Clinical Assessment Ages 4-10

1. Clinical AssessmentAges 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. Risk Factors • 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 Relevant Factors • Environment (School/Home) • Relationships (Loss/Separation) • Traumatic Events • Sexual/physical/emotional abuse • Sleep Patterns • Eating Patterns • Hygiene Changes Symptoms/Behaviors • Caregiver perception of cause • Attempted interventions and responses

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

24. Mental Status Components

25. Mental Status Components

26. Mental Status Components

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!