The Case Formulation in Child

and Adolescent Psychiatry

Nancy C. Winters, MD
a,
*
, Graeme Hanson, MD
b
,
Veneta Stoyanova, MD
a
a
Division of Child and Adolescent Psychiatry, Oregon Health and Science University,
3181 SW Sam Jackson Park Road, Mail Code:DC-7P, Portland, OR 97239-3098, USA
b
Department of Psychiatry, University of California San Francisco,
513 Parnassus Avenue, San Francisco, CA 94143-0410, USA
Put simply, case formulation is a process by which a set of hypotheses is
generated about the etiology and factors that perpetuate a patients present-
ing problems and translates the diagnosis into specic, individualized
treatment interventions. It is central to the practice of child and adolescent
psychiatry. Even if not articulated explicitly, the case formulation guides all
clinical activity. For example, how one understands a childs biologic
vulnerabilities and how they interact with personality or family factors
and the importance assigned to each clearly inuence choices made in the
assessment process and the treatment plan. Despite the widely acknowl-
edged importance of case formulation, it is often taught cursorily in
residency programs, and residents often perceive it as too challenging to
actually perform [1]. Consequently, case formulation is often relegated to
secondary status behind the DSM-IV-TR dierential diagnosis. Such
attitudes are manifested in the American Board of Psychiatry and Neurol-
ogy Child and Adolescent Psychiatry certication examinations. When
asked to formulate the case just presented, candidates generally return a per-
functory statement and transition quickly to discussion of DSM-IV-TR
diagnoses.
How can case formulation be taught systematically and eectively to
child psychiatry residents? This article reviews the various denitions of
case formulation, dierences between diagnosis and case formulation,
how case formulation for a child patient diers from an adult patient,
and case formulation in the context of residency training, including
challenges for residents transitioning from adult psychiatry. It presents
* Corresponding author.
E-mail address: [email protected] (N.C. Winters).
1056-4993/07/$ - see front matter 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.chc.2006.07.010 childpsych.theclinics.com
Child Adolesc Psychiatric Clin N Am
16 (2007) 111132
a suggested structure for constructing a biopsychosocial formulation that
can be applied in a training setting. Several specialized types of psychother-
apy formulation are reviewed in more detail. The article concludes with
a case example of a child psychiatry residents case formulation before
and after discussion in supervision.
Denitions of case formulation
If one searches the literature on case formulation in child psychiatry, one
nds a surprisingly small number of articles relative to its importance. The
indices of several textbooks in child psychiatry (and adult psychiatry) yield
no entries under formulation or any related terms. The nature of case for-
mulation is made more ambiguous by the various terms used for it, which
reects lack of agreement on the denition of case formulation. Commonly
used terms include clinical case formulation [2,3], diagnostic formulation [4],
psychodynamic formulation [57], psychotherapy case formulation [8], and
Engels biopsychosocial approach to formulation [9].
Although these terms are used somewhat interchangeably, they have dif-
ferent emphases. There are, however, some areas of consensus and common-
ality. Case formulation generally refers to an integrative process that
synthesizes how one understands the complex, interacting factors implicated
in development of a patients presenting problems. It is explicitly compre-
hensive and takes into account the child and familys strengths and capac-
ities that may help to identify potentially eective treatment approaches.
The case formulation serves as a testable explanatory model that gives
rise to ideas for intervention and eliminates some options that do not t
the model. Described most succinctly by Nurcombe and colleagues [10],
the formulation asks what is wrong, how it got that way, and what can
be done about it. The case formulation is not static. Just as a childs story
continues to unfold throughout the clinical process with added information,
the case formulation evolves and is continually modied. It may start as
rudimentary and become more elaborate over time.
Case example of the whole story
A 14-year-old girl had been in treatment with a child psychiatrist since
age 11 for severe obsessive-compulsive disorder and generalized anxiety dis-
order symptoms. Numerous medication trials had only brought her partial
relief. Attempts at cognitive behavioral therapy (CBT) or other psychosocial
therapies had always met with resistance on the patients part, and she gen-
erally seemed to be angry about having to attend therapy sessions. After 2 to
3 years of unsuccessful treatment, the patient revealed that she had a severe
phobia to elevators and heights that was making her profoundly uncomfort-
able during sessions. She requested that treatment sessionsdpreviously held
on the tenth oor of the hospitaldbe conducted downstairs in the lobby of
112 WINTERS et al
the hospital. After this change was made, the patient rapidly became an ac-
tive collaborator in treatment and responded surprisingly well to CBT.
The largest body of literature on case formulation is on the psychody-
namic formulation. This approach is heuristically fertile in generating psy-
chologically meaningful hypotheses that translate to psychotherapeutic
interventions, but it does not adequately capture the increasingly recognized
contributions of neurobiology and sociocultural inuences to psychiatric ill-
ness. The biopsychosocial approach to formulation has become the most
widely accepted comprehensive case formulation model. Described in 1980
by George Engel, the biopsychosocial formulation became an organizing
principle for psychiatric education [9]. An internist with psychoanalytic
training, Engel had a profound impact on the eld of consultation-liaison
psychiatry. Engel departed from the biomedical model of understanding
medical illness, which he viewed as isolating components of illness, as would
a bench scientist. His biopsychosocial model was based on systems theory,
which conceptualized the person and the family as components of a hierar-
chically arranged continuum of natural systems. He later emphasized the
importance of dialogue between the patient and doctor in developing
a shared narrative of the patients private experience of illness. Through
this dialogue they would discover the links between the patients personal
life and his or her experience of falling ill [11]. The American Psychiatric
Association Commission on Psychotherapy oered the following denition:
The biopsychosocial formulation is a tentative working hypothesis which
attempts to explain the biological, psychological and sociocultural factors
which have combined to create and maintain the presenting clinical prob-
lem. It is a guide to treatment planning and selection. It will be changed,
modied, or amplied as the clinician learns more and more about the
patient [12].
