Reference no: EM133264253

Service Needs Assessment and Clinical Diagnosis

Client Name: John Doe Jr.

DOB: 2/12/2001

Referring Agency: Norfolk Probation and Parole Referring Worker: Ms. Johnson

Staff Evaluator:

Licensed Clinician:

Date of Clinical Diagnosis:

Identifying Information:

Insurance #: 12345678910

Date of Assessment: 1/25/2016

John Doe Jr. is an 15-year-old Biracial male who lives at 5115 Hampton Blvd, Norfolk, VA 23529. John resides with his mother, Jane Doe, age 42, his brother, Justin Doe, age 16, and his sister Sally Doe, age 13. John has a small scar under his left eye.

Reason for Referral:

Ms. Johnson, Assistant Principal at S.W. High School, referred John to this agency due to aggressive outbursts toward peers when angered, difficulty controlling his anger in an appropriate way resulting in extended periods of time to "cool down" and non-completion of assignments, provoking younger peers toward aggressive actions, frequent non-compliance with rules and expectations in the school setting, and displays of disrespect and defiance toward authority figures.

Presenting Issues:

During assessment, Mrs. Jane Doe, who is reported to be John's biological mother attended assessment. Both she and John identified his continued inability to sustain normal interpersonal relationships as well as continued conflict with peers and family on a daily basis in all settings. In the home setting, Ms. Doe reported John being constantly involved in altercations with his siblings on a daily basis in the home setting. At the time of intake, Ms. Doe described these altercations as screaming and yelling and John often encouraging his sisters to inflict serious bodily harm to themselves (i.e. why don't you just go kill yourself) and having a history of resorting to inflicting bodily harm by punching his sibling when enraged. Per Ms. Doe, John displays this behavior on a daily basis over 5 times per day, which causes a constant disruption to the family unit. In addition, John has extreme difficulty managing feelings and emotions as well as responding appropriately to challenging situations often erupting into angry outbursts, and displaying severe mood swings (i.e. blaming others, yelling, stomping, and screaming) on a daily basis. When asked how these mood swings are triggered, Ms. Doe explained that he "explodes" when authority figures ask him to take responsibility for his behavior, or receives a negative outcome while interacting with others such as losing at a video game. In the home setting, Ms. Doe reported John's emotional deficits as "sucking his teeth, stomping up the steps, talking back, huffing and puffing and yelling out." In the home setting Ms. Doe reported John's emotional deficits occurring on a daily basis and increasing in severity beginning in September of 2009 although she could not identify a significant cause for his change in behavior. During the intake process, John displayed a severe change in mood and affect when discussing his relationship with his biological father, John Doe who recently remarried in the beginning of 2010. When

processing his relationships with others, John verbalized ongoing feelings of rejection and abandonment from his father as a result of his father's blatant display of favoritism toward John's sisters (i.e. buying his sisters clothing and taking them on outings and excluding John) that contribute to his overall display of aggression and sibling rivalry toward his siblings. At the time of intake, John reported harboring feelings of abandonment and resentment toward his father as a result of his lack of communication and meaningful paternal contact, which exacerbates his aggressive behaviors toward his siblings.

In addition to displaying severe emotional deficits as well as being involved in constant conflict in the home setting, Ms. Doe described John as severely distractible and having significant difficulty with completing assignments and tasks on a daily basis. Ms. Doe indicated that John is severely distractible in the home environment, as evident by his needing directives to be clarified or repeated on average of 3-4 times before he will comply or become disoriented by complex commands, for example if John was asked to "put his clothes away and brush his teeth", he puts his clothes away but does not complete the task of brushing his teeth. Furthermore, John's distractibility presents a challenge when asked to complete his homework. Ms. Doe reported that she must stand over John to redirect him during the entire time he works on his schoolwork because he is highly distracted. She explained that she must redirect his inattentiveness "about every five minutes" due to his high distractibility during his daily homework time.

John's problematic behaviors often manifest in the community setting as a result of John's continued inability to sustain positive peer relationships as well as manage feelings and emotions effectively. In the community setting, John has been involved in physical altercations with peers as a result of his inability to manage anger or respond to challenging situations effectively. In the community setting, John reported that the most violent thing he ever did was get into a fight with his friend in the front yard of his house punching him numerous times inflicting bodily injury (i.e. drawing blood) after being triggered by his brother in the home setting. In regards to this incident, John explained that he was not upset with his friend but rather his brother; however, he took out his anger on his friend when his friend asked him what was wrong. In all settings, Ms. Doe reported that John often erupts into unmanageable and aggressive behaviors that often result in confrontations and conflict as a result of John's possession of a negative body image. Ms. Doe indicated that John hates to be criticized and is particularly sensitive to being called "fat" which is a major trigger for his reactive aggressive behaviors. At present, John currently resides in a high crime area of Norfolk, known for drug trafficking and high risk gang activity. John's involvement in conflict in the community setting place him at continued risk of personal danger due to three weeks prior to intake, a shooting of a local teen occurred in client's neighborhood 3- 4 blocks from client's home.

Current Living Situation, Family History and Relationships:

John resides with his mother, Jane Doe, his brother, Justin Doe, his sister, Sally Doe. Ms. Doe reported that John's father lives on the same street as John, two houses away. She reported that John visits his father on a daily basis. John expressed a tumultuous relationship with his father. He explained that his father is "the kind of person who will tell you what he really thinks". John said that his father does not hold back criticism but John knows his father still loves him. However, John said that sometimes he does not "feel" as though his father loves him. Throughout the assessment process, Ms. Doe expressed being the primary disciplinarian in the

home setting and presenting with a dominating and authoritative parenting style. In regards to John's relationship with his father, Ms. Doe verbalized a positive relationship between the two and denied any difficulties or challenges to their relationship, which was a contrast from what was reported by John. In addition, Ms. Doe had a difficult time reporting particular information in regards to John's early years such as his birth weight and inches. At the time of intake, there was no reported family history of suicide, drug, alcohol or incarceration as well as no reported recent grief and loss that would contribute to John's negative displayed behaviors.

