be used in all three scenarios, though
and the caregivers coping strategies (behaviors, skills, perhaps in a different sequence. For example, educa-
problem-solving abilities). This information is key, as tion about development, education about anxiety,
children and adolescents are affected by and influenced helping the caregiver learn how to soothe the child, or
by the cognitions and behaviors of their caregivers. intervening directly with the child. However, the start-
ing point would depend on the conceptualization. In
scenario one, Julie is stressed and angry, while also not
Scenario One
understanding how to be of comfort to Danny. She is
Julie: I think Danny is angry with me and spoiled. He likely to be defensive if told that her stress and state-
always has to have things his way, I dont really think ments to him may be exacerbating the problem. There-
he wants me to work. fore, I would start with the child as the focus (since she
Therapist: And what do you do to help him when he sees him as the problem). I would explain to mom
wakes up? that he may benefit from learning how to help himself
Julie: I tell him to go back to bed and stop feeling by learning relaxation exercises. For younger children,
sorry for himself. Hes in first grade now and its time like Danny, I request that the caregiver learn the skills
to start growing up. simultaneously so that they can support the child by
helping them to remember homework assignments
(practicing the skills) or in case the child forgets some-
Scenario Two
thing about the procedure between sessions. While
Julie: I feel so guilty because I cant be there for him explaining the skill to them both, I routinely mention
to be a good mom. that adults get stressed too, so can benefit from learn-
Therapist: And what do you do to help him when he ing relaxation techniques. Rarely have I had an
wakes up? instance where a parent resisted this approach.
Julie: I hold him for a few minutes and comfort him. Instead, parents express relief that someone recognizes
And then after I tuck him in I cant get back to sleep their stress and doesnt blame them for it, yet gently

encourages them to address it. If this aspect of treat- with. Personally, I found the scoring to be time-
ment goes smoothly, and a solid relationship between consuming but clinically, the CARC yielded valuable
myself and the caregiver begins to blossom, I then con- qualitative information. For example, some children
sider addressing parent beliefs. Specifically, for care- had absolutely no awareness of any physiological signs
givers who are angry and stressed, it should be a of anger (but their parents did!). Some children were
gradual approach (maybe just addressing one of their eager to discuss their feelings, others became so upset
beliefs as part of a session focused on the child) and during the CARC administration that we had to take
one that conveys empathy. As the relationship becomes a break and use coping skills before continuing.
more well-established a more formal and direct focus As the therapist conducts the assessment, several
on parent beliefs may be pursued. questions (not necessarily mutually exclusive) the ther-
Assessment procedures should be developmentally apist wants to be able to answer fairly quickly (one to
sensitive. As information is collected, the therapist two visits) include:
organizes it within a CBT-oriented conceptualization.
Are these childs presenting problem(s) due to defi-
There are many assessment instruments available, and
ciency or distortion?
for young children, assessment will be done via inter-
What is this childs system of thinking (how has this
view and observation (probably during play or inter-
child constructed his/her world and how well can the
acting with the caregiver). For school-age and younger
child articulate/understand information about feel-
adolescents, I prefer instruments that are particularly
ings, thinking, behavior, and bodily symptoms?)
CBT-friendly. For instance, the Beck Youth Invento-
Will it be helpful/necessary for the childs caregiver
ries of Emotional and Social Impairment (BYI) [59],
to be involved in treatment? If so, what will be their
which were developed and normed for children aged
814 years, consists of five separate self-report inven-
tories that measure levels of depression, anxiety, anger,
disruptive behavior and self-concept. A combination
The Working Model
inventory is also available. Each 20-item inventory is
written at the second grade reading level, can be com- Formulate your own working model of the client that
pleted within 510 minutes and scored easily by the reflects a CBT orientation. In other words, the infor-
therapist during the session, providing an opportunity mation about a child (or adolescent and their family)
for discussion of specific items and conveying infor- can be organized such that the childs thinking, feel-
mation to the client and/or family members. I typically ings, behavior, and physical functioning present an
ask additional details about items, adding brief notes. internally consistent picture. Furthermore, to the
A recent review [60] of the BYI notes its limitations, degree that it is possible (depending on developmental
including insufficient evidence for their use by them- level), the formulation should include various levels of
selves to measure treatment effects. However, clinicians cognition (automatic thoughts, beliefs, conditional
are well advised to consider assessment data, including assumptions, rules, schemas) that comprise the clients
results from self-report instruments, within the context system of thinking about themselves, others (partic-
of other information [61] about the child/adolescent ularly significant people and events), and the future.
and their functioning. For adolescents and some school-age children, the cli-
For assessing anger (ages 712 years), I have also nician can make use of Becks Cognitive Conceptual-
used the Childrens Anger Response Checklist (CARC) ization Diagram [39] to organize the material in a
[62]. Features of the CARC that were particularly one-page format. Key would be the childs ability to
useful were the Likert-scale (operationalized using articulate automatic thoughts as well as the accompa-
faces depicting different degrees of anger) and the fact nying feelings, etc.
that the scale uses 10 stories illustrating potentially Clearly, the more cognitively developed a child is, the
frustrating situations. As the clinician and child more ability he/she will have to articulate such infor-
explore the childs anger reaction to each situation, mation. When that is not the case, however, the thera-
responses are organized according to the domains B, pist makes inferences through observation and
C, E, or P (behavioral, cognitive, emotional, and phys- attempts to examine the evidence to for/against the
iological). Although the 10 vignettes give a sense of the inference. For example, the cardinal question of CBT,
childs anger, in general, sometimes I wanted to gather What was just now going through your mind? in the
information about events specific to a child. Therefore, presence of heightened affect is not generally develop-
using the general CARC format, I included vignettes mentally appropriate for a five-year-old. Instead, infor-
based on issues that a particular child was grappling mation would be gathered during story telling or a

structured play that touches on areas of difficulty for medication by another provider, it can be helpful feed-
the child. back to the prescriber to have specific information. For
In my own experience, I have discovered several ben- example, When I saw this client at intake, the score
efits of a well-developed (but continuously revised) they obtained on the Beck Depression Inventory for
conceptualization. First, even as this CBT-oriented Youth [59] (BDI-Y) fell at the 88th percentile. Now,
picture of the client continues to be refined, it pro- two months later, they have seen me for six sessions and
vides a sense of continuity in my own thinking about because I knew they were coming to see you next
the client, leading to an increased ability to recall Tuesday, I had them take the BDI-Y again, with a
details of the clients experiences as well as the ability current score at the 67th percentile. On the other hand,
to identify and explore recurrent themes. It can be the conversation could go like this: When I saw this
quite comforting for client (and their caregivers) to client at intake, the score they obtained on the BDI-Y
find that they make sense to someone else, even fell at the 88th percentile. Their parent tells me they
when they havent been able to put the pieces together arent due to see you again for another six weeks;
yet themselves. Second, the formulation allows however, today, when meeting with the family for the
for a quick guide to the timing and selection of third session, the client completed the BDI-Y again
intervention techniques, as well as how to tailor them and obtained a score at the 95th percentile.
to the individual. Finally, the conceptualization even Empirical literature should be regularly reviewed in
guides the sharing of the conceptualization with the order for the clinician to stay familiar with what treat-
client (and/or caregiver). Why is this important? ments appear to be the most effective, usually termed
Because CBT is focused at two levels simultaneously: EST or EBT. Two recent collections of empirically
addressing current concerns while at the same time based practices for children and adolescents [63,64]
teaching skills that the client can utilize throughout the contain numerous CBT-oriented treatments, including
lifespan. information about specific disorders, age range treated,
and parental involvement (whether and how much).
Furthermore, specific and practical information about
Blending Creative and Scientific Aspects
program protocols (delineated by sessions or steps)
Integrate the creative and scientific aspects of treat- and manuals (for both therapist and clients) or assess-
ment. The creative portion comes naturally to most ment instruments are included. Treatment guidelines
practitioners in the caring professions and consists of included in these resources address ADHD, anger for
the collaborative, warm, caring relationship which school age children, firesetting, OCD, ODD/CD, and
demonstrates to the client the humanity of the thera- anxiety, among others.
pist. Without this foundation, even the most sophisti- For example, the Coping Cat program developed at
cated, accurate and brilliant CBT intervention is likely the Temple University Child and Adolescent Anxiety
to have minimal impact. Disorders Clinic (CAADC) [9] is designed for children
The scientific aspect of treatment includes using aged 713 years who have been diagnosed with anxiety
outcome measures and incorporating research find- disorders, including social phobia, generalized anxiety
ings, protocols or manuals and standard CBT tech- disorder, and separation anxiety. A total of 1618 ses-
niques, as well as using a scientific approach to sions (including two parent sessions) is divided into
treatment. Some outcome measures have already been two phases. Phase one is oriented toward helping the
mentioned above, the results of which should be con- client first acquire coping skills to deal with anxiety,
sidered as data [61] in context of the overall picture of then to practice the skills in phase two. Clients utilize
the child/adolescent. Frequency of administration of the Coping Cat Workbook [65] in parallel with the
outcome measures can be adjusted depending on the treatment sessions. Therapists model the skills and
severity of the clients symptoms, the number of meas- assist with practice (exposure tasks).
ures and length of each, as well as time to score and Because a number of these treatment protocols were
interpret. Other factors that may influence the thera- found to have effective treatment outcomes, therapists
pists decision to have a client complete outcome meas- should use them. However, the manuals should be used
ures over the course of treatment could be when there in a flexible fashion. Doing so provides benefit to both
appears to be a significant change in symptom sever- therapist and client, as the therapist retains the
ity (increase or decrease), to help guide decisions freedom to utilize clinical skills to fit the treatment to
regarding changes in frequency of sessions or when the client and his/her needs. This is best done based on
deciding to end treatment, and prior to reporting to a the conceptualization of the client the therapist has
third party. For instance, when clients have been given developed. Furthermore, the client benefits as they get

