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Child Psychiatric Assessments - What to Expect

Child and Adolescent Psychiatrists are specialised doctors who work with children and young people up to the age of 18, their families, and all those around them (e.g. schools, children services). They treat a wide range of mental health problems and conditions including ADHD, autism spectrum disorders, depression, anxiety, tic disorders, substance misuse and eating disorders, amongst others. They also try to promote mental health wellbeing for the young person.

A first appointment with a Child and Adolescent Psychiatrist usually takes 2.5 hours. It starts with a first part, where the young person and their parents/carers speak to the psychiatrist; a second part, where the young person has a private and confidential one-to-one conversation with the psychiatrist, and a third part, where the psychiatrist gives feedback to the young person and their parents/carers. During the last part, the psychiatrist will also discuss clinical recommendations with the family, and a treatment plan is agreed following clinical guidance on best available evidence and the preferences of the young person and their family. 

The Coronavirus Pandemic has brought sudden change and disruption to all our lives. Whilst face-to-face assessments are still possible, arrangements for a series of remote assessment sessions carried out via video-link (both with the young person confidentially and with their parents / carers) are also offered at the present time.

Prior to the first appointment with the doctor, the young person, and their family (and sometimes their school too) are asked to complete a questionnaire and a pre-assessment form. This is to make sure that the relevant clinical and medical information is gathered. 

What can I do and say to prepare my child for their first appointment with a psychiatrist?

The young person needs to know that the psychiatrist will sit down with them (either in person or via a live session video link) and their parents for a length of time and will explore several difficulties in their lives. For that purpose, the doctor will ask easy open ending questions to the young person and the parents, which they will be free to answer. The doctor will listen to the answers and will never be critical or judgmental, as their role is to better understand the whole situation. Child psychiatrists are very used to hearing all types of things about children, so they will never be surprised by what the young person is saying. Also, child psychiatrists are usually very empathetic, not only towards the child but also towards the whole family environment, so they usually make everyone feel understood and very comfortable.

Are parents usually involved during their child’s appointments with a psychiatrist?

Parents are always invited to participate in the meeting. They are usually the principal source of information concerning the child, especially when the child is too young to participate by themselves. For older children, they are also invited to participate, unless the young person specifically declines or there are legal reasons why the parents cannot be invited. 

As mentioned earlier, most of the first assessments start with the family as a whole (e.g. the young person and their family with the psychiatrist) so that the young person is not meeting the psychiatrist on their own. The psychiatrist will explore the interaction with the child and how the child responds to the parents. As the interview progresses, and only if the young person and the parents feel comfortable, the psychiatrist will ask the parents to leave the room and will stay with the young person to have a more intimate but relaxed conversation with them.

What happens during appointments with a child psychiatrist?

 During the appointment, the psychiatrist will ask about the child’s main difficulties at home, school or in their social life. They will try to ascertain what factors are contributing to these difficulties or maintaining them, and how symptoms started and evolved. The psychiatrist will ask about the child’s functioning at home. They will also explore how the child relates to other members of the family and the problems that parents encounter at home. The social and academic functioning are very important elements too. It is important to reflect on how the young person is coping with the academic demands and how they respond to stress, how is their relationship with their peers, and if there is any bullying. Also, the psychiatrist will consider what hobbies and after school activities they take part in? 

The psychiatrist will ask about general physical health, such as how the child eats and sleeps, and about other medical conditions, such as allergies and previous operations. Finally, the doctor will complete detailed information about pregnancy, birth, and early development of the child to investigate how the child reached developmental milestones. They will also explore the strengths of the child and their family and how those around the young person have tried to support them with their difficulties throughout. 

What are other things that parents are asked to do for the initial assessment?

As stated above, most of the assessments will also involve parents and those children above the age of 8 years completing some forms or questionnaires too (e.g. Conners for ADHD). Only with the child’s and their parents’ permission, the psychiatrist will try to contact school to gather some information about the child’s academic and social functioning there. Whilst some parents may be reluctant to have the school being informed or involved, this is very useful information as children’s functioning and behaviour can be very different in their home and school environments. It also helps in establishing any future liaison work with school. 

While the psychiatrist asks questions, and during the meeting with the child on their own, they will be observing the child’s behaviours and interactions, with both their parents and the examiner too. This is what we call a mental health assessment. It provides the psychiatrist with a list of symptoms that may be suggesting a mental health problem in that particular child. The psychiatrist will be also assessing the risks of the particular child towards themselves and from and towards others (e.g. risk of self-harm, risk of suicide, risk of aggression, risk of neglect, safeguarding issues, etc). 

Finally, some assessments may include additional tests to be done by the child. For instance, with children who are going to be assessed for autism, we will require a separate, standardized observation procedure, such as the ADOS, and a more specific interview that will take a much longer time. Parents will be informed about whether additional tests may be required beforehand. 

Can a psychiatrist legally tell me what my child says during their appointments?

The psychiatrist is legally obliged to keep confidentiality when the young person requests it. Under these circumstances, the young person is informed that the parents will not be informed about the things that they want to keep confidential. Confidentiality is well reflected on the Royal College of Psychiatrists guidelines: ‘Good Psychiatric Practice, Confidentiality and information sharing’.

However, as these guidelines clearly state there are ‘situations where there is an immediate risk of serious harm to a person who may be identifiable or to people who may form a group or community who may or may not be identifiable. The risk may be heightened because the patient is distressed and agitated and may be refusing to consent to discussion of their case with others. There may also be concerns that alerting the patient may actually increase the risk to others; or that attempts to contact the patient, or their representative may result in delay in warning others who may be at risk of serious harm’. In circumstances such as these, the psychiatrist will need to outweigh whether it is in the child’s or in the public interest to disclose the information, and since this is in breach of the duty of confidentiality, the psychiatrist must have a good justification for this decision. Therefore, the young person will be informed that, in the scenario of the psychiatrist considering an immediate risk towards the child or someone else (e.g., life threatening situation, risk of child abuse or neglect, assault, a traffic accident, or the spread of an infectious disease) the psychiatrist will need to share the information provided with those parties that are directly relevant to the case (e.g. children services, police).

As a parent, will the psychiatrist offer me techniques to use in my child’s home and personal life?

Child psychiatrists in the UK usually take a conservative approach and will not immediately prescribe medication, unless clearly recommended by guidelines and good practice. Independently of whether a particular child requires any medication, child and adolescent psychiatrists usually provide some techniques and advice so that the parents are more able to cope with the young person’s needs. A child psychiatrist needs to get to know the young person well, usually the first appointment can only generate basic and generic recommendations. It is later, during subsequent follow up assessments and meetings with the child, parents and/or school, that the child psychiatrist will better understand the specific characteristics and nuances of the young person’s presentation and needs and will be able to provide more tailored specific recommendations and interventions based upon these.