Child Psychiatry Clinical Evaluation Template-1 PDF

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diagnostic psychiatric evaluation template, try to get in as much information as possible in your final paper that is worth a lot....

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Child Psychiatry Clinical Evaluation Template I.

DOB

II.

Age

III.

Informants

IV.

Referred By

V.

Chief Complaint a. By parent, by child

VI.

History of Present Illness a. Patient’s description of current difficulties b. Parent’s (collateral) description of current difficulties c. Recent Stressors d. Review neurovegetative status i. Sleep history should include evening routine, sleep pathology, co-sleeping ii. Energy level iii. Attention/concentration iv. Appetite (weight loss/gain) e. Rule-out Symptoms (“PAM ATE a PEST”): i. Psychosis ii. Anxiety Disorder 1. separation anxiety 2. panic 3. somatic expression of anxiety 4. obsessions and compulsions 5. phobias 6. social iii. Mood Disorder (depression & mania) iv. ADHD v. Tics & Tourettes vi. Externalizing Disorders (ODD/CD) vii. Pervasive Developmental Disorder viii. Eating Disorder ix. Self Injurious Behavior x. Trauma (e.g., physical, emotional or sexual abuse, or witness)

VII.

Past Medical History a. Hospitalizations and surgeries (e.g., myringotomy) b. History of head trauma, loss of consciousness, or seizures c. PCP (name/contact info, last visit, any current treatment, complications or concerns)

VIII.

Past Psychiatric History Shatkin Child Psych Evaluation Template

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a. Prior evaluation for psychiatric illness b. Prior treatment for psychiatric illness (including therapies and medications and effects) c. Current treatment (e.g., provider, medication, psychotherapy, duration, efficacy, etc.) d. History of hospitalizations (& residential treatment, foster care, etc.) e. History of CYF/ACS/DCFS involvement f. History of suicide or homicide threats or attempts IX.

Current Medications (dosage/administration & side effects) a. Include herbal medications, dietary supplements, and vitamins

X.

Allergies to Medications

XI.

Substance Abuse/Toxic Exposure a. Discussing the topic: i. “Do any of your friends (family members, etc.) smoke cigarettes?” b. History of use and abuse (be sure to include inhalants, such as “huffing” gas or “sniffing” glue, and tobacco) c. Toxic exposure (e.g., lead, household chemicals, etc.) d. Frequency of use & last use e. Method of use f. Social sequelae (e.g., DUI, family/job problems, legal complications, etc.) g. Physical sequelae (e.g., hospitalizations, DTs, black-outs, etc.) h. Prior treatment programs (and utility) i. Current treatment (e.g., AA, etc.) j. CRAFFT Screener (Car, Relax, Alone, Forget, Family/friends, Trouble)

XII.

Psychosexual History a. Discussing the topic: i. “Have you ever had a crush? Tell me about that…” ii. “Do you like boys, girls, or both?” b. Assess level of sexual maturity c. Sexual orientation d. Current sexual activity e. Birth control (any mood changes with oral contraception) f. History of menses & Last Menstrual Period g. Pregnancy h. Sexually Transmitted Diseases i. OB/GYN Care

XIII.

Developmental History a. Mother’s fertility (Pregnancies, current living children: PxGy or TwPxAyLz) i. Number of fathers (or mothers) b. Complications with conception, gestation, and delivery c. Use of tobacco, alcohol, and/or illegal drugs during pregnancy d. Use of prescribed medication during pregnancy e. Prenatal care (e.g., regular visits, use of PNVs) Shatkin Child Psych Evaluation Template

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f. Months gestation and type of birth (e.g., vaginal vs. c-section) g. Post-natal complications (infant & mother) h. Milestones (see Normal Child Development Notes): i. Motor ii. Language iii. Toileting (and enuresis/encopresis) iv. Social i. Generally Expected Milestones i. 3 – 5 years 1. enunciates clearly 2. knows age 3. draws/colors (close to within the lines) & stick figures 4. able to initiate and sustain dressing self (interest in clothes) 5. engages in “imaginary friends” and symbolic play 6. identifies numbers and letters 7. active gross motor skills ii. 6 – 9 years 1. able to tell time and tie shoelaces 2. losing teeth 3. writes sentences and spells 4. demonstrates creativity 5. engages in games with defined roles 6. reads iii. 10 – 12 years 1. contributes to assessment 2. involved in hobbies/activities and has independent interests 3. burgeoning romantic interests iv. 13 – 17 years 1. voice and other notable pubertal changes 2. primary interest in social and peer group 3. reproductive development and early sexual activity 4. experimentation with breaking rules, drugs, and EtOH XIV.

Educational History a. Name of school and grade b. Current performance c. Repeats, skipped grades, suspensions, and expulsions d. Bullying or problems with kids and teachers e. Special services received (e.g., speech, tutoring, resource, special ed, etc.) f. 504 services received g. IEP established and last meeting

XV.