The sociocultural aspect of case formulation has received increased atten-
tion recently with the recognition that culture and ethnicity are often
ignored or mishandled through ignorance, personal bias, or countertransfer-
ence on the part of the therapist [13]. Cultural issues are important in child
and adolescent psychiatry because they inuence parenting style, develop-
mental expectations, values and goals of the family, perception of symp-
toms, and attitudes about treatment. The DSM-IV attempted to improve
coverage of cultural issues with inclusion of an outline for cultural formula-
tion, although there are some limitations in its applicability to children and
adolescents [14].
Dierences between diagnosis and case formulation
Diagnosis and case formulation are dierent processes. Diagnosis is a cat-
egorical approach to describing symptoms that occur in reliable groupings,
the aim of which is to establish predictive validity for treatment outcome.
113 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
Diagnosis is atheoretical and draws on the disease concept. Case formula-
tion reects a more dimensional perspective in which problems are viewed
as being on continua from normal to abnormal. Case formulation synthe-
sizes information into a theory as to how problems developed and how
change might unfold. Jellinek and McDermott [15] described diagnosis
and case formulation respectively as the science and art of child and ado-
lescent psychiatry. They commented on the tension between DSM-IV
structured diagnostic interviews and traditional open-ended interviews using
play materials, noting that the rst is quantitative and seeks accuracy,
whereas the second is more qualitative and seeks meaning. Turkat [16]
stated that it is problematic when a diagnosis is used as a formulation,
and the term diagnostic formulation itself is confusing.
The consensus, however, is that diagnosis and case formulation comple-
ment each other and should coexist. Diagnosis by itself does not encompass
the complexity of the individual case. Generally the diagnosis does not tell
the clinician how two children with the same diagnosis, such as obsessive-
compulsive disorder, dier in terms of strengths, vulnerabilities, precipitants
of symptom exacerbations, developmental impact of the symptoms, and
meaning of the symptoms to the child and family. Case formulation is
seen as a vehicle to supplement and apply diagnosis to the specics of an in-
dividuals life. Case formulation also serves as a vehicle for converting a di-
agnosis to a plan for treatment, especially choice of type and timing of
interventions [8].
Connor and Fisher [2] maintain that case formulation must be multi-
theoretical because the current state of knowledge in child mental health
does not endorse any one theory of causality. It must allow for biologic, psy-
chologic, and social multicausality. They further describe diagnostic
assessment as a divergent activity in which information from dierent do-
mains is collected and case formulation as a convergent activity in which
information is prioritized and integrated and relationships among the data
are highlighted.
How the child and adult psychiatric formulation dier
The transition from adult to child psychiatry training presents residents
not only with the challenge of learning to construct a much more complex
case formulation but also of learning a whole new approach to doing
evaluations. Many residents have no experience with child outpatients dur-
ing their adult psychiatry training and are unfamiliar with integration of
data from multiple informants and interacting perspectives. Residents
have an exceedingly steep learning curve in the beginning of training as
they acquire new skills in interviewing and interacting with children of
dierent ages. New knowledge areas to master include normal and abnor-
mal child development, common medical conditions that aect behavior,
family systems theory, childhood psychiatric diagnoses, and pediatric
114 WINTERS et al
psychopharmacology. Learning about development must include the varia-
tions in normal development, the rapid changes in childhood inuenced by
temperament and cognitive capacities, and psychodevelopmental issues,
such as internalized object relations, identity formation, and psychosexual
development. The need to master all of this material is all the more pressing
because of concerns about safety of interventions in a vulnerable child
population.
The rst dierence in the evaluation of children that bears on case formu-
lation is the fact that children, unlike adult patients, are not self-referred but
are usually referred by a parent, teacher, or some other agent. The problem
is not dened primarily by the patient, and child patients may not even see
the behavior expected by the parents or school as desirable. This may be an
ongoing aspect of the formulation that explains limited treatment success.
Externalizing problems are more often the reason for referral, although
they may not be the most psychologically relevant predisposing or precipi-
tating issue from the childs point of view. The child evaluation must use
information from multiple informants, requiring an understanding of the
reliability and point of view of each informant. The clinician also must
form therapeutic alliances with the child and caregivers while still attempt-
ing to retain objectivity.
The chief complaint voiced by a childs parents also carries with it their
expectations for normal behavior, which are ltered through their own psy-
chology and inuenced by sociocultural factors. The parents psychological
vulnerabilities also may explain why they experience the childs behavior as
so disturbing. When the referring agent is outside the family it may even
have dierent ways of labeling or dening problems based on its own inter-
nal requirements. For example, when a school refers a child it may prefer an
autism spectrum diagnosis to establish eligibility for special education
services. The main goal of child psychiatry interventions is to help the child
return to a more normative developmental trajectory, usually dened by the
parents expectations. The childs level of development, which may dier
across developmental domains, is always an essential part of the formula-
tion. The focus of the formulation may change over time with the childs
maturation, continuing and new environmental factors, and added
information.
The conceptual model used to formulate the childs problems must of ne-
cessity be multifactorial and interactional. There is generally an individual
component (focused on pathology within the child) and a systems-based
component (focused on factors in the family or broader systems); an even
more comprehensive ecologic approach is based on analysis of all contribut-
ing factors in the environment. The ecologic perspective is discussed, in
more detail, in the article by Storck and Vanderstoep elsewhere in this issue
[17]. Family assessment and inclusion of family factors are always necessary
in the case formulation of a child. The cause of the childs problems also
may be understood as circular. Family factors contribute to the childs
115 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
problem, but the childs problem in turn causes more family stress, which
serves to perpetuate the problem. Causative factors that are more current
and immediate are most relevant, because they most powerfully alter the
balance for the child, the reinforcement available for change, and the beliefs
of the participants [18].
