In the midst of an overbooked afternoon, you are asked to perform a mental health assessment of Sophie, a 14-year-old girl you have never met. You gather some materials, enter her examination room, and find a poorly groomed girl with her arms crossed over her chest, staring up at the ceiling rather than looking at you. She says to no one in particular, “There is nothing wrong, and I don’t need to be here.” Her mother then speaks for her, describing school struggles, arguments at home, losing friends, and saying “strange” things that include threats to hurt herself and talking to no one in particular whenever she is alone. She has a history of maltreatment by her mother’s previous boyfriend, and in subsequent years she has had “mood swings.” Sophie is picking at the scabs overlaying the linear lacerations on her left forearm.
That sinking feeling you just experienced—the time-stressed challenge of assessing mental health concerns in a pediatric population—is something we have experienced too. We want this book to help, to be the guide you take with you on these kinds of encounters.
Like The Pocket Guide to the DSM-5™ Diagnostic Exam, this book emphasizes a person-centered approach to diagnosis along with practical tools and interview prompts to try with children and with their parents.
Because young people are more likely to receive an initial mental health diagnosis and medication management in a primary care setting than in a specialty care setting, we pay particular attention throughout this guide to what would be practical to perform in a primary care setting. Therefore, we describe things such as
4• How to diagnostically investigate common complaints (Chapter 3)
• How to perform either 15-minute (Chapter 4) or 30-minute (Chapter 5) versions of a diagnostic interview
• Abbreviated DSM-5 (American Psychiatric Association 2013) diagnostic descriptions and criteria (Table 4–1 and Chapter 7)
• Rating scales and suggested uses (Chapters 10 and 11)
• Developmental milestones and red flags for referral (Chapters 3 and 12)
• Psychosocial (Chapter 14) and psychotherapeutic (Chapter 15) intervention basics
• Psychopharmacological intervention basics (Chapter 16)
We expect that different parts of this book will be used in different ways. Some sections of this book will be more helpful when read in their entirety because they describe strategies to approach different aspects of caring for young people. Other sections may be used as in-the-moment references, such as interview questions to try when investigating a specific DSM-5 diagnosis or a table that lists key age-specific developmental milestones.
The following points highlight how this book differs from The Pocket Guide to the DSM-5™ Diagnostic Exam.
• ICD-10 codes for diagnoses are included.
• Diagnoses not commonly made in childhood or adolescence are not included. All content is focused specifically on children and adolescents.
• Discussion of the development of DSM-5 is reduced because it is no longer novel.
• The practical aspects of the text are increased by shortening chapters and adding tables.
• Assessment tools specifically for children and adolescents are introduced.
• Initial treatment strategies—psychosocial, psychotherapeutic, and psychopharmacological—for diagnosed disorders are added.
We certainly did not start out knowing how to interview young people and diagnose their mental and behavioral health problems. We remember struggling through encounters, wondering how to organize the disparate symptoms 5and concerns. Through our struggles, we eventually arrived at a variety of ways to simplify the diagnostic and treatment process and have learned how to organize our approach even in time-constrained circumstances.
As coauthors, we have served in different postresidency clinical roles that include being a rural pediatrician, a pediatric hospitalist, a pediatric emergency physician, a child psychiatrist, a child psychiatric consultant to both tertiary care and rural pediatricians, and an adult inpatient psychiatrist. We have provided both psychotherapy and medication treatments for young people and have been required to adapt what we do for the shifting needs and structures of various care settings. In the course of this work, we have often been humbled by the challenges young people face and the challenges they present to a person who dares to provide them with mental health assistance. After all, few children and adolescents arrive on our doorsteps with neatly described symptoms that perfectly map onto a single DSM-5 disorder. We have both made many mistakes and grown from those experiences.
This book is an experience-based guide to child mental health diagnosis and treatment, intended to provide a variety of practical approaches, tips, and skills to supplement the diagnostic content of DSM-5. We cannot offer any rigid rules to follow when diagnosing or treating mental health disorders in young people because good care for young people cannot be reduced to a checklist. However, we make it easier for everyone to provide excellent care. Whatever your specialty, your practice setting, and your experience level, we can assist you as you journey with children and adolescents in pursuit of mental health.
Working with young people can be very different from working with adults. Young people are often reluctant participants, often with developmentally limited communication skills, who have been presented for care that they did not seek on their own. In addition, the process of diagnosing disorders in a child typically involves gathering information from multiple informants and remembering an age- and developmentally adjusted–diagnostic differential. Particularly when clinicians are working in primary care or other settings 6that artificially limit evaluation times, that sense of a ticking clock increases the challenges in order to efficiently reach a diagnosis and treatment plan for a young person.
The first step to successful diagnosis and treatment is to support the collaborative treatment relationship, what we hereinafter call the therapeutic alliance. Creating a therapeutic alliance with the caregiver at an appointment is comparatively simple when compared with building an alliance directly with a young person.
