All evaluations start with one or several concerns or reasons for the referral. Sometimes the main issue is new, while other times it has been there for a while. This is how, most often the first question is something like:
“What brings you here and why now?”
Maybe the problem has been present for 2 years but it got worse in the last 6 months and a month ago the child has been suspended from school. Understanding the problem is not possible without an understanding of the course or the history of the problem.
In the field of child and adolescent mental health, the problem is often differently defined by the parent, the teacher and the child. From different perspectives, the problem may appear different. It is no unusual for the child to see no problem while the parents and teachers to express numerous concerns. With externalizing disorders (like ADHD, ODD, DMDD etc), the child’s behavior may trouble more the adults than the child.
Is the adult (parent, teacher etc.) defining what the problem is?
Can the child tell you what the problem is?
How different is it from the way the adult sees it?
Common types of problems are:
A symptom – like inattention or sadness.
A behavioral pattern – like the tendency to have a meltdown when criticized.
A temperamental trait – like inflexibility.
A relational issue – like sibling rivalry
A systemic issue – like a problem of placement or custody.
An ability issue – like a developmental problem.
A recent event – like a suspension or a visit to the ER.
We should consider to be the norm that the problem has many facets, and even if one problem is easily identified, others may still be waiting for our exploration.
Problems are deviations from expectations or norms. A sad or anxious child deviates from the expectation that one should be happy. A hyper child deviates from the expectation that one should be able to sit still. And so forth. While many times the norms and the expectations are reasonable, it is not necessarily so.
A question we should always ask ourselves is: are the norms reasonable in this child’s unique situation? Is it reasonable to expect a child with ADHD to sit still for an hour? Is it reasonable to ask for a child with a reading disorder to like reading? And the examples are almost endless.
In the cases in which we may consider that the expectations are not quite reasonable, we are left to consider that the impairment is not only related with a problem that the child has but also with a sub optimal set of expectations.
It may be a useful approximation, that the problems are more profound if she presents with skill deficits and the environment has high expectations. Since skill development is a slow process, clinical improvement is quite likely to improve if the demands are diminished to some extent. This is sometimes quite possible, while other times not at all so.
–How do the child’s abilities compare with her age cohort?
–Are these abilities modifiable?
–Are the expectations adequate for the abilities?
–Should the expectations be decreased?
A frequent issue, present especially with externalizing or disruptive problems, is the issue of choice. If the parent or the teacher thinks that the child’s behavior is a choice, then it is more likely that the attitude will be one of deeper criticism, deeper judgment or even one of moral indignation. It is more likely to lead to a behavior that will be felt (especially by the children with some attachment insecurity) as rejecting. The net effect may then be one of exacerbating the disruptive behavior, with further criticism and perceived rejection.
Consider these two possible ways in which the parent may frame the problem:
- I want Johnny to make the right choice because I expect it.
- I wish Johnny makes the right choice not necessarily because would make my life easier but because would be more adaptive for him. I wonder what stops him to see that?
Which framing of the problem do you think is more likely to be conducive to a collaborative problem solving approach in that family?
Elaborating on the Presenting Problem
One needs to stay long enough with factual descriptors, and should encourage the patient (parent) to stay with this type of information, gently redirecting from the “How” and especially from “Why”. These last two are the hardest questions, so they create anxiety and this negatively impacts ‘objectivity’.
When ‘unpacking’ difficult issues, stay as long as possible with flat, matter of fact descriptors. Questions prompting analytic (how questions) or reflective (why questions) are more likely to trigger irritation or annoyance.
What? (happens/happened) – descriptive, factual
When? (how often/for how long) – descriptive
Where? – descriptive
How? (linking antecedents/consequents) – analytic
Why? (who is to blame) – reflective
Behavior must be understood by its consequences within the environment (function in the environment), with the understanding that: similar behaviors can serve different functions
Because of this, we tend to enrich our understanding of the situation if we explore carefully the antecedents or the conditions of occurrence for the concerning behavior(s).
From Functional Behavioral Analysis we can learn that there are four very relevant conditions:
- When alone
- During unstructured play
- During situational demands
- During social disapproval
The challenging behavior may occur in all or only in some of these situations. Analyzing the differences and similarities may offer useful clues.
Presenting problems and skill level
There are essentially 5 scenarios we need to consider:
The skill level is developmentally ‘average’ or ‘as expected’.
There are delays in skill development such as delay in speaking or in toileting. These are delays without atypicality.
The skills are qualitatively different. This is the case of autism. Social communication, social interactions and the patterns of behavior are not just delayed but they are also atypical.
The inability to use existing skills. A child with depression or anxiety may have the necessary cognitive skills, but not be able to apply them, causing ‘the problem’. For example, a child may overgeneralize that all kids in school are judgmental so will avoid going to school.
The loss of previously attained skills may occur spontaneously in autism but may also follow serious medical and psychiatric disorders, loss, or trauma. For example, a medically hospitalized school-age child may transiently regress with immature behaviors or loss of bowel or bladder control; adolescents developing schizophrenia may lose previously effective interaction skills.
Extending the exploration
- Identify other settings for the problem.
- Identify other problems in the same setting.
- Look for developmentally sensitive settings and tasks – academics, peer relationships.
- Browse for associated psychopathology – ODD, CD, SUD, depression, ADHD.
- Touch on sensitive areas suicidal behavior, drug use with an attention for discrepant information. One denial is never enough, rephrase, and ask in another way.
- About discrepant information – maintain some consideration (keep it in mind as a possibility) even in absence of proof. Withholding information is common, especially when we just met.
- Avoid leading questions (You don’t drink don’t you?) or asking question that are easily denied (Did you ever smoke weed?). Consider “gentle assumption”. “What drugs have you tried? How many times you got drunk? How often do you get drunk? What kind of problems you got yourself in because of alcohol?