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Pediatric Psychiatrist’s Intake Note on Adolescent Report (Assessment)

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Updated: May 19th, 2021

Background Information

The patient is a 16-year-old female who lives with her mother, an elder brother (aged 22), and a younger sister who is 10. She is seeking treatment to address emotional discord and impulsivity. Her parents note the following concerns: absentmindedness, suspected hyperactivity, memory problems, and learning difficulties.

Chief Complaint

The main presenting problem entails emotional discord and poor impulse control that has persisted for the last five months. She also displays attention deficit and signs of hyperactivity. Additionally, the subjective data obtained through the parent interview indicate that the client grapples with attachment and self-esteem. She also struggles with interpersonal relationships at school.

Mental Status Exam

The assessment results (objective data) indicate an absence of impairment. However, the patient exhibits symptoms of psychomotor agitation, intense anger, distraction, and dramatic behavior. The client’s current mental status data are shown below.

  • Physical appearance: Appropriate
  • Dress: Appropriate
  • Psychomotor activity: Signs of exaggerated agitation/restlessness
  • Insight: Low
  • Judgment: Fair
  • Affect: Appropriate
  • Mood: Intense anger
  • Orientation: Oriented x3, i.e., responsiveness and knowledge of “person, place, and time” (Pierce, Kaczor, & Thompson, 2014, p. 15).
  • Memory: Intact
  • Attention: Easily distracted
  • Thought Content: Age appropriate
  • Perception: Average
  • The Flow of Thought: Average
  • Interview Behavior: Overdramatic
  • Speech: Normal

Social Information

In childhood, the social environment is a significant predictor of a child’s wellbeing. According to Pierce et al. (2014), adverse experiences, including maltreatment in early years, are associated with low health outcomes and psychological problems later in life. Therefore, screening is essential to determine the child’s social needs and address them.

For this case, the client, her parents, and siblings live in a suburban family house. The primary caregiver is the mother. The father visits only for a few days monthly owing to a demanding career. The mother drinks and has a history of substance abuse. The family owns a pet (a dog). The client is in the sixth grade, and she is an average student. She struggles with memory problems and learning difficulties that are reflected in her poor grades.

She also grapples with interpersonal relationships with her parents, siblings, and a small circle of friends. She describes her bond with family members as warm. She is an active church member (Catholic). The client reports that her problems started when the family moved to a new neighborhood. She feels ‘misplaced’ at her new school. She denies ever using drugs, smoking, or drinking. The client considers her family to be very supportive.

Medical and Mental Health History

Medical History

The client has no significant medical conditions. Based on subjective data (parent interview), she had no reported complications at birth. She achieved the main developmental milestones at the appropriate age, except speech. She was diagnosed with dyslexia at the age of three. Her visual and hearing acuities are normal. She is not under any prescription drugs for major conditions. However, she experiences occasional migraines for which she takes aspirin.

She has no history of hospitalization nor any drug allergies. The initial interview session also revealed that the client has some learning difficulties. For example, she was enrolled in the literacy remediation program for the last three years to improve her reading skills. Further, according to the mother, she experienced delayed speech for which she received speech-language therapy. She repeated pre-primary because she was not prepared for grade 1.

Mental Health History

The client has a family history of poor impulse control. Her mother struggled with depressed moods as a child. The client first used therapy services at school when aged three years because of the inability to control impulses and maintain focus in class. However, after a few weeks, she refused to engage. According to the mother, she exhibits verbal and physical aggression and undesirable behaviors, such as dishonesty and theft. The client has not been diagnosed with a mental condition requiring hospitalization. She often makes suicidal pronouncements, but there is no reported attempt. However, at one time, she engaged in self-cutting.

