1:-Psychiatric Evaluation and Evidence-Based Rating Scales
The diagnosis of ADHD is based on administering behavior rating scales, and there lacks a gold standard for evaluating this condition (Bélanger et al., 2018). This discussion will address the three essential psychiatric interview components, highlighting the psychometric properties of the Brown Attention-Deficit Disorder Scales. I will outline when it is important to use this scale for clients during the psychiatric interview and utility of the scale to a nurse practitioner.
A clinical interview is intended to determine whether core symptoms of a disorder are present in a patient and the resultant impact of these consequences. A patient is often required to provide examples of how the presenting symptoms have affected social relationships and occupational or academic function. The clinical interview details the patient’s psychiatric, developmental, medical and family history. The psychiatric interview examines symptoms that can be tied to a diagnosis and comorbid conditions. The chief complaint allows the provider to document the patient’s presenting problem in won words. The history of presenting illness details a chronological order of the development of psychopathology. It is essential to understand the contributory factors or etiologies related to the patient’s condition. Essential descriptions of the past medical/psychiatric history include onset, course of illness, duration, severity, and frequency (Sadock, Sadock, & Ruiz, 2015).
Several challenges are encountered in making a diagnosis of ADHD. First, patients have higher comorbidities, particularly those presenting with hyperactive symptoms only or those with inattention type only (Bélanger et al., 2018). Individuals with ADHD have an increased predisposition to depression and diagnosing comorbid psychiatric disorders and ADHD can be a challenging task for the nurse practitioner. One must examine the onset, persistence and course of symptoms related to functional, social or occupational impairments. Despite the utility of the clinical interview in diagnosis of ADHD, an informant such as a parent, teacher or sibling can aid diagnosis and must be available when evaluating the patient to corroborate findings and complete a behavior rating scale (Marshall, Hoelzle, & Nikolas, 2021). An archival record of teachers’ reports, past psychological tests and previous evaluation aids the PMHNP in making an accurate diagnosis.
Challenges encountered during the clinical interview of patients presenting with ADHD include failure of the patient to provide accurate self-report and insight into ADHD symptoms. Poor recall of the ADHD symptoms in children also complicates the past psychiatry report. Patients, particularly adults may be unaware of impairments or symptoms. Some may lack insight into the problem and can link their problems to anxiety, depression, or character/personality traits (Mulraney et al., 2022). Similarly, young adults and children may not provide accurate reports of ADHD symptoms during an interview. Identifying occupational impairments is more difficult in adults compared to children. ADHD symptoms can also present with non-specific symptoms. Overactivity, inattention and concentration problems have multiple etiologies. Lastly, a clinical interview requires a minimum of 1-2 hours.
There are several scales used to evaluate ADHD problems. The Brown Attention Deficit Disorder Scale. These scales can assess several symptoms, such as ADHD executive function and associated impairments. These scales provide age-based norm ratings. The scales have a sensitivity of 92%. The specificity is only 33% in adults with ADHD, those with anxiety, depression or comorbid disorders (Marshall, Hoelzle, & Nikolas, 2021). These scales are useful for situational variability and incorporate comprehensive ADHD evaluation based on the perspectives of parents/teachers and self. The items are contextual and very specific, asking about difficulties a person encountered in specific contexts. They focus on severity and not frequency. The Brown scales also include symptoms of ADHD from the DSM-5 such as functional impairments and executive function. However, Mulraney et al. (2022) reiterated that most of these scales have excellent diagnostic accuracy. However, a single measure by one report can have inadequate specificity and sensitivity when using it for population screening.
2:-Psychiatric Interview
The psychiatric interview is essential in analyzing and appraising the patient’s current and previous mental health issues (Carlat, 2017). Below are the three most essential components of the psychiatric interview process.
