The alert practitioner will detect concerns during the complete health assessment of children and adolescents that might lead to determination of the need for a more focused assessment of mental health. The cognitive and emotional development of children and adolescents produce greater variability in assessment of mental health and can make interpretation challenging; because of this, multiple approaches are recommended to increase reliability in findings. There are many standardized tests available that can be utilized with the techniques of observation and interviewing, which remain acceptable approaches in mental health assessment.
Assessment of mental health requires understanding of normal development, which will guide conclusions about what is normal for the age of the child or adolescent and what should be explored further. Additionally, knowledge of what is expected in development assists in adapting the assessment to the age of the child or adolescent, eliciting cooperation, and determining the emotional state of the child. Finally, in assessing mental health status, it is important to consider that childhood disorders with an organic basis might first present with abnormal behavior and that disorders with a psychosocial basis can have physical effects.
Rationale
It was once thought that young children, in particular, lacked the cognitive and emotional development to experience disorders such as depression. Statistics, however, related to major depressive disorder and suicide in children and adolescents suggest that mental health problems are of considerable concern worldwide. In the United States, the prevalence of major depressive disorder is as high as 1% among preschool children, 1% to 9% among school-age children, and 4% to 8% among adolescents. Suicide in young children is relatively rare and is thought to be more common in adolescents because of the ability to plan ahead. The incidence in older children and adolescents increases with the co-morbidity of other disorders and is second only to injuries as the leading cause of death in adolescents. Studies suggest that children who present with depression frequently have a history of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, or conduct disorder. Subsequent to the onset of depression, adolescents are at increased risk for alcohol abuse, suicide, nicotine dependence, and anxiety disorders.
Extended mental health assessment should be considered whenever there is a central nervous system disorder (whether developmental or acquired); history of even mild untreated head trauma or major life or traumatic events; sudden changes in school performance, behavior, everyday cognitive functioning, or behavior patterns; changes in sensory function; neglect or abuse; and reports of symptoms suggesting mental health disorders.
Preparation
Assessment should begin with simpler aspects of mental health functioning and then progress to more complex or distressing elements later in the interview, when trust and rapport are established and if the need is determined. Standardized tests and behavior scales, such as the Beck Depression Inventory or the Children’s Depression Inventory, can be used to assist in the assessment.
Much of the assessment related to mental health can be readily obtained in other areas of the health assessment. Good observational skills and the ability to establish rapport are essential to performing reliable mental health assessments in children and adolescents. Rapport is established through attentive and nonjudgmental listening. A play area with toys can be helpful when working with young children.
Typically, the parent or caregiver will present the history, but older children and adolescents benefit from privacy and assurance that conversation with them is confidential, unless their safety is at risk. When young children express a desire to share a secret, it might signal the need to disclose important information. Although this information might be important to diagnosis, treatment, or protection of the child, it is important to discuss with the child how secrets that involve harm to the child have to be told to someone and to invite the child to participate in deciding who should be told.
Inquire as to when the problem began; how current behavior is similar to or different from what is usually expected in the child or adolescent; severity, duration, and impact of problem; and significant events occurring before or concurrently with the problem. Inquire about family history of disorders, especially related to history of mental or emotional disorders, substance abuse, self-harm, epilepsy, delayed development, and learning problems. Ask about prenatal influences (drug or alcohol use during pregnancy, smoking, hospitalizations, surgeries), birth and perinatal events (type of delivery, use of anesthetics during birth, bruising, special medical treatments, number of weeks at birth, birth weight), traumatic events, developmental milestones, abuse, changes in the family, school performance, and substance use.
Assessment of Mental Health
| Assessment | Findings |
|---|---|
| Appearance | |
| Observe for hygiene: age-appropriate dressing, evidence of self-harm (e.g., cuts on arms or wrists), needle tracks, hair pulling, picking, weight, distinct facies. |
Clinical Alert
Poor hygiene can indicate depression, suicide risk, abuse, neglect, or homelessness.
Short palpebral fissure, flat midface, short nose, indistinct philtrum, and thin upper lip are distinguishing features in fetal alcohol syndrome.
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| Behavior | |
| Observe the child for age-appropriate attention to play or questions; ease in completing tasks or following instructions; distractibility; fidgeting or squirming; tendency to climb on things or handle things even when asked not to do so; ease or discomfort with quiet play; level of shyness; withdrawal; excessive talk-ativeness; blurting out answers, not waiting for turns; lack of interest in surroundings or caregiver; avoidance of eye contact; oversensitivity to sounds; repetition of sounds; inappropriate laughing or crying; eye blinking; lip licking; twitching; head jerking; staring at nothing; motor retardation; discomfort with contact with caregiver. |
Clinical Alert
Easy distractibility, lack of attention when spoken to, and difficulty following through on directions can indicate attention deficit disorder (ADD), anxiety, or childhood schizophrenia.
