Psychiatric Evaluation Process Insights

Disclosures
With respect to the following presentation, there has
been no relevant (direct or indirect) financial relationship
between the faculty listed above or other activity
planners (or spouse/partner) and any for-profit company
in the past 12 months which would be considered a
conflict of interest.
The views expressed in this presentation are those of the
faculty and may not reflect official policy of Community
Health Center, Inc. and its Weitzman Institute.
We are obligated to disclose any products which are off-
label, unlabeled, experimental, and/or under investigation
(not FDA approved) and any limitations on the
information that are presented, such as data that are
preliminary or that represent ongoing research, interim
analyses, and/or unsupported opinion.
Conducting the Psychiatric
Evaluation
Emily Farb
Marnie Flynn
Referrals
Team referral process
Preparing for an eval
Chart review
School records
Collateral
Have a plan, set agenda-  be ready to test drive your hypotheses, but also be flexible
Strategy- symptom clusters/fly over method
Know inherent temperament/disposition trends and trajectories
Arrested developments, trauma
Remote vs in-person
Consider developmental age
Interviewing- NOT a checklist 
Explain the process
How do we enter
Materials
Who to address first
Never launch into behavioral issues/presenting problems
No jargon
What to watch for (beyond MSE checklist!)
How do they come in, who sits where, interactions etc
Lets do some examples:
14yo moody/angry/shut down teen
6yo anxious
Getting Usable Data
REMINDER: NOT VOLUNTARY
USING THE 3
RD
 PERSON AND METAPHORS 
ASK FOR OPERATIONAL/OBECTIVE DETAILS IN ADDITION TO SUBJECTIVE DETAILS
UNLESS OFFERED, STAY AWAY FROM DIRECTLY ASKING ABOUT EMOTIONS AND CHECK FOR SHARED DEFINITIONS
Must use “back door” – or else they will shut down
“takes me forever to fall asleep”/ “ive had SI, but they go away fast”
THEY WILL ENDORSE WHAT THEY HAVE HEARD PARENTS SAY AND INTEGRATE IT INTO THEIR REPORT
***WATCHING CHANGES IN ACTIVITY LEVEL AND TYPE, LEAVING THE ROOM, ATTENTION, AMOUNT OF VERBAL CHANGES (TONE,
MATURITY, AMOUNT, ETC WHILE PARENT IS TALKING)
***PLAY IS DOMINANT LANGUAGE
KNOW IF CHILD IS HUNGRY, TIRED AND DID/DID NOT TAKE THEIR MEDS AND WHAT TIME!!!
THEY ARE FEARFUL (EXPRESSED IN DIFFERENT WAYS) SO
 
MAKE SURE YOU REVIEW WHAT THE PURPOSE IS (NO SHOTS)
 and 
 WHAT THE
PLAN FOR THE EVALUATION IS SEQUENTIALLY
***START WITH EASY, PLEASANT STUFF:
FAVORITE ACTIVITY-‘THINGS YOU LIKE TO DO’
BEST SUBJECTS-RECESS IS VALID! MENTION ART, MUSIC, SPORTS
PETS? LET THEM ASK ABOUT YOURS
Continued
DO NOT ASSUME THEY SAY THINGS IN THE SAME SPIRIT AS ADULTS: 
Instead of facts being verbalized and handed to you, you have to observe, investigate and
synthesize
SUICIDAL OR HOMICIDAL STATEMENTS MAY JUST BE EXPRESSIONS OF ANGER/MAD
BUT 
IF THEY DO GO TO ED AND SAY THEY ARE NOT SUICIDAL, THIS MAY CHANGE ONCE THEY LEAVE THE
ED!
Pay attention to context
TIME IS PERCEIVED DIFFERENTLY, SO TIE TO DAY/NIGHT, SEASONS, HOLIDAYS, SCHOOL PATTERN
OR KNOWN EVENTS
When inquiring about timelines/duration-anchor it to something
if a time segment is offered spontaneously- do take it seriously
TEENS:
GENERALLY ASK THEM NOT TO TRUST ME
TELL THEM IT IS THEIR CHOICE TO SHARE OR NOT- can say none of your business!
ALWAYS TRY TO OFFER TIME ALONE IN CASE THEY ARE NOT COMFORTABLE WITH PARENTS IN
ROOM
Presenting problem/HPI
Sx at home/school/community
NOTE Changes from baseline
NOTE relevant change in life/events
Frequency, duration, intensity
In their own words and in parents words. Then details, across each domain, separately
eating
sleep
attention/concentration
hyperactivity
worries, panic, sensory, compulsions/obsessions/rituals, phobias
mood
mania
aggression
abuse
Trauma sx – flashbacks, memory lapses, dissociative sx, arousal
ah/vh
SI, SIB
HI
With peers
substance abuse, risk behaviors, promiscuity, legal
DCF involvement- if relevant
What is the difference between HPI and PP?
You do not necessarily need to create a separate section but make
sure you comment on the following- 
when it started, patterns, how
long, how intense, triggers, what improves it, where it happens, other
things that accompany it
P
s
y
c
h
 
