Even the most seasoned and skilled practitioner would like to have at least 30 minutes to perform a diagnostic mental health interview. Determining the character traits, cognitive ability, and emotional health of another person, especially a child or an adolescent, is difficult. So why even discuss a 15-minute diagnostic interview?
Short diagnostic mental health interviews are not ideal, but the reality is that they are performed with young people every day. Primary care and emergency department practitioners are routinely expected to perform very quick interviews. Pediatric primary care practitioners can be expected to evaluate as many as 30 different children per day, which leaves only about 15 minutes to spend with each patient. Emergency department practitioners are pressured to rapidly assess mental health concerns, particularly during evening hours when emergency environments are most stressed.
The time available for performing a mental health evaluation is further constrained when a patient or family is focused on physical health concerns instead. By the time your assessment identifies a psychiatric issue—the anxiety that precedes vague abdominal pain or the dsyphoria that is experienced as a headache—you may have only a few minutes remaining in an appointment to conduct a full mental health diagnostic assessment. Patients also may have the “Oh, by the way...” moments, when major mental health questions are broached seemingly as a practitioner places his hand on the door to leave the examination room.
Practitioners frequently find their available time restricted in one way or another, so it helps to think about how to best use even a small amount of time to advance the care of children and adolescents with mental distress.
The following five steps are one way to efficiently perform a focused mental health diagnostic assessment with a 60child or an adolescent. Even under time constraints, you can build a therapeutic alliance and develop an initial treatment plan by following these five steps.
1. Prescreen mental health concerns with a validated tool.
2. Identify the leading concerns.
3. Identify and address safety issues.
4. Diagnose a probable or unspecified disorder.
5. Recommend a next step.
We recommend the use of pre-interview assessment tools as a standard part of the workup for well-child visits but especially when the chief complaint is a mental or behavioral health problem. Preassessment screening tools engage a patient and his caregivers in the treatment, normalize conversations about mental distress, and assist you in identifying the chief complaint. Several brief screening instruments for a wide variety of mental health concerns are available. One example is the DSM-5 (American Psychiatric Association 2013) Level 1 Cross-Cutting Symptom Measure, which lists selected symptoms of major DSM-5 disorders in a brief format. Versions exist for caregivers of children and adolescents between ages 6 and 17 and for patients between ages 11 and 17. These measures are free and can be reproduced for clinical use and are referenced further in Chapter 10, “Selected DSM-5 Assessment Measures.” We also recommend considering use of the Pediatric Symptom Checklist or the Strengths and Difficulties Questionnaire, two other brief but broad-based assessment measures that have the additional benefit of score validation for children in primary care medical settings.
Whatever screening tool you select for your practice setting, you should familiarize yourself with its scoring system. Most screening tools are designed to have high sensitivity, meaning that they aim to identify anyone who may have a particular diagnosis, but lower specificity, meaning that they will identify some persons for additional concern who ultimately will not have the diagnosis for which you are screening. Positive results in certain categories may suggest follow-up measures to use, such as a high inattention score on the DSM-5 61Level 1 assessment being followed up with the DSM-5 Level 2 Inattention rating scale. Using follow-up measures can increase the efficiency of a clinic and, if patients are followed up over time, can be a good introduction to using validated scales to measure treatment response, relapse, and recovery. At the very least, the results of screening measures also can be used as conversation starters: “I see that you indicated a few concerns in the questionnaire; can you tell me more about that?”
Although the use of brief, broad screening measures is likely best for a fast-paced care facility, if time and the practice plan allow, a more detailed symptom checklist should be considered instead. Tools such as the Behavior Assessment System for Children (Reynolds and Kamphaus 1998) and the Child Behavior Checklist (Achenbach 1991, 1992) take significantly more time for caregivers to complete and for office staff to score and interpret, but once completed, they result in reliable, broad-based pictures of a young person’s difficulties.
