(I know I tend to make lists, but, as Maria in the Sound of Music sings in the song, "Do, Re, Mi," "When you know the notes to sing, you can sing ‘most anything." So having a sense of the range of possibilities, or perhaps, using a computer metaphor, "the full menu" of options, allows you to better select which variables are most relevant in the situation at hand.)
I address many dimensions of mind. Just as the workings of the human body may be conceptualized as occurring on several simultaneous levels: atomic, molecular, macro-molecular (genetic), sub-cellular, cellular, tissue, organ, organ system, and organismic, so also the workings of the mind derive not only in part from all these somatic levels (in the mind's neuro-physiology), but also include a far wider scope of activity: the mind-body interactions, intra-psychic dynamics (i.e., the interplay of the different parts of the mind, such as the inner parent and inner child, etc.); and the interpersonal, family, small- and large-group, organizational, sub-cultural, cultural, and even planetary levels of operation. The point is that these many factors transcend any single theory–behaviorism, psycho-analysis, cognitive theory, etc. The important thing is to be able to keep them all in mind.
In rough order of their appearance in life, then:
of being held, touched, warmth, clothing, was there
swaddling, voice tone, emotions in the home, numbers and consistency of
caretakers, adjustments to feeding, food sensitivity, colic
Were the parents attuned to temperament, balanced between under-stimulation and over-stimulation. Were the stimulus thresholds recognized?. Was there novelty, opportunities for exploration, movement, consistency of being fed, cleaned, cared-for without too much build-up of frustration?
Development of "object permanence": increasing gradual separations from parenting figures and opportunities to discover inner resources for coping. Attachment and Loss: have there been significant attachments to a parenting figure, even a "nanny" that have been disrupted before the age of four? Other caregivers may also be significant, such as a grandparent.
Exposure to alternative attachment figures: Has infant, especially after about six months of age, had opportunities to develop partial attachments to other caretakers and so reduce the purity of the "enmeshment"? (Fathers, uncles, siblings, and others are important relationships to be cultivated.)
Allowing child to sleep in his own crib? (Many parents fail to make adequate boundaries or subconsciously keep infant enmeshed.)
allergies (especially milk allergy) sleep disturbance,
recurrent ear infections, antibiotic treatments irritability,
to explore, develop self-reliance?
Was the child able to be shifted from being fed to holding one's own bottle and implements, beginning to feed oneself?
Are expressed emotions allowed or forbidden? Opportunities for variety of types of play? Who plays with the child? How much?
Opportunities to choose? Are preferences ever honored?
Gradual? Rushed? Pressured?
An experience of mastery or subservience?
Parental use of language: Are there stories, singing, pleasant? Harsh criticism, humiliation, warning, shouts directed at child, at other children, at spouse? Quietness, constriction, mom depressed, fearful? Are the Parents stressed, busy, no time for play, full of doubt, or perhaps unaware of how to play with their children? Parents uncomfortable with their own "inner child" and so envious of play, suppress it in child? Premature pressure for skill building and being "good" instead of playing.
moves supported or
undercut by worry, anxiety, possessiveness, narcissism.
Can parents allow for differences in taste, interests?
Is there empathy for child, humiliation, non-responsiveness?
Sibling relations become increasingly important. Are older sibs supportive or competitive? Is there rivalry? Affection? Does a new younger sib supplant the older or is the transition made palatable by the family? Is the older sib prevented from displacing feelings onto the younger one?
abilities to nurture must be supplemented by abilities
to set limits and enforce them comfortably and consistently. Many
parents have difficulty with this. Fearing spoiling, do they become too
restrictive or harsh?
Fearing "hurting the child's feelings," do they become too indulgent?
Age-appropriate toys, child-proofing home.
school, having other children
around, reciprocal baby-sitting.
Temperamental differences: Are they being noticed or acted on?
are being made for differences?
Exposure to excessive television.
Freedom from overstimulation or molestation.
environments: smoke, pollution,
general uncleanliness, severe poverty
Foods: Use of food as pacifier, as love. Use of junk foods, high fat, high salt, high sugar. Food sensitivities leading to hyperactivity. (food colorings, sugar, chocolate, other foods)
Beginnings of group play. Some supervision and protection from bullies? Prevention of bullying or spoiled behavior towards others? Premature exposure to competition, "losing" while others "win", humiliation, pressure to perform beyond ability?
of growing vocabulary. Interaction, not just
commands or scolding.
