Download Clinical Assessment

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*
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* May require a signed release of information
Risk Factors
Other Relevant Documents or
Sources
 IEPs
 Psych
Reports
 Previous
or Current Service Providers
 Teachers
and Other School Staff
 Family
 DCFS
Members
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 reassessment and monitoring and
documentation of progress
Clinical Loop, Cont’d.
Assessment
Progress
Notes
Service
Delivery
Diagnosis
Treatment
Plan
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 Components
Component:
Take Notice Of:
May Be Used To Assess:
Physical Appearance
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Quality of Self-care
Abuse or Neglect
Medical Concerns
Drug and Alcohol Use or Abuse
Mood (Depression, Mania)
Psychosis

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
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Neurological disorders
Side effects of medication
Tourette's syndrome
Psychotic symptoms
Autism
Mania
Delirium.
Depression
Medical condition

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Medical conditions
Specific language disorders
Autism
Psychosis
Mania
Anxiety
Depression

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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
Tics, mannerisms

Activity level

Arousal level

Coordination

Unusual Motor Patterns

Eye contact, quality, and
movement
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Gait
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Repetitive purposeless movements
Fluency
Volume
Rate
Rhythm
Articulation
Language skill
Stuttering
Mutism
Echolalia (repetition of another
person’s words)
Palilalia (repetition of one’s own
words)
Vocabulary


Psychomotor Behavior
Speech and Language

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Mental Status Components
Component:
Take Notice Of:
May Be Used To Assess:
Thought Content

Overvalued ideas (a false belief that is held with
conviction)
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Preoccupations
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Delusions
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Obsessions
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Psychosis
Obsessive Compulsive Disorder
Personality Disorders
Depression
Clinical risk
Anxiety
Phobias

Quantity (i.e. poverty of thought)

Tempo (i.e. flight of ideas)

Retarded or Inhibited thoughts

Coherency of thought

Perseverations
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Thought Disorders
Mania
Depression
Anxiety
Psychosis
Personality Disorders

Organization of thought (i.e. thought
blocking, fusion, loosening of associations,
tangential thinking, derailment of thought,
circumstantial)

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Developmentally appropriate
vocabulary
Fund of knowledge

Appropriate drawings

Alertness (awareness of & response to
environment)
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Orientation (to person, place, & time)
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Attention & concentration
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Psychosis
Anxiety
Attention Deficit
Intoxication
Neuropsychological problems
Side effects of psychiatric medications
Chronic drug or alcohol use
Brain damage including tumors
Other brain disorders

Memory (short & long term)

Abstraction (the ability to categorize)
Thought Process
Overall cognitive
functioning
Mental Status Components
Component:
Take Notice Of:
May Be Used To Assess:
Mood
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Anxiety
Depression
Mania
Ability to describe their mood
state
Affect
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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).
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
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Depression
PTSD
Psychosis
Mania
Personality Disorder
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Suicidal thoughts or behavior
Self-harming behavior
Thoughts or plans of harming others
Risk-taking behavior
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Anxiety
Depression
Impulse control disorders
Personality disorders
Psychosis
Mania
Drug or alcohol abuse
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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.

Examination of risk
Attitude/Rapport
Mental Status
Components
Component:
Judgment
Take Notice Of:
May Be Used To Assess:

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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
Recognition that one has a mental illness
Compliance with treatment
Ability to re-label unusual mental events (such as
delusions and hallucinations) as pathological
Adaptive capacity
Assets
Motivation for treatment

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Psychosis
Dementia

Client’s readiness for
treatment
Strengths to build upon in
treatment
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Insight
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Strengths
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Suggested Questions for the
MSE with Children

What do you enjoy most?
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Why?
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What is your favorite movie/t.v. program?
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Tell me about it.
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What would you like for your birthday?
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If you had three wishes, what would you wish for? Why?
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What’s the nicest/worst thing that’s ever happened to
you?
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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?
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Who is your best friend? His/her name?
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What do you do together?
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How long have you been friends?
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Do you ever feel lonely?
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When? What do you do?
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What rules do you have in your house?
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What happens when you break a rule?
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Do you usually get blamed for things?
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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?
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What are the worst/hardest things?

Are you the smartest, dumbest in your class or
somewhere in-between?
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How do you get along with your teacher?
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Do you get into fights at school? Often?
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What makes you mad? What makes you sad?
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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; selfdoubts); 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.