Daniel Castellanos, MD Professor and Founding Chair, Department of Psychiatry & Behavioral Health
The Herbert Wertheim College of Medicine Florida International University
June 05, 2014
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Castellanos 2014
Objectives:
1) Identify components of a psychiatric evaluation
2) Identify sample psychological evaluations
3) Identify samples of psychiatric evaluations
4) Identify sample medical reports
5) Recognize characteristics of appropriate psychotropic medication use and behavioral health treatment.
Castellanos 2014
Castellanos2014
Components:
History:
Mental Status Exam
Diagnostic Impression
Treatment Plan
Castellanos 2014
History:
The history seeks to obtain pertinent information related to the child’s problems, strengths, functioning, impairments and background.
Seeks to elaborate a description of current and past problems, symptoms, coping styles and strengths.
Castellanos 2014
History:
Information is obtained from:
Interview of the child.
Review of previous records, including previous psychological, psychiatric, educational, speech and language evaluations.
Interview of the parent(s)/guardian, child welfare professional, and case manager.
Teachers.
Any other persons involved in the child’s care.
Castellanos 2014
Chief complaint
This is the patient's problem or reason for the visit. Most often, this is recorded as the patient's or guardian’s own words, in quotation marks.
This statement allows identification of the problem by identifying symptoms that lead to a diagnosis and, eventually, a specific treatment plan.
To elicit this response, the interviewer should ask leading questions such as "What brings you here today?"
Castellanos 2014
History of Present Illness
An exact history allows one to gather basic information along with specific symptoms including timing. This includes an organized, chronological history of what brings the child for an eval now, including all significant symptomatology, precipitating factors, etc... This includes information regarding why the child is presenting for help at a particular time (the "why now" aspect of the child’s life). This may or may not involve a triggering event related to the symptoms. Include significant modifiers of the illness, including possible physical factors, drug, and alcohol abuse. List all pertinent positive and negative symptoms, which will help to make an accurate DSM-5 (differential) diagnosis.
Castellanos 2014
Past medical history
Medical problems, both past and present, and all medical illnesses.
If possible, try to obtain the child's entire medical records rather than depending solely on self- or family-report.
Includes specific events, such as falls, head trauma, seizures, and injuries with loss of consciousness.
Includes current medications.
Includes medication allergies.
Includes all surgical procedures.
Castellanos 2014
Past psychiatric history
All of the child's treatment, including outpatient, inpatient, residential and therapy-based (ie, individual, family, group), including dates.
Past psychotropic medications and response, compliance, and dosages.
Ask about perceived and observed benefits from the treatments. If so, inquire about the specific type of benefit.
Castellanos 2014
Family history
List any psychiatric, substance abuse or medical illnesses of family members and response.
If a patient's family member has been diagnosed with the same psychiatric illness and has been treated successfully, treating the current patient with that same medication may be appropriate.
Castellanos 2014
Assets
List attributes or strengths of the child.
Castellanos 2014
Social history
Perinatal and developmental information.
Recording an accurate educational history is imperative.
Living situation or housing status.
Include hobbies, social activities, and friends.
History of abuse.
Trauma- type of exposure, single vs repetitive, impact, etc.
Child’s or parents' religious beliefs. Investigate what effect the patient/family beliefs have on treatment of psychiatric illnesses or suicide.
Legal problems.
List past and current use of tobacco, alcohol, and street drugs.
Castellanos 2014
Review of systems
A review of information related to organ systems
1. Constitutional
2. Eyes
3. Ears/Nose/Mouth/Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Muscular
9. Integumentary
10. Neurological
11. Endocrine
12. Hemotologic/Lymphatic
13. Allergies/Immune
Castellanos 2014
Mental Status Exam:
Direct interview of the child or adolescent
May involve completion of rating scales (eg, Child Depression Inventory)
If it is an initial exam prior to treatment, helps establish a baseline to compare after treatment is started
If part of ongoing treatment, helps monitor progress, response to and tolerance of treatment
Castellanos 2014
Appearance : Provides a description of the child, what he/she is doing, wearing, hygiene, grooming and how they look. Speech : volume, rate, idiosyncratic symbols or other odd speech, tone (include any accent or stuttering). Motor activity : rate (agitated, retarded), purposefulness, adventitious (non-voluntary). Mood : The child is asked how they are feeling, usually put in quotes : "depressed," "sad," "great," etc... Affect : observable emotion (euthymic, neutral, euphoric, dysphoric, flat), the range (full, constricted, blunted), whether it fits appropriate to stated mood or content, lability.
Castellanos 2014
Thought process : organization of a child’s thoughts (logical/linear, circumstantial, tangential, flight of ideas, loose associations or thought blocking).
Thought content : basic themes preoccupying the child, suicidality, homicidality, paranoia, delusions, ideas of reference, obsessions, compulsions. If there is suicidal or homicidal ideation, further elaboration is necessary.
Perceptual disturbances : hallucinations (auditory, visual, olfactory, tactile), illusions, de-realization/depersonalization.
Cognitive : level of alertness and orientation. Memory, attention, concentration.
Insight : into issues or problems and/or need for treatment.
Judgment/Impulse control : best determined by history of patterns of behavior and current attitude.
Castellanos 2014
Diagnostic Impression:
Current nomenclature is DSM-5 and/or ICD-9
Assists in defining the treatment plan
May include “rule out” or provisional diagnosis if additional information is needed or the presentation is not clear
Castellanos 2014
Treatment Plan : Initial and Updated treatment plans. Is a continuous process that is updated on a regular basis and as needed. Defines target problems that will be the focus of treatment. Defines the plan to monitor the child, short and long term. May include further medical evaluation when appropriate. May include obtaining more information or seeking further workup to refine the diagnosis or update/refine the plan. Examples include, laboratory studies such as blood tests, CAT scans, MRIs or psychological, educational, speech and language evaluations.
Castellanos 2014
Castellanos 2014
The following checklist is another basic tool to assist in understanding if the psychotropic medication use and behavioral health treatment is appropriate:
Screening, assessment & treatment planning:
Was a medical pediatric examination performed and documented? Is the youth receiving ongoing pediatric care? Was a psychiatric evaluation completed? Is the psychiatric evaluation appropriate? Does the psychiatric diagnosis fit the history? Are Evidence-Based Therapies being provided? Is the impact of trauma addressed by treatment? Are psychosocial services provided? Is there appropriate communication between treatment providers?
Castellanos 2014
Medication monitoring:
Is the medication indicated for the diagnosis? Does the medication “match” the diagnosis?
Are prescriptions appropriately monitored?
Is ongoing efficacy evaluated?
Are appropriate dosages being used?
Are the duration of trials adequate?
Are medication changes increases/decreases systematic?
Is the concurrent use of multiple medications justified?
Is this an infant or preschool child who is being prescribed psychotropic medications?
Castellanos 2014
Castellanos 2014
“If you want happiness for an hour, take a nap.
If you want happiness for a day, go fishing.
If you want happiness for a month, get married.
If you want happiness for a year, inherit a fortune.
If you want happiness for a lifetime, help others." Anonymous Chinese Proverb
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