What is clinical assessment?

Mental health clinical assessment (sometimes called "whole person assessment") is the process of gaining a better understanding of an individual’s concerns, needs, and strengths. A thorough clinical assessment helps the consumer and his family make more informed decisions. The referral question shapes the goals and methods of clinical assessment. The referral question can come from the consumer, her family, or the referring service provider. This question is the reason the mental health assessment is being sought at this time in the consumer’s life. Here are some examples of referral questions:

• How can we reduce the aggressive behaviors of this young boy towards his classmates? OR, How can he interact more positively with his classmates?
• When this young adult says he hears voices, is it due to concrete thinking associated with his mental retardation, or is he experiencing auditory hallucinations (hearing things that aren’t really there)?
• Does this teenager’s severe anxiety about going to his new high school have any connection with his cerebral palsy?
• Can this child understand the material being presented in her current classroom placement?
• Is this young woman really a neglectful mother, or does she have moderate mental retardation and need homemaking support services?
• Does my child have autism?

As you can see, the referral question and the process of trying to address that question is at the heart of all clinical assessment.

How is clinical assessment different than diagnosis?

Diagnosis is a shorthand method of providing information about an individual. It describes the person’s current problems in terms of symptoms.

However, a diagnosis alone does not provide the unique aspects of the individual that are necessary to plan interventions and supports. For instance, the medical diagnosis of anxiety disorder gives us an idea of the condition the person is struggling with. But it does not tell us many other important things, such as:

• severity of the mental illness
• current types of treatment (psychotherapy, medications, Yoga) being used
• level of impairment from the illness or treatment. (How much does the anxiety impair the person’s daily functioning?)
• other important life stressors (financial problems, medical illness, recent death in the family, etc.)

A diagnosis does not convey the person’s unique personality, strengths, and positive attributes. Diagnoses highlight deficit and do not focus on adaptive abilities, other skills, talents, and interests. All of this information is important for mental health assessment and treatment.

How is clinical assessment performed?

Comprehensive clinical assessment cannot be completed in one session. It usually takes several visits. Good clinical assessment has four phases:

1. Helping the consumer/family articulate their question(s).
2. Choosing and conducting assessment procedures to obtain the most relevant information.
3. Integrating (combining) all the findings from the past and present clinical assessments.
4. Providing understandable information and practical recommendations to the consumer, family, and relevant professionals and careproviders.

During this process, the values, knowledge, skills, and experience of the mental health clinician are paramount, because each phase requires careful and complex judgments. The results of the assessment process will heavily depend upon the clinician’s competence.

How does the mental health professional gather pertinent information?

There are many kinds of information-gathering techniques. But all techniques reflect one of these four formats for obtaining information about the consumer:

1. Ask the person himself.
2. Ask someone who knows the person.
3. Observe the person as she behaves in her natural environment.
4. Observe the person in a standardized test situation.

1. Ask the person himself. The backbone of clinical assessment is asking a person direct questions and trying to obtain accurate replies. Questions can range from the most obvious (such as name, age, number of siblings) to more abstract (such as feelings, thoughts, preferences, and intentions). The process of asking questions in a systematic way is called an interview. [See Interviews & History module.] Questions can be asked in a face-to-face interview or in written questionnaires.
   
   Questionnaires (also called "surveys," "scales," and "self-report instruments") are simple, consistent, and cost-effective. However, human nature leads many of us to alter our answers to present ourselves in the best possible light. Individuals with developmental disabilities and mental illness face an additional hurdle. The consumer with this dual diagnosis has both cognitive and emotional challenges (and perhaps physical as well) that make questionnaires difficult to use. For instance, the mental age of an adult with mental retardation should be considered when using questionnaires. [See Mental Health Assessment Tools module.]
   
   
2. Ask someone who knows the person. This format is very useful for all individuals, but especially those with communication impairments. Family members are a good source of information, along with other careproviders, Regional Center service coordinators, teachers, physical or occupational therapists, and others. Sometimes friends and neighbors are available to participate in the clinical assessment process.
   
   These additional informants should not be overlooked because they can be rich sources of information. They often see the individual over a long period of time and have the perspective to help the mental health clinician understand the difference between the consumer’s typical behavior versus unusual behavior. They can describe the individual’s behavior, personality characteristics, strengths, preferences, and other factors that appear to affect his mood and social behavior. They can also point out factors that may not be obvious to the clinician. For instance, a teacher may notice that time of day or noise level affects a student’s learning and behavior, factors that the clinician may not have considered on his own. Also, by obtaining information from various sources, the clinician can began to identify whether certain difficulties are consistent across settings or not, and if not, what factors contribute to the successes and difficulties.
   
   Of course, the clinician may only talk to outside individuals with the specific permission of the adult consumer or parent of a child consumer.
   
   
3. Observe the person as she behaves in her natural environment. Directly observing a person over the course of a day is one of the best ways to obtain information. However, this is an expensive method (cost of the clinician’s time), it is sometimes impractical (the consumer may live too far away), and it may jeopardize the consumer’s or other individuals’ confidentiality . Despite these obstacles, every effort should be made to observe the consumer at home or school, however briefly. Assessments should be planned to include activities that are both successful and comfortable as well as problematic or distressing.
   
   Direct observation helps the clinician discover problem factors that might have gone unidentified by other informants. For example, a parent may not realize that her son becomes aggressive because he doesn’t have the language to communicate his feelings. He may have tried to get his mother’s attention by tugging at her sleeve, but she may have interpreted this gesture as "bothering" her instead of being an attempt at communication. The child’s next step might be to hit her to get her attention. Conversely, a child may be extremely anxious but the mother may not note it to the clinician during the interview because she believes that "this is how he has always been" and considers the behavior to be "just his personality." [See module on Clinical Observation.]
   
   
4. Observe the person in a standardized test situation. Despite their limitations, standardized tests, especially in combination with interviewing, remain the major method of assessment for most mental health clinicians. The essential features of tests are:

• Standard conditions are maintained during testing (that is, the test materials and clinician’s approach are very similar for all consumers taking the test). This reduces subjective bias.
• They are time-efficient for the clinician.
• They provide quantitative measures (a score expressed in numbers or percentages, or age-equivalence) to describe various types of functioning or symptoms (such as intelligence, depression, or thought disorder). Scores are convenient for comparing this individual with others. Scores can sometimes provide evidence of the mental illness improving or worsening over time.
• One of standardized testing’s major limitations is that many of them are inappropriate for individuals with developmental disabilities. When selecting a clinician, it is important to consider his or her competence in selecting the most appropriate tests for such a consumer.

Due to time and funding constraints, clinical assessments may be very limited. However "shortcuts" in the assessment phase often cause poor choices in the treatment process. Most mental health professionals recognize that a thorough clinical assessment is essential for effective and efficient mental health intervention.

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