Assessment Of The Difficult Child

The classical presenting picture of the ''difficult'' child is that of a parent or a teacher rushing a child with deviant behavioural symptoms to the psychiatrist, while the child himself/herself is usually unaware or denying any existing problem.

The first step in the assessment of the ''difficult'' child is history taking. This includes detailed medical, developmental and psychiatric history not only of the patient, but of the family as well. All sources of information must be used - the child, his/her parents, teachers, etc. - in order to create a picture as clear as possible of the child's inner and outer world. As part of this history, there are several structured and semistructured interviews dealing with the history of the child. One of the most well known is the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) [1]. This is a semistructured interview that examines many details, with room for clarifications regarding major symptoms of several disorders in the framework of the differential diagnoses mentioned in this chapter.

The next step would be a clinical examination, which should allow the evaluation of possible comorbidities, acute situations, central personality characteristics, strengths and weaknesses and the child's self-perception as an individual and as part of the community. Clinical examination can be structured, semistructured or unstructured. Neurological and physical examinations are a must in this phase of assessment, mostly to rule out organic diagnoses.

At this point, the clinician must assess the gathered data and check if diagnostic criteria of any of the disorders dealt with in this chapter are met. If not, follow-up may still be warranted according to the circumstances and clinical picture. If diagnostic criteria for any disorder are met, the use of rating scales, neuropsychological tests and neuroimaging tools is indicated.

Rating scales, also sometimes called behavioural checklists, allow quantitative ratings of the adult's evaluation of the child's behaviour and are used as a cornerstone in the clinical evaluation of the child. Their drawback is their subjectivity, as well as the adult's limited knowledge of the child's acts and thoughts. Accordingly, they constitute an essential but insufficient evaluation tool.

Rating scales demand judgement of the child's behaviour in binary terms (yes/no) or in quantitative degree of severity. They are very easy to administer and encompass many functional areas, from internalizing conditions such as depression and introversion to externalizing conditions such as violence or delinquency. Prominent examples of such scales are the Child Behavior Checklist (CBCL) and the Revised Child Behavior Checklist (RCBP) [2].

Widely used scales to assess attention-deficit/hyperactivity disorder (ADHD) include the Conners Rating Scale [3] and the Swanson, Nolan and Pelham Questionnaire (SNAP-IV) [4]. The Eyberg Child Behavior Inventory [5] is used to evaluate conduct disorder (CD) and oppositional defiant disorder (ODD). Common scales for the assessment of post-traumatic stress disorder (PTSD) are the Children's PTSD Inventory (CPTSDI) [6], the Trauma Symptom Checklist for Children (TSCC) [7], the Angie/Andy Cartoon Trauma Scale (ACTS) [8], the Pediatric Emotional Distress Scale (PEDS) [9], the Clinician-Administered PTSD Scale for Children (CAPS-C) [10], the Adolescent Dissociative Experience Scale (ADES) [11], the Children's Perceptual Alteration Scale (CPAS) [12] and the Child Dissociative Checklist (CDC) [13]. The most frequently used rating scale for mood disorders is the Childhood Depression Rating Scale - Revised (CDRS-R) [14], which is a modified version of the Hamilton Depression Rating Scale.

Neuropsychological assessment is necessary when there is a suspicion of a brain disorder, or there is already evidence of brain damage and a need to estimate the nature and the extent of the influence of the damage on cognition, personality and behaviour of the injured individual, or it is impossible to evaluate the situation using the conventional tools of the clinical interview or a regular psychological test. There are a number of comprehensive batteries of neuropsychological tests for children. The purpose of all of them is to assess various functions, such as short-term, medium and long-term memory, motor, visual and spatial perception, orientation, language, cognition, constructing and creating concepts, problem solving and more, by means of various performance tasks.

The continuous performance tests assess the child's ability to cope with a relatively monotonous and boring task over time. This method is considered one of the most reliable ways of differentiating between children suffering from ADHD and normal children. There are a number of subtypes of this test: the Conners' Continuous Performance Test [15], the Test of Variables of Attention (TOVA) [16], and others.

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