The reliability and validity of the psychiatric assessment of the child: II. Interview with the parent

The prevalence of psychiatric disorder in rural school children

The multidetermined nature of psychiatric disorder in childhood calls for a detailed assessment of the individual and his family, and often a team approach to treatment. Since this involves contact with the family over a period of time the delivery of this type of service to children living in remote areas under conditions of geographical isolation can present considerable difficulty. A survey of 10- and 11-year-old children from the far West of Queensland showed a prevalence rate for psychiatric disorder of 10% among those whose parents were willing to complete a questionnaire and attend the child's school for interview. Although this is lower than rates obtained for children living in towns on the East coast and in the metropolitan Brisbane it still represents a sizeable group of children who require psychiatric help in areas where presently none is available. A method of family assessment and treatment for country children evolved by the psychiatric unit of a metropolitan children's hospital, shows the remoteness of home need not preclude the disturbed child from psychiatric expertise, although facilities must be augmented if children from an often forgotten sector of the Australian population are to be covered adequately.

Comparative studies of ulcerative colitis and Crohn's disease in children and adolescents

Ten patients suffering from Crohn's disease and seven children diagnosed as having Ulcerative Colitis were studied with regard to psychopathology, locus of control and several parameters of family functions. A comparison with findings from matched controls revealed higher rates of psychiatric disturbance among the clinical groups. Patients of the two groups did not differ from each other; neither in the amount nor the type of disorder. The predominating pattern was emotional disorder, which was also found in the parents' response to a behavior questionnaire. Further associations of the locus of control dimension to Crohn's disease and family functions to both diseases were found. Among clinical variables only growth retardation tended to correlate significantly with psychopathology, indicating that this consequence of the basic disease process may be more significant than other factors.

Psychiatric sequelae in children treated operatively for hydrocephalus in infancy

This study reports on the prevalence of psychiatric disorder in 45 children of primary-school age who had been treated operatively for hydrocephalus in infancy. A high rate of disturbance was found; presumably this relates not only to neurological factors but also to the child's reaction to his handicaps and to the attitudes of significant people toward him. The symptomatology was predominantly neurotic, and since emotional disorder can be helped by psychological methods it is argued that early psychiatric intervention could improve the quality of life for these children.

The relationship between the Rutter A Questionnaire and an interview with mother assessing child psychiatric disturbance among enuretic children

Forty-one children who were being treated in a paediatric clinic for enuresis were studied to see how many of them were psychiatrically disturbed on clinical assessment and to ascertain the usefulness of 2 cut-off points of T (total) scores on the Rutter A scale in identifying them. A score of 13 or more which had previously been recommended was found to be inadequate in this group of cases. There were indications that a cut-off point of 18 or more was more appropriate. The importance of knowing the base rate of psychiatric disorder in the population on which the questionnaire is being used is emphasized, since this affects the selection of an appropriate cut-off point.

Psychiatric interviewing techniques V. Experimental study: eliciting factual information

Four experimental interview styles, each recommended by experts in the field, were compared for their efficiency in eliciting factual information during the initial diagnostic interviews with the mothers of children referred to a psychiatric out-patient clinic. If encouraged to talk freely, mothers tended to mention most (but not all) key issues without the need for standardized questioning on a pre-determined range of topics. However, systematic questioning was essential in order to obtain good quality factual data. Better data were obtained when interviewers were sensitive and alert to factual cues and chose their probes with care. Clinically significant factual information, idiosyncratic to the family and outside the range of standard enquiry was common, but was obtained satisfactorily with all four styles. No one style was generally preferred by informants. The advantages of systematic questioning for obtaining factual information were not associated with any disadvantages with respect to the eliciting of emotions and feelings.

