Dr. Weiss is head of the Provincial ADHD Program and clinical professor at the University of British Columbia Children’s and Women’s Health Centre in Vancouver.
Disclosure: Dr. Weiss is a consultant to and receives grant support from Eli Lilly, Janssen, Purdue, and Shire. She also receives grant support from the Canadian Institutes of Health Research.
Please direct all correspondence to: Margaret D. Weiss, MD, PhD, Head, Provincial ADHD Program, Clinical Professor, University of British Columbia, Children’s and Women’s Health Centre, Box 178, 4500 Oak St, Vancouver, BC V7T 2Y2; Tel: 604-875-2010; Fax: 604-875-2099; E-mail: firstname.lastname@example.org.
The adult screening diagnostic interview is typically 1 hour. It includes the usual domains of chief complaint, history of the present illness, family psychiatric history, current work and family functioning, mental status, formulation, and diagnosis. Sometimes, but not always, it may also be informed by either a broad-based screening rating scale for psychopathology or a checklist relevant to the disorder being investigated. The question has been asked why adult psychiatrists failed to identify adults with attention-deficit/hyperactivity disorder (ADHD) or even other childhood disorders. The adult interview does not include the key elements that allow childhood disorders to become visible to the clinician.
This is not a minor clinical issue. The majority of childhood disorders do not disappear. These include ADHD, autism, Asperger’s disease, developmental coordination disorder, Tourette syndrome, speech and language problems, and learning disabilities. This column provides adult psychiatrists with the tools to recognize these disorders, understand their implications for adult functioning, and identify why the adult assessment process differs from the child assessment process so that these difficulties may either go unrecognized or reformulated in as adult disorders.
A patient with ADHD who becomes depressed may be seen by an adult psychiatrist as cyclothymic or even bipolar, when hyperactivity is a lifetime pattern. A patient with Asperger’s may be perceived as having “schizotypal personality disorder.” If a patient comes across as articulate but is depressed because they are failing in school, the psychiatrist may miss that the underlying problem is an undiagnosed learning disability. This may be misinterpreted as functional impairment secondary to a mental health condition, rather than an identified learning disability. A patient with a severe nonverbal learning disability and very poor social skills may be seen as having a personality disorder.
This problem of diagnosing childhood developmental disorders within adult psychiatry has become an issue for appropriate delivery of services. For adult patients where the chief complaint is a childhood disorder grown up, it is adult psychiatry that has the mandate to provide service in most centers. There are two problems. First, adult psychiatrists follow an assessment procedure where these disorders are missed. Second, the child psychiatrists and even pediatricians who are trained in such a way so as to be able to conduct a child assessment on an adult patient are not mandated by the service delivery system to see adult patients.
This column reviews each component of a child assessment to identify how and why it allows identification of child disorders, and then discusses how these can be modified to be user-friendly to adult psychiatrists, but also all adult caregivers and general practitions. First, a child assessment includes a developmental history. Table 1 summarizes the key elements of that history that will identify areas of developmental delay or impairment that can provide clues to determine if further assessment is necessary.
This may seem like a lot of childhood information for a 1-hour psychiatric adult interview that is focused on a specific current complaint. This is why my colleagues and I have formatted a patient checklist that can be completed in the waiting room (Table 2).
Without a knowledge of child psychiatric disorders some of the most common psychiatric complaints in adults could be misinterpreted in a way that effects treatment. The second piece of a child assessment that is not typically present in an adult interview is a family interview (includes parent and sibling collateral) and information from a second setting such as a school. Patients with certain disorders make poor self informants. For example, it is not uncommon to have an adult with ADHD say that he does not have any difficulty, or a patient with autism deny that he misses being with other people or has a problem with social cues. Even for adult patients, a hypomanic patient may present saying that, “things have never been so good,” while a second informant might describe them as “a little too good.” This is not unfamiliar to adult psychiatrists. They would never naturally attempt to determine if a schizophrenic patient complaining that his boss hates him and that people at work are “against him” has a diagnosis of paranoid disorder without first obtaining appropriate collateral through the patient.
