Lexington Forensic Neuropsychiatry

Printer-friendly VersionForensic Evaluation of Children

A forensic evaluation of a child is somewhat distinct from the examination noted under Adult Forensic Psychiatric Evaluation.

A child forensic psychiatric evaluation is specific to the age of the child, and, generally, consists of the following components:

  • Complete medical history.
  • Pediatric mental status examination.
  • Pediatric psychological assessment.
  • Review of pertinent medical records and discovery and evidentiary deposition transcripts.
  • Review of preschool and school records.

A child brain-injury evaluation process, in addition to the above general-evaluation techniques, usually includes:

  • Neurological examination.
  • Child neuropsychological assessment.
  • Structural-functional neuroimaging.

The precise assessment that is required for brain-injury assessment is determined by the needs of the case, but, in most instances, the young child will have administered to him/her the NEPSY, a developmental neuropsychological assessment. The child may also require continuous-performance testing for measurement of attention. Older children or adolescents are tested in a manner similar to adults.

Brain injury or brain dysfunction in young children (ages 3 — 12) in most cases evaluated by Lexington Forensic Psychiatry presents with one of two causes:

  1. Hypoxic-ischemic perinatal brain injury.
  2. Trauma-induced brain injury.

Medical History

The medical history of the child includes information regarding developmental processes before and after injury. Information is obtained, to determine the impact of injury upon childhood development and upon learning processes within an academic environment. Moreover, with the child, impairment may cause specific dysfunction within the family. Thus, the child's medical history is explored to determine the impact, if any, upon development-both physical and emotional-as well as academic performance and child's functioning in the family unit. Further history is obtained regarding past pediatric issues, impact upon play and interpersonal relations, past history of learning disorder, attention-deficit disorder or pervasive neurodevelopmental difficulties, family history, social history, and review of systems.

Mental Status Examination

The mental status examination of a child is a face-to-face examination between the psychiatric physician and the child. Generally, the child is evaluated for physical appearance, motoric behavior and speech, ability to relate during the interview, affective appearance, content of thinking, and language and thinking. The interview may also focus upon feeling states, interpersonal relations, self-concept, and general level of adaptation. It is a distinctly different examination than that performed in the adult patient.

The examination of the adolescent patient is more akin to the mental examination of an adult patient. Where important, some of the aspects of examination of the young child are also incorporated into the overall mental examination of the adolescent.

Neurological Examination

The neurological examination of the child varies slightly from that performed on the adult. The neurological examination is performed in the same manner as for adults noted above, except that the more uncomfortable aspects, such as funduscopic examination of the eye, corneal and gag reflex examination, and sensory testing are generally postponed until the end. In younger children, the neurological examination is a catch-as-catch-can procedure, with a considerable amount of information revealed by the youngster's play activities, including the child's dominant handedness, the presence of cerebellar deficits, hemiparesis, and perhaps even a visual-field defect.

The toddler can be difficult to examine. A toddler is best approached by seating the child on his mother's or father's lap, and talking to him or her. The normal toddler is fearful of strangers, and the physician must first observe the youngster and defer touching him until some degree of rapport has been established.

The general appearance of the skull is assessed, and palpation of the anterior fontanelle is generally performed in younger children. Cranial nerves are examined; coordination is observed; sensory examination is performed. The younger the child, the less informative are deep tendon reflexes, and reflex inequalities are common and less reliable than inequalities of muscle tone. Abnormal reflexes, such as the Hoffmann and Chvostek signs may be determined. The presence or absence of clonus is determined. Cognitive function is obtained from the neuropsychological examination.

Psychological Assessment

Psychological assessment of the child is more complex than that of the adult. For children age 8 through 18, a self-report measure is used, in addition to parent findings.

The child psychological assessment, typically, provides information concerning the following:

  • Psychopathology.
  • Functional intellectual capacity.
  • Current and preinjury academic ability estimates.
  • Adaptation and developmental indices.
  • Forensic distortion analysis.

Neuropsychological Evaluation

In the neuropsychological evaluation, measures in children are not as well-developed as the scientific evidence for measures in adults; this is because the child brain is still in the process of development at the time of examination. The human brain does not completely develop and myelinate neuronal fibers until approximately age 25. However, our neuropsychological evaluation generally can give the following measures in children ranging from 3-12 years.

  • Attention/executive function.
  • Language.
  • Sensorimotor function.
  • Visuospatial processing.
  • Memory and learning.

The neuropsychological evaluation of the child may also include measures of:

  • Test intelligence.
  • Psychopathology.
  • Measures providing estimate of preinjury function.
  • Forensic distortion analysis.

Functional/Structural Neuroimaging of a Child

Typically, evaluations by Lexington Forensic Psychiatry of the child brain require some form of imaging. Structural imaging using MRI or CT may be obtained. The results of these scans are interpreted in connection with the neuropsychological examination to pinpoint structural and functional areas of dysfunction which translate into impairment of specific cerebral abilities. With very young children (e.g., 3-10 years), or certain older children, conscious sedation may be required during imaging. For further information regarding brain imaging, please choose Neuroimaging.

Review of Records

In the child, the review of records will consist primarily of examining pediatric records and academic records. Due to the young age of the child, the number of records available is usually much less than in an adult examinee. On the other hand, if the child is learning-disabled or has special needs, those academic records will be particularly useful within the overall forensic assessment. Moreover, school psychological records may be needed to document pre-impairment mental or behavioral dysfunction. The pediatric records serve a similar purpose for determining preinjury mental/physical dysfunction.