Mental Status Examination and Behavioral Observations

 

Confidentiality Disclaimer

Reason for Referral

Identifying information

Developmental History

Medical and Psychiatric History

Short Family and Social History

Short History of School Behavior

Tests Administered

Standardized Instruments

Information Assessment Techniques

Mental Status Examination and Behavioral Observations

Results Form Testing

The following results were obtained with respect to the different domain of functioning of Sebastian based on information from multiple sources.

Cognitive-Intellectual-Executive Functioning

Social-Emotional Functioning

Diagnostic Impression

Confidentiality Disclaimer:

There is a chance that the subject of the report or those who are closely associated with the subject of the report could get psychologically and/or emotionally hurt as the report contains sensitive information about the subject. This report is meant only for people trained enough to read such reports and should not be given to the subject named in the report. In order to ensure that the name of the person who is also the subject of the report is protected, a trained mental health professional should only be the one who should disseminate the report to the subject of this report or to any other individual who is not a trained professional in this field. Liability for any damage that may be caused due to their actions would rest only and wholly with people who release this report.

Sebastian Smith

Gender

Male

Birth Date

5/5/1999

Age

16 years 3-month

Dates of Evaluation

7/17; 7/27/15

Date of Report

8/3/2015

Examiner

Grade

Completed ninth Grade

Reason for Referral

The reason for conducting a psychological evaluation on Sebastian, a 16-year 3 months old Caucasian adolescent, is to find out the current cognitive and emotional status of the individual. Sebastian is troubled with poor school performance for quite some time now for reasons that are not very apparent. He has not been able to perform well despite the school arranging for extensive private tutoring and accommodating the child o many occasions.

According to the preliminary report from the school, poor school attendance, complex family dynamics and possible attending and learning problems are the primary factors that lead to him underperforming in school.

Sources of Information:

Information about Sebastian was got from the ones who ware close to him like his mother, his previous social worker and his former psychologist. Some information was also obtained from his school. Apart from these numerous psychological, educational and medical reports were consulted to link, tally and compare the information and the established facts to come to the conclusion. Medical reports, interview, rating scales and developmental history were the methods to get the information.

The information gathered seemed credible and reliable while observation during testing and standardized psychological, neuropsychological and achievement tests formed the basis for the present state of Sebastian’s learning and behavior. The cooperation and motivation to perform the tests by Sebastian made the validity of his performance on most tests to be accurate.

Background Information:

Identifying information

Sebastian Smith is a 16-year 3 months old Caucasian adolescent who studies in grade 9 and has had problems with his performance at school for quite some time now.

Developmental History

Academic performance and proper social behavior has been the weak points for Sebastian for quite some time now. Sebastian does not enjoy a free flowing relationship with his parents but rather has a complex relationship with both his parents which often leaves him torn between both.

A matter for concern is Sebastian’s ability to maintain motivation in his schoolwork and the study would identify and list recommendations for him. What is most concerning about Sebastian’s condition is his tendency to use of illegal substances or marijuana.

Medical and Psychiatric History:

Sebastian’s mother reported that her child, Sebastian was born without any difficulty through Caesarean section when she was 29 and his father was 31. While the weight of the new born was normal, Sebastian suffered from jaundice as an infant.

There were some medical conditions that he experienced as an infant like sleep difficulties and he rarely slept for more than 2 to 3 hours at a stretch.

For language and gross motor development, the developmental milestones were normal and within the specified range of time for growing children even as Sebastian had a poor appetite as an infant. Sebastian developed bladder and bowel control at night at somewhat later stage in life compared to normal kids. There numerous occasions when Sebastian met with accidents with soccer, skateboard and moped resulting in several broken bones. As a child he has had the usual chickenpox, ear infections and strap throat.

Short Family and Social History:

Sebastian’s mother, serving as an administrative assistant is reported to have no learning or attention problems. However his biological father is unemployed much of the time. It was reported by Mrs. Smith that her husband has been violent on her on a number of occasions until they got divorced. Mrs. Smith is reported to have a history of depression on both sides of the family.

Short History of School Behavior

Sebastian was reported to have low motivation for school achievement and has been troubled with problems related to reading and classroom behavior, as reported by his former teacher. However Sebastian is reported to be creative and has good abstract thinking and understands language well. There are some distinct characteristics in Sebastian that are considered to be harmful such as being nervous and with repetitive habits, being fidgety and restless and has the occasional mood swings. He has a problem with follow through and has difficulty in planning and he does not learn from mistakes as well as being disorganized. However Sebastian fares better in one on one situations. However frustration and depression sets in when Sebastian realizes that he has a problem with his schoolwork. There has been an improvement in the social interactions and his self-confidence is picking up slowly. What is amazing the despite the poor faring in school, Sebastian has shown a flare for compassion and leadership as he responds well to structure and boundaries.

Tests Administered

The assessment of the intelligence, learning processes, academic achievement and emotional and psychological development of Sebastian was done through targeting the domains that govern these functions.

Standardized Instruments:

Weschler Adult Intelligence Scale-Third Edition

Minnesota Multiphasic Personality Inventory — Adolescent Form

Millon Clinical Multiaxial Inventory

Information Assessment Techniques:

Development History Form

Interviews

Primary Sources Inventory

Diagnostic Checklist for AD/HD symptoms

Observation of behavior

Review of the medical reports

Mental Status Examination and Behavioral Observations

Sebastian is a 15-year-old adolescent boy who is reported to be not doing well in school despite all efforts of extra coaching and concessions by the school. During the interview, Sebastian was dressed in formals unlike other adolescents of his age but looked very presentable and averagely impressive.

Sebastian seemed a little distracted during the interview process. He was fidgety and often entwined his fingers or rubbed them unnecessarily. There were obvious indications of lack of concentration o Sebastian’s part as a number of questions had to be repeated during the course of the interview.

It can be said that in general, the mood of Sebastian was positive but appeared to be flat at times. While Sebastian tried to maintain good eye contact during the test sessions, he seemed lost at times which were obvious signs of a lack of concentration. However he interacted quite well socially as is expected from an adolescent of his age. It was thus quite easy to develop a rapport with Sebastian and the conversation was easy and free flowing for most of the time. Often he took cue and started a conversation. While he understood instructions and directions during the tests, Sebastian was also good at following the instructions and leading the instructions. However there were occasions when it seemed that there was lack of motivation in him especially in certain tasks that he took more time to get over with than other ones although all were of the same level of difficulty.

It was ensured that there were no distractions at the testing site and thus it is believed that the results of the evaluation reflected a valid and reliable estimate of Sebastian’s present condition of functioning.

Results Form Testing:

The following results were obtained with respect to the different domain of functioning of Sebastian based on information from multiple sources.

Cognitive-Intellectual-Executive Functioning:

The Weschler Adult Intelligence Scale-Third Edition was used to measure the intellectual potential and cognitive processing abilities of Sebastian. The general intelligence for adults who are over 16 years of age is tested by the WAIS III test.

There are two scales in the test and each of them comprise of 14 subtests. The two scales are – a verbal scale and a performance scale. IQ is the composite of all the subsets. Verbal Comprehension, Processing Speed Working Memory and Perceptual Organization are also measured.

WAIS-III Results

(Index Scores have a Mean of 100 and a Standard Deviation of 15)

Index

IQ

Percentile Rank

Classification

Verbal IQ

77

45.0

50

Performance IQ

85

10.0

35

Verbal Comprehension

95

25.0

40

Perceptual Organization

90

50.0

60

Working Memory

79

18.0

33

Processing Speed

83

35.0

53

Full Scale

84.3

55.0

65

(Subtest Scaled Scores have a Mean of 10 and a Standard Deviation of 3)

Subtest

Scaled Score

Percentile Rank

Classification

Verbal Comprehension

55

Vocabulary

75

Similarities

78

Information

80

Comprehension

77

Perceptual Organization

45

Picture Completion

87

Block Design

85

Matrix Reasoning

83

Picture Arrangement

88

(Object Assembly)

90

Working Memory

35

Arithmetic

78

Digit Span

80

Letter-Number Sequencing

80

Processing Speed

25

Digit-Symbol Coding

79

Symbol Search

75

A measure of the Full Scale IQ (FSIQ) on the WAIS-III that indicates the general cognitive ability of Sebastian has an average range of intellectual functioning (FSIQ=84.3). The reading and thinking abilities of Sebastian was more than those of his same age group by more than 40%. The verbal comprehension, processing speed skills, the working memory and the perceptual reasoning of Sebastian were in coordination with one another and complimented one another as there was no significant difference in his index scores. The general intellectual ability of Sebastian is reflected by the Full Scale IQ score of nearly 85.

Verbal reasoning, concept formation and the knowledge acquired from one’s environment is measured by the Verbal Comprehension Index from the WAIS-III tests.

