Detailed Clinical Assessment in Child and Adolescent Psychiatry (Detailed evaluation in Children)

Detailed clinical assessment of children and adolescents must evolve from a biopsychosocial perspective, taking into account these inextricably interlinked aspects. Clinical history taking and interviewing are one of the most powerful tools available (in the absence of any laboratory investigations) to the child and adolescent mental health professional to make a diagnosis and plan management.
The central goal of a detailed clinical assessment is to come to a case formulation that would guide management decisions. Delineating signs and symptoms through detailed clinical history and examination help ascertain key areas of concern and presence (or absence) of a mental health disorder. To adequately comprehend the origins, maintenance, and factors affecting remission from the disorder, it is essential to place the child within a psychosocial background, relate the presentation to his/her unique context, and to gather details about what has happened to the illness so far, including what has been the treatment and response history. On the face of it, these components appear factual.
The clinician must be sensitive to the child's lived experience, family environment, and culture as well as their developmental and cognitive capabilities. Clinical judgment and expertise are required to assimilate the information obtained from the child and other key informants. In child and adolescent mental health, multidisciplinary inputs are required for almost every child and family and efforts must be made to link the different arms of evaluation and treatment such that there is convergence.
Confidentiality and the limits thereof must be discussed with the child and family. Documentation is a very important aspect of assessment and must be strictly maintained. A comprehensive clinical assessment goes a long way in ensuring interventions in the best interest of the child and family.
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