Comprehensive Assessment of child/adolescent

Complete a comprehensive assessment of a child/adolescent. This should not be a patient that you have encountered in your work, but instead, should be a family member, or child/adolescent of a friend. Assessment should be comprehensive.
Rubric to use as a guide:
1.5 pts
Accomplished
Submits signed informed consent document permitting the learning access to the client and permission to conduct the clinical interview

2 pts
Accomplished
-Discusses with clarity how child/adolescent is viewed within the family. -Describes child/adolescent interests from the perspective of primary caregiver(s) as well as child. -Availability of support for child/adolescent across settings (home, school, community, etc.) -Describes future aspirations of child/adolescent -Measures of child/adolescent self-concept NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

2 pts
Accomplished
-Discusses with clarity how members of the family interact with one another. -Includes information on any family interaction difficulties (e.g., sibling rivalries, defiance’s, hostility toward family members, etc.) -Assessment of psychiatric issues in the family (assessment should extend back to at least maternal/paternal grandparents). NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

4 pts
Accomplished
AGE APPROPRIATE ASSESSMENTS OF: -Assessment of appearance -Assessment of orientation -Assessment of adaptive functioning -Assessment of attention & memory -Assessment of fund of knowledge -Assessment of insight -Assessment of thought (coherence, speed, content, etc.). -Assessment of mood -Assessment of anxiety -OTHER ASSESSMENT OF MENTAL STATUS PARAMETERS AS INDICATED. NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

1 pts
Accomplished
Assessment of child/adolescents: -Cognitive strengths/weaknesses relative to same aged peers -Linguistic strengths/weaknesses relative to same aged peers -Assessment of interactions with examiner NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

3 pts
Accomplished
-Generalized assessment with emphasis on physical parameters, including: -Height/weight -Head, eyes, ears, nose, throat (HEENT) -Cranial nerve testing -Peripheral neurological exam (reflexes) -Lungs (auscultate) -Heart (auscultate) -Abdomen (auscultate) NOTE: Under NO CIRCUMSTANCES will you do a genital/rectal exam or any other exam maneuver requiring removal of clothing items- and while it may be a limitation, auscultation must take place over the clothing. NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

2 pts
Accomplished
-Discusses child/adolescents’ current stage of development. -Presence of any developmental disorders. -Assesses for presence of any traumatic events which could have (or had the potential to) impacted the child/adolescent NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

1 pts
Accomplished
-Discusses any current or past medical issues/health concerns -Describes course of pregnancy including complications/maternal health issues during pregnancy -Were there any health issues during or following birth? NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

1 pts
Accomplished
-Current grade in school -Does child/adolescent have an individualized education plan (IEP)? -Issues with truancy or other disciplinary issues at school? -Evidence of bullying in school? NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.

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