The first meeting is often awkward for the child. A significant amount of time can be spent just making an inhibited or anxious child feel comfortable. Yet even if the session goes well, it represents the child at only one moment in time. My experience has been that three 50-minute sessions are typically required to gain a full picture of the situation. Some children need more than three sessions before they are secure enough to share their feelings and concerns. Depending on the age and temperament of the child, a simple question-and-answer format may be ineffective; much can be revealed by the way the child plays with the toys and games in my office. Sometimes symptoms manifest themselves during the interview, providing a palpable and dramatic opportunity to explore issues underlying these symptoms. In short, the "child part" of the diagnostic assessment tends to flow at a rate moderated by the child's nature and troubles.

In conducting diagnostic interviews, I do not use structured questionnaires, such as those described in Hersen and Turner (1994); Kutcher (1997); and Lewis (1991). Although such questionnaires have their value, they lessen the flexibility with which the time is used and may decrease the patient's spontaneity. At our first meeting, Sammy separated easily from his parents and seemed eager to share his ideas with me. After some difficulty choosing an activity, he selected chess. Halfway through the game, he commented that the king and queen were worried about the pawns, who were small and had little power.

Sammy acknowledged his facial tics, but was unable to stop them. His word-finding difficulties were also evident. He described how his mind flitted to many different ideas all at once, so he would lose track of what he was saying. He showed a slight increase in motor activity as we pursued difficult subjects, but at no time became overwhelmed by these topics.

Sammy's nighttime fears seemed to revolve around death and me-dical illness. While he did not know why these thoughts crowded his mind, he was curious about them. He spontaneously mentioned that he was unhappy because of a "long" punishment, but was unwilling to talk about the event (stealing) which had precipitated the punishment.

Putting It All Together


Just as Sherlock Holmes deduced the criminal scenario from disparate clues, so must the therapist assemble a cohesive picture of the child patient from the multitude of clinical data. The child's story is a tapestry whose strands?biologic, psychologic and social?have been intertwined to make the child who he is. What is the contribution of each strand to the whole picture? And how might the strands be rewoven to strengthen the entire tapestry?

The evaluation data can be grouped in the four major categories:

Biology


Underlying the child's symptoms may be a biologic psychiatric disorder. The severity of the disorder will influence the decision as to whether medication will be part of the treatment.

Various medical factors, such as a long-term medical condition, medication or surgery, might slow or accelerate the child's psychologic growth. For example, a child taking theophylline may feel irritable; will that irritability make it harder for the child to tolerate strong affects? Or will a child who has spent time in a body cast, unable to move, have difficulty establishing psychologic separation from his mother?

Neurocognitive factors influence both how the child processes auditory, visual and tactile input and how the child organizes and expresses information. Consider the school experience of a child with auditory processing problems; as confusion and frustration grow, self-esteem plummets.

And finally, the child's constitution and temperament must be included in any assessment of the clinical situation.

Psychology


The assessment also requires an accurate inventory of the child's developmental accomplishments, intrapsychic world and interpersonal capacities. For example, the child who has failed to master oral issues might be unable to process the intense, turbulent issues of the oedipal stage, whereas the child who has failed to separate and individuate might have difficulty establishing healthy boundaries between himself and significant others. Developmental paradigms for assessment, including those of Anna Freud, Margaret Mahler and Erik Erikson, are described in Lewis and Volkmar (1990).

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