Medical Profile:

Per Ms. Doe, John does not experience any medical conditions or problems.

Developmental History:

Per Ms. Doe, John was born at full term through vaginal delivery weighing four pounds and eight ounces at a length of sixteen inches. Ms. Doe had trouble remembering John's birth weight and length. She reported no complications during or immediately after her pregnancy despite John's low birth weight. She indicated that John was a quiet baby who ate a lot of food. Furthermore, Ms. Doe reported that John met all milestones at the expected times including talking by the age of nine months and walking at one year of age.

Mental Health History/Hospitalizations:

Per Ms. Doe, John has been diagnosed with Attention-Deficit/Hyperactivity Disorder, at a private outpatient practice in 2008 or 2009. Per Ms. Doe, in September 2009, John was prescribed Adderall 10 mg by Dr. Jones to treat his Bipolar Disorder. In December of 2009, Ms. Doe reported that his doctor took John off of his medication regime. Ms. Doe reported that John is currently not prescribed any additional medication regime. In addition, John has previously received Outpatient counseling services through Dr. Jones in Virginia Beach

Mental Status Profile:

John was oriented to person, place, time, and situation at the time of the intake. He presented as a well-dressed individual exhibiting appropriate personal hygiene. John appeared his stated age. He was very well-spoken, able to describe antecedents and consequences to situations at a higher than expected at his age. He maintained appropriate eye contact throughout the session, responding spontaneously to the clinician's inquiries. He exhibited a calm affect throughout the session.

Drug and Alcohol Profile:

Per Ms. Doe, John has no history of drug or alcohol use. However upon meeting with John individually, John disclosed a history of marijuana and alcohol abuse beginning in 2010. Per John, he began drinking alcohol in 2010 in order to achieve peer acceptance as well as to "relate to my dad." According to John he progressed to marijuana usage 1 year later and has most recently been abusing "woohs" which upon clarification from assessor were identified by John as marijuana laced with powder cocaine. At time of assessment John disclosed that he uses this mixture of substance on average of 4-5x per week and currently consumes alcohol 1-2x per week. He reported drinking 2-3 beers per sitting whenever he consumes alcohol which he obtains by paying older adults to purchase on his behalf. Per John, he will often stand in from of convenience stores for hours waiting for someone to purchase alcohol for him. With regard to his

marijuana and cocaine usage, John reports mixing 15$ worth of marijuana with 10$ worth of cocaine "that will put me right for a while."At time of assessment John denied any symptoms indicative of withdrawal, however he did acknowledge increased ability to use more of his substances of choice over time, continued use of each substance despite its self reported negative effect on his mood and ability to function in the school setting as well as cravings to use each of the substances on a regular basis.

Due to John's age and self-disclosure of drug usage, a release of information was obtained for Mrs. Doe to continue to participate in the assessment process with John. John has requested that his substance usage not be disclosed to his mother however he did consent to her participating in the assessment interview and contacting the agency regarding his appointment schedule once services are initiated.

Social/Recreational/Community:

Per Ms. Doe, John has been involved in physical altercations in the community setting as a result of his inability to respond to challenging circumstances. Per Ms. Doe, John is primarily involved in verbal altercations with peers as a result of his inability to manage his reactive aggressive behaviors (i.e. being called fat, so he will scream and yell or assault a peer). At the time of intake, Ms. Doe reported John being enrolled in sports throughout the year in an effort to appropriately exert his excess energy.

Educational/Vocational Status:

John is a regular education 9th grader currently enrolled at S.W High School and has difficulty sustaining and maintaining attention and concentration, completing assignments when due, interacting appropriately with peers in the classroom, and disrespecting teachers and authority figures. In regards to John's behaviors in the school environment, John's teachers reported that he becomes angered in an intense and sudden manner often overreacting to peers and adults. John was reported to require more time to "cool down" after becoming angry which often interferes with completion of his assignments. His attention seeking behaviors in the school has become a problem as he seeks "special treatment" from his teachers. John is also frequently disrespectful toward authority figures when his behaviors are corrected. For example, a teacher told John that his behavior was inappropriate and he would receive a signature and his response was "So... get out of my face". Furthermore, John's advanced age and cognitive development places him at an advantage in comparison to his peers. According to teachers, John uses this advantage to antagonize his peers, which leads to aggressive interactions. At the time of intake, John was observed by examiner intimidating and attempting to assault a smaller peer by dropping his books onto the ground, pulling his pants up, invading the personal space of the peer (i.e. his nose touched the cheek of the peer) and verbally threatening the personal safety of the peer (i.e. I'm going to jack you up, and punch you in your face) after the peer bumped into him in line. This incident was interrupted by examiner who provided verbal and physical intervention to stabilize client.

• Create a DSM-5 addiction diagnosis for this client being sure to indicate the level of severity
• After making your diagnosis, justify your diagnosis by identifying the number of symptoms criteria the client met to justify that diagnosis.
• Once you have given him a diagnosis, answer the following question based on your knowledge of the 42 CFR introduced in module 4 and expanded on in this module's reading:
• John's mother has approached you after you have completed your assessment with John and requests to know everything that is disclosed and discussed in sessions related to his addiction use. How do you proceed in this situation?

Reply to two classmates and provide feedback on their diagnosis.  Do you agree or disagree and why?  Offer alternative diagnoses as well as solutions to this confidentiality dilemma!