Psychiatric interviewing techniques II. Naturalistic study: eliciting factual information

A naturalistic study was undertaken of 36 video and audio taped interviews made by 7 different psychiatric trainees. The interviews studied were those conducted in the ordinary course of clinic work for diagnostic and therapeutic planning purposes by trainees when first seeing the parent or parents of a child newly referred to a psychiatric clinic. It was found that a directive style with specific probes and requests for detailed descriptions was associated with the obtaining of better-quality factual information than that associated with a more free-style approach. Interviewers who talked less and who made use of open questions and checks tended to have more talkative informants. Double questions were liable to result in ambiguous answers, but multiple-choice questions did not appear to cause distortion and in some circumstances might be helpful.

Psychiatric interviewing techniques: I. Methods and measures

An account is given of the overall strategy and measures used in a three-phase study of styles and techniques employed in the initial diagnostic interviews with the parents of children referred to a child psychiatric clinic. The measures of interview style included interviewer activity and talkativeness, directiveness, types of questions and statements, interventions designed to elicit or to respond to feelings, and non-verbal qualities. The informant's response and the interview 'outcome' were assessed through measures of the quantity and quality of factual information obtained, and of the extent of expression of emotional feelings by the informant. Good inter-rater reliability was achieved with most measures. Some difficulties were experienced in achieving comparable thresholds for the recognition of expressed emotions.

A prospective study of children with head injuries: III. Psychiatric sequelae

A 2 1/4-year prospective study of children suffering head injury is described. Three groups of children were studied: (a) 31 children with 'severe' head injuries resulting in a post-traumatic amnesia (PTA) of at least 7 days; (b) an individually matched control group of 28 children with hospital-treated orthopaedic injuries; and (c) 29 children with 'mild' head injuries resulting in a PTA exceeding 1 hour but less than 1 week. A retrospective assessment of the children's pre-accident behaviour was obtained by parental interview and teacher questionnaire immediately after the accident and before the behavioural sequelae of the injury could be known. Further psychiatric assessments were undertaken 4 months, 1 year and 2 1/4 years after the initial injury. The mild head injury group showed a raised level of behavioural disturbance before the accident but no increase thereafter. It was concluded that head injuries resulting in a PTA of less than 1 week did not appreciably increase the psychiatric risk. By contrast, there was a marked increase in psychiatric disorders following severe head injury. The high rate of new disorders in children with severe head injuries who were without disorder before the accident, together with the finding of a dose-response relationship with the severity of brain injury, indicated a causal relationship. However, the development of psychiatric disorders in children with severe head injuries was also influenced by the children's pre-accident behaviour, their intellectual level, and their psychosocial circumstances. With the exception of social disinhibition and a slight tendency for the disorders to show greater persistence over time, the disorders attributable to head injury showed no specific features.

A prospective study of children with head injuries: I. Design and methods

The main unresolved issues with respect to the psychological sequelae of brain damage in childhood are noted, and the previous studies of children suffering head injury are critically reviewed. A new prospective study is described. Three groups of children were studied: (a) 31 children with "severe" head injuries resulting in a post-traumatic amnesia of at least 7 days; (b) an individually matched control group of 28 children with hospital-treated orthopaedic injuries; and (c) 29 children with "mild" head injuries resulting in a post-traumatic amnesia exceeding 1 hour but less than 1 week. The children were studied as soon as possible after the accident and then again 4 months, 1 year, and 2 1/4 years after the injury. The parents were interviewed, using systematic and standardized interview techniques; both parents and teachers completed behavioural questionnaires; and the children were seen for individual psychological testing the WISC, the Neale Analysis of Reading Ability and a battery of tests of more specific cognitive functions. At the final follow-up, the severe head injury group (but not the other 2 groups) received a systematic neurological examination and the school teacher who knew the child best was personally interviewed. The findings are given on physical handicap, neurological abnormality, school placement and psychiatric referrals. All types of disabilities were both more frequent and more persistent in the children with severe head injuries.

