Assessment In Child Psychiatry

• Approximately 10–20% of children and adolescents worldwide have a diagnosable mental health condition at any given time.
• In Hong Kong, community surveys have shown roughly 13–16% prevalence of psychiatric morbidity in school-age children and adolescents.
• The most common categories are:
  • Anxiety disorders (commonest overall) ^[1]
  • Behavioural disorders (ADHD, ODD/CD)
  • Neurodevelopmental disorders (ASD, intellectual disability)
  • Mood disorders (depression increases sharply after puberty)
• Referral pathways in Hong Kong: typically via MCHC (Maternal and Child Health Centre), paediatrician, school, or direct family referral to CAMHS (Child and Adolescent Mental Health Service) under Hospital Authority.

1. Developmental context: A behaviour that is normal at age 3 (e.g., tantrums) is pathological at age 13. You must always compare symptoms to same-age, same-culture norms. ^[1]
2. Limited self-report capacity: Young children cannot articulate internal states; you rely on behavioural observation, parent report, and projective techniques.
3. Multi-system involvement: School, family, peer group — each is both a source of information and a potential aetiological/maintaining factor.
4. Rapid developmental change: The child you assess at age 5 is cognitively, emotionally, and socially very different from the same child at age 10. Assessment must be repeated longitudinally.

More flexible approach: difficult to follow a set routine when assessing children. ^[1] Unlike adult psychiatric interviews, which can follow a relatively standardised structure, child assessment demands improvisation. A 4-year-old will not sit still for a formal MSE; an oppositional 14-year-old may refuse to talk at all.

Who to interview: with parents, with the whole family, and with the child alone (for older children). ^[1] The assessment is multi-layered:

• Parents/carers first (to get the "adult version" of the problem without the child feeling anxious or defensive)
• Child alone (to get the child's own perspective and look for things they won't say in front of parents, such as abuse, bullying, or self-harm)
• Family together (to observe interactional dynamics)
• Other informants (school, social worker, GP)

Obtain collateral information: especially from school (educational, academic, behavioural). ^{[1] [2]} School reports are gold. They tell you about attention span in a structured setting, peer relationships, academic trajectory, and behavioural issues that parents may minimise or be unaware of.

Think of child psychiatric assessment as answering five key questions:

1. Is there a problem? (compared to developmental norms)
2. What is the problem? (characterise symptoms, get a differential)
3. Why has this child developed this problem now? (predisposing, precipitating, perpetuating factors — the "3 Ps" in a biopsychosocial framework)
4. What is the impact? (on the child, family, school functioning)
5. What can we do about it? (management plan)

This parallels the adult psychiatric HPI but with crucial child-specific modifications:

Systematic Comorbidity Screen [1]

This is crucial. Child psychiatry conditions rarely come alone. When a child presents with one problem, you must screen for the others:

• Physical symptoms: headache, stomachache, hearing, vision, seizures, faints — both because somatic complaints may be the presenting feature of anxiety/depression in children, and because organic conditions (epilepsy, hearing loss) can mimic or cause psychiatric symptoms ^[1]
• ADHD symptoms: level of activity, attention span, concentration — ADHD is the great comorbidity with almost everything ^[1]
• ASD symptoms: relationship with peers, close friends, hobbies/interests, behaviour — ASD may present late, especially in girls who mask ^[1]
• ODD/CD symptoms: disobedient behaviour, response to frustration, temper tantrums, antisocial behaviour, aggression, stealing, truancy, delinquency ^[1]
• Mood disorder symptoms: mood, energy level, anxiety ^[1]
• Other behavioural disorders: eating, sleeping, elimination problems (enuresis, encopresis), sexual interest and behaviour ^[1]

• Chronic illnesses: epilepsy (associated with psychiatric comorbidity in ~30%), asthma (anxiety), diabetes (depression)
• Medications: especially those with psychiatric side effects (e.g., corticosteroids → mood changes, beta-agonists → anxiety, anti-epileptics → behavioural changes)
• Allergies
• Past hospitalisations and surgeries (traumatic for young children)
• Hearing and vision testing — undiagnosed hearing loss is a common mimicker of inattention and language delay

• Previous psychiatric diagnoses and treatments
• Previous contact with CAMHS, educational psychologist, clinical psychologist
• Previous psychometric testing (IQ testing, adaptive functioning assessment)

Similar to history taking in adult psychiatry but with the following additions ^[1]:

• Obtain a complete description of main concerns/chief complaint ^[1]
• Obtain a complete history systematically (especially family, psychiatric, neurodevelopmental, educational, medical) ^[1]
• Should also indirectly evaluate the parents in terms of personality, marital relationship, and style of parenting ^[1] — this is subtle but critical. Watch how they talk about the child. Do they use warm language or hostile/critical expressed emotion? Do they agree with each other or contradict?