Case example of the ecologic model
A 15-year-old girl was receiving services in a community mental health
center. Her resistance to following rules and statements of suicidal ideation
were causing her adoptive parents to feel so overwhelmed that they ex-
pressed concern that they could not continue taking care of her. The girl
had received individual therapy for 2 months with little improvement. At-
tempts to add family therapy and recommendation of home visits were
too little, too late, and the young woman was placed in a wilderness pro-
gram and then was to go to a residential center far from her community
and family. Later, it was learned that the adoptive father, a self-employed
farmer, was under enormous stress and was concurrently ling for bank-
ruptcy. This situation contributed signicantly to the familys inability to
grapple with rebellious behavior that represented a normative developmen-
tal challenge for this young woman.
The case formulation process assists in helping the child and adults to
reach a shared denition of the problem, which is important if change is
to be possible. A collaborative model in which families are partners in the
case formulation process has been recommended [18,19]. Each partner in
the process shares his or her formulation of the problem, comes to see
some validity in the others perspectives, and identies what role he or she
expects to play in addressing the problem. Added to the collaborative model
is an emphasis on strengths-based approaches that have been embraced by
system-of-care reforms and the family and consumer movement [20]. Metz
[19] oered the following modications of the American Psychiatric Associ-
ation Commission on Psychotherapys denition of the biopsychosocial for-
mulation to reect these perspectives (changes appear in bold):
A biopsychosocial formulation is a tentative working hypothesis developed
collaboratively with the child and family, which attempts to explain the bi-
ological, psychological and sociocultural factors which have combined to
create and maintain the presenting clinical concern and which support the
childs best functioning. It is an individualized guide to treatment planning
and selection. It will be changed, modied, or amplied as the clinician
and the family learn more and more about the strengths and needs of the
child and family.
The involvement of multiple systems in the lives of children (eg, school,
health care, neighborhoods, child care, and, for some children, child welfare
or juvenile justice) also contributes to the greater complexity of the child
psychiatry case formulation.
116 WINTERS et al
Case formulation approaches related to psychotherapeutic models
The clinicians preferred explanatory and psychotherapeutic models have
signicant inuence on the prominent themes and hypotheses developed in
the case formulation. One of the risks in case formulation is that of eliminat-
ing what does not agree with ones theoretical orientation. This issue has
lent support to use of the more structured and comprehensive biopsychoso-
cial formulation [10].
Case example of the role of the clinicians biases and theoretical models
An 11-year-old boy was admitted to a child psychiatric inpatient unit for
treatment of severe obsessive-compulsive disorder refractory to multiple
psychopharmacologic trials. The referring practitioner, a psychopharmacol-
ogy specialist, indicated that the family functioned well and family issues
should not be a target of treatment, and the inpatient treatment team
followed this formulation. The boy was discharged and then rapidly read-
mitted with continuing severe symptoms. On re-entering the inpatient
setting he stated urgently my familys all messed up! This statement con-
rmed the nursing stas observations during the prior admission. They had
observed that the boys parents were intensely controlling and not psycho-
logically minded and that the sister also had signicant emotional problems
that were not being acknowledged.
Psychodynamic and cognitive-behavioral case formulations do have their
place in developing the specic components of the intervention once it is
chosen. The two most common types of therapeutic case formulations,
CBT and psychodynamic, are described later. More extensive descriptions
of case formulation approaches used in CBT, psychoanalytic therapy, brief
psychodynamic therapy, dialectical-behavioral therapy, interpersonal psy-
chotherapy, and behavior therapy are also available [8,21,22].
Psychodynamic case formulation has been written about extensively, es-
pecially in the adult literature. Psychodynamic formulations are thought to
be appropriate not only for long-term or psychodynamic therapy but also to
inform other modalities [7]. McWilliams [22] holds that the shorter the time
to do the psychotherapeutic work the more critically important are the ther-
apists working hypotheses. The psychodynamic framework addresses such
areas as unconscious conicts, ego decits, distortions in intrapsychic struc-
tures, and problems in internalized object relations [23]. Psychodynamic
case formulation assumes that the goal of therapy is not only symptom relief
but also development of insight, agency, identity, self-esteem, aect manage-
ment, ego strength and self-cohesion, a capacity to love, work, and play, and
an overall sense of well-being [22].
Cognitive-behavioral case formulation is based on premises originally set
forth by Aaron Beck and colleagues about cognitive schemas and informa-
tion processing errors that lead to and maintain symptoms in depression,
anxiety, personality disorders, and substance abuse [24]. CBT formulations
117 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
are used to identify negative core beliefs related to negative developmental
events and generate cognitive restructuring and coping strategies [25].
Case formulation in cognitive therapy identies a patients automatic
thoughts and feelings and behaviors that follow them and then identies
sources or triggers that activate the patients symptoms. Eventually, connec-
tions are made between an incident in the childs life to core beliefs about
himself or herself. Behavioral therapy formulations are particularly relevant
in child psychiatry, because young children are most likely to benet from
restructuring of environmental reinforcements and may not be able to use
the cognitive component of therapy. Behavior therapists focus on functional
analysis of behavior and identify environmental contingencies or reinforce-
ment and apply behavioral principles, including operant and classical condi-
tioning, to make alterations [8].
