Döpfner M, Lehmkuhl G, Berner W, Flechtner H, Schwitzgebel P, von Aster M, Steinhausen H C
Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Universität zu Köln.
Z Kinder Jugendpsychiatr. 1993 Jun;21(2):90-100.
A standardized documentation system for psychopathological findings allowing an assessment of psychiatric disorders in children and adolescents after clinical evaluation of the patient and his or her caregivers is presented. The symptomatology during the previous few months and the symptoms seen during the examination are rated separately. Altogether 113 items in 16 areas are assessed. In addition, motivation to participate in treatment is judged and a global assessment is made of symptom severity. A number of facilities are already employing this documentation system in their routine clinical work. In a first study 597 patients from a routine clinical population seen consecutively were assessed at the start of treatment. As expected, the most commonly recorded symptoms were those of expansive behavior. Such symptoms were seen much more rarely during the evaluation than outside this situation. The documentation system for psychopathological findings complements diagnosis by category according to ICD with a phenomenological description of psychiatric disturbances on the level of single symptoms. It enables simple and economical documentation of clinical findings after evaluation of the patient and his or her caregivers.
