PSYCHOLOGICAL
EVALUATION
|
Client
Information: Name:
Bill R. Smith Date
of Birth: 1/02/86 Dates
of Assessment: 1/5/02 Date
of Report: 2/5/02 Age:
15 years 7 months Evaluator:
Daniel R. Cruikshanks, Ph.D. |
Procedures
Performed/Information Reviewed: Clinical
interviews with client and mom Adolescent
Intake Questionnaire Substance
Abuse Subtle Screening Inventory (SASSI) Child
Behavior Checklist (CBC) Rotter
Incomplete Sentence Blank (RISB) Beck
Depression Inventory (BDI) Burns
Anxiety Inventory (BAI) Symptom
Checklist – 45 (SCL-45) |
Reason for Referral: Mr. Bill Smith is a 15 year old Caucasian male who was referred to me for psychological/substance abuse evaluation by the Cuyahoga County Juvenile Court. At the time of this evaluation, Bill was in the custody of his parents. He had been arrested on 10/31/01 following a Halloween party at his friend’s house. He apparently had left the party and was walking in town when police caught him at the scene of an unrelated arrest of some “kids who stole a motorcycle.” Apparently, he was arrested and charged due to breaking curfew and under age consumption of alcohol (blood alcohol level = .036).
On November 16, 2002, Mr. Smith was judged to be an unruly youth and ordered to submit to this psychological evaluation. The purpose of this evaluation is to determine 1) whether Mr. Smith has alcohol or drug addictions problems, and/or any mental illness(es) that would contribute to these legal problems, and 2) what are the appropriate interventions for the problems identified by this evaluation?
Behavioral
Observations: Mr. Smith presented for the evaluation accompanied
by his mother. The evaluation was
conducted at the offices of My Clinic,
Mother reports no notable problems with developmental milestones. Mr. Smith has no history of prior treatment for mental disorders. He has no prior history of legal problems. He reports some mild problems in the school environment including verbal, but not physical, conflicts with classmates. He reports being sent to the principal’s office twice in the past two months and one in school suspension last month.
Mr. Smith reports that he has frequent, ongoing difficulties with sleep and tends to be very irritable with a temper that is easily triggered. He reports that he is “easily rubbed.” Kids at school “push [his] buttons” and then he gets into trouble.
Mom
reports no significant behavior problems at home. According to her, “He’s
pretty normal.”
Mr.
Smith was evaluated at the offices of My Clinic on 3/5/03. Following the
initial interview, he took the MMPI-A and the SASSI. Additional tests and forms including the
SCL-45, the CBCL, and the Adolescent Intake Questionnaire were sent home to be
completed and returned by mail (3/9/04).
SOCIAL HISTORY:
Family
History:
Mr. Smith lives with his mother, Carol Smith, his step-father, Carl Smith, Sr.,
and his nineteen year old sister, Sue Smith.
Mr. Smith’s parents divorced after 4 ½ years of marriage, and Mr.
Smith’s father has not been a part of his life other than minimally. Mr. Smith
has had no contact with his father in nearly three years. He reports that he “likes” his step-father
and they get along well. Mr. Smith's family lives in a rented home in
Mr.
Smith was cooperative with this interview and evaluation. He spoke freely in response to
questions. While Mr. Smith recognizes
that he has some problems, he believes that this legal problems largely are the
result of “being at the wrong place at the wrong time.” He admits that he was drinking at the party
but that he only had “a couple pf beers.”
He reports that aside from occasional minor problems at school, he has
not been in trouble before. He
apparently gets along well at home, and his mother does not have any complaints
about him.
He
reports that he has consumed alcohol only occasionally and only in small
quantities at any given time. He admits
that he has tried cannabis “a couple of times.”
He reports that he avoids caffeine and states that he smokes
approximately ½ pack of cigarettes per week.
Mr. Smith admits that he his prone to temper outbursts, which he
suggests often are beyond his control. He reports additional symptoms of mood
disorder including disturbed sleep, low self-worth, feelings of guilt, etc.
School
History:
Mr. Smith is currently in the 12th grade at
Despite
these problems, Mr. Smith maintains good grades. At the time of this evaluation, he had mostly
A’s and B’s.
Medical
History: Mr. Smith is not currently treated for any
medical problems.
Mental
Health History: Mr. Smith has never been evaluated or treated for psychological
problems.
Legal
History:
Mr. Smith was arrested on October 31st, 2003 for violating curfew
and underage consumption of alcohol.
