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Running Head: CLIENT HISTORY REPORT DRAFT 1

CLIENT HISTORY REPORT DRAFT 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client History Report Draft

Washburn O Kelly

Psychological Assessment ABS 300 Instructor: Julie Bruno

April 9, 2017

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Identifying Information.

 

Name: Marta Mendez

Age: 13

Sex: Female

Ethnicity: Hispanic

Handedness: Right

Grade Level: Eight Grade (preparing for the 9th Grade)

Parents: Miguel and Maria Mendez

Sibling: Michael Mendez

 

 

II. Reason for referral.

A 13-year-old student by the name of Marta Mendez at the Pearl Harbor Kai Middle School was referred by her School (ACPSTF) Adult and Child Psychological Service Treatment Facility for a psychological assessment for conceivable learning Attention Deficit Hyperactivity Disorder (ADHD). Poor school participation, learning issues, while in participation the child is striving, she becomes irate, resistant, distanced and she seems to be a child with a terrible demeanor are some of the contributing factors that Martha is displaying. The assessment ought to focus on the areas of Martha’s insight, learning forms, scholarly accomplishment and passionate/mental improvement. As indicated by The National Institutes of Health “Hyperactivity Disorder (ADHD) standout amongst the most widely recognized childhood with issues and all children that demonstrate a distinguishable manifestation as they are clinically related.” (NIH 2013). As stated by The American Psychiatric Association (APA) there is 5 percent of American children that are diagnosis with ADHD. Be that has it may the Centers for Disease Control and Prevention (CDC) double the APA’s number. Eleven percent of the American children at the age of 4 through 17 was diagnosis with the disorder.” (APA 2014).

III. Current Symptoms/Presenting Concerns.

Taken from the observation conducted on Martha that shows her learning and behavioral status while testing the legitimacy of her execution and the tests was considered to be exact because of her collaboration and inspiration to play out the tests. Similar behavior took place a year ago and was expressed by Mrs. Mendez who is Martha’s mom at the Silver Lakes Academy, say that Martha’s is lazy, and likes to neglect her chores and regardless of private coaching and facilities from school despite everything she experiences academic challenges all through the school year. Mrs. Mendez ADHDitionally expressed, she didn’t think anything wrong with Marta at that time. Martha’s father was deployed so there was not one to truly assist her with Martha. Marta neglected to assume liability for her activities in school and at home, yet her mother thinks contrastingly and is in concurrence with the school that suggestions have been made to assessed Marta. Dealing with her child’s behaviors, Maria knows that there are no enchantment methodologies, one of her choices to help her daughter is to give her positive acknowledgment and love. I trust certain strategies tend to work best with children such as Marta.

Educational History:

Martha is now preparing herself for the ninth grade, no previous grade has been repeated, however her past school participation been unsatisfactory, her capacity to do her classwork has enhanced yet once in a while she finds herself into potential encounters with her classmates or her teacher and when this happens, the teacher helps Marta to maintain a strategic distance from an out and out conflict in a way that permits her to come back to her right mind. “There are numerous student just like Martha that are currently being alienated and think that its hard to interface with the learning procedure, they have low self-regard and are frequently not able to deal with their outrage.” (Vizard 2009).

Occupational History:

Not has yet a full-time student, Martha wants to complete High School and then head off to college and have dreams of becoming a psychologist. Martha was informed on what a Psychologists really does and she was amazed at the detail of its profession. She was informed that a Psychologists help individuals experiencing injury, mental scatters or substance abuse issues. They ADHDitionally work with individual customers like herself to comprehend main drivers and offer treatment for ADHD. A Psychologists may also survey customers on location, or assess school tests for learning disabilities.

 

Medical History:

 

Mrs. Mendez indicated that she was 24 and her husband was 27 at the time of Martha’s birth, she also has an older brother, Michael and he is normal. There was no complications of pregnancy or delivery, her birth weight was normal and Marta is up to date on her yearly physical which was normal. She may get a common cold now and again, the usual childhood illnesses of chickenpox, ear infections etc, she is not currently taking any medications, however they recently found out that one of her dad brother was diagnosis with depression and ADHS after he return from the war in Iraq.

 

Medical History

AT the time of Martha’s birth Mrs. Mendez stated that her husband was at the age of 27 and she was 24, and Martha had an old brother, Michael and he is normal, there were no inconveniences of pregnancy or conveyance. There were no inconveniences of pregnancy or conveyance, her weight was ordinary and Marta is up to date on her yearly physical which was normal. She may get sick once in a while, the standard adolescence diseases of chicken pox, ear contaminations and so on, she is not currently taking any medications, in any case, they as of late discovered that one of her father-siblings was finding with dejection and ADHS after he come back from the war in Iraq.

