Posted: December 7th, 2022

S.S. 13-year-old cisgender male domiciled

Using the information on additional materials, to

RUBRIC
Family History: (10 points)
Has anyone else in the family (including grandparents, aunts, uncles, and cousins) had a psychiatric illness (including substance abuse)? How about other medical illnesses with a possible familial component (This includes not only classic “genetic” illnesses but also things such as cardiovascular disease and many types of cancer.) Are any aunts or uncles mentioned genetically related to the patient? Is the patient adopted? Included is a genogram
Family Psychiatric History:
Maternal and Paternal sides of the family

Social /Developmental History: (20 points)
A wide variety of information about the patient falls into this category. Several methods of organization are possible. One reasonable approach is as follows and documented with references to norms or deviation from the norms-That means all the following must be referenced from the literature:
Psychomotor
Cognitive
Interpersonal
Emotional
Moral development
Harm to self or others
Trauma History
Habits
Child’s Strengths & Successes
Child’s media diet
Environmental Supports
Please make sure that the deficiencies are addressed in the conceptualization and treatment plan.

School history and current issues impacting functioning (5 points)

Assessment instruments used for diagnosis or other related problems: 2 instruments are to be administered and scores obtained and used in the treatment plan (4 points)

Assessment: DSM-5 Diagnosis and Differential Diagnosis and rationale. Provide references. (5 points)

Conceptual Formulation and Treatment Plan: (25 points)
1. Presentation of a conceptual formulation of your case- must include the synthesis of the case in conceptual terms, support for your diagnosis, identification of the strengths, and what areas need to be addressed as part of the treatment and prognosis for this case. Please include a Risks and Protective Factors
2. In the treatment plan, you must include medication management including dosage and rationale, any labs that need to be ordered, and education for the family and patient. (5 points)-must be referenced.
3. Included is EBP and practice guidelines from the AACAP Practice Guidelines that are the most up-to-date on the APA website or EBP articles for treatment interventions and medication management from Cochrane or systematic reviews or research-based article that are less than 5 years old to support your interventions and medications. (4 different references required) (5 points)
4. Measurable short-term treatment goals that relate back to the conceptual formulation. (3 points)
5. Community resources for health promotion and treatment needed for positive treatment outcomes (2 points)