If you fail to recognize the presence of a mental health concern in advance, you can still choose to pause the evaluation process when such concerns arise and ask for the symptom screening information to be completed before continuing. For instance, you may say, “Given the concerns you just raised, could you take a few moments to complete this information, and I’ll be back to discuss this more with you?” Taking this approach could allow you to proceed with seeing your next scheduled patient during that time and even have the assessment tool scored by an assistant while staying on schedule.
When you have identified a specific mental health concern, a condition- or symptom-focused rating scale could be used instead to provide better diagnostic information. Examples of focused DSM-5 scales include the Level 2 Cross-Cutting Symptom Measures for parents or children to characterize symptom categories such as anger, anxiety, depression, inattention, irritability, mania, sleep disturbance, somatic symptoms, and substance use; these scales are discussed in Chapter 10 in brief but are also available online (www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level2). Other symptom-focused scales have been validated and normed with diagnostic score cutoffs in children and are discussed in Chapter 11, “Rating Scales and Alternative Diagnostic Systems.” Positive results on these instruments more strongly suggest that a particular diagnosis is present, but the use of a diagnostic instrument ultimately relies on the prudent judgment of a practitioner.
62Even the best rating scales and symptom checklists are inherently imperfect, so it is important to understand their limitations. Questions may be misunderstood, may miss key symptoms, may be influenced by a young person’s or caregiver’s tendency to overreport or underreport symptoms, or may be intentionally answered untruthfully. This is why all surveys and questionnaires must be followed up with a personalized diagnostic interview to yield a more complete and reliable picture. For instance, if we see an adolescent who denied having depression symptoms on his rating scale yet appears withdrawn, speaks in a low monotone, and describes feeling hopeless, then depression must be considered, regardless of the scores on a symptom checklist.
Once a pertinent rating scale has been completed and scored, the next step in a brief interview is to identify the young person’s and caregiver’s leading concern for further investigation. Identifying the leading concern can be as simple as asking specifically, “What are you most concerned about today?”
An unlimited list of concerns or complaints is too challenging to manage within a brief investigation, even if the concerns ultimately relate to the same diagnosis, as is often the case with depression. For instance, a family may describe sleep problems, poor academic performance, self-harm behavior, irritability, and conflict with a sibling as separate concerns. If you identify one of these areas, such as self-harm, as the chief concern for that day, with the understanding that remaining concerns such as sibling conflict may need to be addressed at another appointment, then a 15-minute interview can be more fruitful.
Your own careful judgment is the key. For example, if a patient and his caregivers are most concerned about sleep disturbances but your screening tools or examination alert you to a safety issue, you must explain to the family that sleep disturbances are important, but the patient’s safety is the leading concern at present.
Having the patient and his caregivers each identify a leading concern builds your therapeutic alliance and increases investment in your assessment and treatment. When 63a patient and his caregivers believe that you truly understand the leading concern, they are more likely to engage in treatment and follow the next steps you recommend.
Any mental health evaluation, no matter how brief, includes an assessment of safety. If you identify safety concerns, then the near-term care plan needs to account for how to reduce or eliminate that risk.
• If you suspect that self-harm or suicidal behaviors may occur, as when evaluating for depression, ask: “Do you ever think about hurting yourself? Have you ever deliberately hurt yourself?”
• If it is possible that abuse or neglect may be related to the reported symptoms, ask: “Has anything made you feel uncomfortable or unsafe? Has anyone ever tried to hurt you?”
• If it is possible that the child poses a risk to another person, ask: “Have you ever hurt someone else on purpose? Do you have any plans to do that now?”
By inquiring about the circumstances and details surrounding a patient’s (and his caregiver’s) chief concern and reviewing the results of assessment tools, a practitioner can usually arrive at a probable diagnosis in 15 minutes. Confirmation of all but the most obvious diagnoses will take more assessment time or a future appointment to clarify. For instance, you might determine in just 15 minutes that a child has significant developmental impairments, leading to a diagnosis of unspecified neurodevelopmental disorder. Then, during his next appointment you would make more detailed inquiries to refine the diagnosis further, changing that diagnosis to something more specific such as a language disorder or an autism spectrum disorder.
