Clinical Assessment
Ages 4-10
LAUSD School Mental Health
Intern Training
September 18, 2013
Danielle 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
Other Relevant Documents or Sources
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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 interventions
and 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
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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
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Developmental Milestones
Infancy (0-3)
• Motor – sit, crawl, walk
• Speech; Eat; Sleep
• Toilet training
• Coordination
• Temperament
• Separation
Developmental Milestones
Early Years (4-6)
• Social Adjustment
• Separation
• Sexual Behaviors
• Self-Care
Developmental Milestones
Latency (7-11)
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School adjustment
Peer & adult relations/friends
Interest/hobbies
Impulse control
Self-Care
School History
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Type of School
Age & Grade
Academic Performance
Grade Retention
Current/Past IEP
School Changes:
Attitude/Behavior
Attendance/Truancy
Suspension
Child Abuse & Protective Services History
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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
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Family Relationships (current and
intergenerational)
Quality of attachment (attunement
balance & congruence)
Disciplinary Style
Conflict/Violence
Problem Solving
Mental Status Exam (MSE)
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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.
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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.
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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
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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.
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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 Components
Component:
Take Notice Of:
May Be Used To Assess:
Physical Appearance
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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
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Activity level
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Arousal level
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Coordination
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Unusual Motor Patterns
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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
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Psychomotor Behavior
Speech and Language
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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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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
Mental Status Components
Component:
Take Notice Of:
May Be Used To Assess:
Thought Content
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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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Phobias
Quantity (i.e. poverty of
thought)
Thought Process
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Overall cognitive
functioning
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Tempo (i.e. flight of ideas)
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Retarded or Inhibited thoughts
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Coherency of thought
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Perseverations
Organization of thought (i.e.
thought blocking, fusion,
loosening of associations,
tangential thinking, derailment
of thought, circumstantial)
Developmentally
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appropriate vocabulary
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Fund of knowledge
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Appropriate drawings
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Alertness (awareness of &
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response to environment)
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Orientation (to person, place,
& time)
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Attention & concentration
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Memory (short & long term)
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Abstraction (the ability to
categorize)
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Psychosis
Obsessive Compulsive Disorder
Personality Disorders
Depression
Clinical risk
Anxiety
Thought Disorders
Mania
Depression
Anxiety
Psychosis
Personality Disorders
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
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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.
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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
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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
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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?
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?
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Suggested Questions for the MSE with
Children
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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
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“True Story” from a LA County Agency
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7 years old, female, African American
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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”, noncompliance with adult commands,
aggressive behavior towards sibs)
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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!