Presentation Title

James F. Leckman, MD, PhDNeison Harris Professor of Child Psychiatry, Psychology and Pediatrics

Clinical Assessment in CAP: an essential and classical approach in the era of rapidly evolving science

S L I D E #

S L I D E #

1

DisclosuresResearch funding: AEV, UBS Optimus Foundation, The Fetzer Institute, the Open Road Alliance, NIH (R01, Bench to Bedside, R25, T32), Grifols (formerly Talecris), Tourette Syndrome Association Royalties: McGraw Hill, John Wiley & Sons, Oxford University Press, MIT Press

S L I D E #

S L I D E #

Rutter Textbook Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.

S L I D E #

S L I D E #

M. Yanki Yazgan

Contributions from Richard Tremblay, Edmund Sonuga-Barke, Christoph Correll, Tony Charman, Joan Luby, Maria Kovacs, Nathan Fox, Eric Stice, Jane Costello and Adrian Angold

S L I D E #

S L I D E #

Anne ocuk Eitim Vakfi (AEV)

S L I D E #

S L I D E #

Early childhood development is a potential pathway to violence reduction in the home and in the community. The AEV Hypothesis

Is this also a pathway to prevent psychopathology and build a more peaceful world?

S L I D E #

6

Ernst Strngmann Forum41 scientists from diverse backgrounds (basic sciences, early child development, cross-cultural psychology, interfaith dialogue, and peace building) from 15 countries: South Africa, Kenya, Nigeria, Ireland, Finland, the Netherlands, Canada, US and the UK, Germany, Switzerland, Turkey, Israel and Palestine, and Australia met in Frankfurt in October 2013 and a report will be published in November 2014.

S L I D E #

S L I D E #

Pathways to Peace

S L I D E #

S L I D E #

Rutter Textbook Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.

S L I D E #

S L I D E #

Key PointsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Be clear about the questions to be addressed and what the expectations areWho is this child? Why now? What is the context in which the child is living an ecological perspective?What is the nature of the problem(s)Collect the data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

Key PointsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Educate everyone (including the child), concerning science and advocacy, while acknowledging the limits of what we do knowMake connections work together, build a team to formulate, test and refine our joint hypotheses in establishing a treatment planInterface with school personnel, pediatricians and other practitioners

S L I D E #

S L I D E #

An Ongoing JourneyWhat aspects of your career were the most influential in shaping the content of this chapter on Assessment?

S L I D E #

S L I D E #

An Ongoing JourneyWhat aspects of your career were the most influential in shaping the content of this chapter on Assessment?

S L I D E #

S L I D E #

Perspective

We are all interconnected in our ever changing world

Cosmic Dark Matter & Energy

Neural CircuitsSocial Networks

S L I D E #

S L I D E #

Thirty year history close ties to Advocacy organizations -Tourette Syndrome AssociationCommitment to a continuity of careLeadership in research across multiple domains: phenomenology, assessment, genetics, neurobiology, immunobiology, and novel therapeuticsA leading site in the development of new treatments and the next generation of academic leaders

Tourettes syndrome

S L I D E #

S L I D E #

Training

ResearchClinical CareA commitment to provide the best clinical care This tradition is also the starting point for our research and for training the next generation of academic leadersAn Ongoing Journey

S L I D E #

S L I D E #

Many of the most promising leads in research came from our patientsAssessment rating scalesPremonitory urgesWaxing and waning courseComorbidities OCD, ADHDLongitudinal courseFamily history geneticsNeurobiologyInterventions

Reality

S L I D E #

S L I D E #

Tics Tics often arise from a heightened and selective sensitivity to cues from within the body or from the outside world.

S L I D E #

Premonitory Urges "A need to tic is an intense feeling that unless I tic or twitch I feel as if I am going to burst. Unless I can physically tic, all of my mental thoughts center on ticking until I am able to let it out. It's a terrible urge that needs to be satisfied."

S L I D E #

Premonitory Urges There is really no adequate description of the sensations that signal the onset of tics. The first one seems irresistible, calling for an almost inevitable response .... The end of the tic is the "feel" that is frequently accompanied by a fleeting and incomplete sense of relief.

