Ethnicity: Not Given
Date of Evaluation:
REASON FOR REFERRAL:
Sam Harris is a 15-year-old male who was referred by the *(information not available regarding exact referral source, please insert) court for assessment and the development of a treatment program.
According to Sam’s mother, Tammy Harris, Sam was born at Howard University Hospital in Washington DC. His reported birth weight is in the low normal range (6 pounds, 5 ounces). According to Ms. Harris there were no complications during the pregnancy and during the delivery. All of the available evidence indicates that Sam met his development milestones on time and there were no significant issues.
There is no significant family medical history reported in the case notes. Sam’s parents were cohabitating at the time of his birth. According to Ms. Harris, Kirkman Wells (Sam’s father), was abusive to her and she eventually left him. Sam currently lives with his mother, her partner, two sisters, and a cousin in Washington DC. According to Sam he has a total of nine siblings, three of which are paternal siblings and a total of six maternal siblings; however, two maternal siblings are currently deceased.
There are reports of significant physical and emotional abuse directed at Sam from both his mother and his mother’s partner. Sam has been kicked out of the house on several occasions by his mother. Sam reports that he believes his mother does not like him and that she physically abuses him and sometimes does not feed him for days of time. There is an open neglect case against Ms. Harris regarding this treatment.
Sam reported that he has occasional contact with his father and reports from Sam’s probation officer indicate that Sam’s father makes promises to him but does not keep them.
Sam was held back in the first grade. He has an IEP, Emotional Disturbed Classification. He is currently suspended from school and is reportedly failing all of his classes.
Reported medical history appears unremarkable.
Sam reported that he gets in fights constantly and has been involved in over 50 fights. There is no information regarding his social contacts outside of his family.
Substance Abuse History
None reported at this time.
Sam was admitted to the Psychiatric Institute of Washington for an evaluation regarding potential mania. He received a diagnosis of Bipolar I disorder. He is classified with an Emotional Disturbed category in the educational system.
There is an open case of neglect against Sam’s mother.
BEHAVIORAL OBSERVATIONS & MENTAL STATUS
Sam has been reported to be very derogatory regarding his mother and family and has been negative towards staff when he does not get his own way. He does respond to redirection.
DSM-5 DIAGNSOTIC IMPRESSIONS
Rule out 296.99 Disruptive Mood Disorder versus 296.40 Bipolar I Disorder
995.51 Child Psychological Abuse
995.54 Child Physical Abuse
V61.29 Child Affected By Parental Relationship Distress
There is just not enough information in the case history to differentiate a diagnosis of disruptive mood disorder or bipolar disorder in this client. In addition, there is a significant amount of abuse both psychological and physical in this case and family issues that contribute greatly to Sam’s presentation (American Psychiatric Association, 2013). Sam will require a much longer period of assessment in order to ascertain whether or not he is simply reacting to his environment or he has a true bipolar disorder that contributes to these complications.
Sam will need intensive psychotherapy/counseling. This would include intensive family counseling and further assessment regarding the fitness of Sam’s mother to be his primary caregiver and supervisor. At this time it appears as if the level of psychological and physical abuse directed at Sam by his mother and her partner may be significant enough to have Sam placed in foster care. Moreover, Sam will need intensive psychiatric evaluation to determine if medical management of his issues can be of assistance. Currently Sam’s prognosis is guarded at best due to very complicated family dynamics and the need for his parents to be involved in this treatment.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders-5th edition. Washington, DC: Author.
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