h
x
treatment types
 length
 response
 ED visits
 211/911
PHP/IOP
Inpatient
 diagnoses
 medications: what tried, if used as RX, responses good and bad,
idionsyncratic
Getting med rec: Must use TE DROP-DOWN “Pharmacy Assistance”
Developmental Hx Specifics: for Eval in our
setting, the ‘must haves’
prenatal
Perinatal
Labor, delivery, complications and status at birth
Attachment/temperament
Sensory
Play
Milestones- AT LEAST WALKING, TALKING, TOILETING
Separation
School – preschool, peer and teacher interaction, learning, attention/concentration/hyperactivity/impulsivity, held back, accommodations
DCF/systems involvement/TRAUMA- PHYSICAL AND SEXUAL ABUSE/NEGLECT
Social – friends, gender, comfort, romantic
sexuality preference, gender identification
Sexual abuse, physical abuse, neglect, trauma exposure
Caregiver disruptions, losses, moves
Enjoyed activities
Hated activities
what they think about after HS
Extracirricular activities
3 wishes
 
Break 10 min
Family Structure/Function
Structure:
who is present in home
where other significant members are located
Types of connections/relationships
Deaths, incarcerations, presence, work, discipline, organization type
Structure of the physical home – shared rooms, privacy, etc
Function:
Roles
who has psych hx and what dx, what meds and responses, substance, legal, medical illnesses,
medications, diagnoses
Custody and parental rights
Culture/ethnic identification
Beliefs/preferences
immigration status
Exploring family psych history *in detail* – confirm genetic loading, consider intergenerational
trauma (may confound reported psych DX)
FAMILY HISTORY OF SUDDEN CARDIAC DEATH
FAMILY HISTORY OF GENETIC PROBLEMS
Medical
developmental delays
chronic or acute conditions
TBIs
Seizures
Anemia
abnormal bleeding
lead exposure
Asthma
recurrent ear infections
recurrent strep
high fevers
exposure to bacterial/viral infections
lyme/tic borne
Rashes
cardiac hx-murmurs, chest pain with
activity
fainting/dizziness/near syncope
Autoimmune
 eating/elimination issues
enuresis/encopresis
Puberty/menses
Pain- somatic or otherwise
Hearing/vision.
allergies/rxn
Surgeries/hospitalizations, include age
See ROS Handout for more details
Mental Status Exam
Purpose- diagnosis, baseline for changes in functioning, and evaluation of
treatment
Interpreting from the non-verbal
Use narrative form
Drawing (self portrait, family, favorite activity)
Usually involves comment(s) on changes observed across interview
Someone reading the write up should be able identify child in waiting
room
Appearance
A.
 
Face: Symmetry, dysmorphism, scars, lines, expressiveness/expression
B.
 
Eyes: clarity, strabismus, gaze, glasses, eye contact
C.
 
Head: size relative to body, hair coverage, shape
D.
 
Body: dress, nutritional status, hydration, skin, grooming, marks:
abuse, self-mutilation, evidence of injury, musculature
E.
 
Dress: message of style, appropriateness for site and weather
conditions,
gender orientation, flamboyance, neatness/grooming, age-indicated,
tattoos, piercings
F.
 
Gait and posture: smooth, clumsy, sitting, walking, posture
G.
 
