APPENDIX-I CHILD AND ADOLESCENT PSYCHIATRY BRIEF CASE HISTORY & EXAMINATION

Name……………………..Age……..Sex M/F………….Date………………..
Source of referral: Relatives/Friends, School, Others (specify)
Duration of illness: Less than a week, 1-4 weeks, 4-12 weeks, 3-6 months, 6-12 months, 1-4 years,
5years, since birth, not known.
Onset: Acute (1 week), Sub-acute (1-4weeks), Gradual (more than 4 weeks).
Course: Worsening, steady, fluctuating, improving, periodic, not known
Associated physical illness: No/ Yes (specify)
COMPLAINTS AND HISTORY OF PRESENT ILLNESS
Emotion: anxiety, sadness, irritability, agitated, fearful, anger, excessive clinging, shyness,
Idea/ delusion: persecution, reference, grandiose, hypochondriacal, depressive, phobias, obsessions,
passivity, possession, suicide, bizarre
Conduct & Behaviour: obstinacy, disobedience, aggressiveness, defiant, destructiveness, stealing, lying,
delinquent behaviour, attention problems, poor impulse control, hyperactivity, odd, repetitive
behaviour, ununderstandable, disinhibited Behaviour, suspiciousness, talking/smiling to self, irrevalent
talking, apathetic, social withdrawal
Perception: hallucination (auditory, visual, tactile, / olfactory), depersonalization, derealization, illusion
Somatic: aches and pains, numbness, breathing difficulty, weakness, paralysis, tremors, palpitation
Habits: sleep problems, bowel (encopresis), bladder (enuresis), feeding problems, inadequate self care,
thumb sucking, nail biting, tics, stereotypy
Fits: Epileptic/ non-epileptic/ mixed Learning, memory & Scholastic skills: poor memory, low
intelligence, scholastic backwardness,
Developmental problems: speech, language, motor function
Impairment: interpersonal relations, household work, studies, leisure activities
Past history:
Family history:
Examination
Significant physical findings…………………………
Physical development: Average, less than average
MSE:
Appearance: ……. ……….Separation anxiety…… Activity level……
Affect: anxious, sad, elated, irritable, and fearful…….
Thought/ideas: delusions, depressive, suicidal, obsession, worries, phobias, preoccupation
Perception: Hallucinations, modality………….. Attention span…….. ….. Intellectual capacity……………..
Other significant findings…………………

DIAGNOSIS (ICD-10)
AXIS I (Clinical Syndrome including Pervasive Developmental Disorders)
AXIS II (Disorders of Psychological development)
AXIS III (Intellectual level)
AXIS IV (Medical/Physical conditions)
AXIS V (rate 0/1/2) (Associated abnormal psychosocial situations)
AXIS VI (Global assessment of psychosocial disability)
MANAGEMENT PLANNED
STRATEGY OBJECTIVE
1. Drug
2. Further Exploration
3. Psychotherapy
4. Behaviour Therapy
5. Parental counseling
6. Environmental manipulation
7. Hospitalization
8. Investigations-Psychological

PHYSICAL
9. Consultation with other disciplines of medicine
10. Referred to other departments for further management
11. Other (Specify)
12. Special education

ADVICE
 APPENDIX-II
DETAILED CASE HISTORY & EXAMINATION
Name:
Age:
Date of Birth:
Education:
Sex:
Residence:
REFERRED FROM:
INFORMATION
Relationship with Patient:
Name:
Age:
Sex
Education:
Occupation:

CHIEF COMPLAINTS (IN CHRONOLOGICAL ORDER)

HISTORY OF PRESENT ILLNESS
(If the symptoms are present since birth, start history from conception through early and later
development. Give chronological account of symptoms. Mention details of treatment).

Functioning/Impairment: ( A global assessment of the patient’s functioning in the areas of interpersonal

relations with parents, other adults, peers; household work; leisure activities. If impaired- mention
moderately or severely.)

PAST HISTORY
a. Physical illness
b. Psychiatric problems

PERSONAL AND DEVELOPMENTAL HISTORY

History or early Development

1. Parental attitude towards pregnancy: wanted/Unwanted _________________________

2. Mother’s health during pregnancy _________________________________________

i) Generally good
ii) Exanthematous fever in first trimester
iii) Serious illness _____________________________________________________
iv) X-Ray exposure
v) Prolonged drug administration
vi) Attempted abortion
vii) Any other __________________________

3. Nature of birth:
i) F.T.N.D.
ii) Premature birth
iii) Instrumental or operation
iv) Complicated delivery
v) Head injury
vi) Jaundice, cyanosis, delayed cry after birth

4. Feeding habits (till age)

i) Breast_______________
ii) Bottle ________________
iii) Breast and bottle mixed ___________
iv) Weaning age _________________

5. Age of:
i) Neck holding ___________
ii) Tooth eruption ___________________
iii) Sitting ________________
iv) Standing (Unsupported)______________________
v) Walking__________
vi) First word ____________
vii) Three word sentence ___________________
viii) Bowel Control _________________________
ix) Bladder control __________________________________

Development problems (if any) of speech, language, motor function.

