Assessment and Diagnostics
OBSERVATION
CASE CONCEPTUALIZATION
DSM-IV
Record Keeping
PROGRESS NOTES
Progress Notes: Contacts Might Include
 any scheduling phone calls
 missed appointments
 actual face-to-face meetings
 accidental meetings on the street (if you discuss the case)
 assessments performed, contacts for further information
 missed phone calls
 releases for information sent to anyone else
 contacts with anyone not the client about the client
 anything placed on a fax machine or in a mailbox.
 more as needed
Progress Notes: CAP Format
 CAP Format
 C-Content: What actually happened at the contact.
JUST THE FACTS!
 A-Assessment: What you think about what
happened. What is your clinical opinion, judgment,
or personal take on the contact.
 P-Plan: What is the next thing that you plan to do
with this client.
Progress Notes: What does it look like…
 An example in an assessment case file may look like:
Date:
Notes
12/8/10
C-Phoned to set up the intake with Bud. He prefers Thurs & Fri as he
works other days. I said that the intake would take about 1-2 hours.
Scheduled for 12/15/2010 at 2:30 PM. A-He asked a lot of questions
about the process; seemed concerned about the amount of time this
will take. P-Meet to do the intake. As he seems nervous about the
process, I will make sure to keep him informed as we go along.
 An example from a therapy file may look like:
Date:
Notes
10/16/10
C-Met with Jimbo; introduced “Stop and Think.” Assigned him to
come up use at least twice over the next few weeks. A-He seemed to
understand the program and was willing to do it. P-Will meet again in
2 weeks at the high school and go over it again.
Progress Notes: Let me try…
Client called to schedule intake on three different days (1/4, 1/5/,1/6) each
time at 2:30 AM. Client was referred by the psycho-educational system for
“hearing voices” on 1/1. I have not been able to talk to the client.
Date
Notes
Copyright 2007 Brooks/Cole, a division of
Thomson Learning
Record Keeping
CASE CONCEPTUALIZATION
Case Conceptualization: What does it look like?
Initial
Referral
Inattentive
Information
Apriori
Questions
Tools
Health problems?
Interview-Bckgrnd
System = worries?
Interview-Dx
Sleep problems?
Observation-home
Comprehension
problems?
Observationschool
ADHD?
IQ
Achievement
Rating Scales
Case Conceptualization: What does it look like?
Initial
Referral
Information
Apriori
Questions
Tools
Inattentive
10 yr old male
Health problems?
Interview-Bckgrnd
Normal health
System = worries?
Interview-Dx
Normal dev’t
Sleep problems?
Observation-home
Normal IQ and
Achievement
Comprehension
problems?
Observationschool
Tscore=70 on
Inattention
ADHD?
IQ
Mom and teacher
report inattention
Achievement
Observation in
class: inattentive 9
out of 10 intervals
Rating Scales
Case Conceptualization: Let me try!
Initial
Referral
Information
Apriori
Questions
Tools
Diagostics
DSM-IV: INTRODUCTION
DSM-IV: 5 AXIS
What is the DSM-IV?
 Diagnostic and Statistical Manual of Mental Disorders, 4th.
Edition.
 Published by the American Psychiatric Association, a medically
based group.
 Covers all recognized mental health disorders for both children and
adults.


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Common and accepted symptoms
known causes of these disorders
statistics in terms of gender, age at onset, and prognosis
research concerning the optimal treatment approaches
 Mental Health Professionals use this manual when working with
patients:
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
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in order to better understand their illness.
identify potential treatment
help 3rd party payers (e.g., insurance) understand the needs of the patient.
http://allpsych.com/disorders/dsm.html
DSM-IV: Multi-axial Diagnoses
 Axis I
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Clinical Disorders
Axis II
Personality Disorders and Mental Retardation
Axis III
General Medical Condition
Axis IV
Psychosocial and Environmental Factors
Axis V
Global Assessment of Functioning
DSM-IV: Axis I
 Axis I includes: all the mental health conditions
except…
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personality disorders
mental retardation.
 Special notations:
 V71.09 no diagnosis.
 R/O: Rule out needed
 By hx: by history
 A person could suffer from more than one Axis I
disorder, and all are listed with the most prominent
listed first
DSM-IV: Axis II
 Axis II is for reporting Mental Retardation and
personality disorders.
 Seen as “unchangeable” symptoms
 Special notations:



