Clinical Assessment

LAUSD School Mental Health

October 29, 2014

Presenter: Eugene Alper, LCSW

Assessment

A complete and thorough 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

Must be completed within 30 days, but no later than the 2nd claimed service

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

Mental Status

Substance Use Assessment

Other Relevant Documents or Sources*

* May require a signed release of information

Risk Factors

S H A D E Suicide Homicide Abuse Drugs & Domestic Violence Everything Else

Other Relevant Documents or Sources

IEPs Psych Reports Previous or Current Service

Providers Teachers and Other School Staff Family Members DCFS Social Workers Other

The Clinical Loop

The Clinical Loop: Consists of the connection between

the Assessment Symptoms and Functional

Impairments Diagnosis Treatment Plan

Selected Interventions and Services

Progress Notes

Clinical Loop, Cont’d.

Includes the sequence of documentation that supports the demonstration of ongoing medical necessity

Includes the process of continual re-assessment and monitoring and documentation of progress

Clinical Loop, Cont’d.

Assessment

Diagnosis

Treatment Plan

Service Delivery

Progress Notes

Mental Status 

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.

 

Mental Status

The MSE is purely descriptive, includes no judgment of whether the appearance and behavior is normal or abnormal, clinically significant or non-significant.

Although presented as a separate component that is distinct from the history-taking, in reality much of the MSE takes place implicitly as the clinician interacts and observes the child during the individual and family interviews.

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.

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.

MSE with Children:

There are particular challenges in carrying out an MSE with young children and others with limited language such as people with intellectual impairment.

In this group, utilize tools such as play materials

Puppets

Art Materials or Diagrams

with multiple choices of facial expressions depicting emotions

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 Components

Component:

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?

Are you the smartest, dumbest in your class or somewhere in-between?

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?

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!

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

Children’s Global Assessment Scale 

100-91 Superior functioning in all areas (at home, at school and with peers); involved in a wide range of activities and has many interests (eg., has hobbies or participates in extracurricular activities or belongs to an organised group such as Scouts, etc); likeable, confident; ‘everyday’ worries never get out of hand; doing well in school; no symptoms.

90-81 Good functioning in all areas; secure in family, school, and with peers; there may be transient difficulties and ‘everyday’ worries that occasionally get out of hand (eg., mild anxiety associated with an important exam, occasional ‘blowups’ with siblings, parents or peers).

80-71 No more than slight impairments in functioning at home, at school, or with peers; some disturbance of behaviour or emotional distress may be present in response to life stresses (eg., parental separations, deaths, birth of a sib), but these are brief and interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant by those who know them.

70-61 Some difficulty in a single area but generally functioning well (eg., sporadic or isolated antisocial acts, such as occasionally playing hooky or petty theft; consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties which do not lead to gross avoidance behaviour; self-doubts); has some meaningful interpersonal relationships; most people who do not know the child well would not consider him/her deviant but those who do know him/her well might express concern.

60-51 Variable functioning with sporadic difficulties or symptoms in several but not all social areas; disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings.

50-41 Moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area, such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor to inappropriate social skills, frequent episodes of aggressive or other antisocial behaviour with some preservation of meaningful social relationships.

40-31 Major impairment of functioning in several areas and unable to function in one of these areas (ie., disturbed at home, at school, with peers, or in society at large, eg., persistent aggression without clear instigation; markedly withdrawn and isolated behaviour due to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are likely to require special schooling and/or hospitalisation or withdrawal from school (but this is not a sufficient criterion for inclusion in this category).

30-21 Unable to function in almost all areas eg., stays at home, in ward, or in bed all day without taking part in social activities or severe impairment in reality testing or serious impairment in communication (eg., sometimes incoherent or inappropriate).

20-11 Needs considerable supervision to prevent hurting others or self (eg., frequently violent, repeated suicide attempts) or to maintain personal hygiene or gross impairment in all forms of communication, eg., severe abnormalities in verbal and gestural communication, marked social aloofness, stupor, etc.

10-1 Needs constant supervision (24-hour care) due to severely aggressive or self-destructive behaviour or gross impairment in reality testing, communication, cognition, affect or personal hygiene.