What did the practitioner do well? In what areas can the practitioner improve?

            There are several strategies the practitioner used well in the YMH Boston Vignette 5 video with the male adolescent presumably suffering from depression.  These include the practitioner applied a relaxed, interested, and non-confrontational approach.  Though the practitioner initially chose interview questions not typically geared towards males, she eventually discovered the patient expresses distress through anger.  Lastly, the practitioner did a good job of summarizing what the patient said indicating to the patient she was listening which encouraged the patient to share more (YMH Boston, 2013).

            Areas the practitioner could improve include initiating the interview with more male-oriented questions.  She started the interview by asking about the patients feelings and the patient clearly did not resonate with this type of question.  The practitioner should have started by asking about expressions of depression that are more likely to occur in males such as anger and irritability (Zuckerbrot et al., 2018).  The practitioner also had a moment of incongruent flow when she asked about academic performance.  The patient endorsed not doing well in school and the practitioner went right into asking about substance use which seemed to throw the patient off (YMH Boston, 2013). 

            According to Zuckerbrot et al. (2018) adolescents with depression often have difficulty identifying depressed mood and the practitioner should have further assessed additional symptoms that may indicate depression such as fatigue, insomnia, hypersomnia, weight loss or gain, and family conflict.  The practitioner should have incorporated a standardized measure to ensure thorough assessment.  These measures include evidence-based diagnostic interviews, comprehensive questionnaires, targeted scales, and structured clinical observation schedules (Thapar et al., 2015).  According to Bevan et al. (2018) the practitioner should have also assessed for a family history of depression as this is a risk factor for adolescent depression and could indicate specific targeted interventions.

            While interviewing the adolescent patient alone is important with respect to confidentiality, patient autonomy, and the development of the therapeutic relationship, the practitioner should have included direct interviews with the patients family as families and caregivers can provide insight into the patients condition (Zuckerbrot et al., 2018).  Lastly, the practitioner should have assessed for comorbid conditions, such as anxiety disorder, physical abuse, and trauma, as these may affect the diagnosis and treatment of depressive disorders (Zuckerbrot et al., 2018).    

At this point in the clinical interview, are there any compelling concerns? If so, what are they?

  The most compelling concern that was brought up during the clinical interview was the patient endorsing suicidal and self-harming ideation (YMH Boston, 2013).  According to Thapar et al. (2015) depression is the most common mental health disorder reported in psychological autopsy studies of young people dying by suicide.  Many young people consider suicide or self-harm and the course of adolescent depression appears to influence suicidality (Thapar et al., 2015).    

What would be your next question, and why?

            The next question I would ask the patient would be have you ever engaged in self-harming behaviors or do you have a plan to?  According to Thapar et al. (2015) a history of self-harm is one of the most powerful and clinically relevant predictors of eventual suicide.  It would then be crucial for the practitioner to establish a safety plan with the patient which includes the assessment and restriction of lethal means, such as whether the patient has access to medication or weapons (Zuckerbrot et al., 2018).  Additional elements of the safety plan include engaging a supportive third party and developing an emergency communication strategy in case the patient experiences an acute crisis (Zuckerbrot et al., 2018). 

Explain why a thorough psychiatric assessment of a child/adolescent is important.

            A throughout psychiatric assessment of children and adolescents is important because of how challenging they can often be.  Children and adolescents may not be in agreement with having the consultation and are often reluctant to share (Srinath et al., 2019).  Furthermore, children and adolescents may not be able to report the nature, timing, or duration of symptoms.  They also may not report symptoms that might be embarrassing or show them in a bad light (Srinath et al., 2019).  For these reasons, clinical assessments with children and adolescents typically require elaborate gathering of information from the patient as well as multiple sources including parents, teachers, and additional caregivers (Srinath et al., 2019).  Major depressive disorder in adolescents often continues into adulthood, therefore thorough assessment, diagnosis, and management are essential at the onset of symptoms (Thapar et al., 2015). 

Describe two different symptom rating scales that would be appropriate to use during the psychiatric assessment of a child/adolescent.