the best of both worlds treatment that has been Scenario One
shown to be effective for other children with similar
Therapist: So, was there anything upsetting that hap-
problems but tailored specifically for him/her by a
pened during the week?
person who cares about and understands their partic-
Janine: Well, my mom told me she has to get another
ular situation. Since many of the evidence-based treat-
medical test for high blood pressure.
ments or manuals use techniques that would be
Therapist: And that made you feel?
considered part of the standard CBT repertoire, ther-
Janine: Basically terrified.
apists should be familiar with these techniques, the
Therapist: And did you write something about this on
rationale for using them, and the general procedure for
your list of anxious thoughts?
implementing them.
Janine: Yes, My mother might die.
No matter whether a therapist is using EBT, adapt-
Therapist: Well that sounds pretty upsetting. Do you
ing a manual, or individualizing CBT techniques and
think that had anything to do with you having more
methods in treatment, it goes (almost) without saying
sleep problems this week?
that the therapist will combine their interpersonal
Janine: Yeah, I guess I hadnt really thought about it.
skills with analytic skills to make clinical decisions and
Therapist: Did you get a chance to talk with your
to evaluate progress. The standard way in which this is
mom yet?
done is to use the scientific method that consists of the
Janine: No, Im afraid to bring it up, could you help
following feedback loop: data collection, development
me talk with her?
of hypothesis, testing of the hypothesis, then evaluat-
Therapist: Sure, lets ask her to come into the session.
ing (i.e., data collection) leading to a revision of the
hypothesis. This process occurs throughout each Comment: In this case, the therapist has enough infor-
session as the clinician interacts with the client, makes mation to hypothesize that Janines anxiety about her
choices about when and how to intervene, and then mother may have exacerbated the sleep problems. By
judges the outcome. An example will serve to illustrate having her mother come into the session, the therapist
how second-nature this way of thinking becomes for shows empathy, support, and caring yet simultane-
the clinician. ously plans to model for Janine how to talk with her
mother about her concerns. Furthermore, in a sense,
EXAMPLE the information that will be discussed will be a varia-
tion of the Thought Record, as the therapist plans on
Janine is a 13-year-old female who presented showing the client how to gather evidence that will
due to sleep problems once a week and dispute her anxious thoughts about her mother dying.
anxiety in several domains of her life: school, After theyve first discussed it all, the therapist can
appearance, and her mother who is having assist Janine to write it down in a way that makes sense
some medical issues but are not serious. Until to her and that she can access again in the future.
the past quarter, she had always been on the
Honor Roll. Being so bright and motivated to
feel better, she easily grasped the CBT model, Scenario Two
could identify her feelings and bodily symp- Therapist: So, was there anything upsetting that hap-
toms, as well as articulate her automatic pened during the week?
thoughts. By session 2, the therapist observes Janine: Not really just sort of the same.
that Janine has many of the foundational abil- Therapist: When did your sleep problems seem to get
ities that are needed for her to learn about worse?
Thought Records thus plans to introduce them Janine: Well, maybe a couple days after I came here.
to her in session 3. For homework, the thera- Therapist: What would be happening when you were
pist suggests that Janine record anxious sleeping?
thoughts and rate how much they bother her, Janine: Well, I was working on making that list of
using a numeric rating from 1 to 10, 10 being worries after I did my homework like right before
the highest. When Janine returns to session 3, bed.
she reports that her sleep problems have wors- Therapist: Yes?
ened. At this point, the therapist wants to Janine: Well, then when I would wake up that was all
collect information so she can decide how best that I kept thinking about.
to proceed with the session: Therapist: Your list? You mean, like I better get up
and add something to it?

Janine: No, more like everything that was on the list sider collecting empirically supported treatment
kept coming back into my head. Kind of how it was modules [32].
before only worse. The therapist, then, instead of thinking of treatment
Therapist: I see. And then it was hard for you to get as a string of interventions, considers the overall stages
back to sleep. of components of treatment needed in order to address
Janine: Yes. the childs problems. A good example of this is
Therapist: OK, tell you what. Would it be alright described by Kendall and colleagues [66] in working
with you if I keep your list because I know you with anxious children. Although the Coping Cat
worked hard on it but I have something else that I program uses a treatment protocol, with two phases:
want us to do today and well come back to the list education and exposure, the overall strategy of treat-
later. ment could be conceptualized in modules consisting
Janine: Sure. of somatic education, relaxation, self-talk, exposure,
self-reward, and consolidation. Each module may
Comment: In this case, the therapist hypothesizes that
consist of several cognitive and/or behavioral inter-
the sleep problems were exacerbated due to the client
ventions. For example, a goal of the self-talk module
focusing on anxious thoughts. Therefore, although the
would be to help the child identify his anxious feelings
client appears to have excellent cognitive abilities to
and related anxious thought(s), but then to generate an
engage in Thought Records, the therapist is going to
alternative thought that would help reduce anxiety
switch temporarily to behavioral techniques (relax-
level. During the education phase of treatment, the
ation techniques such as abdominal breathing, pro-
child may be learning about his/her anxiety as well as
gressive muscle relaxation, and distraction music, for
how to potentially cope via self-talk. During the expo-
example) to help the client cope. Within a session or
sure phase, the skills are actually put into practice.
two, the therapist believes they will return to Thought
One of the most challenging tasks of the CBT prac-
Records, but she will take one thought at a time off the
titioner is to adapt standard interventions to a childs
list that the client has allowed her to keep in the file in
developmental level, especially at younger ages. As
the therapy office. While the scientific method is not
there is scant empirical information available for
unique to CBT practitioners, the way in which the CBT
younger aged children, the practitioner needs to utilize
practitioner collects (assessment instruments, the
a scientific approach, as previously described. In
way in which questions are asked, etc.) and organizes
general, some rules-of-thumb to follow in this area
information takes place within the context of a CBT
the younger the child, the more often caregivers will
be involved;
Using Standard CBT Intervention the younger the child, the more often treatment will
consist of behavioral interventions;
Familiarize yourself with standard CBT interventions
the younger the child, the more often treatment will
while remembering to adapt them to the developmen-
be activity or play-based;
tal level of the child or adolescent. Details of CBT
the younger the child, the more often treatment will
interventions and techniques are described elsewhere;
address deficiencies (versus distortions);
however, the CBT therapist would have in their
the younger the child, treatment will occur in vivo
toolbox a collection of both behavioral and cognitive
(caregiver would carry out homework assignments
techniques. Typical behavioral techniques include
or support child to do so);
relaxation training, distraction, systematic desensitiza-
the younger the child, the less often the conceptual-
tion, modeling, role-playing, pleasant activity schedul-
ization is shared (but may be shared with caregiver).
ing, graduated exposure (imaginal and in vivo),
behavioral experiments, and contingency management Adapting interventions to the child or adolescents
(including shaping, extinction, positive reinforcement developmental stage and individual interests appears
and punishment). Typical cognitive techniques include to increase the effectiveness of the treatment, since it
guided discovery using Socratic questioning, examin- would be relevant and interesting, probably increas-
ing the evidence to address cognitive distortions, self- ing motivation. Let us examine how a cognitive tech-
instruction, and problem solving. Frequently, both nique Thought Records might be developmentally
cognitive and behavioral techniques may be combined adapted.
in a single intervention, for example, into a lesson or In general, adolescents can be treated more similarly
module [66,67]. In fact, clinicians are advised to con- to adults in terms of their ability to self-reflect and

