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Case Conceptualization 18 Apr

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Bridgette Bell

on 18 April 2018

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Transcript of Case Conceptualization 18 Apr

Cognitive Factors
Personality Factors
by Bridgette R. Bell, M.S.
18 April 2018

"JR" Case
Conceptualization





DIAGNOSTIC FORMULATION
Identifying Information Presenting Problems
Background & History
Interpersonal Style

CULTURAL FORMULATION
Cultural Factors
Social Factors
Environmental Factors
Personality Factors

CLINICAL FORMULATION
Conceptualization
Assessment Sessions
Theoretical Framework
Presenting Problem
ADHD Symptoms expressed in August 2016

Inattentive behaviors

Failure to complete tasks

Fidgety, unable to sit still at times

Low performance in some academic subjects

Daydreaming and “drifting off”

Parents noted issues completing house work and homework; youngest sibling able to focus better

Background & History
FAMILY HISTORY
From Mississippi
Mother expressed both she her brother may have undiagnosed ADHD.
Mother also had postpartum depression with their second child.
A paternal cousin on her father's side has been diagnosed with ADHD and is on medication.

LEGAL HISTORY - Not applicable

SOCIAL HISTORY
Good relationships with her friends and being
Able to meet and get to know other students in school

WORK HISTORY - Not applicable


Identifying Information
Emotional Factors
Typical or most common emotional states - flat, low affect

Mood during interview/sessions - Calm

Appropriateness of affect - expected to be more visible

Range of emotions the client has the capacity to display - within normal limits: calmness, frustration, excitement, humor

Cyclical aspects of the client’s emotional life - not observed
Behavioral Factors
Level of insight - high, client is very self-aware

Capacity for judgment - low, due to life experience and desire to not repeat past mistakes

Mental alertness - high, except when sleep-deprived

Persistence of negative cognitions - moderate (to parents)

Positive cognitions - low

Nature and content of fantasy life - not observed or discussed
Psychosomatic symptoms
Fatigue

No other physical related symptoms

No existence of persistent habits or mannerisms

Abnormal eating patterns - none, would like to try losing weight

Conclusion
- Would benefit from organizational skills training and study skills development as she continues to progress through high school.

- May benefit from continuing tutoring in math skills, particularly in the areas of long division, fractions, algebra.

- Should sit towards the front of the classroom or closest to the teacher in order to address attention skills during
instruction.

- Based on recommendations, may benefit from a more structured learning and homework environment and behavior modification to improve organizational skills.

- Recommend re-evaluation of symptoms in Fall 2018.
Other Considerations
Ethical

Risk Management

Parents/Confidentiality

Age
EDUCATION HISTORY
Mother noticed issues early on, but did not want to be overly sensitive to what she sees as a teacher
Struggled in 8th grade

MENTAL HEALTH HISTORY
No history reported

MEDICAL HISTORY
Takes allergy medication (Zycal 1 pill in 24 hours when necessary)
No other medical issues

SUBSTANCE ABUSE/USE HISTORY
Tried alcohol over the summer.

Parent and teacher reports are not consistent across the board, but some of the symptoms are present in various environments.

The teachers reports were not in the clinical range but elevated in inattentiveness; more elevated in math.

Parent and self reports were consistent and in the clinical range.

This is a provisional diagnosis because with more feedback from more teachers this semester we would be able determine with more certainty. There is consistency between the parents reports and the self report information.


TREATMENT FORMULATION
Diagnosis
Differential Diagnosis
Considerations

CONCLUSIONS
AGENDA

Clinical Intake Interview - 9/15/2017

Mini-Mental Status Examination (MMSE) - 9/15/2017

Beck Youth Inventory - 9/15/2017

Weschler Intelligence Scale for Children, Fifth Edition (WISC-V) - 10/03/2017

Continuous Performance Test 3rd Edition (CPT3) - 10/31/2017

Weschler Individual Achievement Test - Third Edition (WIAT-III) - 11/08/2017

Child Behavior Checklist for Ages 6-18 - October 2017

Teacher􀂶s Report Form for Ages 6-18 - October 2017
DIAGNOSTIC FORMULATION
14-year-old African American female

Junior High School Freshman

Lives with parents and two younger sisters

Normal physical appearance; Dressed appropriately in school attire

Generally presented low energy; Pleasant disposition

Interpersonal Style
Parents describe her as clingy with them; Very family dependent, strong attachment to parents was evident in testing
Friendly to others, no issue making friends
Positive interactions with the therapist
Welcoming disposition, though reserved
Dominance vs. Submission - appropriate with authority figures; fights with middle sister
Love vs. Hate - choose to be pleasant -> indicates loving
Manifestation in Testing
Positive therapeutic dyad
Lack of motivation was not evident
Based on presenting problem, positive attitude towards testing made me consider other issues

CULTURAL FORMULATION
Social Factors
Environmental Factors
Cultural Factors
Theoretical Framework
CLINICAL FORMULATION
Conceptualization
Assessment Sessions
TREATMENT FORMULATION
Differential Diagnosis
Diagnosis
Parents delayed getting child tested many years, does not indicate drug-seeking or diagnosis-seeking

Common Themes
Failure to complete work
Needing to be closely supervised
Forgetful in work and home
Easily distracted
Struggling academically

Working Thesis: Not ADHD
Client is unable to overcome academic and behavioral deficits with tutoring or additional help from parents;
client may meet the criteria for ADHD but there may be a need to address behavioral issues not fully associate with diagnosis
(discipline, personal choice, etc.)


Biopsychosocial Model
- Parent's disciplinary practices may not effectively promote structure needed for high school workload
- Client seemed positive towards some areas during testing, did not struggle with stress associated with attentiveness
- School priorities have shifted -> client likes band and prioritizes
extracurricular activities over
sudying
- Reported best friend was diagnosed and they have similar symptoms
- May have learning disability in math areas
- Parents reported tutoring was not helping
- Allergy medication may lower energy level
-Genetic disposition for inheriting ADHD (Family history)
- African-American family system

- Child order

- Gender differences (boys more likely to exhibit ADHD symptoms than girls)
- School environment vs home environment

- Social pressures associated with achievement

- Long-term life and career planning
- Impact of band culture on schedule/sleep

- New school

- Resources for family, SES/financial needs, school opportunities
Of the nine criteria for moderate ADHD Inattentive Type has met 7 for at least 6 months:
1) often fails to give close attention to detail or makes mistakes
2) often has difficulty sustaining attention in tasks or activities
3) often does not follow through on instructions and fails to finish schoolwork
4) is often forgetful in daily activities
5) often has difficulty organizing tasks and activities
6) often dislikes tasks that require sustained mental effort (particularly in math)
7) easily distracted by extraneous stimuli.
WISC
WIAT
Specific Learning Disability
Dislexia - essay composition, but ruled out due to score
Discalculia - math grades and scored, but ruled out due to student scoring error
Theoretical Framework
Biopsychosocial Model
- Parent's disciplinary practices may not effectively promote structure needed for high school workload
- Client seemed positive towards some areas during testing, did not struggle with stress associated with attentiveness
- School priorities have shifted -> client likes band and prioritizes
extracurricular activities over
sudying
- Reported best friend was diagnosed and they have similar symptoms
- May have learning disability in math areas
- Parents reported tutoring was not helping
- Allergy medication may lower energy level
-Genetic disposition for inheriting ADHD (Family history)
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