Must use psychiatric evaluation template. google the above to watch the video. Document the following for the family in the video, using the Comprehensive Evaluation Note Template: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.
Psychiatric Evaluation Template:
Comprehensive Evaluation Note Template
Date of Evaluation: [insert date]
Client Information:
Name: [insert client’s name]
Age: [insert client’s age]
Gender: [insert client’s gender]
Marital Status: [insert client’s marital status]
Occupation: [insert client’s occupation]
Presenting Problem:
The family presented with concerns about their child’s behavior. The child is exhibiting symptoms of aggression, difficulty concentrating, and hyperactivity. The parents report that these behaviors have been present for several months and are negatively impacting the child’s daily functioning and academic performance.
History of Presenting Problem:
According to the information provided in the video, the child’s behaviors are primarily observed at home and at school. The child is reported to have difficulty following instructions, frequent outbursts of anger, and displays hyperactive and impulsive behaviors. The duration, frequency, and severity of these symptoms have not been clearly specified in the video.
Developmental History:
The video lacks explicit information about the child’s developmental milestones. However, it is essential to gather information about the child’s early development, including motor skills, language acquisition, and social interactions. This information helps to establish a baseline for comparison and identify potential developmental delays or disorders that may contribute to the current symptoms. It would be important to obtain this information through parent interviews and reviewing developmental records or assessments, if available.
Medical History:
The video provided minimal information about the child’s medical history. However, it is crucial to gather information regarding the child’s overall physical health, any past or current medical conditions, medication use, and any history of head injury or seizures. This information is important as certain medical conditions or medications could contribute to or mimic the symptoms observed in the child. Gathering this information can be done through a comprehensive medical records review, discussion with the parents, and coordination with other healthcare providers involved in the child’s care.
Family History:
The video briefly mentioned that there is a family history of attention-deficit/hyperactivity disorder (ADHD), but no further details were provided. It is essential to gather a comprehensive family history, including mental health disorders, substance abuse, and any other relevant genetic or environmental factors. This information helps in understanding potential risk factors and patterns of inheritance. Additional information can be gathered through a detailed interview with the parents and collateral interviews, if necessary.
Educational History:
The video indicated that the child’s academic performance is being impacted by their behavioral symptoms. However, specific information about the child’s educational history, including their academic achievements, learning strengths, and challenges, was not provided. It is crucial to gather this information to assess the child’s cognitive abilities and determine if there are any specific learning disabilities or difficulties that need to be addressed. This information can be obtained through discussion with the parents and coordination with the school or educational professionals involved.
Social History:
The video did not provide information regarding the child’s social environment, such as their relationships with peers, participation in extracurricular activities, and family dynamics. Understanding the child’s social context is important as it can contribute to the development and persistence of behavioral symptoms. This information can be gathered through discussions with the parents and potentially involving other family members or professionals involved in the child’s social life.
Mental Status Examination:
The video did not include a comprehensive description of the child’s mental status. However, a thorough mental status examination is an essential component of the evaluation. This examination includes assessing the child’s appearance, behavior, speech, mood, affect, thought content, thought process, cognition, insight, and judgment. Performing a mental status examination involves a direct interaction with the child and gathering information about their subjective experiences.
Summary and Diagnostic Impressions:
Based on the limited information provided in the video, the child’s symptoms are consistent with a possible diagnosis of attention-deficit/hyperactivity disorder (ADHD). However, this preliminary impression should be confirmed through a comprehensive assessment, including further clinical interviews, collateral information, and psychological testing to rule out other potential mental health or developmental disorders. Additional information can also be obtained through observations and discussions with educators and other professionals involved in the child’s care.
Plan:
Given the limited information available in the video, it is recommended to further evaluate the child to establish a definitive diagnosis. This will involve conducting comprehensive clinical interviews with the child and their parents, gathering additional collateral information, and considering psychological testing if indicated. A referral to a child psychiatrist or a mental health professional with expertise in pediatric assessments may be appropriate. Treatment planning will be based on a comprehensive assessment, which will help determine appropriate interventions, such as therapy, behavior management strategies, and potential medication interventions. Coordination with the child’s school and other key stakeholders will also be important for implementing a comprehensive treatment plan.