clinical assessment ages 4-10
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Clinical AssessmentAges 4-10
LAUSD School Mental HealthIntern Training
September 18, 2013Danielle Mendez, LCSW
Preparing for the First Session
Purpose of the Clinical Assessment
• Lays the foundation for an accurate diagnosis
• Demonstrates medical necessity and the need for services.
• Leads to appropriate selection of treatment plan objectives, services, and interventions
• Is ongoing throughout the course of treatment
Important Assessment Components:
• Bio-Psycho-Social Assessment Interview(s) in which information is obtained from the client and the client’s parent/guardian (for minor clients).
• Outcome Measures - SDQ• Mental Status• Other Relevant Documents or Sources*
• Release of Information
Risk Factors• Events that increase the likelihood of a negative
outcome; can be acute or chronic
S .H .A .D .E• Suicide• Homicide• Abuse• Drugs & Domestic Violence• Everything Else
Other Relevant Documents or Sources
• IEPs• School Cumulative Records• Psych Reports• Previous or Current Service
Providers• Teachers and Other School Staff• Family Members• DCFS Social Workers• Other
Presenting Problem• Reason for referral
• Current/primary symptoms/ behaviors/impairments in life functioning
• Onset/duration/frequency
History of Presenting Problem
Symptoms/Behaviors
Caregiver perception of cause
Attempted interventionsand responses
Relevant Factors Environment (School/Home) Relationships (Loss/Separation) Traumatic Events Sexual/physical/emotional abuse Sleep Patterns Eating Patterns Hygiene Changes
Prior Mental Health History
Suicidality/Homicidality• # of attempts, method, access to lethal means• Interventions• When• Facility (Name or Type)• Type of intervention• Duration• Medication: dosage, response, adverse reactions• Recommendations• Response to treatment• Parent and Child• Satisfaction
Substance Use/Abuse
• Specify alcohol, drug type
• Frequency of use
• Duration
• Pattern of use & last use
Medical History• Illness (Acute/Chronic)• Medications• Allergies• Accidents• Head Injuries• Seizure/other
neurological
• Pregnancy• Sexually Transmitted Diseases• HIV• Vaccinations• Hospitalizations/Surgeries• Vision/Hearing• Dental Health
Developmental History
Prenatal Care Term/Months Birth Weight Age of
Mother/Father/Marital Status
Did mother use alcohol/cigarettes/drugs
Illness/Accidents/ Stressors (family & environmental) during or after pregnancy
Postpartum complications
Developmental Milestones
Infancy (0-3)• Motor – sit, crawl, walk• Speech; Eat; Sleep• Toilet training• Coordination• Temperament• Separation
Developmental MilestonesEarly Years (4-6)• Social Adjustment
• Separation
• Sexual Behaviors
• Self-Care
Developmental Milestones
Latency (7-11)• School adjustment• Peer & adult relations/friends• Interest/hobbies• Impulse control• Self-Care
School History
• Type of School• Age & Grade• Academic Performance• Grade Retention• Current/Past IEP• School Changes:• Attitude/Behavior• Attendance/Truancy• Suspension
Child Abuse & Protective Services History
• Nature of Allegations/Abuse• Age of occurrence• Offender• DCFS or Police Intervention• Dependency Court or Criminal Court Action• Child Response/Parents response to disclosure• Placements and type• Services and type
Family History
Family Composition• Siblings• Stepparents/others• Grandparents• Extended Family• Ethnicity/Culture
Parent/Guardian Information• Education• Occupation• Socio-Economics• Religious Affiliation• Family History - medical, psychiatric
alcohol/drug, legal/criminal
Family History• Family Relationships (current and
intergenerational)• Quality of attachment (attunement
balance & congruence)• Disciplinary Style• Conflict/Violence• Problem Solving
Mental Status Exam (MSE)• The aim of the mental status examination (MSE) is to
be an objective description, not interpretation, of the child’s appearance, symptoms, behavior and functioning as manifested at the time of the examination.
• A well-written MSE enables another clinician or the same clinician weeks, months or years later to have a clear picture of the patient’s mental state at the time of assessment.
• The MSE is purely descriptive, includes no judgment of
whether the appearance and behavior is normal or abnormal, clinically significant or non-significant.
Mental Status – Cultural Considerations
• There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions.
• Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations - without understanding may seem similar though they have different roots.
• Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder.
Children & Mental Status• There are particular challenges in carrying out an MSE
with young children and others with limited language such as people with intellectual impairment. The examiner should explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner.
• In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences. The child’s stage of development should also be considered.