V71.09 no diagnosis.
R/O: Rule out needed
By hx: by history
 A person could suffer from more than one Axis II
disorder, and all are listed with the most prominent
listed first
DSM-IV: Axis III
 Axis III is used for reporting any major medical
conditions that may be relevant to treatment of the
mental health disorder.
 Notations may be listed from the medical listing in
the back of the DSM-IV or may be listed based on the
ICD-9
 Notations found here:
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None: no diagnosis in this area
r/o: rule out
By hx: by history
DSM-IV: Axis IV
 Axis IV is used to report psychosocial and environmental
factors affecting the person.
 Notation of “none” when there are no factors here.
 Examples of these factors include:
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(1) problems with primary support group (divorce)
(2) problems with social environment (death of a friend)
(3) educational problems
(4) housing problems
(5) economic problems
(6) occupational difficulties
(7) legal difficulties
(8) transportation difficulties.
DSM-IV: Axis V
 Axis V, Global Assessment of Functioning, is the
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clinicians best guess of the client’s overall level of
functioning.
GAF is a number between 0 to 100.
Specific ratings for GAF are included in the DSM-IV
NOTE: A GAF of <50 usually indicates significant need
for psychiatric residential care.
A notation might read something like: GAF = 90
There is low inter-rater reliability on the GAF.
It is a “global” assessment so a person with only one
sever problem might rate higher than expected.
DSM-IV: Axis V (cont.)
 81 - 90
Person has few or no symptoms. Good functioning in several
areas. No more than "everyday" problems or concerns.
 71 - 80
Person has symptoms/problems, but they are temporary,
expectable reactions to stressors. There is no more than slight
impairment in any area of psychological functioning.
 61 - 70
Mild symptoms in one area OR difficulty in one of the
following: social, occupational, or school functioning. BUT,
the person is generally functioning pretty well and has some
meaningful interpersonal relationships.
DSM-IV Axis: What does it look like…
Axis I:
296.32
314.00
Axis II:
Axis III:
Axis IV:
Axis V:
Major Depressive Disorder,
Recurrent, Mild
Attention-Deficit/Hyperactivity
Disorder, Combined Type
Mathematics Disorder
No diagnosis
315.10
V71.09
None
Occupational problems,
Educational problems
GAF=80
Copyright 2007 Brooks/Cole, a division of
Thomson Learning
DSM-IV Axis: Let me try it…
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Copyright 2007 Brooks/Cole, a division of
Thomson Learning
Assessment: Interviews
GENERAL BACKGROUND INTERVIEW
DIAGNOSTIC INTERVIEW
Background Interview
 Sections
 Pregnancy/ Birth
 Development
 Health (psychological and physical)
 Education
 Work experience
 Family history
 Social/ emotional/ behavioral issues
 Techniques
 Background questionnaire  Interview
 Timeline interview
Interview: What does it look like…
 Need a volunteer
 Disclaimer: As this is not a therapy session, please
feel free to answer any questions as you wish.
Confidentiality is not assured.
Interview: Let me try…
 Use the DSM-IV criteria for Pica to develop a set of
diagnostic interview questions.
 Remember: Criteria for Pica includes
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Persistent eating of nonnutritive substances for a period of at least 1
month.
The eating of nonnutritive substances is inappropriate to the
developmental level.
The eating behavior is not part of a culturally sanctioned practice.
If the eating behavior occurs exclusively during the course of another
mental disorder (e.g., Mental Retardation, Pervasive Developmental
Disorder, Schizophrenia), it is sufficiently severe to warrant
independent clinical attention.
Assessment: Observation
TIME SAMPLING
EVENT SAMPLING
Observation: Let me do it…
 I am going to pretend to be a child referred for

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
hyperactivity.
Your group is going to identify 5 concrete,
operationally defined behaviors to observe.
One half of the group will do event sampling.
One half of the group will do time sampling (partialinterval).
The observation will last one minute.
Time Sampling: Example
Targeted
Behaviors
@10
sec
@20
Sec
@30
Sec
@40
Sec
@50
Sec
@60
sec
Event Sampling
Targeted
Behaviors
Number of times
In 1 min period