 Two symptom rating scales that are appropriate for use during the psychiatric assessment of a child/adolescent are the Pediatric Symptom Checklist (PSC-Y) and the Strengths and Difficulties Questionnaire (SDQ).  Both of these are brief but broad-based assessment measures (Hilt, 2016).  The PSC-Y is a 35-item measure of adolescent psychosocial functioning that helps to identify and assess changes in emotional and behavioral problems in children (Hilt, 2016). The SDQ consists of 20 items and covers common mental health problems, such as emotional symptoms, conduct problems, hyperactivity, and peer problems, in children ages 2 to 17 (Kuhn et al., 2017).  SDQ results are dimensional as well as categorical (Kuhn et al., 2017). 

Describe two psychiatric treatment options for children and adolescents that may not be used when treating adults.

            Two psychiatric treatment options for children and adolescents that may not be used when treating adults are Acceptance and Commitment therapy (ACT) and Parent-Child Interaction therapy (PCIT).  The goal of ACT is to increase psychological flexibility by helping the child or adolescent be present in the moment and adapt his or her behavior according to chosen values (Thapar et al., 2015).  ACT attempts to improve patient functioning by teaching patients to avoid distressing urges and emotions (Thapar et al., 2015).  PCIT strives to treat disruptive behaviors in children ages 2 to 7 years where therapists coach caregivers in play therapy and operant conditioning skills (Lieneman et al., 2017).  PCIT involves two phases of therapy: child-directed interaction (CDI) and parent-directed interaction (PDI).  The goal of the CDI phase is to encourage warm and secure caregiver-child relationships.  The goal of the PDI phase is to increase child compliance and decrease disruptive behaviors (Lieneman et al., 2017).  Lieneman et al. (2017) explain that during PCIT, clinicians observe sessions through a one-way mirror and communicate with caregivers via ear phones which helps facilitate live coaching of parenting behaviors.    

Explain the role parents/guardians play in assessment.

Parents and guardians play a crucial role in the psychiatric assessment of children and adolescents.  Kuhn et al. (2017) explain that especially for preschool and early school-aged children, assessment information is likely to come mostly from parents as the cognitive function of children limit their ability to report symptoms.  Adolescent patients can be seen as transitional where parent reports and patient reports should be considered relevant data (Kuhn et al., 2017).  The family may also be able to provide insight into the cultural background of the patient which can certainly influence the presentation of depressive symptoms (Zuckerbrot et al., 2018).  Zuckerbrot et al. (2018) explain that although family relationships can impact the presentation of depression, adolescents should be interviewed alone about their depressive symptoms, suicidality, and psychosocial risk factors.  

References

Bevan Jones, R., Thapar, A., Stone, Z., Thapar, A., Jones, I., Smith, D., & Simpson, S. (2018). Psychoeducational interventions in adolescent depression: A systematic review. Patient Education and Counseling, 101(5), 804816.

• This article is considered scholarly because it was published in a peer-reviewed journal (Patient Education and Counseling), all the authors are experts in their field, and there are no conflicts of interest.

Hilt, R. J., & Nussbaum, A. M. (2016). DSM-5 pocket guide for child and adolescent mental health. American Psychiatric Association Publishing.

Kuhn, C., Aebi, M., Jakobsen, H., Banaschewski, T., Poustka, L., Grimmer, Y., Goodman, R., & Steinhausen, H.-C. (2017). Effective mental health screening in adolescents: Should we collect data from youth, parents or both? Child Psychiatry and Human Development, 48(3), 385392.

• This article is considered scholarly because it was published in a peer-reviewed journal (Child Psychiatry and Human Development), all the authors are experts in their field, and there are no conflicts of interest.

Lieneman CC, Brabson LA, Highlander A, Wallace NM, & McNeil CB. (2017). Parentchild interaction therapy: Current perspectives. Psychology Research and Behavior Management, 10, 239256.

• This article is considered scholarly because it was published in a peer-reviewed journal (Psychology Research and Behavior Management), all the authors are experts in their field, and there are no conflicts of interest.                   

Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(2), 158175. 

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutters child and adolescent psychiatry (6th ed.). Wiley Blackwell.

YMH Boston. (2013, May 22). Vignette 5 – Assessing for depression in a mental health appointment [Video]. YouTube. 

Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R. E. K., Laraque, D., & GLAD-PC Steering Grp. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. PEDIATRICS, 141(3), e20174081.