Beginning to answer questions about death, God, prejudice/
Quality of Models: Opportunities to witness appropriate role behavior by adults, older children and peers. Or, exposure to inappropriate behavior as models--arguing, sexuality, drugs, drunkeness, violence, crudity
Moving: Disruption of familiar environment. Loss of friends. Changes of caregivers (nannys, nursery school teachers)
Separation of parents, loss of major caretaker.
play, stories, art, music.
Family roles: alliances, scapegoating, patterns used to gain attention. Formation of early positive or negative identities as "weak," "good boy," "baby," "little mother," "Daddy's girl/boy," "mischeivous," "sissy," "dumb," "just like his father," etc.
impact of illness, Degrees of separation (especially
for younger children). Fears of mutilation, loss of penis or body
Guilt--illness experienced as punishment for misbehavior. Hospital
experiences, degree of trauma, pain.
Amounts of preparation, allowing some control, explaining.
Reinforcement for the "sick role," secondary gain
Unnecessary restrictions of activity. Lack of stimulation, boredom. Complications, disabilities, handicaps.
Some of the variables include: Separations because parent is in
Degrees of worry in child and family.
Lack of information and catastrophic fantasies.
Chronic recurrent illness.
Feeling rejected or neglected by parental withdrawl. Ambivalence
to love/care for and yet resentful towards the sick parent. (Remember
that time in hospital is only a fraction of the overall time the
illness is operating, both before and after hospitalization)
Concern/anger if parents not "taking care of themselves." All
these can be amplified if there was co-morbid psychological factors,
self-pity, helplessness, grumpiness, irritability, non-compliance, etc.
Parental fighting? Parental inconsistency, shifts of mood between
calm and mean
Verbal or physical violence to spouse, sib, or child? Poverty, moving?
parent or other important figure.
Modeling, idea of "escape" mixed guilt and rage
intensity, and quality: Is there constructive
problem solving? Bickering, name-calling, cursing,
violence? Explosive, unexpected, or gradually intensifying?
Chronic or episodic?
What is the mood in between fights--tense, withdrawn, loving? Who tends to "win" and who "gives in"?
Divorce or separation of the parents--or of the client, if s/he is an adult? Many related questions about how that went, what it was about, etc.
Parental demandingness, rigidity, pressure to compete? Was there competitiveness with the child, were there tendencies to degrade, humiliate, verbally abuse? Tendencies towards overprotection, indulgence? Volatility, inconsistency, double binds?
and other animals--Have they been positive or negative?
Spiritual awakening? wonder? beauty?
or associated with discomfort, insect bites, temperature extremes?
with other children, other people on
television? (i.e., people who only know of others at their own
level of poverty or wealth don't experience the problems of envy or the
guilt for being envied.) What have been the degrees of wealth, poverty,
insecurity? Were the children subjected to unnecessary stinginess in
child rearing, purchasing minimal play materials, art supplies,
significantly fewer toys than peers.
On the other hand, was there an excessive indulgence in toys, or was
the person "spoiled" or "pampered" by unrealistically extravagant
parental behaviors. (And could the child whine or manipulate more toys?)
Household Chores: Are there age-inappropriate expectations? Are they unrealistically excessive, or too lax, with few or no expectations.
experienced? Was the client as a child frightened by scary
stories, such as about "hell"
? Did it lead to excessive guilt and self-monitoring,
Restrictions on what is permissible to even admit into consciousness.
Disparaging other religions, peoples, etc. What were the sources of support, positive structuring of thought. Pleasant or stiflingly boring church experiences?
Teachers--harsh, pleasant, alternative models, Step-parents, relatives, grandparents?
Ministers, youth group leaders, neighbors, Friends' parents
Illnesses of grandparents or other significant adults?
Sometimes these illnesses distract parents in their capacity to pay attention to their children.
Psychiatric illnesses, suicides, alcoholism, depression, rage attacks, and so forth especially significant.
Limit-Testing: Stealing, lying, experimenting with fire, How experienced being caught, how dealt with
Opportunities to experience success in areas of talent without being pressured or plunged into premature failure.
Freedom from exposure to excessive performance demands, such as h aving to memorize a complex part for a school play; or having to compete even when child believes she can't win
social or economic class, race, strength, size; physical attractiveness, intelligence, disability; familiarity with other kids or new in school/neighborhood; part of a clique or an isolate
identity: comfort, role adequacy; advantages or
disadvantages of being one's gender in family or culture.
(Some familiers favor girls; some cultures favor boys;
etc.) attitudes of each parent.
being liked as one's assigned gender without feeling exploited or excessively self-conscious
Freedom from excessive praise, comparisons, or being built up unrealistically. (This leads to feelings of being a
fraud, that one can't keep up the show, and/or that less worthy abilities or feelings cannot be revealed.)
