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!