Essay Instructions: Above, there is psychiatric evaluation and a questionary is fallowed by, the questions has to be answered after reading the evaluation:
PSYCHIATRIC EVALUATION
Name: Adam Smithone
DOB: 06/14/94
DOE: 06/12/08 and 06/17/08
Location: Vernia Treatment Facility
IDENTIFYING INFORMATION:
Adam is a 14 year old Caucasian male who lives in Penn City with his biological parents. He is an only child. Adam was transferred to the Vernia Treatment Facility from the Penn City Shelter on 5/04/08.
Adam was admitted to Green Glen Behavioral Hospital on 3/14/08 after he had a severe tantrum at home which ended up with Adam becoming physically aggressive with his father. He hit his father in the face. Adam’ mother did not agree with the discharge planning recommended by the psychiatrist at Green Glen Hospital, and Children and Youth Services took temporary legal and physical custody of Adam.
Adam has severe behavioral problems at home. His behavior has been deteriorating over the past year. Adam is extremely labile, unpredictable and explosive at home. He is constantly on the internet surfing pornographic websites. He used a webcam to expose himself to a girl in Eugene, Oregon. He is sexually inappropriate with his mother. He has tried to fondle her breasts, asked her to help him with sex, and has tried to peek in her bedroom bathroom. Adam masturbates around the house and on top of the stereo.
Thus far at the Vernia Treatment Facility Adam’ behavior has been good. He has achieved the green behavioral level (the highest level of stability). There was one incident where Adam made an inappropriate sexual comment to a peer, but other than that he has done well. Adam is not extremely hyperactive, however, during a family interview Adam was very fidgety and this seemed to be a manipulative act to get his parents to give him candy and attention.
REASON FOR PSYCHIATRIC EVALUATION
Adam was referred for a psychiatric evaluation to assess his current medications, give diagnostic impressions, treatment recommendations, and to determine whether a residential treatment facility level of care is necessary.
RELEVANT INFORMATION:
1. Strengths
Adam is a very personable young man.
Adam’ family is supportive and wants him home with them when he leaves Vernia TF.
Adam is of normal intelligence.
Adam is in good physical health.
2. Concerns
As stated above, Adam has severe problems with impulse control at home. He is sexually inappropriate with his mother. He has no respect for elders or authority.
Adam is very manipulative and constantly tries to control people in his environment. He does not take “no” for an answer, will not listen to any feedback, and insists on having his own way at all times.
When Adam was 11 years old he accused his mother of sexual abuse. He was placed in the Sanctuary Foster Home. When he got out of Sanctuary, his mother felt that Adam was sexually inappropriate with her. The family is afraid of Adam and his aggression and mood swings.
Adam has had several inpatient psychiatric admissions, family-based mental health services, wrap-around services, partial hospitalization program admissions, and has had a prior residential placement. Despite this intensive treatment history, Adam continues to have significant behavioral problems.
The mother suffers from Bipolar Disorder. She was involved in a motor vehicle accident which adversely affected her short term memory. The mother also has Crohn’s Disease. The father is physically disabled with pancreatitis and heart and back problems.
3. Family
Adam has controlled his family for years with his behavior, mood swings and manipulation. His parents are both frail physically. As stated above, mother has Crohn’s Disease and brain damage and father has heart disease and pancreatitis. Adam was in control of the household until approximately one year ago when his mobile therapist began working with the parents to gain control and work on parenting skills. When this service began, Adam’ behavior deteriorated in the home. Adam is extremely narcissistic and he believes that everything should be catered to him. This situation deteriorated to the point where Adam became physically aggressive with his father and was placed in Penn City Shelter.
The mother was involved in Adam’ Treatment Team meeting held 5/17/08. She was very affectionate with her son and made sure to tell him that she loved him several times during the meeting. The mother exhibits some memory problems. The mother is treated by Dr. Momsdoc and is on Elavil and Buspar. On her family’s side, her mother reportedly was diagnosed with Mania / Schizophrenia and had several psychiatric admissions. The mother’s father was diagnosed with Post Traumatic Stress Disorder. The biological father is on Trazodone for depression and for help with sleep.
4. Education:
Adam was attending Penn City High School in the 9th grade in emotional support classes prior to his psychiatric admission. He is doing well at the Vernia Treatment Facility Home School. He is not disruptive. He appears able to focus and concentrate, although he complains that he needs medicine to improve his focus and concentration.
