1. Clinical Assessment Ages 4-10
LAUSD School Mental Health
Intern Training
September 18, 2013
Danielle Mendez, LCSW

2. Preparing for the First Session

3. 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

4. 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

5. S .H .A .D .E Risk Factors Suicide Homicide Abuse
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

6. 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

7. Presenting Problem Reason for referral
Current/primary symptoms/ behaviors/impairments in life functioning
Onset/duration/frequency

8. History of Presenting Problem
Symptoms/Behaviors
Caregiver perception of cause
Attempted interventions
and responses
Relevant Factors
Environment (School/Home)
Relationships (Loss/Separation)
Traumatic Events
Sexual/physical/emotional abuse
Sleep Patterns
Eating Patterns
Hygiene Changes

9. 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

10. Substance Use/Abuse Specify alcohol, drug type Frequency of use
Duration
Pattern of use & last use

11. 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

12. 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

13. Developmental Milestones
Infancy (0-3)
Motor – sit, crawl, walk
Speech; Eat; Sleep
Toilet training
Coordination
Temperament
Separation

14. Developmental Milestones
Early Years (4-6)
Social Adjustment
Separation
Sexual Behaviors
Self-Care

15. Developmental Milestones
Latency (7-11)
School adjustment
Peer & adult relations/friends
Interest/hobbies
Impulse control
Self-Care

16. School History Type of School Age & Grade Academic Performance
Grade Retention
Current/Past IEP
School Changes:
Attitude/Behavior
Attendance/Truancy
Suspension

17. 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

18. 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

19. Family History Family Relationships (current and intergenerational)
Quality of attachment (attunement balance & congruence)
Disciplinary Style
Conflict/Violence
Problem Solving

20. 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.

21. 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.

22. 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.

23. Mental Status Components
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
Anxiety

24. Mental Status Components
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
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)
Attention Deficit
Intoxication
Neuropsychological problems
Side effects of psychiatric medications
Chronic drug or alcohol use
Brain damage including tumors
Other brain disorders

25. Mental Status Components
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
PTSD
Psychosis
Personality Disorder
Examination of risk
Suicidal thoughts or behavior
Self-harming behavior
Thoughts or plans of harming others
Risk-taking behavior
Impulse control disorders
Personality disorders
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.

26. Mental Status Components
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
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

27. 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?

28. 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?

29. 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?

30. 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

31. 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!

32. Thank You!