The Therapeutic Alliance
The therapeutic alliance is the foundation of any psychological management plan and has been proven to be the most important element in all psychotherapy (Carlat, 2017). This component speaks to developing a rapport with your patients. It is important to develop a good rapport early in the interview process to establish trust, warmth, and a positive connection between practitioner and client (Verhofstadt et al., 2021). Building a therapeutic relationship can be accomplished through being emotionally sensitive, displaying competence in the comments and questions, and not holding on to bias or judgments. The practitioner needs to feel comfortable, confident, and knowledgeable. It would be best if you were yourself, empathetic, and sympathetic to the patient’s concerns (Verhofstadt et al., 2021).
Obtain the Psychiatric Database (Psychiatric History)
Obtaining a detailed picture of the client’s psychiatric history, current psychiatric treatment, and other comorbidities affecting the client or their treatment requires a thorough psychiatric history (Carlat, 2017). This element is crucial because it involves getting relevant information for the clinical presentation. The psychiatric, medical, and family psychiatric history aspects of the social and developmental history. Including previous and current medication regimens (Carlat, 2017). This step is crucial because it gives the bulk of information essential to diagnosing. During this step, it is vital to allow the client to express their symptoms and concerns in their own words. Practicing attentive listening and empathizing with clients’ concerns is essential. The practitioner maintains a good rapport throughout the interview (Carlat, 2017).
Interview for Diagnosis
This element of the interview process is essential and challenging to master. It takes specific skills and practice to master getting to a diagnosis (Carlat, 2017). The information obtained from the history is used to make a diagnosis. Diagnosis is the process of determining what mental disorder the client has (Carlat, 2017). This is done by comparing the information gathered in the assessment to the diagnostic criteria for various disorders. These elements are essential because they provide a framework for the interview and help ensure that all critical information is gathered (Carlat, 2017). The diagnostic Statistical Medical (DSM-5-TR) criteria are necessary for the PHMNP to arrive at the appropriate diagnosis for the patient (Carlat, 2017).
Cognitive Disorders Scales: Mini-Mental State Examination (MMSE)
Cognitive disorders are conditions that damage the rational function of a person to the point where regular functioning in society is impossible without some treatment (Carlat, 2017). This disorder includes dementia, motor skill, and developmental disorders. The Mini-Mental State Examination (MMSE) is one of the scales used to assess cognitive impairment in adults 18 and older (Carlat, 2017). It is short, structured, and takes about 10 minutes to complete because most cognitive impairments are diagnosed in an acute care setting (Carlat, 2017). Therefore, MMSE is not used as a diagnostic tool. Instead, it monitors a person’s cognitive development over time (Carlat, 2017).
The MMSE is only one piece of evidence to be considered when evaluating a patient for cognitive impairment (Jia et al., 2021). The MMSE has seven sections, with 30 questions on orientation, registration, attention, calculation, recall, language, and visuospatial ability. Several tasks must be completed to receive a score for a particular section (Jia et al., 2021). Therefore, higher scores on the MMSE indicate better cognitive function, with a total score between 0 and 30 possible (Jia et al., 2021). This scale was first developed in 1975 by Marshall and Newcombe to evaluate the effects of head injury on cognitive function. However, it has been widely used in various settings, including acute care hospitals, primary care settings, clinics, and research studies (Jia et al., 2021).
Since the MMSE can be completed in less than five minutes, it has become a popular tool for assessing cognitive function in the elderly (Myrberg et al., 2019). This tool can be helpful to the PMHNP in determining a client’s cognitive function and would be best utilized during the health history portion of the interview (Myrberg et al., 2019). It is also one of the most extensively studied assessment instruments, with a large body of literature supporting its reliability and validity. Therefore, adults can be tested for cognitive impairment using the MMSE, a short cognitive function test. In addition, it is simple to administer and has good psychometric properties (Myrberg et al., 2019). However, the MMSE should not be used as a diagnostic tool because it does not provide a complete picture of an individual’s cognitive functioning (Myrberg et al., 2019).
