COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT DISCUSSION   

Depression is a common disorder in teenagers.  41.6% of teenagers from age to 12-17 had at least one episode of major depressive disorder in 2020 (National Institute of Mental Health, 2022).  Many things happen in a teenager’s life that can lead to depression, bullying, trouble at home or getting along with peers, peer pressure, and relationship issues are just a few.  Depression can cause a lack of interest in activities, feelings of extreme sadness, irritability, lack of focus, and trouble sleeping (American Psychiatric Association, 2022).  Severe depression can cause feelings of suicide and self-harm.

YMH Boston Vignette 5 Video

In this video I believe the practitioner did well.  The client started off being very reluctant, superficial, but with the probing questions she continued to ask she was able to get him to disclose some important information.  It appears that this is the first time these two individuals have met.  The clinician jumped right into talking with the client.  The client may have been more open at the beginning if she introduced herself or explained what their relationship would be like, including confidentiality (Sharma et al., 2019).  At the finishing of the video, I would have continued assessing the client’s suicidal thoughts.  I will want to find out if he has any plan or intent to act on his thoughts.  If not, I would want to work with him on contracting for safety, working on talking to his parents about the thoughts.  If he has a plan or intent, I would be looking at inpatient hospitalization.  I would also assess if he had any homicidal ideation.

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Why a thorough assessment is important

A thorough assessment is important in a child or adolescent aged client as they are typically more reluctant to talk about issues, out of fear of being in trouble or embarrassment (Sharma et al., 2019).  Clinicians must be aware of this to get an accurate assessment.  Collaborating with other individuals in the client’s life, such as teachers, parents, or other important people can help create a whole picture

Two different symptom rating scales

For rating depression, I would use a HAM-D or a PHQ-9 scale.  The HAM-D scale is based off 17 different categories that are rated on severity of symptoms.  A score of over 23 would indicate very severe depression.  A score of 19-22 is severe depression, 14-18 moderate depression, 8-13 mild depression, and 0-7 normal.  A PHQ-9 is a scale to rate severity of depression also.  This scale consists of 10 total questions, 9 of them used to rate severity.  All the categories are symptoms of major depressive symptoms.  They rate how many days they have experienced these symptoms.  For this scale a 1-4 would be considered minimal depression, a 5-9 mild depression, a 10-14 moderate depression, a 15-19 moderately severe depression, and a 20-27 severe depression.

Two psychiatric treatment options for children

One option for psychiatric treatment for a child is play therapy.  Play therapy is good to use for children up to school age.  This helps a child address and manage feelings in a way they can understand through playing with toys (Koukourikos et al., 2021).  Play therapy allows a child to act out feelings and emotions that a therapist can interpret and find what they mean.  Children often feel more at ease and comfortable when playing with toys, rather than expecting them to use language that an adult would use.

A second option for psychiatric treatment for a child is parent child interaction therapy.  This therapy is used on children who are having a hard time connecting or interacting with their parents.  You would typically see the child acting out behaviorally and unable to control their emotions (Lieneman et al., 2017).  The therapist guides the parent on how to interact with the child to try to strength their relationship and work on how to handle behavioral issues COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT DISCUSSION .

Role guardians/parents play in assessment

For a thorough assessment it is imperative to include the guardian.  The therapist needs to have a picture of everything that is going on with the child.  Having a collaboration from multiple people in the child’s life would be beneficial.  It also would be imperative to continue to include the guardian throughout treatment.  Just to see how they think the child is progressing, if any further issues have come up.  It is also important to the guardian to realize how the child may act with therapy.  They may act out at times if they have had to discuss issues that trigger them.  The guardian needs to be instructed of how to be supportive.

Conclusion

Childhood and adolescents can be a difficult time for children.  They may need additional support at this time if they appear to be struggling with depression.  There are plenty of options for the treatment of a child suffering with depression.  It is imperative that guardians pay attention to their children during these times to catch symptoms more quickly and allow for treatment.

References

American Psychiatric Association. (2022). Diagnostic And Statistical Manual Of Mental Disorders, Text Revision Dsm-5-Tr. Amer Psychiatric.

Koukourikos, K., Tsaloglidou, A., Tzeha, L., Iliadis, C., Frantzana, A., Katsimbeli, A., & Kourkouta, L. (2021). An Overview of Play Therapy. Materia Socio Medica, 33(4), 293. https://doi.org/10.5455/msm.2021.33.293-297

Lieneman, C., Brabson, L., Highlander, A., Wallace, N., & McNeil, C. (2017). Parent–Child Interaction Therapy: current perspectives. Psychology Research and Behavior Management, Volume 10, 239–256. https://doi.org/10.2147/prbm.s91200

National Institute of Mental Health. (2022, January). Major Depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/major-depression

Sharma, E., Srinath, S., Jacob, P., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(8), 158–175. https://doi.org/10.4103/psychiatry.indianjpsychiatry_580_18

BY DAY 3 OF WEEK 1

Based on the YMH Boston Vignette 5 video, post answers to the following questions:

• What did the practitioner do well? In what areas can the practitioner improve?
• At this point in the clinical interview, do you have any compelling concerns? If so, what are they?
• What would be your next question, and why?

