Managing Child Psychiatry

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the child's age and developmental level? (chronological age, cognitive/emotional developmental level, grade in school) — default: obtain
2. Who is the referral source? (parent, school, pediatrician, court, child protective services) — default: identify
3. What is the legal custody arrangement? (biological parents, single parent, foster care, adoption, guardianship, DCFS ward) — default: verify legal consent authority
4. Who can provide consent for evaluation and treatment? — default: verify legal custodial parent/guardian
5. Is there a known or suspected history of abuse, neglect, or trauma? — default: screen (mandatory reporting obligations apply)
6. Is the child currently in school? What type of educational placement? (general education, IEP, 504, special school) — default: obtain school records
7. Has the child been previously evaluated? (psychiatric, psychological, neuropsychological, speech/language, occupational therapy) — default: obtain prior evaluations
8. What informants are available? (both parents, teachers, daycare providers, therapist, pediatrician) — default: multi-informant assessment required

Documents to Request

• Parent-completed developmental history questionnaire
• School records: report cards, IEP/504 documents, disciplinary records, teacher observations
• Prior psychiatric and psychological evaluations
• Pediatrician records including developmental screening results
• Standardized rating scales from parents and teachers (CBCL, Conners, Vanderbilt)
• Neuropsychological testing results if available
• Speech/language and occupational therapy evaluations if applicable
• Child protective services records if applicable
• Birth and perinatal records (for developmental concerns)
• Custody and legal documents (especially in foster care/adoption/divorce situations)

Step 1: Developmental History and Multi-Informant Assessment

Developmental History (obtained from parent/caregiver)

• Pregnancy: Planned/unplanned, complications, substance exposure, medications, infections, gestational age at birth
• Birth: Vaginal/C-section, birth weight, APGAR scores, NICU stay, birth complications
• Motor milestones: Sat independently (6-8 months), walked (12-15 months), fine motor development
• Language milestones: First words (12 months), two-word phrases (24 months), conversational speech (3 years)
• Social milestones: Social smile (2 months), stranger anxiety (8-10 months), joint attention (12-18 months), pretend play (18-24 months), cooperative play (3-4 years)
• Toilet training: Age achieved, difficulties, regression
• Temperament: Easy, difficult, slow-to-warm (Thomas & Chess)

Multi-Informant Data Collection

Child psychiatric assessment REQUIRES data from multiple sources because children's behavior varies across settings and children are unreliable self-reporters (especially under age 10):

• Parent/caregiver interview: Primary history source. Complete CBCL (Child Behavior Checklist, ages 1.5-5 or 6-18), Conners Parent Rating Scale, or disorder-specific measures.
• Teacher report: CBCL-TRF (Teacher Report Form) or Conners Teacher Rating Scale. Essential for ADHD, ODD, and learning difficulties.
• Child interview: Developmentally adapted. Use play, drawing, and age-appropriate language. The interview provides direct behavioral observation and the child's subjective experience.
• Pediatrician: Medical history, growth parameters, medication history.

Step 2: Child Mental Status Examination

The child MSE must be adapted for developmental level:

Preschool (3-5):

• Observe in play: Themes (aggression, nurturing, fear), ability to engage in pretend play, attention span, frustration tolerance
• Separation behavior: How child separates from parent, reunion behavior (attachment pattern)
• Language: Vocabulary, syntax, pragmatic language, echolalia
• Motor: Fine motor (drawing, block building), gross motor, coordination
• Affect regulation: Response to limits, transitions, frustration
• Social engagement: Eye contact, reciprocal interaction, interest in examiner

School-age (6-12):

• Standard MSE domains adapted for age
• Use structured interviews (K-SADS-PL — Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version) for diagnostic assessment
• Assess academic self-concept, peer relationships, bullying (perpetrator and victim)
• Ask about suicidal ideation directly — children as young as 6 can have suicidal thoughts
• Assess screen time, social media use, gaming

Adolescent (13-17):

• Full adult MSE with developmental context
• Confidential portion of interview without parents present (essential for disclosure of substance use, sexual activity, self-harm, abuse, identity concerns)
• Assess: Substance use (CRAFFT screening tool), sexual activity, suicidal ideation (C-SSRS), self-harm, disordered eating, gender identity, sexual orientation, bullying/cyberbullying, social media impact
• HEADSS assessment: Home, Education, Activities, Drugs, Suicidality, Sex

Step 3: Diagnostic Considerations Specific to Pediatric Populations

Common diagnostic pitfalls:

• ADHD vs. anxiety: Inattention may be driven by worry, not ADHD. Comorbidity is common (30-40%).
• ADHD vs. trauma: Hyperarousal, concentration difficulty, and behavioral dysregulation from PTSD mimic ADHD. Screen for trauma exposure before diagnosing ADHD.
• ODD vs. mood disorder: Irritability is a core feature of both. DMDD (Disruptive Mood Dysregulation Disorder) was created for DSM-5 to address chronic irritability: severe recurrent temper outbursts ≥3x/week, irritable/angry mood most of the day nearly every day, for ≥12 months, in ≥2 settings, with onset before age 10.
• Autism Spectrum Disorder: Screen with M-CHAT-R/F (ages 16-30 months) or SCQ/SRS-2 (school-age). Key features: persistent deficits in social communication/interaction + restricted, repetitive patterns of behavior. Formal diagnosis requires comprehensive evaluation including ADOS-2.
• Pediatric bipolar disorder: Controversial. Distinguish from DMDD. Classic mania (grandiosity, decreased need for sleep, pressured speech, goal-directed activity) is rare before puberty. Do not diagnose bipolar solely based on irritability.
• Depression in children: May present as irritability rather than sadness. Somatic complaints (stomach aches, headaches) are common. Use CDI-2 (Children's Depression Inventory) for screening.