 Gestures: intensity, expressiveness, nervous behaviors
Motor/Motility
A. Quality: smooth, jerky, random, purposive, agitated
B. Quantity: hyperkinesis, persistent vs. intermittent, when, how long,
changes in, control of
C:  Type: Motor or Vocal tics, fidgeting, overflow motor, Stimming
D:   Balance: Hop on each foot, walk on line, stairs, eyes closed
E: Coordination: laterality, overflow, ball catch and throw, use of supports
 
Gross vs. Fine Motor: pick up sticks, choice of drawing material:
 
 
3-4 years can draw a O
 
2-5 years can draw +
 
6-7 years can draw: SELF, FAMILY, PREFERRED ACTIVITY
Speech/Language
SPONTANEOUS? BILINGUAL?
Quality: smooth, clear, expressiveness, tone, volume, modulation,
articulation, coherence
Quantity: pressured, speed, poverty of speech, pauses: stuttering
(normal up to 3-4 years), cluttering, monosyllabic
Receptive capacity: follows commands, directions
Expressive capacity: spontaneity, vocabulary
Comprehension
Content: echolalia, word salad, changing neologisms, idiosyncratic nonsense
Writing/ Reading: reversals (normal till age 7), quality, fluency
Nonverbals: congruent
Intellectual Functioning
Estimate to norms: borderline, low, average, high, superior
Creativity
Spontaneity
General Knowledge: ask time, money, new information
Academic: grade, like school, grades, least/ most favorite book/story- what it is about
Comprehension: ask for a joke, tell a joke
Social Intelligence: travel, what to do in situations
Attention: distractibility (to what)
Concentration: count back by 3's
Frustration Tolerance/ Persistence
Organization
Body Parts:
3 years- face and limbs
5 years- wrist, ankles, elbows and knees
7 years-jaw, temple, forearm, skin
Memory/ Time- a poor measure
Thinking and Perception
LOC
Body- boundaries, depersonalization, derealization, self concept
Thought content- themes, delusions, grandiose
Hallucinations- can only distinguish after age 3-4
Obsessions
Compulsions
Phobias
SI/HI
Poverty of content
Magical thinking – persisting after age 8 or 9
Thought Process
Loosening of association- rapid shifts without logic
Flight of ideas- some connection but rapid/ racing
Tangential: never gets to the point
Circumstantiality: gets to the point but digresses
Incoherence: word salad, vagueness, punning, clang associations, neologisms,
echolalia
Perseveration
Thought Blocking- interruptions
Judgment: what would you do if...
Insight: level of understanding in situations
Mood and Affect
Mood: internal/ subjective
Quality: client's terms, describe, intensity
Duration: how long, patterns/ cycles
Pervasiveness: in what situations, triggers
Affect: objective by observer
Predominant affect: anxiety, happiness, sadness etc.
Range: constricted/ full
Appropriateness: relative to discussion
Quality: blunt, flat, constricted, expressive
Intensity: match ? content
Progression: note changes in affect lability
Manner of Relating
A. Separation from caretaker
B. Degree of Independence
C. Style: flamboyant, stoic etc.
D. Passive/ active: introvert/ extrovert
E. Eye contact- beware culture
F. Personal space
G. Manner of approach
H. Approval/ attention-seeking
I. Age level: regressed, precocious
J. Aggression
K. Sexualized behavior
L. Limit testing
M. Curious vs. aloof/disinterested
N. Coping behaviors
O. Objects: peers, pets, transitional objects
Character of Play, Fantasies and Dreams
A. Themes
B. Persistence / repetition
C. Level of development
D. Age of appropriate
E. Rules: ability to follow, understand, cheating (abnormal > 8 yrs. old)
F. Organization
G. Creative vs. stereotyped
H. Open/close: how they start/finish
I. Gender "appropriate"
J. Affect: especially aggression - random, goal-directed, contained
K. Tools to use:
1. Ages 2-5: blocks, animals, sorting, house
Ages 5-7: animals, house, playdoh, checkers, drawing, puppets
Ages > 8: games, balls, drawing
L. Flow: changes in themes, play disruptions, requests to leave
Assessment of Risk
*How to ask across ages
SI
HI
Psychosis
Substance abuse – remind them of confidentiality and importance
relative to medication interactions
Formulation
CONCISE summary of case in light of information available
Captures the ESSENCE and PORTRAIT of the patient
Distinguishes Primary versus Secondary Issues
Weighs the variables and correlations
Clarifies central issues and conflicts with an eye to SOURCE
Guides treatment
Predicts outcome  and possible trajectories
Formulation Continued
Contents
Predisposing factors: genetics, constitutional/temperament,
environmental exposure
