Pediatric Psychiatry History Taking

Key Principles

• Assessment begins the moment the patient enters the room - observe the child's behavior in the waiting area and during the interview.
• Multiple informants are essential: child/adolescent, parents/caregivers, and when possible, teachers or school reports. Each provides a different perspective.
• Child and parent interviews are conducted separately, then jointly at the end.
• Consider the age and developmental stage of the child - both in terms of what disorders are likely and how to phrase questions.
• About 20% of youth have a mental disorder in a given year; psychiatric disorders often co-exist with medical conditions.

Structured Approach: Step-by-Step

Step 1 - Introduction and Rapport

• Introduce yourself and explain the purpose of the assessment.
• Obtain permission to interview the child separately (if appropriate for age).
• Use open-ended questions early to build rapport.

Step 2 - Chief Complaint and History of Present Illness (HPI)

• Ask about mood, anxiety, behavioral changes, and always screen for depression and suicidality.
• Validated screening tools (e.g., PHQ-A, SCARED, MASC) can supplement structured questioning.

Step 3 - Psychosocial History: HEADSS Framework

Step 4 - Full Patient History

a. Pre- and Perinatal History

• Consanguinity of parents
• Assisted reproductive technologies used
• Pregnancy complications, infections, substance exposure (alcohol, drugs, medications)
• Birth: gestational age, birth weight, perinatal complications, NICU admission
• Neonatal period: feeding difficulties, early bonding

b. Developmental History

• Motor milestones: rolling, sitting, walking
• Language milestones: first words, two-word phrases, vocabulary progression
• Social milestones: eye contact, social smile, joint attention, play development
• Toilet training history
• Any regression (loss of previously acquired skills) - always take seriously; raises suspicion for neurodegenerative disorder

c. Medical History

• Chronic illnesses, hospitalizations, surgeries
• Medical conditions mimicking psychiatric disorders (thyroid disease, epilepsy, metabolic disorders, Wilson's disease, PANDAS - acute onset OCD/tics after pharyngitis)
• Current medications and allergies
• Neurological history: seizures, head injuries, TBI

d. Psychiatric History

• Previous psychiatric diagnoses
• Prior treatments (therapy, medications) and response
• Past hospitalizations or emergency visits for psychiatric reasons
• Previous suicide attempts or self-harm

e. Family History

• Psychiatric disorders in first- and second-degree relatives: depression, anxiety, bipolar disorder, schizophrenia, ADHD, autism spectrum disorder, substance use, suicide
• Medical conditions with genetic relevance
• Family functioning, conflict, parental separation/divorce
• Note: family history of alcohol dependency raises consideration of fetal alcohol syndrome; family history of unusual/odd behavior may suggest hereditary conditions

f. Social History

• Who the child lives with; family structure
• Socioeconomic status, housing stability
• Adverse childhood experiences (ACEs): abuse (physical, emotional, sexual), neglect, domestic violence, parental incarceration
• School environment, bullying, peer relationships
• Cultural and religious background

Mental Status Examination (MSE)

Special Considerations by Age

• Young children (under ~7): Rely more on parent report and observation; child self-report is limited. Play-based interview techniques are used.
• School-age (7-12): Can participate more directly; use concrete, simple language; structured interview tools available (K-SADS, DAWBA).
• Adolescents (13+): HEADSS framework is most applicable; confidentiality must be addressed explicitly; motivational interviewing techniques improve engagement.

Differential Diagnosis Tips

• Age at onset guides differential: separation anxiety, ADHD, and tic disorders tend to emerge in younger children; depression and substance use disorders commonly emerge in adolescence.
• Rule out medical causes before attributing symptoms to primary psychiatric disorder (the IACAPAP clinical examination guideline recommends a stepwise approach: brief medical history → basic physical exam → further investigations only if indicated).
• Multiple sessions may be needed for young children - adequate assessment in a single session is often not possible given their rapid developmental changes.

Summary: Interview Structure

1. Introduce and establish rapport (open-ended questions)
2. Chief complaint + HPI (COLDER mnemonic)
3. Psychosocial history (HEADSS framework)
4. Full history: developmental, medical, psychiatric, family, social
5. MSE throughout the interview
6. Collateral: parent interview (separately), teacher/school reports
7. Joint meeting: bring child and parents together at the end

Mental Status Examination (MSE) in an 8-Year-Old Child

Key principle: Much of the MSE is gathered implicitly as the clinician interacts with the child - it is not a separate structured interrogation. Observation begins in the waiting room.