engage in analysis. Frequently, when I have presented and assessing the childs ability to recognize affect
the Thought Record to adolescents and asked them to (her own and others) or by the therapist putting
complete between-session samples, they see it as on a puppet show. Sharing skills could then be
another homework task. So, instead I find out about modeled by the puppets, then practiced by the client in
their interests journaling, poetry, art, music to the session.
make use of what they already do as a vehicle of dis-
covery. Amanda, a 17-year-old female, who presented
Role of Psychoeducation
with anger (especially at home) and depression, had
experienced a recent breakup. When she told me about Use client and/or parent education to promote under-
the paintings and drawings she enjoyed doing, I asked standing of the CBT model and CBT techniques, as
her to bring some into the session. Seeing such work is well as their relevance to the client in his/her life. This
a powerful communication to the therapist! As process actually starts with the initial contact and con-
she described her work to me, I asked the cardinal tinues throughout treatment. An obvious way in which
CBT question, What was going through your education occurs is with the CBT interventions them-
mind? to obtain information while also assisting her selves. Suppose the treatment of an anxious child, Dee,
to connect her thoughts and feelings, as well as to is going to involve relaxation and distraction tech-
address her frequent belief Ill never find another niques, cognitive restructuring, and exposure. Unless
boyfriend. contraindicated, I prefer to have the parent and child
For school-age children, having brief, engaging, and together when I am explaining general treatment
structured written work is quite similar to school tasks. approach (except in the case of very young children)
Therefore, a workbook like Therapeutic Exercises for and usually direct my conversation to the child at their
Children [40] (TEC) is ideal. TEC consists of 18 exer- level with the parent observing. Several benefits follow.
cises designed for children aged 812 years who are The child receives treatment aimed at their capacity
struggling with anxiety or depression. Each exercise and the parent has the opportunity to observe how I
has a name, guidelines for the therapist, tips for chil- will be interacting with their child. Furthermore, the
dren, and a sample. Specifically, the Thought Record parent becomes familiar with the content so they can
has been developmentally adapted with the exercise understand and support their childs treatment.
Catching Feelings and Thoughts, making use of illus- A second way in which education occurs is whenever
trations, coloring, and thought bubbles. Another work- the conceptualization is explained. Again, depending
book available online (electronic book available at on the circumstances, the way in which I share the con-, Think Good, Feel Good: A Com- ceptualization is individualized for each client. Gener-
prehensive Behaviour Therapy Workbook for Children ally speaking, when treatment goals are initially
and Young People [46] contains CBT-oriented exercises formulated and we decide to focus on particular skills
and worksheets. or interventions, I provide the rationale framed in CBT
It would be unlikely that I would attempt to terms. As treatment progresses, I have found that other
adapt a Thought Record for a child under the age of parts of the conceptualization may come to light. At a
eight years because Thought Records assume the pres- later point in treatment, different parts of the concep-
ence of a distortion and has the goal of refuting it tualization may be able to be linked together.
with a logical analysis by examining the evidence. At A third aspect of education concerns homework or
this age, treatment occurs more often in the here-and- between-session assignments to help the child practice
now (in vivo). Therefore, I would typically use play, the skills, whether behavioral or cognitive. The expla-
drawing, storytelling, puppets, games with or without nation I usually give for the assignments is that it will
parent participation. Depending on the presenting be hard to feel much better if the only time they prac-
issue, I would try to design the session so that it would tice new ways of thinking and feeling is in my office.
bring to light issues that need to be addressed. For Homework assignments, like interventions within ses-
example, suppose a six-year-old girl, Janie, tells you sions, are fit to the developmental level of the child.
that nobody likes her or ever wants to play with her. For example, school age children can use structured
You find from talking with her teacher that other chil- workbooks but adolescents may prefer to write poems
dren do keep a bit distant from her since she or keep journals to explore their feelings and thoughts.
tends to be somewhat bossy. Play in the sessions A final (last but definitely not least) way to utilize
can be set up to help her learn turn-taking and/or education is to assist parents in exploring general
problem-solving. This can be accomplished first issues like development or to find additional informa-
by reading a book [68] about the difficulties of sharing tion about the particular issues their child might be

dealing with, such as anxiety or depression. Education Although part of the CBT session structure is to
is not particular to CBT providers; however, as a CBT- solicit feedback, in my experience, I have found that
oriented provider, I prefer to recommend materials clients seemed to give me responses like fine or
that are consistent with the model and that fit the inter- Everything was good. Instead, I have developed
ests and time constraints of the parents. Two general several ways of making sure to give the client the
development books I frequently recommend are Your message that the sessions are a safe place to give feed-
Child [69] and Your Adolescent [70], both edited by a back (including negative) by doing the following.
past-president of the American Academy of Child and During the session (usually session 2) when I social-
Adolescent Psychiatry. For knowledge about emo- ize the client to the CBT model, I explain that we will
tional development, the books by the Philadelphia be working together like a team, to help you/your
Child Guidance Center (covering young children [71], child with your problems. Therefore, it is really impor-
childhood [72], and adolescence [73]) are beneficial. A tant and helpful if you tell me when something I say
good source for helping parents to understand how to doesnt make sense or if you dont agree with it. Do
handle their childs (unpleasant) emotions is The Heart you think you can do that? Frequently, this begins to
of Parenting [74] audiotape with or without its com- elicit client beliefs. For example, if the response is, But
panion book [57]. For parents who want to examine I dont want to hurt your feelings, then I might ask for
and alter beliefs about themselves and their children, I an example of what would be horrible enough to hurt
recommend Why Cant I Be The Parent I Want to Be? my feelings and address their concerns. If the response
[75]. Parents of anxious children may want to review is more like, But you are the expert and I should not
Helping Your Anxious Child [76] or Worried No More be questioning you I give them permission to do so,
[77]. For parents whose children struggle with OCD, explaining that their concerns may not have anything
Freeing Your Child From ObsessiveCompulsive to do with my expertise.
Disorder [78] and What To Do When your Child has However, having such conversations only at the
ObsessiveCompulsive Disorder [79] may be helpful outset of treatment is not enough. Therefore, I have
. . . More Than Moody [80] describes and explains incorporated listening for feedback or asking for it
depression in adolescence, while Helping Your Teen once or twice (or at key points) during a session. That
Beat Depression [81] takes a problem-solving stance. way it becomes second-nature to the client and is part
For parents who want online, easy to access informa- of our ongoing dialogue. Key points have become
tion, sites such as are extremely fairly clear to me by attending to client affect, then
useful, covering a wide array of topics. asking the cardinal question, What just went through
your mind? For example, when working with a mother
of a four-year-old female who was having trouble with
Importance of Feedback
transitions and complying with commands, I had spent
Seek feedback from the client and/or caregivers, both several sessions modeling behavioral techniques like
informally and formally. Some agencies have used a ignoring and redirection. As I coached the mother,
written feedback form that can be completed periodi- preparing her to use these techniques for a few minutes
cally, as often as after each therapy session. In addi- at the next session, her affect shifted, getting cloudy.
tion, as part of the CBT session structure, feedback is As I asked What was going through your mind? she
given/asked for toward the end of the session. Feed- hesitantly responded by saying You are asking me to
back is likely to be part of any therapists work, so do something before I am ready related to her feeling
what is different about this process for a CBT provider? irritable and anxious. With this information, I was able
As a CBT therapist, I view feedback (especially neg- to find out more about how to support her and to
ative) as absolutely vital! That is why I have learned address her concerns. This brief interaction strength-
to encourage it and welcome it. Numerous benefits ened our relationship but alerted me to her belief
occur when the client is encouraged in this direction. that she lacked a skill, a concern which could be
First, it adds to the sense of collaboration and to addressed.
the therapeutic relationship. Second, since feedback Finally, another method for obtaining feedback is
is seen as a two-way exchange, it reduces (though via written forms. Some practitioners use brief client
probably does not eliminate) the power-differential self-report measures that specifically assess the
inherent in the therapistclient relationship. Third, strength of the therapeutic relationship [82]. These
the therapist can get a sense of client (or caregiver) would likely be most appropriate for adolescents or
beliefs, always adding this information to expand the parents involved in treatment. In addition, Friedberg
conceptualization. et al. [83] developed written feedback forms specifically