II SOCIAL AND PERSONAL HISTORY

1. Habits
a) Sleep: i) Normal ii) Fearful iii) Bruxism iv) Any other ________________
b) Feeding: i) Normal ii) Fussy ___________
iii) Over-eating _______________ i
v) Others ________________________
c) Personal care:
i) Adequate ii) Unkempt

2. Neurotic traits
i) Nail biting
ii) Thumb sucking
iii) Morbid fears of persons, animals, and darkness
iv) Nightmares
v) Night terrors
vi) Obstinacy
vii) Temper tantrums
viii) Enuresis, Encopresis beyond 3 years
3. Behaviour problems Stealing, lying, truancy, disobedience, others________________________
4. Play: individual/group, companions: a few/many, older/younger/same age, good/bad/both other
________________________________________
5. Sexual history Normal/Malpractice
III EDUCATIONAL HISTORY
1. Read upto ____________________
2. Education at (i) home (ii) School (iii) Hostel
3. Started reading at ___________________ years
4. Educational problems (if any)
(i) Poor progress
(ii) financial difficulties
(iii) repeated absence
(iv) Poor peer relationship
(v) problems with teachers,
(vi) scholastic skills development
(vii) any others (also make a global assessment of functioning at school here)

5. Failures if any: Class ____________ no of failures

TEMPERAMENTAL CHARACTERISTICS
(Activity, Rhythmicity, Approach- withdrawal, Adaptability, Mood, Intensity of reaction, Threshold of
Responsiveness, Attention-span, Persistence, Distractibility in infancy and later stages)

FAMILY HISTORY
1. Family Tree (with age, sex, personality descriptions and any h/o mental illness in the family)
2. Family Functioning (any discord between family members, lack of communication, any problems with
the family as a whole e.g. isolated family).
3. Parent-child interaction (lack of warmth, hostility towards/scapegoating of child, abuse)

PATTERNS OF PARENTAL FUNCTIONING

(Follow the guidelines given below to elicit information)
Permissiveness/Rigidity
Consistency/Inconsistency
Strictness of discipline/liberal (any inappropriate supervision)
Approval of interests/disapproval
Protectiveness/Non-protectiveness (any overprotection)
Toleration of deviance/non-toleration
Expectations from the child (any pressures, deprivation) Reactions towards the illness

SOCIAL-ENVIRONMENTAL CONDITIONS
(mention any aspect of living conditions which you might consider stressful for the child)
Types of Dwelling
Degree of crowding
Type of amount of help in the care of child
Affluence of the family/degree of financial stress

SPECIAL ENVIRONMENTAL CIRCUMSTANCES

(Like birth, death, illness, accident, divorce, hospitalization etc. in the family, if present mention the
effect of the life event on the child e.g. on self esteem)

PHYSICAL EXAMINATION

MENTAL EXAMINATION
General appearance and behaviour:
Describe Relationship capacity: (response to separation from parents, reaction to interview situation)
Spontaneous motility and speech:
Affective Behaviour (any evidence of anxiety, fear, depression, shyness including the child attitude
towards the examiner)
Attitude towards family, school and play-mates:
Stated interest & content of thought:
Attention span and distractibility:
Intellectual capacity
Motivation: (Child’s knowledge of the reasons for his attendance, his desire for help, his sense of own
capacity to change)

PROVISIONAL DIAGNOSIS (Try, as far as possible, to make multiaxial diagnosis according to ICD-10, See
under final diagnosis)

Final Diagnosis: (ICD 10)

AXIS I (Clinical Syndrome including Pervasive Developmental Disorders)
AXIS II (Disorders of Psychological development)
AXIS III (Intellectual level)
AXIS IV (Medical/Physical conditions)
AXIS V (rate 0/1/2) (Associated abnormal psychosocial situations)
AXIS VI (Global assessment of psychosocial disability)

MANAGEMENT PLANNED
STRATEGY OBJECTIVE
1. Drug
2. Further Exploration
3. Psychotherapy
4. Behaviour Therapy
5. Parental counseling
6. Environmental manipulation
7. Hospitalization
8. Investigations-Psychological

PHYSICAL
9. Consultation with other disciplines of medicine
10. Referred to other departments for further management
11. Other (Specify)
12. Special education

ADVICE