Clinical observation is the process of learning about a person’s mental health by watching him in his day-to-day routines at home, school, or work environments (called natural settings). This special kind of watching and listening provides a wide range of helpful information. Depending on the referral question and the presenting problem, the following sites might be appropriate for a clinical observation:

• A youngster who fights during recess would be observed at school during recess.
• A young adult who has difficulty completing work assignments would be observed at his job site.
• A teenager who displays aggression toward his younger sister would be observed in his home.
• A preschooler who starts tantrumming whenever his mother takes him to stores—especially to supermarkets and malls—would be observed at those places.
• An adult who crouches and hides under furniture whenever he hears a loud siren might purposely be exposed to the siren and observed.
• A young girl who starts to cry whenever she goes into a car would be observed in a car.

The purpose of observing the individual under the very circumstances that are problematic is to identify, firsthand, the factors contributing to the problem.

The clinical observer will focus on a number of specific characteristics or behaviors. Here are some examples:

• appearance (consistent with given age, gender, and activity?)
• body size (well-nourished, underweight, or overweight?)
• hygiene and dress (well-groomed, disheveled?)
• eye contact (good, fleeting, or non-existent eye contact?)
• balance and coordination (age appropriateness and quality of hand, arm, and leg motor skills?)
• attention and concentration, ability to follow directions (remains on task 5 seconds? or 5 minutes?)
• speech and language (tone of voice, vocabulary?)
• mood (emotional expression suited to situation and topic?)
• thinking process (rational? hallucinations or delusions?)
• memory (short term memory, long term memory?)
• ability to interact with others (ability for reciprocity? socially engaging?)
• problem-solving strategies (how is frustration handled?)
• repetitive behaviors (tics, stereotypical movements, or nonfunctional movements?)

A professional can assess, in the course of seemingly casual conversation, an individual’s attention and concentration, language level, and thinking process. By watching a young child on the playground, for example, the professional can informally assess gross and fine motor skills as well as her ability to interact with peers and to follow directions.

1. Clinical observation conducted in a setting that is familiar to the individual and part of his day-to-day routine provides an opportunity to watch the problem behaviors in the very place they occur. For example, if an adult has interpersonal problems with his peers at work, it is highly unlikely that the professional would discern this in her office. And even if the behavior—for example, having difficulty paying attention—could occur in the professional’s office, it still might not surface since the person may be on his "best behavior" in the novel situation of being in a professional’s office but not in his daily lunch group. Behaviors that occur only in specific circumstances—in supermarkets, for example—will not occur in the office.
   
2. Clinical observations are particularly useful in identifying environmentally-triggered patterns of behavior that may not be immediately apparent—either to the person being evaluated or to those who interact with him regularly. For instance, a five-year-old may appear to tantrum randomly, which can create great distress for parents or teachers. A professional observing the child in the classroom, however, may be able to distinguish that the child always tantrums when fine motor skills are required—when, for example, he is asked to string beads or copy shapes—but not during gross motor activities such as putting puzzle pieces together. Or the child may tantrum when three-part directions are given but not during one-part directions.
   
3. Sometimes a clinical observation can occur without the person’s knowledge, especially in the case of children. When a person knows she is being observed, she may be distracted by the observer’s presence, or otherwise alter her behavior. But if the observer visits the child’s classroom or childcare group before the child has been introduced to the professional, then there is less chance of purposefully distorted behavior. Some settings have one-way mirrors which can be helpful in observing family, parent-child, or sibling interactions. An adult or teen should not be observed without her prior consent.
   
4. Clinical observation in natural settings often reveals a person’s strengths and assets. Families and others in a setting where problem behaviors occur are often so frustrated and exhausted that they lose sight of what the person can do well. The outside observer can more readily note the adaptive behaviors. Taking note of an individual’s strengths is a critical factor in his overall success.
   
5. Clinical observations are generally easier for the consumer and his family since the professional enters their world, rather than requiring a one-way-only adjustment by the consumer and his family. Some individuals have mobility challenges, and many families have transportation problems. Clinical observations at home or at work are more convenient and usually less stressful for families.

1. Cost. Natural setting observation is time-consuming and therefore costly. Even if the observation itself is not that lengthy, travel to and from the site adds to the professional’s time commitment. As a result, agencies and insurance companies are less likely to subsidize this assessment method.
   
2. Unpredictability. Another disadvantage is that the presenting problem simply may not occur during the observation period. For instance, a child who bites himself 2-3 times a day (for unknown reasons) may not exhibit this behavior if he is being observed. Perhaps there is a substitute teacher, the schedule has been changed, the student who bothers him is absent that day, etc.
   
3. Reactivity. Sometimes a child or adolescent will act differently when she becomes aware that she is being observed. Thus, the "naturalistic setting" advantage is compromised and the individual will muster her best behavior, or she might begin asking the observer questions. When the naturalistic aspect is lost, the problem behavior often may not surface. Adults can become self-conscious and act differently knowing that they are being assessed. To compensate for this reactivity effect, it is sometimes helpful for the professional to observe the individual over a longer period of time since she has a greater tendency to return, in time, to her typical behaviors. Even if the person adjusts his behavior due to being observed, that provides pertinent clinical information.