Excessive talkativeness, blurting out, inability to sit still, excessive climbing, disregard for instructions, and difficulty organizing activities can indicate ADD or ADHD, fetal alcohol syndrome, anxiety, or schizophrenia (children older than 5 years).
Discomfort with normal touch, lack of eye contact, oversensitivity to sounds, and lack of response to voice, especially in the presence of early feeding difficulties and developmental delays, can indicate autism spectrum disorder in young children.
Hyperactivity, hypoactivity, and other behavioral changes can accompany commonly used drugs (Table 24-1).
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| Assessment | Findings |
|---|---|
| Observe mood (angry, tense, sad, worried, happy, irritable, labile, suspicious, impulsive). |
Tension or expressions of worry can represent a healthy response to stressful events, including hospitalization or assessment.
Clinical Alert
Suspiciousness can indicate presence of delusions and hallucinations.
Anger, in the presence of defiance, blaming, and argumentativeness, can indicate oppositional defiance disorder or extreme stress.
Irritability, anxiety, hypoalertness, or diminished affect or responsiveness can indicate posttraumatic stress disorder when a traumatic event or situation has occurred, especially if there are also disturbing recollections or nightmares, sleep disturbances, memory impairment, difficulty concentrating, and headaches.
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| Irritability, emotional lability, aggressiveness, and disobedience can indicate posttraumatic concussion syndrome when injury to the head has occurred. | |
| Irritability, anxiety, mood swings, disorientation, and hypervigilance can be indicative of drug or alcohol abuse. | |
| Changes in sleeping and eating patterns can indicate increased risk for suicide in the depressed child and adolescent. |
| Assessment | Findings | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Observe verbalizations for expressions of worthlessness or guilt (“I mess up everything I do,” “I’m not good at anything,” “All I do is cause problems”), expressions of aggression (“I am going to kill you”), and appropriateness to situation.
Inquire about changes to eating, sleeping, and elimination.
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Clinical Alert
Expressions of worthlessness and guilt are more common in adolescents than in younger children with depression (Table 24-2).
Talking to self or responding to voices not heard can indicate hallucinations.
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| Eating | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Has there been a change in weight or appetite recently?
What kinds of foods are preferred? Has there been a change in preferences recently?
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Clinical Alert
Over concern with weight, attempts to control weight, excessive exercising, purging techniques, and ritualism around eating can indicate anorexia nervosa, especially in adolescent girls.
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| Assessment | Findings |
|---|---|
| Have there been attempts to control weight? (If there is a positive response to this inquiry, inquire whether there have been variations in weight, whether there are times when child eats so much it hurts, whether the child eats when upset or nervous or bored, whether vomiting has been tried after eating, amount of exercise child or adolescent engages in per day, and whether laxatives or diet pills are being used. Ask, “How much would you like to weigh?”) |
History of early feeding difficulties are found with autism spectrum disorder, including refusal of foods, requirement for specific presentation of foods and utensils, narrowly restricted food choices, and persistent choice of low-texture foods.
Hunger accompanies withdrawal from amphetamines; decreased appetite occurs with withdrawal from marijuana.
Changes in sleeping and eating patterns can indicate increased risk for suicide in the depressed child and adolescent.
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| Sleeping | |
| Inquire about sleep patterns, changes in sleep patterns, nightmares. |
Excessive sleepiness, especially daytime sleepiness, can indicate sleep disorder; substance abuse; or depression.
Insomnia can indicate use of amphetamines and accompanies withdrawal from alcohol, marijuana, and sedatives/hypnotics.
Fear of going to sleep unless near parents; nightmares about separation, especially in the presence of school avoidance; and excessive concern with separation from parent can indicate separation anxiety disorder or generalized anxiety.
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| Assessment | Findings |
|---|---|
| Elimination | |
| Ask about nighttime wetting and daytime wetting or soiling, regression in toilet training. | Regression to nighttime wetting can indicate stress in the preschool-age child. |
| Fecal incontinence by the age of 4 years can indicate neglect, lax training methods, or developmental delays. Fecal incontinence in the child older than 4 years who has previously achieved fecal continence can indicate stress, changes in the child’s life, or depression. | |
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Inquire about interests, friends, school, community.
