repertoire a function of poor learning opportunities,
or does this constriction represent an effort to avoid
close relationships with other people who might be
threatening?”
Clinicians thus begin with thereferral question.It
is important that they take pains to understand pre-
cisely what the question is or what the referral source
is seeking. In some instances, the question may be
impossible to answer; in others, the clinician may
decide that a direct answer is inappropriate or that
the question needs rephrasing. For example, the cli-
nician may decide that the question“Is this patient
capable of murder?”is unanswerable unless there is
more information about the situation. Thus, theThe Case of Billy G.
Billy was in the third grade and having trouble. His
teacher reported a number of classroom behavior
problems. Billy was loud, talkative, and easily dis-
tracted. He was aggressive, and sometimes he struck
the other children. His behavior was impulsive, erratic,
and obviously hyperactive. He had become a totally
disruptive force in the classroom.
Several conferences with the teacher finally con-
vinced Billy’s parents that the problem was not
completely the school’s responsibility. Indeed, much of
Billy’s behavior was mirrored at home, where he was
equally difficult to control. His grades had plummeted
in recent months, but his parents could not believe
there was an intellectual problem. Therefore, it
seemed to them that the explanation must lie in either
physical or emotional factors.
Their first decision was to take Billy to their family
physician. She could find nothing wrong physically and
suggested that they have Billy see a neurologist. After a
full neurological examination, including an electroen-
cephalogram and an exhaustive behavioral and medical
history, the neurologist could not arrive at a definitive
diagnosis.
There was no history of birth trauma, head injury,
encephalitis, or risk factors for neurological disease. At
the same time, a behavioral history compiled from
teachers’reports, parental observations, and the neu-
rologist’s own observations confirmed the existence of
a definite problem.
The neurologist was leaning toward a diagnosis of
attention deficit/hyperactivity disorder (ADHD). However,
the neurologist was psychologically minded, and he felt
that he detected a strained and somewhat hostile rela-
tionship between the parents. In the course of his con-
versations with the parents, he also learned that the
husband was rarely home and seemed totally absorbed in
his ambitions to advance in his job. The mother seemed to
be reacting to her self-perceived neglect by becoming
extremely active in community service and social func-
tions. When Billy came home from school, she was almost
always playing bridge, attending fund-raising activities,or shopping. It certainly seemed that neither parent had
much time for Billy. In fact, only since Billy’sproblemshad
come to a head in school had the parents seemed aware
of him at all.
Thus, the neurologist faced a diagnostic dilemma.
Because stimulant medication (e.g., Ritalin) has often
been effective with such cases, this might be the way
to go. On the other hand, there certainly seemed to be
a pattern of parental rejection that might have pro-
duced resentment in Billy. Therefore, the“hyperactiv-
ity”could be construed as an attempt to gain attention
from the parents and parental surrogates (teachers).
Such a formulation seemed to imply a recommenda-
tion of psychotherapy for the parents and for Billy as
well.
The neurologist was concerned about making the
wrong diagnosis. Medication has its side effects and
might even exacerbate the problem. Further, if the
problem were not ADHD, then Billy’s behavioral reac-
tions might become more established during the time
wasted, and psychotherapy might be more difficult. A
diagnosis of ADHD might also create a greater unwill-
ingness in the parents to accept their role in Billy’s
behavioral difficulties. On the other hand, suppose the
family went the psychotherapeutic route, only to learn
later that the problem was treatable with medication.
Then precious time would have been wasted, and per-
haps avoidable physical harm would have occurred.
Thus, the assessment question became one of
choosing between a behavioral or biological explana-
tion for Billy’s problems—each of which had very dis-
tinct treatment implications. Faced with this quandary,
the neurologist decided to refer Billy to a clinical child
psychologist, who could be expected to administer a
variety of intelligence and personality tests, to inter-
view the parents more thoroughly, and to observe Billy
under a variety of conditions. The neurologist hoped
that a psychological report, coupled with his own
neurological findings, would allow him to arrive at a
more informed diagnostic and treatment decision.THE ASSESSMENT INTERVIEW 163