How to Approach Neuropsychiatric Problems when You are not a Neuropsychiatrist: An Hierarchical Formulation

Abstract

Organizing clinical findings and psychiatric features surrounding young people with suspected brain disorder can be confusing and daunting. Putting the pieces together so that particular symptoms and behaviours fit into the child's experience as a whole requires a systematic way of conceptualizing that experience. One way of doing this is to consider the structure of what the child is experiencing as a hierarchy of organizational levels, each of which depends upon the integrity of the system below. Further, it is helpful for most clinicians to consider the child's functioning; first, in relation to environment and context and, second, intrinsically. That is to say what are the capabilities of a particular child viewed in isolation. The conceptual lynchpin of adaptation ties together the contextual dependency of the child and the intrinsic capabilities of the child. In examining the intrinsic experiences of the child the traditional mental status examination is also presented in an hierarchical form in which global abilities are dealt with first before specific skills. The subtle high-order integrative functions of sensorimotor integration, judgement and insight are presented last because they are the most readily disrupted by all that goes before in intrinsic function. Each level is presented as answering a fundamental question of connectedness to the whole of the child's experience. Finally, the capacity to transform the principal difficulty in examining a child into the central rationale for understanding impairments is explicated.