Comprehensive Client Family Assessment
J.S is an 8-year-old, African American/Caucasian, male.
Presenting problem
Mother reports that she and J.S’s father separated in October of 2015. She reports J.S wishes for her and his father to reunite and get back together. She believes that he could benefit from additional support with understanding the separation of his parents. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room). Mother reports J.S talks to her, but is uncertain if he has any suppressed thoughts or feelings. She shared that J.S’s father was recently on the phone with a women while he was visiting. Mother reports since this J.S has been having a lot of questions about whether his parents will be together again and whether they have other significant relationships. She shared that she wants J.S to understand the concept of his parents being apart.
History or present illness
Mother reports onset of Jayden’s behavior occurred in 2015 when her and Jayden’s father separated.
Past psychiatric history
Mother reports none
Medical history
Mother reports none.
Substance use history
Mother reports none.
Developmental history
Mother reports no delays.
Family psychiatric history
Mother reports anxiety and depression on both J. S’s paternal and maternal side of family. Father is struggling with addiction.
Psychosocial history
J.S reports having a lot of friends. He reports getting along with his friends.
History of abuse/trauma
Mother reports none.
Review of systems
Gen: Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.
Head: normocephalic; denies migraine headaches.
ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty
Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes. Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.
GI: Negative for decreased appetite. Neg for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.
GU: No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.
MS: Denies backache, joint pain, stiffness. Gait is normal and steady.
Heme/Skin: Denies bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.
Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.
Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.
Physical assessment
Vital Signs:
47 Height: inches
Weight: 115lbs
Temp: 37 C.
RR: 16
BP: 110/62
Pulse: 82 BPM
Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in distress, no acute distress, neatly dressed and groomed.
Mental status exam
J.S presents to the appointment with his mother. He alert and oriented x4. Neurologically intact. J.S. is neatly dressed. Polite mannerism and very social. Mood and affect is euthymic and appropriate. J.S. is comfortable interviewing with therapist while mother steps out. He seems to like talking to therapist and asks many questions about games, books, etc. that are present in the room. J.S. denies any SI/HI or A/V/H. Speech is coherent and clear. J.S. fidgets with his hands during interview and processed better after therapist offered Play-Dough to figet with instead.
Differential diagnosis
Z63.5 Disruption of family by separation and divorce
Diagnosis
Seperation and Anxiety Disorder
Case formulation
Mother reports that her and J.S’s father separated in October of 2015. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room).
J.S attended session with his mother. He completed a Basic Emotion Assessment indicating mixed emotions (sad, angry, happy, excited). J.S rated sadness as a 4 on a scale from 0-5 with 5 indicating very sad. Jayden explained, “I am sad that my dad does not live with me anymore.” He reported that he is happy and excited because he will be going to his grandmother’s home for the summer.
According to the American Psychological Association (2013), diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individual developmental level, is prolonged and severe. In accordance with J.S.’s intake assessment and individual therapy session, he fits the criteria for this diagnosis.