Please include the following:
1) relevant information about your client and their environment, including level of functioning, relationships with family and friends, level of support related to the home, school and neighborhood environment, cultural considerations and socioeconomic status.
2) DSM-5 diagnosis and specific symptoms related to this
3) family members and how they have been impacted by the client’s diagnosis, their level of understanding of this diagnosis, their ability to cope with it, and their ability to help the client cope.
4) a treatment plan with effective treatment strategies (goals, objectives) and what the family and school can do to help.
Daphne, a 13-year-old in the ninth grade, was brought for a psychiatric evaluation because of academic and behavioral struggles. She had particular difficulty starting and completing schoolwork and following instructions, and she had received failing grades in math. When prompted to complete tasks, Daphne became argumentative and irritable. She had become increasingly resistant to attending school, asking to stay home with her mother.
Testing indicated that Daphne had above-average intelligence, age-appropriate achievement in all subjects except math, and some difficulties in spatial-visual skills. Several years earlier, her pediatrician had diagnosed attention-deficit/hyperactivity disorder (ADHD) and prescribed a stimulant. She took the medication for a week, but her parents stopped giving it to her because she seemed agitated.
At home, Daphne’s parents’ close supervision of her homework often led to arguments with crying and screaming. She had two long-standing friends but had made no new friends for several years. Generally, she preferred to play with girls younger than she. When her friends chose the activity or did not follow her rules, she tended to withdraw. She was generally quiet in groups and in school but bolder with family members.
Beginning in early childhood, Daphne had had difficulty falling asleep, requiring a nightlight and parental reassurance. Recognizing that Daphne was easily upset by change, her parents rarely forced her into new activities. She did well during the summer, which she spent at a lake house with her grandparents. Her parents reported no particular traumas, stressors, or medical or developmental problems. Daphne had started her menses about 2 months prior to the evaluation. Her family history was pertinent for multiple first- and second-degree relatives with mood, anxiety, or learning disorders.
At first meeting, Daphne was shy and tense. Her eye contact was poor, and she had difficulty talking about anything other than her plastic horse collection. Within 15 minutes, she became more comfortable, revealing that she disliked school because the work was hard and the other children did not seem to care for her. She said that she was afraid of making mistakes and getting bad grades and of disappointing her teachers and parents. Preoccupation with earlier failures led to inattention and indecision. Daphne denied that she was good at anything and that any aspect of her life was going well. She wished she had more friends. As far as she could remember, she had always felt this way. These things made her sad, but she denied persistent depressive feelings or suicidal thoughts. She appeared anxious but brightened when discussing her horse figurine collection and her family.
Please include the following: