Purdue University Depression Disorder Treatment Plan Template Project

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Child / Adolescent Psychiatric Evaluation

Identifying information: Blake is a 10-year-old male in 5^th grade at Frostburg Elementary School. He lives with his mother (Stephanie, 35), step-father (Tony, 38), full sister (Carly, 8), and maternal half-brother (Hunter, 3).

Information sources: Blake’s subjective report. Stephanie’s subjective report.

CC: Anxiety.

HPI: Blake and his mother presented on time for the initial psychiatric evaluation. Both were cooperative and participative in the interview.

Blake and Stephanie were interviewed together. Stephanie reports that Blake was diagnosed with ASD at age 3. He was referred to Kennedy Krieger Center for Autism and Related Disorders for diagnosis confirmation and recommendations for management/treatment. Mother states that they had early intervention services through age 5 which included speech therapy, occupational therapy, and small group social skills therapy, which was very helpful. Blake has always been extremely bright. IQ test completed last school year showed IQ of 121. He could read before he started kindergarten and has always excelled academically.

Blake was diagnosed with comorbid ADHD, mixed type at around the age of 5 by Kennedy Krieger. He has been on stimulants for the last 5 years for ADHD symptom management. Mother notes that medications have been extremely helpful in managing ADHD symptoms, though they are not without their drawbacks. Blake is currently prescribed Vyvanse 80mg PO Qam and Adderall 10mg PO daily after school by his previous pediatrician [his mother is switching to your office because of insurance reasons]. Mother brought in his report cards for the last two years. Grades have been straight As, with the exception of one B in art. Mother reports that he takes both Vyvanse and Adderall daily, including on the weekends and during school breaks. “It is light night and day on the medications. It is a struggle if he misses even one dose”. She states that symptoms of inattention, hyperactivity and impulsivity are noticeable if a dose is missed. Stephanie states that Blake did experience insomnia as a SE of the stimulants. Currently, Blake is prescribed trazodone 50mg PO Qhs. Stephanie says that this works well most nights. He is consistently at the 17^th percentile for height and weight. He denies other SE related to stimulant use.

Stephanie was interviewed alone. Today, she has concerns about Blake’s anxiety. She states that over the last six months or so, Blake has started to exhibit anxiety and excessive worry that has been difficult to manage with behavioral interventions. He “talks a lot about not wanting to die”. Stephanie states that he has consistently brought up concerns about dying and fear of dying, especially in the evenings before bed. He has been worrying about his mother and step-father’s health and the health of his siblings also. He has been spending quite a bit of time online looking up different illnesses and their symptoms. He will frequently tell his mother that he thinks he has the beginning of one illness or another. He has been increasingly concerned about his school performance. Though his work is exemplary, Stephanie feels that he has developed “perfectionism tendencies”. He will be extremely self-critical if he does not get 100% on assignments and tests. He will call himself “dumb” and “stupid” when he makes little mistakes. He will make comments about not being able to “make it in college” and “doesn’t want to turn out to be a disappointment in life”. As a result, Stephanie says that she feels that Blake is often “on edge”. He has been reporting more vague headaches and stomach aches than he ever has in the past. Stephanie has encouraged Blake to journal his feelings and his worries, which he has done – but this seems to have further increased his worry.

Blake was interviewed alone. He explains that he just feels “nervous” most of the time and is very worried about his health and the health of his family. He states that this started after finding out that his maternal GF had a heart attack about 8 months ago. He tells you that he is very afraid of dying and doesn’t want to die. He is fearful that his parents and siblings are going to die. Sometimes, the nervousness gets so bad that it “makes me feel sick”. He cannot identify any aggravating factors or alleviating factors. He doesn’t like how he feels. Blake notes that he does feel “sad” sometimes, but mainly scared and worried. He denies SI and passive death wish. “I’m afraid of dying”. He denies psychosis, paranoia, panic-related symptoms, obsessions-compulsions as defined by DSM-5, and HI.

Mental status:

Appearance: Casually and appropriately dressed and groomed.

Affect: Mood congruent. Extremely restricted range, typical for ASD.

Eye contact: Intermittent and appropriate.

Attitude/Behavior: Cooperative and participative.

