From a drop of water...a logician could infer the possibility of an Atlantic or a Niagara without having seen or heard of one or the other. So all life is a great chain, the nature of which is known whenever we are shown a single link of it. Like all other arts, the Science of Deduction and Analysis is one which can only be acquired by long and patient study...Let the inquirer begin by mastering more elementary problems. Let him, on meeting a fellow mortal, learn at a glance to distinguish the history of the man.
-Sir Arthur Conan Doyle,
A Study in Scarlet
Recently, in reviewing a particularly complicated case with a representative of a managed care company, I was told that I was the only child psychiatrist in the country who could not come up with a diagnosis in one session. I decided to take her criticism to heart and review the format I had developed over 15 years to diagnose children with psychiatric problems. What constitutes an effective child diagnostic assessment? And, considering the pressures of impatient parents and cost-conscious case managers, can such an assessment reasonably be completed in one 50-minute session?
The late psychoanalyst Maurits Katan commented "that today diagnosis no longer should consist in giving a name to a certain group of symptoms but that diagnosis should be based on metapsychologic insight. The diagnosis arrived at by descriptive psychiatry can now be connected with a concept of the structure of the illness concerned. This viewpoint makes...diagnosis consist of a metapsychological evaluation of the total personality." The quote is taken from a speech delivered by Katan in 1957 (Katan, 1959).
Clearly, the tension that exists between purely descriptive diagnosis versus psychodynamic-developmental understanding of the patient has been percolating for decades and began long before the advent of managed care. The DSM-IV (American Psychiatric Association, 1994), the present-day embodiment of descriptive diagnosis, is profoundly important. It provides clinicians with a common vocabulary for discussing a patient's illness and statisticians with quantifiable diagnostic categories for research studies.
But can we really formulate a diagnostic assessment and decide upon intervention using one format exclusive of the other (Tucker, 1998; Kendler and Gardner, 1998)?
Every clinician evolves his or her own format for diagnostic assessment (Freud, 1981; Katan, 1959; Chethik, 1989; Greenspan, 1981; Hersen and Turner, 1994; Kutcher, 1997; Pascal, 1983; Simmons, 1987; Shaffer et al. 1985). While differing in their specifics, these formats share a fundamental root: questions are asked to elicit information that will be assembled into a coherent picture of the origin and complexity of the child's problems. The American Academy of Child and Adolescent Psychiatry has compiled an exhaustive list of these questions (1997a,b), which will not be reproduced here.
Rather, I will illustrate the general method and flow of an assessment of an 8-year-old boy, with examples of the questions and the reasoning that led to my formulation, diagnosis and treatment recommendations.
Sammy: A Case Study
Sammy was an 8-year-old Vietnamese boy born prematurely at 36 weeks following complications of preeclampsia. At 3 months of age, he was adopted by a childless white couple with primary infertility. His biologic mother had been treated pre- and postdelivery with phenobarbital to prevent seizures and had nursed the child before the adoption.
Sammy's APGAR scores were eight and nine, and he had no neonatal problems other than physiologic jaundice. At the time of adoption, his pediatrician found him to be a vigorous, active, responsive infant in good health.
During Sammy's first three years of life, his adoptive parents continued to seek infertility treatments, which culminated in a successful pregnancy. The biologic child, born when Sammy was 4 years old, had congenital orthopedic problems, including a thoracic-cage asymmetry, a mild facial asymmetry and a hip dysplasia that required casting. Over time, Sammy's brother was found to be normal in cognitive and emotional development, lively in disposition and of above-average intelligence.
When Sammy was between 4 and 8 years old, the family was preoccupied with his brother's medical and orthopedic problems. Nevertheless, Sammy did well cognitively, emotionally and socially in nursery school and early elementary school. By the time Sammy was 8, his brother's medical problems had receded and took much less of the family's attention.
It seemed to Sammy's parents that with the diminishment of events surrounding infertility and birth defects came a rush of symptoms in Sammy. He developed frequent stomachaches, which the pediatrician felt were psychosomatic in origin. He began to steal snacks from his classmates, quite overtly and in the presence of his teacher. He was having difficulty finishing spoken sentences, although the teacher reported that he was quite capable in his written work. In addition, Sammy's parents had begun to notice intermittent facial tics, fears about nighttime, difficulty falling asleep and occasional temper tantrums. None of these symptoms as yet had interfered with Sammy's peer relationships.
Sammy's biologic family history was unknown. His adoptive family had many members on both sides with anxiety disorder, and the adoptive grandparents were Holocaust survivors.
American Academy of Child and Adolescent Psychiatry (1997a), Practice parameters for the psychiatric assessment of children and adolescents. J Am Acad Child Adolesc Psychiatry 36(10 suppl):4S-20S.
American Academy of Child and Adolescent Psychiatry (1997b), Practice parameters for the psychiatric assessment of infants and toddlers (0-36 months). J Am Acad Child Adolesc Psychiatry 36(10 suppl):21S-36S.
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington: American Psychiatric Association.
Depression gets doleful diagnosis. Science News. Feb. 14, 1998, p 100.
Chethik M (1989), Techniques of Child Therapy: Psychodynamic Strategies. New York: Guilford Press.
Doyle AC (1930), A study in scarlet. In: The Complete Sherlock Holmes. Garden City, NY: Doubleday, Doran & Co. Inc.
Freud A (1981), Diagnosis and assessment of childhood disturbances. In: Psychoanalytic Psychology of Normal Development 1970-1980; part of the series, The Writings of Anna Freud, Vol. 8:. New York: International Universities Press Inc., pp 34-56.
Greenspan SI (1981), The Clinical Interview of the Child. New York: McGraw Hill Book Co.
Hersen M, Turner SM, eds. (1994), Diagnostic Interviewing. New York: Plenum Press.
Katan A (1959), The nursery school as a diagnostic help to the child guidance clinic. In: Psychoanalytic Study of the Child, Vol. 14. New Haven, Conn.: Yale University Press, pp. 250-264.
Kendler KS, Gardner CO Jr (1998), Boundaries of major depression: an evaluation of DSM-IV criteria. Am J Psychiatry 155(2):172-177.
Kutcher SP (1997), Child and Adolescent Psychopharmacology. Philadelphia: WB Saunders Co.
Laufer M (1965), Assessment of adolescent disturbances: the application of Anna Freud's diagnostic profile. Psychoanal Study Child 20:99-123.
Lewis M ed. (1991), Child and Adolescent Psychiatry: A Comprehensive Textbook. Baltimore: Williams & Wilkins.
Lewis M, Volkmar FR (1990), Clinical Aspects of Child and Adolescent Development: An Introductory Synthesis of Developmental Concepts and Clinical Experience. Philadelphia: Lea & Febiger.
Pascal GR (1983), The Practical Art of Diagnostic Interviewing. Homewood, Ill.: Dow Jones-Irwin.
Shaffer D, Ehrhardt AA, Greenhill LL eds. (1985), Clinical Guide to Child Psychiatry. New York: Free Press; London: Collier Macmillan.
Simmons JE (1987), Psychiatric Examination of Children, Philadelphia: Lea & Febiger.
Tucker GJ (1998), Putting DSM-IV in perspective. Am J Psychiatry 155(2):159-161.