Assessment

General Approach to Assessment in Primary Care

Use your knowledge of developmental trajectories to start the inquiry (refer to page 4 for more detail)
Focus on functioning (refer to page 4 for more detail)
Consider the context in which children are attached and embedded (refer to page 5 for more detail)
- Differentiate new problems from exacerbation of old or chronic problems
- Inquire about prior evaluations and prior and current treatments
Identify environmental stressors (refer to page 5 for more detail)
Assess sleep pattern (refer to pages 30-31 for more detail)
Screen for substance use (refer to page 31 for more detail)
Triage for psychiatric and social emergencies (refer to page 55 for more detail)

ADHD Assessment

Initiate an evaluation for ADHD for any child 4 through 17 who presents with:
- Academic or behavioral problems
- Symptoms of inattention, hyperactivity, or impulsivity
Collect information directly from school and child care personnel who have observed the child, as well as family members (including a noncustodial parent) and youth, using a validated tool such as the NICHQ Vanderbilt Assessment Scale, which includes all 18 DSM-5 symptoms.
Consult DSM-5 for diagnostic criteria.
Symptoms need to:
- Have persisted for at least 6 months
- Negatively affect directly on social and academic functioning
- Present in 2 or more settings and
- Interfere with, or reduce the quality of, social, academic, or occupational functioning

Anxiety Disorder Assessment

Core symptoms:
- Phobias (fears)
- Worries
- Somatic concerns (eg, abdominal pain, shortness of breath, racing heart)
Disorders by Symptom
- Fear or Phobia as primary symptom
  - Separation anxiety disorder
  - Social anxiety disorder
  - Specific phobia (eg, of dogs, heights, closed spaces)
- Worry as primary symptom
  - Generalized anxiety disorder
- Symptoms that may be present in any anxiety disorder
  - Somatic concerns
  - Avoidance
Evaluate using SCARED rating scale
- Provides information about the symptoms of all common anxiety disorders as well as severity of each symptom
- Child and parent versions available
Consult DSM-5 for diagnostic criteria.
Differential diagnosis should include consideration of other medical, developmental, and mental health conditions

Major Depressive Disorder Assessment

General inquiry
- Evaluation may be more complex and nuanced than evaluation of ADHD or anxiety
- Start with general inquiries about areas of function—school, home, family, friends, activities, and enjoyable activities
- Once a clinical conversation is established, it is easier to progress to potentially more difficult inquiries such as self-deprecating and/or suicidal thoughts
Core symptoms
- Depressed or irritable mood
- Weight loss or gain >5% in a month
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Diminished interest or pleasure
- Decreased concentration or indecisiveness
- Worthlessness or guilt
- Suicidal ideation
The PHQ-9 Modified for Teens may be helpful in eliciting symptoms of depression.
Consult DSM-5 for diagnostic criteria.
Assess safety of the home
Evaluation may require multiple appointments; schedule follow-ups relatively soon
Guidelines for the Management of Adolescent Depression in Primary Care (GLAD-PC) provides more detailed information about assessment of depression.

Disruptive Behavioral Problems and Disorders Assessment

Disruptive behaviors, except for severe aggression and major antisocial acts, rarely occur without the presence of other mental health conditions
There is considerable controversy about the appropriateness and validity of "pure" disruptive behavioral diagnoses, except for major antisocial behaviors (eg, conduct disorder)

Oppositional Defiant Disorder Assessment

Core Symptoms
- Angry or Irritable Mood
  - Loses temper
  - Touchy or easily annoyed
  - Angry and resentful
- Argumentative or Defiant Behavior
  - Argues with adults
  - Actively defies or refuses to comply with requests from authority figures or with rules
  - Deliberately annoys others
  - Blames others for his or her mistakes or misbehavior
- Vindictiveness
  - Spiteful or vindictive
The Vanderbilt Assessment Scale for ADHD includes items that can serve as a screener for ODD, which occurs commonly in children with ADHD
Consult DSM-5 for diagnostic criteria.

Disruptive Mood Dysregulation Disorder (DMDD) Assessment

Assessment of Other Comorbid Disorders

Adjustment disorders
- Core feature is the development of clinically significant emotional or behavioral symptoms within 3 months of an identifiable stressor
Substance use disorders
- Common in adolescents
- Screen using the Screening to Brief Intervention (S2BI) or CRAFFT substance abuse screening questionnaire
Learning disabilities or disorders, mild intellectual disability (ID), and communication disorders
- Likely to be suspected or diagnosed during well-child visits or by caregivers or school personnel
- Consultation and collaboration with specialists in neurodevelopmental disorders is recommended
Sleep disorders
- Disorders include:
  - Insomnia (most common disorder in pediatrics)
  - Sleep apnea
  - Narcolepsy
  - Restless legs syndrome
- Core symptom of insomnia is inability to fall or stay asleep that can result in functional impairment throughout the day
- Consultation with a pediatric sleep specialist is recommended when primary insomnia is suspected
Core symptoms of less-common comorbidities:
- Autism spectrum disorder: social communication deficits and restricted repetitive behaviors or interests
- Schizophrenia: hallucinations, delusions, disordered thinking
- Bipolar: manic episodes
- Eating: weight loss, food restriction, binging, purging
- Conduct: behavior violating others' rights and social norms
- Posttraumatic stress: intrusive memories, dissociative experiences, and avoidance or arousal symptoms in response to exposure to actual or threatened death, serious injury, or sexual violation
Obsessive-compulsive: obsessions or compulsions (or both)

Formulation

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