Additional Information

Clarify the patient’s presentation by gathering patient history, observation, criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5), and symptom-specific screening.

• Use HELP skills to gather developmentally appropriate history from both the patient and caregiver to help clarify concerns. Proceed as you would to collect information about physical health concerns.
• Observe the patient, their caregivers, and how they interact together. Observations may include mood, affect,behavior, and engagement. Remember to look for patient and family strengths, not only mental health signs or symptoms.
• Utilize symptom-specific screening tools, such as those for anxiety, attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (commonly known as ODD), depression, suicidality, substance use, and trauma and other adversities.
• In some cases, you will have enough information to diagnose a mental health condition (eg, ADHD, generalized anxiety disorder, major depressive disorder). In general, a mental health condition is diagnosed when specific symptoms are present to a degree that results in impairment or distress. See the Pediatric CareOnline Point-of-Care Quick Reference or the DSM-5 for detailed descriptions of mental health conditions.

Visit the Assessment key clinical activity for more information and links to helpful resources.