What approach is the most appropriate when performing a physical assessment on a toddler?

Know the child and the family - the sociodemographics

Clinicians are busy people. However, spending the first few minutes in getting to know the family is a great tool in developing rapport and adds to the understanding about the context of consultation. In India, for instance, there is a wide variation in parenting and social norms. Educational, occupational, residential and religious backgrounds can give the clinician a frame of reference for “where the family is coming from” and the context of the parent-child conflict. A clinician's consultation chamber can be an intimidating experience for the child and family. Basic information gathering gives them some time to gather their thoughts and adjust to the consultation situation before discussing the “problem.”

Ongoing concerns and Presenting complaints

Parents and children may be unclear about the extent or nature of the problem. For instance, in children with developmental delays, parents may only focus on the fact that the child does not speak, or school refusal may be the presenting concern in a child who has, in fact, had a long-standing mood or disruptive behavior disorder. Development so intricately intertwines with the child's experiences and the parent's repeated attempts at handling difficulties that the clinical picture becomes complex and layered. The clinician must give the parents sufficient time to describe all that they have to say and identify the behavioral concerns. The clinician should, as a rule, identify both ongoing concerns and presenting complaints. Ongoing concerns include all the developmental, psychological, emotional, and behavioral concerns over time while presenting complaints are what precipitated the current consultation. For example, a child with long-standing attention-deficit hyperactivity disorder (ADHD) may have always had complaints from school about incomplete work, restlessness in class, and impulsive anger outbursts; however, the current consultation was precipitated by the school wanting to know if the child is academically capable of writing board examinations. While the real solution lies in addressing the ADHD through pharmacological/behavioral interventions, the urgent issue is communication with the school about the nature of the child's problems and the manner of addressal. Some key questions that could help elucidate ongoing concerns and presenting complaints are depicted in Box 3.

Clinical history of the child's problems

Identifying symptom dimensions

It is ideal if the parents can narrate the concerns they have had about the child from the “start” in a chronological manner, covering details about when they sought what consultation and how it impacted the child, both gains and any adverse reactions. This ideal scenario does not exist in child and adolescent psychiatry. Unlike in adults, the premorbid self is an evolving entity in children and adolescents, and environmental contexts impact a child's behavior significantly. Parents are, therefore, at a loss for how to describe the onset, and course of concerns. Initially, the parents must be allowed to talk about the concerns in whichever manner they want to, starting at whatever point in the child's life they want to. This brings to light the most prominent concerns and the most salient accounts of the complaints. During the parents’ narrative, however, the clinician must note the behavioral symptom profiles that the parent is talking about. Some examples of typical complaints arising from different symptom domains are depicted in Table 1. Complaints pointing towards specific symptom dimensions must thereafter lead into an enquiry about differential diagnoses under that domain. For instance, a child presenting with developmental concerns must be evaluated for intellectual disability, autism spectrum disorders, specific speech, and language developmental disorders and ADHD.

Symptom dimensions in child psychiatry

Diagnostic overshadowing and masking

The clinician must bear in mind two important phenomena – diagnostic overshadowing and diagnostic masking. Sometimes, psychiatric disorders may be missed in children with developmental disorders, because all behavioral symptoms may be considered a part of the developmental disorder, thereby overshadowing primary treatable psychiatric conditions. The presence of developmental disorders can modify or mask the manifestations of a primary psychiatric disorder, by the presence of cognitive, language or speech deficits, especially when the developmental disability is severe, for example, mood disorders in children with developmental disorders may present with excessive laughing or just increase in stereotypic behaviors.

Multiple symptoms

Children may present with more than one symptom. It is important to decipher the order of development of symptoms, for example, a child who presents currently with “fainting spells,” may have had an onset of staying withdrawn, then irritability, then refusing to go to school, and then fainting spells started around examination time. This sequential order of the complaints gives better insight into underlying psychopathological states and helps in management. The clinician must also enquire about the “peak of illness/disability” in the ongoing concerns, and the circumstances around then.

Discrete behaviors

For any discrete behaviors, such as dissociative phenomenon or aggression, it is important to get details about – onset, course, frequency, when does the behaviors occur, how long does the behavior last, precipitating and ameliorating factors. These details add to the conceptualization/significance of the discrete behavior; they may also be insightful for parents and help in planning intervention.

Impact of environmental factors

In elucidating details about behavioral problems and how they have developed over time, the parents should be asked their understanding about the child's difficulties. One may ask, “What do you feel has led to the child's behavioral problems? OR Why do you think these behavioral changes have occurred in the child?” Changes in school, peer group, family environment, parent going away for work, sibling moving out of the house, may be significant factors that the parent can link the onset of the child's problems to. Processing and accepting change can be a complex task for children. Unpredictable interruptions in the formation of a coherent working model of the world can result in confusion, insecurity, and further unpredictability. This is also why bereavement and grief are the most challenging experiences for children. Evolving concepts of life and death interact with a personal loss; behavioral manifestations range from complete indifference to extreme agitation and distress. Children with developmental disorders are especially sensitive to any changes in their environment; they may present with general distress, sleep and food irregularities, irritability, aggression, and even developmental regression. The key is to understand the child's reactions to change and help them make sense of the situation keeping in mind the developmental perspective. In developmental disorders, understimulation can be quite prominent. The parents/caregivers may not understand the transactional nature of child development. The child's daily activities may largely be comprised of solitary play with general overseeing by the caregiver/parent, with little one-to-one engagement and stimulation. This is a sub-optimal environment for child development and would become the prime focus of intervention in children/adolescents with developmental disorders.

