Lịch sử từ nhiều nguồn (cha mẹ, giáo viên, bác sĩ nhi khoa, trẻ em) a. Lý do cho b. Giới Thiệu Lịch sử của c. Bệnh tật hiện tại Đánh giá của các triệu chứng tâm thần d. Lịch sử trước khi sinh, phát triển và Xã hội (bao gồm cả lịch sử sản khoa và sinh, tính khí sớm, cột mốc phát triển | 258 Stubbe Table 1 Essentials of the Child and Adolescent Psychiatric Evaluation 1. History from multiple sources parents teachers pediatrician child a. Reason for Referral b. History of Present Illness c. Review of Psychiatric Symptoms d. Prenatal Developmental and Social History including obstetrical and birth history early temperament developmental milestones toilet training history of trauma or abuse risk-taking behaviors substance abuse friendships sexual behaviors legal difficulties e. Psychiatry History f. Educational History g. Stress level psychosocial adversity h. Medical History and Review of systems i. Family psychiatric medical genetic history j. Child and Family Strengths and Weaknesses 2. Mental Status Examination a. Appearance and grooming including tics mannerisms b. Speech fluency volume rate and language skills c. Ability to cooperate and engage with assessment d. Motor activity level attention frustration tolerance impulsivity e. Mood and affect neurovegetative symptoms manic symptoms f. Psychotic symptoms hallucinations delusions thought disorder g. Anxiety fears and phobias obsessions or compulsions post-traumatic anxiety h. Oppositionality conduct symptoms aggression verbal or physical i. Clinical estimate of cognitive skills j. Insight and judgment 3. Screening physical and neurological examination 4. Diagnostic tests where appropriate a. Lead level b. Thyroid and other screening laboratory tests c. ECG EEG or neuroimaging procedures as indicated d. Psychoeducational testing to rule out learning disability and intellectual impairment at times neuropsychological testing to assess executive functioning and more subtle or complex deficits 5. Rating scales such as Conners for ADHD Beck Depression Inventory for depression etc to assess the number and severity of symptoms. Baseline and follow-up rating scales are helpful in monitoring the effectiveness of treatment interventions and medication regimens. becomes clear with ongoing maturation a more