• Discuss with the family the interview arrangements beforehand — who gets interviewed first matters. Some clinicians prefer to see the adolescent first to signal that their voice matters; others see parents first to get background before seeing the adolescent. There is no fixed rule, but discuss and agree. ^[1]
• Confidentiality: Be explicit. "What you tell me stays between us, unless I'm worried about your safety or someone else's safety." ^[1]
• Screen for: substance use, self-harm, sexual activity, eating behaviour, online safety, cyberbullying

Essential to allow assessment of family interactions and dynamics. ^[1]

Should see the family at the first assessment or soon after it, before the interviewer has formed a close relationship with the young patient or one of the parents. ^[1] — Why? Because once you've allied with one family member, observing neutral family dynamics becomes impossible.

Observe for: ^[1]

• Family hierarchy: most dominant person? Usual spokesperson?
• Other family dynamics: Any alliances? How do they communicate with each other? How do they deal with conflict?
• Others: Who seems most worried about the problem? Any monopolising of the interview? (Ask other members to comment on his/her views)

Many psychiatric presentations in children have organic underpinnings or mimics:

• Growth parameters: Height, weight, head circumference (plot on growth charts — child growth and development ^[2])
  • Microcephaly → consider genetic/metabolic causes
  • Short stature → consider Turner syndrome, growth hormone deficiency, neglect
  • Obesity → consider Prader-Willi, hypothyroidism, medication effects
• Dysmorphology screen: Minor physical anomalies (facial features, hand creases, ear shape) — may suggest genetic syndrome
• Neurological examination: Tone, reflexes, coordination (cerebellar signs), cranial nerves, gait
  • Signs suggestive of neurodevelopmental impairment/delay, e.g., clumsiness, language delay, abnormalities of speech ^[1]
  • Neurological "soft signs" (mild motor coordination difficulties, mirror movements) are more common in ADHD and ASD
• Skin: Café-au-lait spots (neurofibromatosis), ash-leaf macules (tuberous sclerosis — associated with ASD and epilepsy), bruising in unusual locations (non-accidental injury)
• Hearing and vision: Basic screening; formal audiometry and ophthalmology referral if indicated

Consent and refusal of treatment in child psychiatry raises unique ethical challenges ^[3]:

• Age of consent: In Hong Kong, patients aged ≥ 18 can give independent consent. For those < 18, parental/guardian consent is generally required.
• Gillick competence / "mature minor" doctrine: A child under 16 who demonstrates sufficient understanding and intelligence to fully appreciate the nature, purpose, and consequences of a proposed treatment may be considered competent to consent. This is assessed on a case-by-case basis. ^[3]
• Assent: Even when parental consent is obtained, the child's assent (agreement/cooperation) should be sought in a developmentally appropriate way. This respects the child's emerging autonomy.

Why should I be locked up? Ethics in psychiatry. ^[3]

• In Hong Kong, the Mental Health Ordinance (Cap. 136) governs involuntary detention and treatment.
• For minors: Parental consent can authorise voluntary admission. If the child/adolescent or parents refuse treatment but the clinical team believes the patient poses a significant risk to themselves or others, involuntary procedures may be initiated.
• Ethical principles ^[3]:
  • Autonomy: Respect the developing autonomy of the child while balancing protective obligations
  • Beneficence: Acting in the child's best interest
  • Non-maleficence: Avoiding harm (including harm from unnecessary detention or forced treatment)
  • Justice: Fair allocation of resources and equitable treatment

• In Hong Kong, suspected child abuse must be reported to the Social Welfare Department and handled through the Multi-disciplinary Case Conference on Protection of Child with Suspected Abuse (MDCC) framework.
• Types of abuse: physical, sexual, emotional, neglect
• During assessment, be alert for:
  • Unexplained injuries, especially in unusual locations
  • Inconsistent history between child and parent
  • Premature sexualising behaviour (in sexual abuse) ^[1]
  • Fearfulness around specific carers
  • Excessive compliance or frozen watchfulness

• Academic pressure: Hong Kong's highly competitive education system is a significant stressor. Children may present with anxiety, somatic complaints, or school refusal related to exam stress.
• Stigma: Mental health stigma remains significant in Chinese culture. Families may present late, minimise symptoms, or prefer somatic framings ("headache" rather than "depression").
• Language: Assessment may need to be conducted in Cantonese, Mandarin, or English depending on the family background. Interpreter use introduces additional complexity.
• Domestic helpers: Many HK children are primarily cared for by domestic helpers. The attachment dynamics and caregiving consistency must be explored.
• Small living spaces: Hong Kong's tiny apartments mean families live in extremely close proximity, which can exacerbate family conflict and reduce the child's private space.

