Piaget and electronic medical record

To the Editor

The advent of electronic medical record (EMR) in the New South Wales Health Department has highlighted long-standing issues in relation to the assessment and recording of child psychiatric information. In particular, the use of universal EMR protocols makes the incorrect assumption that pre-pubertal children are small adults and can be assessed with the same set of data files. This reflects common misunderstanding of child development, but could present an opportunity to incorporate a more accurate and useful developmental approach into the assessment of children and early adolescents. While changes might be made in a number of areas such as questions about alcohol use, the most important from a child psychiatric perspective is the Mental Status examination.

The developmental insights provided by Piaget (1926) could form the basis of a more useful approach, which reflect a child’s intellectual capacity at particular stages of development. Most important are two crucial developments. The first is the development of spoken language, which allows the transition from sensori-motor intelligence to representational thought, freeing the child from the limitations of direct action. According to Wadsworth (1984), Piaget believed that affective development is also based on capacity for representation and reciprocity of attitudes and values between the young child and others. This development is thought to occur during the stage of preoperational thought from the age of 2 to 7 years.

A further major and significant change occurs around the age of 11–15 years with the development of formal operations, where there is a further ‘freeing’ of thought from direct experience. Formal operations differ from concrete operations in that they allow the child or earlyadolescent to think about thoughts, namely, to reflect. Thus, formal operations are characterised by ‘scientific reasoning and hypothesis building’ (Wadsworth, 1984). Importantly, there are major changes in moral development during this stage, where thereis an evolution from asocial judgement (expiatory punishment) to social judgements (reciprocity), where intent and circumstances can be considered. This is an intensely idealistic stage of development and perhaps accounts for positive and negative influences on idealism and philosophical adolescent thinking. Classical Piagetian teaching could be considered specialised, but it provides a body developmental understandings that are in danger of beingforgotten, as well as potential for further updated investigation.

A more recent set of child Mental Status examinations is provided in Kaplan et al. (2014) textbook, which also indicates childhood differences.