Why 8 Years Old is Distinct

Components of the MSE

1. Appearance

• General appearance, dress, hygiene, grooming
• Body habitus, apparent age vs. stated age
• Dysmorphic or syndromic features (e.g., features of Down syndrome, fetal alcohol syndrome)
• Evidence of self-harm, neglect, or physical abuse (bruising, poor grooming)
• Posture - sitting, standing; level of tension or relaxation

2. Behavior and Social Relatedness

• Ease of separation from parent - does the child cling, refuse, or separate easily?
• Eye contact - appropriate, avoidant, or overly intense
• Attitude toward examiner - cooperative, guarded, oppositional, eager to please, overfamiliar (overly familiar behavior is as concerning as withdrawal)
• Facial expression - flat, animated, sad, anxious, age-appropriate
• Activity level - psychomotor slowing vs. agitation; sustained vs. episodic; goal-directed vs. erratic
• Signs of distress or discomfort during the interview
• Any evidence of responding to internal stimuli (hallucination-driven behavior - talking to self, laughing incongruently)

Per Kaplan & Sadock's Synopsis: "Overly friendly or familiar behavior may be as troublesome as extremely retiring and withdrawn responses." - Kaplan and Sadock's Synopsis of Psychiatry

3. Motor Behavior

• Coordination - age-appropriate fine and gross motor coordination
• Activity level - hyperactivity, restlessness (key for ADHD assessment)
• Involuntary movements: tics (motor or vocal), tremors, stereotypies, mannerisms, unusual postures
• Gait (if observed)
• Focal asymmetries of muscle movement

4. Speech and Language

• Quantity: spontaneous and talkative vs. mute or monosyllabic
• Rate and rhythm: fast (mania, anxiety) vs. slow (depression)
• Volume and tone
• Fluency: stuttering, articulation errors (some residual articulation errors normal at 8 but should be largely resolved)
• Language complexity: vocabulary, sentence structure - assess against age norms
• Comprehension: understanding simple and complex commands
• Prosody (emotional tone of speech)

5. Mood

• Subjective - ask the child directly: "How have you been feeling lately?", "Can you show me on this feelings chart?"
• A 0-10 scale can be used with children: 0 = extremely sad/wishing to end life, 10 = extremely happy
• Assess whether mood changes at different times of day or in different contexts (home vs. school)
• Explore: sleep, appetite, interests, energy level, motivation
• Ask what has helped their mood in the past

6. Affect

• Clinician's objective observation of the child's current emotional state through non-verbal cues
• Describe: range (full vs. restricted vs. flat), appropriateness (does affect match content?), congruence (does affect match reported mood?), lability (rapid shifts)
• Note: flat affect in an 8-year-old is abnormal and may suggest depression, ASD, or psychosis

7. Thought

a. Thought Form (Stream/Process)

• Logical and goal-directed vs. disorganized
• Poverty of thought (thought blocking), perseveration, racing thoughts, flight of ideas

Important: Very young children are expected to have short attention spans and may change topics abruptly - this does not automatically indicate flight of ideas. Context and degree matter. - Kaplan and Sadock's Synopsis of Psychiatry

b. Thought Content

• Obsessions and compulsions (OCD peak onset ~10 years but can present at 8)
• Phobias and specific fears (age-appropriate fears vs. phobias)
• Magical thinking (some magical thinking is normal at 8 but should be decreasing)
• Overvalued ideas, delusions (rare at this age; consider early psychosis if present)
• Ruminations
• Thoughts of harm to self or others

8. Perception

• Hallucinations: auditory, visual, olfactory, tactile
• Illusions (misperceptions of real stimuli)
• Depersonalization / derealization

Per Kaplan & Sadock's Synopsis: Transient visual and auditory hallucinations in young children do not necessarily represent major psychotic illness - but do deserve further investigation. At age 8, hallucinations should be taken seriously and distinguished from imaginary friends or pretend play. - Kaplan and Sadock's Synopsis of Psychiatry

9. Suicidal and Homicidal Ideation (Thought Content - always assessed)

• Suicidal ideation must always be assessed in children verbal and old enough to understand the concept
• Children >4 years of average intelligence can be asked; by age 8, most have a developing (though not fully firm) concept of death's permanence
• Ask directly but gently: "Have you ever wished you weren't alive?", "Have you ever thought about hurting yourself?"
• Also assess aggressive and homicidal ideation

10. Cognition

Anxiety can interfere with performance on digits and arithmetic. An apparent inability to repeat digits or add simple numbers may reflect anxiety, brain damage, intellectual disability, or learning disabilities. - Kaplan and Sadock's Synopsis of Psychiatry

11. Insight

• Does the child recognize that something is wrong?
• Self-appraisal and self-esteem: what does the child think about themselves?
• Understanding of current circumstances: why are they here?
• Can they identify potentially pathological events (e.g., recognizing their worries are excessive)?
• Locus of control: does the child feel in control of their behavior or attribute it to external forces?

12. Judgment

• Child's view of the problem and suggested solutions
• Understanding of what is realistic vs. unrealistic
• Appraisal of social relationships - understanding of friendships, family roles
• Assess through hypothetical situations using age-appropriate language: "What would you do if you found a wallet on the street?"

Practical Tips for the 8-Year-Old MSE

1. Offer drawing materials or simple toys - drawing allows expression of inner world; ask the child to draw their family or a feeling.
2. Use a feelings chart or faces scale to help the child identify and rate emotions.
3. Concrete, simple language - avoid abstract or technical terms.
4. Do not ask leading questions - use open-ended prompts: "Tell me about school."
5. Observe throughout - waiting room behavior, interaction with parents on entry, behavior during transitions.
6. Multiple sessions may be needed - adequate MSE of a young child in a single session is often not possible given their developmental variability. - Kaplan and Sadock's Synopsis of Psychiatry
7. Collateral is essential - self-report alone is insufficient; parent and teacher observations are needed.

Summary Table