• MCHC (Maternal and Child Health Centre) → developmental screening
• Child Assessment Centre (CAC) under Department of Health → comprehensive developmental assessment for children < 12
• CAMHS (Child and Adolescent Mental Health Service) under Hospital Authority → psychiatric assessment and treatment
• School-based services: Educational psychologists, school social workers
• NGOs: e.g., Caritas, Boys' and Girls' Clubs Association, HKFYG — provide counselling and support

During the interview, get an impression of how difficult the child is and how good the parenting is: ^[1]

• Overall compliance to parents' commands: ^[1]
  • Percentage compliance: usually 70–80% (50% is bad, 90% is good) ^[1]
  • Non-compliance: usually on what aspect? How do you handle it? ^[1]
  • Find out how the parent gives commands → can be trained to give better commands ^[1]
• Temper: ^[1]
  • Worst temper/outburst? How severe or frequent is it? How do parents cope? ^[1]
  • Current situation ^[1]
• Symptom screening: ODD symptoms first → screen CD symptoms if ODD symptoms present ^[1] — This reflects the developmental progression: ODD often precedes CD, and early identification of ODD is an opportunity for intervention before it escalates.

The content of childhood anxiety is influenced by developmental stage ^[1]:

• Infants: fear of strangers → social anxiety disorder of childhood
• Preschool: fear of separation, specific objects → separation anxiety and phobic anxiety disorders
• Early adolescence: fear of social situations/personal adequacy → social phobia
• Late adolescence: resembles adult → GAD, panic disorders

Key point: Anxiety and fears can be developmentally appropriate. Diagnose only when developmentally inappropriate (more severe and prolonged than usual) AND causes significant distress + functional impairment. ^[1]

Childhood depression may present differently from adults:

• Somatic complaints (unexplained abdominal pain, headache, anorexia, enuresis) ^[1]
• Irritable mood and anxiety features (rather than classic sadness) ^[1]
• Behavioural problems ^[1]
• Always screen for suicidality — even in young children (suicidal ideation can occur from age 6+)
• Note: ~25% of bipolar affective disorder first presented as juvenile depression in their first episode ^[1] — this is why longitudinal follow-up is essential

In adult psychiatry, you often aim for a single parsimonious diagnosis. In child psychiatry, you should expect comorbidity:

• ADHD + ODD: ~40–60%
• ADHD + ASD: ~30–50% ^[1]
• Depression + Anxiety: ~70% ^[1]
• ASD + Intellectual Disability: ~30–50%
• CD + Substance Use: very common in adolescents

When conditions co-occur, diagnose all that meet criteria. Don't force a single label.

The same underlying disorder presents differently depending on the child's developmental stage:

For every child psychiatric presentation, maintain a low threshold for organic workup:

This is an elegant clinical shortcut from the senior notes:

• Worry about gaining weight → eating disorder
• Worry about having a serious illness → hypochondriacal disorder / illness anxiety
• Fear of being poisoned or killed → delusional beliefs (paranoid schizophrenia)
• Ruminatory thoughts of guilt or worthlessness → depression
• Associated with obsessional thoughts or resisting compulsion → OCD
• Separation or abandonment → separation anxiety, borderline/dependent PD
• Being rejected or inadequate → avoidant PD, social phobia ^[1]

Key conceptual difference: DSM-5 collapsed the old ICD-10 triad (social + communication + restricted behaviours) into a dyad (social-communication + restricted behaviours). This reflects the recognition that social interaction and communication are inseparable constructs. DSM-5 also added sensory hyper/hyporeactivity as a criterion — something not explicit in ICD-10 but clinically very important (e.g., covering ears in loud environments, fascination with spinning objects). ^[1]

DSM-5 Inattention symptoms (need ≥ 6/9) ^[1]:

1. Fails to give close attention to details / makes careless mistakes
2. Difficulty sustaining attention in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions / fails to finish work
5. Difficulty organising tasks and activities
6. Avoids tasks requiring sustained mental effort
7. Loses things necessary for tasks
8. Easily distracted by extraneous stimuli
9. Forgetful in daily activities

DSM-5 Hyperactivity-Impulsivity symptoms (need ≥ 6/9) ^[1]:

1. Often fidgets with or taps hands or feet or squirms in seat ^[1]
2. Often leaves seat when remaining seated is expected ^[1]
3. Often runs about or climbs in inappropriate situations ^[1]
4. Often unable to play or engage in leisure activities quietly ^[1]
5. Often "on the go," acting as if "driven by a motor" ^[1]
6. Often talks excessively ^[1]
7. Often blurts out an answer before a question has been completed ^[1]
8. Often has difficulty waiting his or her turn ^[1]
9. Often interrupts or intrudes on others ^[1]

Why the ICD–DSM difference matters: ICD-10's stricter criteria (requiring both domains + onset < 6) mean it captures a narrower, more severely affected group. DSM-5's broader definition captures the "inattentive" presentation (historically called ADD), which includes many girls and older children who would be missed by ICD-10.