The range for the verbal problem solving, comprehension, and common sense reasoning tasks for Sebastian was in the 55 range and was better than just 35% of adolescents of his age who have an average score of 58.

Spatial processing, fluid reasoning and visual-motor skills are measured by the Perceptual Organization Index. Sebastian’s performance in this field is in the range of 25 range and betters others of his age by 15% whose standard score is 22.

The ability to attend to verbally presented information, to process and analyze the information in the mind and ten to put the analysis to use is measured by the Working Memory Index. Sebastian scored in the 35 range for his ability to hold information in order to perform a specific task and was found to be less than 20% of his age mates (WMI= 40)

Social-Emotional Functioning

To make an assessment of the current emotional functioning, Sebastian was put through the MMPI test which is essentially a true-false questionnaire that analyses emotional functioning.

MMPI-II Results:

Scale

T-Score

L (Lie)-Scale

F (Infrequency)-Scale

55

K (Correction)-Scale

82

Hysteria Scale

Depression Scale

75

Hypochondriasis Scale

90

Psychopathic Deviant Scale

40

Masculine-Feminine Scale

60

Paranoia Scale

80

Psychasthenia Scale

Schizoprhenia Scale

50

Mania Scale

90

Social Introversion

83

The responses made by Sebastian on the MMPI-2 scale tests show that there is a tendency in him to present himself as one who he is not and an attempt to hid the weaknesses. The relatively high score of 80 on ye paranoia scale indicate that he is worried about what others think of him. Sebastian also tries to present a larger than himself image resulting from the paranoia.

The results from the MMPI-2 were within the normal range for average scores of the respondents of his age group. But the 75 score of depression for Sebastian show sthat he has a tendency to get depressed now and then which can grow with age and with inability to cope with failures in life. There are also suggestions that Sebastian could not be entirely satisfied with certain things in his life and with himself. The happening in his life, especially his strained relations with his parents could be the reason behind him being not concerned about what is probably happening to him. This could also explain why he is sometimes lost in his own world which was evident during the tests. There are also indications of problems related to distractibility, difficulty in concentrating, sleeping problems and procrastination.

Diagnostic Impression

The Diagnostic and Statistical Manual of Mental Disorders details the standardized diagnosis for intervention according to 5 Axis:

Axis I: Clinical Disorders

It is diagnosed the Sebastian has adolescent disorders and Anxiety disorders along with a degree of sleep disorder or insomnia. He has also been diagnosed with adjustment disorders

Axis II: Personality Disorders and Mental Retardation

No personality disorder has been found

Axis III: General Medical Condition

There is no general medical condition that has any bearing on the mental healhto fthe adolescent.

Axis IV: Psychosocial and Environmental Problems

There is a problem with Sebastian’s primary support group — the family.

Axis V: Global Assessment of Functioning

S4ebastian is diagnosed with a score of 60 which means that he carries moderate symptoms of difficulty in the social and school functioning context.

Summary:

Sebastian, a 16-year-old student has been experiencing problems with motivation and attention in school and poor performance. There are also indications that Sebastian has symptoms of attention deficit disorder. The cognitive functioning of Sebastian was average and there was no notable difference between verbal and nonverbal functions. Sebastian showed significant ability in math reasoning and verbal comprehension. He was also mature in oral language and skills ofr verbal communication. He however has average academic skills but rarely puts his capacity to complete use. The underlying anxiety and depression as well as the disability in learning are probably the reasons for his lack of motivation, poor working memory, superficial processing and slow processing speed.

Therefore while treating these deficiencies one must keep in mind that interaction of these associated conditions. There was a noted existence of the problems of superficial processing and low mental energy and engagement.

Recommendations:

The following measures are recommended to improve Sebastian’s condition and better his poor performance in school.

1) the management of his depression and anxiety symptoms should be the primary focus of the measures and the intervention programs. The positive growth results of Sebastian needs to presented and reinforced.

2) A follow through of the schoolwork by Sebastian should be made available through the establishment of a structure and boundaries.

3) it would be helpful if Sebastian is given increasing independence and responsibility through a process of progressive multistep program. To increase the confidence and resiliency, some form of rewards and incentives should be given to Sebastian.

References

Goldfinger, K. And Pomerantz, A. (2010). Psychological assessment and report writing. Los Angeles: SAGE.

Groth-Marnat, G. (2003). Handbook of psychological assessment. Hoboken, N.J.: John Wiley & Sons.

No authorship indicated, (2003). Psychological Assessment: Editors. Psychological Assessment, 15(1), pp.1-1.

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