Mental Status ComponentsComponent: Take Notice Of: May Be Used To Assess:
Physical Appearance Age (actual and apparent) Age-appropriate clothes Grooming and cleanliness Differences in body structure,
bruises, scars Height & Weight Physical features of alcohol or drug
abuse Odor
Quality of Self-care Abuse or Neglect Medical Concerns Drug and Alcohol Use or
Abuse Mood (Depression, Mania) Psychosis
Psychomotor Behavior Tics, mannerisms Activity level Arousal level Coordination Unusual Motor Patterns Eye contact, quality, and
movement Gait Repetitive purposeless movements
Neurological disorders Side effects of medication Tourette's syndrome Psychotic symptoms Autism Mania Delirium. Depression Medical condition
Speech and Language Fluency Volume Rate Rhythm Articulation Language skill Stuttering Mutism Echolalia (repetition of another
person’s words) Palilalia (repetition of one’s own
words) Vocabulary
Medical conditions Specific language disorders Autism Psychosis Mania Anxiety Depression
Mental Status ComponentsComponent:
Take Notice Of: May Be Used To Assess:
Thought Content Overvalued ideas (a false belief that is held with conviction)
Preoccupations Delusions Obsessions Phobias
Psychosis Obsessive Compulsive Disorder Personality Disorders Depression Clinical risk Anxiety
Thought Process Quantity (i.e. poverty of thought)
Tempo (i.e. flight of ideas) Retarded or Inhibited
thoughts Coherency of thought Perseverations Organization of thought
(i.e. thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, circumstantial)
Thought Disorders Mania Depression Anxiety Psychosis Personality Disorders
Overall cognitive functioning
Developmentally appropriate vocabulary
Fund of knowledge Appropriate drawings Alertness (awareness of &
response to environment) Orientation (to person,
place, & time) Attention & concentration Memory (short & long
term) Abstraction (the ability to
categorize)
Psychosis Anxiety Attention Deficit Intoxication Neuropsychological problems Side effects of psychiatric
medications Chronic drug or alcohol use Brain damage including
tumors Other brain disorders
Mental Status Components
Component:
Take Notice Of: May Be Used To Assess:
Mood Client's description of his/her mood Clinician’s observation of client mood:
neutral, euthymic (reasonably positive mood), dysphoric (unhappiness), euphoric (elated mood), angry, anxious or apathetic (indifference or suppression of emotion).
Anxiety Depression Mania Ability to describe their
mood state
Affect Emotion conveyed by the person's nonverbal behavior
Appropriateness, intensity, range, reactivity and mobility
Appropriateness to the current situation Congruency with their thought content Range and Reactivity of Affect
Depression PTSD Psychosis Mania Personality Disorder
Examination of risk Suicidal thoughts or behavior Self-harming behavior Thoughts or plans of harming others Risk-taking behavior
Anxiety Depression Impulse control disorders Personality disorders Psychosis Mania Drug or alcohol abuse
Attitude/Rapport Eye contact Ability to cooperate and engage with assessment Behavior towards parents and siblings Cooperation, guardedness, hostility
The quality of information obtained during the assessment.
Mental Status Components
Component:
Take Notice Of: May Be Used To Assess:
Judgment Acknowledgement of problems Capacity to judge hypothetical situations Attitude towards receiving help Compliance with treatment Capacity to make sound, reasoned and
responsible decisions Impulsiveness Planning ability
Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain.
If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others
Insight Recognition that one has a mental illness Compliance with treatment Ability to re-label unusual mental events (such
as delusions and hallucinations) as pathological
Psychosis Dementia
Strengths Adaptive capacity Assets Motivation for treatment
Client’s readiness for
treatment Strengths to build upon in
treatment
Suggested Questions for the MSE with Children
What do you enjoy most? Why? What is your favorite movie/t.v.
program? Tell me about it. What would you like for your
birthday? If you had three wishes, what would
you wish for? Why? What’s the nicest/worst thing that’s
ever happened to you? What would you like to be when you
grow up? Why do you think your
mother/father/parents/grandma brought you to see me?
Suggested Questions for the MSE with Children
Do you have any friends? Who is your best friend? His/her
name? What do you do together? How long have you been friends? Do you ever feel lonely? When? What do you do? What rules do you have in your
house? What happens when you break a
rule? Do you usually get blamed for
things? What are your brothers and sisters
like? Do you get along with them?
Suggested Questions for the MSE with Children
What things do you like best about school?
What are the worst/hardest things? How do you get along with your
teacher? Do you get into fights at school?
Often? What makes you mad? What makes
you sad? How is your mood most of the time
(Happy, Sad, Mad, Scared)? Have you ever felt so bad you
wished you could disappear? Die? Have you ever tried to hurt yourself?
Maggie’s Story
• “True Story” from a LA County Agency
• 7 years old, female, African American
• Presents with Depressive Sxs (irritability, daily crying outbursts, suicidal ideation, lack of interest in play), Anxiety Sxs (separation fears, cannot sleep alone, worries about family members and future), and Disruptive Behavior (“attitude”, non-compliance with adult commands, aggressive behavior towards sibs)
• History of trauma and recent assault by male classmate who touched her in private parts
Role Play the MSE
• Get together with your elbow partner and take turns interviewing each other, and gathering information for the MSE, using the following “student” as the client.
• You have 10 minutes to do this exercise. I’ll have you switch at the midpoint.
• Have Fun!
Thank You!
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