Social diversity: access to adequate numbers of playmates with whom one shares similar interests or abilities.
to peers, recreational activities.
Geographic: can one get around walking or with a bicycle or must one be driven or take a bus. How isolated is the home?
After-school: academic, religious, music, dance, art, pet training, etc.
Informal: building, exploring, skill development, diving (Opportunities or encouragement in hobbies, projects)
Economic: can the family afford clubs, camps, activities?
Social: Is family too busy to transport child? Are there church youth groups? Outings?
Family: Outings, reuinions, holiday gatherings, picnics, celebrations, opportunities to participate, contribute make things, prepare skits, give gifts Who accompanies child? At what age does child go with peers or by self?
Subtle handicaps or deviations: near-sightedness, deafness, shortness of stature or tallness, obesity or excessive
thinness, regional accents. In some areas, even red-hair, odd dress. A little later, premature or late sexual
Occasional homosexual experimentation
Sexual explorations with members of the opposite sex: Were they discovered, and if so, what were the authorities' reactions? Learning about sex. Was there sexual abuse or over-stimulation by older children or adults?
Humiliation or coercion by insensitive or subtly suggestive comments by parents or others
Early sexual experiences– before the youngster can handle them emotionally
maturity. (Later, late maturation and feelings of
Premature pressure for sexual activities. For girls, having to wear lingerie, make-up earlier than they would like
Early homosexual desires, feeling different, vulnerable.
an "in-group" or feeling left out.
Shifting alliances, "betrayal" by "best friends"
Pressure for dating, sexuality, getting a "boy friend" or "girl friend."
Opportunities to earn extra money with odd jobs. Were there any experiments with amateur business, selling lemonade, Girl Scout cookies, tickets to raffles, etc.
Negotiations regarding allowances.
Feelings about holiday gifts, realistic awareness of family finances
Responsibility: First jobs, baby-sitting, lawnmowing, chores.
Special interests emerging: doctor, pilot, military, etc.
Early idealisms and affiliations: Political, Artistic-musical, tv heroes, etc. Religious
family, school, church, club, etc.
Cooking, sewing, carpentry, raising animals, Sports, hobbies, recitals, religious studies,
Scout merit badges and promotions, etc.
many themes continue to expand and interact
because each differentiation allows for the particularities of the
of every role. General categories of roles include:
* friendships and peer groups
* relationships with parents
* schoolwork and teachers
* school as a social setting, behavioral laboratory
* religious and spiritual development
* cultural affiliations, sub-cultures, heroes
* experimentations with the "forbidden"--drugs, sex,
alcohol, truancy, vandalism, theft, etc.
there's a significant amount of use of neuro-tropic drugs,
can very possibly result in longer term neuro-psychiatric sensitivity,
mild psychosis, "borderline" dynamics, sleep and anxiety disorders,
Also, drug abuse generates cravings that remain as a susceptibility. So does alcohol and tobacco use.
Sexual experiences even to mid-adolescence can be profoundly disturbing, generating sexual addiction patterns. (The point here is that youngsters with perfectly "good" earlier childhoods can still fall into long term psychological dysfunctions based on the experiences of addiction-like- phenomena in adolescence.
range of leisure skills, social life, and wholesome
avenues of self-expression is important, and many teenagers prematurely
narrow that range into quasi-addictive and limited behaviors. Excessive
use of video games, role playing games, shopping, television, and other
low activity games can be remarkably depleting of healthy resources.
This list suggests many (but not all) of the factors involved in the development of the child and adolescent. On a related webpage, I discuss the factors in the continuing development of the adult. It gets ever more complex! The sheer number and variety factors indicate why true professionals are worth their fees. It is hoped that they can keep all these factors in mind while doing their evaluations.
The purpose of this list is not to intimidate the student, but to indicate the range of variables relevant to life. It is clear that any single psychotherapeutic system lacks the comprehensiveness needed to fully assess a person's background. Not all of the issues mentioned above need be enquired about during the first or even the first several interviews. With experience, a clinician can get to a point of a working diagnosis in most cases fairly rapidly. However, in the course of ongoing therapy, understanding requires the integration of the whole range of experiences.
Another group of factors to consider are those relevant to making a diagnosis, which in some cases should follow the formal assessment as indicated by the profession's Diagnostic & Statistical Manual (DSM). More often, though, I've found four other factors to be more relevant--the "real" diagnostic categories--discussed in another paper on this website.
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