In Chapter 3, “Common Clinical Concerns,” we outline the more likely diagnoses to consider and some specific 64screening questions you can use when confronted with common pediatric concerns.
Rapid assessments proceed more fruitfully with awareness of the key aspects of common clinical conditions. This is no different from the rest of medicine, in which shorthand understandings of disorders are used to guide clinical suspicion. When an adult reports chest pain radiating down his left arm, we suspect a heart attack. When a febrile infant pulls at his ears and acts grumpy, we suspect an ear infection. In a similar way, we can learn to recognize basic patterns of mental health. When a child experiences several weeks of a persistently low mood and loses interest in the activities and friends he usually enjoys, we suspect major depressive disorder. To help inform your clinical suspicion, Table 4–1 contains a list of common psychiatric conditions and shorthand descriptions. Additional information is available in later chapters.
Remember that these are descriptions of behaviors and symptoms. In isolation, these behaviors are not a diagnosis. In the DSM-5 diagnostic system, for any constellation of behaviors and symptoms to qualify as a psychiatric diagnosis, they must meet two conditions:
1. They cause a significant functional impairment.
2. They are not better explained by another etiology.
The second rule is very important. A child can be inattentive for any number of reasons without having attention-deficit/hyperactivity disorder, and an adolescent can be sad for many reasons without experiencing a major depressive episode. If these kinds of behaviors and symptoms do not significantly impair function or can be better explained by another etiology, a formal mental health diagnosis should not be made. You can (and should) plan to follow up with the child or adolescent to see how these symptoms develop over time.
Under DSM-IV (American Psychiatric Association 1994), a disorder that did not meet full diagnostic criteria but still met the two conditions described earlier could be labeled as a not otherwise specified (NOS) condition. DSM-IV’s NOS diagnosis allowed a clinician to initiate treatment for a patient whose presentation was not consistent with a more specific diagnosis. The heterogeneity of this category discouraged research, frustrated epidemiology, and diminished the clinical utility of diagnoses (Fairburn and Bohn 2005). These diagnostic labels were frequently used in children and adolescents. For example, in a recent national survey of outpatient visits to physicians in the United States, 35% of all visits to physicians for mental health problems resulted in an NOS diagnosis for children and adolescents, and the number of NOS visits grew proportionally over the decade analyzed by the researchers (Safer et al. 2015). NOS diagnoses tend, over time, to be neither reliable nor valid, so they are a poor foundation for an ongoing treatment plan.
65TABLE 4–1. Shorthand descriptions of common DSM-5 diagnoses in children
Attention-deficit/hyperactivity disorder |
Developmentally inappropriate and persistent difficulty with inattention and/or hyperactivity with symptoms present in multiple settings |
Anorexia nervosa |
Restrictive eating and food avoidance, often with an accompanying desire to avoid obesity, which persists despite negative consequences |
Autism spectrum disorder |
A developmentally inappropriate and persistent pattern of predominant impairments in social relatedness and restricted interests and behaviors |
Bipolar disorder |
Discrete episode of elevated mood for multiple days with rapid thoughts, decreased need for sleep, persisting high energy, and unusual risk taking |
Bulimia nervosa |
More than 3 months of recurring episodes of binge eating followed by an intense desire to compensate afterward (e.g., by purging or using laxatives) |
Conduct disorder |
Repetitive significant violations of social rules and the rights of others over the course of a year |
Encopresis |
Inappropriate stool leakage with psychological adaptations, usually facilitated by chronic constipation |
Generalized anxiety disorder |
More than 6 months of persisting but diffuse, changing worries for more days than not that cause symptoms such as tension, fatigue, irritability, and poor concentration |
Major depressive disorder |
More than 2 weeks of low (or irritable) mood coupled with new neurovegetative symptoms (e.g., loss of concentration, low energy, altered sleep or appetite) |
66Obsessive-compulsive disorder |
Time-consuming internal repetition of unwanted thoughts and/or a persistent focus on repeating specific types of behaviors or mental acts (e.g., cleaning, counting) |
Oppositional defiant disorder |
Developmentally inappropriate opposition to and defiance of adult rules and requests for more than 6 months |
Panic attack |
Sudden worry or fear accompanied by body symptoms such as a racing heart rate and physiological arousal (panic disorder considered if recurring attacks are feared and are affecting function) |
Phobia (social or specific) |
Excessive fear of an object or a situation that causes a dysfunctional degree of avoidance and distress for >6 months |
Posttraumatic stress disorder |
A traumatic experience has led to avoidance of trauma reminders, hypervigilance to future threats, and unwanted reexperiencing (including nightmares) for >1 month |
Source. American Psychiatric Association 2013.
