TN 4 (09-04)
DI 22510.048 Pediatric Consultative Examination (CE) Report Content Guidelines - Mental Disorders
A. Policy - General
Specific requirements apply to pediatric CEs for mental disorders, in addition to all general pediatric CE report content guidelines in DI 22510.035. See also DI 25205.015 regarding CE policy in children's cases.
EXCEPTION: The format and discussion of conclusions should follow the standard reporting principles for a complete and competent mental status examination.
B. Policy - Infants and Toddlers
The mental assessment for infants and toddlers should include:
History, including age of attainment of developmental milestones (sitting unsupported, standing, walking);
Responsiveness to visual, auditory, and tactile stimuli (birth to 12 months)
Motor coordination (fine and gross, including left or right dominant);
Communicative behaviors, including pre-speech behaviors (for example, sucking, swallowing, imitation of sounds) and early language behaviors (for example, jargon, single words, phrases, turn-taking);
Manner of relating to and interacting with parent or caregiver, and ability to separate from parent/caregiver;
Manner of relating to and interacting with sibling or peer group, if observed;
Any stereotypical movements;
Perceptual functioning; and
C. Policy - Children of All Ages
The report of mental assessment for children of all ages (or the mental status exam for children 12 and over) should include a description of:
History, including adjustment in school and home (daily activities, social functioning, concentration, persistence, pace);
Appearance and grooming;
Communicative abilities and behavior;
Thought processes (with verbatim examples);
Cognitive functioning, including psychological test findings; and
Any indication of substance abuse.
D. Policy - Children Age 12 and Over
In addition to DI 22510.048D, the mental status examination for children age 12 and over should include:
NOTE: These elements may also be appropriate for children under age 12.