for children aged 811 and 1216 years to measure that can be used to evaluate the strengths and weak-
engagement as well as what was helpful (or not) to the ness of a cognitive therapist. Join organizations such
client. as the Academy of Cognitive Therapy (ACT) and
Association for Behavioral and Cognitive Therapy
(ABCT, formerly known as AABT Association for
Promoting Professional Growth
Advancement of Behavior Therapy). ABCT has an
Monitor and expand your development as a cognitive annual convention during which you can find work-
therapist. Development occurs at two frequently over- shops by leaders in CBT. Finally, read CBT-oriented
lapping levels, personal and professional. At the per- literature, particularly Cognitive Therapy: Basics and
sonal level, CBT practitioners can learn much from Beyond [39], especially the sections covering guidelines
paying attention to their own automatic thoughts [54] in treatment planning and problems encountered in
during the therapy process and about various issues therapy. For information specific to children and ado-
concerning clients. In fact, completing Thought lescents, read Clinical Practice of Cognitive Therapy
Records to examine ones own automatic thoughts with Children and Adolescents: The Nuts and Bolts
and related emotions, as well as completing a self- [30] for a source that is loyal to the basic CBT theory
conceptualization using the Cognitive Conceptualiza- as well as including many practical suggestions
tion Diagram [39] can be quite informative. As one gets that can be applied in daily practice. Finally, add
in the habit of reflecting on the cardinal question CBT-oriented websites ( and
What just went through my mind? there is an ever- to your Favorites list on your
increasing awareness of the connection between ones computer and review them regularly.
own thoughts and feelings, and this information can be
used during sessions. In fact, at times it may be appro-
priate to self-disclose (for the benefit of the client) Summary
automatic thoughts or feelings. For example, Jake, a
14-year-old male, who presented for depression comes The CBT model has shown to be a promising approach
in for the sixth session, and once again, forgot to to ameliorating the psychological problems of adults
bring his homework. You notice you feel irritated but and more recently, to those of children and adoles-
dont realize it shows until he tentatively asks Are you cents. Although much more work needs to be done to
mad at me? At that point, you can deny it (and deprive extend the model further downward and outward to
him of his accurate perception) or you can acknowl- culturally diverse groups, the hard work of various
edge the truth, explaining, Yeah, I noticed that I am groups (researchers, clinicians, developmental experts)
kind of frustrated and what was going through my has come together in a confluence that is having an
mind is that you must feel real overwhelmed and its enormous positive impact on the course of mental
hard to do anything because the last time you were here health treatment for youth.
we tried to make your homework as easy as possible.
It is more that I want to see you start to feel better and
be able to do start to do things to help yourself. This References
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Section II
Common Child and
Adolescent Psychiatric
Attention Deficit Hyperactivity Disorder
David Rube, Dorothy P. Reddy

Introduction History
Attention deficit hyperactivity disorder (ADHD) is References to individuals having problems with inat-
one of the most common neuropsychiatric conditions tention, hyperactivity, and impulsivity can be found as
of childhood and adolescence, accounting for as much early as the Renaissance when Shakespeare made ref-
as 50% of child psychiatry clinic populations [1]. erence to an attention deficit in one of his characters
ADHD is a persistent problem, manifesting its core in Henry VIII. A poem entitled Fidgety Phil was
symptoms throughout the life cycle, from preschool written by a German physician, Heinrich Hoffman
through adult life. ADHD symptoms interfere with a [3]. William James, in his Principles of Psychology,
childs family and peer interactions, academic attain- described a normal variant of character that resembles
ment, emotional development and self-esteem and in the difficulty experienced by children today who are
overall quality of life. Given the high prevalence, diagnosed with ADHD [4].
impairment and societal cost of ADHD, treatment is Clinical interests expanded when an English physi-
essential. cian, George Still, reported on a group of 20 children
ADHD is the most highly studied child psychiatric whom he described as having a deficit in volitional
disorder and fortunately, there are a multitude of inhibition [5]. He described them as aggressive, pas-
evidence-based medication and psychosocial treat- sionate, lawless, inattentive, impulsive, and overactive.
ments available. The American Academy of Child and He reported that there was an overrepresentation of
Adolescent Psychiatry recently established practice male subjects, a family history of alcoholism, criminal
parameters for ADHD [2]. There are more than 400 conduct, and depression, a family predisposition, and
references for those parameters. Thousands of papers the possibility that the condition may arise from an
have been published in journals by practitioners of all injury to the nervous system. Stills observations are
the disciplines that care for children pediatricians, quite common and have been corroborated in later
child and adolescent psychiatrists, developmental and research.
behavioral pediatricians, and child psychologists. In North America, children who survived the great
The purpose of this chapter is to provide the reader encephalitis epidemics of 1917 and 1918 were noted to
with an overview of the history of this disorder, its have many behavioral problems similar to those con-
diagnostic criteria and presentation, epidemiology and stituting what we call ADHD [68]. The cases that
etiology, and a brief description of the developmental were reported and others that have arisen due to birth
differences in the child, adolescent, and adult. In an trauma, head injury, exposure, or infections gave rise
overview of the assessment process, based on the prac- to the idea of a brain injured child syndrome. This
tice parameters established by the American Academy concept evolved into that of minimal brain damage
of Child and Adolescent Psychiatry, differential diag- and eventually minimal brain dysfunction. Many chal-
nosis including comorbidity, treatment planning, and lenges were raised to this label, however, because of the
prognosis and outcome are described. The goal is to lack of evidence of brain injury in many of the chil-
provide the reader with a hands-on approach to this dren who exhibited the symptoms.
very common yet potentially devastating problem for In the late 1950s and early 1960s, the hyperactive
children and their families. child syndrome was described by Burks [9,10] and

Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay
2005 John Wiley & Sons Ltd ISBN: 0-470-0220-94