 Precipitating factors: stressors, developmental, changes, physical
conditions, losses
Perpetuating factors: what maintains
Protective factors: individual strengths, family, support systems,
intelligence, interests
Formulation Continued
How impaired in functioning in different domains
Is disturbance intrinsic or reactive
What is the organic component
What is the range of symptoms: encapsulated or pervasive
Are symptoms transient, cyclical, chronic, consistent or changeable
What psychosocial factors have impacted the picture and WHEN
What psychosocial factors are continuing to impact
What developmental tasks are they working on
What is their range of coping strategies and defense structures
Formulation Continued
Structure
Summarizing statements: include demographics (race, ethnicity, age and
gender) why this patient, why now and most salient features
Description of Non-Dynamic Factors: genetics, environment, pre and peri-
natal, medical issues, LDs, IQ
Psychodynamic Explanation of central conflicts and modifying variables: loss,
abandonment, TRAUMA, Caregiver status, incarcerations, identity themes,
changes in family, migration/cultural or language issues, stage of
development
ACCOUNTING FOR THE DIFFERENTIAL: WHY THIS AND WHY NOT THIS
Strengths/weaknesses
Predicting responses to therapeutics, /PROGNOSIS WITH AND WITHOUT
INTERVENTION
Formulation Continued
DO NOT INTRODUCE NEW MATERIAL IN THE FORMULATION
DO NOT JUST REPEAT OR RESTATE DATA.
YOU HAVE TO SYNTHESIZE THE DATA!!
 CREATES A MAP/RUBRIC
IT SHOULD READ LIKE A STORY AND IS NOT LINEAR
Plan
KIND OF TREATMENT
LEVEL OF CARE AND WHY
IN WHAT ORDER*****
FOR SHORT GOALS-STABILIZATION/RESPITE, ETC.
FOR THE LONG-TERM GOALS
NONPHARMACOLOGICAL THERAPY
COLLATERAL TREATMENT: OT, PT, PSYCH OR NEUROPSYCH TESTING-for what purpose
MEDICAL NEEDS: MRIS, NEUROLOGICAL, ENDOCRINE, RHEUMATOLOGY, ETC.for what
purpose
SYSTEMS/RESOURCES
PHARMACOLOGICAL: sequence, purpose-disorder or symptom relief
PLAN FOR RETURN
Plan Continued
Make sure the plan makes sense
Make sure the plan is DO-ABLE!!!!
Make sure there are no barriers
Make sure the family is in agreement
Make sure you are not overloading the system and compromising the
viability and sustainability
Pearls, Dos and Don’ts
Do not use medical/mental health vernacular
Do not start with “how have you been feeling?”
Use stories and metaphors, related to their interests
Use holidays and seasons for timelines
One question at a time
Be direct with risk assessment
Consider developmental stage and cognitive functioning
Engage playfully in any way you can
Check for understanding-ask for a bit of feedback
LOOK/LISTEN and even use you olfactory sense
Explore the whole picture
Balance story of parents, kids, schools and other collateral informants-include contexts
Know yourself-we are likely to have countertransference/judgment laden responses
Pearls, Dos and Don’ts
Check for understanding-ask for a bit of feedback
Screen for reactions-including you peripheral vision
STAY OUT OF YOUR HEAD
KNOW NORMS for age and cultural framework to understand where and
how they are off the track
MIRROR
Be present and open.
Be expert, but first be humble. You are not an expert around their
experiences
FOLLOW THEIR LEAD-KIDS AND PARENTS
Compete with parents-our job is to help them to help their kids
Pearls, Dos and Don’ts
Don’t Judge
Don’t overfunction (do not do more that they are willing)
Don’t be a bleeding heart
DON’T TALK TOO MUCH/DON’T TALK TOO SOON-GET THE PICTURE
DON’T GET OVERFOCUSED OR DISTRACTED BY CONTENT RATHER THAN PROCESS
People unfold when they feel safe and may DOORKNOB important information.
There are always hidden agendas-mostly unconscious, but not always.
Don’t assume that the story once told will stay consistent.
Don’t keep going if you are digging a hole
Don’t be afraid to be wrong and if you are-TELL THEM
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This presentation provides valuable insights into conducting psychiatric evaluations, including tips on referrals, team processes, interview techniques, and obtaining usable data. The speakers emphasize the importance of thorough preparation, flexibility, and understanding individual nuances during evaluations. Key points cover setting agendas, recognizing behavioral cues, using metaphors for communication, and addressing emotional nuances indirectly. The content focuses on practical strategies to gather comprehensive information and build rapport with patients effectively.