Personal
History and Goals: Mr. Smith is interested in sports such as football and baseball. He also enjoys time with friends and
music. He will graduate in June and
plans to “enter the work force.”
MENTAL STATUS EXAMINATION:
Mr.
Smith was oriented to time, place, and person. Speech quality and quantity were
in the average range for his age. He did not avoid eye contact and was engaged
and engaging. His long and short-term memory appeared to be in tact. He denied
visual or auditory hallucinations and showed no evidence of responding to
internal stimuli during the interview. He displayed thought processes that were
logical, organized and coherent. Insight appeared to be intact. Judgment tends
toward impulsive. He appeared relaxed
and calm throughout the process of the evaluation.
Mr.
Smith denies suicidal ideation or homicidal ideation.
TESTING RESULTS:
Personality Assessment
MMPI-A
|
Raw Scores: |
L=2 |
F=15 |
K=8 |
Hs=6 |
D=22 |
Hy = 17 |
Pd = 26 |
Mf=18 |
Pa=18 |
Pt=26 |
Sc=24 |
Ma=21 |
Si=30 |
T scores: Hs = 47 D = 55 Hy = 43 Pd
= 62 Mf = 42
Pa = 63 Pt = 60 Sc
= 55 Ma = 48 Si = 55
On
the MMPI-A, Mr. Smith
responded to items in a cooperative and reliable manner. The following interpretations are likely to
be a good indication of his current personality functioning.
Mr. Smith’s Clinical Profile is moderately elevated
suggesting he may be irritable and argumentative and tend to transfer blame to
others. He may be easily upset and,
consequently, have behavioral problems.
This elevation is not extreme, however, and is lower than would be
expected for people in a clinical setting.
Although this MMPI-A
profile does not indicate chemical dependency, it does indicate a person at
risk for possible chemical dependency problems.
His elevated Pa and Pd scale scores are not commonly found in
“normative” samples, but are found in about 8% of adolescent boys in
psychiatric ands/or drug treatment settings.
The Content Scales of Mr. Smith’s MMPI-A profile strongly indicate
symptoms of depression including sadness, fatigue, and self-deprecatory
thoughts. He likely sees his life as
uninteresting and not worthwhile. He
often feels lonely, useless, and pessimistic. He also appears to suffer from
several symptoms of anxiety including worry, tension, and sleep
difficulties. Mr. Smith endorsed a
number of items that suggest he sees himself as having many faults and not
being able to do anything well. He sees
himself as flawed and unattractive. He
lacks self-confidence and may be easily dominated by others as he attempts to
fit in.
Interpersonally, Mr. Smith’s profile suggests a
young man who tends to feel emotionally distant from others. He believes that others neither understand
him, nor like him or care about him. He
feels he has no one to rely on for support and does not feel that he can get
such support from his parents. He feels
uncomfortable in social situations and prefers to be alone. He may see the world as a hostile place to
him and that others are out to get him.
He tends to look for ulterior motives whenever people do nice things for
him. He may feel that others make
friends in order to use them, and therefore, he avoids close friendships and
tends not to trust completely those he has.
Nevertheless, he does indicate a desire to succeed
ion life. He may be motivated to do well in school in areas he feels will help
him to that end.
SASSI
Testing
with the SASSI revealed a
pattern of responses that classify Mr. Smith as either chemically dependent or
at risk for chemical dependency.
Although Mr. Smith largely denies excessive drug or alcohol use, he does
acknowledge that he has gotten sick from drinking “repeatedly.” On the Subtle Attributes section of the test,
Mr. Smith responded to items in a manner suggesting that he may be hiding his
consumption patterns and/or that his behavioral attitudes place him at higher
risk for chemical dependency than would be typical for adolescent boys.
CBC
Mrs.
Smith, Mr. Smith’s mother, rated his behavior on the Child Behavior Checklist (CBC). Mrs. Smith rated him for his
competence in Activities, Social and School competence. Mrs. Smith rated her
son in the
With
regard to the Syndrome Scale Scores on the CBC,
Mrs. Smith rated her son in the Borderline
Clinical range for Somatic Complaints noting problems
with complaints of fatigue and stomach problems.
Findings
of the CBC support those of
the MAPI and the RISB in that they indicate a
child who has mood/anxiety problems as indicated by social isolation/discomfort
and somatic problems associated with depression and anxiety. There is no evidence to suggest attention
problems. A diagnosis of ADHD is not
indicated.