Psychiatric disorders in children in long-term residential care: a follow-up study

Ninety-two children who had been examined in a psychiatric study of five to twelve year-olds in long-term residential care were followed up four years later. Three-quarters were still in children's homes, but over half had been moved to different establishments. At both the original study and follow-up, the majority showed evidence of psychiatric disorder. Considerable continuity of behavioural pattern was found, particularly amongst those who originally had antisocial disorders, who were also most likely to have had changes of care-taker during the four years. It is suggested that the persistence of their disorder may be due to a vicious circle of unacceptable behaviour and adult rejection.

The children of psychiatric patients: clinical findings

Findings are presented on 42 children of school age, the offspring of 26 adult psychiatric patients. Psychiatric disorder was found in 19 (45 per cent) of the children, compared with 12 (26 per cent) of 47 children from a control group of families. Families with disturbed children differed from the remaining families in the following ways: presence of frank marital discord, the diagnosis of personality disorder in the parents, the inability of the father to tolerate angry situations, and the presence of siblings of under 9 years of age. Six months later 9 of the 19 children had improved considerably. In almost every family this was associated with improvement in the condition of the parents. It is suggested that the psychiatric disorder of these children is reactive to the presence of emotional turmoil in the families.

A child's relationships after admission to residential care

In a group of 92 children in longterm residential care it was found that those children visited infrequently by their mothers were less likely than those visited frequently or not at all to relate well to their houseparents. That the child's relationship with the houseparents was of considerable significance was suggested by the finding that prolonged contact with the same houseparent was associated with lower rates of psychiatric disorder and deviant behaviour in the child. The implications of these findings for child care practice are discussed.

Institute of Psychiatry Department of Child and Adolescent Psychiatry

There has been a child psychiatry research group within the Institute of Psychiatry since 1952. At first it constituted a section of the Department of Psychiatry and for a while it formed part of the MRC Social Psychiatry Research Unit. However, in 1973 London University established a Chair of Child Psychiatry and since that time there has been a separate Department of Child and Adolescent Psychiatry. The research in this field undertaken up to 1967 has been described previously (Rutter, 1968a) and the present report brings the account up to date with a summary of work carried out during the last eight years.

Research report: Isle of Wight Studies, 1964-1974

The Isle of Wight Studies began in 1964–65 with a series of epidemiological studies of educational, psychiatric and physical disorders in 9- to 11-year-old children. These early studies were financed by the Department of Education and Science and the Foundation for Child Development (then the Association for the Aid of Crippled Children). The findings were fully reported in two books (Rutter, Tizard & Whitmore, 1970; Rutter, Graham & Yule, 1970) and only brief details are included here.

Attainment and adjustment in two geographical areas. I--The prevalence of psychiatric disorder

In recent years there has been an increasing interest in the observation that rates of psychiatric disorder and of educational problems in children may vary considerably according to area and to types of living conditions. However, very little is known concerning the extent to which rates actually differ, and even less about how particular area characteristics co-vary with the rates of different types of child disorder. Gath et al. (1972) found that child psychiatric referral rates were higher in areas of low social status, but data were not available to determine whether the difference lay in the preyalence of disorder or in the likelihood of detection or referral. Reading backwardness has also been associated with low social class areas (Miller et al., 1957; Eisenberg, 1966). In addition, it has been found that reading standards are lower in England than in Scotland (Davie et al., 1972). None of the studies of reading have taken IQ, into account, and it is not known whether the correlates are mainly with IQ or with a specific disability in reading. The present investigation was designed to examine these issues by determining if there were differences in the rates of child psychiatric disorder and of specific reading retardation between an inner London borough and the Isle of Wight. If differences were found, it also sought to examine the reasons for them, in order to elucidate possible causal or precipitating factors.

Structured interview for the assessment of work-related attitudes in psychiatric patients: preliminary findings

A structured interview was developed to assess the drive, realism, self-confidence, and self-rated disablement of psychiatric patients in relation to work. The clinical and research value of the interview was demonstrated by (1) studies of rater consistency, temporal stability, and parallel form reliability, and (2) by an investigation of its predictive validity.