The reality of adult psychiatry is that it is not always feasible to bring in parents, impossible to contact employers, and (apart from the patient’s spouse) not always reasonable to obtain an informed mental status from a second informant that knows the patient well enough to observe his activities of daily living. In adults, obtaining collateral often requires the patient’s written consent, which may not be forthcoming. It is for this reason that my colleagues and I have developed a simple Diagnostic and Statistical Manual of Menal Disorders, Fourth Edition,1 checklist that covers both adult and child disorders and can be given to other informants to allow the psychiatrist to identify when and if critical information is missing and then follow up accordingly. This also allows for the clinician to work with the parent to compare his perception of his symptoms with those who are close to him.
The last disorder worth mentioning in this column is that of personality disorders. The DSM-IV defines these as adult disorders and the diagnosis is made starting at 18 years of age. However, a childhood history often reveals information about the development of personality formation that is critical to offering the patient insight into alternative methods of relating to others, coping strategies, and some of the background of his difficulties. Lastly, although the diagnosis may be made at 18 years of age, it is also true that personality formation continues through the life cycle. Thus, for adult psychiatrists seeing patients with developmental disorders, understanding the background of temperament and psychosocial factors as well as the history of early personality difficulties can be helpful to treatment.
By the same token, child psychiatrists need to be aware of precursors of adult syndromes when they take a slightly different format. It is easier for adult psychiatrists to obtain information on the past than for child psychiatrists to predict the future. Nonetheless, child psychiatry always has it in mind that a child with conduct disorder runs the risk of antisocial personality, and that children with extremely difficult temperament, stormy relationships, self-injurious behavior, and mood dysregulation may later evolve into having a borderline personality. Anxiety and mood disorders usually present early, and child psychiatrists are typically very familiar with the early stages of these waxing and remitting important Axis I conditions. The same is certainly true for addictions (eg, Internet addiction, subtance abuse) across the life cycle.
The objective of this column is to provide adult psychiatrists with a user-friendly method of identifying critical child-onset disorders and a developmental history through a checklist. The second objective is to assure that child psychiatrists are providing the adult patient with a broad-based screen for DSM-IV conditions that includes childhood disorders.
This issue represents a change in our field. It is now going to be necessary to treat childhood disorders grown up, and to provide early intervention for adult disorders that present at a young age. Since adult psychiatrists receive minimal training in the clinical presentation and current treatment of childhood disorders, and since child psychiatrists may not always be current in the latest literature on identification and treatment of disorders usually treated in adult settings, it is our hope this column and the attached checklist will facilitate clinical skill in this area.
The Weiss Symptom Record (WSR; Table 2, pages 24–28) can be completed by any informant at any age since the patient has the option to check “not applicable” and the language is gender and informant neutral. The WSR is included as a tool to facilitate the identification of disorders across the life cycle by pediatric, adolescent, and adult psychiatrists and clinicians. Although this is written as a DSM-IV checklist, it is essential to understand that in a busy practice it allows the clinician to eyeball where the difficulty is and to be sure not miss a particular disorder. It also allows the clinician to identify critical areas of potential differential diagnosis. As in most such checklists in child psychiatry, there are four anchor points. Most patients, where the disorder is not a significant clinical issue, will either check “not at all” or “somewhat.” A diagnosis becomes clinically signicant when disorders are checked routinely on the the shaded section. “Pretty much” is usually interpreted as having a problem and “very much” is usually interpreted as “this is a problem that gives me great difficulty.” The right-hand columns provide the DSM-IV criteria and codes for easy reference. This is not a “validated” scale; it is not diagnostic. However, its serves the useful purpose identified in this column of allowing adult psychiatrists to identify child disorders and child psychiatrists to identify adult disorders, and of making it “easy” for an adult psychiatrist to give the checklist to patients to obtain collateral information from a significant other. PP
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.