S L I D E #

S L I D E #

S L I D E #

S L I D E #

S L I D E #

Take Home Message TS is characterized clinically by a loss in the normal automatic ability to suppress or gate irrelevant information in sensory, motor, and cognitive domains. Intrusive faint sensory information appears to be particularly disruptive in TS

S L I D E #

I finally apprehend the magnitude of the background noise that I have been experiencing for decades the people around me do not share my tics because they do not hear the drumbeat. They do not feel the sensations without sources, do not have irresistible urges to pause in mid-sentence and so on in endless, bewildering varietyFinally and most important, I feel convinced that this complex challenging enigmatic internal world isthe obvious core of Tourette. Hollenbeck, 1999

S L I D E #

S L I D E #

26

It was only through a sustained partnership with our patients that our many of our research efforts were successful: Positive point of view (idealization envisioning positive outcomes) Commitment to a continuity of care has made it much easier to recruit subjects Knowledge sharing Gratitude and acknowledgement Donations to the programReality

S L I D E #

S L I D E #

Knowledge Sharing

S L I D E #

GratitudeWe dedicate this book:To the real experts on Tourette the individuals with this disorder and their families; To all of our mentors and teachers and to Donald Cohen, in particular, for his vision and encouragement over decadesTo our dedicated colleagues across the globe in the advocacy organizations and academic centers who continue to seek ways to improve the well being of individuals with Tourette by reducing stigma and advancing our scientific understanding of this enigmatic disorder

S L I D E #

S L I D E #

In our search for a cure, we must not lose sight of the individual and their family We need to build on the individuals strengths and to keep their development on track Point of View

S L I D E #

S L I D E #

Rutter Textbook Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.

S L I D E #

S L I D E #

Key PointsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Be clear about the questions to be addressed and what the expectations areWho is this child? Why now? What is the context in which the child is living an ecological perspective?What is the nature of the problem(s)Collect the data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

Questions Regarding the ReferralPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Who made the referral? What prompted the referral?What are the key questions to be addressed? Are there differing points of view concerning the need for a clinical assessment? Are there clear clinical or administrative issues that need to be considered before hand?

S L I D E #

S L I D E #

Key PointsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Be clear about the questions to be addressed and what the expectations areWho is this child? Why now? What is the context in which the child is living an ecological perspective?What is the nature of the problem(s)Collect the data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

Who is this child? Why now? Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Inquire concerning this childs strengths and interests, to foster resilience and keep the childs development on trackWhat is the ecology of childs and familys environment at the micro-, meso- and macro-level? Collect the historical and current data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

What Questions do You Have?Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.After mentioning some details about the child or family that were reported in the intake forms they completed before their visit, I typically ask the parents to brag about their child and to mention specific areas of strength and interest. Next, I typically ask the family what question(s) would you like me to answer as best I can by the end of your visit today?

S L I D E #

S L I D E #

Strengths, Interests, SupportPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Parent- and self-reports about the childs areas of interest and excellenceNature of the observed interactions between and among family membersClarity concerning how the child is viewed within the familyOpportunity to build trust and establish a therapeutic alliance and promote resilience

S L I D E #

S L I D E #

Who is this child? Why now? Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Inquire concerning this childs strengths and interests, to foster resilience and keep the childs development on trackWhat is the ecology of childs and familys environment at the micro-, meso- and macro-level? Collect the historical and current data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

A Strategic Decision Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Should the child be part of the discussion concerning the nature and course of the childs symptoms, family accommodation, intervening stressors or associated changes in life circumstances?Childs age and level of maturationCultural norms?Parents decision until adolescence

S L I D E #

S L I D E #

Who is this child? Why now? Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Inquire concerning this childs strengths and interests, to foster resilience and keep the childs development on trackWhat is the ecology of childs and familys environment at the micro-, meso- and macro-level? Collect the historical and current data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