Step 4: Treatment Planning for Pediatric Patients

Psychotherapy (First-Line for Most Conditions)

• ADHD: Behavioral parent training (ages 4-5), school-based interventions, organizational skills training
• Anxiety disorders: CBT (Coping Cat program), exposure-based therapy. First-line per AACAP.
• Depression: CBT, IPT-A (Interpersonal Therapy for Adolescents). TADS study showed combination fluoxetine + CBT superior to either alone.
• ODD/Conduct Disorder: Parent Management Training (PMT), Multisystemic Therapy (MST), Functional Family Therapy (FFT)
• PTSD: Trauma-Focused CBT (TF-CBT) — gold standard for children and adolescents. EMDR also effective.
• ASD: Applied Behavior Analysis (ABA), social skills training, speech/language therapy, occupational therapy
• Eating disorders (adolescents): Family-Based Treatment (FBT/Maudsley) is first-line for AN

Pharmacotherapy Considerations

• FDA Black Box Warning: All antidepressants carry risk of increased suicidality in patients <25 — monitor weekly for first 4 weeks, biweekly for weeks 5-8, then as clinically indicated.
• ADHD: Methylphenidate and amphetamine formulations are first-line (FDA approved age 6+). Monitor height, weight, blood pressure, heart rate. Obtain cardiac history and ECG if family history of sudden death, cardiomyopathy, or arrhythmia.
• Depression: Fluoxetine (FDA approved age 8+) is first-line. Escitalopram (FDA approved age 12+) is second-line.
• Anxiety: SSRIs (fluoxetine, sertraline) are first-line. CAMS study showed sertraline + CBT most effective.
• Psychosis: Risperidone (FDA approved age 13+ for schizophrenia), aripiprazole (age 13+). Metabolic monitoring protocol required.
• Bipolar mania: Lithium (FDA approved age 12+), aripiprazole (age 10+), risperidone (age 10+), quetiapine (age 10+).
• Start at lower doses than adult, titrate slower, and monitor growth parameters.

Step 5: Family Integration, School Coordination, and Legal Considerations

Family involvement:

• Include parents/caregivers in treatment planning (required, not optional)
• Provide psychoeducation about diagnosis, treatment, and prognosis
• Address family dynamics contributing to or maintaining symptoms
• Screen parents for psychiatric conditions (parental depression, SUD, domestic violence)

School coordination:

• Provide documentation supporting 504 Plan or IEP eligibility
• Communicate with school counselor/psychologist (with appropriate releases)
• Recommend specific classroom accommodations

Legal and ethical considerations:

• Consent: Legal guardian provides informed consent; obtain assent from child (age 7+ per AACAP)
• Confidentiality in adolescents: Balance parent's right to information with adolescent's need for privacy. State laws vary on minor consent for mental health treatment (typically ages 12-16).
• Mandatory reporting: If child abuse or neglect is suspected, report to child protective services immediately. Document the report.
• Custody disputes: Avoid taking sides; document objectively; may need separate consent from both custodial parents depending on custody order.

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the developmental context documented for interpreting symptoms and behavior?
2. Are multi-informant data sources obtained and integrated (parent, teacher, child)?
3. Are diagnostic considerations specific to pediatric populations addressed (DMDD vs. bipolar, ADHD vs. trauma)?
4. Are treatment recommendations age-appropriate and aligned with AACAP Practice Parameters?
5. Are consent, assent, and mandatory reporting obligations documented?

Quality Audit

• Developmental history obtained including prenatal, birth, milestones
• Multi-informant assessment completed (parent, teacher, child)
• Standardized rating scales administered to parents and teachers
• Child MSE adapted for developmental level
• Diagnostic assessment considers developmental context and pediatric-specific differentials
• Trauma and abuse screening completed with mandatory reporting compliance
• Suicidal ideation assessed (even in young children)
• Treatment plan includes psychotherapy as first-line when indicated
• Medication recommendations include FDA approval status and Black Box Warning discussion
• Growth parameter monitoring plan documented for stimulants and antipsychotics
• Family involvement in treatment planning documented
• School coordination plan documented (IEP/504 recommendation if appropriate)
• Consent (guardian) and assent (child) documented
• Custody and legal considerations addressed

Guidelines

1. Never diagnose a child based on a single informant — multi-informant, multi-setting assessment is the standard of care per AACAP Practice Parameters.
2. Always screen for trauma exposure before diagnosing ADHD in children with behavioral dysregulation — trauma mimics ADHD and requires different treatment.
3. Monitor growth parameters (height and weight) in all children on stimulant medications — growth suppression is a documented side effect requiring periodic drug holidays or dose adjustment.
4. For adolescents, conduct a portion of the interview without parents present — adolescents will not disclose substance use, sexual activity, or self-harm with parents in the room.
5. Document the informed consent process with the legal guardian AND the assent process with the child — both are required for ethical pediatric practice.
6. Follow FDA Black Box Warning monitoring protocols for all antidepressants in patients under 25 — weekly contact for the first 4 weeks after initiation or dose change.
7. When prescribing off-label in pediatric patients, document the evidence base and rationale for the off-label use — off-label prescribing is common in child psychiatry but requires explicit justification.
8. Mandatory reporting of suspected child abuse or neglect is non-negotiable — the clinician's obligation to report supersedes therapeutic confidentiality.