In an effort to reverse this trend, DSM-5 removed the NOS option in favor of other specified and unspecified disorders. The unspecified and other specified criteria found in each chapter of DSM-5 provide more details than the comparable 67NOS sections in DSM-IV. In general, practitioners are advised to consider an unspecified diagnosis when a young person experiences symptoms characteristic of a mental disorder that cause clinically significant distress but do not meet the full criteria for a named diagnosis. If a practitioner wishes to communicate the specific reason that symptoms in a child or an adolescent do not meet criteria, the practitioner is encouraged to use the other specified diagnosis. In a 15-minute diagnostic interview, practitioners may be more likely to arrive at unspecified diagnostic labels rather than full diagnoses, but this should be a reminder of the need for additional diagnostic clarification later. Children and adolescents deserve the most accurate diagnosis possible.
Treat versus refer decisions end up being based on patient factors, such as diagnosis and severity, along with the fit between a patient’s treatment needs and your abilities and availabilities as a practitioner and the type of services available in your local community.
For nearly every moderate or severe mental health problem, referring a child or an adolescent to a skilled mental health therapist is essential. Explaining why you think seeing a therapist will be helpful may increase motivation for patients and caregivers to follow through on your referral. If caregivers have reservations about working with a mental health practitioner, it helps to address those concerns during the referral and to normalize the referral by saying something like “Just as I would refer you to a specialist to examine your eyes if I thought you needed glasses, I recommend that you see a mental health specialist for the concerns we have identified together.”
For low-severity problems, it may be appropriate to provide coaching on behavior or life management changes a patient and his caregivers can make at home. Providing guidance on how to improve sleep hygiene, to manage a problem behavior, or to support a young person through a life adjustment is 68an everyday occurrence for most primary care practitioners, and we provide some guidance in Chapter 14, “Psychosocial Interventions.” Handout instructions, books, videos, or Web sites so that the family can obtain additional guidance after the appointment also may be of assistance.
For children struggling in school for whom a learning disability is a consideration, we advocate for educational testing. The route for doing this may hinge on motivating the parent to make a written request for a learning disability assessment at the child’s school, which is required in some settings, including the United States.
For very young children with developmental concerns, refer the child to a local early intervention program. In the United States, this involves the federally sponsored Zero to Three program (http://zerotothree.org) or a school district–sponsored program for children ages 4–5 years.
For a significant suicide, homicide, or other behavior-related safety risk, an immediate safety plan or hospitalization should be explored with the local mental health crisis system. For milder risks such as depression without active suicidal thoughts or plans, appropriate parental supervision and monitoring would be enough to detect any worsening risks.
It is usually inappropriate to recommend a new long-term psychotropic medication after only a 15-minute assessment. The exception might be a short-term trial of an over-the-counter medication with low medical side-effect risks, such as melatonin to help with insomnia. However, after a second appointment or any evaluation of a longer duration when the diagnosis becomes more certain, a prescription may be appropriate. Whenever you suspect more severe health disorders, such as bipolar disorder or schizophrenia, you should refer a patient and his caregivers immediately to a specialty mental health practitioner.
If you identify a mental health problem, a follow-up appointment should be recommended. This can serve several purposes:
• Provide enough time to better complete the diagnostic process
• Communicate your ongoing therapeutic connection and support around the problem
• Track the response to any initial intervention so that the treatment plan can be adjusted
• Identify any problems with the referral plan, creating an opportunity for resolution 70