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Mental Health Assessment

Mental health assessment and evaluation are terms that may be used interchangeably in the mental health field.  Both describe a process used by mental health professionals to take a look at and make determinations about a child or adolescent’s mental health. 

In an initial meeting with a mental health professional, or soon thereafter, a mental health assessment (also sometimes called an intake or initial assessment) will be conducted for the purpose of understanding mental health needs and making an effective treatment plan.  A mental health assessment involves assessing clinical symptoms, listening to client/parent reports, and making professional observations.  Sometimes more formal diagnostic tools are used.  

Mental health providers use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to guide their understandng and diagnosis of mental health disorders in their clients or patients.  The DSM is published by the American Psychiatric Association and includes descriptions of all possible mental health disorders in both children and adults.

Because there is no definitive test to diagnose mental health disorders, the process sometimes involves trial and error.  Especially in children and adolescents, it is not uncommon for diagnoses to change over time.

Mental health diagnoses are required by insurance companies as evidence of the need for mental health treatment.  If you are a parent, ask your mental health provider what, if any, diagnosis they have given to your child and why.

In addition to initial therapy/intake assessments, there is a wide array of specialized assessments or evaluations.  Many of these are included below.   

Mental Status Examination The purpose of a mental status examination is to assess the current level of functioning and a client’s mental health state.  In a mental status exam, a mental health professional meets face-to-face with the individual to assess the absence or presence of homicidal thoughts, suicidal thoughts (including any signs of self-injurious behavior), and psychosis.  Psychosis, or impairment in one’s thinking, is detected by one’s 1.) orientation to time, place, and self-recognition, 2.) activity level or aggressiveness and interactions with the interviewer, and 3.) personal goals, thoughts, concerns, family relationships and desires for the future.  A mental status examination is an important part of mental health evaluations.
Psychiatric evaluation A comprehensive psychiatric evaluation usually requires several hours over one or more office visits in order for a psychiatrist to conduct interviews with a youth and his or her caregiver(s).  With the parent or guardian’s permission, other significant people (such as the family physician, school personnel or other relatives) may be contacted for additional information. Psychiatrists gather details about the individual’s development, current problem and symptoms, health status, history of physical and psychiatric illness and treatment, medications, family health and psychiatric histories, school, friends, family relationships, and if needed, laboratory studies such as blood tests, x-rays, or special assessments (e.g. psychological, educational, speech and language evaluation).  Often (though not always) a referral is made for a psychiatric evaluation when a parent, caretaker, or healthcare provider wants to determine if a child might benefit from psychotropic medication as part of a treatment plan.  
Psychological evaluation Psychological evaluations assess the presence of certain conditions, such as depression, anxiety, and susceptibility to stress.  They can also measure general well being and provide an overall picture of a person’s mental health and personality.  A typical psychological assessment includes an interview with the youth and his or her parent or guardian and one or more formal psychological test.   Psychological evaluation results are used to understand and design a treatment plan to address a child’s needs.   
Developmental Evaluation A developmental evaluation is often recommended when a family,  physician,  or school is concerned about a young child’s development. These evaluations usually occur in the child’s home and are conducted by an early intervention specialist and a specialist in the specific areas of concern.  Areas of development that are assessed may include speech, language, and communication; motor development; cognitive skills; self-help and coping skills; feelings and emotions; and relationships to people and social skills.  Contact Children’s Integrated Services at 802-764-5294 for more information about developmental assessments in Chittenden County.
Psycho-educational Evaluation A psycho-educational evaluation is a comprehensive assessment of a student’s functioning in three primary areas that impact learning and school functioning.  These areas are: 1) cognitive ability/learning aptitude, 2) basic academic skill development, and 3) personality, emotional, adjustment, and social factors that might impact learning.  A parent or school personnel can request a psycho-educational evaluation for a child or youth.  When they are deemed necessary, psycho-educational evaluations are often conducted by schools at no cost to families.
Psycho-sexual Evaluation Psycho-sexual evaluations are conducted when there are concerns about a child or youth’s sexual behaviors. These evaluations include an extensive clinical interview with the youth and his or her parent(s) or guardian(s), psychological and sexuality testing, and cognitive and mental status assessments. Other documents and assessments that may be incorporated in the psycho-sexual evaluation are court documents, law enforcement reports, school records, previous psychological evaluations, substance abuse assessments, and statements of any victims of the sexual behavior. Psycho-sexual evaluations help determine whether the concerning sexual behavior(s) place the youth or the community at high, medium or low risk.
Neuro-psychological Evaluation A neuropsychological evaluation can be used to assess cognitive and behavioral strengths and weaknesses of a child or youth, and to diagnose specific medical conditions. Neuropsychological tests evaluate the brain by putting it to work and measuring specific abilities like memory, language, perception, problem-solving and motor and sensory functions.   The results of an evaluation generally lead to specific recommendations for treatment or management of problems. Neuro-psychological evaluations are often used by school districts when other assessments (such as the psycho-educational evaluation) have not provided enough information to develop effective interventions. Evaluations are funded by school districts when deemed necessary.
Substance Abuse Assessment A substance abuse assessment uses comprehensive, formal measures (or tests) to determine the extent and impact of drug and alcohol use. Questions are asked about one’s frequency and quantity of alcohol/drug use but also take into consideration patterns of use and mental health factors. A substance abuse counselor conducts these assessments and determines from the tests the best course of treatment. Referrals for substance abuse assessments are received from families, schools, other service providers, residential treatment programs and hospitals, juvenile corrections and state social services, and from youth themselves.
Trauma Assessment Trauma assessments can provide families, mental health providers, and school personnel with information about possible exposure by children or youth to trauma and an understanding of how the traumatic experience may be impacting daily functioning.  Assessments may include a clinical evaluation with the youth and family, consultations with current mental health providers, projective drawings completed with the child, trauma-focused standardized assessment measures completed by the child and/or caretakers, and review of previous records. The clinician then provides a clinical report with treatment recommendations.  Children are generally referred for a trauma assessment by a mental health provider or treatment team. 
Crisis assessment In Chittenden County, First Call provides crisis assessments for children and youth.  A crisis assessment is indicated when a child or youth is demonstrating signs of potential crisis.  Some examples that might warrant a crisis assessment include when a child or youth is expressing thoughts of self-harm or harm to others, escalation or out of control or dangerous behaviors, and/or an acute parent/child conflict.  First Call clinicians concurrently assess for and work to stabilize children and youth in crisis. If the child or youth cannot be stabilized, the crisis assessment will include determination if further resources are needed to provide safety for the child.  First Call can be reached at 802 488-7777, 24 hours per day, 7 days per week free of charge throughout Chittenden County.  The caller defines the crisis, therefore, if you suspect a child in your care is in crisis, it is appropriate to call First Call.
Threat Assessment (often called Risk Assessments) The Threat Assessment process addresses targeted school violence by identifying, assessing, and managing threatening situations. Risk level is determined by focusing on specific behaviors, actions, and communications of a youth. Appropriate authorities (school personnel and law enforcement with specialized training) gather information, evaluate facts, and make a determination as to whether a given student poses a threat of violence. When a threat is determined, authorities and service providers develop a threat management plan.  If you have concerns about your child being a victim of violence or carrying out an act of violence, contact your child’s school directly to inquire about a threat assessment.