NRNP 6645 COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT

Comprehensive Integrated Psychiatric Assessment

Main Question Post: Comprehensive, integrated psychiatric assessments are the foundation for accurate diagnosis, effective treatment, and positive patient outcomes. Clinicians performing these assessments in the pediatric population understand the value of information attained from multiple sources in building a therapeutic alliance and determining appropriate treatment. This discussion post will analyze a video presentation of a psychiatric assessment of an adolescent male referred by PCP for depression and anxiety.

Proper interview techniques are integral to psychiatric assessments and require good organizational skills and practice. During the interview, the practitioner did well by explaining to the patient what she would be doing and ascertaining from the patient the reason for the visit. The practitioner maintained eye contact with the patient to show interest in what was being said, and when the patient did not understand what the practitioner meant by “how has your mood been lately?” the practitioner rephrased the question to elicit better responses. The practitioner was engaging and smiled, making the patient more comfortable. The practitioner also told the patient that they would discuss his report of anger, letting the patient know that his problem was heard and important. The patient was also provided privacy. Although the practitioner performed good assessment skills, key elements were lost during this interview. The practitioner did not introduce herself nor inform the patient of the confidentiality of their discussion. Although time may have been a factor, I felt that the practitioner too quickly asked questions, seemingly not placing significance on the patient’s responses. In doing so, the patient could be left feeling invalidated and can crush the therapeutic alliance.

According to Hilt & Nussbaum (2016), any mental health evaluation includes identifying and assessing safety concerns. A prudent practitioner will thoroughly assess reported safety issues and implement needed interventions. During the interview with the young male,  compelling concerns were his report that the breakup with his girlfriend makes him really angry with her and others, not knowing why she broke up with him, and not wanting to be alive. Another concern was his possible minimization of substance use. My following line of questions would be regarding present suicidal thoughts as well as suicidal plans and intent. I would also ask about who he lives with and his gun access. Suicide is the second leading cause of death among adolescents, with the peak onset of suicidal ideations occurring during adolescence. The greater the severity of the ideations is associated with a higher likelihood of future suicide attempts (Ordaz et al., 2018).

According to Srinath et al. (2019), children and adolescents often do not initiate evaluation for mental health concerns due to embarrassment or a lack of understanding of symptoms. Therefore, accurate diagnosis and treatment implementation needs thorough assessments that include information from multiple sources and impeccable clinical skills. Comprehensive psychiatric assessments give clinicians, patients, and parents or guardians the tools necessary to improve their quality of life during a challenging time.

In performing psychiatric assessments, practitioners rely on useful tools such as symptom rating scales to facilitate diagnostic accuracy and referral recommendations. One symptom rating scale to use when assessing the child or adolescent is the Level 1 Cross-Cutting symptom measure. This tool lists selected symptoms of major DSM-5 disorders in a brief format and can be used to facilitate conversation during the psychiatric interview. The tool has two versions, one for caregivers and one for children in selected age groups. (Hilt & Nussbaum, 2016). Another rating scale is the Pediatric Symptom Checklist (PSC), a 35-item parent-reported or a 17-item parent and child-reported measure of adolescent psychosocial functioning. The PSC is among the most frequently used rating scales (Bergmann et al., 2020).

When treating children and adolescents, treatment options may differ from that of adults. Example of treatment options used when treating children includes Cognitive Behavioral Play Therapy(CBPT) and Reciprocal Imitation Training (RIT). CBPT is used in younger children and incorporates CBT strategies into play-based interventions leading to therapeutic work and learning during play. CBPT uses puppets or toys to teach children skills to overcome challenges (Bhide & Chakraborty, 2020). RIT is a naturalistic developmental–behavioral intervention that targets social interaction via engagement in extended bouts of reciprocal imitation. RIT is an evidence-based treatment for autism spectrum disorder (Ingersoll et al., 2017).

Parents or guardians play an essential role in child assessments. They often help build a therapeutic relationship between the child and provide and provide valuable insights into presenting problems, history, and behaviors in multiple settings. Parents’ or guardians’ participation in assessments can help build trust and form bonds that ultimately facilitate active treatment participation from the child and family.

References

Bergmann, P., Lucke, C., Nguyen, T., Jellinek, M., & Murphy, J. M. (2023). Identification and Utility of a Short Form of the Pediatric Symptom Checklist-Youth Self-Report (PSC-17-Y). European Journal of Psychological Assessment, Preprints, 1–9. https://doi.org/10.1027/1015-5759/a000486Links to an external site.

Bhide, A., & Chakraborty, K. (2020). General Principles for Psychotherapeutic Interventions in Children and Adolescents. Indian Journal of Psychiatry, 62, S299–S318. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_811_19Links to an external site.

Hilt, R. J., & Nussbaum, A. M. (2016). DSM-5 pocket guide for child and adolescent
mental health. American Psychiatric Association Publishing.

Ingersoll, B., Berger, N., Carlsen, D., & Hamlin, T. (2017). Improving social functioning and challenging behaviors in adolescents with ASD and significant ID: A randomized pilot feasibility trial of reciprocal imitation training in a residential setting. Developmental Neurorehabilitation, 20(4), 236–246. https://doi.org/10.1080/17518423.2016.1211187Links to an external site.

Ordaz, S. J., Goyer, M. S., Ho, T. C., Singh, M. K., & Gotlib, I. H. (2018). Network basis of suicidal ideation in depressed adolescents. Journal of Affective Disorders, 226, 92–99. https://doi.org/10.1016/j.jad.2017.09.021Links to an external site.

Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(2), 158–175. http://doi.org/10.4103/psychiatry.IndianJPsychiatry_580_18Links to an external site.

Network basis of suicidal ideation in depressed adolescents.pdfDownload Network basis of suicidal ideation in depressed adolescents.pdf

Indentification and Utility of a short form of pediatric symptom.pdfDownload Indentification and Utility of a short form of pediatric symptom.pdf

General Principles for Psychotherapeutic Interventions in Children and Adolescents.pdf Download General Principles for Psychotherapeutic Interventions in Children and Adolescents.pdf 

Clinical Practice Guidelines for assessment of children and adolescents.pdfDownload Clinical Practice Guidelines for assessment of children and adolescents.pdf

Improving social functioning and challenging behaviors in adolescents with ASD and significant ID_ A randomized pilot feasibility trial of reciprocal imitation training in a residential setting.pdf Download Improving social functioning and challenging behaviors in adolescents with ASD and significant ID_ A randomized pilot feasibility trial of reciprocal imitation training in a residential setting.pdf

Many assessment principles are the same for children and adults; however, unlike with adults/older adults, where consent for participation in the assessment comes from the actual client, with children it is the parents or guardians who must make the decision for treatment. Issues of confidentiality, privacy, and consent must be addressed. When working with children, it is not only important to be able to connect with the pediatric patient, but also to be able to collaborate effectively with the caregivers, other family members, teachers, and school counselors/psychologists, all of whom will be able to provide important context and details to aid in your assessment and treatment plans.