Component |
What to assess |
Appearance & Behaviour |
Physical appearance |
Gender; ethnicity; body habitus; apparent age; cleanliness and grooming, hair/clothing style, cosmetics and jewellery; syndromic features. |
Manner of relating to clinician and parents |
Ease of separation from each parent; reactions to meeting the clinician (eg eagerness to please, defiance, overfamiliar); eye contact; facial expression. Note presence of
hallucinatory behaviours (eg talking to self; laughing incongruently). |
Activity level |
Psychomotor slowing or agitation, sustained or episodic, goal-oriented or erratic; coordination, unusual postures or motor patterns (eg tics, stereotypies, odd mannerisms, tremors). |
Speech |
Spontaneous and talkative to mute. Fluency, rate, volume, tone. |
Mood |
Predominant emotion over days/weeks (eg euthymic, apathetic, angry, dysphoric, apprehensive, euphoric). Use 0-10 scale (0: extremely sad & wishing to end life immediately, 10: extremely happy). |
Affect |
Current observed emotional state. Describe type, range (constricted to labile), reactivity (blunted or flat to reactive), & appropriateness. |
Thought |
Stream (i.e. speed) |
Poverty of thought (thought
blocking), poverty of content (perseveration), racing thoughts, flight of ideas. |
Form |
Logical & goal-directed or disordered (eg circumstantial, tangential, derailment, looseness of associations, word salad). |
Content |
Obsessions, delusions (eg persecutory, referential, grandiose, somatic, bizarre), phobias, magical thinking, thoughts of harm to self or others. |
Perception |
Altered bodily experiences (eg depersonalization, derealization), passivity
phenomenon, illusion, hallucination (eg auditory, visual, olfactory, tactile). |
Cognition |
Level of consciousness |
Alert, drowsy, delirium, stupor. |
Orientation |
Awareness to confusion of self, current setting, date & familiar people. |
Attention |
Need for redirection/repeating, sustained activity, distractibility. |
Memory |
Immediate (eg repeat numbers, names back), short-term (eg recall three objects at 2 and 5 minutes), long-term (e.g. recall events of past week). |
Ability |
Impression of current abilities; concrete to abstract thinking. |
Insight & Judgment |
Insight |
Intact, partial or poor
insight. Ability to identify potentially pathological events (eg hallucinations, suicidal impulses); acknowledgement of a possible mental health problem; locus of control (internal v external). |
Judgment |
Intact to impaired judgment. Problem solving ability in context of current psychological state (can be explored by recent decision making). |