Mental state examination in children and adolescents — branching viva

Stem

The examiner will test whether you can set up and run a developmentally appropriate mental state examination under pressure, and act on what you find. [7] [8]

Branch 1 — Setting up and the domains

Examiner: How do you begin a mental state examination? [8]

Strong answer: Observe from the moment the young person enters — gait, separation from the parent, eye contact, and behaviour. Use a quiet space, build rapport, and for an adolescent secure time alone with a stated confidentiality line before any sensitive question. [8]

Examiner: Give me the seven domains in order. [7]

Strong answer: Appearance and behaviour, speech, mood and affect, thought (form and content), perception, cognition, and insight and judgment. For each, state what you observe: mood the subjective sustained state, affect the observed expression; thought form the flow, thought content what is thought about. [7]

Branch 2 — Developmental adaptation

Examiner: How does the method change for a four-year-old? [8]

Strong answer: A preschool child cannot reliably report inner states in words, so the examination rests on structured play, behavioural observation, and parent collateral. Read affect from what the child does, observe separation and reunion, and treat the parent as the primary historian. The domains stay the same; the route into them shifts from interview to play. [8]

Examiner: And for the 14-year-old? [8]

Strong answer: Secure time alone, state the confidentiality line, then use open questions and brief validated screens. Ask directly about mood and suicide, because direct questions reduce rather than raise risk. The elicited domains — thought content, perception, insight — come fully into play here. [8]

Branch 3 — Screens

Examiner: Which brief screens do you integrate, and what does each detect? [5]

Strong answer: The SDQ is a broad behavioural screen across emotional, conduct, hyperactivity, peer and prosocial domains, with parent, teacher and self-report versions. The PHQ-A screens depression severity; the USPSTF recommends screening adolescents 12 to 18 years for depression. The GAD-7 screens anxiety. The C-SSRS structures suicide-risk assessment, and CRAFFT screens adolescent substance use. Each is a prompt for deeper assessment, not a diagnosis. [1] [2] [3] [5]

Branch 4 — A positive mood and suicide finding

Examiner: The 15-year-old's depression screen is positive, and she describes passive thoughts of death. What do you do? [6] [5]

Strong answer: Do not file for later. Perform a same-visit suicide-risk assessment — ideation, plan, intent, access to means, prior attempts, protective factors, and whether she can stay safe tonight. Decide between a crisis pathway for high risk and early review with a written safety plan for lower risk. A delayed psychology referral is not safe for a young person with active intent. [5] [6]

Examiner: She discloses a plan and intent for tonight and begs you not to tell anyone. [6]

Strong answer: Active intent is a confidentiality override. Secure immediate safety, do not leave her alone, use the local crisis pathway, explain what must be shared and why, and share the minimum necessary while preserving her dignity and future trust. Do not keep an unsafe promise of secrecy. [6]

Branch 5 — A medical mimic

Examiner: A 12-year-old is agitated and disorientated with fluctuating consciousness. Is this a primary psychiatric presentation? [7]

Strong answer: No — treat any acute cognitive change with fluctuating consciousness as delirium or an organic cause until proven otherwise. Stabilise, exclude infection, metabolic disturbance, intoxication and a neurological event, and only then attribute the picture to a primary psychiatric disorder. [7]

Branch 6 — Confidentiality and systems

Examiner: The sensitive note will show on the parent's portal. [8]

Strong answer: Open-notes and portal transparency are a modern confidentiality risk. Use sensitive-note workflows, confidential contact details, and billing codes that do not betray content, and know your local portal controls. [8]

Examiner extras

• Observe before you interview — the first seconds are the most honest data. [8]
• Record the MSE descriptively; keep the formulation separate. [7]
• Isolated perceptual experiences in children are common and usually transient. [7]
• Capacity and confidentiality are assessed issue-by-issue, not by a single age. [8]