Assessment and Formulation

for Infants, Children &

Adolescents
West African College of physicians
Revision Course, August 12, 2021

Dr Yetunde Adeniyi
MBBS, M.Sc. (CAMH), FWACP (Psych.), ACCAPsych
 Disclaimer
• These slides are mostly from Prof Olayinka Omigbodun’s module on
Assessment in Child and Adolescent Mental Health, centre for Child
and Adolescent Mental Health, University of Ibadan
The Parent/Caregiver Interview (Child & Adolescent
should also give history as is relevant)
Component Parts
• Obtaining demographic information (informants)
• Exploration of the presenting compliant
• Past medical and past psychiatric history
• Structure and function of the family
• Developmental history of the infant/child/ adolescent
• Current functioning of the infant/child/ adolescent
Obtaining demographic information

• Demographic information
• Address
• Date of birth
• Age
• Religion
• Occupation
• Sex (if not obvious)
Obtaining demographic information Informants

• Relation to patient and length of acquaintance

• Interviewer’s impression of informant’s reliability
• Source of referral & brief reasons
Exploration of the presenting compliant

• Presenting complaints or symptoms with duration

• Every effort should be made to remember and document the parent
and patients’ exact words
• It is traditional to state the chief compliant as a verbatim quote
• First words that parents and patients speak about their condition are
usually very revealing
Exploration of the presenting compliant

Open ended questions with checks and probes. Invite parent to give a narrative
description of the course and chronology of the symptoms.

• What is the reason for the referral?

• What is the nature and severity of the presenting problem?
• What is the effect of the problem on the child’s functioning?
• How have others reacted to the child’s problem?
• What has been the course of the problem over time?
• What do the parents think are the likely causes of the problem and what makes it
better or worse
• What do the parents hope to get from seeking help?
Past medical and past psychiatric history
• Has the child received professional help previously?
• Has the child received help for any health condition in the past?
Structure and Function of the Family
• Family Structure and History:
• Parents:
• Ages
• Occupations
• Current physical and emotional state
• History of mental or physical disorder
• Former marriages or cohabitations – Children from these relationships
• Whereabouts of grandparents- age, relationship with patient
Structure and Function of the Family

• Family Structure and History:

• Sibs: – Full – Step or half – Ages – Presence of problems
• Home circumstances
• Sleeping arrangements
Structure and Function of the Family
• Relationships:
• Parent-Child relationship;
• Level of criticism
• Hostility
• Rejection
• What kinds of punishments?
• Safety and supervision provided by parents
• Parental supervision
 Structure and Function of the Family
Relationships:
• Parental relationship & mutual affection
– Capacity to communicate & resolve problems
– Sharing of attitude over child’s problems
– Sharing of responsibilities
• Overall patterns of family relationships
– Alliances,
– Communication
– Exclusions,
– Scape goating
– Financial situation & relationship
The Developmental History
• Pregnancy and delivery
• First months
• Motor development
• Language and speech development
• Social and emotional development
• Attachment and relationships
• Toilet training
• Schooling history
• Life events
 Current Functioning of the Child
• Physical functioning
• School
• Current level of development
• Cognitive functioning
• Eating
• Sleeping, sleeping problems, nightmares
• Elimination problems
• Weight loss or weight gain
Current Functioning of the Child
• Appetite, binge eating
• Activity level
• Behaviour
• Compulsions
• Habits
• Reactions to frustrations
• Mood
• Relationships
• Sexual interests and behaviour
 Child and Adolescent interview
Setting the Child at ease:
• Talk about leisure activities
• Favourite television programmes
• Make problem seem ‘common’
• I see a lot of children who get worried and anxious about things
– What sort of things do you feel anxious about? What sort of things make you
angry at school?
– What sort of things get you upset at home?
– A lot of boys and girls I see worry that something bad will have to their
mother. Do you ever feel that way?’
 Child and Adolescent interview
Younger Children (less than 6 years)
• Toys are very useful – Especially toys of family figures
• Help to trigger the child to communicate about anxieties or give an
insight into his or her inner world (fantasy)
• Drawings may also be useful tools to help elicit information at this age
group
 Child and Adolescent interview
6-10 years
• Children of 6 to 10 years can communicate very well verbally without
toys and drawings
Adolescents
• Cover topics such as sexual concepts, sexual behaviour, the possible
use of drugs
• Should describe in greater detail, than the younger children, their
mood states, relationships with peers and special interests
 Child and Adolescent interview
Consent and confidentiality
•Before concluding an interview with a child or adolescent alone, it is
important to obtain consent to raise any of the matters deemed fit with
the parents
•If child refuses, this should be respected unless the child would be put
in danger as a result.
 Child and Adolescent interview
Mental Status Examination
– Cross-sectional summary of the patient’s behaviour, emotions, &
cognitive functioning
– Information as to the mental state is obtained during the psychiatric
interview as well as through formal testing
– Informal information is based on the psychiatrist’s observations of the
patient & listening to what he/she says
 Child and Adolescent interview
• During the interview, it is important to observe the infant, child or the
adolescent
 Child and Adolescent interview - MSE
GENERAL APPEARANCE AND BEHAVIOUR
•Appearance:
– Nutritional state, Evidence of neglect and abuse, alert, cooperative, agitated, aggressive
•Somatic Complaints:
– Somatic complaints during interview such as headaches, dizziness, ?conversion
symptoms
•General Behaviour:
– Acts too young for age; Acts older than age; unmotivated, verbal aggression, physical
aggression, irresponsible behaviour, stubborn, behaves like the opposite sex, repetitive
behaviours (compulsions, rocking, hand flapping), Habits (nail biting, hair pulling, nose
picking
Child and Adolescent interview- MSE
1. GENERAL APPEARANCE AND BEHAVIOUR
Activity: – Overactive, fidgeting, moves around, underactive
Impulsivity: – Impulsive, Impatient, Acts without thinking
Interaction: – Overly anxious to please, seductive, inappropriate
behaviour, shy, withdrawn, reluctant to talk, overly dependent,
manipulative, overly dramatic, dis-inhibited, lack of social reciprocity,
avoids, eye contact, resistant to comply,
Interaction with Parents/Caregivers: – Ease of Separation, affection
shown
Child and Adolescent interview- MSE
2. LANGUAGE: – Difficulties understanding language, Difficulty
expressing self verbally, including stuttering, unusual or bizarre
language, echolalia, neologisms, babbling, nonsense words
3. MOOD AND FEELINGS: – (Self report) unhappy, sad, depressed,
worries, cries, apathetic, happy, angry nervous, fears, anxiety, feels
guilty
4. AFFECT: – (Observed) congruent, euthymic, angry, irritable, anxious,
elated, sudden changes in mood, flat affect
Child and Adolescent interview- MSE
5. THINKING PROCESSES:
•Stream (speed, ease of flow): – Slow of thought, Flight of ideas,
•Form: – Concrete thinking, disorganised thinking, perseveration,
•Content: – Abnormal thought, delusions, obsessions, preoccupations,
limited fantasy or imagination, poor reality testing
•Possession: – Ownership of the thoughts