Then, address the following. Your answers to these prompts do not have to be tailored to the patient in the YMH Boston video.

• Explain why a thorough psychiatric assessment of a child/adolescent is important.
• Describe two different symptom rating scales that would be appropriate to use during the psychiatric assessment of a child/adolescent.
• Describe two psychiatric treatment options for children and adolescents that may not be used when treating adults.
• Explain the role parents/guardians play in assessment.

Support your response with at least three peer-reviewed, evidence-based sources and explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

The purpose of this discussion is to review and analyze the techniques and method of the practitioner in the vignette 5 video, explain the importance of a comprehensive and integrated psychiatric assessment in children/adolescents, and identify suitable rating scales and treatment alternatives for children and adolescents.

What did the practitioner do good, and what areas can the practitioner improve

Every psychiatric assessment of an adolescent with mental distress will be exclusive; a successful psychiatric examination provides access to an adolescent’s innermost thoughts, impulses, and desires (Thapar & et al., 2015).  In the vignette 5 video, the clinician interviewed Tony with direct questions best suited to his individuality.  The clinician did satisfactorily by asking about the visit’s purpose, when the patient’s emotional distress began, the cause of the precipitating factors (break up with the girlfriend), and eliciting important information such as anhedonia, irritability, trouble getting up in the morning, occasional use of alcohol and thoughts of hurting self (YMH Boston, 2013).  The practitioner should focus on the essential portion of the examination. In this case, Tony was referred by his primary care physician for his anxiety and depression. The practitioner can improve her assessment by spending the remainder of the interview developing a therapeutic alliance and listening to the patient.

An excellent start to the diagnostic interview would be introducing oneself to the patient, asking how he would like to be addressed, setting the expectation, communicating what will be accomplished during the interview, and explaining the applicable confidentiality with the adolescent (Hilt & Nussbaum, 2016).  Identifying the precipitating event and how the patient views his current functioning, thoughts, and behavior affect his psychosocial functioning and how it differs from months ago.  Since the patient is speaking about suicidal thoughts, the lines of interaction must be open, active listening facilitated, and a calm demeanor must be maintained.

Compelling concerns and what would be the next question

The patient demonstrating a comfortable conversation about the thought of self-harm is a critical element in a successful examination.  When an adolescent is in an acute suicidal state due to thoughts of wanting to kill themselves, the emphasis of the intervention is to maintain the adolescent safe until the suicidal state lessens (Hilt & Nussbaum, 2016).  It would be beneficial to ask Tony about the content and nature of the suicidal ideation, the anticipated method, and the method in mind.  The questions would include ‘How powerful is the urge?  ‘Do you have a plan?’ ‘Do you have access to the method you have in mind?’. As part of the assessment, the patient should be asked whether they can keep safe and consider a safety plan that identifies how to survive persistent suicidal impulses in the future.

Practitioners who treat adolescents must be conscious of the federal and state law related to consent and confidentiality in adolescents.  Asking questions such as “Who do you live with?” “Who cares for you, and who can you trust?” can lead to critical questions about the patient’s caregiver.  A contract adhering to a safety plan can still be high risk, does not shield the practitioner or patient, and is not an alternative for a comprehensive assessment, especially with impulsive adolescents.  The level of involvement changes the level of suicide risk, available support, and the capability of patients to connect with those who seek to maintain safety (Hilt & Nussbaum, 2016).

Explanation of the importance of a thorough psychiatric assessment in child/adolescent

A comprehensive assessment can enlighten the practitioner about previous and existing events and conditions in the child’s life that are concerning and impact psychological development.  A thorough assessment also assists in deterring the patient’s personality, whether they can be referred outpatient or need inpatient stabilization.  Psychiatric assessment in children/adolescents is a portion of the practitioner’s connection with the patient, family, and other healthcare providers.  When formulating diagnoses and interventions, practitioners must be alert to medical and neurological disorders that produce mental health symptoms that affect the outcome and treatment management of the child/adolescent because psychiatric disorders affect behavior, mood, perception, and thinking. (Thar & et al., 2015).  For example, when a child/adolescent is being assessed for depression and has a family history of thyroid disease, this indicates a more significant risk for involvement from thyroid dysfunction equated with somebody without a family history.

Receiving a psychiatric diagnosis as a child or adolescent can have various emotional and social repercussions that can generate connotations for a child/adolescent’s self-concept and social individuality (O’Connor & et al., 2018).

