What is a psychiatric assessment about? When does a child need one and what are the implications for diagnosis and treatment? At the Cincinnati Children’s Pediatric Mental Health Conference held in early October, Sergio V. Delgado, MD, Professor of Psychiatry, Child Psychiatry Medical Director and Outpatient Services at CCHMC presented a highly accessible general session covering psychiatric symptoms, parental concerns, learning issues and diagnostic dilemmas. An integrated assessment is important because it includes developmental milestones in addition to what are considered psychiatric and learning issues. Pediatricians are often the first to be consulted, and will know when to refer to a psychiatrist.
When a problem presents, there might be psychiatric symptoms which include ”irritability, disruptive behavior in school, (suspensions), trouble paying attention in class, mood swings, depression, suicide attempts, self-harm, cutting and/or substance abuse.” Delgado named several DSM (diagnostic manual) psychiatric diagnoses. Then there is the ‘mom report’. This report can include ‘outbursts’, ‘rapid mood swings’, ‘anger towards others’, ‘history of ‘getting depressed’’ coupled with a history, and/or record of prior treatments. Parents may become frustrated with therapy, medication, school, and even their own parenting approaches. Signs and symptoms as described by patient, parents- including frequency, variations or intensity, may be 40-60% inaccurate, so a multi-faceted approach is important.
Delgado discussed early years, and subjectivity of others. Is the child secure, anxious, dismissive or disorganized? What is development of cognition, and different learning styles like? He stated that 10-40% of the population have learning weaknesses; 6-7% of population has a formal learning disability; schools often help about 2-3% (based on funding), and 15-20% of the population may have some symptoms of dyslexia. In addition, early life experiences of trauma, environment, intellectual disability, learning disability or brain injury may affect outcomes.
An appropriate visual called ‘Our Expectations’ shows a professorial man behind a desk addressing a bird, monkey, penguin, elephant, fish, otter, and a dog. He says, ‘for a fair selection everybody has to take the same exam: please climb that tree.’ If 80% have a language-based learning disability, and 20% a non-verbal learning disability, this could explain some of the contributing factors to difficulty with learning and behavior. An integrated assessment includes verbal, visual, fluid reasoning, working memory and processing speed. There are contributing effects of cognitive weakness which can include everything from sensory responsiveness to social skills, understanding moral rules, reciprocity, fine motor skills, and impaired insight. As a result, a child or teen might be oppositional, manipulative, truant, disrespectful, and awkward, isolates him or herself, or engages in impulsivity. It is not an equal playing field for differently abled kids.
Delgado presented representative examples as approached from different professionals-occupational, and speech-language. He cautioned that, ‘our expectations need to match with the child’s abilities.’ This might require an IEP (individual educational plan) for the home- and not just the school. He suggested a visual token system to accumulate successes and not lose what is gained. There are also hardwired personality traits. Some children will be more dependent (clingy); others demanding, or self-destructive. Some will reject help altogether. His recommendation is to be humble in the face of a comprehensive assessment and be prepared to offer a large amount of external support. His final slide: ‘it’s okay to be different’ summed up a message of acceptance and hope.
(Photo credit: Image shows Air Force Capt. Kristine Andrews, a pediatrician from Montgomery, Ala. during a Continuing Promise 2011 community service medical project at the Polideportivo medical site in the Caribbean. U.S. Air Force photo is by Staff Sgt. Courtney Richardson. This Image was released by the United States Navy with the ID 110715-F-NJ219-161. Source Wikimedia Commons.)