Integrative case formulations are multitheoretical and allow for integra-
tion of components of dierent therapeutic modalities. Theoretical explan-
atory concepts are explicitly selected because of their applicability to the
facts of the case and to guide individualized treatment approaches accept-
able to the patient at a particular time. For example, a CBT case formula-
tion may be most benecial for an adolescent with generalized anxiety
disorder or social phobia, but this does not exclude psychodynamic hypoth-
eses in the case formulation to explain the meaning of specic symptoms,
the readiness of the patient to address them, and developmental insults
that may have played a role in symptom development. Integration occurs
in the mind of the therapist as he or she develops the case formulation,
not always in the therapeutic application (K. Zerbe, MD, personal commu-
nication, 2005). This perspective led to development of an integrated course
on psychodynamic and evidence-based psychotherapies for children and
adolescents at Oregon Health and Science University child psychiatry resi-
dency program [26]. Readings for the course are drawn from the literature
on CBT, interpersonal therapy, and psychodynamic theory, paired with
continuing case presentations. Review of evidence-based psychotherapy
manuals is another part of the curriculum. Residents develop evolving inte-
grated case formulations using dierent explanatory theories and discuss
implications for selection of psychotherapeutic modalities that may vary
over the course of treatment.
Case formulation in the context of residency training
Case formulation is valuable as a teaching tool in residency programs. It
strengthens a residents understanding of the multifactorial and transac-
tional nature of childhood psychopathology and the process of matching
treatment to the individual needs of patients. It establishes hypothesis test-
ing as the norm and can encourage investigation of the evidence base for
explanatory theories and treatment interventions. Surveys suggest that psy-
chiatry residency programs view case formulation as important but do not
118 WINTERS et al
provide clear guidelines for how to construct formulations [8]. Even experi-
enced clinicians may not routinely construct comprehensive case formula-
tions, and most agree that case formulation is a poorly dened and
undertaught skill [8]. Perry and colleagues [6] described ve misconceptions
to explain why clinicians do not regularly do case formulations: (1) the belief
that case formulation is only for patients in long-term psychotherapy, (2)
the view that case formulation is primarily a training experience and unnec-
essary for experienced therapists, (3) the belief that case formulation is an
elaborate and time-consuming process, (4) the view that a loosely construed
formulation in ones head is sucient and does not need to be written,
and (5) the worry about becoming so invested in a formulation that one
will not accept information that does not t the formulation. They counter
by arguing that case formulations are just as important for short-term as for
long-term treatment, are best in written form, need not be time consuming,
and facilitate understanding of events that may not t the formulation. Sha-
piro [7] added a sixth misconception: formulation is only useful for individ-
uals who plan to do a dynamic therapy with a child. He emphasized that
dynamic understanding also may guide a clinician toward other therapies.
It is also important for understanding the signicance of symptoms to chil-
dren and their families and the risk of changing the dynamic equilibrium of
the person treated and of the family.
Various factors contribute to resistance on the part of residents and fac-
ulty to learning and teaching comprehensive case formulations. Develop-
ment of a case formulation is a longitudinal process. It requires sucient
time to get to know a child and family and the role of all the interacting con-
textual variables. In practice, formulations are continually revised with new
information. This may be a challenge, with nancial and managed care con-
straints leading to shortened lengths of stay in outpatient, residential, and
inpatient settings. Residents need cases of sucient duration to develop
and rene good case formulations. Residents formulations may be rudi-
mentary early in training and should be more comprehensive as their skills
expand over time. They may be more likely to focus on biologic issues early
in training and gain more comfort in incorporating psychological and socio-
cultural issues over time. The fact that most child psychiatry residents enter
child psychiatry after their third year may complicate this progression, how-
ever. In adult psychiatry they have spent much time in fast-paced inpatient
settings in which there is not enough time or knowledge of the patient to go
beyond dierential diagnosis. They have not had the benet of a fourth
year, which generally oers added experience in longitudinal and in-depth
psychotherapy. Instead, when they come to child psychiatry they are thrust
into a dierent world in which formulations require consideration of multi-
ple interacting contextual factors, such as the parents own psychological is-
sues, family dynamics, and the quality of the childs school environment.
Residents who come from adult psychiatry are more accustomed to seeing
a patient as an individual rather than in the context of a family or other
119 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
systems. They no longer come into child psychiatry training with a predict-
able exposure to psychodynamic and family systems theoretical models.
When asked to formulate cases, residents may be apprehensive about
not getting the right answer, because there is no checklist or prescribed
formula for case formulation. Contrast this with the more typically enthusi-
astic reaction to a rating scale that is easy to administer and score and yields
what seems to be (but often is not) a clear answer. Teaching faculty are not
immune to these factors either and may prefer to engage in discussion of
areas that are perceived as more tangible and better dened, such as psycho-
pharmacology. Residents do not understand how case formulation can be
useful. They may be aware of case formulation as a requirement for the
American Board of Psychiatry and Neurology oral examination, but they
do not know how it can inform and guide treatment. It can become another
burdensome requirement, or it may not actually be required in their clinical
rotation sites. Most written documentation is driven by medicolegal or in-
surance requirements and includes the ve-axis DSM-IV-TR diagnosis but
not necessarily a case formulation. Case formulation is often not a formal
part of the curriculum and the literature to support teaching it is scant.
Most of the available articles are about psychodynamic case formulation
in adults. The implicit message is that case formulation is not essential.