Functional consequences of symptoms

Concerns and symptoms picked up by parents must also be assessed for their impact on functional domains in the child's life - at home, at school, with peers, etc. A useful tool in understanding functioning is to ask the parents and child to describe a “typical day” – “What all activities, and at what times of the day, the child does from waking up to going to bed?”, “Who accompanies/supervises the child in which activities?”. Changes in the daily schedule after the onset of the current concerns should be enquired.

Additional information

When children have developmental disabilities/severe mental illnesses, the clinician could also check with the family if they have sought any disability benefits. In addition to being an important part of the management plan, this enquiry serves to enlighten parents on available support systems for disability in the country.

A note on “mobile use” and “gaming” - Epiphenomena as presenting complaints?

In the recent past, children brought for excessive use of mobile phones, and excessive time spent on internet/online games/video games is increasing. The common perception among parents is that the child has become “addicted” to the mobile phone or gaming. Since parents are more commonly able to report an approximate “onset,” course and duration of, say, the excessive mobile use, the underlying pathology may be missed. Children/adolescents presenting with these concerns must be evaluated for the whole range of child mental health issues. Learning issues, developmental deficits, and mood/anxiety states may all lead to this behavioral phenotype either as an escape from “difficulties” or as a manifestation of “novelty seeking.” A primary diagnosis of behavioral addiction rarely holds once other mental health conditions have been evaluated for.

Children in special circumstances

Children and adolescents are being increasingly referred for evaluation to psychiatrists and psychologists, from state-run institutions and agencies, and nongovernmental agencies. These children may be in difficult circumstances such as in conflict with the law or in need of care and protection, many having undergone traumatic experiences such as abuse and/or neglect. While comprehensive forensic evaluation procedures are beyond the scope of this chapter, we highlight some issues below.

It is important to ascertain the reason for referral and ask for a written referral as far as possible. The case-worker's or probation officer's notes are important; both from a case formulation and management perspective. If this has not been made available, it must be asked for from the concerned agency
Documentation is vital. Notes must be pristinely maintained by all parties involved in the care of the child
The clinician must liaise with all the other people and agencies involved in the care of the child and must integrate obtained information to the extent possible
Even if children are referred by the state, every effort must be made to contact the parents of the child, both to obtain history as well as to communicate the plan of management and offer therapeutic help, if required
The purpose of the assessment must be expressly discussed with the child/adolescent, especially with respect to confidentiality and its limits
As far as possible, multiple interviews and opportunities to observe and interact with the child are required before any report is made available
Psychosocial adversities that they may have experienced or are currently experiencing such as abuse and/or neglect must be specifically enquired for in all children and adolescents. If the child comes from an institution, then the care provided at the institution must also be an area of enquiry including the risk of exploitation and abuse
The plan of management including follow-up must be documented and conveyed to the child and the caregivers.

Use of structured assessment tools in child and adolescent psychiatry

Clinical judgment plays a pivotal role in the diagnosis and management of children and adolescents. Careful clinical interviews of multiple informants are usually the best method to aid clinical decision making. Structured assessment instruments and observation methods can sometimes contribute to the process of this clinical decision-making. Two key uses of structured instruments are for (a) diagnostic interviewing, and (b) gathering descriptive information about various aspects of emotional, behavioral and social problems. The latter's utility essentially means the use of rating scales for quantifying symptom severity. Structured tools are also standard practice in the area of research where inter-rater reliability is important. Structured instruments can be categorized based on the domain of symptoms/assessment, and on the administration characteristics of the tool. This has been illustrated in Table 2. The reader will note that the majority of tools are structured, in that the behaviors or items to be assessed are specified and are to be rated in a specific manner. The interviewer must be sufficiently familiar with the tool to correlate the behavior described/observed via history or clinical observation to the items described in the tool. The use of screening tools, structured diagnostic interviews or scales for particular disorders must be used based on the purpose of the assessment. For instance, if a child is diagnosed to have obsessive-compulsive disorder (OCD), the Children's Yale-Brown Obsessive Compulsive Scale may be used to assess the severity of the condition or response to treatment, etc. In the same child, an anxiety or depression screening tool may be used to ascertain anxiety and depression, apart from the clinical interview, to rule out the above-mentioned conditions as they are highly comorbid with OCD and not easily discernible in this population, unless enquired into specifically. Thus, the use of these measures must be done with careful thought regarding the need that the particular measure is going to serve. No measure is a replacement for a good history, examination, and sound clinical judgment. While choosing these instruments, it is also important to consider the psychometric properties as well as other practical considerations including the impact of culture. Another challenge in using these measures is that it may interfere with the rapport that the clinician is trying to develop with the child. The timing, need, and explanation regarding these measures, provided to the child and family, is vital in getting appropriate and useful information from them. However, and this cannot be reiterated enough, that no measure can be a replacement for a comprehensive clinical evaluation and clinical expertise.

Medical history and physical examination

Child and adolescent psychiatry straddles psychiatry, pediatric medicine, and neurology. A clinician needs to take a detailed medical history and conduct appropriate physical examination, and laboratory investigations where needed, to support or refute the provisional diagnosis from a biopsychosocial perspective.[8] For example, a child may be inattentive in school and may hail from a family with limited resources; the physical examination must look for signs of anemia and malnutrition, as contributory factors toward inattention. In a country like India, for many children/adolescents contact with a psychiatrist, in the context of behavioral concerns, maybe their first ever medical contact. Therefore, getting a good medical history/examination is vital for the global health of the child. If a child presents with psychological issues as part of a chronic medical condition such as juvenile onset diabetes or HIV, then the psychiatrist must be part of the multidisciplinary team involved in the care of the child and must be privy to the medical history, treatment provided, and investigations of the child. A history of recurrent falls or fractures/injuries, secondary enuresis or encopresis, must alert the clinician to the possibility of abuse.