How do you assess temperament in a child psychiatry setting?

Assessing Temperament in Child Psychiatry Settings

Use standardized caregiver-report instruments as the primary method for temperament assessment in child psychiatry, specifically the Children's Behavior Questionnaire (CBQ) for ages 3-7 years or the Integrative Child Temperament Screener (ICTS) for rapid clinical screening, combined with direct behavioral observation during clinical encounters. 1, 2

Primary Assessment Tools

Children's Behavior Questionnaire (CBQ)

• The CBQ provides detailed assessment across 15 temperament dimensions for children aged 3-7 years, including Activity Level, Anger/Frustration, Attentional Focusing, Discomfort, Fear, High Intensity Pleasure, Impulsivity, Inhibitory Control, Low Intensity Pleasure, Perceptual Sensitivity, Positive Anticipation, Sadness, Shyness, Smiling/Laughter, and Soothability. 1
• These 15 scales reliably factor into three broad temperament dimensions: Extraversion/Surgency, Negative Affectivity, and Effortful Control, which have been validated across multiple cultures. 1
• The CBQ demonstrates substantial parental agreement and adequate internal consistency, making it suitable for clinical use. 1

Integrative Child Temperament Screener (ICTS)

• The ICTS is a nine-item rapid screening tool specifically designed to identify clinically significant temperament attributes in preschool-aged children referred for emotional or behavioral problems. 2
• Clinically referred children exhibit substantially higher scores on all ICTS subscales except behavioral inhibition compared to general population children. 2
• Adding ICTS scores to standard behavioral assessments (like the CBCL) significantly improves discrimination between clinically referred and general population children. 2

Critical Temperament Dimensions for Psychiatric Assessment

Effortful Control

• Low effortful control is the single strongest predictor of both restraint/seclusion events during psychiatric hospitalization and coexisting psychiatric symptoms in children with ADHD. 3, 4
• Children with poor effortful control require more intensive behavioral interventions and closer monitoring for safety concerns during treatment. 4
• Effortful control should be assessed through both caregiver report and objective measures when possible. 4

Negative Emotionality and Emotional Intensity

• High emotional intensity assessed as early as 6 months of age predicts psychiatric disorder at age 7 years (adjusted OR = 1.56), with stronger associations in girls and children showing persistent high intensity at both 6 and 24 months. 5
• Assess for anger/frustration, fear, sadness, and discomfort as distinct components of negative emotionality. 1
• Children with elevated frustration combined with poor effortful control show the highest risk for behavioral dysregulation. 4

Fearfulness

• Higher fearfulness predicts increased restraint and seclusion occurrences during psychiatric hospitalization, even after controlling for other risk factors. 4
• Fearful temperament may manifest as anxiety symptoms and requires differentiation from anxiety disorders during diagnostic assessment. 3

Integration with Psychiatric Assessment

Predicting Coexisting Psychiatric Symptoms

• Each coexisting psychiatric disorder in children with ADHD is associated with a distinct temperament profile: temperament ratings explain significant variance in psychiatric symptoms above and beyond ADHD symptoms alone. 3
• High surgency combined with low effortful control predicts externalizing symptoms. 3
• High negative emotionality predicts internalizing symptoms. 3
• Assess temperament systematically to identify liability for specific comorbid conditions. 3

Behavioral Observation During Clinical Encounters

• Directly observe the child's behavioral responses during the psychiatric interview, noting intensity of emotional reactions, ability to regulate attention and behavior, approach/withdrawal to novel situations, and adaptability to changes in the clinical setting. 6
• Observe parent-child interactions to assess how temperamental characteristics interact with parenting responses. 6
• Note discrepancies between caregiver report and observed behavior, as these may indicate environmental factors or parental perception issues. 6

Assessment Across Developmental Stages

Infants and Toddlers (6-24 months)

• For autism screening contexts, use the Toddler Behavior Assessment Questionnaire-Revised (TBAQ-R) to assess temperament dimensions including positive affect, negative affect, and effortful emotion regulation. 6
• Children later diagnosed with ASD show lower positive affect, higher negative affect, difficulty controlling behavior, and lower sensitivity to social reward cues at 24 months. 6

Preschool Age (3-7 years)

• Use the CBQ as the primary comprehensive assessment tool. 1
• Consider the ICTS for rapid screening in busy clinical settings. 2

School Age and Adolescents

• Incorporate temperament assessment into the comprehensive psychiatric evaluation as recommended by the American Academy of Child and Adolescent Psychiatry, focusing on how temperamental traits interact with environmental demands and stressors. 7, 8
• Assess whether behavioral problems represent temperamental extremes versus psychiatric disorders requiring specific treatment. 7

Clinical Pitfalls to Avoid

• Do not assume temperament is fixed or untreatable—temperamental characteristics can be modified through targeted interventions and environmental modifications. 6
• Avoid attributing all behavioral problems to "difficult temperament" without screening for underlying psychiatric disorders, medical conditions, or environmental stressors. 7, 8
• Do not rely solely on single-informant reports; obtain temperament ratings from multiple caregivers when possible to assess cross-situational consistency. 1
• Avoid using temperament assessment as a substitute for comprehensive diagnostic evaluation—temperament informs but does not replace psychiatric diagnosis. 7

Practical Implementation

• Administer temperament questionnaires to caregivers during intake or early in the assessment process, before the first clinical encounter when possible. 2
• Review temperament profiles alongside psychiatric symptoms to identify specific intervention targets. 3
• Use temperament data to inform treatment planning, particularly for predicting treatment response and risk of adverse events during hospitalization. 4
• Document temperament characteristics in the psychiatric assessment as part of the comprehensive evaluation. 7, 9