To address these problems, case formulation should be made a formal
part of the curriculum in child and adolescent psychiatry. Case formulation
should be taught in didactic seminars, case conferences, and supervision,
and some written case formulations with supervisory feedback should be re-
quired. The process of learning to formulate is enhanced by case confer-
ences, in which experienced clinicians demonstrate the construction of
a comprehensive biopsychosocial formulation. Especially useful is the op-
portunity for residents to observe faculty doing case formulations in the
moment after seeing a new case. It also can be helpful to distribute written
examples of a succinct, well-written comprehensive case formulation. One
way to practice formulation is to construct it as a group, having each
resident take a turn contributing part of the formulation. The discussion
includes how to develop specic treatment plans based on elements of the
formulation, including the timing of dierent interventions and the progno-
sis. It is essential to create a nonjudgmental climate in which any formula-
tion ideas are acceptable and seen as having merit.
Too often case formulations are taught as part of the initial assessment
but not in the context of cases as they evolve in treatment. It is important
to illustrate how an evolving formulation changes the treatment plan in sig-
nicant ways or, in some cases, may explain a poor response to treatment. It
is also helpful to revisit cases later in the course of treatment that had been
formulated in case conferences. This review provides an opportunity to see
whether the hypotheses generated were borne out and how new information
obtained in the course of treatment modied the treatment plan. In a similar
vein, the case formulation should generate hypotheses about prognosis. It
120 WINTERS et al
should identify potential obstacles or areas of resistance that may arise in
the treatment process and how to address them. A case formulation also
can include consideration of issues that may arise in the therapists reaction
to the patient and family that might present obstacles to progress. For ex-
ample, a resident who knows that she or he identies with a rebellious
adolescent wanting more autonomy may have diculty developing a con-
structive alliance with the parent. Residents also need to learn how to inte-
grate formulation of the parents psychological strengths and vulnerabilities
with the child formulation. This understanding is critical to engaging the
parents in a constructive therapeutic alliance, without which treatment of
the child is generally unsuccessful.
Construction of the case formulation
The case formulation process begins with a comprehensive assessment
that includes interviews with the child and the parents together, the parents
alone, the child alone, and review of ancillary sources of information. The
order of these components varies depending on the age of the child, the pre-
senting problems, and other contextual factors. Broad-band and specic
symptom rating scales can augment the data collected and may be an easier
way for participants to share some information. Information should be
gathered in the areas needed to identify a DSM-IV-TR diagnosis and con-
struct a comprehensive biopsychosocial formulation as described in Table 1
and Box 1. The chief complaint and goals for treatment should be ascer-
tained from each participant, and the signs and symptoms should be elicited
and characterized with respect to onset, precipitants, severity, observable
patterns, the contexts in which they occur, and their eect on the child
and family. A complete medical, developmental, and educational history
should be taken, as should a family assessment and information about the
patients social functioning and sociocultural or environmental factors con-
tributing to the problems. Strengths in the child and family should be iden-
tied and acknowledged throughout the interview and data collection
process.
In the assessment of a child there is a need for balance between direct ob-
servation and inference from limited or indirect information. This balance is
especially important in children with less ability to verbalize and about whom
more inferences are made. The mental status examination is an opportunity
to directly observe and assess areas of the childs functioning needed for the
dierential diagnosis and biopsychosocial formulation. The mental status ex-
amination in child psychiatry uses multiple assessment methods, including
verbal interaction, play, and drawing or other expressive activities. Each mo-
dality provides information about the childs capacities, thought content, and
way of relating to others. Areas in the mental status examination relevant to
the case formulation include observable signs, such as psychomotor
121 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
Table 1
Biopsychosocial formulation grid with examples of predisposing, precipitating, perpetuating, and protective factors in each of the formulation domains
Domains Biologic Psychological Social
Factors
Genetic, developmental,
medical, toxicity,
temperamental factors
Cognitive style, intrapsychic
conicts and defense
mechanisms, self-image,
meaning of symptoms
SocialRelationships
Family/peers/others
SocialEnvironment
Culture/ethnicity, social risk
factors, systems issues
Predisposing
(vulnerabilities)
Family psychiatric history,
toxic exposures in utero,
birth complications,
developmental disorders,
regulatory disturbances
Insecure attachment, problems
with aect modulation, rigid
or negative cognitive style,
low self-image
Childhood exposure to
maternal depression and
domestic violence, late
adoption, temperament
mismatch, marital conicts
Poverty, low socioeconomic
status, teenage parenthood,
poor access to health or
mental health care
Precipitating
(stressors)
Serious medical illness or
injury, increasing use of
alcohol or drugs
Conicts around identity or
separation-individuation
arising at developmental
transitions, such as puberty
onset or graduation from
high school
Loss of or separation from
close family member,
family move with loss of
friendships, interpersonal
trauma
Recent immigration, loss of
home, loss of a supportive
service (eg, respite services,
appropriate school
placement)
Perpetuating
(maintaining)
Chronic illness, functional
impairment caused by
cognitive decits or
learning disorder
Use of self-destructive coping
mechanisms, help-rejecting
personality style, traumatic
re-enactments
Chronic marital discord,
lack of empathy of parent,
developmentally
inappropriate expectations
Chronically dangerous or
hostile neighborhood, trans-
generational problems of
immigration, lack of
culturally competent services
Protective
(strengths)
Above-average intelligence,
easy temperament, specic
talents or abilities, physical
attractiveness
Ability to be reective, ability
to modulate aect, positive
sense of self, adaptive coping
mechanisms
Positive parent-child
relationships, supportive
community and extended
family
Community cohesiveness,
availability of supportive
social network, well-
functioning child/family
team
Adapted from Barker P. The child and adolescent psychiatry evaluation: basic child psychiatry. Oxford, UK: Blackwell Scientic, Inc.; 1995.