  • Psychiatry
  • Evaluation
  • Referrals
  • Interview Techniques
  • Usable Data

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  1. Disclosures With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the faculty listed above or other activity planners (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. The views expressed in this presentation are those of the faculty and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. We are obligated to disclose any products which are off- label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information that are presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.

  2. Conducting the Psychiatric Evaluation Emily Farb Marnie Flynn

  3. Referrals Team referral process Preparing for an eval Chart review School records Collateral Have a plan, set agenda- be ready to test drive your hypotheses, but also be flexible Strategy- symptom clusters/fly over method Know inherent temperament/disposition trends and trajectories Arrested developments, trauma Remote vs in-person Consider developmental age

  4. Interviewing- NOT a checklist Explain the process How do we enter Materials Who to address first Never launch into behavioral issues/presenting problems No jargon What to watch for (beyond MSE checklist!) How do they come in, who sits where, interactions etc Lets do some examples: 14yo moody/angry/shut down teen 6yo anxious

  5. Getting Usable Data REMINDER: NOT VOLUNTARY USING THE 3RDPERSON AND METAPHORS ASK FOR OPERATIONAL/OBECTIVE DETAILS IN ADDITION TO SUBJECTIVE DETAILS UNLESS OFFERED, STAY AWAY FROM DIRECTLY ASKING ABOUT EMOTIONS AND CHECK FOR SHARED DEFINITIONS Must use back door or else they will shut down takes me forever to fall asleep / ive had SI, but they go away fast THEY WILL ENDORSE WHAT THEY HAVE HEARD PARENTS SAY AND INTEGRATE IT INTO THEIR REPORT ***WATCHING CHANGES IN ACTIVITY LEVEL AND TYPE, LEAVING THE ROOM, ATTENTION, AMOUNT OF VERBAL CHANGES (TONE, MATURITY, AMOUNT, ETC WHILE PARENT IS TALKING) ***PLAY IS DOMINANT LANGUAGE KNOW IF CHILD IS HUNGRY, TIRED AND DID/DID NOT TAKE THEIR MEDS AND WHAT TIME!!! THEY ARE FEARFUL (EXPRESSED IN DIFFERENT WAYS) SO MAKE SURE YOU REVIEW WHAT THE PURPOSE IS (NO SHOTS) and WHAT THE PLAN FOR THE EVALUATION IS SEQUENTIALLY ***START WITH EASY, PLEASANT STUFF: FAVORITE ACTIVITY- THINGS YOU LIKE TO DO BEST SUBJECTS-RECESS IS VALID! MENTION ART, MUSIC, SPORTS PETS? LET THEM ASK ABOUT YOURS

  6. Continued DO NOT ASSUME THEY SAY THINGS IN THE SAME SPIRIT AS ADULTS: Instead of facts being verbalized and handed to you, you have to observe, investigate and synthesize SUICIDAL OR HOMICIDAL STATEMENTS MAY JUST BE EXPRESSIONS OF ANGER/MAD BUT IF THEY DO GO TO ED AND SAY THEY ARE NOT SUICIDAL, THIS MAY CHANGE ONCE THEY LEAVE THE ED! Pay attention to context TIME IS PERCEIVED DIFFERENTLY, SO TIE TO DAY/NIGHT, SEASONS, HOLIDAYS, SCHOOL PATTERN OR KNOWN EVENTS When inquiring about timelines/duration-anchor it to something if a time segment is offered spontaneously- do take it seriously TEENS: GENERALLY ASK THEM NOT TO TRUST ME TELL THEM IT IS THEIR CHOICE TO SHARE OR NOT- can say none of your business! ALWAYS TRY TO OFFER TIME ALONE IN CASE THEY ARE NOT COMFORTABLE WITH PARENTS IN ROOM

