The first step is to obtain demographic and other background information from the child and his parents and to determine the reliability of this information. The pediatrician asks the parents and child about their specific concerns, why they are seeking help at this time.

It is important to review precipitating stressful events that may contribute to the behavioral difficulty and address specific concerns; these include academic and school problems, antisocial behavior, emotional conflict, regressive behavior, and interpersonal difficulty. The pediatrician reviews previous treatment and clarifies the effects of the child’s current behavior on family function.

The family history is reviewed, to clarify the child’s status in regard to foster care, adoption, step-parenting, or other family issues. Questions are asked: Who has custody of the child, whose personality does the child’s resemble, and after whom is the child named?

The family background of both parents is reviewed (including their childhood), with particular emphasis on the family atmosphere in the parents’ childhoods, stresses from emotional or economic causes, and the deaths of or separation from close relatives. Information regarding the grandparents and others closely affiliated with the child is gathered, along with a developmental family history of how the marriage evolved. Also included are the quality of relatedness in the current marriage (e.g., frequency of disagreements and how they are expressed), coping mechanisms dealing with conflict in the family, and the relationship with the family of origin. Siblings are described by age, school placement, history of significant illness, personality, and relationship with family members.

A history of familial diseases should include learning disability, intellectual disability, alcoholism, abnormal personality, suicide, homicide, bipolar disorder, and schizophrenia. In reviewing the child’s personal history, one should note the date and place of birth, birth weight, attitude of both parents toward the pregnancy, and whether it was planned or unplanned. If difficulties were encountered during the pregnancy or delivery, the parents’ psychological response to that event should be noted.

Developmental milestones should emphasize social responses, including eye contact, social smile, language communication, and interpersonal attachment. The quality of mother–child (dyadic) relationship and the child–mother–father (triadic) relationship requires review. Interpersonal issues that relate to feeding and illness care must be considered. The parents’ attitudes toward child rearing, particularly in regard to permissiveness and limit-setting, are assessed.

A behavioral review of symptoms (information regarding temperament, early development, emotional responsiveness, antisocial behavior, attentional difficulties, self-stimulation, and play behavior) is obtained. Assessment of schooling includes the age at beginning school, the current grade, schools attended, type of class placement, and emotional adjustment to beginning school. Separation problems upon the initiation of either preschool or elementary school are reviewed. If absences from school were prolonged, or if school years were repeated, that information—along with specific difficulties in reading, writing, spelling, and mathematics—is noted. Study habits and academic goals are reviewed, and the child’s peer relationships are assessed. Whether the child is teased or is a bully is determined, and particular friendships are assessed. Attitudes toward teachers, peers, and schoolwork also are noted.

The child’s awareness of sexual identity is assessed by asking questions regarding curiosity about the body and reproduction and about sexual interests and activities. For the adolescent, the interview covers information regarding the mastery of adolescent developmental tasks and the young person’s attitude toward entry into adolescence. One looks for mature versus pseudomature behavior and attitudes toward peers, family, and authority. Rebelliousness, drug use, periods of depression or withdrawal, and fantasy life are reviewed. Assessment includes how the young person has responded to puberty, with its accompanying changes in body image (voice changes, hair growth, breast development, menarche), and to sexual concerns.

A mental health history is gathered and should include details of disturbances for which treatment was received and how the treatment was conducted. This is followed by a description of the child’s and family’s life situation at present, which includes current housing, social situation, parents’ work, and financial circumstances. The composition of the household, relationship with neighbors, recent stresses, bereavement, losses or disappointments, and how both parent and child have reacted to these are reviewed. A typical day in the child’s life is described, from getting to school, to activities during the school day, the return home, and evening activities.

The physician should consider personality features that are pertinent to the child. These traits include habitual attitudes and patterns of behavior that distinguish the child as an individual. Among personality characteristics are attitudes toward others, with consideration given to the ability to trust others and to make and sustain relationships with them. It must be established whether the child is secure or insecure in interpersonal relationships, is a leader or a follower. The attitude toward interpersonal relationships—whether he or she is friendly, warm, and demonstrative or reserved, cold, or indifferent—is considered. Other characteristics regarding aggressiveness, quarrelsomeness, sensitivity, and suspiciousness are noted. Also considered are attitudes toward the self, including self-dramatizing behavior, egocentric behavior, self-consciousness, and ambition. Attitudes of the child toward personal health and bodily functions are included in assessing whether the child’s self-appraisal is realistic or unrealistic.

An assessment of the personality also includes moral and religious attitudes and an evaluation of whether the individual is easygoing, permissive, overconscientious, a perfectionist, or conforming. Mood is considered in regard to lability or persistence and whether the child’s attitude toward life is optimistic or pessimistic. Clarification about depression, anxiety, irritability, excessive worrying, and apathy is sought. The ability to express and control feelings of anger, sadness, pleasure, and disappointment is reviewed.

Leisure activities and interests (e.g., books, pictures, music, sports, and creative activities) are noted. How the child spends leisure time, either alone or with others, is assessed.

Finally, the physician asks about daydreams, nightmares, and patterns of reaction to stress. Questions about such reaction patterns should explore the ability to tolerate frustration, loss, and disappointment and should seek a description of circumstances that arouse anger or anxiety and depression. Also investigated is evidence of excessive use of particular psychological defenses, such as denial, rationalization, and projection.

The interview with the parent or parents of an ill child should establish a sense of confidence in them by the physician’s careful explanation of the illness and thoughtful responses to their questions. Because parents often must carry out medical and monitoring procedures at home, it is essential that they acknowledge the nature of the child’s illness and understand what they are to do. An effective interview facilitates appropriate care. Because the parents are active participants in the child’s care, establishing rapport with them is essential, as is remembering that parents are reassured not only by what is said but by how it is said. Parents are stressed by the child’s illness and require psychological support.

To understand the parent’s adaptation to the child’s illness, the psychological mechanisms normally present in a time of stress must be appreciated. The most common are denial, guilt or self-blame, projection or blaming others, and excessive dependency on others by the parent or the caregiver. Self-awareness by the physician is critical to understanding the parent’s adaptation. To determine the degree of the parent’s acknowledgment of stress related to the child’s illness or developmental disability, the following questions are suggested:

Difficulties in dealing with stress result from unresolved feelings of which parents may be unaware. The effectiveness of counseling requires a clarification of the degree of stress and the psychological mechanisms used by parents to adjust to a child’s illness. An empathetic approach helps parents to validate their responses and to act with greater confidence.