Daniel Castellanos, MD Professor and Founding Chair, Department of Psychiatry & Behavioral Health

The Herbert Wertheim College of Medicine Florida International University

June 05, 2014

None

Nada

Yoktur

Keiner

nenhum

Aucun

Nessuno

ни один

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