Dr. David Palmiter's Blog for Hectic Parents

In last week’s blog I discussed why the summer can be a great time to get a child or teen a mental health evaluation. This week I will review the elements of a good child or teen mental health evaluation. At the end I will offer a few qualifiers.

(I recently ended a term co-chairing the Pennsylvania Pediatric Mental Health Task Force, a collaboration between the Pennsylvania Psychological Association and the Pennsylvania Chapter of the American Academy of Pediatrics. That task force endorsed the standards I am reviewing here.)

A good mental health evaluation for a child includes the following elements:

• A family interview. “Family” can be legitimately and differently defined across clinicians. For me, it is the youth of concern and his or her parents and stepparents. If the adults cannot be interviewed together (e.g., there is too much resentment) this can be spread across interviews. I find it very difficult to get the relevant information, while building a trusting relationship, in less than 90 minutes. This is an essential part of the evaluation as it is exceedingly difficulty to accurately understand a child’s or teen’s symptoms independent of the context in which that youth resides.

• A youth interview and/or play session. Each child or teen has a great deal of useful information to share. However, s/he may not be able or willing to do so with his or her parent(s) in the room. This is true even among youth who are not psychologically minded or inclined to cooperate.

• The completion of parent, teacher and child behavior rating scales. These scales allow a clinician to measure whether a youth’s symptoms and strengths are atypical among children or teens of his or her age and sex. The available research also suggests that parents, teachers and kids each possess important, complimentary and unique information about a given youth’s functioning.

• A review of academic records. This includes report cards, state achievement testing and relevant special education or disciplinary records. Sometimes parents believe that the school life is not a problem but records suggest that there are important opportunities for growth there. Moreover, such records can present the clinician with information that allows him or her to develop a more nuanced understanding of a kid (e.g., how often a child is tardy or absent, academic strengths and weaknesses).

• A review of any relevant medical, psychological, welfare or forensic records that exist on the youth. I tell families that work with me: “If you’re in doubt regarding whether a document could be important for me to review, include a copy of it.”

• A behavior rating scale that screens for parental wellness. The research and my clinical experience both suggest that the number one complicating factor in mental health treatments for youth is the mental health status of his or her parent(s). (You can find numerous articles on this blog pertaining to the connection between parent and kid wellness.)

I have seven qualifiers for these remarks:

1. Other evaluation tools may also be needed to render a reasonable diagnostic formulation (e.g., psychological testing, medical evaluations, speech and language evaluations).

2. There may be clinical contraindications for doing some of the procedures I have reviewed here. However, if such contraindications exist they warrant discussion.

3. Here’s the elephant in the room: limits on insurance coverage often drive standards instead of the other way around. Too many times I’ve heard clinicians lament that they do not do what they believe is clinically warranted because an insurance company won’t pay for it. Yes, that can be a harsh reality (actually, a very harsh reality). But, parents (and sometimes the youth too) deserve to hear, from the clinician, what the clinician believes is an advisable evaluation plan. Then the parents can decide, once they are informed regarding the pros and cons of their choices, whether they wish to proceed in a truncated fashion (i.e. what the insurance will cover) or do as the clinician recommends. (For my blog entry on paying for mental health services, click here.)

4. Here’s the elephant’s sidekick: child and teen clinicians are busy people who often have large caseloads (put this statement all in caps for those child clinicians working within agencies). A given child or teen clinician may feel too busy to do an evaluation the like of which I’ve described here. If so, this also deserves a frank discussion so that parents can make their own decision about who to see. I have no problem with a clinician doing a truncated evaluation. I do have a problem with a clinician doing a truncated evaluation without informed consent.

5. A diagnostic formulation can hit the bullseye without all of these elements being included. Heck, if a parent honestly answered my questions for 10-15 minutes, and I were to develop a formulation based only on that interview, I might end up being right a good amount of the time. However, I’d be wrong, or importantly incomplete, in an unacceptable number of instances. This is why due diligence is warranted.

6. The evaluation standards I’ve reviewed here include a cost-benefit analysis. (If that weren’t the case, I’d recommend psychological testing for every child and teen.)

7. A good mental health evaluation on a child or teen will offer a thorough review of his or her strengths. And, this will be a central aspect, not just a preliminary or sidebar feature.

There are numerous other issues I haven’t covered here (e.g., what are the signs that a child might need a mental health evaluation, how can one parent get this done when another is resisting it, what’s a good way to approach a school or teacher about participating). But, you can find these topics addressed either in other blog entries (use the search bar at the top right) or in my parenting book Working Parents, Thriving Families: 10 Strategies that Make a Difference.

Next week I will review methods for active partnering and participation with your child’s or teen’s mental health professional. For now, good luck, and click here for referral information.