Family History a. Family psychiatric, substance abuse, and major medical history

XVI. Social History a. Current living environment (e.g., location, type of home, others present) b. Insurance/method of payment for healthcare Shatkin Child Psych Evaluation Template

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c. d. e. f. g. h. i. j.

Parents’ employment Child strengths After school plans (and supervision) Extracurricular activities (hobbies and interests) Relations with friends & others Legal complications (e.g., JDS, FINS, DHS involvement, etc.) Family manner of discipline Religion/belief system

XVII. Review of Systems (current physical concerns) XVIII. Physical/Neurological Examination a. Patient should have had an exam within the past 6 – 12 months for consideration of treatment; or be evaluated by psychiatrist and/or referred to PCP prior to treatment b. You may wish to complete an exam yourself; or to complete a focused exam. c. Vital Signs XIX. Mental Status Examination a. General observations i. Attitude on approach and during interview with examiner (e.g., friendly, distant, irritable, engaged, interested, etc.) ii. Size for age (e.g., growing and well nourished) iii. Interaction with parents (e.g., kind & gentle, harsh & disapproving, behavioral management strategies, manipulations, affection, anxiety, etc.) b. Behavior i. Observe for kinetic activity, impulsivity, and tics ii. Any difficulty attending to interview/activities iii. Motor skills 1. fine motor (drawing, writing, manipulations) 2. gross motor (throwing, bouncing, walking, kicking, rolling, tumbling, running, hand-games) c. Appearance i. Compare against expected developmental level and peer appraisal ii. How the child is dressed (e.g., fashionable/nerdy, clean/dirty, bejeweled/plain, appropriate to the setting and weather, etc.) iii. Any devices (e.g., corrective lenses, wheelchair bound, etc.) d. Speech i. Note delays, dysarthria, phonological difficulties, expressive and receptive/interpretive difficulties ii. Tone and style of speech e. Mood f. Affect g. Perceptual Disturbances (measure against developmental level) h. Thought Processes i. Range (e.g., perserveration vs. broad in scope, etc.) i. Thought Content i. Creative play (e.g., generates ideas, shares, engages the interviewer, etc.) Shatkin Child Psych Evaluation Template

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ii. Comprehension and age appropriate ideas (e.g., participates in story telling, playing games, reading, and conversation) iii. Flexibility (able to lead and follow) j. Sensorium and Cognition i. Child appropriate k. Judgment and Insight l. Reliability and Impulse Control XX.

Additional Assessments a. Other evaluations (e.g., therapists, OT, PT, Speech & Language, etc.) b. Rating Scales c. Neuropsychological Testing d. Educational Testing e. Projective Testing

XXI. Biopsychosocial Assessment a. Biological Factors i. Family history/genetic loading (diathesis) ii. SUDS iii. Physical injury/accidents iv. Medical history v. Medications and effects vi. Prior psychiatric history, diagnoses and treatment b. Psychological Factors i. Identified stressors ii. Compliance/adherence to treatments iii. Coping skills iv. Defense mechanisms at play v. Interpersonal strengths vi. Response to psychological/medication therapies c. Social Factors i. Living situation & family ii. Socioeconomic class iii. Social skills & peer support iv. Access to mental health care XXII. Diagnosis a. Most concerning to least concerning b. Include psychiatric and general medical

Shatkin Child Psych Evaluation Template

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Some Ideas for Interviewing Children: I.

Discussion & Understanding a. Setting i. Where (what is this place – inpatient, outpatient, RTF, etc. and their understanding of it) ii. Why (what did your parents tell you, what do you think, etc.) b. Television, music, and other media (e.g., books) c. School d. Hobbies and interests e. Family and friends f. Current events g. Future plans

II.

Play & Social Skills a. Hand games (ro/sham/bo, miss mary mack, etc.) b. Paper games (airplanes, hang-man, boxes, tic-tac-toe, etc.) c. Board games d. Card games e. Symbolic & Make-Believe Play i. Puppets, dolls, figurines, action figures ii. Cars, planes, and other mobile toys f. Story telling i. Use toys and figures to tell a story (solo & joint) ii. Use picture books

III.

Emotions & Social Skills a. Describe relationships (e.g., marriage, love, friendship, children, etc.) b. Describe feelings (happiness, fear, anger, sadness, loneliness)

IV.

Motor Skill/Coordination Assessment a. Handwriting b. Drawing (family, friends, objects) c. Building (towns, blocks, Lego, puzzles) d. Running, throwing, jumping, etc.

V.

Creativity & Projective Assessment a. Shared and independent story telling b. Joke telling c. Imitative play (e.g., mirroring) d. Making new worlds e. Sentence completion

VI.

Intellectual Evaluation a. Read stories and poems b. Calculations c. Writing activities (words, sentences, paragraphs) d. Thoughtfulness and ideologies (abstract abilities) Shatkin Child Psych Evaluation Template

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