Mental Status Examination (11)
- APPEARANCE: how does the client look?
- BEHAVIOUR: how does the client behave? Body language.
- ORIENTATION: does the client know what time (year, date, month) it is?
- MEMORY: does the client show any problems with immediate, recent or remote memory?
- SENSORIUM: is the client able to attend and concentrate? Perception, delusions etc.
- AFFECT: does the client display a range of emotions? Is the affect appropriate? Flat, appropriate?
- MOOD: what is the general emotion displayed/reported by the client?
- THOUGHT CONTENT and THOUGHT PROCESS: what does the client
want to focus on during the interview? Is the client able to clearly explain ideas? - INTELLECTUAL RESOURCES:
does the client have good verbal
ability? - INSIGHT: is the client aware there is a problem? Does the client know what is causing the problem?
- JUDGEMENT: does the client have the ability to make their own decisions? Can the client make plans and solve problems?
Behavioural Functional Analysis
“The ABCs of behaviour”
»Antecedents (e.g., triggers. Other’s actions, thoughts, feeling)
»Behaviours (e.g., topography, frequency, intensity, duration), explain as if you were describing something on the phone (visual)
»Consequences (i.e., punishment, negative reinforcement, positive reinforcement, response cost, extinction)
Case Formulation – “5Ps”
Presenting problem »Symptoms, disorders, problems Predisposing factors »Historical »Biological/genetic
Precipitating factors
»Current triggers, e.g., events,thoughts, feelings
Perpetuating factors
»Factors that maintain, exacerbate the problem
»e.g., chronic stressors, thoughts, consequences, avoiding the problem
Protective factors
»Factors that can protect against risks
»e.g., good parenting skills “positive parenting”, supportive partner
Report Writing: Purposes of psychological reports
» Provide accurate assessment related information to the referral source and other concerned parties
» Provide an “historical” document of assessment & intervention for someone doing further services down the track
» May serve as a legal document
Components of Psychological Report
»Demographic data »Relevant background »Previous assessment »Assessment techniques, and date and duration of current assessments »Results and interpretation »Recommendations »Summary
Common problems with reports
»Poor organisation »Poor differentiation between test data and other data »Inconsistencies »Failure to answer the referral problem »Irrelevance »Lack of supporting data or behavioural referents »Lack of recommendations »Excessive length »Unclear expression »Grammatical & spelling errors
Some key principles in report writing
- Organise assessment findings by detecting common themes, integrating the main findings and using a theoretical focus
- Be extremely cautious in making interpretations based on a limited sample of behaviour
- Use all relevant sources of information about the child/adult in generating hypotheses, formulating interpretations, and arriving at recommendations
- Be definitive when findings are clear and cautious when findings are unclear
- Use behavioural referents where possible
- Interpret the meaning and implications of scores rather than simply citing test names and scores
- Eliminate biased terms
- Write in a concise manner
- Attend carefully to grammar, spelling, and writing style