Why ODD has three dimensions: Research has shown ODD symptoms cluster into three factors — (1) angry/irritable mood, (2) argumentative/defiant behaviour, (3) vindictiveness — and these predict different outcomes. The angry/irritable cluster predicts emotional disorders (depression, anxiety); the defiant/vindictive cluster predicts conduct disorder. This explains why ODD sits at the crossroads between emotional and behavioural pathology. ^[1]

Why onset type matters: Prognosis is worse for early-onset cases (antisocial behaviour in 40% early-onset cases and only 20% in adolescent-onset cases). ^[1] Early-onset CD is more strongly associated with neurobiological risk factors (low amygdala reactivity, executive dysfunction), while adolescent-onset CD may be more influenced by peer-group and social factors. ^[1]

The same ICD-10 and DSM-5 criteria for depressive episode apply in children, with important modifications in presentation:

ICD-10 Depressive Episode ^[1]:

• At least 2 of 3 core symptoms (Section A): (1) Depressed mood; (2) Loss of interest/enjoyment; (3) Reduced energy
• Plus associated symptoms (Section B): reduced concentration, reduced self-esteem, ideas of guilt, pessimistic thoughts, ideas of self-harm, disturbed sleep, diminished appetite
• Mild: ≥ 2A + ≥ 2B; Moderate: ≥ 2A + ≥ 3B; Severe: all 3A + ≥ 4B ^[1]
• Duration ≥ 2 weeks

Child-specific considerations:

• In children, irritable mood may substitute for depressed mood (DSM-5 explicitly allows this)
• Somatic complaints (headache, abdominal pain, enuresis) are often the presenting feature rather than expressed sadness ^[1]
• Weight gain failure (rather than weight loss) may represent appetite disturbance in growing children

Anxiety and fears can be developmentally appropriate. Diagnosis is made only when developmentally inappropriate (more severe and prolonged than usual) AND causes significant distress + functional impairment. ^[1]

Key criteria for Separation Anxiety Disorder (DSM-5):

• Developmentally inappropriate and excessive anxiety concerning separation from home or attachment figures
• ≥ 3 of 8 symptoms (e.g., recurrent excessive distress when separation occurs/anticipated, worry about losing/harm to attachment figures, reluctance to go out, nightmares, physical symptoms)
• Duration ≥ 4 weeks in children (6 months in adults)
• Clinically significant distress or functional impairment

There is no cure for ASD. Management is about optimising function, supporting development, and managing comorbidities.

Approach to management: psychosocial treatment as mainstay ^[1]

Psychological treatment is first-line ^[1]:

Approach parallels adult depression management but with important modifications ^[1]:

Pharmacotherapy specifics:

Psychosocial treatments ^[6]:

• Cognitive behavioural therapy: monitor, evaluate, and modify negative dysfunctional thoughts and distorted perceptions and beliefs. Use cognitive techniques (e.g., list pros and cons, examine evidence). Increase activity scheduling ^[6]
• Interpersonal therapy: problems are understood in interpersonal context, e.g., facilitate grieving process, encourage role transition, explore interpersonal disputes, improve interpersonal skills ^[6]
• As many as 85% of patients receiving both antidepressants and psychotherapy achieve remission ^[6]

Indications for ECT ^[1]:

• Emergency (life-threatening: severe depression with food refusal, persistent suicidal intent) ^[1]
• Catatonia ^[1]
• Treatment-refractory conditions ^[1]

ECT is rarely used in children but can be life-saving in adolescents with treatment-resistant depression, psychotic depression, or catatonia. Mechanism of action: unknown, but hypothesised to involve ↑neurotrophic signalling (e.g., ↑BDNF) → induces neurogenesis; ↑monoamine neurotransmitter release; transient ↑BBB permeability; changes in brain connectivity ^[1].

In Hong Kong, ECT in minors requires careful ethical consideration, parental consent, and typically specialist MDT approval.

Physical activity is listed as a treatment modality for depression ^[6]. This is not trivial — exercise increases BDNF, enhances monoaminergic transmission, reduces cortisol, and provides structured social interaction. For children and adolescents, regular physical activity should be part of every management plan.

Prognosis: episodic relapsing course, with majority recovering < 3 months but 15% lasting > 18 months ^[1]

Key Complications