What is the recommended workup for a child presenting with behavioral issues?

Workup for Behavioral Issues in Children

A comprehensive psychiatric evaluation is essential, focusing on detailed history from multiple informants (parents, teachers, caregivers), direct observation of the child, assessment for comorbid psychiatric and developmental disorders, evaluation of family functioning and environmental stressors, and screening for medical conditions that may present as behavioral problems. 1

Core Assessment Components

Multi-Informant History Collection

• Gather detailed information from all caregivers and teachers about the child's current behavior, comparing it to the child's baseline functioning rather than age-expected norms alone 1
• Document the frequency, intensity, duration, and contexts in which behavioral problems occur, noting any discrepancies across settings (home vs. school) 1
• Identify specific triggers and patterns of events that reinforce outbursts, including environmental factors and psychosocial stressors 1
• Assess for change from baseline - determine whether behaviors represent new onset, worsening intensity/frequency, or occurrence in new contexts 1

Direct Child Assessment

• Interview the child using developmentally appropriate language, simplifying questions and allowing extra processing time, particularly for children with cognitive or language impairments 1
• Avoid leading questions and monitor for comprehension to prevent rote responses or echolalia 1
• Observe the child's appearance, performance, and interactions during the clinical encounter 2
• Compare behaviors to the child's developmental level, not chronological age, to avoid pathologizing developmentally appropriate behaviors 1

Systematic Evaluation for Underlying Conditions

Psychiatric Comorbidities

• Screen for ADHD, oppositional defiant disorder, conduct disorder, anxiety disorders, mood disorders (including bipolar disorder), and posttraumatic stress disorder - these commonly co-occur with behavioral problems 1, 3
• Assess for suicidality in all children with behavioral disturbances, as rates of suicide attempts are elevated 1
• Evaluate for substance abuse, particularly in adolescents with behavioral issues 1
• Use validated screening measures when available, such as the Developmental Behaviour Checklist (DBC) or Nisonger Child Behavior Rating Form (NCBRF) for children with intellectual disabilities 1

Developmental and Cognitive Assessment

• Evaluate for intellectual disability, developmental delays, speech and language disorders, and learning disabilities through formal testing when indicated 1
• For children under 3 years, assess for developmental delay ≥1.5 SD below the mean 1
• Consider pragmatic language impairment, which can manifest as behavioral dysregulation 1
• Screen for autism spectrum disorders in children with social communication difficulties and repetitive behaviors 1

Medical Conditions Masquerading as Behavioral Problems

• Rule out medical problems that commonly present as behavioral issues, particularly in children with limited verbal abilities: ear infections, headaches, constipation, dental problems, and sleep disorders 1, 4
• Assess sleep patterns and screen for obstructive sleep apnea, which can cause behavioral dysregulation 1
• Evaluate for seizure disorders if there are episodes of altered consciousness or unusual movements 1
• Consider endocrine disorders (diabetes, hyperthyroidism) that may present with behavioral changes 3
• Screen for prenatal alcohol exposure if facial features (short palpebral fissures, thin upper lip, smooth philtrum) or growth deficiency are present 1

Family and Environmental Assessment

Family Functioning Evaluation

• Interview family members in daily contact with the child to understand the family context of symptomatic behaviors 1
• Assess family interaction patterns, including discipline strategies (coercive, inconsistent), parental availability, and conflict resolution methods 1
• Identify family risk factors: parental mental illness, substance abuse, marital conflict, history of maltreatment, and caregiver stress or exhaustion 1
• Evaluate parent-child relationship quality and attachment patterns, particularly in preschool children 1

Psychosocial Stressors

• Document recent life changes: parental separation/divorce, moves, school changes, loss of significant relationships 1
• Assess for trauma and abuse history - children with intellectual disabilities are at particularly high risk 1
• Screen for bullying, especially in children with ADHD or developmental disabilities 1
• Evaluate socioeconomic stressors and access to resources 1

Age-Specific Considerations

Preschool Children (Under 5 Years)

• Exercise extreme caution before diagnosing bipolar disorder or other serious psychiatric conditions in very young children, as diagnostic validity has not been established 1
• Prioritize assessment of developmental disorders, temperamental difficulties, and parent-child relationship conflicts over psychiatric diagnoses 1
• Focus interventions on environmental, developmental, and social factors rather than aggressive pharmacotherapy 1
• Assess for prenatal alcohol exposure if behavioral volatility is present with any dysmorphic features 1

School-Age Children

• Obtain school performance data and teacher reports of behavior in the classroom setting 2
• Assess academic functioning and screen for learning disabilities, as behavioral problems frequently co-occur with learning difficulties 5
• Evaluate peer relationships and social functioning 1

Adolescents

• Screen for substance abuse more thoroughly, as rates are high in adolescents with behavioral problems 1
• Assess psychosexual development and risk-taking behaviors 1
• Evaluate for emerging personality pathology, particularly antisocial traits in those with conduct disorder 6

Common Pitfalls to Avoid

• Diagnostic overshadowing: Failing to recognize co-occurring psychiatric disorders because symptoms are attributed to intellectual disability or another primary condition 1
• Ignoring medical causes: Overlooking treatable medical conditions (pain, constipation, infections) that present as behavioral problems, especially in nonverbal children 4
• Age-inappropriate expectations: Comparing behavior to chronological age rather than developmental level in children with delays 1
• Single-informant bias: Relying solely on one caregiver's report without gathering information across multiple settings 1
• Premature medication: Prescribing psychotropic medications before completing a thorough diagnostic workup and attempting appropriate psychosocial interventions 1, 4

Validated Assessment Tools

• Developmental Behaviour Checklist (DBC): 96 items across 5 subscales with strong psychometric properties for children with intellectual disabilities 1
• Nisonger Child Behavior Rating Form (NCBRF): Parent and teacher versions assessing social competence and problem behaviors 1
• Psychopathy Checklist adaptations: For adolescents with severe conduct problems and callous-unemotional traits 6