Assessment Overview
The interview to assess behavior problems and/or neurodevelopmental and mood disorders can take the same format as any other medical history-taking.
- Description of the problem - "Describe the problem."
- Duration - "How long have you been "concerned?"
- Associations - "Does the problem occur more at certain times or with certain people?"
- Ameliorating factors - "What makes it better?"
- Exacerbating factors - "What makes it worse?"
- Severity - extent of effect - "How much is this problem affecting the child and/or the family?" "On a scale of 1-10, with 10 being the worst impact on your family, how severe is this problem right now?"
Adding the following questions will give you a good start on learning the family's perspective and expectation of the healthcare system?
- Assess perceived cause - "What do you think is the reason your child is doing this?"
- Assess expectation - "What do you hope we can do to help you" or "What help do you need?
Adding a thorough medical/developmental history will provide you clues to etiology of the problems. Find out about family history of neurodevelopmental disorders, and mood and anxiety disorders. Draw a genogram of the family to see who is related to whom and who lives in the family.
A thorough family history and genogram will provide three important sources of information:
- information about the context in which this child lives (who lives in the home, education and work status of the adults)
- significant changes in the child's life (who just moved in or out, is anyone ill or recently unemployed, if one parent is absent - why?)
- information to suggest a genetic factor to the presenting problem (who else in the family has similar problems? Any history of developmental disorders, including learning disorders? Mood or anxiety disorders? Any serious legal difficulties or employment difficulties that might suggest an undiagnosed disorder?)
Always begin with a broad differential. Do not limit yourself to your first impression. If you assume the child has ADHD because the parent says "he's so active" or if you assume the problems arise from the fact that the mother is only 20, you are very likely to miss some important contributing factors in your interview. Furthermore, realize that, more times than not, there will be co-morbidities and/or more than one diagnosis.
Special Notes
Conduct disorder
Sometimes pediatricians use the term "conduct disorder" to refer to poor conduct, such as not following directions and disrespect for authority; however the DSM defines conduct disorders as a set of behaviors severe enough to result in legal action. It is best to avoid use of the term unless the DSM criteria are strictly met and instead simply use the term "behavior problems."
Oppositional Defiant Disorder (ODD)
The DSM provides specific criteria for this disorder, related to consistent poor response to authority. It is important to try to determine what factors underlie the oppositionality, as different etiologies suggest different interventions. Is the child oppositional because there is no attachment to the authority and thus no respect can develop? This suggests an attachment disorder, resulting from early physical and/or emotional separation. Does the oppositionality result from lack of clear directives or lack of consistent consequences for compliance or noncompliance? Does the oppositionality result from impulsivity associated with ADHD (the impulsive response from the child is "no") or from inattention associated with ADHD (the child did not hear the direction, so did not follow it)? Or does the oppositionality result from irritability or lethargy associated with a depressive disorder, or with the flight response associated with an anxiety disorder? It is the opinion of this author that an ODD diagnosis should always be secondary to a primary diagnosis which best defines the etiology.