The 14-year-old girl in the vignette at the beginning of this chapter, Sophie, illustrates the problem with building an alliance. Sophie communicated that she disagreed with her mother’s assessment of the situation and was disinterested in your services. If you were to open DSM-5 and immediately begin asking Sophie a series of diagnostic questions, it would likely only increase her resistance. You must first engage Sophie to obtain reliable responses.
If we were in the examination room with you, we would hear out the concerns of Sophie’s mother, which also serves to solidify the parental therapeutic alliance; we would thank her for the guidance; and we would tell her that after hearing the concerns of caregivers, we speak with all of our adolescent patients alone. We would describe the rules for that discussion—namely, that the conversation is confidential except for safety concerns—and then invite Sophie to sit alone with us. We do so because with adolescents in particular, you develop a better alliance and obtain more honest answers when you interview them without a parent or caregiver present (cf. Ford et al. 1997; Gold and Seningen 2009). However, this guidance must be adapted to each situation; a separation should not be forced on an adolescent who does not want her or his caregivers to leave the room. Younger children, or those adolescents who appear to be developmentally immature, are usually interviewed more successfully with caregivers present and reassuring them.
All young people will have a better therapeutic alliance if they feel noticed, heard, and appreciated, which can be called empathic engagement. Even for practitioners in a time-pressured situation, be reassured that holding back a recitation of targeted diagnostic questions in order to really notice the patient and build a little engagement does not take long. In our experience, creating that engaged therapeutic alliance up front with a reluctant interviewee saves time overall through enhanced cooperation with the diagnostic process.
7Starting with a genuine reflecting statement that follows someone’s lead can initiate engagement with an adolescent, such as saying to Sophie, “You said that you feel fine and that there is nothing wrong. I would like to hear more about what is going well for you right now....” You could also start the conversation by asking about something that is important to the patient but relatively situation neutral, such as, “Your mom said that you go to ____ school; what is that school like?” School, friends, family, and favorite activities can all be appropriate and relatively low-stress conversation starters.
For young persons who seem really reluctant to even start talking, you may find that the conversation flows better after describing something you saw. This shows that you have been paying attention to them. For instance, “It looked as if it was really hard to just sit there and do nothing while your mom was talking. Am I right about that?” If there is a chance to comment on something you saw that relates to the diagnostic theme, you could also take that opportunity, saying, for example, “I saw you shake your head when your mom described what happened yesterday. Did she say something that wasn’t true for you?”
With a very young child, a conversation starter could be a simple observation, such as commenting about what she is wearing or brought with her, such as, “I see you have flowers on your shoes; did you pick those out yourself?” You can also comment on something the young person is currently doing, such as how she is playing with a toy or drawing a picture, to start a conversation.
A more subtle strategy to build the treatment alliance with a young person is shaping how you speak in a way that shows that you will be a responsive, problem-solving partner rather than an authority who will judge her. Metaphorically, this is about getting you and your young patient to sit side by side and to talk about a problem together. That way, the young person can talk about a problem that does not involve who she is as a person. For instance, Sophie may feel less defensive if you conversationally refer to her “mood” having led her to cut herself rather than “you cut yourself.”
A bit of humor can help to get young people talking. If humor does not come easily to you, be aware that showing some humility about yourself can be disarming and get your patient to chuckle a little. Both of us have children of our own who daily remind us that we have not been “cool” for a long time (if we ever were), and we find that openly acknowledging our status as uncool adults can humanize us and put a 8young person at ease. For instance, “What is that band’s name on your shirt?... I have not heard about them before, but that probably means they are cool because I am a bit of a square.”
Building a therapeutic alliance with a young person should lead to learning that young patient’s own true chief complaint. For Sophie, it could be “My mom is driving me crazy,” “My boyfriend is abusive,” “I hear voices,” or any of a number of complaints. This creates a context from which your subsequent and more detailed diagnostic inquiries will logically follow. Following conversational opportunities can go like this: “So, during those times when your mom is driving you crazy, do you ever have thoughts about hurting yourself?” Child and parent chief complaints do not have to align; we have performed many successful treatments from start to finish with young people whose chief complaints never fully aligned with what their parents thought the problem was.
Once you have the young person engaged and talking with you, the diagnostic and treatment process as described throughout the rest of this book should follow along more easily. Once a reasonable therapeutic alliance has been started, it is our experience that asking your patient questions about what she sees as the challenges in her life will be more honestly answered.
In summary, we suggest the following techniques to initiate a therapeutic alliance with a child and set up a useful diagnostic interview:
• When developmentally appropriate, offer to talk with the patient without a caregiver present.
• Start the conversation with an observation or a subject important to the patient.
• Briefly convey that you have noticed, heard, and appreciated the patient’s perspective.
• Show that you are the child’s treatment partner rather than an adult-engaged adjudicator.
• Use a little humor to break the ice, such as confessing your “uncoolness.”
• Ask about the patient’s main concerns or frustrations.
• Try shaping your initial diagnostic questions to reference the child’s own chief complaint.