1
2
2
W
I
N
T
E
R
S
e
t
a
l
abnormalities, the childs description of his or her symptoms, the childs af-
fective states throughout the interview and predominant mood as observed
and described, language and motor functioning, cognitive functioning,
thought process and thought content or perceptual abnormalities, wishes,
self-concept; view of the family, developmental conicts and other psycho-
logical themes, judgment and the capacity for self-observation and insight,
and motivation to change and availability to engage in treatment. Of sig-
nicant importance in the assessment of a child is the identication of
strengths and protective factors. Strengths in the child and family can
be used as foundations for treatment interventions; they generate motiva-
tion for working on the challenging areas through formation of a positive
therapeutic alliance and instillation of hope. The child and familys views
of the problem and its causes and areas they identify as strengths are cor-
nerstones in building a collaborative evolving case formulation.
The biopsychosocial formulation grid in Table 1 adapted from Barker
[27] provides a structure that can be useful for residents. The informa-
tion gathered in the assessment is put into a biopsychosocial framework,
which addresses each of the three domainsdbiologic, psychological, and
Box 1. Construction of the formulation and generation
of a treatment plan
1. Brief summarizing statement that includes demographic
information, chief complaint, and presenting problems from
child and familys perspective and course (onset, severity,
pattern) of signs and symptoms
2. Precipitating stressors or events
3. Biologic characterization
4. Psychological characterization
5. Family and other interpersonal factors
6. Sociocultural and environmental factors
7. Role performance, including level of functioning in major
areas of daily life
8. Strengths and protective factors of the child, family, and
system
9. Differential DSM-IV-TR diagnosis
10. Integrative statement: how the factors interact to lead to the
current situation and level of functioning, prognosis, and
potential openings for intervention
11. Problem list
12. Treatment plan
Note: the four Ps should be included in steps 3 to 8.
123 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
socialdwith regard to the following factors, which have been called the
four Ps [27,28]:
1. Predisposing factors are areas of vulnerability that increase the risk for
the presenting problem. Examples of biologic predisposing factors in-
clude genetic loading for aective illness and prenatal exposure to
alcohol.
2. Precipitating factors are typically thought of as stressors or other events
(they could be positive or negative) that have a time relationship with
the onset of the symptoms and may serve as precipitants. Examples of
psychological precipitating factors may include conicts about identity
or separation-individuation that arise at developmental transitions,
such as puberty onset or graduation from high school.
3. Perpetuating (or maintaining) factors include any conditions in the pa-
tient, family, community, or larger systems that serve to perpetuate
rather than ameliorate the problem. Examples include unaddressed
parental conict, in which a child becomes an identied patient,
a poor match between the educational services, and the childs learn-
ing needs.
4. Protective factors (strengths) include the patients own areas of compe-
tency, skill, talents, and interest and supportive elements in the family
and the childs extrafamilial relationships. Examples in the social do-
main might include the child having a good relationship with an un-
derstanding elementary school teacher or a favorite uncle. In the
biologic domain, the child might have a talent in sports or music
that can be helpful in engaging him or her in treatment and enhancing
self-esteem.
5. Prognosis and potential for change is an additional P that should be
included in the case formulation. This includes identication of areas
most amenable to change and potential obstacles to successful treat-
ment, such as when a youngster with school avoidance is rewarding
by being allowed to stay home for long periods of time.
This grid can be used to facilitate comprehensive examination of areas
needed for a biopsychosocial formulation. After these factors have been re-
viewed, the formulation should be used to develop a problem list, dieren-
tial diagnosis, and generation of a treatment (see Box 1). This content can be
translated into a succinct narrative as illustrated in Box 2 using the residents
case formulation example.
Using supervision to co-develop and rene a case formulation: a child
psychiatry residents case example
The following formulation presented in two parts followed by a postscript
illustrates the interactive, evolving co-development of a case formulation in
supervision. The resident developed the rst formulation after 2 months of
124 WINTERS et al
treatment and revised the formulation to incorporate additional elements af-
ter discussing the case with the supervisor.
First case formulation
A 17-year-old girl was referred for her rst psychiatric evaluation after 8
months of unsuccessful treatment for pain of unclear origin. The immediate
reason for referral was the patients worsening symptoms of depression and
new onset of visual hallucinations. These symptoms had developed gradu-
ally after a febrile illness (presumed to be viral) that presented with vomiting
and diarrhea. Her vomiting failed to resolve after the infection cleared, how-
ever, and had led to a 25-pound weight loss. No medical cause had been
found for the intractable vomiting.
Relevant prior history included additional gastrointestinal diculties.
She had had multiple diagnostic procedures, which were ultimately incon-
clusive. In the initial interview the patient did not express any distress about
her persistent vomiting, although she did report feelings of overwhelming
depression and being scared by visions of people in my room. Her
mother, whose primary concern was her persistent vomiting, brought a cal-
endar and a diary to the interview that contained detailed documentation of
her vomiting. It was not learned until the sixth visit that the patients vomit-
ing had started insidiously approximately 6 months before the presumed
viral infection. Around that time she had a major conict with her biologic
father and decided to stop contact with him.
She also had a history of academic underperformance. A school psychol-
ogists evaluation, performed before the onset of her medical problems 4
years ago, did not qualify her for special education but recommended coun-
seling. The patients mother decided at that time to home-school her to im-
prove her academic performance. Initially, they were part of study groups
with other home-schooled children. Because of the patients multiple medi-
cal problems, low energy, and inability to get out of bed on most days, how-
ever, the mother withdrew her from the groups. The patients social
interaction with peers her age has been limited to a weekly youth group
at church. She reported that she has never been able to have a friendship
lasting more than a month. She is overly sensitive to others comments
and often loses interest in friends after they disappoint her.
