Posted: March 25th, 2021

Discussion: Comprehensive Integrated Psychiatric Assessment

Discussion: Comprehensive Integrated Psychiatric Assessment

Photo Credit: Seventyfour / Adobe Stock

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.

Some children/adolescents may be more difficult to assess than adults, as they can be less psychologically minded. That is, they have less insights into themselves and their motivations than adults (although this is not universally true). The PMHNP must also take into consideration the child’s culture and environmental context. Additionally, with children/adolescents, there are lower rates of neurocognitive disorders superimposed on other clinical conditions, such as depression or anxiety, which create additional diagnostic challenges.

In this Discussion, you review and critique the techniques and methods of a mental health professional as the practitioner completes a comprehensive, integrated psychiatric assessment of an adolescent. You also identify rating scales and treatment options that are specifically appropriate for children/adolescents.

To Prepare
Review the Learning Resources and consider the insights they provide on comprehensive, integrated psychiatric assessment. Watch the Mental Status Examination B-6 and Simulation Scenario-Adolescent Risk Assessment videos.
Watch the YMH Boston Vignette 5 video and take notes; you will use this video as the basis for your Discussion post.
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.

Read a selection of your colleagues’ responses.

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Sample Essay question Answer
NRNP 6665: PMHNP Care Across the Lifespan I

COLLAPSE
What did the practitioner do well?

I think that the practitioner did a good job in exploring the emotions and discovering the catalyst for these emotions regarding this adolescent. Tony is a bit closed off and I think that she sensed that she would have to stop with open ended questions and start asking specific questions about specific emotions to pinpoint his feelings (anger and frustration). Once she got some definitive headway, she started assessing for symptoms of depression, like low energy levels and loss of interest in things. Tony immediately started opening up about his lack of energy to play one of his favorite sports, as well as his loss of interest in school, which is having an effect on his good grades. The practitioner then recaps his symptoms then asks how long he has been feeling this way in order to establish a duration timeline of symptoms. After he gives the answer of 2 months, he then divulges that his breakup with his girlfriend is the catalyst to his depression and anxiety. The practitioner has successfully identified symptoms of depression, duration of symptoms, and cause of symptoms via an assessment interview of open ended and specific questions that guided the adolescent into sharing the information that she needed to make an appropriate diagnosis so that treatment options can now be explored. The video ends with Tony expressing that he sometimes feels like he does not want to be alive and that he has had thoughts of harming himself. The diagnostic criteria for depression are specific, and Tony has demonstrated 5 out of 9 symptoms of depression for a duration of more than 2 weeks (American Psychiatric Association, 2017). To recap, the five symptoms that Tony displays are:

Depressed mood, which in adolescence can be irritable/anger/aggression.
Loss of interest in activities
Hypersomnia
Fatigue and loss of energy
Thoughts of death
Duration: 2 months since breakup with ex-girlfriend.

At this point in the clinical interview, do you have any compelling concerns? If so, what are they?

My primary concern at this point in the interview is Tony harming himself or his ex-girlfriend. Safety is the primary concern here, and with adolescents, it is likely that Tony will need further evaluation in a safe psychiatric hospital environment where he cannot harm himself or anyone else (Sadock, Sadock, & Ruiz, 2015). He expressed that he has thoughts of harming himself and that he sometimes does not want to be alive. This needs to be explored more in regards to a plan, or a timeline. I would also want to find out if he has thoughts of harming anyone else since he has admitted to episodes of anger and feeling aggressive. In my opinion, suicidal and homicidal must be assessed immediately to prevent harm to Tony or someone else.

What would be your next question, and why?

I would ask Tony if he has a plan to harm himself. I would also ask Tony if he has thoughts of harming anyone else.

Why is a thorough psychiatric assessment of a child/adolescent important?

In my opinion, a thorough assessment leads to a more definitive diagnosis, and as a result, leads to a better treatment plan. Ultimately, a child/adolescent can be treated for mental health disorders so that they hopefully do not follow them into adulthood. Most mental health disorders in adults have their root in childhood (Thapar, 2015).

Describe two different symptoms rating scales that would be appropriate to use during the psychiatric assessment of a child/adolescent.

In Tony’s case, I would focus on scales for Depression/Anxiety. The first would be the Kutchner Adolescent Depression Scale (KADS). These 11 to 16 items (depending on the version) self-report scale has been found to be reliable, valid, and diagnostically accurate according to a Chinese study of 3,180 students aged 11 to 17 via multistage stratified cluster sampling (Zhou & Hao, 2016).

The second scale I could use is the widely used Revised Child Anxiety and Depression Scale (RCADS). A 2017 meta-analysis of 146 studies on the reliability of the RCADS revealed that the RCADS was reliable in multiple settings and could be used reliably in different countries and languages (Piqueras, Martín-Vivar, Sandin, San Luis, & Pineda, 2017). As the United States is a melting pot of cultures, this scale would be great for cross-cultural use in my opinion.

Describe two psychiatric treatment options for children and adolescents that may not be used when treating adults.

N-Acetylcysteine is an over-the-counter supplement, powerful antioxidant, anti-inflammatory, and is also the antidote to acetaminophen poisoning. In extreme situations it can be given intravenously to reverse the effects acute acetaminophen poisoning. Through study it has been associated with reduction of symptoms for several mental health disorders, but mainly Autism Spectrum disorder where is shows promise in reducing irritability (Naveed, Amray, Waqas, Chaudhary, & Azeem, 2017). This is very safe stuff. I’ve used it as a nebulizer called, Mucomyst, and it works great at opening up my lungs, although it smells like flatulence.

One psychosocial treatment for children and adolescents that may not be used in adults is Interpersonal Psychotherapy for Adolescents (IPT-A), which is a modified form of the adult version made specifically for adolescents and it focuses being away from mom and dad, people in charge, and peer pressure (Sadock, Sadock, & Ruiz, 2015).

Explain the role parents/guardians play in assessment.

Parents/guardians, school teachers, and family members all play a significant role in the comprehensive psychiatric assessment of a child/adolescent via interviews which can start to paint a picture of the child’s situation and explore the reason for these members to initiate an evaluation, as the child is usually not going to be the one that initiates an evaluation (Sadock, Sadock, & Ruiz, 2015). These individuals surrounding the child can offer insight into behaviors, give examples of behaviors, and share opinions on possible causes of behaviors.

References

American Psychiatric Association. (2017). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association.

Naveed, S., Amray, A., Waqas, A., Chaudhary, A. M., & Azeem, M. W. (2017). Use of N-Acetylcysteine in psychiatric conditions among children And ADOLESCENTS: A SCOPING Review. Cureus. doi:10.7759/cureus.1888

Piqueras, J. A., Martín-Vivar, M., Sandin, B., San Luis, C., & Pineda, D. (2017). The revised child anxiety and depression scale: A systematic review and reliability generalization meta-analysis. Journal of Affective Disorders, 218, 153-169. doi:10.1016/j.jad.2017.04.022

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences, clinical psychiatry (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Thapar, A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Ames, IA: Wiley-Blackwell.

Zhou, H., & Hao, N. (2016). Reliability and validity of the ELEVEN Item Kutcher ADOLESCENT depression SCALE, Chinese VERSION (KADS-11CV). Journal of Child and Adolescent Behaviour, 4(4). doi:10.4172/2375-4494.1000308

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Sample 2