Chess [11]. That syndrome was typified by daily move- type, hyperactive impulsive type, and, for children with
ment that was greater than that of normal children of problems from both lists, ADHD combined type. As
the same age. In the late 1960s, under the influence of one can plainly see from numerous articles, lengthy
the psychoanalytic movement, the second edition [11] history, and controversies surrounding this disorder,
of the Diagnostic and Statistical Manual of Mental much more work must be done to elucidate the core
Disorders (DSM-II) described all childhood disorders clinical problems of ADHD.
as reactions, and the hyperactive child syndrome
became the hyperkinetic reaction of childhood. It was
Core Clinical Criteria
defined as a disorder of overactivity, restlessness, dis-
tractibility, and short attention span. It was asserted As mentioned earlier, DSM-III, DSM-III-R, and
that the behavior usually diminishes in adolescence, DSM-IV differ on how the core symptoms of ADHD
leading to the ongoing myth that ADHD disappears are arranged; however, they are consistent in their
in adolescence. DSM-II included for the first time overall descriptions [1517]. There is agreement that
symptoms of inattention, and by the 1970s research the core symptoms consist of inattention and hyper-
emphasized the problem of inattention and poor activity and impulsivity. DSM-III arranged these
impulse control in addition to hyperactivity. Douglas domains into three separate symptom areas, DSM-III-
[1214] theorized that the disorder consisted of four R into one symptom list, and DSM-IV as two core
major deficits in the following areas: (1) the mainte- dimensions (inattention and hyperactivity/impulsiv-
nance of attention and effort; (2) the ability to inhibit ity). DSM-IV maintains the requirements of an early
impulse control; (3) the ability to modulate arousal age of onset (prior to age seven years), the presence of
levels to meet situational demands; and (4) the ability impairment for six months or longer, and the presence
to delay immediate gratification. Eventually, Douglas of impairment in two or more settings. Inattention
work and other work like it led to a renaming of the includes failing to give close attention to details, diffi-
disorder as attention deficit disorder (ADD) in 1980 in culty sustaining attention, not listening, not following
DSM-III, [15] in which it was noted that it was not through, difficulty organizing, losing things, easily
simply a behavioral reaction of childhood. The cogni- becoming distracted, and forgetfulness. Hyperactivity
tive and developmental nature of the disorder was includes fidgeting, being out of seat, running or climb-
emphasized, and specific symptom lists and cut-off ing excessively, having difficulty playing quietly, being
scores were recommended for each of the three on the go or as if driven by a motor, and talking
major symptom clusters (inattention measurements, excessively. The impulsivity symptom criteria include
hyperactivity, and impulsivity) to assist with the iden- blurting out answers, having difficulty awaiting a turn,
tification of the disorder. DSM-III distinguished two and often interrupting or intruding on others [17].
types of ADD, that with hyperactivity (H) and that Core deficits include impairment in rule-governed
without it. behavior across a variety of settings and relative diffi-
In the DSM-III-R, [16] the disorder was renamed culty for age in inhibiting an impulsive response to
ADHD (attention deficit hyperactivity disorder), with internal wishes, needs, or external stimuli.
a single list of items incorporating all three symptoms Most studies have concentrated on hyperactive ele-
and a single threshold for diagnosis. At that time, there mentary school children between the ages of six and
was insufficient research to verify the existence of nine years. The syndrome may manifest itself differ-
attention deficit disorder without hyperactivity. In ently throughout the life cycle; however, school-age
DSMIII-R, ADD without H is relegated to the cate- children are the most common presenting population
gory named undifferentiated attention deficit disorder, to pediatricians, child psychiatrists, and psychologists.
with the specification that insufficient research existed Weiss [19,22] points out that these children typically
to construct diagnostic criteria. Since the publication present with:
of the DSM-III-R, researchers have found that the
problems with hyperactivity and impulsivity were not inappropriate or excessive activity, unrelated to the
separate but formed a single dimension of behavior. task at hand, which generally has an intrusive or
These conclusions led to the creation of two separate annoying quality;
symptom lists when DSM-IV was published in 1994 poor sustained attention;
[17]. The establishment of the inattention list once difficulties in inhibiting impulses in social behavior
again permitted the diagnosis of a subtype of ADHD. and cognitive tasks;
The DSM-IV currently permits diagnosis of subtypes difficulties getting along with others;
of attention deficit hyperactivity disorder: inattentive school underachievement;

poor self-esteem secondary to difficulties getting ures of attention span research has shown that ADHD
along with others and school underachievement; children, when compared with normal children, are
other behavior disorders, learning disabilities, often recorded as being more off task and less likely
anxiety disorders, and depression. to complete as much as others, looking away from the
activities they are requested to do, persisting less in
Restlessness is measured by well-standardized rating correctly performing boring activities such as continu-
scales and direct and indirect observation [3840]. ous performance tasks, and being slower and less likely
Teachers and parents may not agree with one another, to return to an activity once interrupted [2426]. These
owing to the likelihood that children may act differ- behaviors have also been noted to distinguish them
ently in different situations. A child with ADHD may from children with learning disabilities and other psy-
not show his behavior if he likes a teacher or tries chiatric disorders [20,27]. Poor attention span should
harder at home to please his parents. Consequently, a be carefully assessed, as it can also be very similar to
child being evaluated in a physicians office could sit the poor concentration seen in anxiety and mood
perfectly still during the examination, and the clinician disorders.
may use rating scales in settings where the child spends
the majority of his time. Whalen and Henker [21]
Difficulties in Inhibiting Impulses
suggest that each measure reflects a unique child
perceiver setting example. Over the course of devel- In DSM-IV, hyperactivity and impulsivity have been
opment, the restlessness described diminishes and linked in a common symptom grouping. Impulsivity is
changes from running all the time to not being able to pervasive in everyday tasks in hyperactive children. In
sit quietly in a chair or feeling fidgety in adolescence school, they have difficulty awaiting their turn, inter-
and adulthood. Some hyperactive adults feel restless rupt others, blurt out answers, and engage in physically
even when physical restlessness is not observed [22]. dangerous activities without considering the conse-
Difficulty in sustaining attention contributes to the quences. Accidents in children with ADHD are
difficulties children with ADHD have both in school common [22,28,29]. These children are also less able to
and with their peers. Not paying attention on a given resist immediate temptations and delay gratification
assignment or during class leads to poor school-work. [3]. They tend to respond too quickly and too often
Not paying attention in games and wanting to do when they are required to wait and watch for events to
something different can contribute to unpopularity happen [26]. Shopping with these children in a stimu-
with peers. lating retail environment is often a challenge.
Bewildered parents will report their childs difficul- Impulsivity in ADHD is not only pervasive, it is also
ties with attention. A common complaint is he can likely to be the most enduring symptom as the children
play Nintendo for hours but to do 20 minutes worth grow up [22]. It is the symptom that along with oppo-
of homework requires 12 hours worth of screaming sitional and aggressive behaviors is most likely to result
and temper tantrums. It seems that when a particular in rejection by peers. Many adults can present with a
activity interests a child, he or she can pay attention chief complaint of inability to get along with author-
for hours. However, these same children can have a ity figures on the job as well as multiple reprimands for
poor attention span when attending to tasks they find not following directions.
boring, repetitive, or difficult and that give them no sat-
isfaction. This may be largely a learned behavior, since
Difficulty Getting Along with Others
at school they are constantly told by their teacher to
pay attention, to sit up straight, stop fidgeting, and so Peers often quickly reject children with ADHD
on, which in and of itself can have a large impact on because of their aggression, impulsivity, and noncom-
a childs attention span. Consequently, at home a child, pliance with rules [31]. Children with ADHD may be
especially around homework or task time, can per- unpopular with their peers and may have difficulties
ceive many negative messages. This can in turn prevent with parents, siblings, and teachers [30,32]. These
any person, more so a child with ADHD, from paying children may have few best friends and few enduring
attention to the task at hand. friendships, and this unpopularity and inability to
Parents and teachers frequently complain that these establish and maintain friendships may be replaced in
children do not seem to listen as well as they should life by social isolation. This is another characteristic of
for their age, cannot concentrate, are easily distracted, hyperactive children that is both pervasive and endur-
fail to finish assignments, daydream, and change activ- ing over time [22]. In childhood, sometimes the only
ities more than others [10]. The use of objective meas- person willing to play with a hyperactive child is a