Diagnosis

From the objective and subjective data above, two DSM 5 diagnoses can be made for the client. The first one is the adjustment disorder with a disturbance of conduct (F43.24) because of “emotional or behavioral symptoms” related to exposure to specific stressors happening “within three months” (American Psychiatric Association [APA], 2013, p. 8). The second diagnosis is the unspecified bipolar and related disorder (F31.9). Based on the DSM-5, this diagnostic category manifests as a bipolar-like presentation but does not meet the full criteria for bipolar disorders (APA, 2013). The client’s symptoms informed the two diagnoses.

Adjustment disorder with a disturbance of conduct requires two fundamental criteria: exaggerated distress with overreactions to a stressor significant functional impairment linked to the stimulus (APA, 2013). In the present case, the client identifies the relocation of the family to a new home, forcing her to change school, as the source of her problems. Therefore, moving is a possible stressor. However, its severity is low, and thus, does not warrant a posttraumatic stress disorder diagnosis. The DSM 5 further stipulates that to diagnose adjustment disorder, the distress must not result from preexisting psychiatric conditions or bereavement (APA, 2013). From the information obtained, the client has no history of mental illness nor has she lost a loved one recently.

Patient responses to stressors vary among individuals. Anxiety and fear are the most frequent symptoms. However, other people may experience a loss of interest in social activities, low mood, and aggression (Severus & Bauer, 2013). Therefore, the client’s anger and irritability represent her reactions to the moving of her family and the enrollment in a new school. Further, her attachment problems (emotional discord) and low self-esteem can be as a result of a loss of interest in social activities and relationships. The mild severity of the stressors informed the diagnosis of adjustment disorder.

The unspecified bipolar and related disorder is detected when the symptoms are insufficient to make a definitive diagnosis. According to the APA (2013), the criteria for inclusion entail short episodes of mania, depression, and hypomania and presence of bipolar symptoms that are linked to substance use or neurological conditions. The client’s manic/hypomanic features (absentmindedness, hyperactivity, and impulsivity) indicate an unspecified bipolar and related disorder.

She also has a history of dyslexia and delayed speech, which are childhood disorders of the nervous system. Since the client denies drug, alcohol, and tobacco use, her symptoms may not be attributed to substance abuse but a neurological basis. The DSM-5 criteria incorporate the nature (manic, depressive, or both) and severity of the episodes into the diagnosis of the unspecified bipolar and related disorder (Kaltenboeck, Winkler, & Kasper, 2016). Further, the mental status exam indicates that the client displays exaggerated agitation, intense anger, and distraction, which may be responses to environmental stressors identified above.

References

American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Kaltenboeck, A., Winkler, D., & Kasper, S. (2016). Bipolar and related disorders in DSM-5 and ICD-10. CNS Spectrum, 21(4), 318-323. Web.

Pierce, M. C., Kaczor, K., & Thompson, R. (2014). Bringing back the social history. Pediatric Clinics of North America, 61(5), 889-906. Web.

Severus, E., & Bauer, M. (2013). Diagnosing bipolar disorders in DSM-5. International Journal of Bipolar Disorders, 1, 14-16. Web.

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IvyPanda. (2021, May 19). Pediatric Psychiatrist's Intake Note on Adolescent. Retrieved from https://ivypanda.com/essays/pediatric-psychiatrists-intake-note-on-adolescent/

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"Pediatric Psychiatrist's Intake Note on Adolescent." IvyPanda, 19 May 2021, ivypanda.com/essays/pediatric-psychiatrists-intake-note-on-adolescent/.

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IvyPanda. "Pediatric Psychiatrist's Intake Note on Adolescent." May 19, 2021. https://ivypanda.com/essays/pediatric-psychiatrists-intake-note-on-adolescent/.

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IvyPanda. 2021. "Pediatric Psychiatrist's Intake Note on Adolescent." May 19, 2021. https://ivypanda.com/essays/pediatric-psychiatrists-intake-note-on-adolescent/.

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IvyPanda. (2021) 'Pediatric Psychiatrist's Intake Note on Adolescent'. 19 May.

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