Problems of Assessment

The aim of a diagnostic assessment is of course to arrive at as clear a picture as possible of a patient's mental state. This will include the individual's libidinal phase development, his cathexis of objects, defences, superego structure, and so on. In the case of the adult patient a specific symptom is almost invariably one aspect of a specific syndrome but we cannot, as Anna Freud stressed, make the same assumption with our child patients, who may show isolated symptoms that tell us little as to the underlying disturbance. In the diagnostic assessment of a child our task is to link the behaviour we can see and the symptoms that are reported with possible underlying causes. Such a process will suggest the likely unconscious conflicts underlying the delays, deviations and compromises that are interfering with the patient's mental health.

I propose to describe two cases in which I have been involved as the diagnostician which will highlight some of the difficulties that may face us when attempting to arrive at a satisfactory statement of a particular child's pathology.

Prior to meeting with the child we put together as full a social history as possible, a school report and any other relevant information such as medical reports. The social history will outline the parents' view of their child's problems, the development of symptoms and the child's reaction to them. Also contained in the social history is the parents' account of the child's overall development, physical and social, and an account of the parents' backgrounds, their education and work and the marital relationship.

The first case I will describe highlights the difficulty that the diagnostician may encounter when seeing for assessment a child who is preoccupied with sexual concerns. Keeping a balance between learning about the patient's inner world whilst not appearing seductive, watching for indications of premature transference while assessing the child's treatability, calls for an unusually cautious