DOCUMENTATION OF PSYCHOPATHOLOGICAL FINDINGS - A PROCEDURE FOR ASSESSING PSYCHIATRIC-DISORDERS IN CHILDREN AND ADOLESCENTS

A standardized documentation system for psychopathological findings al lowing an assessment of psychiatric disorders in children and adolesce nts after clinical evaluation of the patient and his or her caregivers is presented. The symptomatology during the previous few months and t he symptoms seen during the examination are rated separately. Altogeth er 113 items in 16 areas are assessed. In addition, motivation to part icipate in treatment is judged and a global assessment is made of symp tom severity. A number of facilities are already employing this docume ntation system in their routine clinical work. In a first study 597 pa tients from a routine clinical population seen consecutively were asse ssed at the start of treatment. As expected, the most commonly recorde d symptoms were those of expansive behavior. Such symptoms were seen m uch more rarely during the evaluation than outside this situation. The documentation system for psychopathological findings complements diag nosis by category according to ICD with a phenomenological description of psychiatric disturbances on the level of single symptoms. It enabl es simple and economical documentation of clinical findings after eval uation of the patient and his or her caregivers.