Ask, “What kinds of things (hobbies, pets) do you enjoy?” or “What kinds of things did you enjoy until recently?” If the child is younger than 3, inquire about playfulness and changes in playfulness.
Ask, “What worries or scares you?”
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Clinical Alert
In the child younger than 3, lack of playfulness and expression can indicate depression, autism spectrum disorder, or sensory disorders.
Withdrawal from activities previously enjoyed, transient enjoyment in activities, or preoccupation with morbid activities can indicate depression.
Excessive preoccupation with fantasy friends or responses to voices not heard by others can indicate hallucinations.
Excessive fears or worries can indicate generalized anxiety or depression.
Lack of interest in making friends, difficulty pretending at play, lack of awareness of feelings of others, significant difficulty with language, and difficulty relating to others can indicate Asperger’s syndrome.
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| Ask the child about his or her friends. “Who is your best friend? How about other friends?” | Withdrawal from friends can indicate depression. |
| Assessment | Findings |
|---|---|
|
“What kinds of things do you do with your friends?”
“Whom do you talk to when you need help with school work?”
“Have your friends changed lately?”
“Do people sometimes annoy you? What do you do when they annoy you?”
Ask the child about school. “What grade are you in school?”
“What do you like about school?”
“Has schoolwork changed for you? If so, how has it changed?”
“What are your teachers like?”
“How many days of school have you missed recently?”
Inquire about coping strategies. “What do you do when you get scared? What about when you get mad or frustrated?”
“Whom do you talk to?”
Inquire about alcohol and drug use. “Do you use drugs or alcohol?” If affirmative, ask about frequency and amount (“How many joints do you smoke a week?”), age at which use began, and situations in which drugs and alcohol are used.
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Sudden changes in friends, dropping grades, and social isolation can indicate drug or alcohol abuse.
Fighting, bullying, threatening, destruction of property, and stealing can indicate a conduct disorder or physical abuse.
Loss of interest in school and dropping grades can indicate depression, substance abuse, or child abuse.
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Inquire about suicide ideation and attempts.
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Clinical Alert
Depression and well-described plans, including
the method and time, who will be at the funeral, and other funeral plans, indicate significant risk for suicide, especially in adolescents (see the box below for other indications of suicide risk).
Sudden involvement in high-risk behaviors, such as drug use, promiscuity, or reckless driving, or noncompliance with treatment (e.g., refusal to take insulin) can indicate suicide risk in the depressed child or adolescent.
Suicide ideation can accompany early crash with cocaine.
Putting personal affairs in order (e.g., giving away treasured possessions, making up with friends)
Verbal cues such as “When I am not here anymore,” “I wish I were dead,” or saying goodbye to family members and friends
Withdrawal from family and friends
No desire to socialize
Fatigue; lack of energy or sudden burst of energy (especially if previously low in energy)
Feelings of sadness, not caring
Easily frustrated
Emotional outbursts or sudden decline in outbursts
Decline in school performance, frequent absences
Neglect of appearance
Changes in sleeping and eating patterns
Impaired verbal communication: related to developmental disorders, depression, ADD, schizophrenia, sensory disorders, situational stressors.
Interrupted family processes: related to situational crisis, child or adolescent illness.
Risk for injury: related to suicide ideation, self-neglect, disregard for personal safety, developmental disorders.
Self-esteem: related to disturbances in body image, personal identity, feelings of worthlessness or guilt, physical or sexual abuse, loneliness, impaired social relationships, school performance.
Impaired skin integrity: related to self-harm, drug use.
Ineffective health maintenance: related to abuse, neglect, substance abuse, alcohol abuse, eating disorders.
Altered nutrition: related to disturbances in body image; vomiting, dieting, fasting, use of laxatives; depression; substance abuse; alcohol abuse.
Self-mutilation: related to poor self-esteem, developmental disorders, depression.
Risk for violence, self-directed: related to mental health, suicide plan, verbal cues.
Disturbed sleep pattern: related to anxiety, depression, nightmares.
Risk for violence, directed at others: related to impulsivity, compromised coping strategies, hallucinations, delusions, conduct disorder, substance abuse.
Social isolation: related to developmental disorder, depression, suicide ideation, disturbance in self-concept.
Altered thought processes: secondary to substance abuse, mental health issues.
Risk for constipation: related to stress, situational crisis, eating disorders.
Altered urinary elimination: related to stress, situational crisis.