There seemed to be signicant enmeshment and ambivalence in the
mother-daughter relationship. The patient uses somatization as a way to ex-
press her feelings. Although her visions are clearly distressing, they have
a phobic, rather than psychotic, quality. She was oered the option of an
antipsychotic medication and later reported relief of her fear but continued
to have the visions. Although the information gathered indicated that she
met the diagnostic criteria for bulimia nervosa after the rst visit, the diag-
nosis of an eating disorder was not introduced until the fth visit. It was felt
that presenting this diagnosis could interfere with forming a therapeutic
125 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
Box 2. Construction of the formulation and generation
of a treatment plan: case example
The patient is a 17-year-old girl who lives with her mother and
stepfather. She was referred by her primary care physician for
evaluation of new onset visual hallucinations and worsening
depression. She has had intractable vomiting with a 25-pound
weight loss after a viral illness 6 months ago; no explanation
has been found despite repeated diagnostic procedures. She
also has a history of multiple other medical symptoms and
pain without identied causes. The patients main concern
is her worsening depression, whereas the mothers main
concern is her vomiting. A possible precipitating event
concurrent with the onset of vomiting was that the patient
had a signicant conict with her biologic father and
decided to end contact with him.
The patient has been home-schooled for the past 5 years
because she was underperforming academically, although
psychological testing revealed no cognitive decits. This
situation has led to some social isolation. Currently, her mother
closely monitors and keeps records of her medical symptoms,
and the two spend much of their time together. Mental status
examination reveals a normal appearing but thin young woman
with signicant depressive symptoms; her visions are more
consistent with anxiety than psychotic hallucinations. Her
sense of self-worth is linked to her appearance, particularly of
thinness. She feels she has no friends and is not secure about
her relationship with her mother. She nds it difcult to
verbalize her emotions and seems to use somatization as a
vehicle for emotional expression.
The patient has several biologic risks for psychiatric difculties,
including being exposed in utero to psychotropic medications,
likely including alcohol. She seems to have an anxious
temperament, which was likely exacerbated by an insecure
attachment related to her mothers emotional unavailability
during her infancy when the parents marriage ended and her
mother began a new relationship with the patients stepfather.
Psychologically, she had difculty with affect modulation in
infancy, which has persisted. She is highly reactive to
interpersonal slights and subsequently has not been able to
form trusting relationships with adults or peers. Her sense of
self-worth seems to be invested in her appearance, which puts
her at risk for an eating disorder.
126 WINTERS et al
Her medical symptoms have particular signicance within the
mother-child relationship and seem to serve the function of
engaging her mothers attention. Her mother oscillates
between being overly attentive to her daughters medical
systems and being unattuned to her psychological needs and
desire for autonomy. There is a secondary gain to the
daughters medical complaints because they elicit the
mothers attention and prevent the mother from leaving
the house, thereby maintaining the mother-daughter
enmeshment. In addition to somatization, she uses the
defense mechanisms of displacement (onto her body),
isolation of affect, repression of anger, and some psychotic
distortion of reality to cope with conicted emotions and
distressing affects. Psychodynamically, the patient seems to
need to be ill or mirror her mothers medically oriented
perception of her problems to stay connected to her mother.
Socioculturally, her family is religious and has concerns about
her acceptance of their value system. Currently the patients
functioning is impaired in all her major life roles, including
academic, peer relationships, and behavior in the family
setting.
The patient also has notable adaptive interests and capacities.
Lately, she has been learning to drive and expresses interest in
spending time with people her age. She is an attractive young
lady who expresses interest in making changes in the way she
approaches life. These motivations, if supported by her
mother, could help her to relinquish her physical symptoms. It
is unclear, however, whether the closeness of the patient and
her mother currently based on her medical symptoms can shift
to a healthy adolescent separation-individuation process.
Diagnostically, she meets criteria for major depressive disorder
with possible psychotic features, bulimia nervosa, and
somatoform disorder not otherwise specied. The problems
to address in treatment include her depressive and anxiety
symptoms, her vomiting, her social isolation, and psychological
barriers in mother and daughter to the daughters normative
adolescent separation-individuation process. The treatment
plan includes (1) pharmacotherapy with an antidepressant and
short-term use of an atypical antipsychotic, (2) individual
psychotherapy with supportive and cognitive-behavioral
components to help the patient develop more adaptive ways
to express psychological needs and conicts and advance
toward normative age-appropriate goals, and (3) family
127 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
alliance with the mother and patient, because they were very invested in
other medical explanations. When it was presented, the patients mother
was reluctant to accept this diagnosis and continued to insist that the patient
was vomiting because of a medical reason that had not been identied. The
mother became distraught when family therapy was recommended and in-
sisted that treating her daughters depression would lead to an improvement
of her appetite and resolve the vomiting. The patient did report dramatic im-
provement in her energy when her antidepressant dose was increased. She
was continuing to spit up in the middle of the night but had not vomited
in 2 weeks. They continued to come for weekly appointments.
Additions made after the case was discussed in supervision
The patient has several biologic risks for psychiatric diculties, including
a history of being exposed in utero to psychotropic medications, likely in-
cluding alcohol. She seems to have an anxious temperament, which was
likely exacerbated by an insecure attachment related to her mothers emo-
tional unavailability during her infancy when the parents marriage ended
and her mother began a new relationship with the patients stepfather. Psy-
chologically, the history suggests that the patient had diculty with aect
modulation in infancy, which continued through her childhood. She is
highly reactive to interpersonal slights and subsequently has not been able
to form trusting relationships with adults or peers. Her sense of self-worth
seems to be invested in her appearance and the desire to change her weight,
which increases her risk of developing an eating disorder.