BDI
With
a score of 22 on the Beck Depression Inventory, results on this test indicate Moderate symptoms of depression were
present at the time of this evaluation.
Notable symptoms indicated include self-blame, sense of failure,
self-loathing, and loss of interest in social relationships.
BAI
With
a score of 25 on the Burns Anxiety Inventory, results on this test indicate Moderate symptoms of anxiety were
present at the time of this evaluation. Notable symptoms indicated include
nervousness, tension, racing thoughts and disturbing dreams.
SCL-45
With
a total score of 45 on the Symptom Checklist - 45, results on this test
indicate Clinically Significant symptoms
on the Depression Scale (Avg. = 2 of 4), the Anger/Hostility Scale (Avg. = 2.33
of 4), and the Paranoid Ideation Scale (Avg. = 2.25 of 4) were present at the
time of this evaluation. Notable symptoms indicated include hopelessness,
loneliness, worries, urges to break things, feelings that others can’t be
trusted that others will take advantage of him.
SUMMARY AND RECOMMENDATIONS:
Mr.
Smith presents as a relatively normal young man who has found himself in
trouble with the legal system. Although
he freely admits to being guilty of violating curfew and underage consumption,
he and his mother suggest that he was “in the wrong place at the wrong
time.” That is, it appears that he would
not have come to the attention of law enforcement had he not found himself at
the scene of another, unrelated crime in progress and been taken into custody
for suspicion of involvement in that crime (for which he was immediately
cleared).
Mr.
Smith presents with mild problems in the school environment including
occasional acting out at the goading of his peers which occasionally results in
reprimands at school. Despite these
problems, Mr. Smith appears to be a good student with above average
grades. According to his accounting
teacher, Mr. Mason, Mr. Smith is a hard worker who presents “no real problems
or concerns.” Mr. Mason observed
moodiness and nervousness and indicated that he occasionally is compelled to be
the class clown.
Based
on interviews, data from mom, a teacher, and the testing battery, there is
clear evidence of a mood disorder.
Following the initial interview, a diagnosis of Depression NOS was made
and Mr. Smith was referred to his primary care physician for a medication
evaluation. Many of the problems and
concerns noted are likely related to the presence of this depressive disorder,
and treatment will likely improve life for Mr. Smith significantly.
Although
Mr. Smith denies excessive use of drugs or alcohol, he does acknowledge at
least occasional use of cannabis and alcohol.
There is not adequate evidence as a result of this evaluation to
diagnose Mr. Smith with Chemical Dependency, but there is evidence to suggest
abuse with risk of dependency. It
appears that at least some of Mr. Smith’s drinking behavior is an effort to
“feel better” and alleviate some of his symptoms of anxiety and depression.
Therefore, effective treatment of the depression may well reduce or eliminate
the risk of chemical dependency.
Chemical dependency often is a consequence of the individual’s effort to
self-medicate and alleviate their mental suffering.
Mr.
Smith is well regarded by his parents and his teachers at school. He appears to be a bright young man who,
despite the problems he has, is a good student who aspires to be successful in
life. Prior to his arrest on October 31,
2001, Mr. Smith had not been in trouble with the law. He has no known history of violent or
destructive behaviors.
Recommended
interventions include the following:
1. Mr. Smith will benefit from
medical treatment of his depressive disorder.
2. Due to the apparent high
risk for chemical dependency, Mr. Smith should be monitored for signs of
substance abuse during the period of his probation.
o
This monitoring should include regularly scheduled urine drug/alcohol
tests.
3. Mr. Smith likely would benefit
from Counseling/Psychotherapy for treatment of his depressive disorder and to
minimize risk of substance abuse/dependence.
Mr.
Smith is a bright young man who aspires to do well and be successful following
his high school years. Assuming
compliance with medical treatment and good response to medications, he is
likely to see his mood disorder resolve resulting in improved comfort in school
and social situations. Since his mood
disorder is not severe and he is young, Mr. Smith is a good candidate for
successful treatment.
DIAGNOSTIC IMPRESSION:
The
following diagnosis is based on the most recent edition of the Diagnostic
and Statistical Manual of the American Psychiatric Association (DSM-IV/TR).
Axis I: 305.00 Alcohol Abuse
296.62 Major Depression Disorder, Single Episode, Moderate
Axis II: V67.01 No Diagnosis
Axis III: no
diagnosis
Axis IV: legal
problems; social problems
Axis V: Current Global Assessment of Functioning
(GAF) = 60/100
Highest
GAF in Past Year = 60/100
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