6. PERCEPTION: – Hallucinations, illusions, derealisation,

depersonalisation
Child and Adolescent interview- MSE
7. LEVEL OF AWARENESS (COGNITIVE FUNCTIONS):
• Attention and concentration: – Problems with concentration, paying
attention, easily distracted, lapses in attention
• Orientation to time, place and person
• Memory (Problems remembering facts):
– Age 8 the normal child should be able to count 5 digits forward and two or three
digits backward
– Age 10 six digits forward and 4 digits backward
– Very poor performance is indicative of brain damage or intellectual disability;
Minor difficulty could be due to anxiety. The child should be able to repeat 3 items ,
5 minutes after they have been presented.
Child and Adolescent interview- MSE
7. LEVEL OF AWARENESS (COGNITIVE FUNCTIONS):
• Intelligence: General vocabulary, Ability to identify parts of the body
• Reading: – Use standardised reading material for age
• Judgement: – Capacity to make the appropriate decisions and
appropriately act on them in social situations.
• Insight: – Capacity to be aware and to understand that he or she has a
problem or illness and to be able to review its’ probable causes and
arrive at tenable solutions
Child and Adolescent interview- MSE
8. MOTOR SKILLS
• Gross motor co-ordination (Awkwardness, clumsiness): Catch a ball,
hop on one foot, show hand (right and left)
• Fine motor co-ordination:
(copy designs: 2 years-circle, 3years-cross, 5years-square, 6yearstriangle,
7years-diamond); writing sample, drawing, making jigsaw, building blocks, using
scissors
 Formulation & Integration
• Process by which suggestions are generated about aetiology or
causative factors – Predispose – Precipitate – Perpetuate

• Patient’s presenting problems • Ensures diagnosis is translated –

Specific, individualized management intervention
 Formulation & Integration
• With information obtained from the assessment – Clinician should be
able to organize information
• Classify mental health problems the child is showing into a diagnosis
Formulation & Integration
• Central to child & adolescent mental health assessments
• Guide all clinical activity
• Important to understand child’s biologic vulnerabilities – How they
interact with family factors
 Formulation & Integration
1.Brief summarizing statement
• Demographic information
• Chief complaint
• Presenting problems from child and family’s perspective and course
 Formulation & Integration
2.Precipitating stressors or events
3.Predisposing issues
4.Perpetuating issues –Biologic characterization – Psychological
characterization – Family and other interpersonal factors –Sociocultural
and environmental factors
Formulation & Integration
• 5.Role performance – Level of functioning in major areas of daily life
• 6.Strengths and protective factors of the child, family, and system
Formulation & Integration
• 7.Differential diagnosis
• 8.Integrative statement – How the factors interact to lead to the
current situation
• 9.Level of functioning
• 10.Prognosis
• 11.Potential openings for intervention
• 12.Management plan- Biopsychosocial model
 Important Points to Note
• Adolescents should always be seen separately at some point
• Children from about 6 or 7 years to puberty can also be seen
separately
• It is not usually desirable to attempt to see very young children
without their parents
Consent and confidentiality
•The clinician should however inform the parents that the child or
adolescent has expressed some private anxieties he or she would prefer
not to communicate with them and stress the fact that it is normal for
children and adolescents to sometimes have private thoughts they do
not want their parents to know about.