younger child or a child with some other similar six large epidemiologic studies [35] found that the
difficulty. prevalence rates in these studies range from a low of
Sociometric ratings from peers indicate that hyper- 2% to a high of 6.3%, with most falling within the
active children cause trouble, get others into trouble, range of 4.2%6.3%. The differences in prevalence
bother others, and are not polite which can lead to rates are due at least in part to different methods
a negative impact on the ADHD childs sense of self of solicitation of population selection, difference of
[33]. The negative effect of hyperactive children on nature in the subjects themselves, nationality, ethnicity,
others has been observed with respect to their teachers urban versus rural status, the sample criteria of
and ability to participate in both dyads and groups of ADHD, and the measures used as well as the inform-
children. Parents may also interact with a hyperactive ants. The Ontario Child Health Study [28] found
child in a more negative and intrusive way. When the ADHD prevalent in 10.1% of males and 3.3% of
hyperactive child improves on medication and becomes females aged 411 years and 7.3% of males and 3.4%
more cooperative, his relationship with peers, teachers, of females aged 1016 years. Cohen and coworkers [36]
and parents improve. Studies are in agreement with in a community survey, found ADHD in 8.5% of
one another in describing the nature of the difficulties; females and 17.1% of males aged 1013 years, 6.5% of
however, it is not clear whether the cause is a social females and 11.4% of males aged 1416 years, and
skills deficit, a performance deficit, or both [3]. 6.2% of females and 5.8% of males aged 1720 years.
In elementary school-age children, the ratio of boys to
girls is typically 9 : 1 in a clinical setting, but approxi-
School Underachievement
mates 4 : 1 in community epidemiologic surveys [36].
Cantwell and Baker [34] showed that even when intel- The investigators first recognized marked differences
ligence was controlled for, hyperactive children were in prevalence rates found that when three systems
behind normal children in their grade level in reading, parent, teacher, and physician all diagnosed the dis-
spelling, and arithmetic. The core symptoms of order, the prevalence was far less than when it was
ADHD impair learning. ADHD children have poorer diagnosed by one of three sources. Schacher and
organizational skills, poor sequential memory, deficits coworkers [38] in the 1975 study in which they returned
in fine and gross motor skills affecting handwriting, to the Isle of Wight to follow up Rutters original
and inefficient and unproductive cognitive styles. The prevalence studies five years earlier, found that 2.2% of
more unsuccessful hyperactive children become in their the 1500 children about whom questionnaires were
school-work, the less they are motivated to succeed complete were still hyperactive. Szatmari [35] found in
because their efforts at times prove fruitless. All these his review that rates of ADHD tended to increase with
factors interact to cause school failure or lower levels lower socioeconomic status.
of academic achievement [37]. It is not uncommon for Teachers typically identify fewer girls than boys with
children to present to clinicians with their parents in ADHD symptoms. The male-to-female ratio ranges
the middle to late middle of the school year, when from 4 : 1 for the predominantly impulsive type, to 2 : 1
grade retention is a distinct possibility for a given child. for the predominantly inattentive type. Even among
children rated by teachers as meeting criteria for any
subtype of ADHD, fewer girls than boys receive an
Low Self-Esteem
ADHD diagnosis or stimulant treatment [35]. In clinic-
In general, when children receive praise and accept- referred samples, the sex ratio can rise to 6 : 1 or 9 : 1
ance from parents, teachers, and students, their [35] suggesting that boys are much more likely to be
self-esteem and sense of self improves dramatically. referred than girls. A recent meta-analysis found that
However, children with ADHD have multiple difficul- girls with ADHD have lower rates of oppositional
ties in multiple areas of their lives. They are criticized behavior and cognitive problems than do boys in both
and embarrassed. At times it is difficult for them to feel community and clinical samples [41]. Among clinically
liked and successful. It is not uncommon for these chil- referred children with ADHD, girls have greater intel-
dren to feel demoralized. With successful treatment, lectual impairment than boys. In the general popula-
however, some of these symptoms may ameliorate. tion, girls with ADHD have less inattention,
internalizing behavior, peer aggression, and rejection
by peers than boys with ADHD. In clinical samples
Epidemiology of ADHD
boys and girls have equal levels of impairment. Barkley
Estimates of the prevalence of ADHD in school-age [18] hypothesizes that these diagnostic criteria were
children range from 3% to 5%. In a recent review of set in a predominantly male distribution, which could

create a higher threshold for the diagnosis for female of 1917 and 1918. Studies of brain morphology have
subjects relative to other female populations and for become more technologically sophisticated. Hynd and
male subjects relative to other male populations. It is coworkers [46] produced magnetic resonance imaging
our experience that a high percentage of females (MRI) findings suggesting that children with ADD
are not diagnosed with ADHD until they present in had normal planum temporale but abnormal frontal
middle or late adolescence with a comorbid disorder lobes. Giedd and coworkers [47] demonstrated reduced
such as depression, anxiety, or an eating disorder. volume in the rostrum and rostral body of the corpus
callosum. This finding has been interpreted as consis-
tent with an alteration of functioning of the prefrontal
Etiology of ADHD
and interior cingulate cortices of the brain [48]. An
It is unlikely that a simple etiologic factor is responsi- attempt to replicate this finding, however, failed to
ble for ADHD. There is an interplay of both psy- show any differences between children with ADHD
chosocial and biologic factors that may lead to a final and control subjects in the size or shape of the entire
common pathway syndrome. For example, genetic corpus callosum, with the exception of the region of
studies have shown there is a strong hereditary influ- the splenium, which again was significantly smaller in
ence in ADHD [42]. However, in addition to the subjects with ADHD [49].
genetic passing on of the disorder, a parent with Studies have demonstrated decreased blood flow in
ADHD may have a poor parenting style, which can the prefrontal regions of the frontal region [55]. Lou
affect or exacerbate a childs attention span or behav- and coworkers [50] and Hynd and coworkers [51]
ioral problems. found that children with ADHD had a significantly
The etiology of ADHD is unknown. A variety of smaller left caudate nucleus, creating a reversed to
physical disorders can be mistaken for ADHD and normal pattern of left greater than right asymmetry of
can co-occur. Physical causes of poor attention may the caudate nucleus. Looking at structural abnormali-
include impaired vision or hearing, seizures, sequelae ties in the basil ganglia in ADHD, Mataro and cowork-
of head trauma, acute or chronic medical illness, poor ers [52] studied 11 adolescents with ADHD and 19
nutrition, or insufficient sleep due to a sleep disorder. healthy control subjects and found that the ADHD
Anxiety disorders, depression, and sequelae of abuse group had a larger right caudate nucleus than the
or neglect may interfere with attention as well. Patients control group. In control adolescents, larger caudate
with Tourette syndrome may be inattentive because nuclear volume were associated with poor performance
they are distracted by premonitory urges to resist on tests of attention and higher ratings on the Connors
ticking. Teachers Rating Scale. These findings, according to the
authors [52], provide further evidence of the involve-
ment of the caudate nucleus in the neuropsychologic
deficits in behavior problems in ADHD. The larger
Some drugs may interfere with attention, including caudate nucleus found in the ADHD group can be
phenobarbital, carbamazepine, and alcohol and illegal related to a failure of the maturational process that
drugs. It is possible that there is an effect only on normally results in volume reduction. Lou [53,54]
children who already have attentional or achievement examined the hypoxic and ischemic brain events of
problems [4345] and that parent reports of adverse premature infants. He demonstrated that the striatum
behavioral side effects may not correspond to more is in a unique position of being highly susceptible to
objective data. Some known conditions, such as fragile ischemia. He stated that ischemic events are particu-
X syndrome, fetal alcohol syndrome, very low birth larly common in premature infants, a fact that seems
weight, and a very rare genetic thyroid disorder, can to explain the high incidence of ADHD in this patient
present behaviorally with the symptoms of ADHD. group. The magnitude of the problem is growing with
However, these cases make up only a small portion of increased survival rates among premature infants. It is
the total population of children with the diagnosis not uncommon for an ADHD/psychopharmacologic
[44,45]. clinic to see many children who have survived prema-
ture births.
The pathophysiology of ADHD has also been inves-
Central Nervous System Findings
tigated using other imaging techniques such as single
As mentioned, early theories of the etiology of ADHD photon emission computed tomography (SPECT) and
attributed it to brain damage, derived from the studies positron emission tomography (PET) [57]. Zametkin
of children who suffered encephalitis in the epidemic and colleagues [55] studied 25 biologic parents of chil-

