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.
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 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.
Most private practice cases start with a phone call. On the line, typically, is the child's mother, driven to seek help by her child's or her own distress, yet hesitant to leap into the unfamiliar world of psychiatry. In asking for a summary of the current problem and its urgency, I also garner impressions about the parent: Is she coherent? Is she anxious? Is she allied with her spouse in the decision to seek assistance? The tone of the initial phone contact is crucial, as it raises expectations in the parent which often influence the ensuing therapist-parent relationship. The parent gets an idea of the methodical, unpressured manner in which the assessment will be conducted. I also outline the structure of the consultation?cost, frequency, approximate number of sessions?and insist that both parents attend the first meeting.
The face-to-face part of the assessment begins with the gathering of essential diagnostic data, such as a description and history of the current concerns, developmental and medical history, marital and family history, and state of the family structure. I ask the parents to describe the child's typical day. Along the way, I observe how the parents interact with one another and assess whether their behavior might factor into their child's problems. I also try to get a sense of their attitude toward their child, their capacity to introspect and their willingness to consider my initial observations.
Gurwitt, who is in a private practice specializing in adult and child psychiatry and psychoanalysis, suggests asking the parents toward the end of the evaluation session their theory of their child's troubles (private communication, 1998). This "team approach" strengthens the ensuing therapeutic alliance and promotes the parents' own thoughtfulness about causation.
I attempt to conduct the data-gathering phase of the assessment in chronological order, commencing with pregnancy, labor and delivery and proceeding to the present. I obtain a similar chronological rundown of the child's symptoms. However, the flow of the interview frequently becomes nonlinear, as parental concerns or questions lead to unexpected, and often fruitful, paths of exploration. Sammy's mother recalled with some emotion the day she and Sammy were stringing a bead necklace. Sammy had become agitated, discarding one bead after another. He had asked desperately, "How can I pick the right bead?"
I interrupted the data-gathering process to focus on this anecdote. When asked how she had handled this upsetting moment, Sammy's mother responded that she had immediately stopped the activity and started to read to him until he calmed down. With further exploration, I learned that this was her usual way of dealing with emotional turmoil. She could not tolerate strong affects and tried to distract Sammy whenever he was in distress. We discussed her early history as it related to affect tolerance. Both parents agreed that the mother's strategy, while meant to comfort, might in the long term make it difficult for Sammy to deal with emotional discomfort. The anecdote led to other questions: What conflicts, anxieties and imaginings did the act of choosing bring up in this child? Might he have a neurocognitive burden, such as impulsivity or an obsessional state, that affects the act of choosing? The entire interchange, though brief, proved to be extremely informative.
Many of my assessments include individual meetings with each parent in the knowledge that certain information is more freely divulged in private. This is where I tend to hear about marital discord, family secrets or developmental burdens of each spouse. In Sammy's case, for instance, I felt that issues surrounding adoption, infertility, birth defects and the Holocaust warranted an individual session for each parent.
Once a decision has been reached to have me meet with their child, the parents and I discuss how they can help the youngster comprehend the purpose of seeing a therapist. Typically, I suggest choosing one of the child's concerns as a reason for the visit. Sammy's nighttime fears had kept him from having a much desired sleepover at a friend's house. His parents told him of their meeting with a "feelings doctor," and that I was curious about this problem and thought I might be able to help.
On the basis of the initial parent interview, I occasionally refer an acutely and severely ill child for immediate assessment in a hospital setting or by a clinic team. In most cases, however, I arrange to see the child to gather further information about the seriousness of the problem and to decide on appropriate intervention.
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.
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:
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.
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).
This category includes family structure, socioeconomic conditions, cultural milieu and education. For instance, are there marital, financial, alcohol or other problems that have influenced the child's development? Is the family able to tolerate the transient turbulence their child might experience as he or she works through issues in psychotherapy? Is the family healthy enough to welcome and help sustain the changes the child makes? Does the child have to contend with instability and violence in the neighborhood or school?
The most appropriate psychiatric intervention depends not simply on the diagnostic label, but also on a variety of factors pertaining to the child and parents. For example, is the child able to introspect, communicate verbally and through play, and relate to a psychotherapist in a way that fosters understanding, growth and development? Is the particular disorder responsive to medication or to a cognitive behavioral approach exclusive of psychotherapy? In any event, the child and parents must be allied with the therapist in the treatment process. Only by knowing the child and the parents can the clinician effectively predict whether they will cooperate with the chosen modality.