Speech: Normal rate and tone of clearly articulated speech

Mood: Anxious

Thought process: Organized. Linear. Age-appropriate

Thought content: excessive worries about health and death of self and family members

Suicidal ideation, plan, intent: denies

Passive death wish: denies

Homicidal ideation, plan, intent: denies

Perception: WNL

Orientation: A&O x 3

Memory: Recent and remote intact

Concentration/Attention: excellent

Insight: fair

Judgment: good

Past psychiatric history: Blake has never had an inpatient psychiatric hospitalization. He did receive outpatient ASD services with Kennedy Krieger from ages 3-7, which included medication management for comorbid ADHD, mixed type. He has been receiving psychiatric medication management through his previous pediatrician’s office for the last 3 years.

Denies lifetime suicide attempts, suicidal threats/gestures, and self-injurious behavior.

Psychiatric medication history:

Concerta – maxed at 54mg/day. Ineffective for ADHD symptoms.

Daytrana patch – maxed at 30mg/day. Ineffective for ADHD symptoms

Melatonin – tried up to 5mg/night. Ineffective for insomnia

Family psychiatric history:

Mother – GAD, depression (Effexor XR 150mg PO daily, buspar 15mg PO BID, klonopin 0.25mg PO daily prn severe anxiety, trazodone 100mg PO Qhs)

Father – committed suicide (unknown MH history/treatment)

Maternal GM – panic disorder, GAD (nortriptyline 75mg daily, Ativan 1mg PO TID)

Maternal aunt – GAD, MDD (Effexor XR 225mg PO daily, abilify 5mg PO daily, ambien 5mg PO Qhs, Ativan 1mg PO BID)

Maternal cousin – OCD (luvox 150mg PO daily, klonopin 0.5mg PO BID)

Past medical/surgical history: none

PCP: Your name, FNP

Allergies to medications: NKDA

Current prescription and non-prescription medications:

Vyvanse 80mg PO Qam

Adderall 10mg PO Q afternoon

Trazodone 50mg PO Qhs

MVI PO daily

Developmental history:

Hx of pre, peri post natal complications: Mother reports uneventful pregnancy, but difficult and traumatic delivery. States that she was not fully dilated when asked to start pushing. States that Blake was “stuck” and began to experience fetal distress. Was delivered via emergency c-section. Purdue University Depression Disorder Treatment Plan Template Project

Known developmental delays: had early intervention services for some speech and fine motor delays noted, in conjunction with ASD diagnosis. Excels academically. IQ 121.

Caregivers in childhood and quality of relationships: Raised by biological mother and father until father’s suicide when he was 3 years old. Mother states that father was never diagnosed or treated, but she suspected “maybe depression or bipolar”. He shot himself in the family home when mother, Blake and his sister were visiting her parents. Mother has not disclosed to the children the nature of their father’s death. Blake has few memories of his father. Mother raised the children alone, then started a relationship with now-husband approximately 5 years ago. Blake gets along with his mother “very well” and with his step-father “pretty good”.

Siblings and quality of relationship(s): One full sister and one half-brother. Typical relationships with both.

Problems in elementary school: Straight A student. Maintained on stimulants throughout for management of ADHD symptoms.

Current academic status: Excellent

Substance use history:

ETOH: denies past/present use

Drug: denies past/present use

Nicotine: denies past/present use

Caffeine: mother restricts use.

Family substance abuse history:

Maternal great GF – alcohol dependence

Maternal uncle – alcohol dependence

Maternal second cousin – alcohol dependence

Legal history: denies

Social history:

Living arrangements: lives with mother, step-father, full sister and half-brother.

Support system: Blake feels like he has an excellent support system. He is very close with his family of origin and his maternal side of the family. He does have contact with one paternal aunt and uncle, as father and both paternal grandparents are deceased. He has one good male friend in school, who also has ASD. He also really likes his robotics team “coach” at school. Purdue University Depression Disorder Treatment Plan Template Project

Religious/spiritual orientation: None identified by the family

Social network: Blake belongs to the robotics team at school. He attends activities twice a week in the evenings related to robotics. He has been involved in sports in the past, but did not care to continue. He also enjoys taking French horn lessons and practicing his instrument.

Trauma history:

ACE = 3 (father died by suicide, likely had undiagnosed mental illness, parents were separated)