Comprehensive Integrated Psychiatric Assessment of a child or adolescent
Evaluate comprehensive integrated psychiatric assessment techniques
Recommend assessment questions
Review the Learning Resources concerning the comprehensive integrated psychiatric assessment.
Watch the Mental Status Examination video.
Watch the two YMH Bostonvideos
Child and Adolescent Diagnostic Assessment Worksheet
IDENTIFYING INFORMATION: (age, gender, and ethnicity of client; parents)
CHIEF COMPLAINT: (in the client’s own words)
HISTORY OF PRESENT ILLNESS: (this should create the timeline and details of the child/adolescent symptoms so that it leads to the clinical assessment and formulation)
PAST PSYCHIATRIC HISTORY/PREVIOUS PSYCHIATRIC VISITS/HOSPITALIZATIONS:
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
CURRENT MEDICATIONS (INCLUDING COMPLIANCE):
PSYCHOSOCIAL HISTORY: (who the child lives with, relevant cultural information, school, grade, teacher, friends)
Sexual Orientation/Gender Identity (if unknown, evidence of gender dysphoria):
(NOTE: If LGBT, elicit “out” status, family dynamics): _________________________________
History of physical/emotional/sexual abuse: __________ History of bullying: _________Religion: ________
FAMILY HISTORY OF PSYCHIATRIC ILLNESS:
History of Family Suicide Attempts/Completed Suicides:
SUBSTANCE ABUSE HISTORY:
Smoker: _____History of alcohol, marijuana, meth use/abuse: ____________________________________
REVIEW OF SYMPTOMS:
GENERAL WELL BEING:
-Child/parent reports that (she/he) is sleeping (well, poorly, fair). States that (she/he) has trouble (falling asleep, staying asleep, or waking up feeling as if she/he had not slept at all).
-Further, reports (low, fair, good) energy throughout the day. Comprehensive Integrated Psychiatric Assessment of a child or adolescent.
-Child/parent acknowledges (poor, fair, good) appetite (if fair/poor, indicate how long this has persisted for). Any significant weight loss/gain.
MENTAL STATUS EXAMINATION: (see Kaplan & Sadock’s Synopsis of Psychiatry: Behavior Sciences/Clinical Psychiatry for Child MSE)
CLINICAL FORMULATION: (Discuss diagnostic reasoning here.)
DIAGNOSIS USING DSM-5:
(Begin with psychiatric diagnosis that the patient is being treated for; then, in order of relevance/importance/significance to the overall clinical picture, list the diagnoses. DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Other conditions that are a focus of the current visit or help to explain the need for a treatment or test may also be coded.)
PLAN OF TREATMENT:
Comprehensive Integrated Psychiatric Assessment
The Vignette 4 video describes a 16-year-old teenage client who presented for a mental health assessment. The client was referred by the mother and he claimed that he was not aware why he was referred for a mental health assessment. The video indicates that the client is not interested in the assessment and the therapist utilizes various techniques, where some are helpful while other techniques are not helpful. This will be discussed in this post. Comprehensive Integrated Psychiatric Assessment of a child or adolescent.
What the Practitioner did Well
Before the session starts, the practitioner informs the client regarding confidentiality. According to Sadock et al (2014), confidentiality is the foundation of effective therapeutic relationships and effective treatment (Wheeler, 2014). Secondly, the practitioner actively engaged the client and asked him regarding his opinion which indicates that the practitioner believes about independency of the client’s feelings and thoughts. The client responds positively and both his eye contact and verbal interactions improve. As per Sadock et al (2014), engaging adolescents leads to a better rapport because they feel they are being given a chance to have their side of the story heard. In addition, the practitioner asked regarding other individuals in the life of the client which informs him that the client ha better relationships with his coach and girlfriend. The client is very comfortable talking about these relationships which can inform the practitioner.
Areas the Practitioner need to Improve
The practitioner can improve in a few areas. For example, the provider tries to air his own opinion regarding what he thinks of the client’s mother. This is evident where the client reports that the mother feels he has an “anger management” issue and the practitioner tells him that the mother has his won reasons for stating so. At this point, the practitioner uses facial expression and a voice tone that indicates that he completely disagrees with the client’s perspective. Such an approach can make the client feel alienated. This is clear, where the client withdraws and looks down. According to Sukhodolsky et al (2016) the ability of a practitioner to read the body language of clients is an important skill. Comprehensive Integrated Psychiatric Assessment of a child or adolescent.
Some of the concerns include that the practitioner fails to come up with strategies that the client and the mother can adopt for effective communication. The client claims that the mother is nagging. This can be perceived as a family issue or a developmental issue since teenage boys are not likely to disclose their personal feelings to their mothers (Bista et al, 2016). It is also important for the practitioner to acknowledge the client’s feelings about the whole issue. At this point, the practitioner reflects and normalizes the aversion of the client talking to his mother through humor. This resonates with the client and assists in improving the connection between the client and the therapist.
The Next Question and the Reason
The therapist did not address the client’s possible risky behavior. Therefore, I would assess if the client has any issues to do with substance or alcohol abuse. The first question would be “have you ever been in a CAR driven by a person (including yourself) who was intoxicated or had been using drugs or alcohol?” This question is derived from the CRAFFT screening tool. According to Sadock et al (2014), substance abuse or alcohol abuse can significantly affect psychiatric symptoms as well as the treatment. Comprehensive Integrated Psychiatric Assessment of a child or adolescent.
Bista B, Thapa P, Sapkota D, Suman S & Paras P. (2016). Psychosocial Problems among Adolescent Students: An Exploratory Study in the Central Region of Nepal. Front Public Health. 4(158).
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Sukhodolsky D, Smith S, Spencer M, Karim I & Piasecka J. (2016). Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents. J Child Adolesc Psychopharmacol. 26(1), 58–64.
Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company Comprehensive Integrated Psychiatric Assessment of a child or adolescent.