Psychiatric disorder in the young adolescents of an industrial town

The opportunity to conduct a prevalence study of psychiatric disorder among young adolescents arose because a Family and Community Project had been established in Blackburn and the neighbouring town of Accrington. This Project, which is under the direction of Dr. G. Rose, aims to study the causes and possible methods of prevention of delinquency. As part of the survey, the secondary school population had been screened by means of questionnaires given to parents, teachers, and the children themselves, and this provided the starting point for the study described here.

A behavioural screening questionnaire for use with three-year-old children. Preliminary findings

The development of a questionnaire to be completed by parents for use in screening preschool children is described. Ninety per cent of children attending a psychiatric clinic were identified when the criteria were a score of 11 or more points on the behaviour scale and/or inability to speak in 3-word phrases, and/or speech which was very difficult to understand. The questionnaire could be used as a basis for collecting information systematically about preschool children, and as a screening device for identifying children with behaviour difficulties and developmental delay.

Organic brain dysfunction and child psychiatric disorder

The total population of 11,865 children of compulsory school age resident on the Isle of Wight was studied to determine the prevalence of epilepsy, cerebral palsy, and other neurological disorders. With the use of reliable methods, children selected from screening of the total population were individually studied by means of parental interviews and questionaries, neurological examination and psychiatric assessment of each child, information from school teachers, and perusal of the records of hospitals and other agencies. The association between organic brain dysfunction and psychiatric disorder was studied by comparing the findings in the children with epilepsy or with lesions above the brain stem (cerebral palsy and similar disorders) with those in (1) a random sample of the general population, (2) children with lesions below the brain stem (for example, muscular dystrophy or paralyses following poliomyelitis), and (3) children with other chronic physical handicaps not involving the nervous system (for example, asthma, heart disease, or diabetes).Psychiatric disorders in children with neuro-epileptic conditions were five times as common as in the general population and three times as common as in children with chronic physical handicaps not involving the brain. It was concluded, on the basis of a study of factors associated with psychiatric disorder, that the high rate of psychiatric disorder in the neuro-epileptic children was due to the presence of organic brain dysfunction rather than just the existence of a physical handicap (though this also played a part). However, organic brain dysfunction was not associated with any specific type of disorder. Within the neuro-epileptic group the neurological features and the type of fit, intellectual/educational factors, and socio-familial factors all interacted in the development of psychiatric disorder.

The reliability and validity of the psychiatric assessment of the child: I. Interview with the child

Surprisingly little has been written on the interview with the child as a diagnostic tool, in contrast to the voluminous literature on the therapeutic interview. Whereas standard texts on child psychiatry usually include a discussion of the physician-child relationship and of the use of play situation, it is rare for there to be any systematic account of the interview with the child as a diagnostic procedure.

A five to fifteen year follow-up study of infantile psychosis. II. Social and behavioural outcome

The two major follow-up studies of children suffering from infantile psychosis, that of Kanner's cases (Kanner, 1943 and 1949; Kanner and Eisenberg, 1955; Eisenberg and Kanner, 1956; Eisenberg, 1956; Kanner and Lesser, 1958) and that of psychotic children seen by Creak (1962, 1963a and b) have shown the generally poor prognosis for these children. In both studies about half the children were in full-time residential care (usually mental sub-normality hospitals) at follow-up, and only 5 per cent. to 17 per cent. could be said to be well adjusted. Similar findings have been reported in the other published studies (reviewed in Rutter, 1966a). Kanner and Eisenberg have described the course of the characteristics of aloneness or autism shown by all or nearly all children with infantile psychosis (Kanner, 1943; Kanner and Eisenberg, 1955; Eisenberg and Kanner, 1956). Although some psychotic children emerge from their solitude to a greater or lesser extent, a lack of social perceptiveness usually remains even in adolescence or early adult life.