Format/Grammar/Spelling/Turnitin. (5 points)
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Chief Complaint: “I get a lot of thought that I cannot stop. I feel empty, and the thoughts mess up my grades, and I won’t have a future.”
Mother and father “S.S. gets bothered/ disturbed by recurring thoughts about day-to-day small incidents and things that are part of one’s daily life. He constantly debates his liking when it comes to sports or any other extracurricular activities. These thoughts are recurring, and he cannot ignore them most of the time. This stops him from doing things and makes him very sad. He has lots of anxiety and keeps worrying about the past and future. He is a perfectionist and a very bright student, and he likes to ace everything else. For example, he started participating in cross country and would not like to be 2nd or lose a race. That makes him sad. Many times, he says, “I’m sad or depressed.” This has been happening for a while but has increased recently. He had a few therapy sessions last year, but that didn’t help him.
History of Present Psychiatric Illness
S.S. 13-year-old cisgender male domiciled with his parents in Watchung, NJ. He is an only child. He was referred by his parents for psychiatric Assessment due to anxiety which started in 4th grade over his grade. Mom notes that he is an honor student and is labeled as gifted. The mother notes that he has been getting intrusive thoughts since he was eight years old, questioning himself and checking. He will be running cross country this year. Dad reports that he is concerned that S.S.’s thoughts are more intrusive. He obsesses over his sprinting, affecting his ability to focus during the school day. He gets obsessive intrusive thoughts about inadvertently causing harm. The mother reports that he asks her if he broke a window at a neighbor’s house even though it did not happen. He requires intensive reassurance at the end of the day that he did nothing wrong. His parents feel that it “interrupts his day to day life,” and he worries that this is affecting him so much that he wonders if he will succeed with these intrusive thoughts. He told his mom that he wonders if life is “worth living” due to his thoughts, which make him depressed. He was an only child. He was born in the USA. Both parents work in IT from home, and Dad rarely travels. The parents have been married for 25 years. Mom reports that it is a good marriage. Parents report that it was a happy marriage. Mom had multiple miscarriages, and she had IVF with a donor egg. Mom was 36 when he was born. His parents reported that he was a perfect child. He is a superior student and scores “near perfect tests on standardized tests.” No separation issues were reported. Mom reports transient tics with vocal grunting in 4th grade for a few months. Mom notes that he will wring his hands later when he is anxious. Parents report past two months, they see a climax in the OCD patterns. He does not have OCD with symmetry, germs, food, oself-carere. No evidence of PANDAS due to Strep or URI. Last year he had two sessions of therapy and then two sessions with another therapist. His parents report that he is a good sleeper and a good eater. He tells mom that he likes girls but does not have time for them but asks mom about girls he likes. He is in all honors classes and is currently in 8th grade. He spent his summer learning algebra. He wants to attend a charter high school for Math, Science, and engineering. It is a magnet school in the public high school that accepts top students. He likes math and science. He reports that he loves his parents and is close to them. He feels that “they understand me the most.” He has a group of friends and reports that he has 12 close friends who run cross country with him, and “we are supportive of each other.” He hangs out with kids in the neighborhood. He has an apple watch but no phone. His parents told him that “it would be a distraction.” He does not text or chat. He uses his watch to call friends or briefly text. He admits to obsessive thoughts and thinking, “I could have done better, and these thoughts have no value.” He reports that he cannot stop the thoughts, and he cannot push them away. He denies sexual or religious thoughts. He overthinks conversations and whether he offended his friends. He reports that he gets obsessive and needs to learn “everything about sports, and it gets obsessive.”
He reports passive suicidal thoughts with no plan or intent for the past few weeks due to not being able to stop the thoughts and fearing they would distract him, but he would never harm himself.
He has a few sessions of therapy but did not like it because “they just told me to breathe and did not understand it.” Anxiety from age 7-8 whereby he did rituals and had to touch things repeatedly. No hospitalizations. The parents report that he has overall health is good. No history of trauma or abuse. He achieved his developmental milestones at appropriate developmental levels. S.S is an only child. He lives with two married parents who are in IT. He has many friends and is “a leader.” No IEP or 504 plan at school.

MSE
Appearance Appropriate, Casually Groomed, Good Hygiene
Attitude Cooperative, Pleasant, Good Eye Contact
Psychomotor Activity Normal, No Abnormal Movements
Affect Normal Range , Congruent to Mood, Appropriate to Context
Mood Anxious, Unhappy
Speech Clear, Normal Volume, Rate, Rhythm, Spontaneous
Thought Process Normal, Linear
Thought Content & Perceptions Normal
Orientation Awake, Alert, and Oriented to Person, Place, and Time
Memory Recent and Remote Memory Intact
Insight Good, Age Appropriate
Judgement Good, Age Appropriate
Concentration Good, Age Appropriate
Behavior Normal
Attention Attentive
Suicidality Denies
Homicidally Denies
AIMS / EPS Not Applicable
Assessment Instrument Used
PHQ-9 =3 which indicates no depression
GAD-7 score = 14 moderate anxiety
Though not completed a Children Yale-Brown Obsessive Compulsive Scale can help assess his progression of OCD tendencies.
Family History
His parents denied any medical or mental health concerns. S.S. mother is 49 y/o and his father is 50 y/o. His maternal grandmother and grandfather are 72y/o and 73 y/o respectively. His maternal grandmother and his uncle (50 y/o) have schizophrenia. His paternal grandfather and grandmother are 75 y/o and 70 y/o respectively. They both have hypertension, diabetes, and arthritis. The patient was conceived via a donor egg. The parents did not want to disclose more about the donor which would be of significance to note any genetic loading or other risks that the patient may be predisposed of.

Dx: OCD, GAD.
Differential tic d/o, adjustment disorder

Zoloft 25 mg was started and he was referred to therapy

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