Ecology of the HomePeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Parental self-esteem and psychopathology, parental strain, parental discord, availability of one-on-one time with parentsSibling relationships and conflictsLevel of hubbub, computer/video games, access to the internet;Family resources including pets, extended family, neighbors, religious community

S L I D E #

S L I D E #

Who is this child? Why now? Peace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Inquire concerning this childs strengths and interests, to foster resilience and keep the childs development on trackWhat is the ecology of childs and familys environment at the micro-, meso- and macro-level? Collect the historical and current data from multiple sources and formulate hypotheses along the way

S L I D E #

S L I D E #

History of Present IllnessPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Gain clarity concerning the course and function of the symptoms, intervening stressors or associated changes in life circumstances, triggersPresence of co-morbid conditionsDevelopmental, educational, family and medical historyPresence of familial vulnerabilities relevant to prognosis

S L I D E #

S L I D E #

Interview with the ParentsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.The parental interview is focused on the childs presenting problems, medical and family history, early development, school progress, and peer relations as well as on gathering information concerning the home and family environment including the parents child-rearing techniques and the methods of discipline used.

S L I D E #

S L I D E #

Interview with the ParentsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Often the best place to start is to address the reason for referral and determine what it is about the childs behavior, feelings, or social interactions that are of the greatest concern to the parents.

S L I D E #

S L I D E #

Interview with the ParentsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.How do the parents understand their childs problems? How predictable are the symptoms in a given set of circumstances? How much do they vary depending upon which parent is there or which class the child is in?

S L I D E #

S L I D E #

Interview with the ParentsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Are there other contextual features that appear to make the situation better or worse?

Identifying specific antecedents (triggers) can provide valuable clues to what function the symptoms have.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.This is the best part of my jobThe clinical assessment of young children differs fundamentally from that of adults and adolescents. While it is useful to monitor the childs behavior and social interactions in various contexts including when the parents are present, it is also crucial to spend time with the child.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Care needs to be taken to minimize the childs distress when being separated from their parents.This can be performed by reassuring the child that they can be reunited with their parents, if necessary. The child also needs to see exactly where their parents will be located during their interview.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.For younger children, the opportunity to play in a less structured fashion can help put the child at ease. Asking the child talk about what they enjoy doing and exploring is often a good place to start. Having an on-going activity, for example, drawing a picture or building something, permits the child to respond more spontaneously to the clinicians queries.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Some clinicians find it helpful to ask the child questions such as, If I were a magician and could grant you three wishes, what would those wishes be?Eventually, the clinician will need to address the issues that prompted the referral.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Open-ended questions will work the best and be the least prone to distortion and suggestion: What did your parents say about why you were coming in to see me today?What is most upsetting to you? What do you wish might be different? Is there anything you worry about every day?

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Be present in the momentWhile it is important for the assessments of children of all ages to have an appropriate degree of structure and standardization, the clinician also needs to be open to the unexpected.Otherwise, important information and insights may be missed.

S L I D E #

S L I D E #

Time with the ChildPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Variations in the style and content of the interview may differ considerably depending on the childs symptoms. The interview with the child will also include many elements of the mental status examination. At the end of the interview, the clinician should review with the child what they have both learned about the childs reasons for being seen and how he or she feels about it.

S L I D E #

S L I D E #

Key PointsPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.Educate those engaged (including the child), concerning science and advocacy, while acknowledging the limits of what we do knowMake connections work together, build a team to formulate, test and refine our joint hypotheses in establishing a treatment planInterface with school personnel, pediatricians and other practitioners

S L I D E #

S L I D E #

Knowledge Sharing

S L I D E #

Next Steps - Treatment PlanPeace is a multi-faceted construct; defined differently from various disciplinary perspectives, itmost often refers to a state of harmony characterized by the lack of violent conflict.Peace-building is a term used by the international development community to describe theprocesses and activities involved in resolving violent conflict and establishing a sustainablePeace.What is the nature of the problem?Initial impressions concerning treatment prioritiesConsensus buildingClear understanding of next steps follow-upTeam building

S L I D E #

S L I D E #

Thank you

Questions?

S L I D E #

S L I D E #