dren with ADHD. These parents had histories sugges- clude that catecholamine function and its modulation
tive of ADHD but were never treated. Fifty adults are probably involved in the pathogenesis and treat-
matched for sex, age, and intelligence quotient [IQ] ment of ADHD, respectively. Thus, they suggest that
score acted as controls. Glucose metabolism was the lack of response to one stimulant may predict
studied while the subjects were performing an auditory responsiveness to another.
attention task lasting 35 minutes. PET scans were per- McCracken [59], in reviewing the current thinking
formed during the test and were analyzed. Zametkin on the neurobiology of ADHD, points out that all
and coworkers [56] found an overall glucose metabo- medication shown to be effective for this disorder
lism decrease of 8.1% in the cortical areas, affecting 30 increased dopamine release and inhibition of the nora-
of 60 brain regions. The main regions affected were the drenergic locus ceruleus. Mesocortical dopaminergic
premotor and prefrontal cortex in the left hemisphere, cells are linked with the prefrontal cortex, which is
areas associated with attention. The cause and effect involved with attention. Children with chromosomal
of these findings are not clear, but should prompt abnormalities such as the excess Y syndrome may show
further research. In a follow-up study subjects, as com- problems with attention, but the chromosomal abnor-
pared with the control group, demonstrated less statis- mality shown in that population is uncommon in chil-
tical significance. Adolescent females with ADD did dren with ADHD. However, other evidence suggests
have reduced glucose metabolism globally, compared that ADHD is highly hereditary in nature [62]. Family
with normal control females and males and compared genetic factors have been implicated as an etiology for
with males with ADD. Amen and Carmichael [57] ADHD for over 25 years, and heritability has been esti-
compared 54 children and adolescents with ADHD mated to be between 0.55 and 0.92. Concordance was
diagnosed by the DSM-III-R and by Connors Teach- noted as 51% in monozygotic twins and 33% in dizy-
ers Rating Scale criteria as well as a non-ADHD gotic twins in one study [61]. Family aggregation
control group. Two imaging studies were done on each studies have also shown that the ADD syndrome and
group a resting study and an intellectual stress study, related problems often occur in closely related family
the latter done while the participants were doing a con- members, and adoption studies have also supported
centration task. Sixty-five percent of the ADHD group genetic hypotheses [60,63]. Cantwell [63] and Morrison
exhibited decreased profusion of the prefrontal cortex and Stewart [64] reported higher rates of hyperactivity
with intellectual stress, compared to only 5% of the in the biologic parents of hyperactive children than
control group. Of the ADHD group who did not in adoptive parents with hyperactive children. These
show decreased profusion, two-thirds had markedly studies suggest that hyperactive children are more
decreased activity in the prefrontal cortices at rest. likely to resemble their biologic parents than their
Many of the brain imaging studies contained small adoptive parents. Cadoret and Stewart [65] studied 283
sample sizes and have yet to be replicated. In consid- male adoptees and found that if one of the biologic
ering structural and neuroimaging studies, it is unclear parents had been judged delinquent or to have an adult
what is cause and what is effect. Are the abnormalities criminal conviction, the adopted-away sons had a
causing symptoms of ADHD or are the symptoms of higher likelihood of having ADHD. Twin studies have
ADHD causing reduction in glucose metabolism? It is also demonstrated a high rate of concordance in
hoped that further studies with larger sample sizes will monozygotic twins when compared with dizygotic
lead to a clearer understanding of this phenomenon. twins. Gilger and coworkers [66] found that if one twin
The use of stimulants, a cornerstone in the treatment was diagnosed with ADHD, the concordance for the
of ADHD, has raised the possibility that the disorder disorder was 81% in monozygotic twins and 29% in
is caused by a dysfunction of the dopaminergic and/or dizygotic twins. A recent study done by Cook and
serotonergic systems. Early reports describe brain coworkers [67] implicated the dopamine transporter
transmitter metabolites such as MHPG as being lower chain in ADHD: analysis revealed significant associa-
in the urine of hyperactive children than in normal tion between ADHD and the transporter locus. This
childrens urine; however, these studies have not been study was repeated by Gill and coworkers [68] in 1997.
replicated. Other studies that measured the urinary At this time the heritability of ADHD is accepted, but
amino acids phenylalanine and tyrosine found no dif- the exact mechanism for this has yet to be determined.
ferences [58]. Zametkin and Rapoport [58] conclude
that the studies comparing ADHD and normal chil-
Family and Psychosocial Factors
dren with respect to monoamines in their metabolism
in urine and plasma, cerebrospinal fluid, and platelets It is possible to conclude, because of the high heri-
have been disappointing. However, these studies con- tability of ADHD, that many children will have at least

one parent with ADHD. Hence, it is unclear how much effect of sugar by selecting as probands 28 hyperactive
of the difficulty the child has in his family comes from children whose parents claimed they became hyperac-
parenting, how much from having an ADHD parent, tive after ingesting an excessive amount of sugar. No
how much from strictly genetics. Hechtman [69] in her differences were found in this study in behavior or
follow-up studies of 65 families with ADHD children attention between children given sucrose, glucose, or
and 43 families of matched normal control subjects, saccharine-flavored placebo. Recent studies have con-
found that families of children with ADHD have more firmed this. Again, however, any particular child could
problems than families of normal children. But these be susceptible to the effects of sugar.
problems improve as the child with ADHD grows up
and leaves home. Generally, family interactions with
children with ADHD are problematic but improve
when the child is on medication and when the child Children and adolescents diagnosed with ADHD
becomes an adult. A relationship between family dys- commonly have other diagnosable psychiatric disor-
function, solo parenting, welfare status, and urban ders [77]. As many as two-thirds of elementary school
living in hyperactivity was found in the Ontario Health age children with ADHD referred for a clinical evalu-
Study [28]. ation have at least one other psychiatric disorder [75].
It is therefore incumbent upon the evaluating clinician
to assess a child with ADHD and to evaluate as well
Environmental Toxins and Dietary Findings
for the presence of other conditions [78].
A study of 501 children in Edinburgh reported a In general, the presence of a second or third comor-
doseresponse relationship between high blood levels bid disorder indicates a more serious problem with a
of lead and ratings on the Rutters Teachers Rating worse prognosis [22,76]. If a comorbid condition is
Scale, most notably on the aggressive antisocial hyper- found, this will obviously affect the treatment plan,
active subscores. Thompson and coworkers [70] con- including medication choices, psychotherapy treat-
cluded that high blood levels of lead produce behavior ment, school consultation, and placement options.
and cognitive disorders in some children. Ferguson Gaining an understanding of comorbidity in
and his group [71] found a small but significant ADHD can potentially lead to a greater understand-
correlation in their longitudinal study of lead in ing of the syndrome. Weiss [22], citing Biederman,
dentin levels, intelligence, school performance and points out that it is possible that comorbid disorders
behavior. do not represent distinct entities but are different
It is possible to conclude then that children of low expressions of the same disorder; or that they may rep-
socioeconomic status are the ones likely to have high resent distinct disorders, sharing a common vulnera-
blood levels of lead and may thus be a group at risk. bility and representing subtypes of ADHD. It is also
This is an important factor, especially in urban or possible that ADHD may be an early manifestation of
metropolitan centers. Fetal alcohol syndrome, which the comorbid disorder or that ADHD may put a child
results from exposure to alcohol while in utero, may at risk for the development of another disorder. In con-
present with similar syndromes to ADHD. It is possi- sidering comorbidity, one must be careful to assess the
ble that the known craniofacial features associated population being studied. Clinical samples may suffer
with fetal alcohol syndrome are one form of the minor from what is called Berksons bias, which means that
physical anomalies known to be associated with comorbidity seen in clinical settings may be artifactual,
ADHD [72]. since that population may represent children with
In the 1970s, the Feingold Diet written by Dr. Ben more severe psychopathology and more substantial
Feingold claimed that half of all children with ADHD impairment in their functioning, leading to higher
could be cured by a diet that eliminated all food addi- rates of comorbidity [77,78].
tives. Connors [73] summarized both positive uncon- The prevalence of comorbid conditions in ADHD
trolled studies and mainly negative controlled studies appears to be high. In a community study, Bird and
and concluded that, in general, food additives were not coworkers [79,80] carried out a probability sample of
a significant cause of the syndrome, except possibly in the population aged 416 years in Puerto Rico. They
an occasional child. Parents also began to believe found that among children with ADHD, 93% had
that sugar may cause the syndrome and many parents comorbid conduct and oppositional disorders. Comor-
still limit sugar and food rich in sugar to children with bid internalizing disorders ranged from 50.8% for
ADHD. A controlled study carried out by Behar and anxiety disorders to 26.8% for depressive disorders.
coworkers [74] was designed to maximize any possible Cohen and coworkers [81] conducted a longitudinal

