Sometimes parents are confused by the way that pediatric psychiatrists interview their children for the first time. It can be puzzling to see a psychiatrist playing checkers for an hour with a child while asking seemingly random questions. This is particularly confusing to parents who have received psychiatric care themselves, and had a much different experience of what it means to receive therapy. I believe that part of the confusion is due to the fact that the evaluation and treatment of children with ADHD and other psychiatric disorders has some subtle and not so subtle differences than the assessment and treatment of adults. In today's blog I'd like to go over some of these differences to demystify some of what goes on in the assessment of children for psychiatric conditions.
One of the most obvious differences between the assessment of adults and children is that the evaluation is almost never the child's idea. Someone in the family, school, or community usually feels that an evaluation is warranted and the child sees a doctor whether they want to or not. Children with ADHD sometimes aren't even aware that their behavior is that problematic and they say that they feel fine. Adults, with some important exceptions (e.g. emergency involuntary psychiatric evaluations), usually bring themselves to a psychiatrist and tell the doctor what's bothering them. Since children rarely bring themselves to see a psychiatrist for the first time, their evaluation usually involves talking to many people (parents, siblings, teachers, etc.); because usually it is a family or community member that notices something's wrong and brings the situation to light.
Another reason why assessing and treating children differs from adults is that children can function quite differently in different environments. While the child may appear to have no symptoms in my office, he or she may be highly impulsive, aggressive, or disorganized while in school or at home. The child may not remember the exact circumstances of their aggressive outbursts and it can be difficult to get all the facts by simply asking the child directly. In children diagnosed with ADHD, it's very helpful to have teachers and parents fill out checklists of symptoms and repeat these checklists as treatment progresses.
One of the benefits of talking to adults with psychiatric problems is that I am an adult too. How children talk about their feelings, perceive the world, and remember events are all much different than adults depending on what stage of development they are in. Abstract ideas are often lost to school age children, so it often takes patient, subtle interviewing in order to understand whether a child is hallucinating or talking about a cartoon he saw last night. Development also becomes an issue in the assessment of children if a child has a delay. Feelings of anger, anxiety, and depression can stem from not keeping up with peers in school or a delay in language development. That's why a great deal of the psychiatric assessment involves detailed questions about childhood milestones (when the child first crawled, walked, spoke, etc.).