  7. Presenting problem/HPI Sx at home/school/community NOTE Changes from baseline NOTE relevant change in life/events Frequency, duration, intensity In their own words and in parents words. Then details, across each domain, separately eating sleep attention/concentration hyperactivity worries, panic, sensory, compulsions/obsessions/rituals, phobias mood mania aggression abuse Trauma sx flashbacks, memory lapses, dissociative sx, arousal ah/vh SI, SIB HI With peers substance abuse, risk behaviors, promiscuity, legal DCF involvement- if relevant

  8. What is the difference between HPI and PP? You do not necessarily need to create a separate section but make sure you comment on the following- when it started, patterns, how long, how intense, triggers, what improves it, where it happens, other things that accompany it

  9. Psych Psych hx hx treatment types length response ED visits 211/911 PHP/IOP Inpatient diagnoses medications: what tried, if used as RX, responses good and bad, idionsyncratic Getting med rec: Must use TE DROP-DOWN Pharmacy Assistance

  10. Developmental Hx Specifics: for Eval in our setting, the must haves prenatal Perinatal Labor, delivery, complications and status at birth Attachment/temperament Sensory Play Milestones- AT LEAST WALKING, TALKING, TOILETING Separation School preschool, peer and teacher interaction, learning, attention/concentration/hyperactivity/impulsivity, held back, accommodations DCF/systems involvement/TRAUMA- PHYSICAL AND SEXUAL ABUSE/NEGLECT Social friends, gender, comfort, romantic sexuality preference, gender identification Sexual abuse, physical abuse, neglect, trauma exposure Caregiver disruptions, losses, moves Enjoyed activities Hated activities what they think about after HS Extracirricular activities 3 wishes

  11. Break 10 min

  12. Family Structure/Function Structure: who is present in home where other significant members are located Types of connections/relationships Deaths, incarcerations, presence, work, discipline, organization type Structure of the physical home shared rooms, privacy, etc Function: Roles who has psych hx and what dx, what meds and responses, substance, legal, medical illnesses, medications, diagnoses Custody and parental rights Culture/ethnic identification Beliefs/preferences immigration status Exploring family psych history *in detail* confirm genetic loading, consider intergenerational trauma (may confound reported psych DX) FAMILY HISTORY OF SUDDEN CARDIAC DEATH FAMILY HISTORY OF GENETIC PROBLEMS

  13. Medical developmental delays chronic or acute conditions TBIs Seizures Anemia abnormal bleeding lead exposure Asthma recurrent ear infections recurrent strep high fevers exposure to bacterial/viral infections lyme/tic borne Rashes cardiac hx-murmurs, chest pain with activity fainting/dizziness/near syncope Autoimmune eating/elimination issues enuresis/encopresis Puberty/menses Pain- somatic or otherwise Hearing/vision. allergies/rxn Surgeries/hospitalizations, include age See ROS Handout for more details

  14. Mental Status Exam Purpose- diagnosis, baseline for changes in functioning, and evaluation of treatment Interpreting from the non-verbal Use narrative form Drawing (self portrait, family, favorite activity) Usually involves comment(s) on changes observed across interview Someone reading the write up should be able identify child in waiting room

  15. Appearance A. B. C. D. abuse, self-mutilation, evidence of injury, musculature E. Dress: message of style, appropriateness for site and weather conditions, gender orientation, flamboyance, neatness/grooming, age-indicated, tattoos, piercings F. Gait and posture: smooth, clumsy, sitting, walking, posture G. Gestures: intensity, expressiveness, nervous behaviors Face: Symmetry, dysmorphism, scars, lines, expressiveness/expression Eyes: clarity, strabismus, gaze, glasses, eye contact Head: size relative to body, hair coverage, shape Body: dress, nutritional status, hydration, skin, grooming, marks:

  16. Motor/Motility A. Quality: smooth, jerky, random, purposive, agitated B. Quantity: hyperkinesis, persistent vs. intermittent, when, how long, changes in, control of C: Type: Motor or Vocal tics, fidgeting, overflow motor, Stimming D: Balance: Hop on each foot, walk on line, stairs, eyes closed E: Coordination: laterality, overflow, ball catch and throw, use of supports Gross vs. Fine Motor: pick up sticks, choice of drawing material: 3-4 years can draw a O 2-5 years can draw + 6-7 years can draw: SELF, FAMILY, PREFERRED ACTIVITY

  17. Speech/Language SPONTANEOUS? BILINGUAL? Quality: smooth, clear, expressiveness, tone, volume, modulation, articulation, coherence Quantity: pressured, speed, poverty of speech, pauses: stuttering (normal up to 3-4 years), cluttering, monosyllabic Receptive capacity: follows commands, directions Expressive capacity: spontaneity, vocabulary Comprehension Content: echolalia, word salad, changing neologisms, idiosyncratic nonsense Writing/ Reading: reversals (normal till age 7), quality, fluency Nonverbals: congruent

  18. Intellectual Functioning Estimate to norms: borderline, low, average, high, superior Creativity Spontaneity General Knowledge: ask time, money, new information Academic: grade, like school, grades, least/ most favorite book/story- what it is about Comprehension: ask for a joke, tell a joke Social Intelligence: travel, what to do in situations Attention: distractibility (to what) Concentration: count back by 3's Frustration Tolerance/ Persistence Organization Body Parts: 3 years- face and limbs 5 years- wrist, ankles, elbows and knees 7 years-jaw, temple, forearm, skin Memory/ Time- a poor measure

  19. Thinking and Perception LOC Body- boundaries, depersonalization, derealization, self concept Thought content- themes, delusions, grandiose Hallucinations- can only distinguish after age 3-4 Obsessions Compulsions Phobias SI/HI Poverty of content Magical thinking persisting after age 8 or 9

  20. Thought Process Loosening of association- rapid shifts without logic Flight of ideas- some connection but rapid/ racing Tangential: never gets to the point Circumstantiality: gets to the point but digresses Incoherence: word salad, vagueness, punning, clang associations, neologisms, echolalia Perseveration Thought Blocking- interruptions Judgment: what would you do if... Insight: level of understanding in situations

  21. Mood and Affect Mood: internal/ subjective Quality: client's terms, describe, intensity Duration: how long, patterns/ cycles Pervasiveness: in what situations, triggers Affect: objective by observer Predominant affect: anxiety, happiness, sadness etc. Range: constricted/ full Appropriateness: relative to discussion Quality: blunt, flat, constricted, expressive Intensity: match ? content Progression: note changes in affect lability

  22. Manner of Relating A. Separation from caretaker B. Degree of Independence C. Style: flamboyant, stoic etc. D. Passive/ active: introvert/ extrovert E. Eye contact- beware culture F. Personal space G. Manner of approach H. Approval/ attention-seeking I. Age level: regressed, precocious J. Aggression K. Sexualized behavior L. Limit testing M. Curious vs. aloof/disinterested N. Coping behaviors O. Objects: peers, pets, transitional objects

  23. Character of Play, Fantasies and Dreams A. Themes B. Persistence / repetition C. Level of development D. Age of appropriate E. Rules: ability to follow, understand, cheating (abnormal > 8 yrs. old) F. Organization G. Creative vs. stereotyped H. Open/close: how they start/finish I. Gender "appropriate" J. Affect: especially aggression - random, goal-directed, contained K. Tools to use: 1. Ages 2-5: blocks, animals, sorting, house Ages 5-7: animals, house, playdoh, checkers, drawing, puppets Ages > 8: games, balls, drawing L. Flow: changes in themes, play disruptions, requests to leave

  24. Assessment of Risk *How to ask across ages SI HI Psychosis Substance abuse remind them of confidentiality and importance relative to medication interactions

  25. Formulation CONCISE summary of case in light of information available Captures the ESSENCE and PORTRAIT of the patient Distinguishes Primary versus Secondary Issues Weighs the variables and correlations Clarifies central issues and conflicts with an eye to SOURCE Guides treatment Predicts outcome and possible trajectories