The patient also had developmental problems that manifested in aca-
demic problems in elementary school 4 years ago. After an unrevealing ed-
ucational assessment, she was home-schooled, which further limited her
opportunities to develop peer relationships. In the past 5 years she endured
multiple medical evaluations and procedures and four hospitalizations for
medical problems, which further interfered with her schooling. She is not
able to verbalize her anger, and her vomiting seems to correlate with emo-
tional distress in place of verbal expression.
Her medical symptoms seem to have particular signicance within the
mother-child relationship and seem to serve the function of engaging her
mothers attention. Her mothers response to her oscillates between being
overly involved and attentive to her medical symptoms and being
therapy to help the mother-daughter relationship support
the daughters age-appropriate separation-individuation.
The initial goal of family therapy would be to develop a
constructive alliance with the parents, which requires respect
and validation of their goals and values and their concerns
about the daughters ability to handle more autonomy.
128 WINTERS et al
unsupportive regarding her psychological vulnerabilities and desire for au-
tonomy. She emphasizes medication as a solution to psychological prob-
lems, which minimizes the importance of her own and the patients
psychological involvement in the treatment process. There is a secondary
gain to the daughters medical complaints because they elicit the mothers
attention and prevent the mother from leaving the house, thereby continu-
ing the mother-daughter enmeshment.
In addition to somatization, she uses the defense mechanisms of displace-
ment (onto her body), isolation of aect, repression of anger, and reaction
formation to cope with conicted emotions and distressing aects. The pa-
tients comment that she never felt connected to her mother suggests that
the use of somatization is associated with what Winnicott referred to as
a false self [29] incorporating the need to be ill or mirror her mothers
symptom-oriented perception of problems to stay connected to her mother.
At times, she also uses the defense of psychotic distortion of reality. Another
possible contributor to her anxiety, aective, and psychotic-like symptoms
could be trauma related to multiple invasive medical procedures or possible
physical abuse as a child.
Alongside these constitutional and psychological vulnerabilities, the pa-
tient also has some adaptive interests and capacities. Lately, she has been
learning to drive and started expressing interest in spending time with people
her age. She is an attractive young lady who expresses interest in making
changes in the way she approaches life. These motivations, if supported
by her mother, could help her to relinquish some of her physical symptoms.
It is unclear, however, whether the closeness of the patient and her mother
currently based on her medical symptoms can shift to a healthy adolescent
separation-individuation process. The treatment plan includes individual
psychotherapy with supportive and cognitive-behavioral components to
help the patient develop more adaptive ways to express psychological needs
and conicts and help her advance toward normative age-appropriate goals.
Family therapy has been recommended to help support the mother and
daughter to recongure their emotional involvement to support age-appro-
priate separation-individuation. The mothers need for the daughter to re-
main dependent by being medically ill may be dicult to address without
the mother receiving her own individual therapy, however.
The resident used the Defensive Functioning Scale in the DSM-IV-TR
[30] to consider the patients symptoms in terms of their defensive functions.
The addition of an expanded psychodynamic formulation helped the resi-
dent more fully understand the patients extreme dilemma. Her desire for
age-appropriate autonomy was directly in conict with her ongoing need
to repair a historically weak emotional connection with her mother. Relin-
quishing her physical symptoms would require her mothers willingness to
work to accept a less enmeshed form of relatedness with her daughter,
with the attendant psychological risk (for both of them) of her daughter feel-
ing free enough to develop other intimate relationships.
129 CHILD AND ADOLESCENT PSYCHIATRY CASE FORMULATION
After developing the expanded case formulation, the resident felt she was
working more successfully to help the daughter develop age-appropriate in-
terests and greater autonomy. The last part of this evolving formulation oc-
curred when she received a letter from the mother indicating her intention to
end the treatment because her daughter was becoming more disobedient at
home and not embracing the values of the family. In debrieng with the su-
pervisor, additional information was shared and integrated into the formu-
lationdthat the patients mother had become emancipated as a teenager
because of a dicult family situation. With her own potentially unresolved
adolescent separation, helping her daughter navigate these challenges would
understandably generate internal conict. By reviewing the case formulation
and its prediction of obstacles, the resident understood that an earlier
formulation of the mothers dilemma would have helped her work more
eectively with both partners. She recognized that it would have been help-
ful to put more therapeutic time into working directly with the mother and
stepfather to fully understand their goals and develop a collaborative formu-
lation and treatment plan.
Summary
Case formulation plays a central role in guiding treatment planning in
child and adolescent psychiatry. It helps synthesize many complex factors
into hypotheses about the cause of the problem. This comprehensive, indi-
vidualized picture helps to translate the diagnosis into the choice of where to
put therapeutic resources at a particular stage of treatment. The biopsycho-
social approach to formulation is the most comprehensive and facilitates the
clinicians attention to all the major domains. The case formulation is an on-
going and dynamic process, an evolving story or narrative that is modi-
ed as more information is added. Because children must be seen in the
context of their families, schools, neighborhoods, and larger ecology, the
case formulation in child and adolescent psychiatry is more contextual
and relies on multiple perspectives gleaned from a lengthier interview pro-
cess. In general, case formulation has not been taught extensively in psychi-
atric residency programs, and even experienced clinicians do not routinely
construct comprehensive case formulations. Most clinicians agree that
more time should be spent teaching and modeling construction of the for-
mulation in didactics, supervision, and case conferences. Including the child
and family in the construction and ongoing revision of the formulation and
addressing their strengths and needsdnot just problems or pathologydpro-
motes the therapeutic alliance. Integration of multiple theoretical and ex-
planatory perspectives can be useful in teaching and applying the case
formulation process. Clinical examples in the article illustrate aspects of
the case formulation and residents use of supervision to develop more elab-
orated and comprehensive case formulations.
130 WINTERS et al
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