The decision to recommend psychiatric treatment is a difficult one. It is quite typical for a child to become symptomatic while accomplishing a developmental step. And some children, as they continue to grow, play and relate to family and peers, get better on their own. But some do not. After completing my evaluation, I arrange a summation meeting with the parents to convey a sense of the child's strengths, weaknesses and symptom complex, and to make recommendations for intervention when needed.
I recommend psychiatric treatment if:
If the parents reject the recommendation for therapy, I add a final child meeting to the consultation so that the child and I can talk over my ideas and say good-bye.
"All medical specialties," asserted psychiatrist Robert L. Spitzer, M.D., "overemphasize diagnoses and sometimes lose sight of the patient." (Science News, 1998). According to the DSM-IV, Sammy is classified as a 309.24, 307.21, 314.01 with moderate psychosocial stressors and a GAF (Global Assessment of Functioning Scale) of 70. But my mind paints a hundred faces of children with those descriptors. Do we not need a richer view of Sammy, one that ties his symptoms to his inner world, one that puts a unique face on the child? In the biologic arena, Sammy was burdened by neurocognitive vulnerabilities?tics, probable attention-deficit/hyperactivity disorder and possible verbal learning disability?that might have made him feel out of control and overwhelmed by incoming stimuli. His prematurity and early exposure to phenobarbital might have contributed to his biological issues.
The psychological component of the assessment revealed that Sammy had accomplished many age-appropriate developmental tasks: separating from his parents in most situations, forming relationships, being curious about his situation, and identifying problems and proposing theories about them. He was able to bear some intense feelings, but intermittently became overwhelmed, as evidenced by his tantrums, separation anxiety and somatic symptoms. Clearly, he had work to do in the arenas of self-soothing and affect tolerance. Sammy knew right from wrong. He was empathic and gentle in his judgment of himself and others. He had, for the most part, achieved age-appropriate ego and superego capacities. In short, Sammy was well into the stage of development referred to as latency.
In my sessions with him, Sammy had difficulty choosing activities, and there was an impulsive quality to his initial choices. The fact that Sammy, himself, had been chosen by his adoptive parents might have burdened his own ideas about choosing and setting aside the unchosen. He was reluctant to discuss the adoption. Sammy was concerned about his brother's orthopedic problems. He said the facial tics occurred because his own body sometimes felt uneven. Perhaps the "uneven" feeling had as much to do with an underlying biologic disorder as with unresolved feelings about his brother's problems, which included facial asymmetry.
Sammy's home environment seemed stable. His parents agreed to try to expand their own capacity to tolerate feelings and to help Sammy do the same with his own feelings. To Sammy's parents I communicated my psychodynamic hypotheses about particular symptoms so that they gained a sense of how I think about their child. I introduced the notion that Sammy's biology and dynamic issues can intertwine to create his symptoms. For example, his stealing might have both an impulsive root, due to the attention-deficit/hyperactivity disorder, and a psychodynamic root, in which the stolen items served as a metaphor for the parental attention he had lost to infertility and his brother's medical problems.
I recommended that Sammy begin a child psychotherapy plus psychopharmacologic evaluation, neuropsychological testing and possible medication trials. Clearly, Sammy was amenable to psychotherapy, since he was thoughtful about his problems, used metaphor and symbolic play, and tolerated to some degree the painful affects touched upon during the assessment. The treatment goals: to allow Sammy some relief from neuroco-gnitively driven symptoms; to help him understand his biologic self; to help him understand his life experiences and how he may have made sense of them in ways that frightened and worried him; to increase toleration of strong affects; to promote self-soothing capacity and strategies. I also recommended ongoing parent guidance sessions.
When I was a second-year medical student starting my clinical rotations, I was anxious about determining diagnosis. A senior physician told me the following story. An attending psychiatrist brought a group of medical students to assess a patient. "Always listen to the patient," he said, "for therein lies the path to diagnosis." Then he left the room. Upon his return a few minutes later, the students confidently announced the correct diagnosis: porphyria! Stunned, the psychiatrist asked them how they had figured out the diagnosis so quickly. The students had really listened to the patient; they had asked why he was in the hospital, and he had named his illness. Were all diagnostic assessments only that simple!
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