5. Community:
As stated previously, Adam spends a lot of time surfing pornographic websites. He used a webcam to expose himself to a girl in Eugene, Oregon. He believes this girl is 14 years old. He calls her, writes letters, and chats with the girl. His mother is concerned that he will run away to Oregon to be with this girl. Other than this relationship, Adam does not have friends and tends to be socially isolated.
6. Drugs and Alcohol:
Adam denies drug or alcohol abuse. Written records do not report any problems with drug or alcohol abuse.
7. Services and Service History:
Adam has had outpatient counseling, family-based mental health services, wrap-around services, inpatient admissions, partial hospitalization program admissions, and residential placement in 2007.
Adam has been diagnosed with ADHD, Oppositional Defiant Disorder, and Bipolar Disorder.
8. Medical:
Adam has no significant medical problems and no known drug allergies.
9. Legal:
Adam is currently under the custody of Vernia Treatment Facility.
INTERVIEW:
Adam is a slightly disheveled 14 year old Caucasian male who looks his stated age. He is cooperative with the interview. He maintains good eye contact. For the first part of the interview Adam is somewhat guarded. He then becomes extremely talkative and euphoric. He states that his mood is “fine”. He denies depression. He denies suicidal or homicidal ideation.
Adam speaks quickly. His thought processes are tangential. He mumbles.
Adam fidgets in his seat. He is somewhat distractible. Adam notices everything in the office. For example, when this examiner calls his mother for permission to start a new psychotropic medication, Adam notices that she did not press a “1” on the telephone.
Adam tries his best to be ingratiating. He appears to be of normal intelligence. Adam denies auditory or visual hallucinations. His sleep and appetite are normal. His judgment is poor.
DISCUSSION:
Adam is a 14 year old boy with a history of severe mood swings, hyper-sexuality, and explosiveness consistent with Bipolar Disorder. In addition to this, there is a family history of Bipolar Disorder.
Adam’ manipulation, inability to listen to rules, and aggressiveness are consistent with Conduct Disorder.
Adam’ fidgetiness and distractibility as well as his impulsivity are consistent with ADHD.
Adam’ hyper-sexuality, sexual molestation of his mother, and sexual preoccupation is extremely concerning. He seems to be on his way to becoming a sexual predator.
DIAGNOSIS:
Axis I: 1. Bipolar Disorder, NOS 296.80
2. ADHD
3. Conduct Disorder
4. Sexual Abuse of a Child (perpetrator)
Axis II: Deferred
Axis III: Noncontributory
Axis IV: Stress Level of 5 due to removal from home and chaotic environment, poor social skills, and conflicts with adults.
Axis V: GAF: Current: 45 Past: GAF: 43
RECOMMENDATIONS:
1. Pharmacotherapy. I would recommend starting Adam on Straterra 40 mgs. PO QAM for one week and then 80 mgs. PO QAM thereafter. In approximately one month after the Straterra has begun working I would recommend stopping his Concerta due to concerns that stimulant medication can destabilize Bipolar Disorder.
I would recommend checking a Tegretol level to determine whether Adam’ is within high therapeutic range.
I would recommend increasing Adam’ Geodon to 40 mgs. PO QHS and titrating it upward to help him with aggression and impulse control.
2. Sexuality Evaluation and Treatment. Adam has severe sexual problems and requires an evaluation and treatment of these difficulties.
3. Individual Therapy. Adam requires individual therapy to help him develop coping skills and to stop his constant attempts at manipulating others.
4. Family Therapy. Adam requires family therapy to help his parents take back control of the household and learn how to set reasonable limits and structure without having episodes escalate into violence.
5. Residential treatment facility placement. Adam has severe problems with aggression, impulse control, hyper-sexuality, and oppositionality. Adam requires a residential treatment facility for the safety of himself and others. I would recommend that he remain in The Vernia Treatment Facility program for the next 90 days. This is medically necessary for Adam’ treatment.
QUESTIONS TO ANSWER:
1.) First, describe what is the primary problem. Don't us labels, use descriptions.
What stands out for you in the client's behaviors, thinking, and affect (feelings).
2.) Look at the Axis 1 diagnosis. Does it match your description of what you believe is
the problem. Do you agree with the diagnosis?
3.) Look at the medications; look them up on line. Do they fit the symptoms?
4.) If you were the clinician, counselor, or therapist, what would be the primary issue
you would want to address?
5.) Are there any discrepencies, contradictions, or concerns that stand out for you?
There is no RIGHT answer. This is an exercise in looking at real psychological disorders,
gaining experience in analyzing psycholgical reports, viewing them critically, and
proposing a remedial plan - it always comes down to: "what will you do with the client?"
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