Explanation of the role of guardians in the assessment

The parents/guardian’s involvement in child/adolescent assessment plays an integral and valuable part in the treatment, given that the child has to be evaluated and managed in the context of their caregiving environment.  A child/adolescent may be able to report the symptoms but may overlook reporting the duration, time, and nature of the problem.  Parents can elaborate and provide information to the practitioner.

Multisource information is a requirement for a comprehensive psychiatric assessment, diagnosis, and management (Srinath, Jacob, Sharma & Gautam, 2019).  Parents can offer to support their child/adolescent in coping and communicating.  A psychiatric assessment aids the child and the family in building a clear understanding of their difficulty and allows the family to reflect on the information they share.  Collateral information is necessary because some patients may provide inaccurate information to avoid hospitalization.

 Rating scales suitable to use throughout the psychiatric assessment of a child/adolescent

The Pediatric Anxiety Rating Scale (PARS) is a clinician-rated tool for assessing the gravity of anxiety symptoms related to separation anxiety, social phobia, and generalized anxiety symptoms aged 6-17 (Thapar & et al., 2015).  It comprises a 50-item symptom checklist of anxiety symptoms and the information collected from the interviews with the child/adolescent and the parent/guardian.  The practitioner scores each symptom as yes/no during the past week.  PARS helps determine whether a child/adolescent’s anxiety level is more similar to those with or without anxiety disorder (Research Units on Pediatric Psychopharmacology Anxiety Study Group & et al., 2018).

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The practitioner uses the Brief Psychiatric Rating Scale for Children (BPRS-C) to assess variation in problems among children/adolescents and evaluate the changes in problem scores to various treatments (Mpango & et al., 2020).  The scale is used for the assessment of emotional and behavioral problems.  It has seven subscales, each consisting of three items.  The subscales are behavioral difficulties, depression, thinking disturbance, psychomotor excitation, withdrawal-retardation, anxiety, and organicity (Mpango & et al., 2020). The total score indicates the symptoms’ overall severity.

Psychiatric treatment choices for children that may not be used when treating adults

Applied Behavioral Analysis (ABA)is an evidence-based mental health treatment for children and adolescents with an autism spectrum disorder.  ABA consists of adult-led learning principles in a real-life setting, including conceptually systematic, analytical, behavioral, and social skills, self-management, cognitions and pre-academic (number concept and letters), and technology training (Alves & et al., 2020).  Each dimension contributes to the intervention by cultivating learning, social communication, interaction, and behavior through a favorable environment.

Play therapy for kids is a combination of talk and play therapy that provides an opportunity to understand better and manage their conflict, feeling, and behavior (AACAP, 2019).  It involves toys, puppets, games, and drawing to aid the child in recognizing and verbalizing their feelings.

Conclusion

Practitioners can efficiently perform a focused mental health assessment with a child/adolescent by building a therapeutic alliance, using a validated tool, identifying the leading concern, purpose, and benefits of evaluation, identifying the safety issue and diagnosing a probable disorder.  The articles used in this discussion are all scholarly articles from Walden and Google Scholar Database and were referred by respected authors that are knowledgeable in their field.

References

Alves, F., De Carvalho, E., Aguilar, L., De Brito L., & Bastos, G. (2020).  Applied behavior analysis for the treatment of autism: A systematic review of assistive technologies, in IEEE Access, vol. 8, pp. 118664-118672, 2020, doi: 10.1109/ACCESS.2020.3005296 COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT DISCUSSION .

American Academy of Child and Adolescent Psychiatry.  (2019).  Psychotherapy for Children and Adolescents: Different Types; no 86.  https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychotherapies-For-Children-And-Adolescents-086.aspxLinks to an external site.

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

Mpango S., Ssembajjwe W., Muyingo SK., Gadow KD., Patel V., Kinyanda E. (2020). Adaptation and validation of a brief DSM-5 based psychiatric rating scale for childhood and adolescent mental health in Uganda: The Child and Adolescent Symptom Inventory-Progress Monitor (CASI-PM). Vulnerable Children & Youth Studies.  2020;15(2):144-154. doi:10.1080/17450128.2019.1686672

O’Connor, C., Kadianaki, I., Maunder, K., & McNicholas, F. (2018).  How does psychiatric diagnosis affect young people’s self-concept and social identity?  A systematic review and synthesis of the qualitative literature. Social Science & Medicine, 212, 94–119.  https://doi.org/10.1016/j.socscimed.2018.07.011Links to an external site.

Research Units on Pediatric Psychopharmacology Anxiety Study Group., Zehgeer, A., Ginsburg, G. S., Lee, P., Birmaher, B., Walkup, J., Kendall, P. C., Sakolsky, D., & Peris, T. (2018). Pediatric anxiety rating scale. Child & Youth Care Forum, 47, 633–644.

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

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.).  Wiley Blackwell.

YMH Boston.  (2013, May 22). Vignette 5 – Assessing for depression in a mental health appointment.https://www.youtube.com/watch?v=Gm3FLGxb2ZULinks to an external site.COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT DISCUSSION