study of 776 children and adolescents aged 918 years depressive comorbidity in children and adolescents
using the child and parent Diagnostic Interview Sched- with ADHD. Five of the seven studies found signifi-
ule for Children (DISC). They noted that of children cant associations between ADHD and depression,
with ADHD, 56% had comorbid conduct disorder, indicating that ADHD appears to be more prevalent
54% had oppositional defiant disorder, 23% had over- in depressed children than in children without depres-
anxious disorder, 24% had separation anxiety, and 13% sion. It has been reported that 15%75% of children
had major depressive disorder. The Ontario Child with ADHD also have mood disorders. Gittelman and
Health Study [82,83] found similar high rates of coworkers [76] did not confirm that major depression
comorbidity using DSM-III criteria. The investigators occurred more frequently in the adolescence and adult-
found that among children with ADHD, 42.7% had hood of ADHD-diagnosed children compared with
comorbid conduct disorder, whereas the comorbid normal control subjects.
internalizing disorders among children with ADD There is some evidence, however, that suggests that
were less common 17.3% for somatization disorder these disorders may be related to each other, in that
and 19.3% for depressive disorder. Substantiating familial risk for one increases the risk for the other [89].
Berksons bias, McConaughy and Achenbach [84] Faraone and coworkers [90] began to examine the
compared comorbidity rates based on parent/teacher finding that ADHD is more common in children with
and subject reports, comparing matched community child-onset mania as compared with adolescent-onset
and clinical samples. They found that the comorbidity cases of bipolar disorder. They hypothesize that
rates in the clinical sample were significantly higher ADHD may signal a very early onset of bipolar
than the population sample, regardless of the inform- disorder. There are children who, in addition to their
ant and instrument. The odds ratios showed high symptoms of ADHD, suffer from extreme irritability,
comorbidity of aggressive behavior with attention violence, and decompensation. The authors suggest,
problems, and attention problems with social prob- that these children, when they present with or are diag-
lems. On the Child Behavior Checklist in the youth nosed with ADHD, may have a subclinical case of
self-report, the odds ratio was also high for anxious or child-onset mania. Clinical experience suggests that
depressed state with attention problems. a substantial number of children with ADHD may
benefit from a trial of a mood stabilizer in addition to
psychostimulants. Wozniak and coworkers [91] and
Comorbid Oppositional Defiant and Pliszka [92] found that children with mania plus
Conduct Disorders ADHD had an excess of relatives with both disorders
and that both disorders co-segregated in these
Barkley and coworkers [85] prospectively studied the
families. A comorbid association between ADHD
psychosocial outcome of 123 hyperactive children and
and anxiety disorders has been found to be between
66 normal control subjects, eight years after initial
25% and 40% in clinic-referred children. Pliszka [93],
assessment. They found that more than 80% of the
in replicating his own previous study, looked at three
hyperactive children continued to qualify for an
groups one with ADHD alone, one with ADHD and
ADHD diagnosis, with 60% qualifying for opposi-
anxiety, and a control group and found that the
tional defiant disorder (ODD) and conduct disorder
groups were significantly different across the spectrum
(CD). ODD and CD can occur with ADHD in about
of ADHD behaviors. The ADHD-only group had the
40% of hyperactive children [80]. Between 35% and
most abnormal behaviors, followed by the ADHD
60% of clinic-referred children with ADHD meet the
plus anxiety group, and then the control group. He also
criteria for a diagnosis of ODD by seven years of age
found that the association of anxiety disorders with
or older, and 30%50% eventually meet the criteria
ADHD seemed to reduce the degree of impulsiveness
for CD [80,85]. A substantial percentage of clinic-
in subjects compared with those with ADHD without
referred children with ADHD also qualify for diagno-
anxiety disorders.
sis of antisocial personality disorder in adulthood
Tic Disorders (Including Tourette Disorder)
The evaluation of comorbidity of ADHD and
Mood and Anxiety Disorders
Tourette disorder is complicated because the diagnosis
Angold and Costello [88] reviewed epidemiologic of ADHD tends to precede in time the diagnosis
studies using DSM-III or III-R criteria that dealt with of Tourette disorder. ADHD does not appear to

elevate the risk for the diagnosis of Tourette Table 10.1 Criteria for the diagnosis of ADHD.*
disorder; however, among individuals with Tourette
disorder, 48% may qualify for the diagnosis of ADHD The diagnosis requires evidence of inattention or
[94]. hyperactivity and impulsivity or both
Six or more of the following symptoms of
Learning Disabilities and Poor inattention have persisted for at least six
Academic Functioning months to a degree that is maladaptive and
inconsistent with developmental level:
The vast majority of clinic-referred children with Often fails to give close attention to details and
ADHD have difficulties in school performance. They makes careless mistakes
often score below normal or below the scores of con- Often has difficulty sustaining attention
trolled groups of children on standardized achievement Often does not seem to listen
tests [23,94]. It is not clear what causes this. Academic Often does not seem to follow through
differences can be found in preschool ADHD children, Often has difficulty organizing tasks
which may imply that the disorder takes a toll on the Often avoids tasks that require sustained
acquisition of academic skills and knowledge even attention
before first grade. Between 19% and 26% of children Often loses things necessary for activities
with ADHD are likely to have one type of learning dis- Often is easily distracted
ability, conservatively defined as a significant delay in Often is forgetful
reading, arithmetic, or spelling relative to intelligence,
with achievement in one of these three areas at or below Hyperactivity and impulsivity
the seventh percentile [18,95]. There is conflicting evi- Six or more of the following symptoms of
dence as to whether children with ADHD are more hyperactivity and impulsivity have persisted
likely to have learning disabilities. Some subtypes of for at least six months to a degree that is
reading disorders associated with ADHD may share a maladaptive and inconsistent with
common genetic etiology [97]. developmental level:
Often fidgets
Often leaves seat
Speech and Language Disorders Often runs about or climbs excessively
Often has difficulty with quiet leisure activities
An elevated prevalence of speech and language Often is on the go or driven by a motor
disorders has been documented in many studies of Often talks excessively
ADHD children, ranging from 30% to 64% of the Often blurts out answers
samples. The converse is also true: children with speech Often has difficulty awaiting turn
and language disorders have a higher than expected Often interrupts or intrudes
prevalence of ADHD. Cantwell also describes a type
of comorbidity as lack of social savoir faire [96]. He Symptoms that cause impairment:
describes it as an inability to discern social cues, Are present before seven years of age
leading to difficulties in interpersonal relationships. Are present in two or more settings (e.g., home,
The comorbidity when specific learning disabilities are school, or work)
defined more stringently is probably 10% to 20%. Do not occur exclusively during the course of a
pervasive developmental disorder,
schizophrenia, or another psychotic disorder
Are not better accounted for by another mental
Diagnosis and Assessment
disorder (e.g., a mood disorder or an anxiety
Diagnostic criteria for ADHD can be found in Table disorder)
10.1 that follows. The diagnosis of ADHD is a clinical
diagnosis. It is made on the basis of a clinical picture * The criteria are adapted from the Diagnostic and Statisti-
that begins early in life, is persistent over time and cal Manual of Mental Disorders, Fourth Edition, Revised.[17]
pervasive across different settings, and causes func-
tional impairment at home, at school, or in leisure

Specialized tests, such as the Continuous Perfor-

CASE ONE mance Test, the Wisconsin Card Sorting Test, the
Matching Familiar Figures Test, and subtests of the
Martin, a six-year-old boy who was diagnosed
Wechsler Intelligence Scale for Children-Third Edition
with ADHD, came in for a clinical visit with
(WISC-III), should not be considered diagnostic of
his father one afternoon after baseball practice.
ADD. There is no specific diagnostic test for ADD,
The father stated that practice began at
despite the frequent requests of parents and others for
approximately 5:00 p.m. and that Martins last
discrete psychologic testing in which the conclusion is
dose of methylphenidate was at lunch at
the diagnosis of ADHD. Psychologic testing can elicit
school. The father described Martins per-
findings that are consistent with a child who has the
formance at baseball practice as awful.
diagnosis of ADHD.
Martin saw no reason for his fathers concern.
A medical evaluation should include a complete
The father stated that Martin would sit in
medical history and a physical examination within the
the outfield and watch the birds, airplanes,
past 12 months. Any effects of medication and vision
and runners on a nearby track. He failed to
or hearing deficits should be ruled out. Other medical
pay attention when balls were thrown and hit.
factors predisposing to ADHD include fragile X syn-
Adding an afternoon methylphenidate dose to
drome, fetal alcohol syndrome, G6PD deficiency, and
Martins regimen helped improve his hitting,
phenylketonuria. Risk factors include prenatal influ-
his batting average, and his status on the base-
ences such as poor maternal health, young age, use of
ball team.
alcohol, smoking, toxemia or eclampsia, postmaturity,
and extended labor. Health problems or malnutrition
in infancy also appear to contribute.
Speech and language evaluation may be required as
The parent interview is the primary input in the suggested by clinical findings. Occupational therapy