  26. Formulation Continued Contents Predisposing factors: genetics, constitutional/temperament, environmental exposure Precipitating factors: stressors, developmental, changes, physical conditions, losses Perpetuating factors: what maintains Protective factors: individual strengths, family, support systems, intelligence, interests

  27. Formulation Continued How impaired in functioning in different domains Is disturbance intrinsic or reactive What is the organic component What is the range of symptoms: encapsulated or pervasive Are symptoms transient, cyclical, chronic, consistent or changeable What psychosocial factors have impacted the picture and WHEN What psychosocial factors are continuing to impact What developmental tasks are they working on What is their range of coping strategies and defense structures

  28. Formulation Continued Structure Summarizing statements: include demographics (race, ethnicity, age and gender) why this patient, why now and most salient features Description of Non-Dynamic Factors: genetics, environment, pre and peri- natal, medical issues, LDs, IQ Psychodynamic Explanation of central conflicts and modifying variables: loss, abandonment, TRAUMA, Caregiver status, incarcerations, identity themes, changes in family, migration/cultural or language issues, stage of development ACCOUNTING FOR THE DIFFERENTIAL: WHY THIS AND WHY NOT THIS Strengths/weaknesses Predicting responses to therapeutics, /PROGNOSIS WITH AND WITHOUT INTERVENTION

  29. Formulation Continued DO NOT INTRODUCE NEW MATERIAL IN THE FORMULATION DO NOT JUST REPEAT OR RESTATE DATA. YOU HAVE TO SYNTHESIZE THE DATA!! CREATES A MAP/RUBRIC IT SHOULD READ LIKE A STORY AND IS NOT LINEAR

  30. Plan KIND OF TREATMENT LEVEL OF CARE AND WHY IN WHAT ORDER***** FOR SHORT GOALS-STABILIZATION/RESPITE, ETC. FOR THE LONG-TERM GOALS NONPHARMACOLOGICAL THERAPY COLLATERAL TREATMENT: OT, PT, PSYCH OR NEUROPSYCH TESTING-for what purpose MEDICAL NEEDS: MRIS, NEUROLOGICAL, ENDOCRINE, RHEUMATOLOGY, ETC.for what purpose SYSTEMS/RESOURCES PHARMACOLOGICAL: sequence, purpose-disorder or symptom relief PLAN FOR RETURN

  31. Plan Continued Make sure the plan makes sense Make sure the plan is DO-ABLE!!!! Make sure there are no barriers Make sure the family is in agreement Make sure you are not overloading the system and compromising the viability and sustainability

  32. Pearls, Dos and Donts Do not use medical/mental health vernacular Do not start with how have you been feeling? Use stories and metaphors, related to their interests Use holidays and seasons for timelines One question at a time Be direct with risk assessment Consider developmental stage and cognitive functioning Engage playfully in any way you can Check for understanding-ask for a bit of feedback LOOK/LISTEN and even use you olfactory sense Explore the whole picture Balance story of parents, kids, schools and other collateral informants-include contexts Know yourself-we are likely to have countertransference/judgment laden responses

  33. Pearls, Dos and Donts Check for understanding-ask for a bit of feedback Screen for reactions-including you peripheral vision STAY OUT OF YOUR HEAD KNOW NORMS for age and cultural framework to understand where and how they are off the track MIRROR Be present and open. Be expert, but first be humble. You are not an expert around their experiences FOLLOW THEIR LEAD-KIDS AND PARENTS Compete with parents-our job is to help them to help their kids

  34. Pearls, Dos and Donts Don t Judge Don t overfunction (do not do more that they are willing) Don t be a bleeding heart DON T TALK TOO MUCH/DON T TALK TOO SOON-GET THE PICTURE DON T GET OVERFOCUSED OR DISTRACTED BY CONTENT RATHER THAN PROCESS People unfold when they feel safe and may DOORKNOB important information. There are always hidden agendas-mostly unconscious, but not always. Don t assume that the story once told will stay consistent. Don t keep going if you are digging a hole Don t be afraid to be wrong and if you are-TELL THEM

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