Assessment of Mental Health

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.

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	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.
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