Psychiatric History:

Utilizing data from different sources, the accompanying domains of how it works was broke down as far as the impact on Marta’s learning and behavior. According to Marta’s clinical profile from (ACPSTF), it demonstrated that there is no detailed psychiatric, medication or substance utilized. Also, her profile demonstrated various genuine conduct issues, for example, school maladjustment and family conflict, then again, she frequently neglects to use her ability to accomplish up to her potential.

Social history:

As stated by Mrs. Mendez (Martha’s Mother) that Martha has a brother that is older than her. Her Brother’s name is Michael and she is a senior and very athletic in school. Miguel Mendez who is Martha’s father is a Sergeant Major in the U.S. Army and Maria Mendez is a Certified Nurse Anesthetist. Martha is from a normal family with no reports of abuse in their home. The assessment focused on the areas of Martha’s knowledge, learning forms, scholastic accomplishment and passionate/mental advancement. the result from (ACPSTF) demonstrated that Marta’s conduct is for self-delight chasing, egotistical and is uncaring to the necessities of others.

Attention deficit disorder (ADHD) is a lack of ability to concentrate consistently scatter with and without hyperactivity, hyperkinetic motivation issue, hyperactive disorder, hyperkinetic response of adolescence, insignificant cerebrum harm, negligible mind brokenness, and undifferentiated shortage issue. unfocused response to what is really going on the world is the outcome of this disorder. Individuals who are experiencing this issue have difficulty in disregarding stimuli that are not significant to the present tasks. The Encyclopedia of Neurological Disorders states that “The neurological signs of ADHD are unsettling influences of what are known as official capacities. In particular, the six official capacities that are influenced incorporate:

• the capacity to sort out thoughts

• the capacity to move through designs

• short-term memory

• the capacity to recognize passionate and intelligent responses

• the capacity to settle on a contemplated choice

• the capacity to set an objective and plan how to approach that objective

 

More than half of the people that are diagnosed with ADHD meet the criteria is set in place by the American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) for no less than one of the accompanying different sicknesses:

 

• learning disorder

• restless leg disorder

• depression

• anxiety disorder

• antisocial conduct

• substance abuse

• obsessive-enthusiastic behavior

 

Ten months beyond the concentrated treatment stage just in symptom domains which will reduce over time is the advantages of intensive MedMgt for ADHD. ADHDitionally, “The MTA pharmaceutical methodology demonstrated holding on huge predominance over Beh and CC for ADHD and oppositional-resistant side effects at 24 months, despite the fact that not as extraordinary as at 14 months. Extra advantages of Combover MedMgt and of Beh over CC was unable the be found. The groups contrasted altogether in mean measurement (methylphenidate reciprocals 30.4, 37.5, 25.7, and 24.0 mg/day, separately) Proceeding with medicine utilize incompletely intervened the holding on the prevalence of Comb and MedMgt. Here we assess the determination of these helpful impacts 10 months past the 14 months of serious meditation.” (AAP).

 

 

 

Reference

 

Adult and Child Psychological Services (2016). Retrieved February 22, 2017 from: https://treatment.psychologytoday.com/rms/prof_detail.php?profid=296856&p=1%20

 

National Institute of Mental Health Multimodal Treatment Study of ADHD Follow-up: 24-Month Outcomes of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Retrieved from: http://pediatrics.aappublications.org/content/113/4/754.short

 

Encyclopedia: Attention Deficit Hyperactivity Disorder-Gale Encyclopedia of Neurological Disorders (2016). Retrieved from: http://www.encyclopedia.com/medicine/psychology/psychology-and-psychiatry/attention-deficit-hyperactivity-disorder

Health line (2014). ADHD by the Numbers: Facts, Statistics, and You. Retrieved from:

http://www.healthline.com/health/adhd/facts-statistics-infographic

 

U.S. Department of Health & Human Services. (2013). Attention Deficit Hyperactivity Disorder (ADHD). Retrieved from: https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=25

 

Vizard, D. (2009). Meeting the Needs: Meeting the Needs of Disaffected Students: Engaging Students with Social, Emotional and Behavioral Difficulties. Retrieved from: http://site.ebrary.com.proxy-library.ashford.edu/lib/ashford/reader.action?docID=10427346 &ppg=10

 

 

 

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