Pregnancy, milestones, school, family structure, family psychiatric history. The longitudinal frame for understanding current presentation.
Encounter card
Setting
First encounter for adults (focused); more comprehensive in pediatric/adolescent assessment.
Opening move
For developmental history, ask about pregnancy/delivery (if known), milestones, school performance, peer relationships, behavioral patterns in childhood. For family history, ask about psychiatric and substance use disorders, attempted/completed suicide, and major medical conditions.
Sample language
"What was your childhood like? How would your family describe you as a kid?"
"How did school go for you?"
"Are there mental health issues in your family — depression, anxiety, bipolar, schizophrenia, addiction?"
"Any suicides or attempts in the family?"
Listen for
Developmental delays, learning differences, ADHD signs from childhood, autism traits, attachment patterns, family trauma, adoptions, parental mental illness/substance use, multigenerational psychiatric patterns. Pattern of inherited risk (bipolar I, schizophrenia, completed suicide are particularly heritable).
Common pitfalls
Skipping developmental history in adults. Asking "any family history?" instead of category-by-category. Missing adopted patients who don't know biological family history. Inferring diagnosis from family pattern alone.
Red flags / escalate: Strong family history of completed suicide (heritable risk). First-degree relative with bipolar I or schizophrenia (substantially increased risk). Adverse childhood experiences in the developmental history.
Documentation
Brief developmental summary. Family psychiatric history in detail, by relationship. Genogram useful for complex families.
Real-world reality: Care coordination time (letters, phone calls, messages with other providers) is unbilled in fee-for-service models but reimbursed in some value-based contracts (CPT 99490+). Document the time and consider coding when applicable.
Family history of bipolar I or completed suicide changes clinical decisions — informs whether unipolar antidepressant might destabilize; informs risk stratification.
Warm grey-tinted clinical notebook page, sienna accent. The developmental history frame — pregnancy → milestones → school → peers → adolescence → adult function. Margin clusters on each phase.
Developmental and family history extend the time frame of the psychiatric evaluation backward — into childhood, into family of origin, into the longitudinal pattern that shapes who this patient became and what runs in their family. Both matter clinically.
Developmental history is more focused in adult evaluation than in pediatric (where it's central). Brief inquiry into pregnancy and birth (when known), early milestones, behavior in childhood, school performance, peer relationships, family environment, adolescence. Specific things worth asking: childhood ADHD signs (in adult ADHD presentations), autism spectrum traits, learning differences, behavioral problems, anxiety as a child, attachment patterns, family disruption. The adult with new "memory problems" may have had untreated ADHD since childhood; the adult with relationship difficulties may have an attachment pattern from family of origin that's now playing out in current relationships.
Family psychiatric history matters because much of psychiatric illness is heritable. Ask category by category: depression, anxiety, bipolar disorder (specifically — many patients say "depression" when grandmother had bipolar I), schizophrenia, addiction, autism, completed suicide. Family history of completed suicide in a first-degree relative substantially elevates the patient's risk and changes risk assessment.
Bipolar I in family changes prescribing. The patient with depression and a first-degree relative with bipolar I has elevated probability of being bipolar themselves. Antidepressant monotherapy is riskier. Take a careful hypomania history; consider mood stabilizer consideration before SSRI alone.
Family medical history beyond psychiatric matters too. Diabetes affects which antipsychotic to choose. Cardiac disease in young relatives affects stimulant decisions. Specific drug allergies or reactions in family members may suggest pharmacogenomic factors.
A simple genogram helps organize complex family histories. For most adult evaluations, a brief written family history (three generations, by relationship, with relevant conditions) suffices. For complex family dynamics affecting current presentation, the genogram becomes a clinical tool.
A simple genogram with psychiatric annotations — depression, bipolar, schizophrenia, suicide, addiction. Margin notes on what each pattern suggests.
The anchor
Developmental and family history provide the longitudinal frame for understanding current presentation. Family history of bipolar I, schizophrenia, or completed suicide carries practice implications.
High-heritability conditions — bipolar I, schizophrenia, completed suicide — and how they change clinical decisions. Margin clusters on practice implications.
Prove it
A 22-year-old presents with recurrent depression. His father had "depression" and died by suicide. His paternal aunt has "bipolar." His mother has anxiety. How does this family history change your approach?